the healing muse

Volume 5, 2005

Juan

Michael D. Burg

About ten people have already been briefed, but as more flood into Trauma Room #1, each wants an updat. e"Blunt trauma, full arrest," I repeat as each new physician, nurse, tech, or other healthcare provider enters. "That's all we know. We'll learn more when the paramedics arrive."

Looking around the room, I see my team members getting ready: strapping on goggles and masks, tying on gowns, and snapping into gloves—preparing for battle. As they don their medical armor and talk, the room hums with an electric buzz. It's the pre-game jitters.

The paramedics had radioed in moments before. "This is RA 147, working a scene with a man down outside his car. On our arrival he had agonal respirations and a thready pulse. He’s 1144 now, intubated, CPR started, IV wide open. ETA two minutes, code 3."

Agonal breathing reminds me of a fish out of water, gills open, straining to suck in oxygen. A thready pulse means shock, cells suddenly starved for sustenance, the heart's efforts insufficient for the body’s needs.

As an emergency physician at a busy teaching hospital, with fourteen years of post-residency experience, I get it . . . instantly. I can picture the incident. Rescue ambulance 147 paramedics are providing medical care to a man lying on the ground by his car. He was barely alive when they arrived. Now he has no signs of life. One intravenous line is in and flowing, a tube has been inserted into the throat to provide oxygen and ventilation, and chest compressions are ongoing. Driving top speed, they'll be arriving at my hospital in two minutes, sirens howling, lights flashing.

The short, hurried call has brought the trauma team running. Moments later the paramedics wheel their patient into the trauma room, CPR in progress. Their report is terse. "Approximately forty-year-old male found down outside his vehicle in near cardiopulmonary arrest after his car hit a pole. IV, oxygen, intubation, CPR, transport," intones the paramedic, her flat voice carrying the emotional impact of typewriter keystrokes. "No response to therapy. Front-end damage to the vehicle, no seatbelts, no airbag, unknown closing speed, no other medical history available."

Paramedics primarily care for patients, which is different from "working a scene." Sometimes a human-to-human connection is made. Caring happens then. Sometimes it's just a job; that's "working a scene."

The paramedics—no matter how seasoned or how tough—are often tender, almost lovingly so, with patients. This is especially true for the infirm elderly and children. The paramedics seem to bond with them, even during their brief time together. I often overhear comforting words as the medics transfer patients from the hard, narrow ambulance gurneys to ours. "The docs and nurses here are great. They'll take good care of you. Everything will be all right."

This one's different. From the beginning it seems as if this patient is nameless and faceless to the field personnel. Perhaps it's because he never spoke to them. The paramedics didn't have time to check his wallet, so he's come in as a "John Doe" and is assigned a trauma number. I notice that he's young, maybe mid-thirties, about the same age as many of the paramedics. Possibly it's too painful for them since they identify with him. They don't want to see themselves as he is now, found down, lifeless, after a car crash. Distance may be a way to avoid painful thoughts of mortality. I can't dwell on it, but it strikes me as odd, atypical, and sticks in my head.

In the same way, the emergency department workers—nurses and doctors alike—treat this "found-down-full-arrest" not like a human being but like a spent biological object. Alive moments ago, his heartbeat, thoughts, and speech made him one of us. Suddenly he's been relegated to another, lesser, category.

He's unceremoniously moved from the paramedic gurney to the resuscitation bed, deposited there with a rough thump. Most in the room set to work on him like miners digging into a seam of ore. A workaday atmosphere exists; but there's something more, an unusual sense of disrespect that sets me on edge.

As the emergency department attending physician, I head half of the trauma team, the part concerned with managing the patient's airway. I’m also responsible for directing the overall care of the patient, for running the resuscitation and making sure that the team follows a priority-driven approach. I've been an attending for fourteen years, the last six of which have been spent in academia, teaching doctors in training. I now work at a trauma center, one that sees much of the horrible medical stuff that gets splattered across page two of the newspaper in the "Your Community" section.

Resuscitations are supposed to be orderly. An organized approach benefits the patient. Many medical interventions happen simultaneously. There is, after all, plenty to do when someone arrives all but dead in the emergency department. But chaos shouldn't rule. The most important things should happen first, then those of lesser import, and so forth. Practically, however, a well-ordered trauma resuscitation is more often the exception than the rule.

The surgical portion of the trauma team, headed by an attending surgeon, consists of medical students, physician assistants, interns, residents, and nurses. Simply fitting all those bodies into our trauma room and around the patient's bed is nearly impossible. The emergency department personnel are involved too, so we need a place to stand. Respiratory therapists, X-ray techs, hospital supervisors, EMTs, ward clerks, and others with a role in the proceedings crowd in also. Finally, anyone else who feels he or she would like to play along comes in to watch. There's always an overabundance of nervous energy crackling in the room. With that many over-amped people packed into a tight space the scene sometimes degenerates.

Many surgeons—even the budding ones—like to yell, their raised voices demanding attention for their every action, no matter how trivial. Cacophony is the result; minor and major merge and overlap. "Hand me a glove and some lube," bellows the surgical intern charged with doing the rectal examination.

"I need a line set-up here, now," screams another, frantically trying to establish an intravenous infusion.

"Catheter tray, stat!" squeaks the lowly medical student. He may be putting in his first urinary catheter, but he’s learning from his superiors.

As long as the important parts of the resuscitation are going smoothly, I let all this and more wash over me, ignoring much of it, so long as the ABCs—airway, breathing, and circulation—are being attended to. In this case they are, as are other potentially life-saving procedures and interventions. I can block out the bedlam swirling about the bedside. Even the attending surgeon's voice shrieking, "5, 4, 3, 2, 1, X-ray!" or "Move it or lose it!" in an overly dramatic and unnecessary effort to clear the room of those not wishing to be repeatedly irradiated, fades into the background.

I float above the scene, feeling as though I'm looking down on a gang fight. I'm slightly detached from some of the minor details of the battle for life but hyper-aware of how the overall effort is going. I’m focused on the big picture. It's a skill I learned as a senior resident. I can tell if we’re winning or losing. We're losing this time.

This detached approach also allows me to teach my resident during the chaos. We stand side-by-side at the patient's head, our masked and goggled faces kissing distance apart, hemmed in by the respiratory therapist and her ventilator to my left and the ever-present lookyloos to our right.

Alexis Choi, the resident, is a vibrant, intelligent woman in the throes of "senioritis," that end-of-residency-training languor that takes hold after four years of one hundred-hour workweeks and innumerable taxing encounters. I had senioritis once myself, a really bad case. Only sex and dreams of graduation kept me sane as I plodded through the final few months of my senior-resident year. I don't know how Alexis is coping with her burnout. I suspect she has her own strategy, but I don't know her well enough to ask.

When I was an intern, a senior resident pushed me toward a horribly mangled patient as he outlined the man's multiple life-threatening injuries. When we reached the patient’s bedside, he slapped me on the back, turned and strode off, cheerily quipping over his shoulder, "This bud's for you." That offhand line was his attempt to spark confidence in the struggling neophyte physician under his command. I never felt more alone or scared in my life, until the next time.

As a senior resident myself, I often flippantly suggested that patients in their death throes "only had the flu." I considered myself a great wit at these moments. Many on my team apparently agreed, since my line, "It’s only the flu," routinely elicited peals of laughter and many similar comments. With an attitude like that I'm sure I abandoned my junior residents during their moments of greatest need.

I have since emerged from my affective anesthesia, but I was deeply under at one point in my career. I lived there once, but I never want to return to that emotional cocoon.

Keeping our voices low, Alexis and I discuss medications, the need for various interventions, diagnostic strategies, airway management, whatever is relevant to the situation at hand. Thinking and performing properly under pressure are necessary skills for emergency physicians. I quiz Alexis so she can learn to process vital information during times of extreme stress. I can do it; I learned it as a trainee myself. It’s likely that Alexis will eventually work at a smaller hospital. She won't have a tremendous trauma team to sweep into her department every time a dead person is brought in. She'll have to prioritize and use her more limited personnel wisely. We thrash all this out and more.

Sometimes, during resuscitations, a sense of reverence or respect (or perhaps awe) pervades the room; sometimes a party atmosphere ultimately prevails. In this case it's the latter. It's unclear exactly why this has occurred, but it has. Most, but not all, of the doctors and nurses are caught up in it.

The shift—from cool callousness to overt mockery—occurs when the intern doing the rectal examination refers to it as the "hospital handshake." There are chortles all around. Initially our patient is clad only in pants, his shirt cut away to allow for monitoring leads and IVs. Someone comments on his fat stomach bobbing this way and that as his chest is compressed during CPR. I wonder who said that, but I can’t look up or even address the speaker since I’m busy confirming airway tube placement and function with Alexis. Besides, the hubbub in the room and the critical nature of the situation preclude discussion. I store the comment away for later reflection. Many other remarks are made as the man's pants are scissored away and his genitals revealed. A nurse grunts that finding his penis to insert a urinary catheter will be a real challenge given his fat belly, his small "package," and the movements of his flaccid body being buffeted about during the efforts to revive him.

It has become obvious that this man will not survive, no matter what we do for him. One of the senior residents dryly observes that our patient will shortly be "taking a dirt nap." Some take this as a signal to begin playing with his mangled arms and legs in an effort to clinically diagnose his orthopedic injuries. Each limb is twisted in a different grotesque way, angled sharply into unnatural positions from the force of the impact of his car hitting the pole.

Off to my left I see a burly resident attempting to straighten the patient's left thigh where a bone protrudes from its lateral border. He's not trying to be helpful; it's a contest for him. "Can I do it?" his face seems to say. He looks around the room to see if any of his mates appreciate his wrestling match with the leg. No one really notices, but he continues to push and pull, jerking the body back and forth until I command him to stop. One of the emergency nurses begins waving the man's abnormally limp right wrist about aimlessly, stating, "This is all screwed up, too." She seems irked when I ask her to please cease what she's doing. But she stops and busies herself with charting. I can see I'm not making friends. All the while, various voices are commenting about how this man is "kicking the bucket," "buying the farm," "going toward the light," and so forth. For me, it's a grim tableau, and I feel powerless to reconfigure it since almost everyone is playing along, and I'm outnumbered twenty-five to one. If outsiders were watching, they'd think they'd stumbled into a house of horrors.

Finally it's over. The patient is "pronounced," as we say in medical shorthand. He came in dead and stayed that way. The gallows humor ends because there's no longer a subject any more; he has passed away, literally and figuratively. Cleanup begins, and I have a chance to draw a full breath and think about what just happened.
I look down at my patient's face. It is in repose, eyes closed. Tubes stick out of his nose and mouth. A smear of dried blood lies across his forehead; his head rests in a puddle, which frames it like a corona. Were it not for his ashen gray color, I could imagine him sleeping, perhaps about to awaken from a nightmare. I notice that the dead man is younger than I, much younger, and I'm not that old. His hands are those of a laborer, the skin rough and cracked, the palms thick with calluses. His neck and torso are thick too. Muscles and fat bulge beneath his skin. Were he walking past me on the street, intact, there's nothing about him that would draw my attention. He's ordinary looking, just a man.

As the trauma room clears, I ask Alexis to find his family and notify them of our patient's sudden death. She nods her assent and begins to search about for some form of identification. I watch as she pulls the dead man's wallet from the right rear pocket of his bloody, shredded jeans. It falls open in her gloved hands, to a picture of two little girls, his girls, their picture shown so often his billfold has developed a memory, marking the most-dear place in his life. Instantly tears well in Alexis's eyes. From the foot of the patient's bed she murmurs, "He had a life; oh my God."

The janitor's mop swishes back and forth softly on the yellow linoleum floor awash in blood.

The man's wife and brother, who had been outside in the waiting room, fell to the ground screaming when told he was dead. They beat their chests and clutched at the hem of Alexis's coat. I noticed that Alexis's normally bright white doctor's jacket was sullied with faint spots of blood. Other wet patches marred its purity as well. She had dabbed at the discolorations with hydrogen peroxide but some stains are almost impossible to remove.

Our patient was thirty-seven, married, a workingman on his day off, helping friends move furniture. His name was Juan. His accelerator had apparently gotten stuck, and he'd crashed into a pole at high speed. The picture in his wallet was of his two children, ages three and five. According to his wife, he was scheduled to donate one of his kidneys to his sister with renal failure who was on hemodialysis.

I found myself wishing that all the members of the trauma team could have observed the Trauma Room #1 epilogue. "Blunt trauma full arrest" were no longer words I could use to describe Juan's life, not even the tiniest part of it, the portion I had witnessed. They were small, cruel, and demeaning, as odious as some on the team had been during our patient's final moments.

I saw something of my resident-self again today, in me and in others. My initial encapsulation of Juan as "blunt trauma full arrest" stirred echoes. It sounded like a slightly milder version of, "It’s only the flu," my long-ago catchphrase used to dissociate myself from pain and loss.

I was thankful that I'd learned the particulars of Juan's life only after it was ended. I needed the detachment to focus and perform properly during my attempts to save his life. Alexis needed it too as she tried to master the moves inherent in a complex resuscitation. But we both desired to know something of our patient as a person. Talking with his family, studying his face, and crying over his children's photograph enshrined in his wallet were part of that.

I often compare my professional detachment to the aperture of a camera. It adjusts to changing conditions. If a large influx of light is required, it expands accordingly. If less light is needed, it contracts.

I didn't want images of Juan's two little girls dancing in my head while I focused on saving his life; that's far too distracting and emotionally too close to home. I can't cry and bleed for every patient, especially while they're in extremis. Their pain isn't mine, nor is the sorrow their family members experience. I can't be too near, or I'd dissolve at every bedside in the ED. However, when the critical moment passes, and the patient either stabilizes and improves or worsens and dies, I have to open up and let a portion of their life touch mine. We're all in this together; that's my feeling. That human-to-human connection has to be a part of what I offer in medicine. I'm cheating myself and my patients if I do less than that.

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