Sunday, July 30, 2006

Memorable patients: part four

I didn't know her name until it was over, much too late. What I knew was she was thirteen and that on this winter day someone in her family had been pulling her behind their car, on a sled. No doubt laughing and looking in the rear-view mirror, the person driving had whipsawed around a corner, and the young girl -- probably screaming (fear? delight?) -- held onto the sled as it careened off the road and into the side of a concrete culvert. The girl took the blow in the middle of her right side. Reportedly, as they helped her up, crying, she fainted. The family member did what a family member who'd pull someone behind a car on a sled would do: took her home and laid her on the couch. About forty-five minutes after that, when she was unarousable, 911 was called. Half an hour after that, she arrived in the ER, in full cardiac arrest, which was also the way the medics had found her.

There was still electrical activity in her heart. Her pupils were dilated, we couldn't measure any blood pressure. But she was thirteen. Several IVs were started, massive fluids infused, and she started to produce a pulse. Her belly was greatly swollen. We got her to the OR before the O-negative blood arrived (it can be given fairly safely to anyone, regardless of blood type), and continued the resuscitation until it seemed possible to anesthetize her and cut her open.

Blood had filled her abdomen. I scooped it out, mopped it out, suctioned it out. Her liver looked as if someone had inserted an M-80 firecracker into it and lit it off. As soon as I'd gotten in -- you can slash inside pretty rapidly when you need to, making a nick in the upper abdomen, inserting a couple of fingers, lifting up hard, sticking the scalpel between the fingers and zipping straight south in one motion -- I'd put a clamp across her abdominal aorta, just below the diaphragm, to limit the amount of blood that could enter and leak out; plus, it helps maintain blood pressure to the head and heart. I stuffed a few packs into the crater of her liver and pressed on them. Had I gotten to the point of trying to repair the damage, it would have been hard as hell.

Instead, my aim was just to control bleeding, enough to give the assembled group of nurses and anesthesia folk time to catch up on her fluid needs, push in pint after pint of blood; try to get her stable enough to see what would happen. Clamp on the aorta: done. Pack the liver: done. Pringle maneuver: did it. For a while, we observed a sustained blood pressure, so I made ready to see what I could do about the wreckage. Then her EKG complexes started to widen. Eventually, they became slower and slower, flattening out, resistant to all the drugs that were tried. I took turns with the assistant compressing her chest. And finally, when it was beyond obvious, we stopped. In-field CPR for half an hour before arrival, plus who knows how long in arrest before the medics arrived: too little, too late.

When you close an abdomen after a failed rescue, the OR is silent. No beeps from monitors, no sighs of the ventilator, no small talk. You use a large suture on a giant needle, taking big bites of tissue, making it quick. On a thirteen year old, with a baby's beautiful skin, healthy tissues giving more resistance to the needle than usual, perfect organs disappearing from view, you are sewing through tears. You feel the loss as if it were your own.

I went alone to the family area. I've done that walk a few times: If the earth were to open up and swallow me at that point, it'd be ok with me. The mom was there, maybe a few others. Seeing the look on my face, she stepped toward me, hand in a fist, pressed against her mouth. "I'm sorry," I said. "I couldn't save her." Without a pause, the mom began beating me on the chest, with both fists, hard, yelling and moaning, crying, "What do you mean you couldn't save her? Why? Why? How could you not?" "I'm so sorry," I said, again, finding none but the predictable words. "We tried everything, but there was too much damage." Letting her beat away without raising my hands, forcing back the obvious statement: had she been brought in immediately we'd have had a chance. "Oh my God. How could you not save her? Oh my God, oh my God, oh Amy, oh Amy."

So that was her name. Amy.

54 comments:

Willow-esque said...

This one gave me goosebumps! That must have hurt you. Was she the first one lost in your OR? How did you deal with that?

This will sound strange--I lost a patient once. She had terminal cancer and was on geropsych. It was simply her time, and there was nothing I could do, because of a DNR. I remember the frustration, wanting to do CPR, knowing I shouldn't (couldn't), and at the same time, knowing it would do no good. The only result would have been chest trauma had I done that. But still...

DisappearingJohn said...

Yep, I definitely enjoyed all four memorable patients..

Great posts, and a great blog...

John

Sid Schwab said...

willow-esque: it's pretty rare, as you know, to lose a patient in the OR, and it's especially painful. It's implicit that if a patient's there, there's a chance. On the other hand, it's virtually exclusively ones who start with the odds stacked high against them -- trauma victims mainly, or people about whom you and the relevant family and patient have said a 1% chance is better than no chance. Still, it feels like failure. In this case, what I remember vividly -- and it happened at least 15 years ago -- is the feeling of being beat upon by the mom. It can almost make my chest hurt.

There are -- he says, hawkingly -- several, descriptions of losing patients, both in the OR and out, in my book, amply linked elsewhere in this blog.

Intelinurse2B said...

*gulp*

Moof said...

That was --- spell binding. Dr. Schwab, you have a definite gift.

Thank you for sharing it all with us.

I imagine that those are the events that you carry with you for the rest of your life. Just reading them seems to change something inside ... I can't imagine what living them would do.

dr. whoo? said...

Heartbreaking and beautifully told. Well done.

enrico said...

Wow. Beautifully shared. That's about all I can say.

james gaulte said...

The chief of surgery at Tulane in the 1960s used to say a surgeon was a physician who could operate.Sometimes a surgeon is a physician who can operate and be able to write in such a way that a reader-medical and otherwise-can share the drama,excitement and pathos that transpires during another day at the office for a physician who does surgery.

Familydoc said...

I have been there in another life in another country at war - you brought it all back in a sudden rush - I thought I had forgotten but remember again why it is so important to feel this way.
When this stuff no longer affects us in this primal , visceral way - time to retire , quit or change career - thank you.

beajerry said...

Great stories, but I don't know what to make of you "hawking" your book.

Is this good or bad?

Sid Schwab said...

Well, now it's me: I don't know what to make of the question...I can't tell if you're criticizing the hawking, or my concern about hawking. In any case, here's how I feel about it: I have a blog, and I wrote a book. The two are separate but not entirely unrelated in that I want people to read both. So, when relevant, I'm inclined to mention my book in some of my posts. On the other hand, I feel slightly ambivalent about it, because I don't want readers of this blog to see it just as some sort of wordy PR. So I"ve usually made some slightly embarrassed side comment about hawking, as if to acknowledge that some may see it as crass. And yet.... I like my book and people who read it seem to as well (I'd link to reviews, but I won't). So I do hope this blog will be a pathway to discovering the book. But now that I'm blogging, I'm doing it for its own sake, because I like it. The blog is always unfinished and fluid. The book is done.

Dr. Charles said...

amazing story, all too common but to live it once must change you forever. thanks for telling it.

beajerry said...

"The blog is always unfinished and fluid. The book is done."

Very good point.

kt said...

wow, first story i have read and i am just dumbfounded. i am surrounded by more death b/c of my field. but it is not always immediate, not it the way you described and certainly not on 13 yr olds.

Jordan said...

Fabulous post.....giving bad news is horrible....most people outside the medical profession don't realize that you carry this with you the rest of your life.

Intelinurse2B said...

Dr. Schwab-
Please consider submitting something to Change of Shift next week. I see you already link to Emergiblog, the home to Change of Shift, but Im hosting next week and I'd love to have something from your blog or book because I enjoy them both.
Thanks!

Hoping4more said...

Wow, spell-binding! I am thankful there are amazing people such as yourself willing to do such a job with all of the difficulties and heart-aches. Must take a toll on you! *blog hugs* and lots of encouragements! thank you for being a surgeon!

Hoping4more said...

Thank you for dedicating your life to helping others; and you still continue to in retirement with your gifts of sharing these events.
many thanks! ***

Cathy said...

I just read you this evening for the first time. You're a wonderful writer and and even more wonderful Dr. I don't know how you guys do what you do.

Here's is something else I didn't know until recently. Why are all doctors also excellent writers? Is it because of the experiences you have that make the words flow? Or, is there something connected to writing and practicing medicine?

The latter doesn't really seem possible, as one really has nothing to do with the other.

Sid Schwab said...

Cathy: thanks for your kind words. I think the docs who are good writers are writing, and the ones that aren't, aren't. I know a few docs who might have slept through English 101. (In my case, my freshman English class in college made a huge difference: we wrote three essays a week, and the prof printed up parts and distributed them to the class: in small seminars we tore each other apart. I think it helped.) But I do agree with your premise that most docs have seen plenty that makes for good subject material. I've got more in me, I know that much.

scalpel said...

That story was heart-wrenching on many levels. So often it seems that bad choices lead to tragedy, and how quickly a happy adventure the next moment can turn horribly wrong.

Facing the family with the worst possible news never gets any easier, does it?

kim said...

Oh man...there's silence here, too.

And tears.

Mama Mia said...

I had a very similiar experience with an 8 year old in a canoe behind a snow mobile. Thank you for remembering this 13 year old so poignantly.

TC said...

I know about that silent OR. You worked so hard to save her when she didn't really have a chance. And then having to talk with the family who is expecting you to be able to "fix it". That sucks.

Anonymous said...

I have your book on order. Can't wait for it to arrive.

Playmakur42 said...

I read your book long before happening to find your blog. Your apologies for mentioning that you wrote a book are unecessary. Those who enjoy these stories would love your book, and you are doing them a service by making them aware it exists. It played a small yet integral part in my decision to pursue a career in medicine and potentially general surgery. Thanks for the insight into your life!

GDad said...

Dr. Schwab,

I teared up a little. My son is 12, and before he joined our family, he might very well have been riding a sled behind a car.

Your writing is superb.

wackyvorlon said...

Absolutely heartbreaking.

ERnursey said...

Very sad story.

But.....the family was pulling her behind the car and when she was unconscious took her home and laid her on the couch for close to an hour before calling 911 and then blame you for her death. Good grief.

wackyvorlon said...

I'm not surprised by their reaction. For most people, it's a virtual impossibility to accept that they had killed their own daughter. Someone must be blamed, and their grief prevents them from blaming themselves.

athenivanidx said...

gah..........I can't believe people can do such silly things.........pulling the kid in a sled behind the car?

That doesn't make much sense to me.......at all.

You were a saint for not reacting when the mom was beating on you like that..........

oh btw........two of the links in your blog are broken or don't exist anymore........the one about the "Pringle technique" and when the patient's EKG readings began to "widen"

both are links from trauma.org

very well written story.........

The Integral of athenivanidx

CountyRat said...

Brings back memories. It always feels the same, even after decades, doesn't it? I comfort myself with the thought that the only way to make it stop hurting would be to forget them. I would rather keep hurting, if that is the price remembering them exacts.

Be well, Doc.

Anonymous said...

I actually frowned at the mother there.

The child is very badly injured and yet she is not taken to a hospital straight away. Waiting for half an hour to call 911? It's going to get better somehow?

Then the doctor is expected to do the impossible and save a life. When that fails, as was to be expected he gets "how could you not have saved her." It's the doctor's fault now?

The doctor has to live with the mental anguish from not having been able to save a badly injured child and the mother is piling on the guilt?

Denial is not a river in Egypt.

Craig Jenkins said...

I'm sorry for my crudity but Fuck Me. Man I'm glad you do what you do - much respect - because I'm pretty sure I couldn't.

Good luck out there.

Craig

Wynner3 said...

While I read the post time seemed to be at a stand still. I'm still stunned by what I read.

Anonymous said...

What a sad and unforgettable story...
but you know you did the best that you could and that is all you can do, so it's important to be at peace with yourself.

Thanks for sharing.

Lynn Gardenhire said...

Don't mean to pick; but, I have always understood that O+ was the Universal Donor, not O-.

sth said...

In a grim kind of way, you're fortunate this doesn't happen often.

My first child was stillborn - a totally unexpected event, and utterly devastating. However, I only had to go through that once. I've often thought of those ob/gyns (and the delivery room nurses) who deal with high-risk pregnancies, and who have had numerous babies die. It must be terrible.

Anonymous said...

I worked in the OR for 16 years. I remember going with the surgeon to talk with the family after a very similar case.

I will stand by this statement until I pass on: That was the hardest damn thing I will ever do.

Josh said...

I'm crying for Amy. Hope her family was able to find strength to move on.

Sid Schwab said...

lynn gardenhire: lucky you happened by. You learned something. O- is the universal donor, AB+ is the universal recipient.

Kate said...

Oh geez... I can't imagine the guilt and the loss you must feel when you find that all of your skill, all of your technology, when everything you know is simply not enough... But to know that all of it could have been prevented by the people who loved that child... To know that it was senseless stupidity and a complete disregard for that child's safety that brought her to you...

...and to have those very people be angry with you for not being able to fix their mistake, their incompetence as parents...

I don't know how you guys do it, day in and day out and still maintain the compassion that you so obviously have for the human race. You are a better man than I, sir... A better man than most of us...

Anonymous said...

Dear Dr Schwab,
Thank you, very much for the great blog. Could you describe in detales how to clamp the aorta just below the diaphragm.

Thanks.
Badriab.

Sid Schwab said...

Badriab: in the context of an emergency such as this, it's done essentially blind, by feel: reaching in with one hand above the stomach at the g-e junction, feeling the aorta behind the esophagus, and guiding a large vascular clamp across both. If and when the situation becomes semi-stable, there may be the opportunity to place it more carefully.

Sid Schwab said...

I should add this: in an emergency, the first thing to do is reach in and compress the aorta between your thumb and fingers; then, if it takes a while to get the right clamps, you can compress it with a "stick sponge." There are also instruments with a very broad and flat distal end, for placing over the aorta and pressing down on it.

CharmCityChica said...

So glad to have found your blog. I am going to devour every word of it. I work in Trauma Research at the R. A. Cowley Shock Trauma Center in Baltimore, Maryland. While I have no formal medical training (I have a public health degree so far) I am infinitely interested in everything I see going on around me and am constantly trying to learn as much as I can about what ails every patient that comes through our doors.

I have seen several scenarios play out just like the one you just described - the 15 year old boy living in the inner city who had his entire life ahead of him with honor roll and marching band...his promising life taken from him in a case of mistaken identity by a local drug dealer and four fatal gunshots (the boy was still talking and begging for reassurance of life as he was lying in our trauma bay where the attending surgeon was trying her damndest to keep him alive through two cardiac arrests and make good on her promise)...the young woman who was well known and much loved at the high school she worked at helping underpriveledged kids get into internships, who had her throat randomly slashed as she waited in line with her boyfriend at a convenience store. Unfathomable and horrific.

My job is currently working on studies dealing with coagulopathy and traumatic brain injury in addition to two drug studies. I love my job and am dying to know more about medicine.

Thank you for such a well written and heart-felt blog.

Sid Schwab said...

Chica: Thank YOU!! I'm glad you found the blog, and hope you enjoy wandering through it. Sounds like you're well-immersed in things medical, in an important area.

Ela said...

This is really sad. You know, sometimes, reading online blogs somehow makes stuff less real, but this really touched me.

(Hi, I'm new to this blog.)

Sid Schwab said...

Thanks, lea. Glad you found the blog.

John Valenty said...

Exactly, while they could have saved their own daughter (they crashed her into a cement wall for crying out loud!?), they are now blaming you for her death. You must be very strong.

The MacSween Cup said...

Simultaneously horrifying and moving. Thank you for writing that, and for doing all you could to save Amy.

Doug Varty said...

Simultaneously horrifying and moving. Thank you for writing that, and for doing all you could to save Amy.

sonya said...

So sad :(
RIP Amy.

I thought you wrote that beautifully Sid, with such compassion.

Sid Schwab said...

Thank you, Sonya. It was a long time ago, but I still feel it, very acutely.