MUSINGS

No Man Left Behind

It started out like any other day. An older manwas brought to the hospital following multiplefainting episodes and falls. He was found to bein complete heart block, and a temporary cardiacpacemaker was placed. In a short period of time,he became dependent on the temporary pacemakerto keep him alive. But the device started failing toreliably maintain his heart rate, so he was quicklybrought up to the operating area for a permanentpacemaker insertion. We proceeded rapidly asthe failing temporary pacemaker was allowing hisheart to stop for increasingly long periods of time.However, such things are not uncommon andwhile there was a sense of urgency, the surgeryproceeded in a relatively routine fashion. Aftermaking an incision in the upper chest, I openeda blood vessel and (using x-ray fluoroscopy)guided permanent pacemaker leads into the heart.Satisfied with the positions, I sutured down theleads and focused on enlarging the area where thepacemaker itself would lie. It was a routine case,just like the numerous ones I had done before.Then it happened. The sound of an explosionsuddenly erupted through the operating area andthe very floor below us shook. Then everythingwent black. Operating areas usually have nowindows and are dependent on artificial light.Backup power sources are supposed to kick inwhen the flow of electricity to the hospital isinterrupted, but nothing happened. There wasabsolute blackness. After what seemed to be aneternity (but was likely only a few moments),very dim lights appeared around the edges ofthe room, emitting just enough light to see darkshadowy outlines of people and equipment. Analarm began to sound just as the acrid smellof burning plastic began to fill the room. Thenursing supervisor poked his barely visible headin through the door and yelled, “There is a fire inthe basement below us. The hospital has almostno power; everybody must evacuate now!” Totake the patient out of the operating area nowwith an open wound, the temporary pacemakerfailing, and the permanent pacemaker not yet inplace, would almost certainly have led to hisdeath. “No,” I said calmly. “I need to finish.”“Everyone out now!” the supervisor yelled again.“Anyone who wants to leave can,” I said. Therewas a scramble of shadowy figures as people left.

doi: 10.1111/pace.12333

But, oddly, new figures appeared. “Someone get aflashlight,” I said. In a few moments one appeared.In its light I could see that there were three nursespresent. “Are you staying?” I asked. One of themlooked me in the eyes and said, “No man leftbehind, sir; if you stay we stay,” I knew each ofthem and suddenly realized they had all been inthe military (two were still in the Reserves). Hiswords resonated deep within me. Soldiers risktheir lives together (as do police and firemen),and form a deep bond of trust and obligation(“The Band of Brothers” as Shakespeare put it).1It is the “Soldier’s Creed.” You count on yourcomrades being there when you need them, justas they trust you will be there when they needyou. That same bond is present in all of us, likethe bond between doctor and patient. I nodded myhead in understanding and set to work. The scenewas surreal. One nurse held a flashlight whilethe others monitored the patient and opened thesupplies. I worked as quickly as possible. Soon thepacemaker was in place and the patient’s rhythmwas restored. As I sutured the wound closed, Ibecame aware that the room was uncomfortablyhot and the air foul. I began to sweat profusely.The whole time the alarm rang incessantly. After Iplaced the final bandage on the wound, we quicklyslid the patient onto a wheeled gurney table andrushed through the doors down the hallway. Aswe did, we could see smoke was starting to appearin the air around us. Luckily, the operating areaswere located on the first floor of the hospital. Werolled the patient into the now deserted lobby andout the front door into the street. As we rushed outinto a crowd of people, the fireman rushed in. Thepatient would live, and we had all made it out. Inoticed people were staring at me and realized Iwas still wearing the bloodstained surgical gown Ihad been operating in. I turned to the nurses whostayed with me, shook each of their hands, andthanked them profusely. Each said the same thing:“No man left behind, sir.”

We later learned that a large transformer inthe basement directly below the operating areahad exploded, knocking out both the regular andemergency power sources to our section of thehospital. A large fire had ensued, which the firefighters battled to contain. When word of whathappened spread among the staff, I was said tohave been either a hero or a villain. The nursing

1Shakespeare W. Henry V, Act IV Scene iii 18–67.

©2013, The Authors. Journal compilation ©2013 Wiley Periodicals, Inc.

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GRUBB

supervisor filed charges against me, saying myfailure to evacuate (with the patient still cut open)constituted “reckless endangerment” of the staff.Several days later, I was told to report to theoffice of the Chief of Staff. I entered his officewith a deep sense of foreboding. A trauma surgeonand former chief of Surgery, he was known forhis tough demeanor and no nonsense style. Afterentering his expansive office, he greeted me andasked me to take a seat. A large imposing figure,he was legend at the institution. He had been acelebrated trauma surgeon in Korea and Vietnam.His memoirs had served as the inspiration formovies and television shows. The walls werecovered with memorabilia of his time in themilitary, the most prominent of which was aframed Silver Star medal, the military’s highestaward for heroism. In a calm matter-of-fact voicehe said, “Tell me what happened.” I felt a sinkingfeeling in the pit of my stomach, as I explainedwhy I could not leave the patient as he was, andwhy I had to finish, despite the danger posed bythe fire. When I had finished he said, “You realizeyou placed yourself and others in jeopardy.” Inodded my head. “Would you do it again?” heasked. I nodded my head, and after a momentadded, “No man left behind, sir.” At this he satback, stroked his chin with his hand, and saidnothing. He appeared lost in thought. Finally, afterwhat seemed an eternity, he spoke. “During theKorean War I was stationed in a MASH unit nearthe front line. The North Koreans and Chinese hadmounted a surprise offensive and were pushingback our forces with heavy casualities. We wereflooded with seriously wounded young men. I wasoperating nonstop. I had just begun to operate ona young man with an abdominal wound when wereceived orders to evacuate the base. We started

to hear shell fire and explosions in the distance.Soon shells were hitting the base. A nonphysicianCaptain poked his head into the OR and told us toevacuate now, and leave the young soldier behind.But I could not let a young man die that I knew Icould save. So I refused and continued to operate,despite the fact that one of the explosions hadstarted a growing fire on the base. I finished thesurgery, with bullets and explosions all aroundus. We loaded the young man (and ourselves)on the back of the last truck out of there, justmoments before the camp was overrun. The CampCommander wanted to court martial me, but anewspaper correspondent who had been at thebase had already filed a story about it. So suddenlyI became a hero.” He paused for a moment. “TheArmy then presented me with the medal you seethere,” he said, gesturing to the wall.

He held up the papers that contained thewritten complaint against me. “So they want me toreprimand you for the same thing I was awarded amedal for.” He took the papers in his large hands,wadded them up into a ball, and tossed it into awastebasket. He arose, walked to a cabinet behindhis desk, and returned with a bottle of Scotchand two glasses. He poured some of the fragrantliquid into each and offered one to me. He raisedhis glass in a toast, as I did mine. As our glassesclinked together he smiled. “No man left behind,”he said. I nodded, sipped the amber liquid, andfelt its warmth fill my chest.

BLAIR P. GRUBB, M.D.Distinguished University Professor of Medicine and

Pediatrics College of Medicine Health Science CampusThe University of Toledo Toledo, Ohio USA

e-mail: blair.grubb@utoledo.edu

388 March 2014 PACE, Vol. 37