When you close an abdomen after a failed rescue, the OR is silent

I didn’t know her name until it was over, much too late.

What I knew was she was thirteen and that on this winter day someone in her family had been pulling her behind their car, on a sled. No doubt laughing and looking in the rear-view mirror, the person driving had whipsawed around a corner, and the young girl — probably screaming (fear? delight?) — held onto the sled as it careened off the road and into the side of a concrete culvert.

The girl took the blow in the middle of her right side. Reportedly, as they helped her up, crying, she fainted. The family member did what a family member who’d pull someone behind a car on a sled would do: took her home and laid her on the couch. About forty-five minutes after that, when she was unarousable, 911 was called. Half an hour after that, she arrived in the ER, in full cardiac arrest, which was also the way the medics had found her.

There was still electrical activity in her heart. Her pupils were dilated, we couldn’t measure any blood pressure. But she was thirteen. Several IVs were started, massive fluids infused, and she started to produce a pulse. Her belly was greatly swollen. We got her to the OR before the O-negative blood arrived (it can be given fairly safely to anyone, regardless of blood type), and continued the resuscitation until it seemed possible to anesthetize her and cut her open.

Blood had filled her abdomen. I scooped it out, mopped it out, suctioned it out. Her liver looked as if someone had inserted an M-80 firecracker into it and lit it off. As soon as I’d gotten in — you can slash inside pretty rapidly when you need to, making a nick in the upper abdomen, inserting a couple of fingers, lifting up hard, sticking the scalpel between the fingers and zipping straight south in one motion — I’d put a clamp across her abdominal aorta, just below the diaphragm, to limit the amount of blood that could enter and leak out; plus, it helps maintain blood pressure to the head and heart. I stuffed a few packs into the crater of her liver and pressed on them. Had I gotten to the point of trying to repair the damage, it would have been hard as hell.

Instead, my aim was just to control bleeding, enough to give the assembled group of nurses and anesthesia folk time to catch up on her fluid needs, push in pint after pint of blood; try to get her stable enough to see what would happen. Clamp on the aorta: done. Pack the liver: done. Pringle maneuver: did it. For a while, we observed a sustained blood pressure, so I made ready to see what I could do about the wreckage. Then her EKG complexes started to widen. Eventually, they became slower and slower, flattening out, resistant to all the drugs that were tried. I took turns with the assistant compressing her chest. And finally, when it was beyond obvious, we stopped. In-field CPR for half an hour before arrival, plus who knows how long in arrest before the medics arrived: too little, too late.

When you close an abdomen after a failed rescue, the OR is silent. No beeps from monitors, no sighs of the ventilator, no small talk. You use a large suture on a giant needle, taking big bites of tissue, making it quick. On a thirteen year old, with a baby’s beautiful skin, healthy tissues giving more resistance to the needle than usual, perfect organs disappearing from view, you are sewing through tears. You feel the loss as if it were your own.

I went alone to the family area. I’ve done that walk a few times: If the earth were to open up and swallow me at that point, it’d be ok with me. The mom was there, maybe a few others. Seeing the look on my face, she stepped toward me, hand in a fist, pressed against her mouth. “I’m sorry,” I said. “I couldn’t save her.” Without a pause, the mom began beating me on the chest, with both fists, hard, yelling and moaning, crying, “What do you mean you couldn’t save her? Why? Why? How could you not?” “I’m so sorry,” I said, again, finding none but the predictable words. “We tried everything, but there was too much damage.” Letting her beat away without raising my hands, forcing back the obvious statement: had she been brought in immediately we’d have had a chance. “Oh my God. How could you not save her? Oh my God, oh my God, oh Amy, oh Amy.”

So that was her name. Amy.

Sid Schwab is a retired surgeon and author of Cutting Remarks: Insights and Recollections of a Surgeon.

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  • http://jamesbsnider.wordpress.com James Snider

    Sid, These are the most powerful 800 words I have read in a long time. Thank you for sharing. – James (Medical Marketing Professional and son of a retired Radiologist)

  • ninguem

    Mixed feelings. I can think of half a dozen stories like that over the years. Kids getting killed being pulled on sleds, pulled by automobiles driven by adults who should know better.

    A mix of sympathy and a strong desire to smack the idiot.

  • http://Www.drmartinyoung.com Martin Young

    A lifetime of practice cannot erase memories like these….

  • Liz

    Thank you – I’m a person with several rare chronic medical conditions who spent several years being brushed off by doctors who chocked it up to being psychological or fibromyalgia. I still struggle with a lot of anger toward the medical community as a whole for the years of additional and unnecessary hell I experienced, and–though I’d never it on anyone–it somehow helps me to reconsider my perspective when I read such beautifully written but harrowing accounts of the hells you all experience from your side of the table.

  • Tom Dean

    Wow, Sid…
    Being involved in drama like that every day tends to make us somewhat calloused towards it – you have a gift with your writing, sir.

  • Medstud4

    Thank you for sharing this story. I am just starting my residency in EM and remember vividly the first death I experienced in med school. It was a case similar to this, a 17 year old, with extensive damage in her abdomen. I began CPR as the surgeons worked to control the bleeding. When the case was called, I had to close the abdomen. Cases like these are hard to swallow and impossible to forget.

  • Jerry

    Few understand what you feel. My moment: Young girl, six month twin pregnancy. I tried, but it was essentially over before we started. We tried anyway. Three deaths at once. Such a quiet, lonely room.

    I have only done this once in my career, I went to the funeral. Open casket with the two of them in her arms. Decade ago, still hurts.

  • Meg

    Wonderful, powerful piece, but one nit-picky question (I’m obviously not a doctor)…wouldn’t you have learned the girl’s name before going out to tell the mom? How would you even know you were talking to the right person?

    • Jack Adams

      When you walk into a waiting room like that… you KNOW who the mother is without having to ask.

  • David Jacobs

    I know I’m going to sound incredibly calloused for these comments and apologize in advance. I am a General Surgeon who has been in many of the same situations that you have described. They are all difficult and stay with you. As a young man, straight out of residency, I probably would have done EXACTLY what you did. But after having doing this for over 15 years, my opinion has changed. Perhaps I have become jaded; perhaps I have acquired wisdom.

    I’m sure you know, both based on the literature and your own experiences, that the girl was essentially dead when she presented to the hospital….

    “There was still electrical activity in her heart. Her pupils were dilated, we couldn’t measure any blood pressure.”

    “But she was thirteen”…

    Aye, and there’s the rub… you knew that the chance of resuscitating her (asystolic arrest after a blunt trauma) was anecdotal if not close to zero… but because of her age, and the situation, you let your emotions dictate your response and actions.

    As a result, you probably wasted a significant amount of blood and blood products, stressed out anesthesia and the OR crew, and have made a mother think that the death of her daughter is a fault of a doctor or the health care system, not because of someone’s jackass behavior. It’s now not the fault of the driver of the car, but YOUR = OUR fault that she couldn’t be saved. This is what malpractice suits are made of. And it doesn’t matter that you did everything you possibly could and then some… a sympathetic jury will only see a grieving mother and pictures of a life that “could have been saved…”. After all, if she wasn’t salvageable, why did you make the attempt in the first place? – that will be the argument of the attorney.

    We are not gods. We are, for the most part, smart, hard working, caring people who would do anything to save a life, whether or not we get paid for it.

    And that is our downfall.

    • Jerry

      You are right. It sounds callous.
      You are right. Many resources were spent.
      But I do not think you are right about the god thing. It wasn’t god-like to try to save her.

      In the days that we were gods (before my time), we would have been right to look at her pupils fixed and dilated and decided then and there to make the decision to let her die in peace.
      Stop and calmly push everyone away from her body. Stop putting in another IV.
      Stop and wait for the final electrical events and spasms of her muscles. You would go out to the family and let them know. “She has died and been brought back for a short while. She is going to die again, soon. There is too much damage to her brain already to proceed any further. Do you wish to be with her in her final moments? I will take you to her.”

      That is a god moment, when they look at you and realize, you won’t try, because ‘I know’ it would be a waste of time and other resources, but you alone made the decision not to try. In retrospect, a good decision. The autopsy would have supported your decision.

      The other doctor was human. It was human to want to try even though he knew, this doesn’t look like it is going to end very well. When he let his emotions guide part of his decisions, he was no longer god-like.

      • David Jacobs

        Excellent points. Well stated. Thank you.

      • Jimmy

        When a doctor lets their emotion guide the decision, it ends up being like a TV drama such as Grey’s Anatomy.

        It was taught at my medical school that futile CPR is unethical and unjustified, but Truog (http://www.nejm.org/doi/full/10.1056/NEJMp0908464) argues otherwise (or rather presents the opposing argument for consideration).

        • David Jacobs

          Jimmy,

          Thank you. I was unable to read the article (requires purchase), but I would agree that futile CPR is both unethical and unjustified. Unfortunately, these days, as physicians, we do what is required by “the law”, or “the policy” or “the guideline” as opposed to what is best for the patient. I’m not even sure they teach a course in medical ethics at medical schools anymore… probably has been replaced by EMR and customer service training.

          Having said this, there are times when I have kept a patient “alive” as long as it was not causing them pain or suffering (or wasting limited resources)…long enough for a family member to process what has happened or to say goodbye…at that point, the family member is a patient too…

          Most physicians, sooner or later, have to deal with death. We are trained to preserve life so vigorously though, that sometimes any death is seen as a failure (“failed rescue”). This is simply not the case. People are born, people die. We have much less control over this process than we would like to think. We are not omnipotent.

          I fully recognize that Dr. Schwab did what he felt was right at the time and would not care to second guess him… I have been in the same situation myself many a time. But perhaps after having faced mortality so many times in my career, I have more perspective than I did as a younger man. Our focus should not be to preserve life at all costs, but to protect and improve a patients quality of life… death is not the enemy, suffering is.

  • aek

    I’ve sure missed your writing and am so appreciative of this.
    Where’s the link to your inestimable Surgeonsblog?

    http://surgeonsblog.blogspot.com/

    Ah! There it is. I hope a lot of readers will visit and spend time there.

    Thanks, Sid.

  • http://msrenegade.com Marie

    “…with a baby’s beautiful skin…”

    So evocative, so perfect.

    I hope her mother eventually appreciated how hard you tried and what a good human being you are.

  • Margaret McIntyre

    Because the surgeon acted as a human — a heroic human, I pray the mother (and all of the folks involved in the snow sledding behind the car caper) will come around to understand what a human surgeon, the human OR staff, and the EMT’s have experienced–how our actions resonate through humanity.

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