Hero

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A colleague of mine was recently questioning her capabilities having lost yet another patient who had arrived nearly lifeless after being shot.  She was despondent over the nation’s overall complacency about our gun violence epidemic giving her far too many opportunities to fail or succeed as a trauma surgeon. Truthfully, neither quick decisive action nor expert surgical skill was enough to repair that much damage. Not in the hands of any trauma surgeon.

As trauma surgeons we bring everything we have–every ounce of energy and drive, countless years of specialized training, and an ever expanding armamentarium of medical technology to fix broken bodies–to our work but sometimes we simply feel like failures, both unable to save our patients and unable to move the dial on policies that might ameliorate gun violence.

Here are the words of support that I offered to my friend: a compassionate, highly skilled trauma surgeon who without hesitation took a hemorrhaging gun shot wound victim to the OR to try to save his life:

“The grief is understandable. For your patients. For your community. For our society. You have a skill set that makes you brave enough to even try, my friend. As a trauma surgeon when you hear audible hemorrhage you run toward it, just like the police run into the gunfire or the firefighters run into the flames. Each and every patient is lucky to have you and your strength; their families will be grateful for your efforts and empathy no matter the outcome. Don’t be too hard on your self.”

Having been raised in a culture of morbidity & mortality conferences where we scrutinize every decision and every action preceding a death or complication, having a chosen specialty whose goal is to salvage badly damaged bodies, and living in a world where these patients keep appearing in our trauma bays even when we speak up about gun violence, this self-doubt is common among us.

But sometimes we just needed to be reminded we are heroes who have chosen to run toward the audible bleeding so we can get up and go back to work the next day.

The Dignity of Pants

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“Please don’t cut off my pants,” he pleaded. “I am homeless and they are my only pants. Please.”

He could say these words as we were conducting our initial assessment in the trauma bay so at least he was hemodynamically stable with an intact airway at that moment in time. However, he had arrived seconds earlier with potentially life threatening injuries as a level 1 trauma activation. Based on the location of wounds that were visible on his torso this was a real possibility so we needed to quickly conduct our secondary assessment. That meant rapid exposure by taking the trauma shears, one on each pant leg from my assistants, as we examined him from head to toe, front to back, in every crevice or crease that might hide a wound.

I looked him straight in the eye and said “Don’t worry. We will get you a pair of pants but right now we have to take care of you.”

Straight in the eye.

He relented. How could he not? The pants were already cut off even as I made eye contact. The process takes just seconds in the hands of a coordinated trauma team.

He was a very polite young man. He didn’t yell or kick or scream. He followed all of our instructions. He quietly told us his health, social, and family history. He told us he was scared. His life story mirrored that of many of our trauma patients: food insecurity, lack of affordable housing, few resources for education and job training, addiction, interpersonal violence, an endless vicious cycle. He was caught in that cycle and it was obvious that he was heartbroken to be there. He wanted a better life and tonight in the trauma bay, without his pants, he had failed once again to break it.

I always say that I was attracted to a career in trauma surgery because I am part surgeon and part social worker. In reality neither I nor the social worker employed by my hospital to help patients in need of socioeconomic support have much to offer our patients with these very real struggles. The policy level changes and investments that would bring grocery options, better schools, safe and affordable housing to our most underserved areas are not in our control. Even for those patients who want to make a change there are too few addiction treatment beds and job training programs. While these issues are clearly predictors of health, they are managed partly (addiction services) or entirely (basically everything else) outside of the healthcare system.

Yet every day we see the ravaging effects of socioeconomic insecurity on our population’s safety and well-being when they become our patients. We open the trauma bay doors and provide the full armamentarium of modern medicine to save a life acutely while feeling powerless to save lives at the societal level*.

We finished examining and working up our patient. He was not going to die that night and could be discharged. Discharged where? It was 3 in the morning. The social worker could give him the address of a shelter in town. There might be a bunk free. She could refer him to addiction treatment. There might be an available bed. A local non-profit might intervene in the light of day if we could make the connection.  But we had no way to guarantee that this man, who was lucky to be alive, would not simply just slip back into his otherwise unlucky life after discharge.

Oh, and there weren’t even any pants to give him. The social worker’s closet of donation was empty of men’s pants it turns out**.

This was not something the trauma team to could bear. We might not be able to provide our patient with better groceries, housing, or addiction treatment to this man who in all of his words and actions as our trauma patient showed us a deep hope to be in a better place in life; but the least we could do is provide him the dignity of a pair of pants to head back into his unfair reality.

So we pooled our cash on hand, asked him what size he wore, and waited until the local Target and Kohl’s opened***. The next morning the light in his face and the sincere words of gratitude when he saw his new jeans and a back up pair of track pants and shorts felt like as much of an accomplishment as stabilizing the unstable patients who had entered the trauma bay earlier or the exploratory laparatomy we had done.

“Thank you. Thank you. Thank you,” he said. “I really need these. Thank you.”

He needs so much more. But this was the least we could do.


*NB: Most trauma centers do provide targeted injury prevention like helmet, seat belt, or firearms safety education through small investments or grant funding but these typically address to specific injury mechanisms rather than social policy.
**Men be like the ladies and cull your closets seasonally; donate to your local trauma center.
***If any Kohl’s or Target folks are reading this consider donating items or gift cards to your local trauma center.

An Explanation: The #1 tool in your physician’s toolkit

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It was almost a formality, me rounding on that patient that day.

The obstruction had resolved. The nasogastric tube was out.   If the diet advanced as expected he could be discharged to continue his chemotherapy. He was not even my primary patient. He was on the heme-onc service so I wasn’t even responsible for the paperwork.

Yes, he was dying of cancer. That was not news to him. Nor was the nausea and vomiting that he had come to expect in the wake of periodic infusions of poison. That which was intended to kill the cancer cells also killed a little bit of his insides with every dose. But the distention and obstipation was new. He had not felt right 4 days ago and he had rightfully come to the ER.

His diagnosis was small bowel obstruction. However, one could not tell from the CT scan if it was due to adhesions from his cancer surgery some years ago or due to new tumors scattered in his pelvis which had in recent months made him the unfortunate bearer of the “stage 4 cancer” moniker. As if the side effects of chemo for his cancer recurrence were not enough, now he had to suffer through this. But he was better by the time I met him as the new attending on a consulting service.

My exam confirmed the residents’ optimism that the obstruction had resolved. It was likely adhesions given the swift improvement and I noted how the nasogastric tube works to relieve such obstructions to the patient and his wife. But I explained that we were not sure, based on the original CT scan, if the cancer was playing a role in impeding the flow of GI contents. Either way, as long as he was able to tolerate oral feeds he could resume his cancer treatment with the hopes that the same symptoms would not recur. He did not need an operation in the immediate future. The patient and his wife were relieved.

As I concluded my visit, I asked (as I always do) if there were any other questions.

“No,” replied the patient’s wife. “But thank you so much. In all our time here, no one has explained what was really happening. Thanks for making it so clear. We really appreciate it.”

________________________________________________________________

I know I have written about this before-about the power of clarity in the medical encounter.

But seriously, I was at least the 4th attending physician to meet the patient not to mention the countless 1st through 6th post-graduate year trainees who had cared for the patient before I met him. Yet no one had taken the few minutes it would take to explain why the patient felt so miserable and how an uncomfortable tube down his nose might help.

Understanding the disease process is pathophysiology 101. Explaining it to the patient is doctoring 101. Sure, doctoring 201 is the art of explaining it in a way that caters to a patient’s educational and verbal capacity without instilling fear; but that no one had even tried just made me sad as a physician and as an educator. Once again, I took solace in the fact that there was a resident with me to both observe the explanation and to witness the words of gratitude. Hopefully, that’s my way of paying it forward just a little bit.

So at the risk of sounding too preachy let me leave you with this: If you take care of patients, remember they and those who love them are humans in a state of crisis. Amidst the pain, the fear, and the uncertainty of what’s to come, taking a moment to offer an explanation for the suffering can go so much further than any medication or procedure. Consider it the #1 tool in your physician’s toolkit.

The Miracle Worker Gets a Hug

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The tension between the desire to provide the best care and the system putting up road blocks was building the entire day. As the surgeon advocating for my patient, it felt like the smoldering rapidly progressed to full on conflagration. And yet, the patient and his family were calm and full of grace.

On morning rounds, I told my patient that his hernia remained reduced but there was an area along the bowel that had been stuck the prior evening that looked worrisome on CT scan. His vitals, exam, and blood work were reassuring, I explained. There was no imminent rush, no immediate threat to bowel or life. However, it made sense to get this done as soon as possible. The patient, and his wife at the bedside, understood. I had explained a clear set of options for what to do about the hernia depending on a) how the bowel looked when we put the cameras in and b) based on my understanding of his baseline co-morbidities. He was a smoker with a chronic cough that exacerbated his hernia. I spent a little bit of time counseling him that this might be an ideal time to quit. Anything to ameliorate the cough during the recovery process and beyond would reduce the chance of recurrence.

Those words “as soon as possible” resonated in my head as the wait for OR time dragged on all day.  Circumstances were at a systems level well beyond my control; the absence of an immediate life threat meant I had no real leverage other than rants about patient satisfaction and costs of prolonged length of stay. This meant nothing given that there were patients who truly needed life or limb saving interventions, including one of my own who arrived at 5pm with free air.

This patient was too stable.

I had run up to his bedside a few times during the day with updates to the effect of “not sure yet…but you continue to look good…as soon as possible” He and his family–thankfully–were remarkably affable while I was becoming more and more agitated at the OR inefficiency in between urgent cases.

[I could write a dissertation on OR efficiency, or lack of it. And, certainly this is not a problem limited to my workplace. But that’s not what this blog is about.]

I was not on call that night. The OR could finally accommodate the case in the late evening. It went as well as could have been expected. The bowel looked great. The patient got the best case scenario of the options I had presented to him some 16 hours previously.

When I went to talk to the patient’s wife afterward in the waiting area it was almost midnight. She was exhausted from a day of anticipation. From two hours of anxiously waiting while her husband was in the OR. She gave me a giant hug and thanked me so profusely for sticking by him. “I know you have been here since so early this morning,” she said. In the moment of that most genuine embrace, the fire went out and the frustration of the day slipped away.

The next day, in preparation for discharge, the patient was exuberant. “You’re a miracle worker doc!” he exclaimed. “I’m done with the butts now. Forever. Thanks to you. And you fixed my hernia. You’re a miracle worker.”

It took me a while to figure it out since it’s been forever since someone referred to cigarettes as butts to me. The miracle was not that I fixed the hernia. It was that for the first time in 50 years he was motivated to quit smoking. His wife would stop too, she told me that day.

It was a tough day at work but this lovely couple thought I was a miracle worker deserving of a hug despite it all. No anger. No bitterness. Just genuine gratitude, a case that went textbook well, and some preventative medicine to boot. What more could a beleaguered surgeon ask for?

[Posted with patient’s permission.]

Hey Doc!

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“Hey Doc!” I heard the patient say as I blazed by Bed A.

Bed A is the ‘door’ bed. My patient was in Bed B, the ‘window’ bed. I had just met him; it was a new inpatient consult. For all the rules and regulations surrounding patient confidentiality, the curtains between beds do little to protect privacy since inevitably there will be audible conversations about symptoms, diagnosis, and management between patients and the doctors, nurses, or family who visit them.

The residents had already seen the patient in Bed B and were reviewing his case in detail with me between OR cases. I looked at my watch, contemplated typical OR turnover time for a moment, and decided we had enough time to get the consult done.

When I got to Bed B, I introduced myself to the patient and sat at the edge of his bed. I explained that I had already reviewed his story, lab data, and imaging and confirmed these facts. I stood briefly to perform my physical exam before beginning to scrawl on an index card. I simplistically portrayed the complex anatomic relationships between the liver, the gallbladder, and the pancreas and the series of tubes (the biliary tree) that connect these organs. I described how stones form when the balance of three ingredients (bile salts, lecithin, and cholesterol) in the viscous fluid (bile) made by the liver, and stored in the gallbladder, gets off kilter and how those stones can then cause blockages at various points along that biliary tree. I showed the patient where his problem was and used hash marks to explain the operation and what would be removed.

Before getting my patient’s signature on the consent form, I made sure any questions were answered and asked if he wanted me to call a family member to summarize the details. He said no and signed.

Conversations like this take time. Whether it is the 4 patients per 15 minute block in clinic or the patient who I am rushing to see between OR cases, I invariably feel pressed for time when talking to patients. But I do what I have to do, often skipping meals or holding in bodily functions while incorporating a brisk walking speed to keep up with competing demands, none of which seem to incentivize having thoughtful and thorough conversations with patients and/or their families.

After telling the patient in Bed B that I would see him in the pre-op holding area the following day, I upped my walking pace so I could run back down to the OR to my next patient. I had already taken too long and was anticipating the reprimand of the OR board. And that’s when I heard the patient in Bed A.

“Hey Doc!”

“Ugh” I thought to myself, “I really don’t have the time to find this guy’s nurse for his pain meds or to figure out how to keep his IV from beeping…”

But how could I not stop? He was addressing me directly so I paused and turned to him from the threshold to the room.

“Hey Doc! It ain’t none of my business or anything but I just wanted to say that there would be a lot less fear in healthcare if all doctors explained things the way you do.”

I was humbled by this man’s feedback. I hoped my residents were listening, both to the man in Bed A and to what had just transpired before Bed B.

I find it very irritating when students or residents peel away or talk among themselves, as if they are sick of hearing what I have to say, while I am having conversations with our patients. To me, modeling doctor-patient communication is my greatest gift to them as a teacher and a mentor. I want them to listen, to observe, to understand that every encounter is a chance to learn.

As we hustled back to the OR, I turned to the residents and proudly said “For as much pride as we surgeons take in doing the perfect operation or nailing a difficult diagnosis, what happened back there might have been the highlight of my career.”

Grief

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I have been waiting for a moment of joy in the profession that did not involve death to write again. It turns out that those moments are few and far between and I feel compelled to write a few words today. Writing, sharing, letting out the feelings I must keep at bay when I am with my patients and their families is therapeutic. 

Bearing witness to physical pain and emotional suffering is part of the job. The opportunity to ameliorate the body’s failure and to transcend the soul’s response are part of the allure of the work of surgeons, in particular trauma surgeons like myself. A good day at work for me–a day when I get to flex my life saving muscle and bask in the glory of my critical care prowess–is a bad day for anyone on the receiving end of my clinical skills and empathy, no matter what the outcome.

No one wakes up expecting to be at the center of a human tragedy. Yet, as trauma surgeons we are thrust into a peripheral role in such tragedies daily. In my typical week on service (a few nights on call, 7 days of rounding, two clinics, and reams of accumulating paperwork) the balance of patients with minor injuries, good outcomes, or major life saves typically outweigh those with severe life-threatening injuries at risk of high morbidity and mortality.  But this has been an atypical week.

These last 6 days have been filled with inexplicable events and unimaginable losses for my patients and their families. Car crashes, suicide, house fires, occupational hazards, animal attacks, physical abuse, interpersonal violence. The causes have been varied. The effects have been a river of tears flowing through a mountain of grief. The landscape of sorrow created by these tragedies has exhausted me far more than the overnights and the ~110 hours logged in the effort to provide round the clock trauma care.

As surgeons, we hope not to grow too used to it, not to become cold and unfeeling in the face of human tragedy. But we need some way to move on. This week, I feel buoyed by gratitude of surviving family members and the supportive words from fellow providers. The warm embrace and patience of those who love me and care for me during those few hours away from work have also helped. But with one more day to go, I am simply wishing for a quiet last day on service devoid of human tragedy. No more bravado in the trauma bay. No more delivering bad news. No more grief for the people in my catchment area. We all need a break.

[originally posted 3/6/2016]

Ski Practice

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To her it was like any other day. She had dropped him off, as was their usual routine, and gone into the city to see a friend.

He was an experienced member of the ski team. Practice was familiar. Take the lift up, ski down. Take the life up, slalom down. Take the life up…

It all happened quickly. He slipped through rail of the lift. The impact on the cold, hard packed snow was devastatingly complete. Perhaps it was his head, or maybe his spine, but vital functions were cut off immediately; he went into cardiac arrest. The ski patrol started CPR. Someone alerted dad. He arrived almost as quickly as the paramedics. They intubated him with efficiency and continues advanced cardiac life support.

He arrived as my patient immobilized with a long spine board and a cervical collar. He was intubated and CPR was ongoing. He had lost vitals signs at least 20 minutes ago. Dad was by his side as he rolled into the trauma bay. We kept coding him for the next 45 minutes. His pupils were blown. His skull base was boggy. We knew it was futile but he was someone’s child. It was hard to let go. But we did.

When I told dad, he was alone. He had not grasped the magnitude of on-going CPR and was utterly shocked when I told him his son was dead. My lip was quivering as I delivered the crushing news; my tears followed soon after he began to sob.

He asked me to call his wife. I told her it was serious and to arrive quickly but safely. Her grief is something that I will forever hold with me. I cried with her too. And, though it was not the first, nor would it be the last, time, that I would cry with a family experiencing sudden loss, my ability to be with these parents–REALLY BE WITH THEM–at the darkest moment of their lives reminded me, somewhat paradoxically, of the joys of my profession.

The Final Chapter

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He had loved her with all his being for more than 6 decades. In the last 2 years of their 61 year marriage, he had watched helplessly as dementia wrapped its noose around her, slowly tightening its grip on her mind and pulling her away from him.

When I met him I knew the injury was irrecoverable. Her brain was consumed by hemorrhage that had filled the space (cerebral atrophy) left behind by progressive dementia and then some, deflecting the midline between the two hemispheres nearly 12mm.

I asked him what had happened. She had tripped and fallen. For all her mind’s frailty, her body was still strong and agile for her 83 years; how she stumbled in the small living room they had shared for more than 50 years remained a mystery.

She was still breathing on her own but her brainstem’s ability to preserve this vital function was succumbing quickly to the pressure building from above. She appeared to be peacefully sleeping. He had not yet grasped that she would not be waking up.

I asked him what life was like at home before today. She was no longer aware of who, what, when, where, and how. A nurse would come daily to help her bathe and dress. She would then spend most of her day in a trusty old recliner. He would cook and feed her, then put her to bed every evening. They had no children. They had outlived their siblings.

Theirs was a story of two lifelong friends and lovers. Every Sunday he would take her for a drive. He wanted her to see the sun and the trees and the world outside their home. This was romance in the denouement of life. And here I was, suddenly a supporting character in the final chapter of their love story.

He cried quietly as I explained the magnitude of the injury. Like too many of my octogenarian patients, she had no advanced directives. None of the providers who knew her far better than I had thought a discussion of code status was worthy it seems. So this was my role.

We talked for a long while. After reviewing what all the technology in my critical care armamentarium might do and not do for the love of his life he said to me, “I don’t know I what will do without her. I don’t know any other life. I don’t have anyone else.”

His heartache was palpable.

There was surprise and some expression of dismay at the administrative hassle I caused when I planned to send her home with hospice services directly from the ER that day. I am grateful for the ER physicians, nurses, and social workers who helped me execute that plan even though it would have been far more convenient for us to simply admit her to the floor.

That she would die peacefully in her home of five decades with her partner of six by her side is the kind of medical outcome that looks poor on paper but feels good to the surgeon’s soul.

Dear Drunk Driver, “Tonight”.

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Dear Drunk Driver,

Tonight, I am tired.

Tired from lack of sleep, tired from the long hours, and tired from bearing witness to your destruction.

Tonight, you caused an accident while under the influence of alcohol.  And, you are badly injured, requiring emergency surgery.  Your liver is hard, cirrhotic, and unforgiving.  Although I can get you through this first surgery, I know you will not survive.  I know over the next few days, your broken and beaten liver will begin to fail, your kidneys will stop working, you will start bleeding from every orifice of your body, and you will die.

Tonight, I met your family.  They thought you had quit drinking, but they asked, and I answered, “Yes.”  “Yes” you had been drinking and “yes” your liver carries the scars of your addiction.  “Yes”, it is likely you will not make it.  I saw the hurt cross their eyes, the anger, the embarrassment.  And then, the part that I dread the most, the part I was hoping wouldn’t happen – but it always does… They asked about the accident.  They asked if someone else was injured.  They asked if the other person was okay.

And a fresh, new, searing pain begins, because…

Tonight, you killed someone.  Someone’s husband, wife, father, son, mother or daughter isn’t coming home.

I see a shadow cross your daughter’s soul as her mascara weeps down her face and stains her arms.  I see your son’s image of you crumble upon the impact of my words.  I see their shame, their sorrow, with no outlet other than tears.  Their heartbreak reaches out and stabs at me, their confusion begs my sympathy.

Tonight, another family is being informed of their loved one’s death…  Their souls, and hopes, and dreams are extinguished with the two words, “I’m sorry”.

Tonight, you are blissfully unaware and asleep…disoriented, medicated and sedated because of your own injuries.  But while you sleep, perchance you dream… of all the wreckage you have caused.

Tonight, you have blazed a trail of tears.

Tonight, I am angry.

Angry you didn’t know better, angry at all the hurt you have caused.

Tonight, I am angry.

Because I know this will happen again.

When does this end?  When will you stop assaulting your body, your family and your friends?  When will you stop tearing through lives, ripping out the hearts of people you know and of people you don’t?

When will you stop?

Please, let it be-

“tonight”.

Sincerely,

Your trauma surgeon

** This writing does not describe one particular patient or event, but is the unfortunate result of many patients and experiences I have had over the years. **