Extreme Medicine (8 page)

—

D
ALLAS'S NEW FACE WASN'T
immediately perfect in appearance. The tissues were swollen and bulky, and the lines of surgical incision were evident. The face itself remained largely inanimate and without sensation. Pomahač had expected all of this. It would take time before the full benefits of this procedure would make themselves known. But even in those early days, it was clear that Dallas had been transformed. He bore almost no facial resemblance to the man who had been injured in that cherry picker more than a year earlier. But now, where there had been a blank canvas of skin, there were individual features: a nose, eyes, a mouth, lips, and the more definite bony contours that make a face recognizable.

Further sculpting of his features was necessary. Once the swelling had subsided, Pomahač trimmed excess tissue. Nerves and muscles needed time to become reeducated. But when Dallas returned many months later, it was clear to all that the surgery had been a great success. His appearance was improved to the point where he might enter a room without anyone giving him a second look.

More impressively still, the nerves had begun to establish themselves. Dallas could now begin to express himself once more—relearning how to smile and frown. He even regained his sense of smell. But most important of all, he gained sensation in the skin of his new face. For the first time since his accident, he could feel his daughter's kisses on his cheeks.

—

T
HE TALE OF
D
ALLAS
W
IENS'S FACE
tells us much about medical science's most spectacular triumphs, but it is in burn units all over the world where the everyday battles against fire are being won by slow and painful increments.

Without McIndoe and his Guinea Pigs, the man lying in front of me now, body ravaged by burns, would have no hope of being restored to something of his former life. As it is, at least we can give him a fighting chance—providing we can get to the specialist unit in time.

We finally close the doors on our helicopter. The rotor blades spin up, the motors whining as they get up to speed. We rise backward from the helipad with the idea that, should the overloaded engines fail, we have an outside chance of crashing into the helipad rather than the streets below. The oxygen levels in my patient's bloodstream continue to fall.

An aircraft alarm begins to ping in the cockpit. It is continuous and sounds malignant. I look around at the patient buried in wires and tubes, at the equipment we have jammed into the rear of the vehicle. The cabin is packed. We have wedged the gear in around the crew, me, and Louise, the nurse. I imagine the strain on the engine and rotor blades. The ping of the alarm persists. It is, at this early point in the flight, a mystery to me how we'll manage to get our helicopter safely to its destination.

“Don't worry,” says the pilot, as if reading my mind. “Everything gets easier once you start moving forward.”

T
he ward rounds start at 6:30
A
.
M
.
That's the good news. The bad news is that the pre-round, when the intern visits all of the patients to prepare for the ward round, starts at 6:00
A
.
M
. I am the intern with one of the trauma surgery teams, at the very bottom of the hospital hierarchy.

It's the late 1990s. The worst of the local drug-fueled gang wars are coming to an end, but there are still plenty of guns around in Washington, D.C. The city jockeys for position as the murder capital of the United States. Not so long ago, there was an average of one murder a night in the square mile around the White House. This is not how I imagined the nation's capital.

I work twelve to fourteen hours a day. Every third day, our team is on call. Those days I work from 6:00
A.M
. through the night and the following day, thirty-six hours at a time. I have never worked so hard. I stay in an apartment about half a mile from the hospital. I'd imagined that I'd spend my free time getting to know the city, but I'm completely spent by the time the days are over. On the nights that I make it back to the flat, I force myself to stay awake long enough to make a microwave meal and eat it standing at the counter.

As time goes by, I become a little nervous about my neighborhood. The next time I see my resident, Carlo, I mention the shady characters I've noticed hanging around.

“Have you seen any shooting yet?” he asks. I misunderstand his question, thinking he's referring to our caseload in the hospital.

“Sure,” I say. “We see victims of shooting through the trauma rooms every night.”

“No,” he says in a thick Colombian accent, “have you seen, from the window of your house, someone take a gun out of their pocket and shoot somebody else?”

“No,” I tell him.

“Then you don't live in a bad area.”

—

T
HE CRASH PAGER GOES OFF.
Trauma Call. GSW. ETA 3 mins, flashes the message on the screen. I climb out of the top bunk, trying not to tread on the junior resident in the bed below. GSW is the unit's standard abbreviation for “gunshot wound.” I hurry along to the trauma room. I'm not sure what time it is or how long I've been asleep. We arrive at the same time as the patient. The paramedics spit out a string of jargon: “Eighteen-year-old female, GSW chest, signs of life on scene, arrested in the chopper, no output.”

She is wearing a blue dress with polka dots. Her feet are bare—presumably the shoes are somewhere at the crime scene—but she looks as though she's been out on the town. A pretty African American girl, her makeup and hair done carefully.

The crew that has just arrived on the helicopter continues with cardiac resuscitation while moving her to the gurney in the trauma bay.

“OK,” says Manish, the senior resident, “let's crack the chest.” There is no equivocation; there is no time. The surgery must happen here, surgery of the most drastic and invasive kind. They must open the chest, expose the heart and lungs, look for a source of injury—a reason why her heart has stopped—and fix it. It needs to happen now.

A pair of scissors makes light work of her party dress. Another trauma nurse is getting the surgical trays ready. One of the junior residents is covering her torso in iodine solution as a hurried surgical prep.

Manish is taciturn at the best of times. The pace and gravity of the case don't make him any more verbose.

“Knife,” he says levelly.

The handle of a scalpel is placed in his hand. Manish runs its blade across the skin, making an inch-long incision in the side of her chest, just below her left breast. He pushes forceps into the exposed muscle, separating the fibers and creating a tract. He repeats this exercise on the right side of her chest. If air has become trapped in the pleura, the lining that surrounds the lungs, then its accumulation might be enough to stop the heart from beating. This is what Manish hopes for: that these simple holes in the chest wall might be enough to release trapped air and resuscitate the arrested heart. But tonight there is no such luck. He must proceed.

Manish returns to the right side of the chest and runs the knife along the line of the fifth rib, extending the incision he's already made until it reaches the breastbone. He divides the muscle between the ribs and then introduces the rib spreader—a gothic-looking piece of stainless-steel hardware with a ratchet system that separates a pair of blunt claws, pulling the chest apart, separating the fifth rib from the sixth, exposing the contents of the chest cavity beneath.

In less time than it has taken you to read this description, I am looking at her stationary heart and lungs.

Manish works quickly, inspecting the pericardium. This baglike structure surrounds the heart like a glove around a hand. If it becomes engorged with blood, it will compress the beating chambers and stop them from pumping. This, too, is relatively easy to remedy, but today it's not the source of our problems. There is blood everywhere in the chest cavity. A suction tube gurgles away. Manish shells the heart from its protective pericardial sac. He inspects it, hoping that there might be a simple hole, amenable to quick repair. But this is not the case.

He moves farther up into the chest and at last finds the injury. A bullet has torn the great vessels surrounding the heart; her blood has been pumped out into her chest. The emptied ventricle has struggled and then failed to beat. There is no easy fix to this. The team stops resuscitating.

Manish asks the flight paramedics how long she has been down—without a pulse. “More than half an hour” is the reply. He looks at the clock on the wall and calls out the time of death.

The team leaves, Manish first and then the other residents. The most junior member of the team is left with the task of closing the chest. I am that person. A huge curved needle on the end of a wire is handed to me. I am left alone with a girl who perhaps an hour ago was at a party when a man with a gun sprayed rounds into the room. One passed into her chest and through her heart and its surrounding vessels. In an effort to save her life, Manish had searched for that injury, hoping to address it and then restart her heart, racing to restore a fresh supply of blood to her oxygen-starved body and brain. But the mess of ruptured vessels and chambers had proved too complicated to repair in the short time that he had.

In the heat of the moment, during the resuscitation, it is easy to be objective about things, to separate yourself from the horror of the event. Even as a lowly intern, you have a job to do, even if that job is to watch and learn, starting the process of preparation that gets you ready for the time when it might be you wielding the knife and making the decisions.

Alone with her, it's harder. As a student, the world of medicine appears to be full of patients who are much older than you, who are enduring things that you don't need to worry about just yet. But she is younger than I am, maybe even a teenager. She belongs back at the party, not lying here on a gurney with her dress cut to pieces.

The surgery she's undergone, an emergency thoracotomy, is a technique honed for precisely this situation. In skilled hands, in the right circumstances, it gives a victim of otherwise lethal penetrating chest trauma a 10 percent chance of survival. The immediacy with which it is brought to bear is startling. It is in some respects a simple, albeit violent, intervention. And today it wasn't enough.

Watching that procedure so deftly executed and with such surety, it is tempting to think of cardiac surgery as though it were an ancient art honed over centuries. But learning how to open a chest and confidently operate upon the heart is something that took almost the entire history of medicine to learn.

—

I
F YOU PLACE THE PALM
of your right hand flat in the middle of your chest, its heel lying in the center of your breastbone and your fingers extended so that your middle digit points at your left nipple, you can gain a good impression of where the heart lies anatomically. And while the beat of its apex is best felt well to the left, where the tips of your fingers resting on your chest now lie, the bulk of its mass is surprisingly central. Neither does the heart lie flat in the cavity of the chest; it is instead slightly rotated, its right side more exposed toward the front of the chest, its left slightly hidden to the rear. The whole arrangement sits protected behind the breastbone and a formidable cage of ribs; an evolutionary nod to the heart's central importance—and vulnerability.

From the breastbone, the route to the heart is an inch in a straight line, but that trivial distance took medicine more than two thousand years to travel. The twentieth century saw centuries of dogma set aside and cardiac surgery advance in great leaps and bounds. These feats of exploration laid open the continent of the heart to science and medicine just as Scott and Amundsen paved the way to the Antarctic interior.

—

O
UR EXPLORATION OF
the world's extremes is in essence an exploration of ourselves and the limits of the human body. It is our physiology and our inability to protect it effectively from the outside world that put the remote corners of the Earth beyond our grasp until well into the
twentieth century.

That exploration also saw us turn to the frontiers of medicine, to explore the limits of physiology in health and disease. The same revolutions in science and technology that extended our explorations of the physical world helped to push back the frontiers of medicine and surgery.

There were, at the start of the twentieth century, many facets of human anatomy and physiology that stood largely unprobed—foremost among them the human heart. While nineteenth-century scientists had begun to map the organ's function and complexity,
it remained a territory upon which medicine still feared to trespass. As late as the fifth decade of the twentieth century, as World War II raged, the heart was still a continent as dangerous and unknown in the eyes of surgeons as Antarctica was to explorers of the heroic age.

Physicians saw the heart as largely inviolate, a sacred and complex whole that must remain intact and unaltered, an organ with which surgeons could and should not interfere. This dogma was as old as Aristotle's teachings and remained unchallenged until the very end of the nineteenth century. Medical textbooks warned against tampering with the heart. In his 1896 text,
Surgery of the Chest,
esteemed surgeon Stephen Paget made his position clear: “Surgery of the heart,” he famously declared, “has probably reached the limits set by Nature to all surgery: no new method, and no new discovery, can overcome the natural difficulties that attend a wound of the heart.”

Overcoming the received wisdom of the past, making that leap of surgical faith, was a feat that required the terrible but unique catalyst of war.

—

I
T IS WINTER 1917.
Somewhere on the Western Front, a British infantryman is marching forward across the frozen earth of no-man's-land. There is a blizzard in the air and a biting wind sweeping across the battlefield. His clothes are no match for this weather, but the crack of gunfire presents a more immediate threat. From the German trenches, there is the sound of chattering machine guns; the firing positions are perhaps five hundred yards away. At that range, in this visibility, there is a faint hope that their hail can be avoided.

The German machine-gun crews fire hundreds of rounds a minute, pausing only to clear stoppages, improve accuracy, and prevent their weapons from overheating. Each bullet can travel half a mile in under a second. They spin around their long axes in flight, held stable by the same law of physics that keeps a child's spinning top upright, making the machine gun accurate over large distances. It is the velocity of the round and the kinetic energy carried with it that makes the bullet so lethal.

The soldier advances, a rifle in his right hand. His left is raised in front of his face to shield his eyes from the heavy drifts of snow. Through that blizzard, a spinning machine-gun round finds him.

The bullet travels through his left arm, just above his elbow, slowed by muscle and flesh. It continues, exiting the arm, piercing first his tunic pocket and then its contents—a notebook and a bundle of letters—before encountering the wall of his chest and finally the substance of his heart.

At the time of World War I, gunshot wounds to the heart were almost invariably fatal, and cardiac surgery was still looked upon dimly. Back in 1883, Christian Albert Theodor Billroth, one of the founding fathers of abdominal surgery, had these words for would-be pioneers: “A surgeon who tries to suture a heart wound deserves to lose the esteem of his colleagues.”

Views such as these continued to hold sway well into the Great War. In 1916, Major George Grey Turner, a doctor in the service of the British Royal Army Medical Corps, addressed an audience of surgeons bound for military duty. Although he had plenty of advice on other topics, he had little to say on injuries to the chest. “These,” Grey Turner told his audience, “are commonly thought to be beyond the scope of surgery, and to merit very little attention. . . .”

Yet the following year, in 1917, Grey Turner received a casualty recently returned from the Western Front, eighteen days after he had been injured by a machine-gun bullet—our infantryman with the bullet holes in his arm and his correspondence.

The soldier was in surprisingly good health and was indeed embarrassed to have been forced to arrive at the hospital on a stretcher. Grey Turner examined him and found evidence of a bullet's entry at the front of his chest but, ominously, no exit wound.

At the time of World War I, medical X-rays were a novel invention, but their value in locating bullets and shrapnel was rapidly recognized, and they were quickly adopted by military hospitals.

The X-ray tubes at the disposal of hospitals of the time were primitive: a cathode and anode fashioned from metals such as tungsten, separated in an evacuated glass flask and driven by the electricity from an oil-powered generator.