Puella cum Cultello

girl with a knife – the tired ramblings of a female surgeon-in-training

Tag: sadness

The three hapless amigos

Friday nights are perfect for hanging out with your buddies and partying, maybe going a little nuts.  It’s just innocent goofing off, all fun and games… until someone wraps a car around a lamp post and the three amigos are pulled from the wreckage.

Well, first, there’s the dead one.  He never had a chance.  The impact tossed him around for a few seconds, until he was ejected.  He landed 30 feet from the car.  There was no life left in him to salvage when the cops arrived.

Then there’s the organ donor.  He was driving.  By the time the medics got him out, his body and brain were already giving up.  They kept his body alive long enough to get him to the ER.  Then we were able to keep him alive long enough to gather the family.  Mom, dad, and little brother look shell shocked this morning.  Grandma’s still crying.  There’s about thirty friends with tear-streaked faces loitering about in the hallways.  People are asking each other, “How could this happen?”

Easy peasy, I want to reply,  Take three young men who believe that they’re special immortal snowflakes, add a case of beer, and the keys to dad’s sports car.  Voilà.  Instant wreckage.

Instead, I walk past, head down, in respectful silence.

Finally, there’s the spoilt brat.  There’s always one.  He has a couple of extremity fractures and the delightful attitude of Verruca Salt.   He appears to be doing his best to antagonize the nurses. Periodically, you’ll hear him bellow from across the ward, “Nurse!  I want some water!  Nurse! Where’s my food, I’m hungry!  Nurse!  Gimme my pain meds!”

I wonder if he’s confused and believes that he’s at Burger King.  You don’t get to have it your way in the hospital, buddy.

Perhaps, for now, he thinks he’s the special-est snowflake of them all.  But eventually,  even he will melt into nothingness.

Code Blue

Because I could not stop for Death,
He kindly stopped for me;
The carriage held but just ourselves
And Immortality.
-Emily Dickinson

In medicine, we confront death on a daily basis.  It’s been 8 years since I started medical school, but for me, it remains sad, terrifying, poignant, brutal.

The first code I participated in was all of these and more.  I was on call on a Saturday evening with another 3rd year medical student, W. It had been a slow day, and we were just hanging around, studying, chatting, and waiting for 6pm.  W had taken a short break while I continued reading, but she’d been gone for a while.  I decided to give her a call.

While we’d been separated, she had been drawn into a “code blue” on the fifth floor.  This was was where ventilator-dependent patients, among our sickest, were placed – never a good sign.  I raced up the stairs before W could tell me the room number.  I knew that when I reached the ward, the crowd that assembles at every code would lead me to the correct place.

I no longer remember the patient’s name, or even what she looked like.  But I do remember that she was a young woman, diagnosed with an aggressive cancer while her children were still in need of mothering.  Even though her condition was terminal, her husband had insisted that everything possible be done for her.  Death had been looming for weeks, but he wanted their children to have their mother for every possible second, no matter how incapacitated she might be.  She’d spent the last few days alive but unable to interact with them in any meaningful way.  On this quiet weekend afternoon, with none of her family nearby, her body was finally giving up.

She was one of my first lessons in clinical detachment.  During this code, she wasn’t a wife or a mother anymore, she was just another patient, one we were trying to keep alive at her family’s behest.  We knew that we were fighting a losing battle, even if her husband had refused to accept the limits of our abilities.

A couple of residents were taking turns pumping her veins full of medication and pounding on her chest, the respiratory therapist was trying to keep pushing air through her tracheostomy, and W was standing in a corner, holding up an IV bag and looking as though she hadn’t yet decided whether to cry or vomit.

I caught our resident’s attention and asked what I could do.  I became the designated equipment runner, a task complicated by the fact that I was unfamiliar with this floor and couldn’t get into any of the locked supply rooms.  I proved far more adept at relieving W from her imitation of an IV pole.

The code went from bad to worse.  The patient’s heart wasn’t responding to medications, chest compressions, or electrical shocks.  The pumping of the ambu-bag was frequently interrupted by attempts to clear the secretions which were plugging up her trachea.  Blood-tinged froth bubbled from her mouth and nose.  Her pulse was thready despite the fluid and medications we were giving, and her blood pressure was too low for our monitors to detect.

Finally, after 40 minutes of this, the attending running the code allowed us to admit that we had lost this round: “I’m going to call this one. Everyone agree?”  She named the major team members one-by-one, making sure that there was consensus, that we had done all we could.

As the techs, nurses, and residents filed out, W and I stayed.  The attending taught us the steps of confirming brain death: the patient was totally unresponsive; she didn’t have any brainstem reflexes; there were no breath sounds.  We were instructed to ignore the slight fluttering of eyelids before her dull eyes were hidden – it was merely a sign of residual electrical activity in her peripheral nervous system, not an attempt to show us she was still clinging to this world.

Neither W nor I were sure to say or do next.  We’d seen dead people before, from the cadavers in anatomy lab to the autopsies in pathology.  We’d met hundreds of patients already.  But today, for the first time, we had watched someone die.

No lecture, no group project, no role-playing session prepares you for that moment.

So, we reverted to helpful medical student mode and tried to assist with the clean up, using damp towels to wash the body of a woman we had never known while she was alive.  The nurses would then tidy the rest of the room to allow her family to say their final goodbyes.

After wiping the last of the blood from her face, we covered her limp, broken body with a clean sheet, as though concealing our collective defeat.

She was finally at peace.  We were not.