Monday, 29 February 2016

Heart

I held a beating heart in my hands today.  It wasn't beating when I first saw it.  The heart belonged to a 20-year-old kid, though I didn't know that at the time.  I didn't even know his name.  

What I did know, however, was that he was dead.  And it was my job to reverse that.

The ambulance called in the late afternoon with a 3-minute ETA on a multiple gunshot wound victim with CPR in progress.  They managed to place an intra-osseous line and give him some IV fluid on the way, but salt water can't restart a heart. 

After a flurry of activity, our team was ready when he arrived 4 minutes later.  He looked like any other kid when they rolled through the doors - thin, muscular, a young face with a close-cropped scruffy goatee, a tattoo of some initials and a date on his left upper arm.  What made him different was the absent look in his eyes and the medic sitting on him, pushing rhythmically on his chest.  They yelled out some information as they transferred him from their stretcher to ours:
Twenty years old.  Found barely breathing about 8 minutes ago, stopped breathing 7 minutes ago.  Gunshot wounds to the chest, right arm, left groin.  Asystolic.  
Dead.

A cursory glance at him revealed a gunshot wound to the left chest just above and medial to the nipple.  Directly over where the heart is.  The mortality rate for such an injury is very high, and when the patient comes in dead it approaches 100%.

This kid had only one possible chance, though I knew that chance was fleetingly small at best.  I grabbed a scalpel - the big one.  A splash of iodine on his chest seemed more for show rather than any possible actual antisepsis.  I incised from his sternum all the way down the side of his chest to the bed.  I inserted a Finochietto retractor and opened his chest wall as widely as it would go, cracking a few ribs as I went.  The chest was full of blood, as was the pericardium (the tough membrane that surrounds the heart).  The heart was twitching, barely moving.  I grabbed the scissors and opened the pericardium widely.  The heart was struggling, trying, but there was nothing to pump - it was empty.  Nearly his entire blood volume was now on the bed, on the floor, on my shoes.  I started squeezing the heart, trying to circulate what little volume he had left.

By this time others had placed multiple IVs, including a large-bore central line in his femoral vein.  Blood was running into him as fast as the rapid transfuser would go.  Epinephrine was injected.

The reason why the heart was empty was immediately evident - there was a hole in the left ventricle, the main chamber that pumps blood to the body.  Everything we were giving him had drained right out.  I plugged the hole temporarily with my finger, but when a bullet goes in, it must also come out.  I found the exit wound on the back side of the left ventricle, and plugged it with another finger.  Now the heart began filling.

And still I continued squeezing.

I shouted for some pre-loaded pledgetted sutures and repaired the anterior hole first, taking care to avoid the anterior interventricular vessels.  This is a very difficult prospect as the heart continued to 1) move (weakly), trying to restart itself, and 2) bleed.  Stitch, plug, squeeze.  Stitch, plug, squeeze.  I turned the heart over and repaired the posterior wound in the same way.

Stitch, squeeze.

And then it started beating again.  Hard.  Rhythmically.  

Above the din I loudly asked someone at his head to check for a carotid pulse.  "I GOT A PULSE!  I GOT A PULSE!" someone shouted back at me.  I don't even remember who it was.

I checked my repairs - a tiny bit of oozing, but they were solid.  As his heart started pumping away stronger and stronger I put my fingers on his neck and confirmed a carotid pulse.  Ba-dum.  Ba-DUM.  For one ephemeral moment I thought he had a chance.  Then my eyes went up to his - his pupils were blown.  Fixed and dilated

God. Damn. It.

My mind immediately started going over the possibilities - maybe we had been fast enough.  Maybe the pupillary reaction would return.  Maybe.  More blood.

I went back to look at my repair, and the heart wasn't pumping nearly as hard.  The epinephrine was wearing off.  I looked at the monitor and his blood pressure was dropping.  And then his heart stopped again.

Squeeze.  Squeeze.  Squeeze.

More blood, more epinephrine.

Squeeze.  Squeeze.

Nothing.

The transient moment had passed.  I took one last look at the motionless heart, looked at the clock, and found myself pronouncing another young kid dead.  It was about 6 PM.  I had no idea where the previous 70 minutes had gone.

This young man is not the first death I've had, and he won't be the last.  Death is something we deal with regularly, and every single one hurts.  But for some reason this one really hit me.  Hard.  

I can't say exactly why this loss struck me so much harder than most others.  Perhaps it is because my best wasn't enough to overcome what I intellectually knew to be a fatal injury.  Perhaps it was because of that brief moment when I thought he could be the 1% who survives.  Perhaps it is because no one ever came for him.

I still don't know his name.

37 comments:

  1. It's because we become personally invested in these patients we've only just met a few moments ago, despite our higher brain telling us that's not a good idea because we know the most likely outcome. However I think if we didn't do so at least every now and then it's probably time to hang it up.

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  2. Hey Doc. You don't seem one to sentimentality, and I know you already know this, but you did what you could. You tried to give life to the dead, without knowing his name. You tried your damndest to defy fate, and you succeeded far beyond what you could or should be expected to. Almost might only count with horseshoes and hand grenades, but you gave your all. You failed in the end, but honestly, you did better than 99.99% of people on Earth could have.

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  3. Yeah. 8 min was prob too late. That said, I'm very sorry; I have seen a few attempts like this in my career and none of them ended well either. It sucks no one came to claim him. Very sad. But it sounds like you did all you could, and based on my own trauma bay experiences, you stuck with it longer than most. This is one after which a stiff drink is probably in order.
    YB

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  4. How terribly sad. Do you suppose it was gang related?

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    1. Since there doesnt seem to have been any form of identification- otherwise they could have contacted someone and doc would know his name- it seems it was likely a mugging that had gone badly. Poor guy...
      Connor

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    2. Good point, Connor. I was most likely making an ass out of myself by assuming this was at the hospital in the poorer neighborhood. God forgive me for assuming he was a gang member.

      RIP young man. We may not have known you, but we will remember you.

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    3. Not a terrible assumption to make- especially considering multiple gun shot wounds. Your guess is as valid as mine. Sometimes, people dont carry their ids with them. It happens. It also might have been a random driveby or some psycho who did it- in all likelihood, we will never know. And thats partly what makes it so sad.
      Connor

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    4. Another good point. I was naive enough to not carry my wallet (with driver's license ensconced inside it). Two reasons this is bad: its illegal to drive without your license in your possession and even more than that, I couldn't be easily ID'd in case of an accident.

      All that aside, it is tragic. :(

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  5. Doc, thank you for this post. I feel honored to have read it.

    I am honored to tell you I admire how hard you and your staff labored to save this young man. He didn't die alone and uncared for.

    God forbid I ever arrive in trauma: I would want you for my surgeon.

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  6. Damn it! So close, and yet so far.

    This is why I could never do what you do Doc' (even if I had the skills to do so). The 1% would never be enough to sustain me through the futility of the 99, even when I knew I was doing everything that could be done.

    You do a job that very few of us could do and you manage to retain a sense of humour and humanity about it that even fewer could achieve. It sounds like nothing short of sorcery could have saved this guy and maybe, just maybe, the next one will be that 1%.

    Keep it up Doc' - and thank you for sharing the downs as well as the ups.

    Ugi

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  7. I'm sorry, I'm so sorry. I'm sure you have cried, this post is a cry, but I have added my tears as well. Tears for him and tears for you. Thank you for caring, and for sharing.

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  8. thank you for all you do, Doc. Keep fighting the good fight.

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  9. for some reason the virtually hopeless cases always hit people the hardest. particularly when it is someone young. the fact that nobody claimed the body and nobody protested his untimely death is just the bitter icing on the unpalatable cake.

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    1. I think it might have to do with the fact that while when there is hope and it fails you knew you did everything you could, while when there is almost no hope there is almost nothing that you can do, and it makes you feel so helpless. You want to help, but you just can't, because nobody can.
      Connor

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    2. It might be related to the fact that we work harder on a patient that has a chance of survival but doesn't survive - and the physical strain adds to the mental strain.

      the ones that have no chance at all have little effort, and little emotional investment. If there is family you feel for the family, but I have been on calls where it was quite literally a matter of touching the patient and knowing they're gone.

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    3. Fair point Ken. As someone who saves lives and has to confront that sort of thing, your the expert here not I. i can only begin to guess, hypothesize and philosophize.
      Connor

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    4. and emotions are often the opposite of logical. so I can really only claim expertise in what makes ME tick. - and some people might claim I'm not qualified for that.

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  10. Sometimes there just are no words. ((hug))

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  11. I was tempted to write a sarcastic comment saying what john would no doubt respond to this with- something about the blood type not being mentioned or some other bullshit. But i dont have the fortitude (only other thing i could think of than the obvious- decided to forgo the pun) to do it. Sometimes its not the ones we know who hit us the hardest- sometimes it hits us hard because we don't.
    Connor

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  12. I can't imagine how hard that must have been for you. I'm so sorry. :( Thank you for sharing it with us, for reminding us that you are more than the Bastard you portray yourself as...

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  13. You are amazing at your job, and you have a wonderful heart. As hard as these times can be, it is wonderful that, with all you have seen, you are not jaded to it. It is also nice to see that you are emotionally strong enough to admit when something tugs at your heart. His family may not have been there for him, but you and your team were. If he had any conciousness at all, he knew he had people fighting for him, and although you were all strangers, he would have died knowing he wasn't alone. Thank you for sharing this story, and for all the amazing things you do.

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  14. Dear DocBastard,
    First of all I love your blog. Secondly, I have to say this is one of my favourite posts of all time. I'm a fourth year medical student, meaning I should graduate next year and I think mortality is the thing I find hardest in med school. It sometimes makes me wonder whether I'm strong enough to deal with it day in day out. Which is why I appreciate that even people with experience in the field are sometimes struck by it, enough to share it. It hurts me when some of our consultants are blasé about patient death, despite knowing it's probably a coping mechanism, so it's refreshing to see someone admit that they're not evet effected.
    Anyway, this post is probably too long and morbid, but ultimately I wanted to say thanks and I'm sorry dor your loss :)

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    1. I'm not even in the medical field, and I know I'm guilty of taking the blasé approach towards death as a coping mechanism. Sometimes that's just the easier way to go. Thankfully we don't all take the easy way out. This one even hit me, someone who didn't even know this poor guy. So there's hope for even the people who think themselves the hardest against some of the worst things that can happen.

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    2. emergency responders pretty much HAVE to be able to compartmentalize the emotional impact.

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  15. "Perhaps it is because no one ever came for him."

    I'm so very sorry, Doc. He was probably a runaway and far away from home. Maybe no one will come for him, but I hope that somehow they eventually find out so they can mourn him as dead, rather than missing.

    It's tragic.

    I hope you were able to sneak in some BIG hugs to the family after you got home.

    Wednesday

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  16. He died in the best hands possible.

    You've also saved lives and reunited families, don't forget that.

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  17. Thanks for the kind words. This episode was quite recent, and I had a similar one just two days later, which also contributed to my maudlin mood when I wrote this. I haven't written about the second one yet and don't plan to because it was too similar to this one.

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    1. I guess it's human nature to focus on situations that *didn't* work out as we'd hoped, instead of reflecting on those that *did* have a positive outcome. Still, I hope that you'll take some comfort in recalling all the lives that *did* get saved, and were otherwise positively affected, by your intervention.

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  18. This post is beautifully written. You may not know his name, Doc, but by sharing this story, you have memorialized a young man that otherwise would have been forgotten.

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  19. Doc Bastard, you may be many things to many people, you are not though a heartless bastard.
    Thank you for all you do whether it is successful or not. Sometimes you may be the only one who cares about what happens to someone.
    It takes a lot to be there at the final breath, especially if you fought hard to make sure it wasn't final.
    You can't win every fight, no matter how much you want to and try.
    Life can sometimes decide to be a bitch and thwart you at every corner, sometimes giving you a fleeting glimpse of hope, a this might just be the one to break the rule, to be the exception only for it to be snatched away.

    Big hugs and thanks for sharing such a personal moment.

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  20. (Sigh.) Wherever you are seems to have way too many guns in it. Keep up the good fight.

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    1. *too much crime. Theres a difference
      Connor

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  21. As a fellow medical staff (who works in the ER), I can relate to what you mean by how death is something we deal with often, but they hurt each time at a different level. I may not be at the bedside trying to save a person's life, but I can understand to a certain point since I am responsible for all the administrative stuff for every single patient (nothing cannot be carried out unless I process it). It is devastating enough when I see older people die, even more devastating when I see people around my age die, and the worst of all when a child dies.. and to make it worse, when they go without their loved ones by their side. I still remember the case where a toddler died and the parents arrived much later due to their assumption we would take their child to a hospital they normally go to instead. Nevertheless, you tried your best and unfortunately, no matter how hard you try, when it is time for someone to go, there is nothing we can do to prevent it from happening.

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  22. I couldn't believe it. My uncle died at age 23 from almost the exact same circumstances. He was shot in nearly the exact same locations with very similar injuries. He arrived barely alive at the hospital, but he was quickly lost in surgery. Nobody knew he was shot until he was already gone. So I suppose that is why this touched me so much. My heart goes out to you. You did everything you could. That young man had his heart, literally, in the right hands. My mother was very close to my deceased uncle, and reminisces about him often. When discussing his death, she fondly refers to the doctor who tried to save him despite never meeting him. Know that there are people out there who think of you in that same way even when the outcome is not good. The doctor did everything he could and, in our situation at least, that was everything. You have a beautiful soul, Doctor!

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  23. I'm a social worker in a level one trauma center. I had this kid too. Same age, same injuries. I remember his name, because as our trauma surgeon was cracking his chest, I was talking to the mom about her son. "He was a good kid" she kept saying. Some just hit you incredibility hard. You take the hit, but damn those son's of bitches hurt!

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  24. I thank God for doctors like you every single day. My son, who was 16 months old at the time (he is 14 years old now) was involved with my dad in a mva. My dad died. A doc like yourself brought my son back to me.

    If i were ever hurt bad enough to need emergent surgery i would want you as my surgeon.

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  25. 3 days ago my nephew lost his best friend to a gsw to his heart. The child was 15 and was murdered my a 26yo and another 15yo. The victim snuck out to meet a friend at 2am. We are still reeling. RIP to the 20 yo you tried to save and RIP to the 15 yo they tried to save..

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