January 14th, 2004

Nescafe rabbit

And I didn't wash the blood off my hands until nearly noon...

Today, O Best Beloved, I lied to a patient. I didn't know I was lying to her, and I certainly didn't mean to; I was saying the same thing everyone else was. I told her, O Best Beloved, that she was going to be all right. We all did. We told her that she was going to be just fine, that we would take good care of her.
And we tried, O Best Beloved. We tried right up to the moment BW looked at the clock and took his hands off her chest for the last time. We tried until they ran out of drugs to put in the needles, ran out of tubes to put in her body, ran out of hope that her heart would start beating again on its own. We tried, O Best Beloved, and she never knew how hard we tried.

And in the end, we failed.

We were in M&M this morning, listening to the usual arguments about when to put a tube in and when to pack a wound, and thanking ourselves that we were Team III instead of Team II, for reasons I'll not say in a public journal, when suddenly my pager roused me from my drowse just like every other pager on the trauma team. 78F STAB WOUND ETA 5 MIN. We ran - we don't wear our winter coats across campus, not even in the 15º air that permeates the campus in the early morning - back to the hospital, pulled on booties and gowns and gloves and hats, found someone who knew that it was multiple stab wounds, to the neck and chest, that it was apparently her male relative's perpetration, and nothing else. Vitals came in on foot half a minute ahead of the cart; systolic BP 70.
(Warning: technical talk ahead - ask if you need explanations)
We did our ABC's like a good trauma team - Airway clear; Breathing without difficulty - she was talking to us, even, breath sounds on both sides; Circulation - well, there was a lot of blood, but nothing gushing, and we had two litres of saline in her pronto and a unit of O- blood going in shortly after. Pulses in her extremities evened out as soon as we got some fluids in, and we could doppler all the way to her DP's and radials. Disability survey revealed no gross deficits, and we Exposed every inch and looked for more wounds.
She was talking to us, O Best Beloved. Talking to us with something like 15 stab or slash wounds across her neck, chest, and hands. ED staff kept asking her for history, keeping her talking, looking for air leaking or any signs of impending respiratory distress. Trauma team looked over the worst of the neck wounds, declared it a Zone II, and quickly discussed OR versus angiogram. OR won out, and forty-five minutes after she came in the door we were on our way to the OR to explore her neck wound and find out why it was still bleeding fairly steadily despite the pressure dressings.
I told her on the way to the OR, O Best Beloved. I told her we would take good care of her. BW told her it would be short and we'd get her a bed to rest in. I helped steer her bed into the OR, and she helped us scoot her over to the operating table.
It was when we lowered the head of the OR table and anaesthesia put the face mask on her that all hell broke loose. It's hard to remember what happened exactly, I was in shock after a few minutes. She fought the mask, thrashed, pulled it off, the resident replaced Andy (one of my fellow students) holding it on. She said "I can't breathe! I'm going to die!" They gave her something to get her intubatable faster, in her IV. She stopped fighting, they bag-masked her, JB said "Get a tube in her, she's desatting," and they tried. They got it in her stomach first time, we heard the bubbles. They tried again, resident shook his head. "I can't see past the epiglottis."
So we cric-ed her. Took a knife and cut a slit in her skin, JB stuck his finger in (he says it went into the trachea without another cut, which makes us wonder if there was a wound there we didn't know about or suspect) and they stuck a tube into her lungs through her cricoid cartilage. And she was already in asystole, heart not beating. BW started chest compressions. JB and Dr.S tried to get the trach tube sealed well. Her sats stayed low, even with the machine pumping air into her lungs, and she never regained a heartbeat. They tried drugs. They tried needle decompression and chest tubes. They checked femoral pulses and arterial blood pressures and nothing - nothing, O Best Beloved, worked. And after fifteen minutes of trying everything, BW said "I'm getting ready to call it." And he looked at the others, and some of them nodded a little bit, and he took his hands off and looked up at the monitor. There was a single blip, one soft beep in the silence, the echo of his last compression, and then nothing. She lay there, chest rising and falling with the soft swoosh of the vent, a mockery of breathing, and there was no other sound.
And he stepped back off the step, and he said "God damn it." And a few moments later, a nurse said "Time of death: nine forty-three." And someone wrote it down.

After a little while, Dr.S got the fiber-optic laryngoscope and looked in her throat, and he could barely get that tiny three-millimetre scope down into her trachea, it was so compressed from outside. She would have been impossible to intubate - but she should've been oxygenated by the cric tube; he visually verified that it was in the trachea with the scope. Maybe she bled more than we thought, once her pressure was up. Maybe something else went wrong. Maybe she had a clot just waiting to go to her brain. We'll know if we find out what the coroner says. Ours is not to reason why, O Best Beloved, nor to wonder overlong at the cruelty of man. Ours is to save lives, when we can.

And sometimes, O Best Beloved, we can't. And it hurts. O, God, it hurts.

I left with JB, my hands still feeling cold from holding her arm on the table, trying to feel a radial pulse, and we went up to the burn unit to peek in on a surgery up there. He had to do another tracheostomy, a non-emergent one this time, but we didn't have informed consent yet, so we went to the pantry instead and JB gave me a Drumstick. And the ice cream, strangely enough, helped a little bit.
It helped a little more to finish rounds near 11, and to be told that the man with the bullet in his brain is going home today - walking out of the ICU, two days after being shot in the head. It helped to see the 16-year-old who was an unrestrained passenger in a car vs. telephone pole collision (wear your seatbelt, O Best Beloved) going to rehab today - talking, and going to rehab. When I came on service his only daily goal on his white board was Wake Up. It helped to see the traumatic arrest moving around, trying to talk to his family. It even helped to take stitches out of a prisoner's nose, and to then go upstairs and take more stitches out of another woman's nose. She told me I had an aura of peace and goodness about me; she could tell I was a Christian. That's what she said. It was a strange encounter, but it settled me even more.
It helps to see healing after death, and the tears I never had a chance to shed are no longer stinging my eyes and burning my throat as I choke them back. I've seen a code before; but I've never seen someone die in front of me. I'm twenty-five years old, O Best Beloved. I shouldn't have to. But I do have to, because someone has to, so that people don't.

I realised around 11 that I had a smear of dried blood on my arm, and drips on my scrubs, from trying to hold her on the table. I washed it off, with soap and water and alcohol scrubs, and I wondered at how easily it came off. When her family was told that the doctor wanted to speak with them in the quiet room, they literally ran from the ED. There was no-one who wanted to stay and be talked to. Will they erase her as smoothly and completely as her blood came off my skin?
I'll remember. At least I'll remember. It's the best care I can take of her now.