The surgical rotation during my third year of medical school showed me many things that I had never witnessed before. The inside of a human chest cavity with its contents representing the essence of life and rhythmically squeezing to a steady beat; the same breast surgery undergone by my mother and her mother before her upon their diagnoses of breast cancer many years ago; countless steel tools whose names I still cannot begin to pronounce despite hearing the attending surgeon again and again call them out in the operating room. All these things provided learning points that I had been prepared to encounter prior to rotating through surgery. The learning point that I could have never prepared for, however, was processing a patient’s death for the first time.
I was on my second round of night shifts, which started when the sun began to sink over the city and ended just as the skies warmed with hints of pink and orange, when our team ran to the emergency department in response to a level 1 code. En route to the trauma bay, my chief resident provided me and another resident with an overview of the impending scenario in breathless fragments as we hustled down the fluorescent-lit hallway. 29-year-old male. Five transthoracic gunshot wounds. Hemodynamically unstable. Massive transfusion protocol initiated. I tried to take mental note of these different pieces and formulate them into a clinical picture as we readied ourselves with gowns and shoe coverings to protect ourselves from the anticipated bloodshed.
When the patient arrived in the trauma bay, the somber expressions of the first responders immediately betrayed how much irreversible damage had already been done. Streaming blood saturated the patient’s pants and shirt, although these were partly obscured by the firefighter straddling the stretcher, hands vigorously pumping his chest in a feeble attempt to force the bullet-punctured heart to circulate blood. The patient’s eyes were wide open and staring blankly at the ceiling as chaos broke around him in the trauma room. Nurses rapidly attached electrocardiogram lead wires as surgeons cut away bloodied clothes and broke open kits to perform an emergency bedside thoracotomy. I stood back and observed the scene with a paradoxical sense of calmness yet overwhelmed by the mayhem nearly into submission.
It was in this dazed state when I heard my chief resident finally speak over the wordless bustle of the trauma room: “Everyone, stop,” and just like that, the background din of tearing plastic wrappings and tennis shoes scuffing linoleum floors ceased into silence.
This sudden stillness forced every person in the room to finally acknowledge the inevitable truth that had been staring us in the face since the code was called. Our patient had been pulseless for fifteen minutes and any additional intervention could not save him. After several long seconds, another physician nodded in agreement with my chief and all the hands formerly covering the patient’s body vanished. A knowing silence unlike I had ever experienced before enveloped the trauma bay as each one of us processed the implications of withdrawing life-saving interventions.
Previously, when I had heard of someone dying from traumatic causes, I had imagined that every possible measure suggested by modern medicine had first been attempted. I had pictured the transfusion of bags upon bags of packed red blood cells, the repeated defibrillation of the patient’s heart, the countless rounds of epinephrine pushed through peripheral IV lines. I could not fathom feeling confident declaring “time of death” without first knowing beyond a shadow of a doubt that every effort had been taken to save the patient’s life. That way, when the family would ask about how their loved one had died, the medical team could truly say that they had tried everything.
As I rejoined the surgeons on the walk back to our workroom following the trauma code, I was angry. They quickly returned to their normal conversations about the various planned surgeries scheduled for the following day and the remaining tasks on that evening’s to-do list. Yet I was still in disbelief that they had given up so quickly on our patient. It seemed unfair that the patient’s family members, those who loved him and were closest to him, would never have a say in the extent of life-sustaining measures taken during his final moments. And yet, a small handful of strangers wearing scrubs did. How could the residents move past this monumental moment so quickly into their mundane tasks? Did this man’s death mean so little to them? My eyes watered as I walked beside my residents, processing emotions of incredulous frustration and an overwhelming sense of isolation. Despite their physical proximity, the unphased dispositions of the surgeons made them seem a million miles away, separated in space and time from me as I struggled to comprehend this loss of life.
It wasn’t until several days later, after witnessing several more unsalvageable trauma codes, that a realization dawned on me. It wasn’t that the surgeons didn’t appreciate the gravity of death, and it wasn’t that they had cut corners in managing our patient. It was that they had understood their role as physicians, and I had not.
Physicians are the captains of a medical team, navigating critical decisions about when to cease life-sustaining treatments and when to stay the course. These decisions require more than just a mastery of medical knowledge; they require an understanding of ethics and a kind of wisdom exclusively garnered from weathering crises again and again. While studying the four principles of medical ethics in medical school, I had never considered the principle of nonmaleficence to encompass anything other than “doing no harm” in the most obvious of contexts. Avoid egregious medical errors. Practice integrity in your encounters with patients and their families. Try to keep your patient alive if at all possible. The concepts of “do no harm” and allowing the death of a young man seemed to be diametrically opposed. However, the principle of nonmaleficence applies to the treatment of patients in death as well as in life, and as such, it implicates that pursuing inappropriate life-saving interventions is ethically contraindicated.
Physicians are also tasked with shouldering the tremendous emotional burden of sickness while acting rationally and abiding to strict protocols. They cannot surrender to romantic notions where every patient can be saved or that miracles will consistently intervene, as it is not their job to be overwhelmed by grief and existential anger. Instead, those emotions should be spared for the patients. Maintaining emotional composure helps emphasize that the focus of the provider-patient relationship is centered on the patient and their family.
Despite the months that have passed since my first encounter with death, the pivotal lessons learned from this experience continue to shape my interactions with critically ill patients and their families. I now realize that while grief is a natural part of medicine and should be emotionally processed, it is paramount that physicians compartmentalize these emotions to act in the best interests of their patients. As such, I can approach conversations regarding goals of care in hospice settings and do-not-resuscitate advance directives, conversations that had formerly sapped me of energy and left me hollow at the end of the day, with renewed strength and perspective.
As I walked to my car after my final day on general surgery, I reflected over the knowledge garnered from my weeks spent in operating room. I had become highly familiar with surgical knots, running subcuticular stitches and wound vac changes. But more importantly, I finally understood the nature of a physician’s role in caring for a patient.
Image credit: Custom artwork by the author for this Mosaic in Medicine piece.