“Hey man, we have an ex lap going into OR 18,” said my junior resident.
I looked at my watch. The time was 2:45 AM. I was still trying to shake the cobwebs from my head when my junior added, “ACLS in progress.”
That got my attention. “Room 18?” I confirmed. “I’ll be right down.”
I hurried to the OR and grabbed a mask, looking through the window as I did. Despite the flurry of activity surrounding the patient, I could see that the left side of his chest was cut wide open. I could see his heart beating through the incision.
People were already engaged in resuscitation as I entered the OR. I quickly surveyed the scene – patient status, monitors, lines, etc. – as I stepped to the head of the bed.
“What’s the story?” I asked my attending.
“This guy fell forty feet from a train,” he replied. “Get an a-line started.”
I grabbed an a-line start kit and an ultrasound as I stepped around to the patient’s arm, anticipating difficulty finding a good radial pulse. “He fell off a train? Strange place to be at two in the morning.” I felt for a pulse, got nothing, and fired up the ultrasound. In place of a pulsatile artery, I saw a shallow round vessel that was slightly less compressible than its neighbors. After two attempts at cannulation, I was rewarded with sluggishly pulsing arterial blood.
By the time I secured the arterial line, the surgeons had already opened the abdomen and unleashed a torrent of blood. I stepped to the head of the bed and began directing the patient’s resuscitation together with my attending. The first ABG was not reassuring. pH 6.75, PaCO2 over 70, base deficit approaching 30, iCa around 0.7...things were looking less than stellar for this patient.
Over the next several minutes, we continued resuscitating the patient with blood products, vasopressors, calcium, and other drugs, attempting to keep up with the rapid blood loss that continued on the other side of the drape. I asked my attending what else had transpired prior to our operative management, and he told me that the patient had arrived in the ED with cardiac activity but without a palpable pulse. He quickly proceeded to complete cardiac arrest, at which point a code was called. The ED attending was ready to pronounce the patient, but the chief surgical resident on call performed an emergency thoracotomy, applied an aortic crossclamp, performed manual cardiac massage, and injected two doses of intracardiac epinephrine, at which point the patient recovered a perfusing rhythm and was rushed to the OR for surgical management.
“What do you see in there, John?” I asked the surgery resident.
“He’s got a huge liver laceration,” he answered.
“Is he making any clot for you?” I asked.
“Not really.”
So we continued with our management, administering packed red blood cells for oxygen-carrying capacity and plasma, platelets, and cryoprecipitate to promote clotting. But the bleeding was too fast, and we seemed to be falling behind.
“Give him factor VII, 90 mcg per kilogram,” ordered the attending trauma surgeon.
Factor VII is a recombinant clotting factor. It is reserved for cases of severe coagulopathy in which other attempts to control bleeding have failed. This is for two reasons: it can promote dangerous amounts of clotting in many patients, and it costs about $1 per microgram. The requested dose of 9 mg was therefore something to be given only when necessary. We called the pharmacy and placed the order.
After a few minutes, the factor VII arrived and was given. Still the patient continued to bleed. Still the surgeons attempted to control the hemorrhage. Still we persisted in our resuscitative attempts. The trauma surgeon ordered 10 mg more factor VII, and this was given.
And then the trauma pager sounded.
“Major trauma alert,” read my junior as he took the pager from his hip. “Gunshot wound to chest.”
“I know about that patient; he’s stable,” said the trauma surgeon, “but I should still go eyeball him.” With that, he scrubbed out and left the OR.
For the next ten minutes, we continued our resuscitative efforts as the surgery resident packed the patient’s abdomen in an effort to tamponade the bleeding. But when the attending surgeon returned, we still seemed not to have made much headway. And in addition, the patient’s pulmonary status was worsening, probably from all the blood products he’d received.
“How’s it going, John?” the attending surgeon asked as he re-gowned.
“Um...not excellent, sir,” the surgical resident responded. “He’s still bleeding pretty bad.”
“He’s not looking great up here, either,” I told him. “We’ve got increasing airway pressures and decreasing sats. I haven’t been able to suction anything out of his tube, either.”
Our resuscitative efforts continued in earnest as the attending surgeon and attending anesthesiologist conferred. Ultimately, they decided that the best course of action would be to pack the patient’s abdomen and take him to the ICU for continued resuscitation and respiratory optimization on an ICU ventilator.
My attending and junior transported the patient to the ICU while I stayed behind in the OR to reconcile the chart and ensure that all blood products and controlled substances were documented appropriately. It took me over an hour, and I eventually determined that the patient had received over 80 units of blood products in our attempt to save his life.
Unfortunately, there is no happy ending to this story. The patient required more epinephrine upon arrival in the ICU and another code was called within minutes. Within forty-five minutes of leaving the OR, it was all over.
The next day, I went to church. I spent some time talking to a friend and told him about my patient. By the time I finished, he was shaking his head.
“I don’t know how you guys do it.”
“Do what?”
“How you handle taking care of these sick patients without losing it? I couldn’t handle it.”
I had to think about his question a bit before I could answer. While I’ve been involved in the care of several patients who have died, none has affected me quite as much as the first one did. After this most recent patient death, I had finished my charting, driven home, and gone to bed. Was that callous? Had I become insensitive to the sanctity of life, able to attend its passing with as little emotion as I would feel watching the “death” of character played by a television actor? The patient who had just died was someone’s friend. He was someone’s son. Maybe he was someone’s brother. Maybe their husband. Maybe their father.
So how did I deal with my proximity to such tragedy? I maintained clinical distance from the situation, viewing the patient as a case rather than as a man. And even as I realized this with a wave of guilt, I knew that’s how it had to be.
Maintaining clinical detachment from tragedy in the hospital is how I maintain the composure and professional objectivity to make decisions under pressure. It’s how I keep my nerve when I know a poor decision could result in considerable harm or death to another person. It’s how I reset after a difficult or complicated case so my next patient can receive my full attention and best care. It’s how I fall asleep mere hours after watching the life leave another human body. I can’t speak for my colleagues, but emotional detachment from tragic circumstances is the coping mechanism that helps me face serious illness and say, “I can handle this.”
And yet, in my quieter, more reflective moments I often feel the humanity of my work rush back to the forefront of my consciousness. I find myself regretting my inability to cure all ills, and I pray that God will right the wrongs that defy the limits of human ability and of mortal comprehension. It’s during such times that I remember the faces and the voices of those who have slipped beyond the veil of this life and into the next. I pray that they have peace, and that their loved ones may find comfort even as they grieve. I think of my own father and give thanks for the outstanding medical care that eased his pain at the end of his mortal journey, and I pray that I may have the wisdom, knowledge, and sound judgment to provide such excellent care even when faced with disease that exceeds my ability to heal.
During these reflective moments, the patients cease to be cases; they again become human beings, men and women whose time on Earth came to an end. Inevitably, I reflect on the tenuousness of life and of the common threads that tie all of us together, the events and needs that we all experience. Then I realize that each patient who dies is not just a patient; it is my brother.
And with that realization, I have wept for those I was unable to heal.
