Monday, April 25, 2011

Dead on Arrival

One day during your surgical residency you'll realize that you've come to a point where you yourself can actually save a life. Be it through your split-second diagnostic reasoning that diagnoses an aortic dissection or your expedience in rushing a patient to the OR to evacuate an intracranial hemorrhage. With this power, however, comes the bitter fruit of knowledge that makes you cognizant of when a life could be saved, but wasn't.

He wasn't even 20. But the death of his friend the day before was too much for him to handle. While drinking the sadness of life with the spirits of liquor he suddenly found himself falling, to be reawaken to the piercing pain of reality as the spikes ran through his legs. He lay there, dangling from a fence, the blood in his head squeezing consciousness from him as the twinkling of lights from anoxic brain damage painted the last mobile of stars he would see in this world.

He was unresponsive when the paramedics found him. His left pupil was fixed and dilated when we moved him from the gurney to the recovery suite table. He has a left sided hemorrhage, probably a subdural, I thought to myself. He needs a CT scan and an emergent hematoma evacuation, I continued. He's young, his brain isn't too compliant, he may have herniated already, but we need to give him a shot.

My patience quickly smoldered into helpless rage as I watched them place bilateral chest tubes, multiple central lines and IVs, and turn him to check for spinal injury. Guys, let's get him to CT now. But not knowing how serious his pneumothoraces were, or how indicated the chest tubes were, I couldn't argue with the ABCs (airway breathing circulation) of trauma. Honestly though, it should be airway, brain and CT for someone with a blown pupil. The CT scan confirmed the subdural hematoma, and we rushed him to the OR. As I sawed off the bone and cut open the dura, blood clot shot out of the operative field and I knew the brain underneath was probably already dying from ischemia. The brain continued to rise up like muffin tops in an oven, and as the cortex herniated through our bony window the attending surgeon told us it was futile. Close the skin, he said. There's no hope, he finished. My senior resident and I looked at each other. Maybe we could open more bone, maybe there's more medical management we could do to help reduce the intracranial edema. But we knew as well as he that it was too late. He had probably already stroked his whole dominant hemisphere and even if we did decompress him adequately would remain a vegetable for the rest of his life. He didn't want to live anyway, what right did we have to save him? Still, we could have. To save life, and even return it to those that throw it away, that is a surgeon's power, his duty even, if you will. As I closed his skin, pushing down the brain that still tried to escape out of the boy's scalp, each stitch I wondered how we could have gotten there faster, how if a matter of seconds could have made a difference.

Only earlier we were consulted on a 7 year old boy who's spinal cord was internally severed from a motor vehicle accident. The injury is incompatible with life, I told the peds ICU team. The boy's father had killed himself the year before. His mother had killed him by driving under the influence. She posted bail and made it to his bedside in time to tell me that she thought she saw tears coming from his eyes sometimes. Yes, I thought, wouldn't you cry too if your mother's stupidity resulted in your death?

There will always be lives we cannot save. And sometimes even harder is realizing that by the time they reach you, there is no life to be saved. But for the rare instances where seconds mean another smile, another laugh, another breath of fresh air, we work tirelessly to improve, to be ready, so that when we scrub out of the OR we can look at their families with relief, not regret, and be met with tears of joy, rather than the wails of despair.

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About Me

I'm a quixotic idealist that's readjusting to the reality of the world around him. An aesthetic at heart, willing to not shower a week at a time to go camping, exploring, hiking, etc. I love food, poker, and anything that can be turned into a competition.