Recently, I was on call for surgery at a hospital in New York City. At 2 a.m. in the morning, we were paged to a trauma in the ED. After we stabilized the patient and moved him for CT scans and x-rays, I noticed a small stretcher tucked away in the back part of the ED, a place typically reserved for overflow patients when we run out of rooms.
The patient in the stretcher was a well-appearing, 27-year-old male who appeared to be in no acute distress. Except for a small, 3 cm laceration on the back of his head, the patient did not have any other apparent injuries and continued to vigorously tap away at a cell phone game. At first glance, the patient appeared stable to me, even though a small pool of blood had collected on his sheets. I thought, “He does not require close monitoring so that’s probably why his nurses placed him back here.” I quickly took a mental picture of the patient and refocused back on the trauma patient at hand.
Twenty minutes passed before I saw the patient again. He was still glued to his cell phone game, but this time I noticed the pool of bright red blood had expanded down to his back and knees. I moved a little closer behind him to examine the laceration at the back of his head and it was pulsating blood. A coagulated pool of blood had formed between the laceration and his cervical collar, and it was apparent to me that he had been bleeding out this entire time. When I asked him what brought him into the ED and how he felt, he retorted, “I just bumped my head on the stairs. I’m fine!” and continued back to the cell phone game.
As a third-year medical student, we are considered to be the bottom of the totem pole in the hospital. After spending the first two years studying for our Step 1 boards, the only clinical medicine we know comes from what we have read and heard about in books and lectures. Our questions are frequently met with laughter or are berated for lacking common sense. And in the fast paced world of the ED, nobody has time to answer stupid questions. “His nurse probably knew he had a head laceration,” I reasoned . “There’s no need to alert anybody. He’s not even my patient. The ED staff is more than capable of handling this.”
A minute passed. And then another. Nobody came by to see this patient, who continued to bleed. I hesitated against speaking up, since we were in the middle of a trauma. But I couldn’t wait any longer. I asked an ED nurse if he was her patient. “No,” she said before hurrying off. I told another nurse that a man was actively bleeding and he said, “Go get his nurse!” After a few more failed attempts, I had had enough and pulled aside my resident. “I think this man has been bleeding profusely for some time. What should we do?” His eyes widened as he saw the amount of blood that had soaked into the sheets. He reached for a pair of gloves and told me, “Get a suture kit, now!”
I hurried off to the supply closet and came back with a bunch of supplies. The patient was now writhing in pain as we dug around with our fingers inside his wound, trying to locate the bleeding vessel. We liberally injected lidocaine before exploring deeper with pickups and clamps. I tried to dab away the blood so that we could see into the laceration, but blood instantly filled the cavity. We couldn’t localize the source of the bleeding and our attempts to blindly clamp the vessel were met with frustration. Anytime we thought we stopped the bleeding, blood would spontaneously squirt out, like water spewing from a compressed hose. When the blood splashed up against our glasses, my resident and I looked at each other and knew we needed more help.
We wheeled the stretcher out of the back corner and into the trauma bay where we applied Yankauer suction into the wound. This helped us visualize the lacerated artery quickly. We clamped the vessel to stop the bleeding and tied it off with sutures. Given the amount of time he went unnoticed, we estimated that that patient’s estimated blood loss was anywhere from 500-1000 mL and gave him IV fluids to help replenish his intravascular volume. When the chaos had settled, a very surprised ED attending entered the bay. “He was playing on his cell phone just a few minutes ago!” she exclaimed. She thanked us for our work and my resident commended me with a quickly muttered, “Good job.”
Our collective gaze turned back to the patient, who was clearly exacerbated from the ordeal. “How much more would he have bled out if I had not said anything?” I speculated. “And how could a patient go unaccounted for that long in a Level 1 trauma center?” Surprisingly, this is not unheard of. Earlier this year in January, a 30-year-old man died in the ED waiting room of St. Barnabas Hospital in the Bronx after going unnoticed for more than eight hours. Like this hospital, St. Barnabas Hospital is also a Level 1 trauma center with facilities capable of handling the most severe injuries, let alone a small head laceration.
How could something like this happen in this day and age? Simply put, hospitals don’t have enough staff to take care of the number of patients it sees in a typical day. Everyone knows this but little is done about it. With millions of newly insured people under the Affordable Care Act, it is estimated that by 2025, the United States will be short 130,600 doctors. We often solve this problem by working residents long hours. Many will sometimes be up for well over 24 hours before signing out from work. I’m often asked by my friends outside medicine: “How is it okay for someone to be operating and treating patients for so long, on such little sleep?” Honestly, I never have a good answer to this question. I don’t know how to solve this problem in the long run, but I think I know how to alleviate it on a small-scale basis.
If we are going to be short on the number of doctors, we must demand the best out of the few that we have. I may be in the nascent days of my career, but in my short time on the wards, I have learned that combining small skills and following through on the little things can help make anyone a more effective physician.
1. Be diligent and meticulous. Hundreds of people are employed by hospitals to ensure that it runs smoothly, but orders are often lost when passed from person to person and EMRs can be faulty. As a physician in charge of someone’s care, we are responsible for everything that happens to the patient, even if we are not directly completing the task. Follow up on blood work and labs that are sent off. Verbally communicate orders to nurses and make sure they repeat it back to confirm receipt. Check and re-check.
2. Always make yourself useful. Use all your time to be doing something. In the operating room, we are often taught to keep our hands busy in order to make the attending surgeon’s job easier. Check up on your patients when you can. If you have some downtime, write notes and place orders. If you know that a task will need to be done later, try to complete it ahead of time. And most importantly, don’t forget to eat, sleep, and take care of yourself.
3. Be vigilant. We need more vigilant people to become health care providers. I would encourage anyone who is observant and those who take in their surroundings well to consider a career in medicine. A good physician uses all of their senses to pick up information. Sights, sounds, touch and even smells can tell you much about a patient’s well-being even before a scan or study. (Thankfully, taste is no longer apart of this.)
4. But most important: No matter how small you may feel, always ask good questions and be unafraid to speak up. Don’t ask questions that you can Google or ones you already know the answer. This will just annoy people or even worse, feed your ego. But speak up if you are uncertain or don’t understand something. The learning curve in medicine is extremely steep and you will never learn if you don’t speak up. You never know — you may save someone’s life in the process.
Information from ABC7 New York, WHO, and AAMC were used to complete this article. Specifics and identifiers have been slightly altered to protect patient privacy.
Andrew Ho is a medical student.
