It happened one wintry night in 1965. I was in my third year of medical school during a rotation on the pulmonary service.
My supervising intern had been busy all evening admitting a dozen people in various stages of respiratory distress; they were suffering from ailments ranging from flu to double pneumonia.
It was my job to collect each patient’s sputum and culture it on a Petri dish, which would take several days to grow out. I also prepared stained slides of each sample. We did this in hopes of being able to visually identify the offending bacteria, so that we could speedily administer the appropriate antibiotic.
This was painstaking work: the intern and I had to repeatedly re-check the patients who weren’t improving. Every few hours, we’d return to listen to their chests, assessing the progression of their pneumonia. Then we’d check our findings against X-ray pictures, adjust their antibiotics, collect and look at their sputum specimens again, and wait for them to get better.
Slowly, most did. But I found the testing and re-testing tedious and unsatisfactory, as its results were incremental, subjective, often subtle and hard to measure.
At about midnight, a patient was admitted in severe respiratory distress. A large, blowsy, faded-blonde woman in a flowered housecoat, she was gasping for air. Even though she was taking large breaths, she couldn’t get enough oxygen; she visibly tired and turned bluer even as we examined her.
A quick listen to her chest disclosed normal lung sounds on the right side, but silence on the left. A chest X-ray confirmed our suspicions: a collapsed left lung. Air was escaping from a burst blister on that lung’s surface. As it filled up her left chest cavity, it was simultaneously pushing the woman’s heart and great vessels to the right and compressing her left lung so that it couldn’t re-inflate.
The left chest cavity needed to be emptied of this air at once. The intern put in an urgent call to the surgical resident on duty.
A few minutes later we heard the squeaking wheels of the surgical cart as it approached, pushed down the dimly lit corridor by a robust nurse.
She parked the cart at the foot of our patient’s bed, undid a tray of instruments, positioned the woman in a semi-recumbent position with her left arm over her head, and painted an eight-inch circle with an alcohol swab on her chest, all the while speaking reassuringly in a soft, clear voice.
The surgical resident emerged from the shadows and walked into the circle of light cast by the portable operating lamp.
His pristine, starched white uniform and standing collar made me feel conscious of my limp, somewhat soiled white jacket, its pockets stuffed full of instruments and treatment manuals.
The resident bent over the patient and briefly listened to her chest, then spoke slowly and directly to her.
“You have a tension pneumothorax. It limits your ability to breathe. I will place a small tube into your chest cavity, which will release the tension and let your lung expand normally.”
With that, he turned to the nurse, who placed sterile gloves on his hands.
After injecting a local anesthetic, he made a one-centimeter skin incision just below the patient’s armpit. Holding a trocar (a sharply pointed instrument inside a hollow tube) in his right hand, he felt for a space between her ribs with his left index finger. Then, in one swift, smooth motion, he thrust the trocar between the patient’s ribs into her chest cavity.
There was a hiss of escaping air, and a startled cry from the patient. Almost immediately, her breathing grew easier.
The resident stitched the chest tube into place as the nurse connected it to a suction apparatus.
Peeling off his gloves and placing them on the cart, the resident spoke to the patient again: “This will allow you to breathe better and rest easy. In a few days, after the lung heals, I’ll remove the tube.”
With that, he turned and walked away.
Silently, the intern and I watched his white-clad figure recede down the empty corridor. We noticed that the scrub nurse was smiling as she gathered the instruments and reassembled her cart.
At that moment, I knew that I would become a surgeon.
About the author:
George T. Saj practiced medicine and surgery for nearly forty years. He served as director of surgery and president of the medical staff at Mountainside Hospital in Montclair, NJ, and a governor of the American College of Surgery, keeping a journal all that time. “Reading it now, I’ve discovered that there is much to learn from the retelling.” Since his recent retirement, he has devoted his time to writing and sculpture (georgesaj.com).