A flair for the traumatic

For a split second, the room is totally still.

All eyes – and there are a lot of them: nurses, doctors, techs, an EMT standing just off to the side – are trained on Heather Evans, M.D. On the table in front of the seasoned trauma surgeon is a young man with a gunshot wound to the chest. His body is motionless. There is no breathing. No heartbeat. CPR does nothing. So she plays the only card she has left. She cuts him open and begins giving him compressions. Directly on the heart.

Her lips don’t move, but the rhythmic motion of her shoulders seem to count out loud.

One. Two. Three. Four. Five. Six.

And she brings him back.

 

They’re all moving again now. Talking. Shouting. A nurse calls for an IV bag. Monitors in the corner chirp their computerized cries for help. 

Evans hollers to a resident to take her place – “Put your hands right here – where mine are,” as they wheel him toward the elevator, away from the Emergency Department. A cluster of nurses and doctors cram in, encircling the patient as the doors close. “Push the 4! Push the 4!” The elevator complies, rapidly ascending to the surgical trauma OR. 

It’s 5:52 a.m., and Evans has been on her feet for 14 consecutive hours. There’s been a car crash, a ladder fall, a drunk man who picked a fight with a plate-glass window. The only thing Evans hasn’t seen during this shift is sleep. 

Welcome to the dice roll of the on-call trauma surgeon: Sometimes it’s oddly quiet. Sometimes it comes up snake eyes. 

“This job is beyond crazy at times,” she admitted later. “But days like this – when we get the opportunity to fix people, to save lives – these are what we live for.”

Working hours

4:13 p.m. The day before. 

Evans walks into her office on the fourth floor of the Clinical Sciences Building at MUSC. She talks on the phone to her boss as he brings her up to speed on cases that await her. She fiddles with the collar on her shirt as she stares out the window, listening.

 

“Mmm hmm,” she says. A pause. A laugh. A frown. Evans makes faces that would put a mime to shame. Another “Mmm hmm.”

She drops her shoulder bag on the chaise lounge – what is sometimes generously referred to as her “bed” on evenings when she does an on-call shift – and sighs deeply. 

Not even five steps into her office and her day has already started.

Surgeons often joke about the concept of “working hours.” The reality is their jobs never really have a clean starting and stopping point. They don’t have the luxury of hanging up a “Sorry, we’re closed” sign in the window. That’s because life never takes a break. Humans make mistakes. They text while driving. Try to make that unmakeable jump on a dirt bike. Start a fight over a girl. And accidents happen. Some minor, some severe – but all are important to the people they happen to. 

So the word “downtime”? It doesn’t apply to surgeons. 

As Evans finishes her call, she fires off a quick email, dons her white lab coat – a stark contrast to her navy blue scrubs and trademark lime green Birkenstock polyurethane clogs – and strides out the door toward the surgical trauma intensive care unit, or STICU. It is here that she will link up with colleague Cynthia Talley, M.D., to talk through what’s in store for her and her team over the next 17-plus hours. That’s assuming nobody new comes in – an assumption that is scrapped less than two hours later. 

Decisions, decisions

According to the National Center for Injury Prevention and Control, trauma is the leading cause of death for people under the age of 45. In the United States alone, it accounts for more than 150,000 deaths. In other words, Evans and her colleagues have their work cut out for them.

Her first stop today is Bay 12, the temporary home to a car crash victim from the day before. While driving home from a visit with his mother, he was hit broadside by a motorist running a red light, sustaining multiple spinal fractures, a pelvic fracture and a head injury. His eyes are closed, and he lies motionless – his head immobilized with a hard cervical collar. Evans and four other physicians huddle nearby.

 

With a stack of papers in her left hand, Evans says, “We need to figure out what’s going on with his platelet count,” mindlessly clicking her pen with the other. She orders a host of tests and then tells the resident closest to her: “Text me when you know his tally.” 

And just like that, she’s off.

 

As she crosses the hall that bisects the STICU her phone pings. She’s on her way to Bay 2 to check in on a patient who was admitted 48 hours earlier – the victim of a robbery gone wrong. She puts the phone to her ear and says her name – just her last name – and listens. A long pause, then one of her signature faces. “Bad idea,” she says resolutely.

It’s an elderly patient with renal failure at another hospital. They want to transfer him to MUSC Health. “We can’t risk moving him,” she tells them. Even though MUSC Health would be able to give him more specialized care, she said later, the transfer might be more than he can handle. This will be one of about a dozen or so difficult yet snap decisions Evans will have to make over the course of her shift.

She’s barely had enough time to put the phone back into her pocket when it makes another sound – slightly different this time. She looks down at the screen. It’s a trauma alert. MUSC Health has two kinds, Evans explains. Trauma B is a nonlife-threatening event, something like a trip and fall. Then there’s trauma A … the really bad kind. 

Bay 2 will have to wait. 

It’s an A. 

Unfair fight

“How are we looking, guys?” Evans asks, just moments after passing through the double doors into the first-floor ED. When patients with severe or life-threatening injuries first arrive at MUSC, this is where they come. Just a few paces from the daily humdrum of the Horseshoe, where students and employees walk to and from surrounding buildings blissfully unaware of the chaos unfolding just yards away, the ED is ground zero for patients with critical care needs. It can accommodate as many as six patients at once. It’s here they are diagnosed and, if necessary or possible, stabilized. Then, if conditions warrant, they are moved to one of several operating rooms on the floors above.

In 2012, MUSC was recognized by the American College of Surgeons as a Level 1 trauma center, the first in the state to earn the designation. Trauma centers are ranked as Level 1, 2 or 3, depending on the level of care they can provide. Level 1 centers must have trauma surgery, anesthesia and operating room capabilities available at all times as well as on-call specialists who can respond quickly. MUSC Health checks all the boxes. 

“I don’t really get nervous. But sometimes I just have to remember to breathe.”

 

– Heather Evans, M.D.

Surrounded by nearly a dozen nurses and physicians, a young man who can’t be more than 20 lies on a gurney, howling in pain. His right arm is heavily bandaged. 

“Do you know where you are right now?” Evans asks him, trying to take his mind off his pain and gauge his faculties. “What year is it?”

He’d been drinking, and in frustration, slammed his fist through a window outside a bar. EMTs who arrived on the scene said there was a trail of blood a hundred yards from the window to where he was found. He’s sustained severe arterial damage and has no feeling in his arm from his elbow down. As he writhes in pain, eyes unable to focus on anyone or anything, his body begins to shiver violently.

“Why can’t I feel my fingers?!” he shouts.

Nurses remove a makeshift tourniquet, and Evans surveys the damage. As she’s doing so, in between ear-piercing cries of pain, the man slowly starts to get feeling back in his fingertips. Evans probes a few spots with her gloved fingers then says: “You’re going to be OK. You have a very deep cut. You’re going to need to have surgery, pal.”

His wounds are serious, but he’s going to live. One fire out. On to the next.

The eyes have it

Back in the STICU, Evans is finally able to check on Bay 2. The nurses tell her he’s doing OK. “Would love it if it was better,” one says. Evans orders a new radial arterial line for him as well as a few other changes. She’s hopeful these subtle shifts will produce more incremental improvements.

“I’ll be back to check on him in a bit,” she says. But she makes that promise right before all hell breaks loose.

It’s just after 7 p.m. now, and a man who had come in earlier complaining of severe stomach pain has deteriorated rapidly. Scans reveal nothing obvious, except for one small spot that has Evans and the rest of the staff stumped. 

As she sits in the radiology lab, everything is pitch dark, save for the three giant computer monitors displaying the patient’s abdominal scans. Surrounded by a handful of radiologists, Evans and STICU medical director Stuart Leon, M.D., begin floating theories based on what they’re seeing, their faces glowing like kids around a campfire.

 

“Could just be some noise on the imaging,” Leon says, more of a question than a statement. 

Evans: “It could. But why is he having such acute pain?” 

“Well, there’s that,” Leon says. 

Though not ideal, the group decides the only way to know for sure is to open him up. 

“I’ll go talk to him and get his consent,” Evans says. As she steps out of the lab, she makes a quick call to share the plan with surgical resident Starr Friedman, M.D., who is up on the 10th floor with the patient. Minutes later, the two exit his room, consent granted. It’s time to prep him for surgery. That should buy Evans just enough time to eat her dinner: a red Thai curry tofu bowl she snagged at Whole Foods on the way into the office. 

“You take small victories where you can get them,” she says, smiling. “I don’t always get to eat.”

Behind the double doors

The clock on the wall displays 8:34 p.m. as Evans hangs her white coat on hook 31, just outside OR 18. She puts her surgical scrub cap and face mask on, then walks to the hand-washing station to scrub in. Once inside the OR, she surveys the patient. The circulating nurse helps Evans with her gown and gloves – she’s a size 7 underglove, size 7 overglove; most surgeons wear two pairs for protection, and there’s evidence that it can help reduce the likelihood of infection. In the span of six minutes, he’s draped; the bright surgical lights are turned on; protocols are exchanged between the surgeon, anesthesiologist and nurses; and they’re cutting him open. 

 

“What about us” by Pink plays over the speakers as Evans reaches deep inside the man’s abdomen. “Scans are great,” she says, her voice slightly muffled through the mask, “but there’s no substitute for seeing with your own two eyes.” 

It takes a bit of time, but she finally discovers the problem. It’s no simple fix, but she’s confident she can finally give this man some relief. She will stand over him for nearly three hours, meticulously working. Three minutes before midnight she finally closes him up. 

Time to give the family the good news.

Rounds and rounds

It’s 1:34 a.m., and Evans has revisited both Bay 2 and 12, circled back to the man with the arm gash, talked to two other hospitals that want to transfer patients to MUSC Health and examined a man who was hit by a car while riding his moped.  

Just after 2 a.m., she returns to her office to try to get some sleep when, much like a newborn in the middle of the night, her phone cries out for her again. She sighs heavily and looks at the screen. The man with abdominal pain is awake and feeling much better; he wants to thank her. The look on her face says it all – it’s really great to be loved, just not when you’re this tired.

 

Nearly a full hour later, she finally returns to her office to get some much-needed rest. However, the very thing that makes Evans such a skilled surgeon – her quest for perfection – doesn’t simply stop. She goes over the day’s patients in her head, thinking of ways she might have done things differently, done them better. She’s just about to drift off when the final call of her shift comes in. 

It’s the gunshot victim.

A harsh reality

Blood is everywhere. The floor. The table. Evans’ gloves and chest.

“Who’s prepping the abdomen?” she shouts. “Hold that airway!” she adds. Or maybe that’s another doctor. It’s hard to be certain. A quick headcount reveals 20 people in the room, none without a critical task. 

“Come on guys, let’s get this done!” Evans barks. Now she needs epinephrine – and calcium – the words “hurry the hell up” implied in every single syllable she utters. An anesthesiologist brings more blood. They’re going to need it. The man is hemorrhaging massively, his blood pressure now 49 over 28, with a pulse of 36. 

 

“Suction!” Evans pleads. The man is fading, and his abdominal cavity is filling up with blood faster than they can get it out. Finally, she can see what’s she’s working with, and the news isn’t good: The bullet has lodged itself in the man’s spinal column after shredding the inferior vena cava and slicing past the liver. The damage it wreaked as it spiraled through his body is becoming more evident, and he’s bled out his body’s entire blood volume three times. 

It’s 6:59 a.m. when her colleague Talley – who is leading the front- and back-end of this trauma-shift relay race with Evans – walks back into the OR. A quick debrief from Evans, and she jumps in to help. Eight minutes later the two come to the same somber conclusion: The fight is over. 

 

In stark contrast to just a few minutes earlier, the OR is now calm and quiet. There are 19 fewer heads in the room now. Not 10 feet from the body of the man whose life she so desperately tried to save for nearly three hours, Evans now sits alone – her legs crossed atop a stainless steel instrument table. For once, her expression doesn’t give away what you’re certain she’s thinking: “I could have done more.” The internal torture, always going on behind the scenes, is tucked away where only other surgeons are allowed. She’s not thinking about the robbery victim who has made a turn for the better or the man whose severe abdominal pain has abated. It’s the one who didn’t make it that she fixates on. 

And that’s what makes her great. 

It’s because of people like Evans that even the craziest, most out-of-control days at MUSC Health have their silver linings. Today she lost a patient. But every day, all around, miracles big and small are happening. A toe that can now wiggle. A quick trip outside for fresh air. A smile on the face of somebody who finally gets to go home, a second chance granted. 

As the end of her shift approaches, Evans quietly finishes her operating notes and pushes through the doors of OR 19 to head across the building for the surgical department handoff meeting. It’s the last bit of business she has to take care of before she gets to go home.

Where, one can only hope, she’ll finally get some sleep.