The Most Important Lessons from Residency: Lesson Two

“The LORD gave and the LORD has taken away; may the name of the LORD be praised.”  -Job 1:21

What follows is not for the faint of heart . . .

I learned the second of the most important lessons on the worst day of my residency.  To understand this better, I also need to explain the two weeks prior to this tragedy.  I was a second year resident working solo in the PICU (yes, all my worst experiences involve the PICU).  My attending was a locum tenens attending who was filling in for our regular intensivist.  He strolled into the unit each day at the time that he pleased.  He scrolled through his yahoo page as I presented patients.  He found me too incompetent to write orders for my patients or make any decisions about their welfare.  At the same time, my department entered into a power struggle with the trauma department, each with different ideas about how best to care for critically injured children.  I saw elevated blood pressures and recommended treatment to the trauma attending.  My attending did not support me.  The trauma team ignored me, except when they forgot to write orders or fill out paperwork when they would call and tell me to take care of it.  I was worn out, tired of fighting, and alone.  The only saving grace of that time was my favorite attending who stopped by every afternoon to fill her tea cup from the unit’s hot water tap.  She always stopped to encourage me.

My second Saturday in the unit, I offered to take a shift for a friend who needed the weekend off.  The unit was quiet, and I finished my pre-rounds quickly and waited for my attending to arrive.  At 8:15, just after he strolled in, we were paged to a trauma in the emergency room.  A two-year-old with severe injuries from a minor car accident was unresponsive in the trauma bay.  He had been sitting in the front seat, unrestrained, and the car’s airbag deployed when his mother rear-ended another car.  The trauma team quickly assessed him and slid him through our CT scanner.  My attending barked orders for dopamine and norepinephrine infusions while the others worked.  This toddler had a ruptured spleen, an immediately life-threatening injury, so the trauma team rushed him to the operating room for an emergency splenectomy.

My attending and I returned to the PICU to wait.  Within the hour, the child was brought back to the unit, a large, oozing incision spanning the length of his abdomen.  The trauma attending pulled my attending and I aside.  While in the OR, the CT reconstructions of the child’s head and neck became available.  The child had irreversible swelling of his brain, completely blurring all normal structure.  He also had an 8mm displacement of the first vertebra, completely severing his spinal cord at the base of his brain.  These are injuries that are incompatible with life.  I heard this, and my attending heard this.  He was standing with me.  This is why I have trouble understanding the events which follow.

I understood this child to be dying, succumbing to injuries that were beyond repair.  He arrived back in our unit with his blood pressure dropping despite his three pressor infusions, his heart rate slowing.  Despite his dismal prognosis, rather than discuss the depth of his injuries with his family, my attending began aggressive life saving measures.  Within minutes, we were in a full code because the child’s heart had stopped perfusing his body.  We took turns crushing his heart between his breastbone and spine, artificially producing a heartbeat.  He received multiple infusions of drugs designed to “jumpstart” the heart.  His severe abdominal injuries caused him to bleed within his abdominal cavity, from his incision site, and from a laceration on his tongue.  The bruises on his face blackened and swelled.  We called for all the blood products available from the hospital’s blood bank, infusing them so quickly that there was no time to warm them before pushing them into his body.  His heart rate returned for brief moments, but the code was always resumed.  We did these things to this child for three hours, even though medical literature is clear that after 15 minutes, the chance of survival is very poor.  Finally, my attending demanded that the trauma team take the child back to surgery.  Thankfully, the trauma attending refused, stating what seemed obvious to the rest of us, that continuing this treatment was futile and cruel.  Refusing, my attending continued his efforts until the child’s parents asked to hold their son.  Even then, his heartbeat continued erratically for over an hour because of the volume of drugs he had been given.  I sat by the monitors, hoping this child’s spirt had left him long before we began all the painful things we had done to him.

My attending had nothing good to say to me that day or any day that month.  He remained critical of everything I did, not trusting me with even simple orders.  That Saturday in the PICU, I saw the ugliest side of medicine.  I watched a child die from preventable injuries, and I watched a doctor inflict unnecessary pain and suffering upon this child and his family.  Numb, I drove home that night thinking only one thing:  blessed be the name of the Lord.  I realized that day that unspeakable tragedy occurs on this earth every day.  It occurs irrespective of social class or available medical care.  Humans are fallible, and they sometimes make terrible decisions, but I serve an infallible God.  Regardless of all of these things, my God is still God.  He promises to right this world some day.  Blessed be his name.

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