Collin Mulcahy and Woods Nash
March 4, 2016
This essay—narrated in the voice of a third-year medical student—is co-authored by a postdoctoral fellow in humanities and ethics.
It was my first trauma rotation, my second night on call. At 18:30, our team’s pagers went off, alerting us to a case coming in. I packed up my half-eaten dinner and walked quickly to the trauma bay, glancing at my pager: “38 yo female, MVC, ejection, HR 144, BP 60/20, GCS 3, ETA 3min.” In other words: very bad. It was a head-on collision in a Houston suburb. Unrestrained, our patient was ejected from the vehicle and found unresponsive with multiple injuries to her extremities. She was also hypotensive and tachycardic—the classic picture of hypovolemic shock caused by internal hemorrhaging. Like our other unidentified trauma patients, she was assigned an alias: Juliet 237.
Upon arrival, she’d been intubated, had breath sounds bilaterally, and had good carotid pulses. Bedside FAST exam—a type of ultrasound—revealed large amounts of free fluid around the liver, spleen, and right lung. The care team found her pupils fixed and dilated, an expanding abdomen, and what appeared to be multiple fractures. Soon, the decision was made to take her to the OR for exploratory surgery. There, they discovered a severe liver laceration and, worse still, a tear in a remote part of her inferior vena cava—an injury almost no one survives.
Memorial Hermann Hospital in Houston, Texas, has the busiest trauma center in the world. This stems from a combination of Hermann’s rich history—Life Flight was started here by renowned trauma surgeon James “Red” Duke—and the sheer prevalence of trauma in the fourth-largest U.S. city. Home to more than six million people, the Houston area is served by only two major trauma centers. For third-year medical students like me, this combination makes for a fascinating rotation—a place to learn lessons that can’t be gleaned just anywhere.
I scrubbed in and was soon elbows-deep in blood. The trauma team called a liver transplant surgeon to assist in stabilization. We began what turned out to be a four-and-a-half-hour surgery involving over 100 units of blood products. It was a highly technical procedure that had only a slight chance of success. But through it all, I could think of little more than how quickly things had changed for this woman. One minute, she’d been driving down the road with her friend. A few seconds later, her life was irrevocably altered. Within half an hour, she was strapped to an OR bed with her intestines on the table. Nothing could be the same for her again.
But it worked. Despite her complex condition and the mountainous odds against us, Juliet 237 was stabilized. When she was delivered to the ICU, however, a CT scan of her head revealed severe brain swelling. Neurosurgery determined that her injury was “non-survivable”—she was brain dead. In the Emergency Department, she’d been unstable, so there was no way to obtain a head CT before initiating a dramatic surgery to “save her life,” as we imagined we were doing. All the while, her brain wasn’t functioning. It wouldn't have mattered if we’d replaced her ripped liver with a fresh one and fixed every broken bone. She was gone, and would remain gone.
In light of that outcome, some might wonder: Why do the surgery? The simplest answer is trauma protocol. We must attend to the most urgent matter first. Delay surgeries to await CT results, and patients die. That much is plain.
But for me, there’s another question to be asked about Juliet 237: Did she help us remember that medicine has limits? As a student, I bring unrealistic expectations to work every day. Part of me still believes we should be able to save anyone, every time. “I knew theoretically that my patients could die, of course,” physician Atul Gawande writes of his early years in practice, “but every actual instance seemed like a violation, as if the rules I thought we were playing by were broken. I don’t know what game I thought this was, but in it we always won.”1 Juliet 237 was a profound reminder. Even some of the best can’t save a patient who is brain dead. A threshold had been crossed. One shouldn’t have to rotate through the world’s busiest trauma center to come to grips with this basic point: some kinds of damage can’t be undone.
That lesson could serve as a common thread for medical students as we move from one care setting to the next. Consider the woman who endured a difficult labor and emergency C-section only to lose her baby to SIDS two months later. Or the dazed parents I encountered on pediatrics: their infant has Trisomy 13 and isn’t expected to live past her first birthday. And how could we console the 82-year-old demented gentleman and the caregiving daughter he no longer recognizes? Later, on psych, I met a schizophrenic man who adamantly refuses treatment while continuing to hear voices who tell him to kill himself. Nor can I forget the cancer patient in remission whose house burned down with her mother inside the night before she was scheduled for discharge.
The list could go on and on.
Many of us encounter such patients daily. But because we wish to think of ourselves as successful, it’s tempting to focus on what can be fixed and suppress our awareness of limitations. The truth, however, is that there are many kinds of suffering, and we can’t always heal—or heal fully. As students, our job shouldn’t only be to learn the medical principles behind patient management. We also should be taught to recognize the limits of our profession and to grapple with tragedies that happen along the way.
For decades, public health scholars have noted that some of the staunchest obstacles to health are socioeconomic2—and medical students must appreciate these, too. The limits that concern me here, however, are not structural but existential—impasses like moral obscurity, shifting identities, irreversible decline, shortcomings of words, inept empathy, and finitude. Good mentors can show us how to deal with these experiences, but not all mentors will take the time or possess the requisite wisdom. To reach more students effectively, these topics should be the focus of a course—one that draws on ethics and psychology, religion and sociology, history, literature, and more. Such a course would have two central questions: How have humans found—or failed to find—meaning in the face of intractable sickness and death? And as we join our patients in the midst of such struggles, how do we care for ourselves and our colleagues? There are exceptions,3 but most medical schools seem to be missing these lessons: how to keep ourselves well while bearing others’ pain—including the suffering medicine cannot assuage. Addressing those topics is a daunting task, but we must confront them. I’m still a student, but I already fear the long-term toll these regular doses of futility and loss will take.
I overheard a familiar note of impotence after we learned that Juliet 237 was brain dead. It was a stunted exchange between a surgical fellow and a resident: “Do you ever wonder what the hell we’re doing here sometimes?” “All the time, man. All the time.”
It’s time we had help with our helplessness.
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References
1. Gawande A. Being mortal: medicine and what matters in the end. New York, NY: Metropolitan, 2014: 7.
2. Marmot MG, Rose G, Shipley M, & Hamilton PJ. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health 1978;32:244-49.
3. Certificate Program in Humanities and Ethics, The University of Texas Medical School at Houston. Accessed September 3, 2015. https://med.uth.edu/mcgovern/programs/certificate-program/