An Open Letter to My Elected Officials on Firearms and the Deaths Trauma Surgeons See Daily

An Open Letter to My Elected Representatives

February 23, 2018

Dear Elected Official:

As a trauma surgeon and one of your constituents, I was heartened to hear that you are reconsidering your views on how to protect Americans from the ravages of our national gun violence epidemic. I am writing to share my first hand experiences along with known facts about widespread use of guns in the US today. In my line of work I am all too familiar with the lethal potential of firearms, especially when coupled with a cavalier attitude that many legal gun owners in America have that they or their families are somehow immune to the deadly power of guns. While every life I save is a privilege, my greatest success as a trauma surgeon would be to significantly reduce the number of people who need my care. Injury prevention is as fundamental to my work as is operating. In the case of firearms-related injury, there is much work to be done. I hope my perspective on the morbid consequences of Americans’ unfettered access to firearms will be helpful as you consider what should be done to protect each and every one of us from a death that is truly 100% preventable.

As a trauma surgeon, I have held countless ounces of brain matter in my hands while examining a self-inflicted gunshot wound. Occasionally, someone shoots themself in the chest, aiming at the heart. Most often, however, the suicide victim points a gun, legally purchased by themself or a family member, at the temple or roof of the mouth aiming at the brain. At such close range, despite my expert skill in trauma care, the damage is far too severe to reverse. It is a uniquely American reality that homes across the nation, occupied by residents experiencing deep depression, are also filled with firearms acquired for sport, hunting, or presumed personal protection. Of the nearly 96 Americans who die a firearms-related death in the US daily, nearly 59 die as the result of suicide. People with suicidal thoughts are three times more likely to succeed if they live in a home with a firearm. Furthermore, while 9 out of 10 suicide attempts with a gun are successful, only 1 out of 10 attempts by all other means succeed. To be sure, we as a society need to lift the stigma on psychiatric disease and enact policies that increase our nation’s mental health workforce and require both insurance companies and hospital systems to treat mental health conditions like any other illness. However, given that the leap from suicidal ideation to death by suicide is shortened by the presence of firearms, we must also take steps reduce access to firearms in US homes.

As a trauma surgeon, I have felt the anguish of too many parents who learned that their child was dead from me. Occasionally, the child was a teen who, in the absence of strong public education, housing security, and hope for an economically sound future, turned to a life of gang warfare in our urban centers. But more often, a child’s death has been deemed in our societal discourse an “accident.” Yet, the presence of the firearm used in the “accident” is in fact very intentional. Our fellow citizens routinely purchase these deadly weapons and keep them in their homes, thinking they are for defense, sport, or hobby. I wish I did not know the horror of a child killed “accidentally” by a sibling, a friend or even themself, but I do. The adult gun owners in each of these cases would swear to be well-versed in firearm safety. But, having seen that child lying cold and lifeless in my trauma bay, I know that they were overconfident in their ability to safely store their firearms. Nearly 1,300 American children die of gunshots every year. Worldwide, of all children who die this way, the US accounts for 91% of them. And, despite the characterization of our nation’s urban centers as the source of the majority of our dead American teenagers, it is important to note that only one in five teens who suffer a firearms-related death was involved in gangs; the vast majority of firearms-related deaths among teens in our nation are, in fact, due to suicides and these supposed “accidents.” Certainly, we should address the problem of urban violence among our youth and the illegal firearms trade that makes it so easy for them to kill each other (recalling that all illegal guns were at one point legally acquired). And, as the number of children lost in school shootings impossibly rises, we absolutely should address the pervasive issues affecting our boys today which might make any one of them turn against their classmates with lethal force. But these efforts would not be nearly enough given that the vast majority of children killed by firearms in the US die in settings with legally acquired guns one “accidental” death or suicide at a time. We must reduce the widespread presence of firearms in American homes and we must stop giving those who choose to keep deadly weapons near their children a pass when their carelessness results in a death.

As a trauma surgeon, I have also taken care of too many people, most often women, who have been shot dead in an act of domestic violence. When my patients have been beaten (by hands or weaponized object such as a bat or pipe) or stabbed (by weaponized knife or bottle) by their abuser, I have a realistic chance to heal them of their physical and mental wounds and get them to a safer place. However, firearms make it too easy for the abuser to become a murderer and I am robbed of the opportunity to end the cycle of domestic abuse in a positive way. Of all women murdered in this country, 45% are murdered by someone who supposedly loves them. This risk of intimate partner violence spans all sociodemographic groups but women residing in homes with firearms are 5 times more likely to be murdered by their abuser than those whose abusers do not have easy access to a gun. To be sure, we need as a society to address the root causes of domestic violence in the US and expand services nationally to help people in abusive relationships leave. However, it is clear that easy access to firearms is the major cause of domestic abuse fatalities; we must at the very least put a halt to how easy it is for abusers to acquire guns.

As a trauma surgeon, I have been fortunate not to have to care for victims from a mass shooting event; but I have trained repeatedly for mass casualty response. Years ago, we used to prepare for something like a bus crash or a building collapse; these days we prepare for shooters. Sadly, I have had to learn from the experiences of my fellow trauma surgeons in places like Newtown, Orlando, Las Vegas, and Fort Lauderdale. There is no glory in caring for victim after victim arriving with bullet holes, only grief; and then one must have the fortitude to bury the grief and move on to the next victim. Often, however, the grief is not from the patients coming into our trauma bays. Rather it is the eerie quiet in the empty bay picturing all the lifeless bodies that never needed to come to the trauma center. We have seen over and over in our country the highly lethal mix of angry people (some with true mental illness but most simply filled with rage) and easy access to firearms, typically legally acquired by self or family member. Surely, reducing overall access to firearms must be part of the equation in improving our collective right to life, liberty, and the pursuit of happiness while we are at school, the movies, and other public venues.

As a trauma surgeon, I have also trained for active shooter events because sadly, in additional to training for years to become the highly skilled professional that I am, I must now also be prepared to get shot in the line of duty as a healthcare provider. From 2000 to 2015 in the US, there were 241 hospital-related shootings. This statistic really hit home when cardiac surgeon Michael Davidson was shot dead in his clinic by a disgruntled family member whose mother had died of a known complication of major heart surgery. He was around my age. His wife was a college classmate. He was killed by a volatile man who lived in my community just 40 miles away. Complications are a part of what we do as surgeons no matter how expert we are, or how much caution we exercise in doing our work. To live in fear that my own death might be the consequence of my professional efforts, because so many of my patients and their families are legal gun owners, is something that my years of training simply did not prepare me for. Here again, the lethal combination of rage and access to firearms is painfully apparent. To be sure, we must make efforts to understand why people come to hospitals prepared to kill – whether it is a critically ill loved one or a physician who they see as responsible for a complication; but, we cannot simply continue let the answer to rage be grabbing one’s readily available firearm.

As a trauma surgeon, I can also provide some insight into the “good guys with guns” concept that people sometimes put forth as a solution to our nation’s gun violence epidemic. As evidenced by the seasoned hunter who shot off his reproductive organs cleaning his rifle or the experienced officer who shot himself while moving firearms from one cruiser to another, I have seen that even the most highly trained “good guys” sometimes don’t understand the power of their guns. Furthermore, the few times that I have been the one to care for a fallen police officer has taught me that even the “best of guys,” armed, well-trained, and experienced, can be taken by the actions of an enraged person with a gun. I was not on call recently when an officer shot while responding to a domestic altercation was brought to our trauma bay; my partner’s efforts to save his life proved to be futile. I can hear the wails of the grown men in blue who lost their partner that night as if I had been present because, sadly, I have heard those wails before. They are somehow even more haunting than the cries of a parent who has a lost child. To be sure, criminals intent on killing will find a way; however, in the decade leading up to 2016, 537 US police officers were killed by a perpetrator wielding a firearm. In contrast, those attacking with a knife, a bomb, or fist/strangle caused just 26 officer deaths in the same time period.  It seems clear that even the “good guys” are not immune to rage-filled persons armed with guns. Therefore, seriously limiting access to firearms will necessarily make more of a dent in our nation’s firearms-related death epidemic than arming others who are unlikely to respond quickly enough to make a save or, worse, might accidentally shoot themselves or someone else.

As a trauma surgeon, I have also seen the impact of high-powered military style assault weapons. As an interested professional, I have deliberately read reports on the autopsies of so many killed with such weapons in our nation’s most recent mass shootings. While all firearms are manufactured with the purpose of maiming or killing, make no mistake about it: the destructiveness of high velocity missiles that can be fired multiple rounds at a time makes semi-automatic assault rifles like no other gun. These kinds of weapons cause tissue damage that is unfathomable, leaving unrecognizable parts that were once part of a living, breathing human. Regarding ownership of such deadly weapons for the sport of hunting, I would argue that if you are such a bad shot that a bow & arrow or a shotgun does not suffice, then you should buy your meat from the store and take up a new hobby. Having seen firsthand what these assault weapons do, I see no reason why any civilian should have access to them for any purpose.

I am grateful that you have taken the time to read about my experiences. Based on my vantage point as a trauma surgeon, and as a concerned citizen, I have several suggestions that I hope will protect all of us from dying from a gunshot(s).

  • Firearms buybacks for those who simply no longer want to live subject to the possibility of the kinds of death I see daily
  • Deny gun permits to those with any history of domestic abuse, restraining orders, anger management issues, school suspensions, animal torture, and the like which all point to tendency for moments of rage
  • Mandate biometric trigger locks so that only the one legal owner of any firearm could use it, and not a thief, or a child, or a suicidal family member
  • Regulate firearms use and liability as we do with automobiles through required firearms training and testing and insurance to cover death/injury/anguish should anyone else get struck by a bullet from your gun
  • Allow survivors and states to sue gun manufacturers for wrongful death as we do for other consumer products (e.g., swimming pool drains, fertilizer, toys, airbags)
  • Prosecute adults whose negligent storage of a firearm leads to “accidental” death at that hands of a child
  • Ban the manufacture and sale of high velocity semi-automatic weapons and multiple rounds of ammunition along with a mandatory buyback of all such weapons followed by fines or jail time for those later found to be in violation of such laws

Again, I am heartened to know that reducing the burden of firearms related death in our society is among your legislative priorities. While I am not an expert in any such policy issues, as you have read, I am sadly an expert in people who die with bullet holes and buckshot wounds. Please do what you can to rid me and my colleagues of these horrific images and make all of us safer.



Heena P. Santry, MD MS



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

“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.

The trouble with discourse that drives us apart in response to a death in the line of duty

My heart sank when I heard the news that a local police officer had been killed in the line of duty. I was not on call that day but I knew exactly what the words “he was taken to a local hospital where he was later pronounced dead” meant. As trauma surgeons we provide care for those injured in senseless, often preventable ways daily. But when an officer is stricken it hurts so deeply because we share a position with them at the forefront of the worst that happens in our society.

So when I heard the news I mourned for the officer, for his family, for his colleagues, for all of law enforcement, and for the people who tried so valiantly to save his life and would forever be asking themselves “was there something else we could have done?”

Let me assure you, there was not.

As with all trauma centers, we have a comprehensive morning report where we discuss all of our new patients: what was the mechanism, how did they present, what was done for the work-up and subsequent treatment? So it was clear that the trauma team did everything they scientifically or physiologically could in this case. In morbidity and mortality* terms, this would be a ‘non-preventable’ death.

Here’s the thing though, of course it was preventable. And we are all (as members of the community, as his brothers and sisters in law enforcement, as representatives of both sides of the criminal justice system, as providers in the healthcare system) asking this same question “why, why did a good man—a good cop, a good husband, a good father, a good son, a good citizen—die this way?”

In a statement to the press less soon after losing her son, the officer’s grief-stricken mother was quoted as saying there is “no respect for police anymore” suggesting perhaps that a pervasive devaluing of law enforcement by society might be at the root of her son’s preventable death. She was no doubt alluding to the national discourse evolving in recent years due to some high profile episodes where the actions of responding officers have been questioned. Some actions have been proven to be criminal by our justice system, as in the case of an Oklahoma City Police Officer who serially raped women he had pulled over, in other cases, however, the facts in support of criminal behavior beyond a reasonable doubt are less clear (e.g., Officer Parker of Madison, AL and Mr. Sureshbhai Patel; or Officer Wilson of Ferguson, MO and Mr. Michael Brown; or Officer Pantaleo of New York, NY and Mr. Eric Garner).

Clarity notwithstanding, there has seemingly been a shift in public rhetoric questioning of infallibility of those on the front lines of law enforcement. Sadly, in some cases the rhetoric has escalated to vitriol, rioting, and even directed acts of violence against law enforcement.  It truly is maddening that a man, fueled by the overarching discourse questioning police intentions and behavior, would then seek an opportunity to kill the police as in the case of Mr. Ismaaiyl Brinsley who gunned down Officers Wenjian Liu and Rafael Ramos of the NYPD, not during the act of apprehension or while committing another crime, but just because.

However, no matter what the headlines are, the overwhelming majority of our men and women in blue are good men and women who take on their duties with the best of intentions and model professional behavior. And so, when this good man’s mother cites this volatile discourse as a possible cause of his death—as much as my heart breaks for her—it hurts our community by suggesting a local conflict where there was none.

By all accounts, the cop killer in this case was a sociopath lacking any respect for human life or the laws of our society in general as evident by a lengthy record replete with charges ranging from cocaine trafficking, to assault & battery, to weapons possession. Those of us who are not career criminals might get tachycardic or diaphoretic during traffic stops but our natural instinct is to reach for our license & registration, not for our gun. A man with no moral compass felt cornered and so he fired; but, this was no more because he was cornered by an officer than if I had made some gesture to this armed and dangerous criminal during my nightly dog walk.

So, while a family, a profession, and a community mourn, I urge each of us to contemplate how the criminal justice system might have functioned differently to prevent this senseless tragedy but to avoid stoking fired up rhetoric that pits people against the police and police against the people. Discourse that drives us apart stands in the way of viable solutions to combat the socioeconomic and psychological factors that may drive one to a lifetime of crime in the first place and to take those who cannot be rehabilitated off the streets before another preventable death, be it of an ordinary citizen or a man/woman in blue.


*Morbidity & Mortality, or M&M as it is called is a weekly conference held by surgical teams to review all deaths and complications in an effort to learn more about the systems-based and disease-based processes that led to the adverse outcome.



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.


The Miracle Worker Gets a Hug

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 filled with 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. But, 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.]


The Final Chapter

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 came 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 itt 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.





Hey Doc!

“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.”


Ski Practice

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.

A Belated Thank You

It was late. I had just finished a straight-forward appendectomy. I explained the findings and expectations for recovery to the family gathered in the waiting area. There were a lot more people there than in the emergency room just a few hours earlier.

“Yes, he will most likely be going home tomorrow morning,” I answered in response to a final question from a family member. I shook the mother’s hand and turned to walk away. Everyone’s expression was one of relief. It’s an every day diagnosis and procedure for us; for them, it’s quite possibly the scariest thing to have happen to a love one.

Except it wasn’t.

“I think I know you,” I heard when my back was already turned. “Do you take care of people in car crashes?” It was a timid inquiry.

“Yes, I am an acute care surgeon. I do trauma and emergency general surgery.”

“You think you took care of my daughter. Years ago. She died in a car crash. She…”

I cannot imagine how difficult it must have been for that mother to be back in that hospital, back in a bland waiting room with fluorescent lights illuminating my face again. I simply can’t. But, I had a crystal clear memory of that morning. Nothing was left to the imagination that day. Nothing needed to be discerned by the powers of radiation vectors.

It was a long time ago. Still, the image of that poor girl, a life I could not save, a body badly mangled by someone going the wrong way at highway speeds, was seared in my brain. It was truly horrific. The bodily damage was unlike I had ever seen before. My boss with more than 30 years more experience was there too. Neither had he.

“…Thank you for everything you did. You were so kind to us. You told us she didn’t suffer. You let us wail and you held us. We never said thank you.”

“Yes, I remember,” I gulped. I felt a lump in my throat, a tear in my eye.

CPR was in progress upon arrival. There was nothing to do but be kind. Words of gratitude were neither needed nor expected. It’s what we do. However, the reminder that families are grateful when we tell them we removed a vestigial organ without incident or when we deliver the soul-crushing news that their child is dead was deeply appreciated. For the lives we cannot save, with kindness and empathy we can at least spare those left behind from just a little bit of suffering in the midst of so much agony.


“Not again,” we all silently sigh when the page comes through. He arrives under lock and key and stays that way no matter what our plan.  Every trauma surgeon and nearly every resident has previously participated in his care over the years.

He has a life sentence.

The abdomen is socked in. There is no more retrieving the foreign bodies piercing his abdominal cavity. We have been there and done that. If something is visible on the outside we can pull it out. Now we just have to hope whatever was injured causes a process that walls itself off and does not cause too much physiologic compromise.

But what about the psychologic compromise? He does not wish to end his life; that much is clear. But he is looking for escape. The lure of the secondary gain is strong. He has admitted to us:

The food here is better.

The nurses are cute.

I don’t want to be near the pedophiles.

With our incarcerated patients, it is not our place to address these cries for help. We can’t imagine the fortitude it must take to clandestinely acquire a sharp object and then meticulously drive it through the abdomen wall into whatever organs lie beneath; but, we must stay focused on the anatomic issues and potential complications.

He is screaming at us now. The guards tell him to calm down. Now it is his words that pierce our ears:

You have to cut me open.

Please put me to sleep.

I am not a bad person.

As trauma surgeons we view all patients as equal. They all deserve the same compassion and high standard of care no matter what the circumstances of the injury, no matter what the personal status of the patient. We never, not ever, inquire as to the circumstances of the crime(s) for which the patient is serving his sentence or how long the sentence is. None of that matters. He is our patient and we provide him the best care possible.

Today the best care possible is to provide minor bedside care with local anesthetic to remove a foreign body. To calm him down I take his hand while the residents work. I lock his eyes so he will stop trying to see their sterile field. I ask him about himself. I am not sure why but it seemed like the natural thing to do.

He tells us where he grew up. He describes his childhood. He takes a sentence to describe his crime and then speaks more in detail about how the next 37 years of his life sentence led to today. He says:

I wasn’t always like this.

I used to be normal.

Now, this is the only way I know how to cope.

The self-inflicted stab wound will be fine. No hospital food needed. No bedside care from nurses needed. But before he goes back to his bunk with the pedophile, I tell him that we are sorry things turned out this way for him. We wish him luck trying to cope better but we fear he won’t be that lucky.

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

Hot Heels, Cool Kicks, & a Scalpel

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…

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