Puella cum Cultello

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

Tag: trauma

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.

Keeping control

You immediately wonder what actually happened.

She came in with increasing abdominal pain after falling down the stairs 3 days ago.  It’s an isolated splenic injury.  The story doesn’t add up.  The mechanism of injury doesn’t fit.

Why wait so long?  What is she hiding?

Her boyfriend seems off-kilter from the start.  Something about his manner – his eyes, his words, his tone – he reminds you of someone you once knew.  Someone you thought you’d never have to see again.

She barely opens her mouth to speak.

He answers for her.  He controls the conversation.  He becomes her voice.

Her ex-husband and son are with her as well.  They ask to speak to your team after rounds.  They don’t believe her.  They’ve seen what she’s become – a shell of herself.  His plaything.  They know.

He did it.  He’s done it before.  He’ll do it again if – when – she goes home with him.

The next day, he knows he’s been exposed.  He’s far too friendly, too obvious, too familiar with all the women in the room.  He gives you an ingratiating smile.  It’s a calculated greeting, intended to give him the same power over you.

Your stomach turns, and your jaw sets.  You can’t – won’t – refuse to – look him in the eye.  He cannot have that.

She finally goes to the OR when the bleeding won’t stop.  You want to shake her when she wakes up, to make her see sense, to give her the courage she needs – before he sees her, before he can bewitch her again.  Your fists clench, and the flames begin to burn inside you again.  Because you know how this story goes.

But in the end, you realize… this is not your battle.  And she’s not the one you’re really angry with.

Waking up slowly

When I first saw her in the trauma ICU, she was posturing.

B was a college student who had been on a skiing vacation with her family when she lost control and broke her leg.  She was taken to a hospital closer to the mountain, where her fracture was repaired.  Unfortunately, she’d suffered from fat embolism during the operation.  Fatty marrow from inside the bone had entered her bloodstream, eventually becoming lodged in her brain.  When she wouldn’t wake up, her family asked for her to be transferred to our specialist trauma center.

For the first few days she was with us, B showed very few signs of improvement.  Her parents were at her side every day, and during our rounds, they would insist that she was progressing.  I didn’t see it though.  When we examined her, she would grimace and extend her arms – decerebrate posturing, a sign that her brain was massively damaged.  Patients with this type of response to stimulation typically don’t do well.

But our attending, Dr. D, remained optimistic.  He said it was too soon to tell.  Patients with fat embolism tended to do very well in the long-term, he insisted to a skeptical crowd of residents.  He sent us articles to back up his claims, but I still couldn’t believe that B would ever wake up, let alone return to any kind of normal life.

After about a week of this, B was physically well enough to be sent to a regular hospital ward.  She was still quite unresponsive, but Dr. D was unflappable – “Give her a little more time – you’ll see.”

Some weeks and many patients later, I was getting ready to move on to my next rotation.  I was chatting with G, one of the trauma coordinators.  She knows me quite well, so she knows which patients bother me the most.

“So, girlwithaknife, remember B?  She’s going home soon!”

“Really?  To rehab?”  I assumed she’d be sent somewhere for traumatic brain injury.

“Nope, she woke up, she’s done her rehab, and she’ll be going home-home.”

“No way!”  Just a few weeks ago, I was convinced that she’d remain in a permanent vegetative state.

Later that afternoon, I found some time to duck out of the ICU.  I walked over to the rehab unit and found B’s room.  I knocked and heard her voice for the first time, weeks after first meeting her.

“Come in.”

The girl who I thought would never return to independent life was sitting up in a chair with her healing leg propped up.  She was awake, alert and oriented – and serenely buttering a slice of toast.

I introduced myself and sat down.  She apologized for not remembering me.  I could only shake my head and chuckle at her words.  I still couldn’t believe she was awake.  We had a brief conversation before I had to leave her room and return to work.

I left feeling oddly settled.  I was wrong, Dr. D was right.  And I couldn’t have been happier about that.

With apologies to Robbie Burns…

The best laid schemes of brides and grooms
Go often awry,
And leave us nothing but grief and pain,
For promised joy!

It is an honor, I suppose, to be allowed into people’s lives at the worst moments, to see them at their most vulnerable.  That privilege is most apparent in the trauma room, where we see men and women whose lives have been altered suddenly, their weaknesses exposed.  We often see tragedies, but, sometimes, it’s clear that things will be OK.  Eventually.  And with how many bad endings we encounter, avoiding the gallows humor of these more positive situations is hard.

Several years ago, we had multiple traumas arrive from a single vehicle accident.  They were several young women, very nicely dressed, and clearly, they had been headed for a celebration of some kind.  As we evaluated each of the patients, we learnt more of their story.

This was a bridal party, and they were on their way to the rehearsal dinner when the driver, the bride, lost control of her car.  Luckily, everyone was seat-belted, and the car was moving relatively slowly.  No broken bones, no major injuries, although there were many scrapes and bruises.

Well, except for the bride.  She’d hit her head on the steering wheel, though luckily, she appeared not to have a concussion. Unfortunately, she did have a fat lip, a black eye, and at least one missing tooth.  When the groom arrived, he was beside himself with concern for his soon-to-be-wife.  He was very grateful that she had survived relatively unscathed and didn’t appear concerned by her appearance at all.  By the time the women were discharged, it was clear that while the rehearsal dinner was cancelled, the wedding would continue as planned.

The team retreated to our work area to finish our notes.  As I was scribbling, I thought about the poor young driver, feeling immense pity initially.  This accident, after months of planning, untold expense, and worry… in the end, she would never be able to show her children beautiful photographs from her wedding day.  Instead, she would have memories of her bruised and battered face for the rest of her life.

Of course, it could have been much worse.  In this case, the show would go on, the couple would still be able marry, and they had the opportunity for a long and happy life together.  Her facial injuries would eventually heal, and, well,  she would have quite a story to share with her grandchildren.  At least she could look forward to a tropical vacation with her new husband.  After all this, it would be nice and relaxing.  Hmmm…  I chuckled quietly.  The resident next to me turned her head, giving me a quizzical look.  I just shook my head and muttered, “I’m terrible!”

“Why?” she asked.

“Well, imagine the look on the face of the front desk clerk when they check in together at hotel for their honeymoon…”

We both collapsed into giggles.