W. Roy Smythe, MD
Texas A&M Health Science Center, Temple, United States
Red blood cells in a vessel
by Jemère Bohnert © 2011
My beeper went off again. I got up out of my seat in the empty hospital cafeteria, walked over to the wall phone and dialed zero. Zero is exactly how much energy I have for anything right now, I thought.
As a senior cardiothoracic surgery resident in my ninth year of surgical training in Philadelphia, I had taken call in the hospital for the entire weekend. Now Sunday evening, I was finally nearing the completion of that shift. I silently reviewed the events of the previous 48 hours as I waited for the hospital operator to answer: I had performed an emergency coronary bypass operation in the middle of the night on Friday, took care of patients in the intensive care on Saturday, and completed a double lung transplant that night (with organs that I had “harvested” from a donor in a tiny hospital somewhere on the Jersey shore).
At least the last one was on the shore, I thought. Flying in by helicopter from the west always promised a good view of the ocean and the surrounding boardwalks. If you were lucky, as you passed the shore the sun would set behind you, its light reflecting off the breaking waves. From that vantage point, the waves looked strangely, but beautifully immobile, transmitting the golden light like luminescent comets moving parallel to the shore. For a moment, the beauty made you forget the incredibly macabre business of organ harvesting.
“Hello,” I said laconically, “this is Doctor Smith, CT surgery.” I still had a bite of pepperoni pizza in my mouth.
The operator responded, in a thick South Philly accent, “A call for you, doctor.”
I agreed, sighing, “Sure.”
“Rob!” the voice of my attending crackled on the line excitedly. “We have a possible acute dissection coming in from Lancaster. You probably should go on up to the helipad.”
A dissection meant that the wall of a patient’s aorta may have torn and separated, like layers of laminated cardboard. This could result in a lack of blood flow to vital areas of the body or, in the worst-case scenario, rupture into the chest or abdomen resulting in death from internal exsanguination.
I hung up and shuffled back over to my aquamarine plastic tray, finished off my soda, and headed, with a fried apple pie in my hand and cheese crackers in my lab coat pocket, to the elevator bank that would take me up to the helipad. I knocked on the locked, unmarked, metal control room door and was buzzed in. The guys up there always enjoyed company. Sitting in a stark ten-by-six space for hours listening to the police radio and staring at a blank radar screen, they rarely see another human being.
“Hot one coming in, doc!" the dispatcher said, smiling. “Aorta, right?”
“That’s the rumor,” I replied, as I watched the helicopter appear on the horizon. I scanned the familiar movements of the machine as the pilot deftly swerved the hovering machine around, landing it squarely, almost gently, on the big red cross painted on the center of the shiny, white concrete surface.
I stepped into the hallway outside the control room and waited for the flight medics to bring the patient through the doorway to the elevator bank. I stared down at the waxed tile floor and listened as the thumpa-thumpa—thumpa——thumpa sound of the helicopter blades diminished and stopped before the door burst open.
The medic pulling the stretcher, in a white flight helmet, nodded at me expectantly. The patient was an elderly woman. Her grey hair pulled back into a small bun, she had plum-shaped, cherubic cheeks and a very warm smile. I noted that she was wearing worn, blue terry-cloth slippers with little, pink flowers embroidered on them instead of the usual cheap, hospital-issued booties—probably hers from home.
She was wide awake, and looked up at me. “Are you my doctor?” she asked.
“Yes, I am.”
“You look too young.” As she laughed, the skin around her eyes crinkled affectionately, and she reached out her hand—trembling, but purposeful. I smiled back at her and reflexively took her hand. I was struck by her firm grasp and how soft, warm, and comforting it was. Her thumb, as if by habit, caressed the back of my hand. My mother used to do that, I thought.
“Are you in pain?” I asked.
“No doctor,” she replied. “Some before, but it passed. I really think I’m going to be fine.” I rode down the elevator with her, my hand still in hers, to the intensive care unit. Once there, the junior residents and nurses who staffed the unit leapt into action. They were like mechanics in the pits at a race track, placing intravenous lines and starting medicine to lower her blood pressure. I took the large cardboard envelope that was lying under her stretcher over to an X-ray view box and put the images of the CT scan that the previous hospital had performed on the lighted panels.
I picked up a wall phone and asked the operator to call my attending surgeon at home. “Hey,” he answered. “What we got?”
“A 68-year-old black female,” I replied, “moderately obese and hypertensive, with no current complaint of pain. All of her pulses are normal. Labs are off, and I’m looking at the films now.” I stopped for a moment and glanced at the last couple of images. “The films are poor quality, but it looks like she has both an aneurysm … and a dissection.”
“Hmm,” he replied, “that's rare. It’s either one or the other—an aneurysm or a dissection.” While a dissection is a tear in the arterial wall, an aneurysm is a “ballooning out” of the aorta, leading to a thin wall that is prone to rupturing as it grows. Both require serious medical attention.
“I know,” I replied, “but the aorta is about six centimeters, and I think I see two lumens in the upper thoracic area, as well as a tear.”
“Okay, whatever,” he replied, a little exasperated. Even though I had read a CT scan almost every day for the last two years, his tone implied that he couldn’t trust me, “Get an MRI, and give me a call.”
“She’s a real sweet lady,” I mentioned, uncharacteristically, before hanging up the phone, “reminds you of someone’s grandmother or something.”
We transferred her to Radiology. As the MRI technician prepped her for the exam, I stepped out into the adjacent control and viewing room. The technician then fiddled with computer; waiting for the machine’s loud roar, I absent-mindedly watched the patient’s monitor. The patient’s pulse rate had begun to drop: 90, 78, 63, 52, 44, 38.
Crap! I thought. She’s about to code!
“Turn off the magnet and bring me a thoracotomy tray!” I yelled as I pushed open the door to the scanner room. I ran up and felt her neck—no pulse. She had lost consciousness and was still breathing, but barely. Her monitor showed a pulse in the 30’s. “Call anesthesia, now!” I yelled again. I reached down and felt her groin—no pulse there either.
One of the nurses brought in the instrument tray. “She’s ruptured!” I yelled. “Betadine!” The nurse handed me a bottle. I tore off the top and squirted it haphazardly onto her left chest. I ripped open the light blue, paper-covered instrument tray and grabbed a scalpel. I plunged it savagely between her ribs just under her left breast and cut laterally down toward the table, opening all the way into her pleural space with one cut.
A torrent of blood rushed out. As if someone had spilled a very large punch bowl, I heard it splash onto the floor at my feet. I grabbed a rib spreader, shoved it into the gash in her side, and cranked it quickly. I reached deep into the chest with my left hand, behind the lung, while grabbing a big clamp with my right from the tray. I felt frantically for her aorta, knowing the only slim chance I had of saving her was to clamp across it above the aneurysm, high in the chest. But ... there was no aorta. Where is the aorta, dammit?
There was just a tubular wad of something soft and unformed, like rolled-up, wet toilet tissue. The thin walled aneurysm, made even thinner by the dissection, had basically disintegrated. I took my hand out of her chest and stood there, staring into the garish opening, as blood continued to pour out onto the table. It had already soaked through my shoes, and I could feel my toes starting to stick together. I watched helplessly as her heart beat with a slow, exaggerated, mechanical motion in the wound for the last few times, quivered a moment, and then stopped.
Two days later, as I was contemplating the possibility of going home at the end of another long day, one of the other attending surgeons called me up to his office. “We’ve been offered a heart transplant, but we have to get out in the next half-hour or so to procure it. You probably should go on up to the helipad.”
"Sure," I replied, thinking about the fact that the next 24 hours of my life had just been scripted—with none of the acts performed at home. My beeper went off, and I walked over to a nearby secretary’s desk to answer it. It was a number I didn’t recognize, but, based on the prefix, it was from inside the hospital somewhere.
“Hello, this is Dr. Smith.”
“Yes,” an official sounding voice on the other end responded, “this is Dr. Jones, Chief of the division of MRI imaging in radiology.”
“Oh hey, Dr. Jones. What can I do for you?”
“I want to talk to you about the case from a couple of days ago,” he replied.
“Oh, yeah,” I replied, “that was terrible. ‘Horrible’ actually might be a better word. We had hoped that you guys could get us some images. You always do such a great job on these cases. It was a real shame; she was a really nice woman.”
“Um-hmm,” he replied, his tone seemingly in commiseration. I continued, “A real problem, we … we thought it was actually a dissecting aneurysm. Those, as you know, are uncommon. It might have been hard to fix regardless.”
“Um-hmm, yeah,” he replied, “but what about the blood?”
“Oh, yeah!” I shot back, shaking my head. “I wondered whether or not the entire thing started because the dissection blocked off of the true lumen of her aorta. Maybe that caused the rupture. Who knows? That might explain the huge amount of blood out in such a short time, you know, under pressure—no where else to go but out.”
“No,” he countered. “What about the blood? What about the blood on the damn table?”
I hesitated. “Uh, yeah, well that’s what I, uh ... think happened, you know, with the rupture and everything, and ...” He cut me off. “What I mean, Dr. Smith, is what are you going to do about all the blood? All the blood that spilled out onto my MRI table?”
“I’m not sure I follow you,” I replied, confused.
“Listen, here’s the deal,” he stated emphatically. “That MRI table is worth about 20,000 dollars, and you ruined it. What are you going to do about that?”
I paused, squinted, and gripped the phone tightly in my hand. I had been staring ahead blankly and unfocused, but my knuckles gradually came into view out of the corner of my right eye as they blanched white and began to ache.
After a long, silent moment, I loosened my grip on the receiver and simply hung it back up. I walked over to the elevator bank outside the office area and rode up to the waiting helicopter.
W. ROY SMYTHE, MD is Chairman of Surgery for the Texas A&M Health Science Center College of Medicine and the Scott & White Healthcare System, as well as Professor of Surgery, Molecular, and Cellular Medicine, and the holder of the Glen and Rita K. Roney Endowed Chair in Surgery. He has been a prolific writer on diverse topics, writing and publishing manuscripts, editorials, essays and abstracts related to his clinical and research activity, as well as surgical history, education, health care delivery, and medical human interest.
About the artist
Jemère Bohnert is originally from Flint, Michigan. She completed her undergraduate degree at Lake Forest College in Illinois in studio art and chemistry. She recently received a Master of Science in Biomedical Visualization at the University of Illinois-Chicago. This month she will begin her career at Understand, a patient education company in Reno, Nevada. Her focus as a biomedical artist includes visually recording scientific functions and accurately portraying internal anatomical workings. She has the ability to communicate anatomical and scientific information in the form of 3D computer modeling, concept design, computer animation and 2D illustration. Visit her website at: www.jemerebohnert.com.