A MATTER OF LIFE AND DEATH

The Emergency Room

by John K. Petty

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"We learn to care for the ill and dying--we unlearn our distance from illness and death. When caring for a patient, the learning and the unlearning are never far apart."

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It begins with a pulse. He is brought in to the trauma room on the ambulance stretcher. The room explodes with activity as the awaited guest arrives. Vital signs. Transfer to our stretcher. Clothing cut off. Monitors connected.

All of this happens very quickly, as everyone has done it so many times before. Everyone but one. I wait at the foot of the stretcher, eager to help, but doing my best to stay out of the way. It is enough to be present and help when possible. From my vantage point, there's not much I can do--not that anyone particularly needs a medical student's help. I put my hand on his foot and take his pulse. I feel life as it beats beneath my fingers. This is how we introduce ourselves.

He is a young man about my age. His face is badly injured, with lacerations on his forehead, cheeks, and lips. He has blood in his mouth and in his red hair. His neck is immobilized in a rigid plastic collar. His eyes are open and he groans in pain. He rocks slightly on the stretcher but is otherwise still. He does not move his legs at all. He is somewhat responsive when given commands. He has his name, Patrick, tattooed on his left shoulder. The rescue workers have scribbled some vital signs and other important information on his arm.

The workers tell us his story as best they know it. Patrick was riding his mountain bike on the boulevard nearby when he was struck by an automobile and thrown to the pavement fifteen yards away. It was not long after the accident before the rescue team came to him.

Everybody has something to do. The chief resident supervises all of the activity. He permits the third-year resident underneath him to give most of the directions and interjects only when necessary. The third-year resident is rapidly, but methodically, giving instructions to the rest of the team and performing a physical exam, knowing that the chief resident is keeping a knowledgeable eye on the whole situation as well. The intern is taking orders, helping with the physical exam, and otherwise doing what needs to get done.

I'm at the end of the chain of command. I do whatever the intern, or anyone else, tells me to do. After the initial burst of activity, I am given a few tasks. I leave the foot of the bed to fetch, open, and hold supplies for the intern. When given the chance, I draw blood. Much of the time, I'm simply keeping my eyes open, watching, learning, trying to stay out of the way, feeling pulses.

Medical school is about learning. As students we fill our heads with anatomy, physiology, pathology, and pharmacology. We learn to ask the right questions of patients. We train our ears to listen. We train our hands to feel. We train our minds to put it all together for the good of the patient.

Medical school is also about unlearning. In learning patient care, we must unlearn many of our social reservations about what is proper and appropriate. We learn anatomy--we unlearn our revulsion to dead bodies. We learn to take a history--we unlearn our inhibition about discussing embarrassing and personal subjects. We learn to perform a physical exam --we unlearn the inappropriateness of touching and probing a stranger's naked body. We learn to sample body fluids with needles--we unlearn our desire not to inflict pain on another. We learn to clean and dress wounds --we unlearn our disgust for what is malodorous, bloody, and raw. We learn to care for the ill and dying--we unlearn our distance from illness and death. When caring for a patient, the learning and the unlearning are never far apart.

Those of us on the trauma surgery service are not the only ones involved in caring for this patient. Contributing their efforts as well are the emergency room nurses, the anesthesia team, the IV team, and the X-ray technician. All act at the direction of our resident. In the next concentric circle out from the immediate team stand the representatives from other surgical services, orthopedics and neurosurgery. They must wait until we have stabilized the patient before they can come and make their assessment. They watch like a pack of Serengeti jackals waiting for the lions to eat their fill. Pride. I make eye contact with the medical student on the orthopedics service and wonder if he isn't a little envious of me here in the middle of the action while he waits.

The initial wave of activity ebbs; the preliminary findings are stable. The neurosurgery resident quickly starts his neurological exam. A light in his eyes. "Squeeze my finger." Tap with a reflex hammer. "Can you feel this?" Patrick can't move his legs. The resident tries to determine at what level the spine has been damaged. While this is going on, I'm inserting the urine catheter. The X-ray technician is weaving in and out, sliding film under the patient and having us clear out episodically while he activates the portable X-ray machine.

The anesthesia team expresses concern about protecting Patrick's airway, in light of his facial injuries. They ask if they can put him to sleep and place a breathing tube down his throat. Our chief resident agrees. Patrick is still semi-conscious and groaning. He will tolerate our actions much better if he is asleep. Sleep will palliate his torture. With an injection in his IV, he drifts off peacefully, and the anesthesia team takes over the responsibility of breathing for him.

The attending surgeon on-call phones in to respond to his page. The chief resident gives the surgeon a brief assessment of the situation. "Things look pretty good so far," he tells the attending. "He hasn't had his CT scan yet. Ortho and neuro are doing their assessments right now. So far he doesn't look like a Ôgeneral surgery' case. I feel confident managing him down here in the ER, but if you want to come see him, that would be fine." The attending surgeon commends the resident, but says that he'd like to see the patient himself.

While this conversation transpires, we continue with our activity. One of the nurses is going through Patrick's backpack to get identifying information and to put his belongings in an envelope for safe keeping. In his wallet she finds a student identification card. He is an undergraduate at a nearby university. I wonder if he's been studying for his final exams and if he's getting his room packed up for the summer. Perhaps he's graduating. Perhaps he'll be starting a job soon. Perhaps he's going to start medical school this fall. What a terrible time to have this kind of an accident.

The nurse also finds a can of malt liquor in his pack. No one else seems to bat an eyelash at this finding. Those who work in the ER see the casualties of alcohol all the time. Perhaps they expect to find it implicated in almost all of the trauma cases and are surprised when it is absent. Wine and spirits poison the blood and breath of injured patients all of the time. The spell of alcohol is not magical. The glamour of a halftime advertisement could not be further from what I see before me. Whether or not the patient had been drinking can be demonstrated only by a blood test. In the eyes of the ER jury, only a negative test can exonerate him. The current evidence is circumstantial, yet it threatens a conviction and consequent forfeiture of compassion.

The discovery of a silvery can makes sense in the situation, but does not make sense of the situation. It cannot make sense of the insensible. It cannot explain the unexplainable. It cannot straighten what has been made crooked.

Soon the chief resident decides that Patrick is stable enough to be taken to the CT scanner to evaluate internal injuries. As we unlock the brakes of the stretcher to wheel him out of the ER, the attending surgeon walks in: "Before you take him upstairs, I'd like to evaluate him down here." We lock the brakes while the chief resident updates the surgeon.

Knowing that this will take some time, the intern turns to me and tells me that I should take a blood gas. I've been taught how to do this, but never done it before. It's not a complicated procedure--basically take the syringe and aim for the pulse. I get all of my apparatus together and take the patient's arm in my hand. I can feel a steady pulse. I put on my gloves and swab the spot with alcohol. I take the syringe and prepare to unlearn. I can't feel the pulse anymore. I feel around, but I can't find it. I call the intern over to give me a hand. He gives me the look of a disappointed parent and comes over to instruct my amateur fingers. He finds only a trace of a pulse, but is incapable of intercepting it with the needle.

He feels for other pulses, but can find none. Very quickly it becomes apparent that something is wrong. The monitor shows a plummet in blood pressure and an increase in his heart rate. Immediately, the attending and chief resident take charge. They feel for pulses and listen for a heartbeat. I take my post at the foot of the stretcher. The chief resident asks for a scalpel and rib spreader. They open his chest and blood comes pouring out. Patrick has a tear in his aorta. His heart and left lung are exposed, and the attending reaches in to see if he can control the bleeding. I almost can't believe that I'm witnessing this perilous procedure. Opening his chest and exposing his vital organs in this nonsterile environment is a drastic move, but without it, he will quickly bleed to death. My adrenaline is high as I hold his pulseless foot.

"I think I've got it clamped," the attending exclaims with his hands in Patrick's chest. "We need to get him up to the operating room now!" We start hooking up portable monitors, clearing out apparatus, and covering up the patient.

"What would you like me to do?" I ask the intern.

The attending barks: "John, go upstairs and scrub now. Once we get up there, I'm going to want you to take my place with this clamp while we scrub."

Me?! I wonder to myself. I'm the guy who's never done a blood gas before, remember? Before I can even complete this thought, I am bolting out of the emergency room. As I sprint down the hall, I begin preparing myself for the moment at which I will have Patrick's life at my hands. I can hardly believe all that has been going on--the sudden decline in Patrick's course, the excitement of opening his chest, the intensity of repairing a torn aorta, the thrill of rescuing life from death. We save.

I scrub and rinse my hands quickly. I back through the door into the operating room and find the OR team frenetically setting up for battle. Packages opened. Tubing connected. Instruments arrayed. I stand in the corner with dripping hands, waiting for a sterile towel.

The doors open again, and Patrick arrives with all of his attendants. The attending is still at his side, hands in his chest. He doesn't leave. He doesn't see me. He seems to have forgotten the instructions he gave in the ER. They need help transferring Patrick to the operating table, so I contaminate my hands and help pull him over from the stretcher. We secure the band around his waist and extend his arms straight out to either side so that the anesthesia team will be able to access IV lines for blood and fluids without contaminating the operating field. Bags of blood and water pour into his veins as fast as possible. While we have been transferring the patient, the third-year resident has scrubbed, gowned, and gloved. He takes the attending's place while the attending scrubs. I step away from the table.

The lights are focused, and the attending furrows his brow. A tense hush falls on those in attendance as the operation begins.

"Should I go scrub?" I whisper to the intern on the sidelines. "Or would it be better for me to watch from here?"

"You can scrub and go to the field, but just try to stay out of the way," he counsels.

As if I need to be reminded. A breath could scarcely be more inconspicuous.

I scrub and come to the table as the blood and water continue to flow in the tubing. I see Patrick's heart, the fountainhead of his pulse, revealed by the hole in his side, more exposed and more vulnerable than it was down in the ER. It beats irregularly, giving rhythm to an unknown cadence. His lungs march to a mechanical metronome, but his heart breaks stride.

The attending works rapidly, seemingly oblivious to the cardiovascular choreography before his eyes. He is focused on the torn aorta. He asks for clamps, sponges, and retractors; he instantaneously receives them from the scrub nurse. While he works, he gives terse directions to the resident at his side. "Hold this. Clamp that. Take that."

Clamps and sutures become weapons of battle. The fight continues to a point where the chief resident pauses and shakes his head. Keep fighting, I think. The attending perseveres with his strokes and flashes. He stops. The room is silent. Keep fighting, I pray. He rejoins the battle with passion and speed as he had before. The heart has stopped its march except for occasional, futile paroxysms. The attending at last surrenders his weapons. He injects a syringe of adrenaline directly into the heart, a final, desperate offering.

Patrick's broken body lies motionless on the table. His blood spilled on the floor. The hole in his side. His arms outstretched. His heart at the crux.

No pulse.

The attending calls me over to his side. "John, come over here, and I'll explain what's been going on," he says to me. Pointing to Patrick's chest, he says, "Here's the arch of the aorta. Left common carotid artery. Left subclavian artery. Descending aorta. In any accident with sudden deceleration, the arch is well-tethered by the major vessels coming off, but the descending aorta has only the flimsy intercostal arteries holding it in place. So, it continues forward while the arch stays in place. If the deceleration is great enough, it can tear right along here like this one did."

I nod politely, "Uh huh." Patrick is transformed from patient to anatomy lesson, yet he looks the same to me. I can't believe he went so quickly. I put my hand into his side in disbelief. At what point did he die? When he hit the pavement? When he was sedated in the ER? When his blood pressure dropped? Was it when we stopped our efforts? The resident said that it was much before that. That moment felt like death to me.

Now we tend to the body, undoing much of what we've done. The drapes are removed. The intravenous lines are pulled. The third-year resident and I stand over the body, stitching closed the hole in his chest. My awkward hands need more learning, but the resident guides me through an even row of stitches. A meticulous wound closure is the least we can do for him now. The family will want to see the body. It is enough to be present and help when possible. The attending is writing in the chart as we work. He asks, "Did anyone talk to the family?"

"I saw them quickly as we were heading up to the OR," replies the third-year resident. "I told them he had been in a bad bicycle accident and we were rushing him up to the operating room to do an emergency operation. I said we'd do all we could, but his chances didn't look very good. I felt bad dropping a bomb like that on them and then running off, but I thought they needed to know that the picture didn't look very promising."

Everyone knew the big picture before we got to the operating room. Everyone but one. Everyone but two. The instant his pulse faded, the surgeons must have known. They must have known that his prognosis was grim. They must have known that their best efforts would probably fail. I was dazzled. I was excited. I was intoxicated with saving. I was clueless. I didn't know. Now I know.

We finish our stitches, and as we tie our final knots, the third-year resident proclaims, to no one in particular, "He was supposed to get married next weekend. His fiancee was in the waiting room." As we start to wipe the blood off of his wound, my eyes tear up, and I sniff behind my mask. I think of my wife of five months. "You okay, John?" the resident asks. I nod my head, "Uh huh." We clean up the body as best we can, but his broken face proclaims the violence he has suffered.

We pull off our gowns, gloves, and masks as we leave the operating theater. Through the doors and down the hall we walk toward the family waiting room. I can see them waiting, waiting for the surgeon to come and speak their greatest fear into reality. The father has his arm around his wife and stares intently at the floor. The mother, with eyes full of tears, clutches a wadded tissue in one hand and a crucifix in the other. The sister sniffs quietly, resting her head on her husband's shoulder, her tears trickling down his shirt. The fiancee, widowed before she was wed, sobs with her face in her hands.

Death stings.

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Petty '92 is a fourth-year medical student at the University of North Carolina School of Medicine, where he is conducting research in clinical ethics. Names in this article have been changed to protect confidentiality.

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