I was working the evening shift in the emergency department (ED) of a Level One Pediatric Trauma Center. One of the duty docs got a call for a referral from a nearby community hospital. Seems a 16-year-old kid was hitting balls in a batting cage when he got beaned in the right temple. He was briefly unconscious, but doing well since. They took X-rays and a CAT scan, which revealed a depressed temporal skull fracture, and decided to ship him to us.
He arrived sitting up on the cot talking. Then he started seizing — eyes rolled back, back arched, neck rigid, whole body jerking. “Hey doc!” The two doctors assigned to the ED ran in. IV cart on one side, airway cart on the other. RSI and intubation, RT on ventilation, neuro paged stat. Idle staff began to congregate around the doors to see what was going on. They were abruptly pushed aside by the chief of neurosurgery, who still happened to be in house. Middle aged, short of stature and stout of carriage, he possessed the demeanor of a guy, well, shall we say, in charge. After all, this was a doctor with a dedicated neurosurgical team that could anticipate his every desire. But today, all he had was us.
He shoved passed everybody, glanced at the patient, grabbed the CT scan, held it up to the light for about five seconds, and said, “We’ve gotta do it here. Where’s the ESG?” (Electrosurgical generator — the thing that looks like an arc welder they use to cauterize bleeders in the OR). “We don’t have one,” a nurse replied.” “Well GET one,” the doc yelled as the nurse scurried out toward the operating room (OR). “I need two volunteers,” he grunted. I looked around the eight or so nurses in the room — they either stood frozen or seemed to take a step back, trying to blend into the wall. I was just being deferential by waiting, but heck, if that’s the way it is…. “I’ll help,” I said stepping forward, in harmony with the other medic in the room who did the same thing. “Get gowned,” the doc grunted.
So the nurses helped us into the sterile gowns and gloves and the cautery was rolled in and someone got out the neurosurgery tray and broke the seal and opened the lid and there they were, about 1,000 unmarked clampy thingies all strung on a long metal stick like a shish-kabob. The only way to get them off was to dump the whole lot into the tray, which I did with a crash. The doc positioned me on the right and Jeff on the left. “Hand me a *******,” he said. “A what?” I asked. “A *******,” he said again. “Hey doc, I have no idea what a ******* is. Gimme a hint here.” “It’s a clamp with no serrations on the teeth.” I asked, “Oh, why didn’t you say so?” He glared at me and barked, “Where’s the drill?”
The drill, in this case, was a plastic manual cranial drill in a sealed sterile plastic tray, probably a bit pricier than its equivalent at Home Depot. I’m sure this neurosurgeon was used to the cranial drill being handed to him assembled, with the handle at the perfect angle and the crank positioned just so. Today, he was lucky one of the nurses opened the package for him. Just like a wood drill, this one had a bit and a chuck and an Allen wrench to tighten it all up. He fumbled trying to put it together and some pieces flew out of the tray. He growled, “Where’s the damned Allen wrench?” and barked, “Open me another kit.” Same thing happened, wrench went flying. “Hey, call maintenance and tell them to get up here with a set of Allen wrenches,” I said to a nurse by the phone. She replied derisively, “We can’t do that!” I asked, “Why not?” “It won’t be sterile” she said. “You’re kidding, right?” Then I heard a strange voice behind me offer, “I’ve got Allen wrenches in my truck.” I asked the voice who he was. “His dad. I’m a plumber; I got any tool you need. My truck’s right outside,” he said. His voice was steady, the calmest in the room. I was just about to ask, “So what are you waiting for” when the doc found the wrench and tightened the bit in the drill.
A quick cut through the skin, a couple of twists on the drill, and there were two holes a couple of centimeters apart in the guy’s skull. I was on the cautery: “If it bleeds, zap it” he told me. Jeff was on 60cc syringe filling duty. AD would stick the tip in one hole and blow the clots out the other. When there were no more clots and the saline was coming back clear, he said “OK, let’s get him to the OR.”
We wheeled him into the OR to the horror of the staff, appalled that the great unwashed masses from the ED were invading their holy sepulcher of sterility. The doc’s crack crew hadn’t arrived yet, so he sent us troglodytes to the storage room to fill a list of supplies. Yeah, right — the only things we could identify on the list were sterile sponges and a box of sutures. Luckily, his people arrived shortly thereafter and shooed us out like a herd of sheep that had wandered into the Library of Congress. They did a proper craniotomy, evacuated any remaining blood, put him back together and sent him upstairs.
A couple of days later I had the oh-so-rare experience of seeing a patient ex post. He and his mom came down from his room upstairs to thank the ED staff. It was a Rescue 911 moment of smiles at the firehouse. Folks watching EMS reality shows must think this happens all the time. But we know it really happens, well, almost never. I must admit, it was pretty nice.
