1/ Code three

Nov. 9, 2006—p.m. 11:16

The trauma alert went off in Parkview Medical Center’s emergency department. Four miles from the hospital there had been an accident.

“I have a sixteen-year-old female involved in an MVA,” a paramedic informed the triage nurse at Parkview by CB radio. “She is awake at the scene, arousable. But she appears to have some head and neck injuries as well as chest and abdominal injuries involving the steering column.”

The girl’s Volkswagen Jetta had jumped the curb and hit a telephone pole at high speed. Although she was wearing a seat belt, the front end of the car was crushed and the steering wheel driven back into her, pinning her to her seat. Rescue personnel had tried to move the seat back, but the tracks were jammed and they were forced to squeeze her out the best they could. Using all his strength, a fireman pulled the wheel a few inches away from the girl while paramedics carefully tugged on her until she was freed.

“We’re arriving code three in four minutes,” the paramedic said.

Ted Cogan, the senior trauma surgeon in the hospital that evening, came down to the emergency department from his on-call room on the second floor just as the paramedics were wheeling the victim into the hospital. Cogan was a tall man of medium build made to look even taller by the clogs he was wearing, which, when he walked on the hard, bare floors of the hospital, came out sounding like the slow clip-clop of a horse pulling a tourist carriage.

Only a few minutes earlier, he’d been resting comfortably in bed, dozing. One side of his hair, graying at the temples, was standing on end and his green scrub shirt was not tucked into his pants in the front. Rumpled as he was, though, the look didn’t add years to him. Instead, it gave him a boyish charm, as if he were late for school, rather than on time for work.

The paramedics steered the victim into the trauma room. White and young with blond hair, she was looking up at the ceiling, her mouth covered by an oxygen mask. In the room, the head trauma nurse, Pam Wexford, started barking orders at an intern: “We need you on that side. No, there. OK, on three, we lift.”

They transferred the girl, who was strapped to a hardboard stretcher, her neck stabilized by a cervical collar, from the paramedics’ gurney to the trauma-room gurney. Cogan moved into the room, but stood off to the side, trying to stay out of the way of the emergency workers. Although he was at the top of the pyramid and technically in charge, there were few, if any, instructions he had to give in these early moments because standard procedure was in effect. The team would make sure the victim had an airway, they’d take her vital signs, start an IV, draw a blood sample, and strip off her clothes. Then they’d take preliminary X-rays of her neck, chest, and pelvis.

“Dr. Cogan, so nice of you to join us.”

This was John Kim, the chief surgical resident, talking and working on the girl at the same time. Kim was thirty but he looked twenty. A baby-faced Korean-American. Cogan liked him, if only because he possessed the two qualities that made just about anybody tolerable: he was competent and had a good sense of humor.

“Wouldn’t miss it for the world,” Cogan said. “What happened?”

“She hit a telephone poll doing about 50.”

“Ouch.”

“90 over 60, Doctor,” Pam Wexford said. “Pulse 120. Hemoglobin 15.”

The girl’s blood count was normal. But her blood pressure was lower than normal and her heart was running fast, which probably meant she was losing blood—the question was from where. She didn’t appear to have any major external lacerations, so they were probably looking at a fracture, some sort of chest trauma, or the laceration or rupture of an organ, Cogan thought.

“We’re going to have to cut your clothes off,” Wexford said to the girl. “So please try to remain still.”

The girl responded by opening and shutting her eyes and groaning. She was wearing jeans, which made the cutting more difficult, but Wexford, a real-life version of Edward Scissorhands, still managed to shred her pants, mock-turtle neck shirt, bra, and panties, in under a minute. When she was finished, Cogan went over to a counter, where there was a latex-glove dispenser, and pulled out a couple of gloves. He stretched a glove over each hand, then turned his attention to the victim, who was lying naked on the gurney, her legs spread slightly apart. He noted that she was a thin, well-proportioned girl with muscular legs and a flat stomach. She had four or five superficial wounds—cuts and scratches—on her arms and face, then a deeper cut and bruise on her right shin that an intern was attending to.

“How’re we doing, Cynthia?” Cogan said to the X-ray technician.

“Ready when you are, Doctor.”

“Pam?”

“BP 90 over 60. Pulse 130.”

“OK, Cynthia. Gimme a Kodak moment.”

The X-ray technician moved the portable X-ray machine over to the victim. When it was in place, she told everybody to clear the room except for one intern, who was putting on a lead apron, preparing himself for the unenviable task of pulling the patient taut (by the feet) during the cervical shot. Cynthia took several X-rays, repositioning the machine for each new shot, always making sure to remind everybody to “clear” before she pressed the remote switch from where she stood behind the lead screen that prevented her from being exposed to the radiation.

As soon as she was done, the rest of the trauma team came back into the room and resumed their duties. A couple of zealous interns whose names Cogan always got mixed up started firing questions at the girl, who mainly responded with groans and grimaces.

Intern #1: “Do you know where you are? Do you know how you got here?”

Intern #2: “Miss, are you allergic to any medication?”

Intern #1: “Are you allergic to antibiotics? Penicillin?”

Intern #2 (touching her leg with the needle): “Can you feel that?”

Intern #1: “Miss, I’m going to have to give you a rectal exam. OK?”

“80 over 60, Doctor,” Pam Wexford said. “Pulse 150.”

“All right,” Cogan said. “Do we have a name for her yet?”

The nurse glanced at the paramedics’ paperwork. “Kristen,” she said. “Kristen Kroiter.”

“Kristen,” Cogan said, speaking to the girl. “Is that your name?”

She didn’t answer. She just opened and closed her eyes.

“OK. I’m Dr. Cogan and this is Dr. Kim and we’re here to help you. We’re all here to help you. You’ve been in a car accident and you’re in a hospital. Do you understand that?”

With the oxygen mask still covering her mouth, the answer came out sounding like a grunt but it was affirmative enough for Cogan to continue.

“I’m going to ask you a few questions and give you a quick examination so we can determine your condition. OK?”

She groaned. Then, squirming a little in the restraints, she murmured through the mask: “It hurts so much.”

“I know it hurts,” he said, taking her hand. “And I’d like to make it so it doesn’t hurt. But I can’t give you anything just yet because if we give you something you might not be able to tell us where it hurts and we need you to tell us where it hurts so we can make it better.”

He examined her eyes, then said: “Eyes are equal and reactive.”

Lungs were next.

“Kristen,” he said, “I want you to try to take some deep breaths.”

As he listened with his stethoscope, a wave of pain appeared on her face every time she took a breath. But her lungs appeared to be clear. “Breath sounds equal and present bilaterally,” he announced to the team. Then to her: “Does it hurt when you breathe?”

She had trouble answering him so he told her if she didn’t want to speak that she could just squeeze his hand. She could squeeze his hand, couldn’t she?

She could.

Next, with his free hand—his right—he began to examine her chest. Her skin was warm and moist—she was sweating; Cogan noticed sweat building up on her forehead. He worked his way slowly across her chest, pressing gently on her rib cage, feeling for tender spots. All of a sudden, she screamed, and Cogan felt one of her fingernails dig into his hand. He quickly let up on the spot.

“OK,” he said. “I’m sorry.”

He pressed down again, this time more gently on the left side of her abdomen. She didn’t scream but groaned instead, then closed her eyes and said, “Please.”

“Tender left upper quadrant with possible crepitance of left lower ribs,” he announced.

Just then Cynthia, the X-ray technician, came back into the room and said: “Film’s ready, Doctor.”

“Thanks. Kristen, can you hear me?”

The girl opened her eyes.

“You’re doing good,” he said. “I have to go away for a minute but Pam here is going to take care of you while Doctor Kim and I take a look at what’s going on inside of you. But we’ll be right back.”

Cogan got one more reading on her vital signs—her blood pressure and pulse were holding steady—then he went to the other side of the room, where Kim had put the X-rays up on the light box and was looking at her chest X-ray. He was looking at her lungs. White was air. Black was nothing, emptiness, a non-functioning lung.

They were looking at white.

“No pneumothorax,” Kim said, informing Cogan of what he, too, saw: neither lung had collapsed. “But she’s got rib fractures. Left ribs 9-11. That’s why she’s having trouble breathing.”

Rib fractures were extremely painful. They turned grown men into babies.

“I think that’s it,” the younger doctor went on after a moment, looking at her neck and pelvic X-rays. “C-spine is clear and her pelvic films are normal.”

“Doctor,” Wexford said, her voice more urgent than it had previously been. “Her blood pressure is falling. She’s getting more tachycardic.”

Both surgeons turned around and looked at the machines. She was 80 systolic. Her heart rate was up to 170. Her hemoglobin down to 12.

Kim looked at him, his face tense. They both were thinking the same thing.

“Do you want me to do a wash?” Kim asked.

“I’d better do it,” Cogan said.

He went back over to the patient and asked a nurse for a peritoneal lavage tray. “Quickly, please,” he said. His voice remained calm but the whole team immediately went on alert, for everybody knew that Cogan, unlike some surgeons, made such demands only when the situation truly called for it.

A “wash” was short for a peritoneal lavage, a procedure in which a saline solution is injected into the peritoneum, the membrane lining the abdominal cavity, then aspirated back into the syringe. If the saline solution comes back bloody, it means there is blood where there shouldn’t be.

Cogan made an incision in the girl’s belly button, then carefully pushed a narrow piece of plastic tubing into the hole he’d made. Next, he attached the tubing to a syringe filled with saline solution and, with his thumb, slowly squeezed the plunger on the syringe, gradually pushing the saline solution into the girl. When the syringe was almost empty, he carefully began to pull up on the plunger, aspirating the fluid back into the syringe.

What came back was a deep red.

“Grossly bloody,” he said, handing the syringe to a nurse. Then, after a brief pause: “OK, ladies and gentlemen. I think she’s got splenic rupture. Hang more fluid, cross her for six units, and let’s get her to the OR stat.”

With that order, the whole team began to focus its efforts on transferring the girl, along with her IVs, from the fixed gurney she was lying on to one that had wheels and was mobile.

“Kristen,” Cogan said to the girl, taking her hand. “You’re doing good but we’re going to take you upstairs so we can take a look at what’s going on inside you if we have to. Do you know where your parents are? We need to get their consent if we have to operate. Is there a number where we can reach them?”

He knew she probably wouldn’t be able to answer him but the rules said he had to at least make an attempt to contact the parents of a minor before he operated on her.

Her eyes were vacant; she looked at him, then closed them.

“OK, let’s go,” Wexford said loudly. “Head or feet, Dr. Kim?”

Kim took the feet at the front end of the gurney and pulled, while Pam pushed from the back where the girl’s head was. The team’s job was finished. The girl was officially Cogan’s patient.