My fellow resident Jeff and I worked traumas together. When he called me down to the trauma bay because of a concurrent head injury, we were always in sync. He’d assess the abdomen, then ask for my prognosis on a patient’s cognitive function. “Well, he could still be a senator,” I once replied, “but only from a small state.” Jeff laughed, and from that moment on, state population became our barometer for head-injury severity. “Is he a Wyoming or a California?” Jeff would ask, trying to determine how intensive his care plan should be. Or I’d say, “Jeff, I know his blood pressure is labile, but I gotta get him to the OR or he’s gonna go from Washington to Idaho—can you get him stabilized?”
In the cafeteria one day, as I was grabbing my typical lunch—a Diet Coke and an ice cream sandwich—my pager announced an incoming major trauma. I ran to the trauma bay, tucking my ice cream sandwich behind a computer just as the paramedics arrived, pushing the gurney, reciting the details: “Twenty-two-year-old male, motorcycle accident, forty miles per hour, possible brain coming out his nose…”
I went straight to work, calling for an intubation tray, assessing his other vital functions. Once he was safely intubated, I surveyed his various injuries: the bruised face, the road rash, the dilated pupils. We pumped him full of mannitol to reduce brain swelling and rushed him to the scanner: a shattered skull, heavy diffuse bleeding. In my mind, I was already planning the scalp incision, how I’d drill the bone, evacuate the blood. His blood pressure suddenly dropped. We rushed him back to the trauma bay, and just as the rest of the trauma team arrived, his heart stopped. A whirlwind of activity surrounded him: catheters were slipped into his femoral arteries, tubes shoved deep into his chest, drugs pushed into his IVs, and all the while, fists pounded on his heart to keep the blood flowing. After thirty minutes, we let him finish dying. With that kind of head injury, we all murmured in agreement, death was to be preferred.
I slipped out of the trauma bay just as the family was brought in to view the body. Then I remembered: my Diet Coke, my ice cream sandwich…and the sweltering heat of the trauma bay. With one of the ER residents covering for me, I slipped back in, ghostlike, to save the ice cream sandwich in front of the corpse of the son I could not.
Thirty minutes in the freezer resuscitated the sandwich. Pretty tasty, I thought, picking chocolate chips out of my teeth as the family said its last goodbyes. I wondered if, in my brief time as a physician, I had made more moral slides than strides.
A few days later, I heard that Laurie, a friend from medical school, had been hit by a car and that a neurosurgeon had performed an operation to try to save her. She’d coded, was revived, and then died the following day. I didn’t want to know more. The days when someone was simply “killed in a car accident” were long gone. Now those words opened a Pandora’s box, out of which emerged all the images: the roll of the gurney, the blood on the trauma bay floor, the tube shoved down her throat, the pounding on her chest. I could see hands, my hands, shaving Laurie’s scalp, the scalpel cutting open her head, could hear the frenzy of the drill and smell the burning bone, its dust whirling, the crack as I pried off a section of her skull. Her hair half shaven, her head deformed. She failed to resemble herself at all; she became a stranger to her friends and family. Maybe there were chest tubes, and a leg was in traction…
I didn’t ask for details. I already had too many.
In that moment, all my occasions of failed empathy came rushing back to me: the times I had pushed discharge over patient worries, ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged into various diagnoses, the significance of which I failed to recognize—they all returned, vengeful, angry, and inexorable.
I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease—and utterly missing the larger human significance. (“Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from.”) A mother came to me, newly diagnosed with brain cancer. She was confused, scared, overcome by uncertainty. I was exhausted, disconnected. I rushed through her questions, assured her that surgery would be a success, and assured myself that there wasn’t enough time to answer her questions fairly. But why didn’t I make the time? A truculent vet refused the advice and coaxing of doctors, nurses, and physical therapists for weeks; as a result, his back wound broke down, just as we had warned him it would. Called out of the OR, I stitched the dehiscent wound as he yelped in pain, telling myself he’d had it coming.
Nobody has it coming.
I took meager solace in knowing that William Carlos Williams and Richard Selzer had confessed to doing worse, and I swore to do better. Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Technical excellence was not enough. As a resident, my highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness. When a patient comes in with a fatal head bleed, that first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (“Maybe it was his time”) to an open sore of regret (“Those doctors didn’t listen! They didn’t even try to save him!”). When there’s no place for the scalpel, words are the surgeon’s only tool.
For amid that unique suffering invoked by severe brain damage, the suffering often felt more by families than by patients, it is not merely the physicians who do not see the full significance. The families who gather around their beloved—their beloved whose sheared heads contained battered brains—do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery—or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew—the full, vital independent human—now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.
Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.
—
With my renewed focus, informed consent—the ritual by which a patient signs a piece of paper, authorizing surgery—became not a juridical exercise in naming all the risks as quickly as possible, like the voiceover in an ad for a new pharmaceutical, but an opportunity to forge a covenant with a suffering compatriot: Here we are together, and here are the ways through—I promise to guide you, as best as I can, to the other side.