It was my last night on the trauma service at University Hospital. We had just seen a patient in the pediatric emergency department with a dog bite and were slowly meandering back to the main emergency department when my intern’s pager went off “911 INBOUND TRAUMA 14-19 yo male traumatic arrest CPR x 15 min in field ETA 3 MIN”
We were only a few feet from the trauma bays so we had already seen the ED staff scurrying to triple-check the equipment in the first trauma room, which is never a good sign. Only three minutes away – this must have happened on University Campus – no time or no need for a detailed signout.
We barely have time to put on gown and gloves before EMS rolls through the door doing chest compressions. The meager story comes flying at us: unidentified young male pedestrian struck by motor vehicle, witnesses at the scene said he was down for 5 minutes before EMS arrived, initially had a pulse but arrested while being loaded on the stretcher and was immediately transported. No IV access. Not breathing spontaneously. Pupils fixed and dilated bilaterally. In a hard cervical spinal collar.
At this point during the trauma protocol, a lot of things are happening spontaneously: he is intubated and placed on a ventillator, needles are placed into each chest to drain potential air collections since his lungs sound like they are barely filling with air, he has no palpable pulses in his neck or groin, defibrillator leads are attached and his rhythm is analyzed. Large bore IV’s are placed in each arm, and fluids are flying in. Blood is on the way.
I am doing chest compressions while shoulder to shoulder with two residents jabbing very large needles – one destined for his femoral vein and the other to suture in the tube in his chest – into our patient. Occasionally I pause for someone to precisely pass a needle into him – but then his heart stops – so I can’t pause for too long. As per protocol, someone taps me on the shoulder after a few minutes and I step back and help the intern place a catheter into his penis (there is air in the catheter – a sign of bladder rupture). I am able to take another step back.
Braces. Just a freshman kid riding his bike back on campus. Braces and acne. Braces bouncing with each compression of his chest. Braces and tubes.
In a traumatic cardiopulmonary arrest less than 10% of patients survive to leave the hospital, and up to 90% of those that do “leave” have severe neurological injury, which means that the only thing we’ve given them the ability to do is circulate blood on their own. Can’t breath. Can’t communicate. Not even basic reflexes. Just a blood pressure and a pulse. Only 1% regain any modicum of humanity.
Still, we try everything – CPR, we get a shockable rhythm (Vfib), shock him, and miraculously get a pulse back. He’s in sinus tachycardia now – we can work with this – and so we keep working. We find a tidal wave of blood in his belly – we can potentially stop this bleeding, if we can get him stable enough to survive the trip across the hall to the operating room. But his blood pressure is an illusion created by the drugs we’ve given him to keep his heart beating. Within mere minutes of each dose of epinephrine he drops back down – blood and fluids are flying into him almost a liter a minute through a large central line in his femoral vein and the lines in his arms, but he is still bleeding into his belly, his pelvis, and both of his shattered legs. Even if we could stop all of this bleeding somehow, his neurologic function will likely never return. He may have a high spinal cord injury, brain injuries – but we work, for far longer than the guidelines say we should, and fight for this kid.
Tonight, he will be part of the 99%.
I watch his blood pressure until I can’t watch it any more. The attending has already made the call – taking the boy to the operating room would only change the location of his death. We keep covering him with blankets. The ED nurse starts teaching the nursing student. The police officer and two detectives plant their eyes firmly on their shoelaces. I don’t need to stay here to watch the numbers go from double to single digits. As I pass by the police officers, I want to say something to them, to express my hopes that they expeditiously apprehend the perpetrator of this crime (“catch that m—–f—-r”), but I silently pass. I head to the other end of the ED to see the next consult. There are always other patients to see, always other patients to see. I come back to our desk to write up my consult, just in time to hear a zipper being drawn.
I wish I could say I had some grand epiphany, or that I was the hero, or that I could do anything – but none of those things are true. His death unlocked no grand mysteries in my mind. I didn’t resolve to rage, rage against the dying of the light. I didn’t strong arm the nurses out of the way and keep pumping his heart after it stopped. I walked away and examined a man who had a belly ache (he should probably stay away from Thai food).
I watched two patients slip away that week. Their monitors got louder and more insistent, and then we turned them off. We talked about it, briefly, with few words and no feeling because no words and no feelings would do. We kept working, kept moving, and when I got to my car I sat, finally, alone and cried until the sun was finished rising, and then I drove home.