Extreme Medicine (11 page)

Bailey, it seems, was driven by something more than simple ambition. As a twelve-year-old child, he witnessed his father dying in his mother's arms of heart failure, breathless and coughing up bloodstained sputum. In his eyes, an operation that could spare someone that fate was worth all that he and his patients would suffer in its development. His Christian duty, as he saw it, was not to stop but to succeed.

It's worth remembering that these events were also a product of their time. The absence of formally organized committees to oversee medical ethics contributed to a more permissive, less well-scrutinized style of practice. But perhaps also the war, so fresh in the collective memory, altered the perception of acceptable risk. Arguably society was more willing to accept sacrifice in the face of a war, whether against military foe or disease. Whatever your perspective, if it wasn't for the dogged determination of Bailey, Harken, and their peers, the fate of the brave Claire Ward—and that of the many thousands of patients who followed in her footsteps—would have been very different.

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W
HERE DOES THE LINE LIE BETWEEN
innovative new therapy and experimentation? It is blurred at best, and pushing against the frontiers of physiology and medicine presents the physician with difficult ethical issues. Here the fate of explorers of the physical world departs sharply from that of our physician pioneers. Explorers risk their own lives; doctors risk only the lives of those under their care, making their endeavor easier and at the same time infinitely harder.

But it was in this way that the last great chasm in all of surgery was crossed: the yawning gap of an inch from the wall of the chest to the heart. The continent of the heart was finally open for exploration.

A
t the Battle of Waterloo, Wellington noticed a French doctor in the midst of combat, attending casualties and moving them quickly by horse and cart from the battlefield to the rear. Upon discovering that it was Dominique-Jean Larrey—chief surgeon to Napoléon Bonaparte—the British general ordered his men not to fire in the doctor's direction and, according to legend, lifted his hat in salute.

In medicine, the importance of speed has long been recognized. Larrey, present on the battlefields of the late eighteenth century, had witnessed heavy-artillery units wheeling and then retreating rapidly from the advancing enemy while casualties were left behind unattended. Only after hostilities ceased were the wounded collected and transported to field hospitals, introducing significant delays before definitive surgery could begin. And in an age of more powerful firearms and artillery, surgery often meant the amputation of more than one shattered limb.

For those soldiers whose treatment was delayed longer than twenty-four hours, Larrey noted that death was far more likely. His solution was to embed agile horse-drawn carriages with frontline troops so that the injured could be quickly carried from the field of battle during combat. Coupled with a rudimentary system of triage in which the casualties were prioritized according to the severity of their injuries, this innovation transformed battlefield care. Men whose traumatic injuries would have previously proven fatal were able to survive largely because of the speed with which they were attended. The system was first implemented in the closing decade of the eighteenth century, and its virtues were instantly recognized. Larrey's “flying ambulances” were soon adopted throughout the armies of France.

Of course ambulances wouldn't actually take to the air until well into the twentieth century. The first helicopter evacuations of casualties took place in World War II, and by the time the Korean War arrived, the sight of casualties being ferried through the sky to mobile army surgical hospitals—better known as MASH units—had become iconic. Helicopter evacuation of battlefield casualties continued to play a key role during the Vietnam War, dramatically improving the survival rates of severely injured soldiers. As a consequence, during the 1960s, civilian hospitals in the United States started to adopt these military solutions and began to use air transport to respond to trauma scenes—road accidents, shootings, stabbings, and the like.

A new goal had arrived. For the best chance of survival in the face of traumatic injury, it was understood that treatment should begin as soon as possible. The concept of the “golden hour” was introduced: the idea that after injury no more than sixty minutes should elapse before a patient received definitive care. The message was clear: Delays in the treatment of victims of trauma were no longer acceptable. By the closing decades of the twentieth century, the process that Larrey had started during the Napoleonic Wars had led to a revolution in civilian trauma care.

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I
N
J
ULY 1998, AFTER MY BRIEF
stint as a student intern in Washington, my colleagues and I stood on the steps of the medical school wearing capes, mortarboards, and smiles that were impossible to wipe from our faces. It was over; we had graduated. We threw our hats high into the air and the official photographer clicked away.

As newly qualified doctors, we moved into the Middlesex Hospital eight weeks later, twenty-four fresh-faced juniors, wide-eyed and terrified. We had studied for more than five years, endlessly learning and reciting the vocabulary and grammar that underpinned the art of medicine. We had learned the language well enough; there was no other way to pass the final exams. But starting work was a challenge on a different scale. It was like going to live forever in a country whose mother tongue you had only just started to speak.

In the first few days, we received instruction on everything from how to wash your hands to the correct way to complete a death certificate. They crammed the pockets of our long white coats with handbooks and then shoved us out onto the wards. For all of our training, we were, at the beginning at least, worse than useless. We were guided not only by our senior medical colleagues but by nurses, ward clerks, and hospital porters—all of whom, at that stage, knew far more about our job than we did.

Most evenings those of us who weren't on call retired across the road to the Cambridge Arms. There were better pubs, but to the exhausted house officer, this one had the virtue of being closest. We would drink too much, share the stories of the day, and laugh at one another's most recent misfortunes and breathtaking displays of ignorance.

We quickly discovered that most of the job wasn't about life and death. Too much of it revolved around filling in forms and organizing the list of patients. As the team's most junior doctor, your job was to keep a faithful inventory of the patients in your care and their medical complaints, guiding your senior team around from bed space to bed space so that they could bring their experience and knowledge to bear.

Still, there were rare, terrifying occasions when you were temporarily alone—usually in the middle of the night, standing at the bedside of a blue and breathless patient. Knowing immediately that they were sick and that you didn't have the skills to stop them from crashing, you picked up the phone and called for help. After the phone went down you had a few hundred seconds of responsibility: a brief opportunity to make a difference—or at least to hold the line and prevent things from getting worse—before the cavalry arrived. This was how all of the emergencies were supposed to work. You were little more than a sentinel: responsible for summoning a much more capable team to confront something beyond your abilities. Complex, rapidly evolving disease that threatens the life of a patient demands a swift and definitive response. The world of medicine has come to understand that trauma is precisely that: a complex, fast-moving disease.

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A
S A STUDENT, I LEARNED THAT
trauma
derives from the Greek word for “wound.” In the world of medicine, it refers to injuries sustained as a result of violence or accident. That pair, violence and accident, are as ancient as the species itself. To the noninitiate, the mechanism by which they compromise the function of the human body looks as though it should be easy to grasp.

Trauma is, after all, not the result of a bacterium invisible to the naked eye or a virus that subverts biology at the molecular level. It is not like heart disease, in which unseen plaques of cholesterol lurk in the fat-laden vessels of the coronary circulation, nor is it like cancer, in which some arcane malfunction in the script of our DNA leads to the unstoppable division of a cell and its eventual invasion of our vital organs.

When you're first introduced to the specialty of trauma, it is a relief to encounter a disease entity in which the link between cause and effect appears absurdly clear. In your imagination, it is little more than the transfer of energy to a mechanism and the disruption of its vital structures or the rupturing of its fuel lines. Only, like everything else in medicine, under the magnifying glass, it turns out to be brutally complex.

Still, your first foray into the specialty of trauma is deceptively straightforward. “Keep the oxygen going in and out; keep the blood going round and round” remains the mantra. The familiar Boy Scout, ABC priority list is the first step: Fix the Airway first, then Breathing, and last, Circulation.

There are subtle modifications. While clearing and opening the airway, you have to pay attention to the spinal column. The bones of the spine—the vertebrae stacked carefully on top of one another—form a hard but flexible hollow tube that protects the bundles of nerve fibers running in the soft tissue of the spinal cord. If this bony armor has been damaged, then the cord will be vulnerable to injury, and waggling the neck around is likely to damage those nerve fibers and sever their connections, leaving the patient paralyzed in all four limbs. For the traumatically injured, protection and immobilization of the spinal column high in the neck are deemed as essential as the letter A in the list of ABC priorities.

Then, after having dealt with injuries threatening the Breathing or the Circulation, you're taught that in trauma the alphabet goes a little further than C. There is a D and E to look after too. D stands for Disability and is a way of making you remember to look for signs of injury to the spinal cord by making sure that the power in the muscles and the sensation in the body's extremities remain intact. The E is for Exposure, and is an aide-mémoire to make sure that you have looked from head to toe for hidden injuries. Casualties lying on stretchers have been known to bleed to death from small, penetrating wounds or scalp lacerations hidden from frontal view. This is why trauma teams unceremoniously shear clothing from victims and then roll them naked onto their side.

Confronted with the worst traumatic injuries, it's easy to get distracted and miss easily treatable but potentially fatal injuries. The ABCDE approach is a tightly honed protocol, designed to offer a systematic approach to trauma that stops casualties from dying of precisely such oversight. Properly adhered to and executed, this system, dubbed the Advanced Trauma Life Support protocol, will get you through the worst five minutes of even the most horrific trauma case.

At least that's the idea.

—

I
N THOSE FIRST FEW MONTHS,
we became marginally more competent and much less scared of just about everything. We got used to being exhausted, because the worst weeks still ran to over a hundred hours. We lived and worked in the same building. Our dorm rooms lined a corridor on the fourth floor. Though we tried to make them feel like home, with scattered posters and plants, they were little more than a place to sleep.

Weekends, we'd make a break for freedom. On a Friday afternoon, if you weren't due on call, you got yourself out of the hospital as fast as you could. Those who remained, holding the pagers and covering the emergencies, looked on with envy as colleagues fled the building.

On Friday, April 30, 1999, it was my turn to be on call with the surgical team. It was the start of a bank-holiday weekend, which served only to accelerate the usual exodus. I stood at the rear entrance of the Accident and Emergency department dressed in hospital greens, watching the ambulances come and go.

The A&E was windowless and always looked the same. Open twenty-four hours a day, every day of the year, it was constantly illuminated by flickering fluorescent tubes and the glow of the X-ray boxes. Inside, the whirling hands of the clock on the wall somehow didn't give you a proper sense of the passage of time. We gathered in the quieter moments at the rear entrance to the hospital, with its less than spectacular view of the car-park asphalt and the subtle aroma of ambulance diesel, to catch sight of the fading light or breaking dawn.

It was a fine and unusually warm evening. By half past six, all but the most essential staff were gone. The department was quiet, and the casualty waiting room nearly empty. People drawn out by the good weather were packed into pubs and bars throughout the city and well on their way to being drunk. The injuries—the usual catalog of assaults, road accidents, and ankles turned on cobblestones—generally followed later, after people were kicked out onto the streets. I turned back into the department.

On the wall next to the nurses' station was the red phone, an old Bakelite thing with a dial. It took only incoming calls and rang with the old-fashioned trilling of a real bell. It was there so that the ambulance service could call ahead and tell us if they were bringing something bad in, giving us time to assemble and prepare in the big resuscitation bays at the back.

Just before a quarter to seven, the red phone rang. Alex, the nurse in charge, listened intently, scribbled some details, and put the handset down. Usually a pithy case summary about the imminent arrival of a single patient would follow: a heart attack, a massive drug overdose, or perhaps a stabbing. The department was set up to tackle these blue-light emergencies without breaking its stride. A small team would peel off into the crash rooms and get on with the resuscitation while the ingrown toenails, superglue accidents, coughs, and colds continued to stream in through the front door.

But this call was different. Alex raised her voice to make herself heard. There had been a bomb, she told us, in a nearby pub in Soho. There were many casualties. A major incident had been declared so that we could prepare to receive casualties. That was all the information we were given.

We all stopped for a moment, trying to digest the news. Then the sound came, with heart-stopping strangeness, of every pager in the hospital bursting into song simultaneously. A machine-gun succession of monotone chimes was followed by the crackling of the pagers' tiny loudspeakers. “Major incident declared,” came the slow and deliberate voice of the switchboard announcer, and then again: “Major incident declared.”

The trauma team assembled in the crash rooms: a surgical registrar, a senior house officer, and me; our consultants were already on their way back to the hospital. The red phone rang again. There were many people injured and some trapped. The ambulance service was asking for a mobile team of doctors and nurses to go out to the scene.

The surgical registrar didn't want to lose surgeons who would likely be needed to run the resuscitation bays or assist in operating rooms. I, on the other hand, could be spared.

The mobile team was comprised of three doctors and three nurses. The accident and emergency nursing staff, familiar with the major-incident drill, manhandled us through the preparations. I was pushed into an equipment room that I had never before noticed. I found myself pulling on a fluorescent suit and donning a hard hat. A trauma pack, full of equipment and drugs, was shoved into my hands. And then I was being ushered out into the ambulance parking bays. Before anything more could be said, a pair of ambulances screamed into the parking lot and flung their rear doors open. The six of us climbed inside.