Time is a gift in the ER

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Fourteen hours into their shift, the intern headed down to the lobby to pick up the delivery. Today it was Indian food. He struggled to push the elevator button while holding the bags but managed to make it up to the top floor ICU. The rest of the surgeons gathered around the table cluttered with spent pens, journal articles and unused bottles of lidocaine to eat. Someone offered up their extra samosa to share. The sun drooped lower in the sky, and the light outside burned golden and fought with the pale white glow from the fluorescent lights inside.

The day had been so hot that the doctors could see it from the hospital windows: the streets shimmered. People stayed inside, huddled in the air conditioning and sucking down popsicles while trying to ignore the slick of sweat on their foreheads. Finally, the sun started setting, and the temperature dropped five degrees, ten degrees. The houses were glowing tangerine in the fading sun. People emerged to sit on the steps, or on plastic chairs on their front porches. Someone started up a radio down the street. The kids fought over the small bicycle. When one of them won, the other started drawing fire trucks on the sidewalk with a nubbin of chalk.

In the call room, all the phones went off at once. “Level 1 trauma, male GSW,” the attending sighed. The room emptied, and they went to the trauma bay to prepare. They left the table strewn with half-empty takeout containers, lids off, chicken korma congealing.

The elevators had been slow to come, and the patient was already there when the surgery team arrived to the trauma bay. His clothes were off, and the nurses were getting IVs. His heart rate was 143.

The junior resident started her survey, noted the bullet wound just above his belly button, dead center. She had the team roll him to check for other wounds, and there were none. His body was still an unsolved mystery — Where did the bullet go? What did it hit? How bad is it? She processed these questions in an instant and continued her exam. The chief resident frowned at the foot of the bed and called for blood, an X-ray, did we have the IVs yet, what’s the blood pressure, what are the breath sounds, any crepitus, any other injuries?

The attending grew increasingly frustrated — from her perspective everything was moving slowly, so slowly. Her years of training made it seem like everyone else was moving too slowly, but really the team had only been in the bay for two minutes. The patient was losing time, a precious and finite resource. She stood silently, watching everything with an impassive expression on her face. She let the residents work and made sure nothing was missed.

Another minute passed, and the X-ray showed the bullet was just to the left of the spine, but it was still a mystery: there was only one dimension seen, and a surgeon needs three.

Six minutes had passed. The FAST exam was positive. The heart rate was 151. The blood was running in, a thin maroon lifeline. The attending and chief resident looked at each other, and the attending said, “Call the OR, we’re coming up, get the monitor ready.” The chief resident leaned over the patient to speak to him and to help get the IV lines in order.

“I’m so thirsty.”

“I know, we’re giving you water through your veins. Do you have any allergies?”

“No. I have asthma.”

“OK. We have to take you to surgery. You have a belly injury.”

“Am I going to die?” The patient’s eyes were huge. He was a child. The resident looked at him and felt like he was looking through time. Later, when thinking about the patient he would see him running towards a cheery ice cream truck. He would see the nervous and sweaty first kiss. The hug from his mom for acing his geometry test.

“We’re doing everything we can.” I don’t know yet.

They were in the OR. The drapes were on, the chief resident and attending stood opposite each other in their sterile blue uniforms, ready to do battle with time and the lethal triad. The anesthesia team milled about putting lines in and pushing drugs and blood, units of blood, donated by people across the county, the state, the country, platelets, clotting factors, plasma, never enough.

The medical student adjusted the lights so the attending could see better. The kidney: shattered. The bowel: multiple holes. The aorta: spared.

The kidney in a bucket, bleeding slowed but blood still welling up from where the bullet was buried in his back, a permanent trophy that no patient wanted to win. The bowel was fixed, stapled, but it was a temporary solution. The patient was still not doing well. Everything was oozing and nothing helped. The anesthesia team was giving meds to keep the blood pressure up and the attending looked at the chief and they called for abdominal packing — after two hours of surgery the patient needed a break and time to resuscitate.

In the ICU the patient needed more blood. His family was there, crying, shocked. His mother was quiet, holding his hand. His sister was wailing loudly at the center of a throng of cousins, aunts, uncles.

An hour passed. He worsened.

Two hours passed. He was bleeding.

Three hours. They went back to the OR. The surgeons had been awake for 23 hours, but they didn’t feel weary — there was serious work to be done.

The bleeding was coming from the patient’s back and welling up at the base of his abdomen. Still, nothing worked. A lumbar artery? Embolize it! A discussion, the interventional radiologist was called in. He was the patient’s last chance.

But the patient was not ready. He never would be. He was too unstable to move anywhere except back to the ICU. He was barely alive.

The surgeons had spoken to his mother about how he was going to die. They had done everything they could but his injuries were too much. She didn’t want her son to get chest compressions.

His mother held his hand when he died minutes later. The nurse shut the curtain as she wept over her son’s still-warm body.

The chief resident went back to his call room to get ready for morning report. He took a minute to cry. Then he drank a Red Bull and got back to work, the caffeine making him feel stretched and thin. The weariness was finally setting in, exhaustion held back by caffeine.

In the ICU outside the patient’s room, junior resident looked him up on Facebook and found out he had a young son. Most of the pictures were of them laughing. She clung to the fact that they had been able to give his last moments to his family, even if all the future moments of his life had been stripped away. The medical student sitting next to her had a glazed look on his face and asked, “What if everything you can do is not enough?” She replied, “You keep going. At least he was with his family. We were able to give them that”. It was her only consolation.

The junior resident rubbed her eyes and called the medical examiner. She didn’t need to look up the number.

Lauren Schmidt is a surgery resident.

Image credit: Shutterstock.com

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