By Will Smythe
Reprinted, with permission from Hektoen International: A Journal of the Humanities, Volume 3, Issue 2 – May 2011 (Special Issue – Death and Dying) http://www.hektoeninternational.org
My beeper went off, again. I got up out of my seat in the empty hospital cafeteria, walked over to the wall phone, and dialed zero. “Zero is exactly how much energy I have for anything right now”, I thought. As a senior cardiothoracic surgery resident in my ninth year of surgical training in Philadelphia, I took call in the hospital for the entire weekend, and I was nearing the completion of that shift on a Sunday night. I silently reviewed the events of the previous 48 hours as I waited – an emergency coronary bypass operation in the middle the night on Friday, taking care of patients in the intensive care the next day, and a double lung transplant Saturday night – organs that I had “harvested” from a donor in a tiny hospital somewhere on the Jersey shore. “At least it was the shore,” I pondered. There was always a good view of the ocean and the boardwalks when you flew in by helicopter from the West. If you were lucky, and the sun was setting behind you, the light reflected off of the breaking waves, which looked strangely immobile from that vantage point, but beautiful, like luminescent comets moving across the water parallel with the shore. For a moment, it made you forget the incredibly macabre business you were up to.
“Hello,” I said laconically, “this is Doctor Smith, CT surgery”. I still had a bite of pepperoni pizza in my mouth. The operator responded, in a thick South Philly accent “a call for you dawcta… I agreed, sighing, “sure”. “Rob!”, the voice of my attending crackled on the line, excitedly, “we have a possible acute dissection coming in fromLancaster. You probably should go on up to the helipad” A dissection meant that the wall of the aorta of some patient may have torn, and separated, like layers of laminated cardboard. This could result in a lack of blood flow to vital areas of the body, or in the worst case scenario, rupture into the chest or abdomen and death, literally, from internal exsanguination.
I hung up and shuffled back over to my aquamarine plastic tray, finished off the Diet Coke, and headed, with a fried apple pie in my hand, and some leftover cheese crackers in my lab coat pocket, to the elevator bank that would take me up to the area adjacent to the helipad on the top floor of the main hospital building. I knocked on the locked, unmarked metal control room door and was buzzed in. The guys up there always enjoyed company, as they sat in the stark ten by six space for hours at a time listening to the police radio and staring at a blank radar screen, without visualizing another human being. “Hot one coming in, doc!” the dispatcher said, smiling, “aorta, right?” “That’s the rumor,” I replied, as I watched the helicopter appear on the horizon, followed by the familiar site of the pilot deftly swinging the hovering machine around and landing it squarely, almost gently, on the big red cross painted on the center of the shiny white concrete surface.
I stepped out into the hallway outside the control room and waited for the flight medics to bring the patient through the doorway to the elevator bank. I stared down at the waxed tile floor, and listened as the “thumpa-thumpa–thumpa—thumpa” slowed, then stopped, and a moment later the door burst open. The medic pulling the stretcher, in white flight helmet, nodded at me expectantly. The patient was an elderly woman. She had plum-shaped cherubic cheeks, grey hair pulled back into a small bun of some sort, and a very warm smile. I made a mental note that she was wearing worn blue terry cloth slippers with little pink flowers embroidered on them, instead of the usual cheap hospital-issued booties – “probably hers from home”. She was wide awake, and looked up at me. “Are you my doctor?” she asked. “Yes, I am.” “You look too young,” as she laughed, the skin around her eyes crinkled affectionately, and she reached out her hand – trembling, but purposeful. I smiled back at her, and reflexively took it. I was struck by how firm her grasp, and how soft and warm and comforting. Her thumb, as if by habit, caressed the back of my hand. “My mother used to do that,” I thought. Are you in pain?” I asked. “No doctor,” she replied, “Some before, but it passed. I really think I’m going to be fine”. I rode down the elevator with her, my hand still in hers, to the intensive care unit. Once there, the junior residents and nurses staffing the unit leapt into action, like mechanics in the pits at at a race track, placing intravenous lines, and starting medicine to lower her blood pressure. I took the large cardboard envelope that was lying under her stretcher over to an Xray view box, and put the images of the CT scan that had been performed at the small outside hospital on the lighted panels.
I picked up a wall phone and asked the operator to call my attending surgeon at home. “Hey,” he answered, “what we got?” “Sixty-eight year old black female,” I replied, “moderately obese, hypertensive and with no current complaint of pain. All of her pulses are normal. Labs are off, and I’m looking at the films now.” I stopped for a moment and glanced at the last couple of images. “The films are poor quality, but it looks like she has both an aneurysm,… and a dissection.” “Hmm,” he replied, “that’s rare – its either one or the other, an aneurysm, or a dissection.” An aneurysm was a “ballooning out” of the aorta, leading to a thin wall, also prone to rupturing as it grew. “I know,” I replied, “but the aorta is about six centimeters, and I think I see two lumens in the upper thoracic area, as well as a tear.” “Okay, whatever,” he replied, sounding a little exasperated, as if he couldn’t trust me even though I had been at this just about every day for the last two years, “get an MRI, and give me a call.” “She’s a real sweet lady,” I mentioned uncharacteristically, prior to hanging up the phone, “reminds you of someone’s grandmother or something.”
We finally got her transferred down to the MRI area and prepped for the exam. I stepped out into the adjacent control and viewing room. As I stood and absent-mindedly watched the patient’s monitor, and as the technician did some last minute changes on the computer prior to starting the study, the patient’s pulse rate slowed… 90, 78, 63, 52, “crap!, I thought, she’s about to code”…44, 38… “Turn off the magnet and bring me a thoracotomy tray,” I yelled as I pushed open the door to the scanner room. I ran up and felt her neck – no pulse. She had lost consciousness and was still breathing, but barely. Her monitor showed a pulse in the 30’s. “Call anesthesia, now!” I yelled again. I reached down and felt her groin – no pulse there either.
One of the nurses brought in the instrument tray. “She’s ruptured!” I yelled, “Betadine!” The nurse handed me a bottle and I tore off the top and squirted it haphazardly onto her left chest. I ripped open the light blue paper covered instrument tray, and grabbed a scalpel. I plunged it savagely between her ribs just under her left breast and cut laterally and down toward the table, opening all the way into her pleural space with one cut. A torrent of blood rushed out – I heard it splash onto the floor, and onto my feet, sounding like someone spilling a very large punch bowl. I grabbed a rib spreader, shoved it into the gash in her side, and cranked it quickly. I reached deep into the chest with my left hand, behind the lung, while grabbing a big clamp with my right from the tray. I felt frantically for her aorta, knowing the only slim chance I had of saving her was to clamp across it above the aneurysm, high in the chest. But…, there was no aorta, “where is the aorta, dammit?”… the was just a tubular wad of something soft and unformed, like rolled-up wet toilet tissue. The thin walled aneurysm, made even thinner by the dissection, had basically disintegrated. I took my hand out of her chest and stood there, staring into the garish opening, as blood continued to poor out onto the table, it had already soaked through my shoes and I could feel my toes starting to stick together. I watched helplessly as her heart beat, with a slow exaggerated mechanical motion in the wound the last few times, then quivered for a few moments, then stopped.
Two days later, as I was contemplating the possibility of going home the end of another long day, one of the other attending surgeons called me up to his office. “We’ve been offered a heart transplant, but have to get out in the next half-hour or so to procure it. You probably should go on up to the helipad.” “Sure,” I replied, thinking about the fact that the next 24 hours of my life had just been scripted – with none of the acts performed at home. My beeper went off, and I walked over to a nearby secretary’s desk to answer it – it was a number I didn’t recognize, but from inside the hospital somewhere, based on the prefix.
“Hello, this is Dr. Smith.” “Yes,” an official sounding voice on the other end responded, “this is Dr. Jones, Chief of the division of MRI imaging in radiology.” “Oh, hey Dr. Jones,” what can I do for you? “I want to talk to you about the case from a couple of days ago,” he replied. “Oh, yeah,” I replied, “that was terrible – horrible actually might be a better word. We had hoped that you guys could get us some images, you always do such a great job on these cases. It was a real shame, she was a really nice woman.” “Um-hmm”, he replied, the tone in his voice sounding to me as if he was commiserating. I continued, “a real problem, we…, we thought it was actually a dissecting aneurysm – those, as you know, are uncommon. It might have been hard to fix regardless”. “Um-hmm, yeah,” he replied, “but what about the blood?” “Oh, yeah!” I shot back, shaking my head “I wondered whether or not the entire thing started with her blocking off the true lumen of her aorta with the dissection, and maybe this caused the rupture, who knows? That might explain the huge amount of blood out in such a short time, you know, under pressure – no where else to go but out.” “No,” he countered, “what about the blood? What about the blood on the damn table?”
I hesitated, “Uh, yeah, well that’s what I, uh… think happened, you know, with the rupture and everything, and…” He cut me off, “what I mean, Dr. Smith, is what are you going to do about all the blood, all the blood that spilled out onto my MRI table?” “I’m not sure I follow you,” I replied, confused.
“Listen, here’s the deal,” he stated emphatically, “that MRI table is worth about 20 thousand dollars, and you ruined it. What are you going to do about that?”
I paused, squinted, and gripped the phone tightly in my hand. I had been staring ahead blankly and unfocused, but my knuckles gradually came into view out of the corner of my right eye as they blanched white, and began to ache.
After a long silent moment, I loosened my grip on the receiver, and simply hung it back up. I walked over to the elevator bank outside the office area, and rode up to the waiting helicopter.