It’s July. For me, that means the end of another academic year in residency. Most residencies are three years long, and that means that around half the people I went to medical school with graduated residency last week, and are moving on to working in their own practices, taking their first jobs as fully-fledged physicians. In Emergency Medicine, about 2/3 of the programs are 3 years long, and the rest, like mine, are 4 years.

I’m a senior resident. My final rotation of third year was on Life Flight. It was one of those gigs where you sit around for hours at a time, kicking your heels and bullshitting with the crew, until the call comes, and once it comes, you’re on. All in, laser focused, working hard. You make judgement calls and decisions based on the best information available to you, and hope that you’re right.

courtesy of @kevinquickphotography

We had one call where a gentleman had somehow flipped a piece of heavy machinery and was intubated, and he had a spinal cord injury, and they were worried about bleeding in his brain. I remember completing his exam, he had diminished breath sounds on the right hand side, but I didn’t get a copy of his chest x-ray in his folder. He’s a big guy, and we don’t carry some of the stronger drugs on the aircraft, because of refrigeration issues, so we are fighting to keep this guy sedated in the air. Suddenly, his ventilator starts alarming that the pressures are too high, and he’s not getting enough volume. There are lots of things that can cause this, like kinks in the line, vomiting, anything that raises restricts airflow in the circuit.

I check the tube and the line, and everything is connected and unkinked. I turn up the driving pressure, but it’s still going, and he’s barely getting 150 cc’s of air each breath. The pressures are in the 60’s, which is high enough to blow a hole in a lung as soon as think about it.

I drop a tube into his stomach and suction the junk out. This helps, but only for a minute. I unhook him from the vent, check everything again, and reconnect him. Still high pressures. And then I check the tube. It has a balloon at the end that gets inflated to hold it in place on the other side of the vocal cords. I can’t see that balloon, but it’s attached to a small hose that protrudes from the mouth at this end, which is where we inflate and deflate it from. That hose is bulging. The pressure is from somewhere inside his actual chest and not his belly, enough pressure to squeeze air backwards out of the balloon and upstream into this hose.

If he was coughing or vomiting, the pressure would let up intermittently. It doesn’t. The only other thing that I can think of is that somehow this guy collapsed his lung, and the air we are blowing into him is getting trapped. That trapped air can compress his other lung, and eventually, his heart.

Normally, in the ER, I would put my stethoscope on his chest and listen. If he had no breath sounds on that side, awesome! I’d have an answer. But in a helicopter, my stethoscope is worthless against the thrumming sound of chopping rotors. We have an ultrasound, but it’s buried under other equipment behind the bolted seat of my flight nurse, and we wont be able to dig it out before we land, much less in time to make an informed decision about whether or not to make a hole in this guy’s chest.

I could tell you all the things that I considered in that moment that he was thrashing, his oxygen dangerously low, and the ventilator flashing angry red lights, punctuating warning sirens I knew were sounding, but that I’d never hear over the din of our transport.

I could tell you that I weighed the cost of being wrong. What if I put a needle in his chest and the lung WASN’T collapsed? What if he is really just coughing, and I shove a 4 inch long needle the size of a tire gauge into this guy’s chest? What if I’m missing something else?

But I had checked everything else.

And so what? What if I WAS wrong? I put a hole in his chest and he didn’t need it. Maybe he bleeds a little. Maybe he leaks a little air.

Compared to what would happen if I was right? If his lung was collapsing and he didn’t get the needle, that would be it. The end. Squish all the blood out of his heart by pumping air into the space around it until it’s too tight to fill up anymore.

I felt down to the third rib right in front of his chest on the right side, because that’s what had been diminished on my exam when I could hear him. My flight nurse and I eyeballed each other, her pushing sedation meds to try to keep him calm with that breathing tube in his throat, and I plunged this needle right over the top of the rib into his chest cavity. I left the plastic tube in place and pulled the needle out, and felt the top of the hub with my finger as air pushed against it.

I checked the vent.

Volume of 310. Not the 500 this huge guy needs, but better.

I watched the squiggly line tracing the air moving through his breathing circuit as his next few breaths got deeper and the airway pressures dropped back below 40. Still high, but we were almost at our destination.

He calmed.

We landed.

The receiving team when we rolled into the trauma center eyed the needle hub skeptically.

On television, doctors always eventually figure out what’s wrong with a patient, piecing together their history and tests until the puzzle makes a perfect image of the illness.

My life isn’t like that.

I still don’t know if I was right. I don’t have access to the computer systems at the trauma center and I can’t look up his chart to see if he had any evidence of a collapsed lung.

Sometimes that’s the game in my world. I won’t have an actual answer, and I have to use the information I have at my disposal to make the best decision I can.

We also have to weigh the likelihood of a bad outcome against the cost and inconvenience of a major workup. Some ER doctors order lots of tests and are very aggressive about investigating diagnoses. Some ER doctors would rather a patient wait and see what happens, instead of ordering a battery of tests right away.

This year, I have to start to figure out what kind of an ER doctor I am.

And, as daunting and humbling as that task seems, I’m looking forward to it.