Friday, December 29, 2017

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?


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. 

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