A Murderer, His Victim, and Equality of Care

Two gunshot victims in the trauma bay a few hours apart – the first did not survive and the second one was clinging to life.

In medicine we’re required to (and should consistently desire to) provide equal care for all patients that walk through the door no matter their story, race, ethnicity, gender, sexual orientation, or any other factor. We’re supposed to do it without bias – without any trace of our individual human emotions and backgrounds that may sway us to subconsciously show preference toward one patient while repelling us away from another.

But how does that creed come into play when the victim clinging to life is the one that shot and killed the first victim?

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One of the few things that television shows get right about medicine is when a high level trauma comes in and the patient is unstable – the characters always take off running down the hallways to the trauma bay once the trauma alert goes off.

It really isn’t too different in real life.

So when we got the first high level trauma page in the late morning, there was no hesitance. We rushed to the trauma bay, fingers slamming the elevator button over and over again (as if it would make it arrive faster), weaving in and out of visitors, patients, and hospital personnel with breathless ‘excuse me’s!’ as we narrowly avoided colliding with people in our haste to get there.

When we arrived, the trauma was just being rolled in. CPR was being done, and the patient’s clothes were cut off to follow the protocol and do a full evaluation.

But a bullet straight between the eyebrows is overwhelmingly not something that is survivable.

CPR was stopped and time of death was called.

I walked away from the trauma bay where the patient was and stood there awkwardly for a moment, still unsure in these moments of what to do or where to go. I remember looking at the third year medical students next to me to ask if they were okay. They solemnly nodded and provided some form of assurance that I can’t specifically recall.

It was soon after that the background of the situation unfolded – a disgruntled former employee went into the restaurant he had recently been fired from and shot the chef. For the following few hours, he remained in the restaurant holding people hostage.  It was a major restaurant on the main street in the city and the entire area was shut down and cordoned off.

I’ve always tried to fathom what it would be like to be in such a situation – to find myself in a sudden, dangerous scenario that couldn’t have been predicted and can’t be controlled. As I have gained more experience in surgery – particularly in trauma and burn – I become increasingly conscious of the fact that at the end of the day, life is out of our control no matter how much we try to think that it is.

One instant can change everything.

The thought never fails to make me squirm, and working on trying to let go of that fear has been a newfound, and much appreciated, goal of mine. Sometimes I succeed, sometimes I fail.

But I digress.

As those hours ticked by, life and work and the routine continued.

I went out to lunch with some faculty and other students. It was hard to make small talk knowing that a family had just lost their loved one in a horrible way and that down the road an unimaginable terror was still happening in that restaurant. My sandwich had no taste and I remember the coffee I got after lunch tasted bland.

When I trudged back into the workroom and sat down for another afternoon of following up on patients and new consults, the team and I spent some time talking about the hostage situation. It remained at the forefront of our minds. One of the other medical students happened to know someone that was currently working in the area and he was providing us with updates.

It wasn’t soon after we got back to the workroom that he uttered the words “I just heard that the gunman was shot and it’s all over.”

As if to echo his statement, the trauma pager went off. It was a chilling confirmation and we looked at each other with unsurprised glances.

In a perfect repeat from earlier we rushed downstairs, each of us with a high suspicion on exactly who was being rolled into the trauma bay.

It was the gunman in critical condition.

As I helped remove his clothes to do a full evaluation (repetitive motions for unrepetitive situations), I watched everyone work on their parts of the trauma workup.

I admired how there was no difference in their actions, no vocalization of distaste towards the patient, and no hesitation to provide the same amount of effective, efficient care that any other person would receive.

As they worked, I wondered if the image of the current patient’s deceased victim – eyes wide open and with a bullet between the eyebrows - was going through their minds as it was going through mine.

At this point, I was standing as an observer, trying to figure out how to make myself useful. I bent down and picked up his tattered pants with gloved hands to look for any form of identification, as we didn’t have a name for the patient yet. When I couldn’t find anything, I placed them back down in the same spot. A few moments later, the police came and put them in an evidence bag and I remember shaking my head at the surreal feel of the situation.

After confirming that he was stable and getting routine imaging on him, he was rolled up to the ICU. It was one of my last days on the rotation and I never did find out what happened to him when I left – whether he lived or died.

Months later and I’m 100% certain of the fact that I truly hope that he lived. However, what I am uncertain of is whether that feeling is out of obligation or out of true emotion. The ambiguity in my mind still bothers me, and I haven’t stopped to really and truly sort out my thoughts until writing this.   

It would have been so easy – so very human of us – to react in a manner unbefitting to the patient…to the murderer. Especially having visually seen the consequence of his actions hours before.

I’ve often found in moments where I’ve had undesirable (for lack of a better word) patients, that it helps when I look more to their past than their present.

What was their background? What could have led to them doing this - to acting this way? Outside of a few select scenarios, there’s really never an excuse for murder…but I do believe that people are a product of their environment, and that those factors can help create a person that could be capable of such a heinous crime.

A truly vicious cycle.

Later that evening I went out to dinner by myself. I was sitting at the farthest seat against the wall at the bar, silently drinking a beer and eating a cheeseburger while scrolling aimlessly through my phone. A couple next to me struck up conversation with the bartender and the day’s situation unsurprisingly came up. They worked through the events amongst each other, the disbelief evident in their tone as they commented, speculated, and wondered out loud.

I remember listening in silence, finding it bizarre that part of their conjecture was a reality I had seen and that I had answers to some of their rhetorical questions. However, one unanswerable question that everyone had, myself included, is what ultimately drove him to do something so horrific.

It came out later that the gunman had mental health issues, which can sometimes go hand in hand with a very difficult life depending on the nature of the illness.

Nevertheless, that doesn’t change or excuse the fact that he coldly and deliberately murdered someone.

In what can be an extremely difficult situation to find any form of empathy or desire to treat patients like this with the same care that we attempted to provide to his victim, perhaps knowing their background can lead to a softened mindset to be able to do what is right by the patient.

I have always thought that one of my strengths is my ability (or at least constant effort) to integrate patient stories, backgrounds, and compassionate patient-provider connections into the very logical, left-brain, goal-oriented field of surgery. These aspects unfortunately clash on occasion due to the time restrictions and nature of not just surgical services, but our healthcare system as a whole. However, it’s a balancing act that I stubbornly desire to maintain.

After this experience, I have thought of ways to maintain that perspective in difficult situations such as this.

But perhaps there’s another way to look at it.

In constantly trying to find that correct equilibrium of involving emotions and keeping them removed from situations, perhaps this is a scenario where cutting off emotions is not just the best option, but instead is what is most necessary to best to treat the patient…to provide the patient with the highest quality care while also treating them with equal dignity.

Still, caution needs to be had with that line of thought so that emotional exclusion doesn’t inadvertently turn into a jaded coldness.

With all of that being said, I ultimately suppose that my hope of his survival is created from an abstract mix of emotion and objective commitment…a moral creed where an excuse or motivation isn’t needed and at the end of the day the reasoning statement that I stand behind is simply “I’m doing this because it’s the right thing to do.”

Because at the end of the day, the shooter – the murderer - was still the most important person in the room…the patient. 

Shades

1.

I once had a patient who told me about his lost love.

He was a writer. Middle-aged. And his voice was so soothing that it immediately brought a mental halt to the rush that clinic usually consisted of.

There are a few patients that I wish I could have had more time with – more time to hear their stories, their backgrounds…what makes them tick. These patients are automatically able to keep me present, to slow my mind that’s always waiting and watching and planning for the next thing.

He was one of them.

And it was peaceful.

He told me about his wife that had died from a rapid form of multiple sclerosis. It was a story of death I had unfortunately heard many times before in the hospital, but my breath caught when he not only told me the amount of years but also the months, weeks, and days it had been since she died.

He recounted how he had dreamed the other night about her. The emotions he expressed were so raw, and his desire to be with her so heartbreakingly, poignantly felt, that tears threatened to spill over and I felt chills go through me. There was a selfish part of me that in the moment (and even months later) ached for a true, mutual love like he had.

Her presence should have been (was) there. His voice remained the same calm cadence as he spoke, though not without cracks of emotion breaking through. Had those cracks been present every day of the years, months, weeks, and days since her death?

I walked out of the room looking at the world a shade differently due to him, my world having slowly been filled with more and more shades as third year had progressed and I learned more and more lessons from incredible patients.

Is it ironic that he was at clinic for an issue with his heart?

2.

I once had a patient who was starved by her step-father.

She was five. Severely underweight. Her step-father abused her, hit her, and withheld food from her to the point where she had been eating paint chips to try to get nourishment.

Her mother was just as malnourished as my patient was, but far more haunted and far more defeated.

I was in the pediatric floor hallway with my team one day as the little girl rode by on a mini tricycle, a wide smile on her face as she looked forward right past us and kept going without a single glance.  

I never saw her mother smile like that, and I sadly wondered if the little girl was one day going to have the same smile – one that never surpassed grim and forced.

On my last day on the service, I went in to say goodbye. The little girl ran up to me and excitedly showed me her painting.  I’m torn on whether it was painted in blue or purple, but I remember one of those colors was her favorite.

It’s been over a year and I still hope that excitement and smile is still there.

3.

I once had a patient that I accidentally caused unnecessary pain.

It was a simple staple removal from a surgery on his neck. It had been awhile since I had removed staples and I accidentally removed the first one incorrectly. He gasped in pain as the staple dug in deeper, and the shame and fear I felt at just that minor error raced through me.

I apologized (but does that even matter?).

It took me a couple of minutes to slowly correct my mistake. My voice was clear and reassuring as I distracted him from the added pain by asking about his life story and his family, though I’m glad his head was turned away from me so he couldn’t see my hand shake as I slowly (and painlessly) removed the rest of the staples the correct way.

At the end – he thanked me and told me to have a nice day. I probably wished him the same.

I walked out of the room feeling inadequate. If I had screwed up something so stupidly simple, how was I supposed to handle anything else? Imposter syndrome at its finest.

Since then I’ve removed plenty more staples, never making the same mistake again. I’ve also done more difficult procedural techniques since then with no problems.

However, I still remember that staple and the pain I caused.

I also remember the humbling power and responsibility that I had over causing or not causing that pain.

“Do no harm” is the ideal command of perfection that should be applied to every person and every situation.

But what do I do about the fact that I am so imperfectly human?

4.

I once had a patient that gave birth to her first child.

She and her husband were a kind, soft-spoken Indian couple. They didn’t speak much during her laboring process but their joy didn’t need to be expressed in words – I could see it plainly written across their faces. It was an unashamed nervous excitement, and the energy of it permeated the entire room.

I sat with her at the foot of her bed for at least 2-3 hours, working through each pained push alongside of the nurse, listening to her baby’s strong heart beat on the monitor as we encouraged her to take deep breaths.

Her husband never let go of her hand.

As the end (or was it the beginning?) neared, the attending walked in and we put on gowns and gloves. The foot of the bed was dismantled to get ready for the final pushes. The excitement grew. The simple, soft-spoken encouragement turned into loud cheers from everyone and I was reminded of when I used to play sports in high school.

Everybody was distracted in the room by the closeness of the baby’s arrival but I felt hesitation as I stood where the resident or attending would normally stand – in the spot of the person that would deliver the baby. I took a moment in the loudness of the room to look back at the attending that was standing right behind me.

I leaned toward him and murmured softly, “You know I’m a 3^rd year medical student and not a resident, right?”

He smiled and nodded. I haven’t forgotten that twinkle in his eye as he gestured forward and my uncertainty disappeared.

A few minutes later the baby was delivered – a girl. The nurses took the healthy, crying baby from the attending’s hands and mine and placed her on her mother’s chest.

I’ve done a lot of cool things in medical school, especially as I delve further and further into the surgical world, but helping to deliver their little girl still has to be one of the most amazing things I had the privilege of doing.

I also still feel honored to have been able to witness their first moment as a family - the look of pure emotion on the face of her parents one that I’m certain can’t be rivaled in our present day society.

5.

I once had a patient that refused to give up.

Would it then be a contradiction to say she that was admitted to the psychiatric unit for depression and suicidal ideation?

She was 16 and had already been through more mental, physical, and sexual abuse than any human being, let alone someone her age, should ever have to go through.

I spoke with her for nearly two hours. A nurse practitioner was in the room with us, tuning in and out to the conversation and occasionally chiming in, but overwhelmingly leaving the conversation up to me.

The girl’s kind demeanor was just one of many things that struck me about her. There was no coldness, no bitterness, and no anger – though any of those emotions would have been justified. Instead, she had a simple reserved softness along with a dry sense of humor and a resigned sadness in her eyes.

A part of me lamented at the fact that the conflicting parts of her personality were likely due to the way life had treated her, while another part of me was hopeful at the obvious glimpse of resilience that she portrayed.

The prepared, organized (and impersonal) template of questions quickly gave way to a more natural life conversation that interestingly still gave me all of the information I needed for official documentation.

We talked about things that made her cry as she shared some of her life story for the first time with me. I tried to contain my tears the best I could but she must have noticed them at some point (and that’s okay).

We also talked about things that made us laugh. We were 10 years apart in age but still close enough within a generation that we could share pop culture references, giving each other a knowing, humorous glance when the older nurse practitioner tried to join in and comically failed. 

We went from one moment talking about the ridiculousness of 50 Shades of Grey to another talking about how she slept for a week on a mattress by a dumpster behind a closed down taco restaurant. The casual juxtaposition of topics made my head spin and reorienting myself during our conversation was challenging.

I left that day shaken, angry, and heartbroken that she, by no choice of her own, was born into a life situation that persisted in trying to snuff out the light she so clearly exuded.

As each day progressed, and as therapy, medication, more tears, and healthy discussions with nonabusive family members occurred, I saw her get stronger. The potential promise in her future with the life goals that she had was hopeful.

On my last day – a Friday – I took her aside and wished her the best and told her that I had enjoyed getting to know her as a person. She thanked me for listening and told me she was going to miss me for the rest of her admission. We gave each other a hug.

I don’t know what happened to her but I think of her often. I sometimes check her patient record to see if anything new happened and I can never discern if I feel relieved or frightened that there have been no new records since she was discharged. She was the backbone of a speech I gave a few months ago – an example that will always remain fresh in my mind on the strength of patients through adversity and the power that can exist between a patient and those that are taking care of them.

When she does cross my mind, I always hope that she’s doing well and that life has been more kind to her, but just as importantly, I also hope that she’s continued to fight with the resilient spirit I saw those few days when she was my patient. 

The Red Line

“Time of death – 9:13am.”

I was standing behind the red line in the trauma bay, the marking an arbitrary delineation to somehow make us feel removed (but how?) from the organized chaos that was usually happening on the other side of it.

I didn’t feel very removed from it that morning.

The trauma had come in during morning sign out, a routine in the medical world where whatever team was going to be leaving would run through the list of patients with whomever was starting their shift. It’s a ritual we’re all familiar with…and it’s one we often hold onto throughout a shift, a harbinger of the fact that it’s okay for us to finally leave and go back out into society.  

That day’s sign out came at the end of working nearly a 29-hour shift. I had caught my second wind early that morning, finally being able to do something useful with my fourth year medical student status as I hastily prepared the lists of patients as my residents were downstairs tending to yet another trauma. It was the twelfth one of that night and though my team was exhausted, I admired how the residents worked through it with fortitude, their only comments being a simple “I’m hungry” or “I’m tired” throughout the night, if that. I often wonder what they looked like when they weren’t in the workroom – when they were walking the halls of the hospital alone at night where no one could see them.

I worked through the lists quickly. Vitals. Ins and outs. New labs. Check. On to the next patient and repeat. 18 of them. I went and said good morning to some of the patients I had routinely been seeing, one having been hit by a truck in a parking lot and another having survived a self-inflicted gunshot wound to the inside of his mouth and brain. I made copies and left for the elevator, stopping along the way to look outside the window of the 10^th floor at the ending sunrise. I was content in that moment and I took a picture.

Morning report started at 8:30am, each of the teams showing up to go through the list of updates with patients. It was towards the end of it that the trauma came in – was it the 13^th one of the night or the 1^st one of the morning?

It was a gunshot wound. The patient was coming in hypotensive. As residents rushed out to get downstairs to the trauma bay before it arrived, I lazily stayed upstairs with the rest of my team, ready to leave and go home to eat and fall asleep. It was a last minute decision that I decided to go downstairs just to watch the trauma.

There were more people than usual crowded around behind that red line, some spilling over into the trauma area itself. It was quiet, which was something I still found myself occasionally surprised by. Everyone pictures the loud chaos that is often presented in television shows, but in reality it’s not like that. Quiet is needed to yell out what’s happening with the patient - orders and physical exam findings and IV access success being shouted out in a systematic fashion. My job as a medical student was to silently cut off patients’ clothes and cover them with warm blankets through the process – to cover up their dignity as I also ironically cut away the only thing they came into the hospital with.

This time was essentially no different, except for this trauma I was a witness, and instead of seeing a stable patient, I walked up to something quite different.

A cracked open chest. Blood spilled on the floor. Resuscitative measures being done in full force. The critical care fellow’s and attending’s hands shoved into the patient’s chest, around his heart, desperately searching for the injury.

They found it. A bullet through the heart. From the posterior left ventricle through to the anterior. An injury that can’t be survived. Everyone stopped what they were doing and time of death was called. 9:13am. I could see the patient’s feet poking through the blankets they were covered with, already looking more pale. There was a part of me that wanted to reach out to touch his toes just to see if they were already going cold from lack of blood flow. The patient’s face was uncovered.

The trauma attending took time after that to teach. It wasn’t every day that there was fresh anatomy splayed open and available like it was. He reached in and explained the difference in feel between the esophagus and the aorta, a major vessel coming out of the heart that delivers blood to the rest of the body. The former has a gritty feel, the latter does not.

There was a part of me that was initially outraged at the objective coldness of what was occurring. The patient had just died in a horrible fashion. What were his family or friends thinking, if he even had any? Were they picturing us doing everything and anything we could to save their family member? That had indeed been done, but what would they have thought about us doing an advanced anatomy lesson so quickly afterwards? The patient’s toes may have started going cold, but certainly there were still parts that were warm.

But then, as my brain so often does (out of necessity?) in this world we call medicine, it split to look at it from a more objective standpoint. There is no doubt that what he was teaching would save more lives in the future, in an emergent situation where perhaps the only thing a doctor had to rely on to save a life was not imaging, fancy equipment, or even visual inspection, but instead just a blind feel to identify a major injury – the gritty versus the smooth. It was a very real possibility and I recognized the importance of the moment despite my reservations.

Discomfort in my gut, and still not sure how to feel, I gowned up and stepped forward past the red line to look and to feel and to learn (it never ends). I could see the black specks on the patient’s lungs – evidence of a smoker. It was the first thing that stood out to me. Inspection – check. I looked at the attending and asked if he could show and teach me. He nodded and began. I indeed felt the difference between the gritty esophagus and the smooth aorta. Next, I moved to the heart. Still warm. How about the toes? The attending showed me where to feel, and soon after one of my fingers moved through the back of the heart as another moved through the front. They met in the middle in a way that they should never have been able to had a bullet not carved a path through the tissue. Palpation – check. Auscultation could not be performed as the heart was no longer beating and the lungs were no longer breathing.

I didn’t linger after. I removed my gown, gloves, and mask and stepped back behind the red line. I contemplated what to do next and the first thought that popped into my head was whether I should go eat breakfast right then or to wait until I got home. The thought came before I could stop it and I immediately blanched, feeling shame crawl through me. I then spent a moment feeling torn over whether I should even feel ashamed of thinking of eating right after what had just happened.

I struggle a lot these days with the concept of humanity in medicine, especially in the field of surgery. How can one maintain their sense of humanism and vulnerability and emotional connection when one is constantly subjected to seeing difficult, horrible, and emotionally impactful things on a constant basis? Is there a way to healthily disconnect? It’s something I fear for myself quite frequently, and thinking of whether to eat breakfast or not, brought up that fear immediately.

I thought back to earlier in the evening when another patient had arrived with a knife broken off in the back of his neck after being stabbed by a man that had been stalking the patient’s granddaughter. The patient was miraculously stable, but nobody initially knew if the knife had been embedded in any of the major arteries or veins in his neck. It was that time frame which was the most terrifying and uncertain. The patient was lying on the trauma bed during this period, unable to move so as to not disturb the knife. He was fully coherent, though his speech was soft and mumbled. I remember leaning down as close as possible to gather as much medical history and information as I could – it seemed almost silly to be asking the patient when their last meal was (a necessity in case they needed to go to surgery), and I could only wonder what the patient was thinking.

Was he thinking that he was going to die? He must have. I can’t begin to imagine the fear that must have been going through him. Death had been a very real possibility (but his toes were still warm). The only sign that betrayed his knowledge of the situation were the tears rolling down his face. As he answered my questions he was unable to reach up and wipe them away. I grabbed a tissue and spent a moment dabbing at his tears and holding his hand in silence. It was the only thing I could do. I had a thought that doing just that simple thing was equally as important as any question I had asked. Because what is medicine or healthcare if humanity is absent?

Thankfully, the knife had missed his major arteries and veins by centimeters and it was safely pulled out in the OR without causing a lung collapse. He was moved to an ICU bed due to difficulty with extubation, but other than that there were no issues. However, we did discover later that the patient had stage 4 lung cancer. The irony was not lost on me – saved by external forces only to undoubtedly succumb to internal forces in what was probably a few months.

I went home that morning with thoughts of these two stories heavy on my mind, both a humbling example of the successes and failures of medicine in many different ways and how human connection weaves its way through every patient that comes through the doors of a hospital. I also went home unsure of how to feel, and was too exhausted to even begin to figure it out. I did know that I was disturbed and scared by the semi-removed thoughts I had during the last trauma of the day and what the future was going to hold.

Will I be able to find a balance? How much should I remove my emotions from a situation, not just to protect myself, but also to protect a patient from the fact that emotions can skew a logical decision? Is there a healthy way to do it? I’ve watched the residents during trauma calls and they all seem removed from it (note – I do not mean or imply that in a negative way; it’s just fact). What were they feeling on the inside? Anything? Did they go home and process after? How do they cope?

Can I handle this? Am I strong enough?

I don’t have answers to any of these questions, and I don’t think I will soon. At least not until I experience more and have a few years under my belt. And even then, I still will probably have the same questions but from a different perspective. I can imagine that the questions never truly end. I can say one thing about myself that I do know – I’m stubborn as hell. And that fine balance between disconnecting and connecting is something I desperately hope to maintain the correct perspective on. May my stubbornness help with that.

Right now, the most I can do as I work through the entire process of developing a career in medicine is to keep striving to be the doctor – and the person – that I want to be…one that doesn’t forget the human connection behind it all.