Self-Inflicted

“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.

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Hero

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.

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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.]