The Making of a Plastic Surgeon: Two Years in the Crucible Learning the Art and Science

Prologue: Dawn

I believe that plastic surgery is the most fascinating and misunderstood specialty in medicine. With that in mind, I hope my book will give the reader an honest and entertaining peek into my world.

Prologue-  Dawn

The little car came to a squealing stop under the lights of the ambulance entrance to the emergency room, close enough to activate the motion sensor and send the large, sliding glass doors hissing apart. As acrid smoke rose from the tires, the car doors flew open and three teenage-age girls spilled out, pulling a fourth out of the back by her arms and legs. She was semi-conscious, her body limp, head lolling as they dragged her toward the entrance and shouted for help. After a brief moment to take this in, the ER staff sprang into action.

The year was 1982. I was a resident in general surgery at the U.S. Naval Hospital in Oakland, CA, finishing the third year of a five year residency. The term “resident”, was a throwback to the days when doctors in training actually resided in the hospital during those years. I was rotating for several months through the University of California Davis Medical Center in Sacramento, one of the premier trauma centers in the country. The head of the Department of Surgery was F. William Blaisdell, widely acknowledged as the father of modern trauma care in the U.S. As a resident on the trauma service, I covered the emergency room twenty-four hours on, twenty-four hours off, for all trauma cases brought to the medical center. I was already doing some operations myself but always under the direct supervision of an attending surgeon or a fifth year (senior) surgical resident. I was expected to call the senior surgical resident, Ernie Neuman, if a trauma patient needed to go to the operating room. Neuman, in turn, notified the attending surgeon, who only came in if Neuman felt he couldn’t handle the case himself. 

It had been an unusually quiet day and I happened to be cruising through the emergency room as a break from reading in my on-call room, when the ER doors slid open to reveal the desperate scene. The exhilarating- and simultaneously terrifying- thing about trauma was that you just never knew what would roll in from one moment to the next. You could be having a cup of coffee and chatting up the ER staff one minute and the next you would be up to your elbows in blood fighting to save someone’s life.

The ER staff placed the slim eighteen-year-old girl on a gurney and began to roll her toward an examination room. Her friends were all shouting at once. I did not pay too much attention to the bedlam, assuming this to be another case of acute alcohol intoxication or drug overdose that seemed to be prevalent in this age group. I was just turning away when the words, “She’s been stabbed!” stopped me in my tracks. I broke into a run toward the group. We diverted the gurney to the room reserved for major trauma patients and transferred her to the bed there. The trauma team mobilized and went to work setting in motion the seemingly chaotic, but highly organized, bustle of activity that is acute trauma care.

As we pieced the story together later, Dawn had been in a fight with another girl, who pulled a knife and stabbed her in the chest. The nurses began pulling supplies, setting up intravenous fluid bags, tubing, surgical instrument trays, etc. One nurse applied a blood pressure cuff to her arm and electrode leads to her torso to monitor her blood pressure and pulse. The resident on call for anesthesia arrived and slapped a mask over her face to administer oxygen while monitoring her vital signs. I cut off her clothes, bra, and panties with scissors and quickly examined her, the staff helping me to log roll her onto her side to check her back, an often overlooked site of injury in trauma situations.

The only finding was an unimpressive one inch cut just under her left breast. There was little actual bleeding but, with each breath, there was pink, bloody froth bubbling from the wound, indicating a lung injury. A penetrating chest wound of this type can be very dangerous with the potential to injure vital structures in the chest. 

The first step of treatment called for placing a tube into her chest to look for bleeding and to treat a punctured lung. I had inserted a number of chest tubes up to that point and was comfortable doing the procedure unassisted.

Just as I prepared to make the small incision with a scalpel to insert the chest tube, the anesthesia resident said quietly, “We just lost her.”

She no longer had a detectable pulse or blood pressure. He immediately placed a breathing tube into her windpipe to gain control of her airway and began to breathe for her using a bag to administer pure oxygen. In this clinical setting the drill called for immediately opening her chest, a procedure called an emergency thoracotomy. In common surgical parlance, it is referred to as “cracking a chest.” I had only seen this done a couple of times and neither patient survived. There was no time for reflection or hesitation. I immediately abandoned my small chest tube incision and sliced halfway around the left side of her chest with the scalpel cutting through skin, fat, and the muscles between the ribs, entering the chest in seconds.

There is nothing delicate about opening someone’s chest in this manner. It is an act of surgical desperation intended to save a patient who will otherwise surely die. I inserted a medieval- looking device to spread her ribs called, appropriately enough, a rib spreader, and cranked the big blades apart to reveal her left lung and left side of her heart.  There was relatively little blood in the chest cavity. Each time the anesthesia resident squeezed the bag, air hissed out of the lung through a small slit made by the knife blade. At first glance, nothing explained her sudden collapse. When I pushed her lung aside with my hand, however, the cause became immediately obvious.

Dawn’s pericardial sac, comprised of a thin, fibrous membrane which contained her fist-sized heart and should have been translucent, was bulging and tight, with a deep purple color indicating that it was filled with blood. Her assailant’s single stroke could hardly have been more lethal, as the slim knife blade had slid past the lung, just nicking it, then penetrated the sac and punctured a small hole in her left ventricle, the largest, most muscular chamber of the heart. With each contraction of the ventricle a high-pressure jet of blood gushed into the sac. A small clot of blood had sealed the rent in the sac. With each contraction of her heart, the pressure within the inelastic sac rapidly increased, preventing the heart from filling adequately until it could no longer pump any blood at all. In the most literal sense, Dawn’s lifeblood had squeezed the life out of her.

The condition, called pericardial tamponade, would kill her within minutes if not relieved. Using scissors to slice the length of the sac, I evacuated the blood and clot, and saw the bleeding hole in the tip of the ventricle. Instinctively, I plugged the hole with my finger. Relieved of the pressure and with the hole plugged, her struggling heart promptly filled up with blood and, after a few tense moments, her pulse and blood pressure returned. Neuman had already been notified and arrived as we took her to the operating room with my finger in the hole as I ran alongside the gurney. I had never held another’s life in my hand in such a literal manner. I was so focused on my single task of keeping that hole plugged that the magnitude of the situation did not really hit me until later.

In the operating room, we transferred her from the gurney to the operating bed. The nurse prepared and draped Dawn’s chest and my arm into a sterile surgical field. Ernie quickly scrubbed, donned a sterile gown and gloves, and joined me at Dawn’s side. He took a curved heart clamp and carefully placed it across the stab wound, then closed it as I slowly withdrew my finger from the hole. With the hole securely clamped and her vital signs now stable, everyone breathed a sigh of relief and a palpable sense of calm descended on the scene for the first time.

From that point, things moved along as though this was a routine, elective case. I went out, scrubbed my hands, gowned, gloved, and rejoined him. In an unexpected and unspoken acknowledgment of my investment in this young girl’s life, he stepped aside and gave me the place at the table normally occupied by the principal surgeon. He assisted me in sewing up the hole and repairing her lung. By the time the attending surgeon arrived from home and peered over our shoulders, the operation was essentially finished. 

“Looks good. I think you boys can manage without me”, he said and left the operating room. Dawn made a complete and rapid recovery as only a resilient teenager could and left the hospital a week later.

I rotated out of the U.C. Davis Medical Center and returned to Oakland soon thereafter. I never saw her again. Even now, more than three decades later, I occasionally think about Dawn and wonder what became of her. I wonder whether she made the most of her second chance at life.  To this day, it is the single most dramatic moment in my medical career. Nothing I have done since has come close. My reward was the ultimate accolade for a trauma resident, a curt, “Nice save, Bosshardt,” from Dr. Blaisdell the next day when I presented her case to him and the full trauma team on our morning rounds.

General surgery provided numerous opportunities for such affirmation. Saving lives was the name of the game. The general surgeon was arguably the “King of the Hill” among specialists, trained to operate anywhere on the body and care for critically ill or injured patients. Why would anyone turn their back on that to pursue a specialty seen by many, including some of my colleagues, as trivial, emblematic of wretched Hollywood excess, the domain of vain celebrities and the well-to-do? Some of my surgical peers felt that pursuing plastic surgery was a waste of all the surgical training we had been through. To the public at large, plastic surgery was often seen as symbolic of a vain and frivolous society and plastic surgeons as cosmetic “nip and tuck” specialists only. I confess that even I felt this way at times. So, why indeed? The answer to this question came later, along the journey which began long before I had my encounter with Dawn.

Richard T. Bosshardt, MD, FACS