Sunday, August 13, 2017

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 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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