Deep Trauma

Later that evening, as Riley was on her way to the locker room to change out of her scrubs and head home, she ran into Hudson. The intern had come back to the ER from the operating rooms, he told her, to give an update on their GSW patient.

She remembered the long, tedious days of internship and felt a pang of empathy for him. The dark circles under his eyes told a story of their own, and when he reported that the patient was in the ICU recovering from surgery in stable condition, he did so without any spark of satisfaction.

“Thanks for the info,” Riley offered, but the way he stalled in the hallway, not making any move toward the exit, made it clear he wasn’t finished. “Was there something else, Dr. Hudson?”

“Well . . . yes, actually, ma’am, I also wanted to thank you for your patience with me earlier, Dr. Brighton,” he said, his eyes finding the floor. “Sorry for being—”

“We’re all a work in progress, Hudson,” Riley broke in. “I accept your apology. I believe you thought you were doing the right thing by asking me to wait for your chief to arrive. As a medical student, you were no doubt a victim of the Hippocratic oath. The ancient edict of ‘first do no harm’ isn’t as straightforward as it sounds. I do understand your reluctance about my plans to put in a chest tube without an X-ray—never mind.” She cut herself off when she noticed his eyes glaze over with fatigue. “Come with me, Hudson. There’s something you should see.” She led the way down the hall to the radiology library.

A moment later, they both stood in a darkened room as she pulled out an old chest X-ray from its oversize cardboard envelope in a locked drawer and slipped it onto the lighted viewing box for him to examine. The film had been taken five years earlier on a trauma patient just like the one they had treated that afternoon. A twenty-three-year-old man with a gunshot wound to the abdomen.

“Take your time,” Riley said, studying Hudson’s face while he, in turn, examined the X-ray. His eyes swept over the film methodically, first from top to bottom and then from left to right, tracing every line. “When you’re finished, list everything you see wrong with this picture.”

Riley leaned her elbows on the counter. She couldn’t wait to get out of her grimy scrubs and go home, but the spark she saw growing in the intern’s eyes made the delay worthwhile.

“Well, for one thing, the obvious findings include a metallic fragment in the soft tissue of the upper left chest wall.” He turned to her. “It’s probably a bullet or bullet fragment. And then, number two, there’s a pretty significant pneumothorax—the left lung looks almost eighty percent collapsed. And thirdly, the patient’s trachea is deviated significantly from the midline, indicating that this is a tension pneumothorax.” He stepped back from the film, seemingly satisfied with his answers. The light from the viewing box reflected off his rectangular glasses, giving him a somewhat robotic appearance as he waited for Riley to confirm his observations.

“You’re not wrong, Dr. Hudson,” she said, choosing her words carefully, noting he had grasped only the lowest-hanging fruit. “Those are three important findings on this film, and in your words, they are ‘obvious.’ But there’s a fourth, more critical issue, that we’ve missed. And this one might surprise even a seasoned clinician.” She waited a moment before adding, “The most significant problem with this X-ray, Dr. Hudson, is the fact that it was taken at all. Tension pneumothorax is a dire emergency, one that will kill a patient in minutes. It should be diagnosed solely on physical exam. Unfortunately, in the time it took to obtain a chest X-ray on this young man, he died a painful and unnecessary death.”

Before she could finish, the intern was cupping his face in his hand; her message on the hazards of analysis paralysis had seemingly found its mark.

“So, you see, Hudson, ‘first do no harm’ is not a decree that we, as physicians, shun all potential hazards. When the stakes are highest, we may need to take the biggest risks. And the truth, the hard truth, is we will make mistakes. That’s the burden we carry along with the awesome privileges we are entrusted with every day.”

The intern stood frozen, staring down at her in silence. She wasn’t sure, but Riley thought she saw a glimmer of tears building behind his glasses. She’d seen it a thousand times before in medical trainees. In like a lion, out like a lamb.

 Teaching was hard. Learning was harder.

“It took courage to question my decisions today in the middle of an emergency. That’s an admirable quality in an intern, and one that makes you an ethical patient advocate. Go home now, Dr. Hudson, and get some rest. We’ve all had a big day.”