The day that medicine broke her and destroyed her innocence

I was a third-year medical student in the first week of my obstetrics rotation. The obstetrics program was known to be high-pressure, its residents among the best. Mostly women, they were a hard-core group–smart, efficient, motivated–and they scared the heck out of us medical students.

I remember the day clearly: Not only was I on call, but I was assigned to the chief resident’s team. I felt petrified.

We’d started morning rounds as usual, running down the list of patients in labor. Five minutes in, my chief got a “911″ page from the ER, located in the next building. This seldom happened, so instead of calling back, we ran downstairs and over to the trauma bay.

We walked into pure chaos. The patient was 27, in her last weeks of pregnancy and actively exsanguinating–bleeding to death. She and her husband had been fighting; apparently he’d picked up a kitchen knife and stabbed her in the neck.

As the ER physician and the trauma surgeon worked rapidly on the woman’s neck, my chief readied herself to deliver the baby. She turned to me.

“Quick, get me a sterile gown and a scalpel.”

Helping her to gown and glove, I could see the other physicians getting coated by the blood spurting from the women’s neck. She’d been talking when she arrived by ambulance; she wasn’t talking anymore.

The nurses were pumping blood into large-bore IVs in both of her arms, but the patient’s blood pressure kept dropping. On the fetal monitor, we saw the baby’s heart rate starting to dip.

My chief cleared her throat: “Okay, guys, we’re gonna lose the baby if we don’t do something fast!”

Without taking his eyes from the patient, the trauma surgeon said authoritatively, “We can’t. If you cut her, she’ll die. Give us a minute.”

“It will take a minute-and-a-half to have this baby out,” said my chief. She got no answer.

She stood poised over the patient’s abdomen, arm raised, scalpel in hand and ready to pounce.

The patient’s blood pressure dropped even faster, and the baby’s heart rate plummeted.

“It’s now or never,” said my chief. Then the cardiac monitor began beeping.

“Ventricular fibrillation!” The ER physician grabbed the cardiac paddles and shouted, “Clear!”

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back–and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.

The electrical shocks, delivered over the course of several minutes, didn’t revive the patient. Her wavy cardiac tracing flattened into one long, straight line.

By then it was too late to save the baby. Its heart rate had been too low for too long, causing severe, irreversible brain damage. As we listened, the fetal monitor went silent.

The walk back to the obstetrics floor was eerily quiet. I wanted somehow to comfort the chief…to comfort myself…but I didn’t know how. As we reached the nursing station, she slowly came unwound.

For the first hour, all she wanted to do was talk. She grabbed every resident and nurse who walked by, going over and over what had happened. If only she had disregarded the trauma surgeon, things could have been different…

Then she became intensely quiet. She sat at the table in the middle of the nursing station, her face contorting into a myriad of expressions as she mentally replayed the events. Occasionally she raised her right arm as if wielding the scalpel again.

Finally, she put her head down and started to cry–loud, disconcerting sobs. The staff and patients passed to and fro, largely ignoring her. No one seemed to know how to comfort such a strong, accomplished physician in her time of need.

And there I stood–helpless in a sea of sadness and pain.

She cried for what seemed liked hours. Then she picked up the phone, made a call, placed her pager on the table and left the hospital.

A few minutes later, an attending came in to replace her, to pick up the pager and to collect me.

The next day, my chief returned to work. She acted as if nothing had happened. No mention was made of the day before.

She finished the year and is now a well-known attending physician at a prestigious medical center.

I’ll always remember that day as the day that medicine broke her–destroyed her innocence. To me, she seemed like a soldier who had witnessed her first death in battle. Would she ever be the same? Or had she lost a sacred part of herself forever?

I feel sure that this is what happened because I remember when medicine broke me–one lonely night, watching helplessly as a patient died in the intensive care unit. I’d bet that most of my colleagues have had similar experiences. We rarely talk about them, but you might get some answers if you asked our loved ones.

They would tell you how we changed over the course of our medical training. How one day we came home from work seeming different. How a young, eager, empathic man or woman gradually became angry, frustrated and often cold. How we started out suffering with our patients, but ended up suffering from them.

And that’s the paradox of medicine. We enter this profession out of a passion to help others. But repeated exposure to the most agonizing situations causes pain that can make us retreat into a shell of cynicism or “clinical objectivity.” There, we risk losing the softness, warmth and caring that sent us into medicine in the first place.

Now, years later, I know that some of us–the lucky ones–recover. For me, the anger and frustration started to reverse six years ago with the birth of my son. Gradually, I learned to tend the wounds that medicine had inflicted on me. Now I’m no longer so scared of being hurt. Now I can cry with my patients, not because of them.

And now I finally feel like the physician I’d always hoped to be–a little more caring, a little more loving and a little less afraid of what the future will bring.

Jordan Grumet is an internal medicine physician.  This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.

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  • http://briarcroft.wordpress.com Emily Gibson

    Jordan,
    this is a powerful story well told, and I know there are a few clinicians who have, like you, started to write about what they have seen and experienced. Even for me, thirty years into my work as a family physician, I have found that writing down my stories makes all the difference.

    Emily Gibson M.D.

  • Sandra

    Wow. My moment of meficine breaking me was one late night when I had 2 teenage girls, both named Erica, dying of osteosarcomas, painful hortible deaths. That night, I concluded, finally and once and for all, that there can be no God — or if there is a God who would allow these innocent Ericas to die such horrible deaths, that I wanted no part of any God like that.

  • http://fertilityfile.com IVF-MD

    Thanks for sharing. We all have stories like this. Horrible things happen in life, especially in the field of sickness and health, but they are balanced by incidents of great joy as well. As physicians, we seek a balance between crying like a normal feeling human being and being strong so that we can help minimize future suffering.

    Medicine will remain for me an emotionally exhilarating as well as a potentially emotionally devastating experience. To all the students contemplating a career as a physician, these are the pluses that need to override all the minuses that are being imposed on us.

  • jsmith

    Medicine didn’t break her. She was back at work the next day. If it had broken her, she wouldn’t have come back.
    Seeing people die sucks big-time, especially young people. But it’s part of the game.
    Being friendly and empathic is important in medicine. But you have to be tough and you have to know your limits(as did this chief resident).Threading that needle is sometimes difficult. Thanks for reminding us of this.

  • Marc Gorayeb, MD

    The author tells a compelling story. The narrative is that the chief resident lost her innocence because of a trauma surgeon’s poor decisions. There aren’t enough facts to judge whether the trauma surgeon’s decision-making was poor under the circumstances.
    Frankly, I’m not sure I can rely on the few facts that were recited. For example, electrical shocks were delivered “over the course of several minutes.” In any teaching institution, it would be remarkable to perform external electrical cardioversion/defibrillation for several minutes in an exsanguination arrest.
    Because many essential details were withheld, and because the details that were actually provided are suspect, I’m not prepared to accept the conclusion that “medicine” did something wrong to this innocent resident. Particularly if the facts were massaged to make the story more dramatic. Taking poetic license has no place in a story designed to malign the training provided in our teaching institutions.
    Most seasoned physicians have seen their share of deadly outcomes and suffering, and have engaged in obsessive second-guessing. But this is a bleak, surreal portrayal of the effects of medical training and practice on physicians.

  • alex

    Marc: I’m assuming the point was about the emotional impact of tragedy. Cause the story is pretty insane if you’re supposed to surmise she should have done differently.

    The trauma attending was the person making the calls by both seniority and primary service, and any attempt to disregard that would have been disastrous (for the ob resident). And if the patient had a potentially survivable neck injury, doing a c/s on her while she was bleeding out in order to save her baby would have been criminal. Maybe if the story was “unsurvivable GSW to head” it would be controversial, but the trauma surgeon was completely correct here.

  • http://fertilityfile.com IVF-MD

    Dr. Gorayeb, I’m not a trauma specialist but I was thinking along the same lines as you. Also, haven’t there been cases where doing an emergent cesarean actually HELPS the mother’s hemodynamic status? It has something to do with relieving harmful venous compression caused by the weight of the baby.

  • Jerry

    “Interesting” cases often end in a near miss or a complete disaster and are buried in my memories until something makes them jump to the surface. The stories often involve a gallows humor, a bit of exaggeration to make a point, but there is no need to really go to the level of making it up. Reality is truly stranger than anything I can make up. There was a book, “Kill as few patients as possible.”, Dr. Cohn. Now, after 30 years of medical experiences, I see how easy it is to acquire the basis for that book.

  • Melissa Smith

    Very well written. I enjoy following you on Twitter and reading what you have to say. I am an Occupational Therapist and have had a few moments myself. I am grateful for the family support I have…think this is what helps get many of us through the tough stuff!

  • Jeanja

    Dr. Gorayeb, I do not think this article criticizes either the decision-making in the EMR or the medical training process. After all, Dr. Grumet’s own loss of his own innocence was unrelated to either decisions or training: “medicine broke me–one lonely night, watching helplessly as a patient died in the intensive care unit.” The article about losing innocence, namely the ability to empathize, due to “repeated exposure to the most agonizing situations.”

    Fortunately, at the end, he indicates that empathy can be regained. Too bad there’s not a recipe for how.

  • ninguem

    The Kobayashi Maru.

    Section the woman, she surely dies, but the baby has a chance of survival. IF the trauma surgeon can control bleeding, there is a chance of saving both.

    OB resident cuts, maybe the surgeon was one clamp away from controlling the bleeding and saving both.

    There is no good answer to this.

    “destroyed innocence?” Only to someone who really thought medicine is like a TV show. A soldier who saw her first death in battle? This IS a battle.

    How you handle the disasters, the no-win situations, IS important. It won’t be her first time. Destroyed her innocence? Maybe it made her a physician.