Michael Crichton - Five Patients

He gave the films to the radiologic resident, who put them up and dictated: "Unit number zero zero six, AP and lateral of the left forearm. There is a transverse fracture of the radius in the distal third, as well as the ulna, period. Numerous fragments of bone are scattered around the fracture site, period. Considerable soft tissue swelling…" Here he stopped, realizing Hussey was impatient. "Chest film normal," he dictated, and gave them all to Hussey, who returned to the patient and supervised his transport to the operating room on the third floor.

It was now six o'clock. The operation was scheduled for 6:15, at which time on the OR blackboard was written:

KM 7 PVT. SERVICE SEVERED ARM MONCURE/CHANDLER

In the operating room, Dr. Brian Dalton, the first of three anesthetists who would work during the six-hour procedure, was administering an axillary block, injecting lidocaine (a novocaine-like drug) deep into the armpit, to dull, during the preparation, sensation in the nerves that ran out to the hand. While this was being done, Moncure discussed the operation: "What we're going to do here is stabilize his bones, and then deal with soft tissues as need be. I think we'll find a lot of crush damage to muscle bellies, particularly flexors, but intact vessels and nerves." He observed that while clinically there was questionable nerve damage, a crush injury could produce this without any actual cutting of nerve fibers; under such circumstances the damage was probably fully reversible.

At 6:10, while the axillary block was being administered, Hugh Chandler, the orthopedic surgeon, arrived and looked at the X rays. He said that he would stabilize one bone, the radius, and worry about the other, the ulna, later. Moncure was outside the OR, scrubbing according to the MGH version of the ritual: three minutes of washing to the elbow with a hard bristle brush, using orange sticks to clean under the nails, followed by a dunking to the elbows in an alcohol-germicidal solution. When he finished his scrub he came in, put on a pair of sterile rubber gloves, and began to wash the arm with a safety soap and alcohol. The nerve block was beginning to take effect, and it was possible to move the arm less gently without hurting the patient.

The patient was still awake, but dazed. He stared at his arm curiously, as if it did not belong to him. Moncure asked him how it had happened. Peter Luchesi explained that he had been working in a private shipyard and a boom had fallen on him. It weighed seven hundred pounds and it had struck his shoulder glancingly, knocking him overboard. But as he fell, the boom had somehow landed on his hand, leaving him dangling over the side, with his hand pinned down. This was just after lunch. The other workmen were not on the boat, so Luchesi had managed to get back up on the deck alone, and attempted to lift the boom. He could not do it without help. Fifteen minutes passed before the others arrived and were able to lift the boom.

He delivered the entire story in a monotone, while he stared at his hand. Moncure asked him how it felt now, and he said it was beginning to hurt again. As the surgeons began to drape the injured arm with sterile cloths, which entailed considerable manipulation of the hand, he complained more. The axillary block was not working well. With all preparation made, now was the time to produce general anesthesia.

Dalton, the anesthetist, leaned over Luchesi and said: "I'm going to put this mask over your face. You'll breathe only oxygen. Then I'll give you an injection that will make you fall asleep. Don't worry about a thing, just breathe and relax."

Luchesi nodded. The mask was put over his face and he breathed, staring up at Dalton, who proceeded to inject pentathol intravenously. Luchesi blinked once and closed his eyes. He was sleeping soundly, but would continue to do so for only a few minutes. Then he would wake up, unless more pentathol, or a different anesthetic, was administered.

Luchesi was fed pure oxygen for several moments, to be sure he was fully oxygenated. Then Dalton injected succinylcholine, a substance that paralyzes the entire body-including respiratory muscles-briefly. He removed the mask, opened the mouth, squirted a jet of cocaine down the throat to anesthetize the windpipe and prevent reflex coughing, and slipped a tube down the mouth into the windpipe. This provided a direct channel from the mouth into the windpipe and lungs, and prevented a major cause of death from anesthesia, namely, vomiting up of food from the stomach and blockage of the windpipe with this material.

The entire process of intubation took only a few seconds. Once intubated, Luchesi was fed oxygen and nitrous oxide, a mild anesthetic. Alone, nitrous oxide would not provide sufficiently deep anesthesia to permit surgery, but the axillary block was also helping. When it wore off, halothane, a more potent gas, would be added.

The operation began shortly before seven. There were seven people in the operating room at that time. Five were scrubbed: Moncure and Chandler, sitting on one side of the outstretched hand; Dr. Charles Brennan, an orthopedic resident, and Steven Kroll, a medical student, on the other side; and the scrub nurse, standing with two trays of instruments at her fingertips. Also in the room but not scrubbed were the anesthetist and the circulating nurse.

Around the hand, it was tight quarters. The scrub nurse first pinned sterile towels across the backs of Moncure and Chandler; this was because the upper-most portions of their backs, where the sterile gowns were tied, were unsterile, and she did not want to touch them by accident.

In general, the operating room is divided conceptually into "clean" and "dirty" areas. The operative field, meaning the exposed area of skin which has been shaved, scrubbed-and generally covered with plastic-is clean. The rest of the patient, covered with sterile drapes, is dirty. The fronts of the surgeons are clean; their backs are dirty. Anything above the level of the table is clean; anything below is dirty, and surgeons never let their hands fall to their sides. Hands, scrubbed and rubber-covered, are clean; faces, capped and masked, are dirty, and it is poor form to get one's face too close to the operative field or to touch one's mask with one's gloved hand.

The first incision was made over the underside of the wrist, just back from the thumb. The object was to find and locate the radial artery in that area. Moncure and Chandler discussed their procedure as they went, and agreed to find and evaluate the principal structures first: the radial and ulnar arteries, which run toward thumb and little finger respectively; the radial and ulnar nerves, which run with the arteries; and the median nerve, which enters the hand at mid-wrist.

As they began work, they found that the crush injury, with its hemorrhage and swelling of tissues, made identification of structures difficult. Five minutes into the operation, the radial artery was accidentally nicked. A fine, thin stream of blood spurted up in a foot-long arc. This was quickly clamped, and Moncure sewed it up with a small needle, perhaps no larger than twice the size of a typewriter parenthesis mark, and the operation proceeded. Moncure isolated the radial artery for a distance of several inches through the wrist. Everyone commented on the fact that pulsations through the artery were not as strong as they would like. The artery was flushed with heparin to prevent clotting further along its course in the hand.

At 7:20, Dr. Leslie Ottinger, another surgeon, entered the operating room. He had been working next door in OR 8 for six hours, repairing a crush injury to a man's thigh. Moncure, without looking up, said to Ottinger: "Were your vessels intact?"

"No," Ottinger said. "The femoral artery and vein were completely crushed. They were separated by three centimeters." "How's he doing now?" "Fine," Ottinger said, "if he stays open." He watched the dissection of the hand for some moments. "You find the radial artery yet?" "We nicked it," Moncure said. "Well, that's a good way to find it," Ottinger said, and left.