Without a guide, a new doctor must practice on the living
A screaming mother ran toward me with a blue, floppy infant. She handed him off gently, the tiny month-old body impossibly heavy and hot. He wasn’t breathing, but Irma, the best ER nurse on the planet, had an oxygen mask and bag ready, and in seconds we had the kid on the bed.
The mother stuck in the hallway, alone, her face twisted and unable to move, as if someone had nail-gunned her feet to the linoleum. The staff poured by her like a human river around a rock, running toward her dying son.
Not much freaks out an urban ER staff, but a dying kid can come close. We break our fear by using our training, what we’ve seen before, what we know.
But what happens when we haven’t seen it before?
The intubation went quickly. The lungs filled with each squeeze of Irma’s bag. His face was hot to the touch, eyes dull and lips cracked -- sure signs of infection and dehydration. The nurses tried hard to start IVs for fluids and antibiotics. Needles went into little hands and feet and arms as his blood pressure dropped. They failed.
After a minute, I called for an IO kit -- an interosseus needle, the “hail Mary” of IV lines in kids. Irma’s eyes went wide, the other nurses looked at me. An IO? They’d never done one. Neither had I. But I was about to. Without it, this boy would die. His heart rate was already slowing down, an ominous sign that told me he was going to arrest.
“Interosseus” means “into the bone,” which tells you where the needle goes. It is the most brutal ER procedure I know -- and absolutely essential. The IO is “T-handled” like an old-fashioned wine opener, except instead of a corkscrew on the end, there is a huge needle, bigger than a pencil lead, longer than a toothpick, with a razor-sharp cutting point. You screw it into the leg bone just below the knee with a hard, twisting motion. Not into a vein or an artery or some yielding tissue, but into hard bone that never collapses, no matter how low the blood pressure gets.
Actually, I had done an IO before -- but on a chicken leg. I wasn’t going to tell the nurses that. Unlike in adults, there is no such thing as a pediatric cadaver lab or a source for “practice” pediatric body parts. It’s a hard line that we cannot cross, the “violation” of a dead child, even for the best of reasons.
But as I assembled the IO needle, I wished that some living relatives had been able to overcome their horror, both for the dying child on the bed and for the new doctor beside it. This boy deserved better than to be my first.
Everybody knows that donated cadavers in medical school help turn students into doctors. What is less well known is that donated bodies affect real patients, every day.
At UCLA’s ER, I supervise doctors who put in complicated and dangerous breathing tubes and central catheters, and standing next to me are the ghosts of all those willed body donors whose newly dead bodies stayed still and silent while new ER residents blundered through the insertion of life-saving chest tubes and central lines in a procedure lab.
Eventually, experience replaces our cadavers with a legion of living bodies. This is how doctors are made, not in classrooms but first in cold flesh, then in warm blood.
The very experience of dissecting a human body changes medical students, and so makes it harder for doctors to comprehend the recent call for the end to UCLA’s Willed Body Program.
The horror at the thought of donated bodies being cut up -- apparently for profit -- is, of course, understandable but by overreacting, society risks increasing the suffering of living patients, at the hands of doctors who really want to do no harm.
The leg of the child felt nothing like a chicken, as I began to twist the needle in. The bed was surrounded by nurses and doctors, but the kid and I were all alone, and Irma, my good luck charm of a nurse, seemed a million miles away.
In a few seconds, the needle was in and the fluids and antibiotics began to flow. Irma asked if she could place the other IO in the opposite leg, and this being a teaching hospital, I stepped around the bed and talked her through it, as though I’d done a hundred of them.
The crisis passed and the staff relaxed as the boy’s heart rate and blood pressure started to come back up. Irma inserted the second line with sure and steady hands. I buried mine deep in the pockets of my white coat, hiding sweaty palms and the secret of the chicken leg where my patient’s mother couldn’t see them.
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Mark Morocco is an emergency medicine doctor at UCLA Medical Center. He is also a staff writer and medical supervisor for TV’s “ER” and a consultant for “Third Watch.”
