UNOWN

County Potential
Three patients. Three stories. One consistent path. All roads leading towards the same end-game, each in a different way, but each with a similar final tragedy that has already revealed itself, or will do so very soon more likely than not. As I reflect on my last three weeks on the vascular and trauma surgery teams at one of my school's county hospitals, I would like to set aside my usual mildly humorous ranting and excessive self-parody, and in it’s place write about three patients that affected me deeply, each serving to teach me about what doctors (and society for that matter) really face on a daily basis:


During the first week of my service, our team was called to consult on a four year old female patient who has been sporadically and incompletely treated for childhood leukemia, presenting to the emergency department during a blast crisis at the sickest time, in the most precarious position, and with the least chance for survival. When we saw her, she was in the pediatric ICU, with at least four different tubes running in and out of her, and her mom sitting anxiously at her bedside. She had just survived a crisis with the quick administration of blood pressure drugs, but an unfortunate side effect was that the persistent blood vessel constriction so severely decreased the blood flow to her extremities that her petite legs were darkened up to the knees, her hands darkened to the wrists...

I was assigned to one patient a few days ago, a 17 year old male who ripped apart his radial artery and some of the tendons to his hand after punching through a glass window. When I first met him, he was in the ICU, having been operated on throughout the night to restore and preserve as much hand function as possible. He was mildly sedated, but not so much that I couldn't sit down with him and talk about what had happened. He had a bad day. He could not find his keys to the house. He had to use the restroom extremely badly. So what happened next? I punched through the window. After being transferred to a regular bed and being reunited with his family and girlfriend, this patient became a lot more animated, now proudly displaying a beaming smile plastered across his face, much more glimmering than the soft cast plastered across his arm. He could not move his thumb, he could not sense touch on his thumb or first finger, but with the attention he was receiving, he hardly noticed...

The ER bell rang and a cacophony of pagers went off. "GSW [Gun shot wound] times two to the back, times one to the neck." An urgent trauma was on its way, and the trauma team and its adopted medical students for that night's call began preparing the tools necessary to resuscitate this patient. Then came the next message. "ETA [Estimated time of arrival] 15 minutes." 15 minutes? The man had been "found" on the street after a supposed gang altercation, brought to our trauma center because the previously closest center to him had been shut down recently due to cost concerns. After that second message sprayed through the room, everyone's tension level decreased. No chance. No stress about messing up the opportunity to save someone’s life, because this life had already passed. About 15 minutes later, he finally arrived, and the standard resuscitation procedures ensued. Chest compressions, breathing, two attempts to shock the heart. The attending physician pointed out to us the abrasions all over this man's legs, indicating that he had likely been run over by a car multiple times. This man's blood started pooling on the floor of the ER, seeping out his back while a nurse frantically pushed on his heart, one beat at a time...

After examining the extremities on the four year old with leukemia, the attending physician looked at us, then said rather bluntly, "It's all coming off." Auto-amputation. This child's legs, blackened by an acute case of severe lack of blood flow, were becoming necrotic. Her body would soon recognize this process and wall off the dead tissue over the course of the next few weeks, culminating in this poor child’s extremities literally falling off, without the aid of any knife, scalpel, or blunt object. This child, sedated and unaware of her fate, slept peacefully in her bed. Her mother, upon hearing the news, looked out the window and cried, too ashamed and afraid to look any of us in the eye while the tears rolled quickly across her tired eyes, knowing full well that had she been able to take her sick daughter to the hospital more frequently, more urgently, this fate might have been prevented. The attending walked out of the room, and our chief resident instructed us to clean the dead legs and arms still attached to her body and bandage these wounds as if there was still a fighting chance for their survival. What choice did we have? What chance does a leukemic child with no legs have? We carried out these orders, more for our own peace of mind than for the patient or her mother.

The next day, I went to sit down with my window-breaking friend one more time. Except when I walked in, I found his girlfriend in bed with him. They were cuddling. I apologized for the intrusion, but explained that I needed to do a quick exam as part of my daily routine. While doing the exam, I asked this 17 year old what he was planning on doing with himself. Finishing high school? Plans for college? Any ideas to avoid punching out windows in frustration again? None. He had everything he needed: his friends, his girl, his right hand in due time. Discharged that afternoon, he was back on the street that evening.

20 years old and three bullets to the back and neck. It didn’t take long before the attending physician waved his hand in a back and forth motion across his own neck. This man was dead. Likely dead on arrival, surely dead shortly thereafter, and absolutely the first person I have ever witnessed die right before my eyes. However, it was his eyes that struck me most – his eyelids were still open and I could see for the first time that glazed look of death, with one eye rolled in one direction, the other pointed in a completely different direction, and neither with any purpose whatsoever. The doctors quickly scrubbed out and moved on to see the next potential surgical patient in the ER, but I stayed to watch as the nurses carefully removed the tubes forced through this man’s body in an attempt to save his life just minutes before. They then took off the blood-soaked sheet under him and replaced it with a clean white sheet, which they draped over his body and face before wheeling him out of the ER and into a storage room. Unidentified upon arrival, he was just another pulseless John Doe, lying forever peacefully while waiting for a tearful family to discover him one last time.


Three weeks at a county hospital on a surgical rotation and I can finally say that I have received my first taste of what real life medicine is all about. There have been plenty of funny moments, some that would be more than appropriate to share in this forum. There have been some truly touching moments for me personally, as I have followed some patients from surgery to complete recovery. But thinking about these last three weeks, I could not shake the lasting impression these three patients made on me, because each was young, and each came to the hospital in a state that would have been totally preventable had the circumstances of their lives that led them to this point been even slightly different. Instead, their potential was cut short, or would most likely lead them down a shortened path in due time.

So many people think that medical professionals have a simple goal to make people who are sick become healthy again, but as I am just beginning to appreciate, it is far more complicated than that. How do you change someone who shows up almost literally on a deathbead, having never seeked out medical care before, with no means or access to any basic health care in the past? Where does one’s own potential, developed from years of upbringing in a certain environment, around certain people, and with certain predispositions, come into play, regardless of any intervention the best doctors in the world could come up with? I am not going to pretend that I have any clue what the answers to these questions are, and I am not even convinced I am asking any or all of the right questions in the first place. Perhaps it is a complete lack of sleep that has taxed my brain in this way and led to this rambling of a post, but I find that I can only sit here and vent my frustrations about what I have seen, that I cannot even go to sleep in spite of my exhaustion until I get my anger out in words.

As it stands, I can only hope that in a public health care system so obviously set up for failure, there are enough successes to make us feel good enough to continue treating these patients and get through the day. That there are enough treatable patients to make us feel like we are actually helping people reach their full potential.
posted by The Fake Doctor at 10:17 PM