How a Gruesome Close Call in the ER Turned a Young Doctor Into a Surgical Visionary

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Nov. 7 2013 4:39 PM

“A Heart Beating Around Her Finger”

How a close call in the ER turned a young doctor into a surgical visionary.

Ambulance Emergency

Photo by clean_fotos/Shutterstock

The following is excerpted from Play at Work: How Games Inspire Breakthrough Thinking, by Adam Penenberg, published by Penguin.

In the late 1990s, Dr. Carla Pugh was working the night shift in the emergency room at Howard University Hospital when a stabbing victim was carted in. He was a John Doe: no wallet, no credit cards, no identification, unconscious. Paramedics had placed a bathmat-size piece of gauze on his chest, and when Pugh peered underneath it, she saw a deep slice in his right chest and a lung hanging out. With such extensive injuries, there should have been a lot more bleeding; but with so little blood loss, the man—despite the savage wounds—should have still been awake. They stripped off all the gauze and bandages when Pugh spotted a tiny hole in his chest. She realized the knife must have nicked his heart.

Holy crap, Pugh thought. “Put in a chest tube,” she ordered the resident on her team. “If we don’t get a gush of blood we’ll crack his chest.” When no red geyser was forthcoming, they prepped the patient for emergency surgery, inserting a breathing tube to get him oxygenated and help his heart beat. They rushed him to the operating room, where he flatlined.

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The anesthetist readied paddles to shock his heart.

“No!” Pugh shouted. “Give me a scalpel!”

There was no time for niceties. She poured sterile solution right out of the bottle, soaking her gloved hands and the knife—she wasn’t even wearing a surgical gown—and ripped open the man’s chest. Shoving her hand inside, she rooted around until she located the hole and plugged the leak with her finger. His heart jumped back to life.

It was 2 a.m. and there wasn’t time for the thoracic surgeon on call to get there. Pugh marveled at the feeling of a heart beating around her finger. In all of her years of training, she had never touched one as it pumped blood through a living, breathing human being. If a sharp object pierces a beating heart, the outer incision ends up wider than the one on the inner wall, which doesn’t move as much. Because it results in such an unusual shape, under normal circumstances doctors would cover the hole with a special patch made of soft metal and shaped like a bullhorn. The nurses couldn’t find any bullhorns that would fit, however, so they had to sew it closed the old-fashioned way. Pugh looked over to her resident, who was set to begin.

“You’re not stitching with my finger in here,” she said. One errant move and he could poke a hole in her finger or stitch her to him. Who knew if the patient was HIV-positive or plagued by other infections? Thinking quickly, she decided to tag team it: Pugh would start each stitch, since she could feel where her finger was, then pass the thread to the resident, which he would tie off. She would inch her finger over and they would repeat the process.

With the first stitch, blood squirted out. They had to hurry.

A few days later Dr. Pugh was making her rounds when she entered her John Doe’s room. She found him sitting up in a chair, smiling through a haze of painkillers.

“You look great!” she said, surprised at the transformation. “You almost died.”

“I heard,” he said. “You’re the one who saved my life.”

It was all over the hospital. Pugh had even earned a nickname: “Magic Finger.”

More than a decade after Pugh’s emergency-room heroics at Howard University, I’m in her lab at the University of Wisconsin hospital finishing up a hernia operation. Just about done—all I need to do is put in the last few stitches. The miniature camera attached to the end of the two long needles I’m clumsily manipulating doesn’t lie: I’m a lousy surgeon. Fortunately, the patient isn’t alive. In fact, he never lived—he’s actually a cloth box with different layers of mesh—which look like the internal organs of a human—and laparoscopic tools, all of which sit on a base consisting of two Frisbees.

If Pugh is disappointed in my performance, she doesn’t let on. After her close call with John Doe, she decided to make it her life’s work to improve training methods for surgeons and other physicians. No patient’s survival should depend on luck or happenstance; the only way to ensure that a doctor has the skills necessary to act in a broad range of emergencies is for her to practice, over and over. This ultimately brought Pugh here, where she runs the hospital’s simulation training center and is a leader in surgical education. The center has state-of-the-art medical simulators, including a $200,000 medical mannequin that mimics a patient in distress. It cries out in pain, wheezes, coughs, and dies at least a few times a week.

The training device I performed surgery on was Pugh’s invention: A laparoscopic ventral hernia simulator, a relatively low-tech gizmo compared to the hospital’s high-definition surgical simulations. Low-tech is precisely the point. Pugh built it to mimic how surgery feels from the vantage point of a surgeon. It deploys the same tools used in a typical laparoscopic procedure: the same scope, mesh, suture, and instruments. Residents and other trainees can locate the hernia defect using the laparoscopic camera, determine how to repair it, judge the best stitching methods, and select the appropriate size and type of repair mesh. After completing the “operation,” the trainee can pull back a flap and look closely at the stitching. Pugh cobbled the device together from off-the-shelf parts procured from various stores and cloth: cotton, silk, burlap, polypropylene and other synthetics.

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Touch in medicine is not hard to quantify but difficult to explain. Because more and more surgeons perform operations wholly in simulations while their patients lie across the room, doctors can go their entire careers without ever touching the inside of a patient. That’s why Pugh has embraced analog teaching methods in a digital world. She has created a bevy of simulations for surgical procedures, all of which are made from layers of different types of cloth to mimic a human's insides, and none of which have sensors. There’s one that mimics part of the Whipple procedure for patients with pancreatic cancer, others to simulate the removal of a tumor from the colon and an operation on large or small intestines, and another that simulates another kind of hernia procedure. She has these high-touch simulators made by a fabric vendor who she trained and who keeps all the proceeds.

Pugh also added a baby delivery simulator to her line of sims. She formed the birth canal out of liquid latex shaped into a pelvis and performed surgery on dolls by widening their shoulders and using a metal frame to extend them.

“I made their heads bigger or smaller,” she says, “because different sizes and shapes may make it difficult for them to be pulled through the birth canal.”

Her first simulation was a pelvic exam in a box. She taught herself C++ coding, ripped apart a mannequin, and placed sensors at various points—off-the-shelf microprocessors that measured pressure on a scale of 1 to 10. There was no textbook to tell her where to situate them; she guessed based on her own experience. The sensors enabled the simulator to offer feedback never before available on palpation: the use of touch in clinical practice for diagnostic and therapeutic purposes. The results were displayed on a computer screen, which helped guide a user’s hands to the right places and apply a suitable amount of pressure.

Pugh began placing sensors in all manner of mannequins: harvesting them from medical supply stores, then customizing them. She built one to mimic a prostate, another the rectum, a third, breasts. She scoured art supply, fabric, and hobby shops, hardware stores, and even Toys R Us. She checked out porn shops to inquire about penises—circumcised and noncircumcised, erect and soft, in different sizes and shapes—which shopkeepers found hilarious.

“Everywhere I go, anything I see, touch, and feel is fair game for building a human being or a part,” Pugh says.

Then she came up with the idea to mimic specific diseases. Through trial and error, she discovered that various tumors could be represented by anything from dried lima beans to glass beads, from hard rubber balls to pom-poms encased in oily condoms. Lentils embedded in rubber were particularly good for mimicking fibrocystic breast changes, a noncancerous condition, and she melted plastic to imitate cysts or thickened tissue. She filled simulated breasts with “tumors” and lumps represented by lentils, beans, and clay; she sliced the edges off ice cube trays and embedded the slats in foam to make ribs. Squishy balls did a nice job of representing ovarian masses; hard wooden balls worked well for ovarian cancers.

“I use lots of water balloons, lots of condoms, lots and lots of arts and crafts,” Pugh says. “I take my team on field trips to the hobby shop and tell them ‘I need a rock hard tumor of various sizes.’ ”

Building human beings out of common, everyday parts earned Carla “Magic Finger” Pugh another nickname: a “medical MacGyver.” It’s one she relishes.

Excerpted from Play at Work: How Games Inspire Breakthrough Thinking, by Adam Penenberg, published by Penguin.

Adam L. Penenberg is an assistant professor at New York University and assistant director of the business and economic reporting program in the school's department of journalism. You can email him at penenberg@yahoo.com.

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