Monday 20 June 2016

Coincidence vs fate

"Aren't you going to do something to help her?  Why aren't you helping her?!"

These were the very first words that Marilyn's grandmother yelled at me as I walked through the door of her ICU room before I even had a chance to introduce myself.  She was visibly shaking, Marilyn's mother's makeup was smeared down her cheeks, and her father was sitting quietly in the corner in stunned disbelief.  Meanwhile, Marilyn (not her real name™) was lying on the bed motionless, which is exactly the way she would stay. 

But I'm getting ahead of myself.  Let me start at the beginning. 

I don't really believe in fate or destiny.  The idea that everything is planned for us or that "everything happens for a reason" is something my sciencey brain can't seem to abide.  The Call Gods may disagree with me, but I prefer to think we're all in control of our own present and hence have control over our future as well, so anything chalked up to fate is simply a coincidence.

Enter Marilyn.

This particular Friday was nearly silent.  I sat around (not really) waiting all day (not really) for trauma patients to arrive, but none came.  At 2 AM that night (well, Saturday morning I suppose, but my brain doesn't give a shit about semantics at 2 AM) the Call Gods decided it was finally time to fuck with me as my pager told me I would be getting a Level 1 stabbing in five minutes.  That means wounds to the head, torso, or neck typically - you know, the type that can kill you.  I swept out of bed and power-walked (as fast as I can power-walk at 2 AM) down to the trauma bay where my team awaited the patient's arrival.  When he arrived 2 minutes later, I anticipated a long night ahead of me. 

Wait wait wait.  You said "When he arrived".  Marilyn isn't exactly a man's name.  Are you confused, Doc?  

Not at all, you're just jumping the gun.  This obviously was not Marilyn, who was not to arrive for a few more minutes.

As I was examining his stab wound to the left lower chest, one of the nurses ran in to the trauma bay to tell me that another Level 1 would be coming in 10 minutes, this one a car accident victim, stable vitals, but unresponsive.

Fabulous.  Just what I needed, two patients, at the same time, at 2 AM, both level 1s, after a quiet day.  What a strange coincidence.

Just before the new trauma arrived I was able to determine that the stab wound was superficial and threw some staples into the wound (perfectly straight, thank you very much).  When Marilyn rolled through the door, everyone in the room, from the nurses to the janitor, could immediately tell that something was seriously wrong.  Though her eyes were open, they had a vacant, dead look in them.

And she wasn't breathing.

The ABC's of trauma dictate securing an airway before anything else, so the anaesthesiologist inserted a breathing tube as I did a cursory evaluation.  There was a touch of blood on the back of her head, an abrasion on her great toe, and fixed, blown pupils.  SHIT SHIT SHIT.  That usually means one of two things: death or impending death.  The two immediate questions were 1) why, and 2) what can I do to stop it.  Starting with question number 1, I had absolutely no idea.  I usually have a suspicion why someone may be dying, but not with Marilyn.  She barely had a scratch on her.

Something didn't add up.

The possibilities ran through my mind.  Internal decapitation . . . drug overdose . . . massive internal bleeding . . . alien mind abduction.  Admittedly some were more plausible than others.  A few minutes later her CT scans revealed the answers to both questions.  Question #1) Why was Marilyn dead or dying: bleeding in her brainstem.  A lot of it.  Bleeding on the brain itself can be drained and the cranium decompressed to reduce pressure.  But the brainstem is a different story.  In that location it doesn't take much to cause major problems, but there was enough that her brainstem was herniating through her foramen magnum.  And that detail answered question #2) What can I do to stop it: absolutely fucking nothing.  Though I couldn't confirm it yet, Marilyn was likely already brain dead, and there was nothing I (or anyone else) could do to help.

Her parents lived several hours away, and as I waited for them to arrive, yet more information came in from the lab, the police, and Marilyn's boyfriend.  As the police interviewed the boyfriend (who got there well ahead of Marilyn's parents), the seemingly endless stream of coincidences began stacking up.  Marilyn was 20 years old, healthy, no medical issues other than a history of drug abuse.  And her boyfriend had been driven to the hospital from the hospital by the police. 

Wait Doc, wait just a minute.  "To the hospital from the hospital"??  What the hell does that mean?  Are you confused again?

Yes, "from the hospital".  According to the police officer, Marilyn's boyfriend had been taken to Outside Hospital earlier in the evening after overdosing on heroin.  Not coincidentally, Marilyn had been on her way to Outside Hospital to pick him up when she veered over three lanes and was broadsided by a tractor trailer/semi/18-wheeler.  

I coincidentally was looking at her labs as the police officer was telling me all this.  Her blood alcohol level was 0, but not coincidentally her urine tox screen was positive for marijuana and heroin.

Indeed, Marilyn had been doing heroin with her boyfriend when he overdosed, and she hadn't yet come down when she got in the car to drive.

The aforementioned meeting with Marilyn's family came a few hours later after she had been moved to intensive care.  After I let Marilyn's grandmother scream at me and (finally) got a chance to introduce myself, I explained that A) this is a nearly universally fatal injury, B) the bleeding was not treatable due to its location, and C) Marilyn was not going to survive.  

That went over exactly as well as you would expect.  But after listening to the consulting neurosurgeon tell them the exact same thing, Marilyn's mother took a few minutes and several deep breaths before putting it in perspective: "I believe in God and I believe He has the power to heal, but if that's what He chose for her, then I'm sure He has a reason."

The following day an apnea test and cerebral angiogram both confirmed she was brain dead.  Marilyn's father gave me a firm handshake as he thanked me for being so kind and understanding, and her grandmother refused to look me in the eye.  I had the impression that she somehow thought it was my fault, that I had forced Marilyn to do heroin, get in her car, and crash into a vehicle 10 times larger than hers.  Her mother, as despondent as she was, was somehow much more forgiving in her grief.  Unlike other parents that we've discussed on this stupid blog, she opted to pursue organ donation.  

I have no idea how many lives Marilyn's tragedy was able to change for the better.  Was her death predetermined?  I don't know, but I somehow doubt it.  Maybe it was fate, or maybe it was just a series of bad circumstances combined with bad luck.  Regardless, I have no doubt that the recipients are more than grateful for their second chance at life.


  1. I was thinking the stab wound guy was going to need a transplant and fate or coincidence brought you a brain dead woman in the nick of time, thus the title: Coincidence vs. fate

    Still, good to hear that some people benefited from a needless tragedy.

  2. It must be terribly difficult for both you and the family to accept that nothing can be done in those circumstances. I might well be as rude as the grandmother in a similar situation. I hope not, but more than anything I hope I'll never find out. Organ donation can't be much of a consolation but perhaps it is some.

    Those must be tough days Doc' - hope you don't get too many like that.


  3. Doc, you jinxed yourself by using the "q" word.

    1. Yes. I stopped working 8 years ago and I still hate that word.

    2. In these parts, "good" is the bad word, and "quiet" is preferable. At least, that's what I THINK the Call Gods hear.

  4. I never knew drug abusers/addicts could donate. You learn something new every day. Thanks, doc.

    1. I didn't think addicts organs could be donated either. Wouldn't there be a chance of aids or hepatitis?

    2. They test for all those things.

  5. "I had the impression that she somehow thought it was my fault, that I had forced Marilyn to do heroin, get in her car, and crash into a vehicle 10 times larger than hers"

    Perhaps she was venting at you, when inside she wanted to vent at her child, the dying girl's parent.

  6. I believe the universe has a plan for people. I also believe they can and do frequently choose to ignore that plan and do their own thing.

  7. So sad when a young person's life ends tragically because of her or his own poor choices. Still, it's commendable that the family not only opted for organ donation, but was able to accept the reality of Marilyn's not being able to recover.

    Up until a few years ago, I always believed that accepting the death of the mortal body was something that *everyone* did, even though I know that moving through the different stages of grief is a different journey for each person, and the denial stage takes a bit longer for some. After following all of these medical futility cases that we've seen in recent times, I have a whole new appreciation for those who *can* accept reality.

  8. What a rotten day but I'm glad that some good came out of it. I hope that the recipients live long, healthy lives and Marilyn's family got some comfort out of knowing they helped others despite their own loss.

  9. This is exactly why I didn't go into medicine! I had planned all my life to be an MD. I took all the math and science in high school I could cram in my schedule. I got a Chemistry degree. Then I went to work for a huge hospital. Even now in my 60's I can't stand gore, pain, or suffering because of what I saw working in that hospital all those years ago. Thank-you so much for being able to do the job I could not do. As a society we need people like you so very much.

  10. Marilyn sounds like a string of bad choices. On the other hand, if you are driving down the road the day after the 500 year flood and a 300 year old oak tree falls over on your car (it happened in Roswell, GA on Sept. 15, 2009) and kills you, it was just your turn to die. I don't care if you want to call that fate or coincidence. There are no fingers to point at anyone.

    1. sometimes bad things happen. this is a fact of life.

  11. That's the thing. Marilyn's death was her fault. But sometimes, good people die, not because they aren't strong enough, or not fast enough, and not fast enough, but because they happened to be unlucky at a time they needed to not be.

  12. Or was ashamed at her initial behavior.

  13. Everything happens for a reason. Sometimes the reason is you're stupid and make bad decisions.

  14. Honestly Doc, I find it a bit overly simplistic to state on one hand that there is no fate/predetermination etc and on the other say that we are masters of our destiny... i would say that regardless of cause, things outside of our control WILL happen but it is our choices that enable us to be prepared to marginalize them...

    1. Of course it's overly simplistic. That's somewhat the point.

  15. I think that when grandkids start making bad life choices, the parents tend to be quite aware of what is going on but will shield the grandparents. The grandmother, after the initial shock, may have been to embarrassed to face you with the knowledge that her own blood went so far down the wrong path and that she was wrong to chew you out.
    - L


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