It takes three or four large guys to get this guy on the stretcher. The patient is highly agitated. I made the universal sign for intubating someone (thumb down throat) to my resident. “That’s my plan,” he says.

In the meantime, the OTHER trauma arrives. The one we knew about. My resident wanted to stay with the first one, so I went to see the second.

This guy, though, with a GSW to the RUQ, had stable vitals and was talking. The nurse says to me, “Tetanus, Ancef, morphine, Zofran, fluids.” I nod. God, I love ER nurses.

So after putting in orders on both patients, I went back to see the progress on the other guy.

My resident had intubated the patient, got labs, a chest X-ray, started O-negative blood and everything! Wow! Except, his pressure was still 70/30.

I called our trauma surgeon and told him about our two customers. He said he was on his way.

“I think he needs a chest tube,” my resident said. True enough, that would be a first thought. There was a bullet hole right through the middle of his chest. But I wasn’t sure about that.

“I think you need to stick a needle in his heart.” Note the statement above. A bullet hole through the middle of his chest. “Let’s look at the chest X-ray.”

Pretty darn clear, no pneumothorax, and a bullet probably sitting in or next to the right side of the heart – causing pericardial effusion, thus causing tamponade, thus the hypotension.

Which led me to my next statement. “Get yourself a very long spinal needle and the ultrasound machine.”

As I was about to page the trauma surgeon to let him know that we were going to stick a needle in his patient’s heart, he walks in the trauma bay.

“Oh goody,” I said. “We were just about to drain a tamponade.”

He took a look himself with the ultrasound, and he agreed with that plan. Especially since the patient’s pressure wasn’t responding to blood and fluid resuscitation.

We attempted that, but the patient continued to crump.

Then our surgeon said the five magic words every EM resident dreams of hearing (especially when there are no surgery residents around). “Get me a thoracotomy tray!”

At this point, my resident turned red. Really red. The nurses all scrambled for the proper equipment and gloves for the three of us. The guy’s pressure was still 70/30. As the anticipation built, my resident turned fuchsia. He was finally going to get to do this. After 3 years of residency and jockeying for position with those surgery residents …