The large man on the surgery table
had been shot five times in the abdomen at
close range by a small caliber pistol wielded by
his lover. He had been brought to the Los
Angeles County General Hospital ER where he
was quickly examined, then sent as a “Red
Blanket” to the surgery suites on the ninth
floor. As he was being anesthetized by the gas-
passer at the head of the table, the third-year
surgical resident made a rapid examination to
determine the man’s status: Stable? Bleeding
heavily? Site and extent of the injury? What x-
rays were needed that could be done quickly
while the man was being stabilized? There
were several grades of urgency in transferring
a patient from the ER to the Medical or
Surgical suites, from 1 to 5. Red Blanket was
the ultimate grade of urgency above 5 and the
ER staff placed a red blanket on the patient to
indicate that he had earliest transport on any
elevator. The elevator operators, seeing a
patient with a red blanket, would empty the
elevator quickly so that the patient could be
taken non-stop to the appropriate floor for
care. After several years the red blanket
morphed into a small red piece of cloth about
the size of a bandanna, but it was still called a
Red Blanket Emergency.

After making an incision in the midline just
below the rib cage, the third-year surgical
resident could not get at the many bullet-
shredded blood vessels at the hilum of the
liver to repair them and stop the terrible
bleeding, so he called the attending surgeon
for advice. The resident then ordered me, the
intern, to hold a large towel against the
bleeding sites in the liver. Where I had to put
the towel was in the dark way up under the
edge of the rib cage. The resident had called
the attending surgeon at 0300 hours and at
0330 hours he arrived in the surgical suite
from his home in Pasadena. After being
informed of the problem by the third-year
surgical resident, and then examining the
patient, he had no solution! He had obviously
never faced such a situation in training or in
his present surgical practice.

I had started med school at age 31 so was
older than the third-year surgical resident.
When I saw that no ideas were forthcoming
from the attending surgeon (who was also
young) to save this man’s life, I suggested
that the third-year resident call the fifth-year
surgical resident in the hospital, while I kept
the towel stuffed against the bleeding liver
vessels. Although I could see that the third-
year resident was uncomfortable in taking my
suggestion with the attending right in the
room, he looked at the attending who signaled
the resident to go ahead and contact the fifth-
year resident on call.

Fifth-year surgical residents at this large
teaching hospital were also called vascular
residents and were held in awe by all us lowly
students. They were the brightest of the bright
and had been in competition with other
residents for almost five years. By the time of
their fifth year these men had seen almost
everything that mortal man suffers and had
fixed unspeakable problems.

Without hesitation, and without more than two
words to the third-year man, the fifth-year
man took a scalpel, and starting at the middle
of the pectoralis muscle on the right, cut down
through the skin and muscle to the ribs. Then
he took large bone shears and quickly cut
through the ribs on the right anterior part of
the chest, cut through the diaphragm with a
scalpel, folded the ribs out of the way and
delivered the bleeding liver out of the darkness
and inaccessibility of the body cavity where
the gunshot blood vessels pumped their
Stygian rivers of doom. He then very rapidly
began to sew the numerous gunshot wounds
in the vessels shut, restoring blood supply to
the liver, while the third-year surgical resident
and I held the liver up where he could get at
the blood vessels. The life-threatening
bleeding stopped. Without another word to
anyone, including the discomfited attending
surgeon, the fifth-year man backed away from
the patient, stripped off his surgical gloves and
exited the surgical suite, leaving the third-year
resident to close the wound.

As a lowly intern, I was greatly impressed.
There was no doubt in my mind that a
significant teaching experience had developed
right before our eyes without blarney. No one
in that room that night, confronted with a
similar situation in the future, would have any
difficulty solving the problem.

Cal Lewis practiced family medicine for 40 years in Monterey,
California, and Nevada. He owns a cattle ranch in Nevada and is
retired from medicine. “Red Blanket” is excerpted from his memoir,
The Healers.
by Cal Lewis, MD