“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 10th 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 13th one of the night or the
1st 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.
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