Trauma Surgery

I wake up in the pitch black to a sound, some sort of beeping that won’t go away.  Waking up is arduous; my limbs feel like tree branches, even my blood feels sluggish.  I don’t just not know where I am, I don’t know who I am, or what “awake,” is.  That is how deeply I was asleep. 

And then it dawns on me, that I am a medical student and I am in the on-call room, and that god-awful noise is my beeper.  I reach for my glasses and end up knocking the lamp and my pager off the bedside table.  I flail around in the sheets, trying to reach down and right the lamp.  Finally, I close my fingers around the pager and silence the alarm.  I think seriously about going back to sleep, but I don’t.  I read the tiny display on the beeper, “trauma alert: 39 yo male.”  I struggle to stand.  The beeper goes off again while I am still holding it.  More details: “trauma alert: 39 yo male. sledding accident.”  This should be good.

I stumble into my clogs, pull a surgical cap over my bed-head, and put on my white coat.  I shove a granola bar into my mouth as I trot off down the hall to the maze of tunnels that will take me to the trauma bays.

Trauma Male #1 is just being rolled off the ambulance as I arrive.  He is sitting up on the gurney, neck braced, moaning and holding his stomach, a line of blood dripping from his right nostril onto his shirt.  I pull on a gown, gloves, and a mask, and dig the shears out of my white coat pocket.  As the medical student on the trauma team, my main job seems to be Carrier of the Shears, which are useful for removing pesky things like clothes and bandages.

And this is no exception.  As the nurses swarm the patient and start shouting out vital signs, my chief motions me over, “Cut off the shirt and the pants,” he says, and then whirls off to make sure we are next in line for the CT scan.

I sidle up to the gurney, trying to introduce myself to the patient before I cut off his clothes and avoid getting in the way of the nurses, who seem to be doing actually important things, like placing IV lines and taking a history.

I stand to the left side of his head as he tells the nurse, “I was in the toboggan and couldn’t steer and we turned sideways and slammed into a tree.”  He points to the upper left side of his abdomen. “It hurts right here,” he draws a perfect circle over his spleen.  Hmm. I remember that spleen lacerations are graded, but I can’t remember what the criteria are.  Hopefully I will have time to sneak off and look this up before my resident pimps me on it.

“Hi sir, I just need to cut off your clothes so we can see your injuries without moving you too much,” I tell him. 

“You don’t need to cut them, it’s just right there, I can just pull my shirt up.”

Well shit.  Cutting off the clothes is my one job, and my resident will not be happy with me if I fail to do it.  Also, while I see his point that the area is already pretty accessible, it could be that this pain is distracting him from other injures. 

“I’m sorry sir, but we need to make sure you don’t have any other injuries.  I will cover you up with this sheet--”

He cuts me off, “please don’t cut my clothes.”

My resident appears behind me, holding his own pair of shears. (Way to make me feel useless.)  “Sorry sir, it is protocol here in the ED.” And then starts cutting.  “You get that side,” he says to me.

So I do, despite the fact that I am pretty sure this is assault.  Gritting my teeth, I start at the ankle and cut his jeans all the way up the leg to the waist band.  My resident does the same, and soon we are able to peel off his pants.

Which is when we notice that in addition to whatever sled-related splenic injury he has sustained, Trauma Male #1 has been shot in the penis.

My eyes dart up to the patient’s face – he looks horrified and humiliated and also a bit pale.

I have a sinking feeling in the pit of my stomach.  Partially, I am sure it is a visceral reaction to this type of injury, which I must admit squeaks me out the same way the all-wrong angle of broken bones still makes me queasy.  But the other part of this feeling is just knowing that we are in a rural hospital in Virginia.  I don’t believe the social and psychological awareness of the medical staff here is going to be sophisticated enough to deal gracefully with any of the scenarios that could lead to a man being shot in the penis.  We deal well with tractor accidents.  But mental illness? gender dysphoria? domestic violence?  These are not our strong suits.  And above and beyond the relatively temporary violation of having his pants cut off against his will, I have the sense that this man is about to have a whole prolonged interaction with healthcare that will be marked by violation.  And of course, I will participate in it. 

The resident raises one eyebrow and then sort of shrugs.  There is some dried blood around the patient’s crotch, but no active bleeding.  No one else on the trauma team seems to have noticed our discovery – it’s a small caliber hole and I guess most people make an effort not to stare at the patients’ junk.  My resident grabs the sheet from my hands and covers the patient up before directing the team to roll him onto one side and inspect his back.  We roll him up, and the intern runs her fingers down his spine. “No visible injuries,” she reports, and we lie him back down.

The resident listens to his heart and abdomen, pokes his belly a bit to elicit some groaning. Apparently nothing is concerning.  “Ok,” he says, “take him to CT.”  Lead-covered technicians appear and whisk him down the hall to the radiology suite.  I stay behind and look at my resident.  “I’m paging urology, go see if he has any spleen lacs.  If not, he’ll be on their service.”

Obediently, I trot off to the radiology control room.  If his penile injury is visible on CT, it certainly isn’t visible to me, and no one else comments on it.  We stare at his spleen, which looks normal.  The radiologist confirms – no laceration to the spleen.  We also “clear” his cervical spine – meaning we don’t see any fractures, so he is allowed to remove the horribly uncomfortable collar.  Normally we would probably discharge him now, but the resident appears to tell to technicians who are maneuvering him off of the CT scanner and back onto the gurney, “take him to room twelve.”

Room twelve is one of the more private ER rooms, with a real door that closes and is not made of glass.  Usually this room is occupied by women with gynecological complaints, so that a pelvic exam can be performed in relative privacy.  We wheel Trauma Male #1 in there.  A nurse gives the resident a questioning look and he says, “we’re waiting on a consult from uro – just keep him comfortable until they get here.”

And then the pagers are going off again – mine, the resident’s, the nurse’s.  “Trauma alert: 62 yo male. MVA.”

“Motor vehicle accident,” my resident explains, “bay two.”

I ready my trauma shears, hoping my task is less complicated this time. 

After the whirlwind of Trauma Male #2, I try to go back and check on #1, but he is nowhere to be found.  It is hours later, he could have been admitted to urology’s service or discharged home or he could have left AMA (against medical advice).  I don’t actually know his name or medical record number, so I can’t check the computer.  On our next shift together, I ask the resident, and he says he has no idea either.  Then he says, “I hope that guy did ok.”

I’m impressed with the way the resident handled the situation – maybe not with a nuanced theoretical understanding of the various issues that could lead to someone shooting himself (or being shot by someone else) in the penis – but at least with decency and discretion.  Decency and discretion delivered immediately after he cut the man’s clothes off against his will (which I still think is wrong and feel wrong for participating in).  

But it’s good to be reminded that people aren’t all one thing.  We aren’t either all good or all bad, we have good moments and bad moments.  I hope that Trauma Male #1 did ok, too.  And I hope that I will do better next time.

The Healer's Art

On the first day of Medical School, I shaved a dead man’s scrotum.  No one else in my anatomy group would do it.  It’s not something normal people do. They were trying to tell us that we were no longer normal people.  I didn’t believe them.  I kept sneaking looks at my cadaver’s face, wondering if he liked chocolate or had grandkids or had ever studied philosophy.

In the second half of the first year, some of us took an extra class; The Healer’s Art.  We sat in a circle on the rug or lounged sideways in armchairs.  We wore jeans and chewed gum. I still brought my laundry home on holidays.  I was going to join Doctors Without Borders as soon as I got through residency.

In the middle of the circle, a physician in a bolo tie read us a poem.  An anatomy professor guided us in meditation, sounding a small chime.  Meditation and poetry were my bread and butter, but this seemed so hokey.  We giggled and squirmed on the carpet. 

They asked us what we liked about life before medical school, about who we were before medical school.  I thought they were crazy.  I was twenty-two years old; surely I was a fully formed person; surely they could not make me something less.

Two years later, I participated in the torture of an old woman. 

Mrs. Beedle had been in the hospital for 287 days.  Initially admitted for pancreatitis.  Fifty-three procedures later, she had a colostomy bag and an open abdominal wound stretching from her belly button to her sternum.  It was covered with synthetic mesh and black foam and a vacuum apparatus designed to remove pus and digestive juices.  We were waiting for tissue to grow over the mesh, like shrubbery over the wire armature for a topiary. 

Mrs. Beedle had grown delirious, and her wrists had to be tied down because she kept pulling out her IVs.  That morning, I came with the team of surgical residents to change her wound vac.  We swooped in, pulling on yellow isolation gowns over our white coats.   

Her eyes found my face.  “Help me.  Let me die,” she mouthed around the suction tube in her throat.  She was NPO again.  Nil Per Os.  Starving.

Her hair was short and wispy around her face.  She looked like a bird.  Her skin was so dry and thin it seemed made of millions of microscopic feathers.  Her daughter had signed a consent form, we were to continue treating her.

I wanted to unhook her from all these tubes, rub lotion into her dry hands, stroke her wispy hair.  I wanted to wrap her in a quilt and read to her.  But I could not. 

Mrs. Beedle was going to die, and badly.  I could not go with her.  I had to stay here and learn to change wound vacs and check electrolytes.  I had to finish this procedure and then scrub in for an appendectomy and then try to sneak downstairs to the cafeteria to eat a banana.  I had to get a good grade on this rotation.  Most of all I had to stop feeling her hole ripping through my own stomach.

I was there in that hospital room that smelled of latex and bile, and that was the last place I was. I felt my eyes glaze over and a dullness come into my limbs.

I looked away from Mrs. Beedle’s face.  I cut the new piece of black foam to the right size. I set out the saline solution.  The resident peeled back the old bandage from her belly, and when Mrs. Beedle screamed and thrashed, I helped hold her down. 

I thought about the meditation chime.  How was that pallid sound supposed to help this?

When I was a child, a man once came to our door, asking to mow the lawn.  He needed money, he said, to buy formula for his new baby.  Mom said no, that Dad would mow our lawn.  I ran after him with all forty-three dollars of my saved allowance.  When I gave it to him, he picked me up and hugged me.

Now I think people like that will probably just buy booze. 

I’m not the same person I was before, because now I’ve got this hard, cynical exoskeleton.  It keeps those holes from wheedling into me, the cancer from seeping into my bones.  My patients look different to me, they aren’t like me.  Women with chronic low back pain who just want drugs.  Men with diabetes raging out of control who won’t take insulin.  Children born with AIDS because their mothers were too irresponsible to take their medicine.  I reinforce my exoskeleton with ways it is their own fault, of reasons bad things can’t happen to me: I obey dress codes, speed limits, open container laws, I make good food choices and keep my BMI in the healthy range.

Then there is rage.  I feel it in the back of my throat and in my fingertips and behind my eyes.  I am angry at them for suffering.  How dare they bring me their grief, their pain, their sadness?  What answer do they think I have for them?  I’m just some kid who has attended two and a half years of grad school.  Yet they cling to me, their needs suffocating and insistent. 

It’s an effort to come back to the surface, to quiet the rage, to strip down the chitin from my hard shell.  I study patience.  I practice making eye contact with strangers and thinking un-cynical thoughts.  I adopt an aggressive form of mindfulness, digging my fingernails into my skin when I feel the first prickles of dissociation. I meditate on vulnerability, on filing down my exoskeleton, on really listening. 

It will never come as naturally as it did before.  I am not the same person.  But here I am, in my white coat, and patients keep coming, thrusting their cares into my hands and expecting me to help, not roll my eyes.  And so I keep trying.

The Shooting (Star)

My clock radio went off at seven even though there was no reason to get up.  It was spring break, and I was home from college, isolated from most of my friends, and had nothing to do.  Facebook had not been invented yet.  I lay there in my twin bed in my childhood bedroom letting the dulcet tones of Morning Edition wash over me.  President Bush was saying something asinine again, the stock market seemed to be going well.  In local news, absolutely nothing was happening.  Except there would be a meteor shower tonight. 

Astronomy is not normally my thing. I built a pretty rocking paper maché model of the solar system back in the day, but that is where my interest ended.  It didn’t matter.  This sounded like a reason to get out of the damn house.

Baltimore City is not exactly an area of low light pollution.  I could not think of anywhere in the city that it would be dark enough to actually see stars.  From my parents’ house the night sky usually looked like a dark orange smear.  But outside the city, out in the suburbs where my grandparents lived, there was a baseball field where I knew the turned off all the lights by about nine.  The meteors would not be at their peak until midnight or so.

I called my friend Shannon, who was still in high school but also on spring break.  She was game, as was her boyfriend, Matt.  I would pick them up around eleven, and we would head out of town. 

I stewed at home all day, complaining loudly about how bored I was.  My dad, who works from home, has an amazing ability to tune out human speech, and I am sure this was the only reason he did not strangle me. 

Finally it was the appointed hour.  I bundled up and headed out to my car, Gay Lightning.  Gay Lightning was a champagne-colored 1991 Nissan Stanza sedan with a cranky transmission.  She had been so christened because of a rainbow lightning bolt decal that I had placed on the rear windshield.  The car had automatic windows that only worked on the left side, and a CD player that stole and repeated CDs for months at a time, refusing to eject.  Gay Lightning had selected Savage Garden as the soundtrack of choice for spring 2003.

I picked up Shannon and Matt at her folks’ house, and they climbed into the car with flashlights and snacks.  We headed on out of town. 

When we got to the field by my grandparents’ house, it seemed pretty dark.  We rolled out our blankets and stared at the sky.  Nothing.  We lay there in the grass and ate the snacks and talked about the meaning of life and what we would do if we were in charge of the world, and wouldn’t it be nice to start a commune someday?  We didn’t see a single shooting star.

By 2:00 am, clouds were rolling in, and it was obvious we weren’t going to see anything.  We packed up our blankets and finished up the crackers and apple slices.  We drove back into the city.

I love driving through the city at night.  It seems empty in a friendly way, and I like all the lights and infrastructure without all the people and traffic.  We were cresting a hill on Cold Spring Lane, which had been part of my regular commute to high school, when I saw it.  A man darted into the street right in front of us and dropped to the pavement.  I had to slam on the brakes on Gay Lightning to avoid hitting him.  The three of us sat there for a split second in shock.

I put the car in park and jumped out.  The man was lying in the road right in front of my car, clutching his shoulder, which was oozing blood.  Not spurting, but oozing at a good clip.  I hadn’t hit him, had I? It took a long time for my brain to realize that he had been shot. 

Hmm, shot seemed bad.  I looked up.  The street had filled with people, most of them on their cell phones.  I assumed the calling 911 was covered.  No one else was approaching the victim; I guess they figured I had that covered.  I squatted next to him.  “Hey, are you ok?” Stupid question, really, since the rapidly expanding pool of blood I was squatting in seemed to indicate that no, he was not ok.

“Think so,” he grunted.

“Good,” I said, “What’s your name?”

“Michael.”

“Hi Michael, I’m Mali.  Are you hurt anywhere other than your shoulder?”

“Don’t think so,” he grimaced.

“What happened?”

He tried to shrug in response.  Shrugging being a shoulder-based action, this did not seem to go so well for him. 

I had taken basic first aid, and I thought that I should apply pressure to his wound.  I also knew that I did not have any latex gloves on my person, and that I didn’t really want to touch this guy’s blood.  I always thought I would be cooler than that, more self-sacrificing – that in an emergency, “universal precautions” be damned!  But I had a strong sense that I should not touch his blood, and so I did not.  There didn’t seem to be a lot I could offer him. 

“You keep taking deep breaths, ok?  I’m going to go check on why the ambulance isn’t here yet.”

I stood up and walked away from him.  In the front row of the crowd of onlookers, one woman seemed to be shrieking and turning an unnatural shade of green.  I walked over to her and she grabbed my arm as if she was drowning.  I guided her to the curb and had her put her head between her knees and take deep breaths. 

I much preferred this non-bleeding patient.  The deep breaths seemed to be calming her.

“Do you know Michael?” I asked.

“No, I don’t know either of them, but that one back there looks bad.  I don’t think he’s gonna make it.  I never seen someone look so bad,” she pointed down the side street.  “This one looks ok,” she said, pointing to Michael.  She had a lilting Caribbean accent that I hadn’t expected.

I nodded.  I decided I didn’t want to see the one that didn’t look so good.

The police arrived before the ambulance.  They put on latex gloves but still didn’t touch Michael.  They didn’t walk into the pool of his blood.  They took statements from us, asked us what we saw, scribbled in their little notebooks, ignored the squawking of their radios.  The ambulance came and the EMTs tromped through the blood puddle to strap Michael onto a stretcher.  I went back to his side while the EMTs fussed with the straps and oxygen tubes. 

“Good luck,” I told him.  What else do you say?

He nodded at me.

A little while later another ambulance came and loaded up the body bag from the side street.  It drove away without sirens.

Shannon and Matt and I looked at each other.  Before I climbed back into Gay Lightning I tried to rub the blood off the soles of my sneakers onto the curb.  We drove home, silent except for the Savage Garden soundtrack.

I don’t really know what lessons to try to glean from this experience, about myself, about my city, about violence or race or the actions of crowds.  Two men were shot.  One died.  I am not sure if they shot each other or were shot by someone else.  I don’t know what happened to Michael.  The shooting was not reported in the paper.

Years later, with four years of medical training behind me, I think I would do the same thing.  I wouldn’t touch his blood.  I always thought self-sacrifice was something to be valued, something noble.  I always thought that a white girl being afraid to touch a black man’s blood would be a mark of irrational racist fear. 

And maybe it is.  Maybe I’m not as anti-racist as I think I am.  But I know enough about blood-borne pathogens to know that while the risk of HIV transmission is incredibly low, the risk of Hepatitis transmission is higher.  Neither of these risks are zero.  It’s not a risk I am willing to take. 

I got tired of thinking about this, pondering its meaning.  I bought a box of latex gloves and put them in my car.