Something I've been meaning to share for a while, and a school assignment finally made me put it down in words.
The weekend before my first
month of surgery, I got into a terrible fight with my family. We were celebrating my dad’s 69
th birthday, and as usual, my parents and my
brother started spouting their opinions about my future medical career. I told
them that surgery was simply, just not going to be my thing. I had no interest
in the specialty and just wanted to make it through the next two months
relatively unscathed. They insisted that I shouldn’t write it off, that I would
make a great surgeon since I have small hands, that it would be a better
specialty option than anything else I had in mind. When corned, I become
defensive, and amidst our steaks that evening I lashed out at my family. I told
them to mind their own business. I was going to hate surgery and there was
nothing they could do about it.
As these things usually go, I would later eat my own
words. I ended up really liking the rotation and even contemplating a general
surgery residency. Although I’ve now decided to pursue another path I have to
admit that I learned a lot on that rotation. I grew as a medical student and as
a person. I interacted with a lot of patients that I will never forget. And
this is the story of one of those patients, a man named Russ.
In
reality Russ wasn’t really my patient.
He was assigned to one of the trauma surgeons and the surgery residents put in
all his orders, but I followed his progress my entire month on the SICU
(surgical intensive care unit) so let’s just call him my patient. Russ’ story
is one of those bad-luck stories that reminds you of how fragile and cruel life
can be.
Russ
was a perfectly healthy 72-year-old man who was out walking his dog one weekend
afternoon when he was hit by a car. The car drove off and Russ was left with a
broken pelvis, broken left femur, ruptured left iliac vein and crushed bladder.
The first time I saw Russ he was on his hospital bed, intubated and sedated. He
had metal scaffolding screwed into his pelvis to help stabilize it during the
healing process. His entire left leg was covered in a wound-vac (pretty much
fancy Saran wrap that helps protect exposed tissues). His limbs were swollen,
yellow, covered in little scabs. His lips were cracked and bloody.
During
my first week on the SICU I went about my duties, collecting Russ’ vitals,
listening to his heart, feeling his pulses, peeking under the sheets and
checking his wounds for any overt signs of infection. Every morning when I
walked into the room around 5:30, I would say, “Good morning Russ. It’s me,
Kat, I’m just here to see how you’re doing”. I did this for about a week
without any response. My greeting went unanswered, and I was able to poke and prod
without any objections from my patient. On September 10th, the day
before my birthday, I walked into the room as usual and said hello. Russ opened
his eyes and turned his head to look at me. I jumped. I ran over to Russ’
bedside, my eyes quickly getting misty. He looked at me and I asked, “Do you
know where you are?” He shook his head no ever so slightly and I started
telling him about what had happened. Whether he truly understood me I don’t
really know, but he was awake and communicating, and I was pretty much over the
moon. As I drove home that day I truly felt like Russ’ awakening was an early
birthday present, and I was really optimistic about his recovery.
I
wish this were otherwise, but Russ did not continue to make much progress.
Although he was awake and alert, he constantly fought the intubation tube down
his throat. He struggled so much that he had to be sedated, since he wasn’t
strong enough to breathe on his own yet. Over the next week or so Russ had to
face a string of different challenges on almost a daily basis.
The
ICU is such a scary place because it tends to be home to “super bugs” that
infect the patients trapped, and often strapped, to their hospital beds. Russ
had one line infection after another. I remember during my first week of the
rotation, I expressed some distress at morning report that Russ’ white count
was elevated. I was a little upset when the residents didn’t seem to pay much
attention to it, but I quickly learned, the only reason they didn’t look
surprised is because they knew he would eventually get an infection.
Russ
also required a lot of trips down to the OR with the orthopedic and plastic
surgery teams. Ortho was trying to fix his femur, but this was complicated by
the fact that he had almost no skin left on that leg. Plus it was swollen to
four times its normal size. Anesthesia would wheel Russ down to the OR almost
every other day. When he came back he was always doing poorly. The surgeries to
repair him would literally almost kill him – after the OR his blood pressure
would be extremely low from all the blood loss he had sustained. We would pump
him full of pressors (to get his BP up) and lactate ringer (to keep fluid in
his arterial system). Needless to say, I did learn a lot about fluid
resuscitation from Russ. Somehow, we managed to bring him back to life each
time, but overall it was a terrifying cycle.
Through
all this running about, I got to know Russ’ wife and daughter. This may sound
horrible, but the first time I met Russ’ wife I really wanted to ask her what
had happened to his dog, but I restrained myself. You see I adopted a dog when
I started medical school, and he is pretty much the center of my world. When I
heard Russ’ story I knew that if I were in his shoes, when I woke up, I would
want to know if my dog was alright. Somehow the topic came up and it turned out
that Russ’ dog was perfectly fine. Probably the utilitarian thing to say is
that it would have been better if Russ was okay and instead the dog had died in
the accident. But, that’s not how things went and you can’t turn back time.
I
tried to update Russ’ wife and daughter as best as I could. Sometimes things
were just too fast paced in the SICU or I didn’t completely understand what was
going on. When they were visiting him we would all talk to Russ together. They
told him about the friends and family members that were thinking about him.
Russ’ wife told me that their church had been really supportive and was helping
her out by cooking meals and finishing chores. They showed him videos of his
dog and told me how if they said Russ’ name in front of the dog, she would cry
and start whimpering, wondering where he was.
That
first month went by pretty quickly, and it was time to change services. As I
started my second month of surgery with another team, I was disappointed that
Russ had not made much progress. His biggest problem was his left leg – to put
it simply, the leg was trashed and they were thinking about amputating it. I
tried to stop by Russ’ room when I could. Even though he was technically awake
he was still pretty out of it, and I just wanted to check in with his wife or
daughter.
About
two weeks into that second month, I asked a fellow student who was now taking
care of Russ, how he was doing. She told me that he had started bleeding from
his rectum and that the team was trying to figure out what was going on. When I
saw my old SICU resident later that day, I joked and said, “I heard Russ is
doing GREAT!” because actually, bad news regarding his progress was not all
that surprising.
About
a day or two later, I had some free time and decided to visit Russ in the
afternoon. I got up to the SICU, walked to his room, and he was gone. There was
an unfamiliar woman in his place. At that moment I knew what had happened, but
I was in shock and didn’t fully process what his absence meant. I stood there
for a second when a fellow student sitting at the nurse’s station asked what I
was looking for.
I replied, “I came to check on
my old patient but he’s not here anymore.”
“Oh, that guy? He’s dead.”
I
walked out of the SICU and took the elevator down to the first floor. When the
doors opened I ran straight into my SICU attending, a young trauma surgeon that had been hired the previous year. He must have seen the look on my face
because he said, “I know.” We exchanged a sad glance, but we couldn’t really
talk about Russ since there were other patients around, and after a few seconds
we were both on our way. I found out later what had happened. Once the bleeding
started, the SICU staff called for a GI (gastrointestinal) consult. GI didn’t arrive
until nine-hours later. They diagnosed a bleeding rectal ulcer but it was too
late. Russ was really crashing this time. His family decided to withdraw care
and he died a few hours later.
I
took everything pretty hard. At first I was really angry. Why did it take nine
hours for someone from GI to see Russ? Maybe if they had seen him sooner he
wouldn’t have lost so much blood. I thought about how his case had been
regarded by the surgery attendings and residents. What mistakes had we made in
his care the past month? I also felt guilty that I hadn’t seen Russ or his
family one more time before he passed. I wish I could have said goodbye or
expressed my condolences.
Although
some people do recover from terrible injuries, in retrospect, Russ probably
started his whole SICU journey with only a slim chance of getting better. In
the end it was Russ’ family who decided to withdraw care. I think they knew how
much he loved life and understood that he wouldn’t want to perpetually be in a
state where he was barely hanging on. I never had a conversation with Russ or
his family about his end-of-life wishes, but maybe it would have helped me as a
student to have done so. I know how important this will be for my future
interactions with patients. Maybe it never came up because we didn’t want to
consider that possibility – at least in the beginning. Whether Russ was aware
of it or not, he suffered. He was not going to be able to return to his old
life before the accident, and I think his family made the right choice for him.
I
know that Russ is a patient who will stay with me throughout my entire career.
What happened to him was unfair and tragic. This is going to sound cliché, but
for me, his story really is a reminder that you never know what is going to
happen in life. We should try to appreciate our blessings as much as we can,
even when our worlds are falling apart. This experience also taught me the
value of compassion and actually being present in a moment. Taking that extra
minute to talk to a patient or family member can make a big difference in
someone’s day-to-day life. You may not be able to control all the end outcomes,
but you do have control over the way to treat and respect others. I wish that I
could have seen Russ walk out of the hospital and back into the arms of his
wife, his children, and his dog. It didn’t happen, but I am grateful to have
met him and participated in his care. I hope he is at peace, in whatever place that
may be.
