Author: heenastat

Acute Care Surgeon who blogs about joy in the profession.

A Stranger’s Hug in the Midst of a Pandemic

FeaturedA Stranger’s Hug in the Midst of a Pandemic

Social distancing has had differing effects on each of us during the COVID-19 pandemic. In our personal and professional lives we experience the absence of interpersonal interactions unless there is a dire need or essential role, the muting of facial expressions and muffling of intonations of voice, and the relegation of hugs to immediate household members differently. The raging extrovert and empath in me has been emotionally bereft since March 13th (because yes, I do take the risk of virus transmission seriously).

For the last 24 hours I have been spontaneously bursting into tears at random moments of the day. For the first time in nearly half a year I experienced human touch from someone other than my spouse or my children and every time I think about that moment I cry. I am not clear if these are tears of joy or of sorrow.

Photo by Anna Shvets from Pexels

I rushed the love of someone’s life to the OR urgently. The risk was extraordinarily high and time was of the essence. Due to the pandemic, I was unable to meet family in person and had this terrifying conversation filled with uncertainty regarding life or death over the telephone. My team and I did everything we could and were able to get the patient off the table. When someone has surgery their family can visit the hospital. I went to speak with the patient’s husband in person not long after we finished our damage control surgery. It was clear that our intervention had not had its intended effect. The patient was dying and her husband decided not to pursue further heroic efforts.

I was physically and emotionally exhausted. I stood a few feet away from my patient’s spouse. We both wore masks. My face was further obscured by my full wrap eye protection. I said, “I am so sorry.” He reached up for my shoulders and said “Thank you. Thank you for everything you did. She lived a good life.” I hesitated awkwardly for a split second. Then I let him hug me. COVID be damned. He wanted to hug me and I needed to be hugged.

Today, more than 24 hours after call ended, my body still aches from the 28,000 steps taken and the many contortions in several operations. And, the feeling of that hug lingers with me. I cry because I am heartbroken for a stranger’s loss – my entire relationship with the patient and her family lasted less than 4 hours. I cry because it felt so wonderful to be embraced, even so briefly, even though under such circumstances, by someone other than my immediate household members.

I am grateful to be able to do the work that I do to save lives and even more so for the family members who lift me up even when my efforts as an acute care surgeon fail. But when a pandemic is stealing lives from our populace and joy from so many aspects of my life, a stranger’s hug is the best reminder of why I keep showing up day after day.

 

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Behind the Mask – The (Socially) Distant Acute Care Surgeon

Social distancing has now become the norm across the land. This is a necessary effort to prevent the spread of the coronavirus and its potentially deadly consequences. The ‘COVID lockdown’ as I call it in my casual conversations has had a ripple effect across many lives and industries beyond the patients and families and day-to-day work of the US healthcare-industrial complex.

In these days of COVID, the new normal for me is covering myself for all encounters. Asymptomatic infection is high. In any given day, I will see multiple new patients in short order and even with the highest level of hygiene, I might be the greatest risk to a patient for whom a trip to the hospital is unavoidable. I do not shake hands. I do not begin with a warm smile to ease the anxiety. I do not hand out my card with a reassurance that my partners and I are available 24/7 – just call.

I am a surgeon. I am no stranger to donning a mask for sterility in the OR or for bedside ICU procedures. I am no stranger to donning a mask to protect a vulnerable cancer patient who nevertheless needs me to examine their abdomen. And when my hands will be touching a body part during an exam, I am no stranger to donning gloves.

My hands and cuticles are raw year round because they are no strangers to repeated contact with 70% alcohol-containing solutions.

I still perform the exam. I still explain the diagnosis and my rationale for the treatment options in a level of detail that would make residents roll their eyes (if they were still allowed to see patients by my side). But I don’t ask for permission to sit at the foot of the bed while I do so. I don’t gently lay a hand on a covered knee while having a very difficult conversation.

Often, family members will ask if it’s okay to hug me at the end of an encounter (even if the outcome was their loved one’s death). Currently, patients are not allowed visitors outside of very rare exceptions. There is no hugging in COVID lockdown.

Sometimes, I cry with my patients who never expected to need a surgeon until the day they met me. Tears are a body fluid. There is no crying in COVID lockdown.

But my patients are so very alone right now. Whatever they are stricken with – and luckily for me and for them so far it hasn’t been COVID-19 – these are dark and scary times in their lives and they are all alone. Completely, totally alone. And I can do nothing to ease that loneliness behind my mask.

The warmth and non-medical touch during these encounters matters as much as detailed explanations but I am trapped behind my mask, unable to be the kind of surgeon that I truly am on the inside. I feel inadequate even though my clinical acumen and technical skills are unchanged by the COVID lockdown.

I am compliant with the need to be distant and sterile during these encounters because it is how it must be. However, the heartbreak of every encounter is real for me and my patients. Some will survive; some will not. Will they or their families be grateful for the surgeon behind the mask who played a role in some way?

Who am I to say. 

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COVID and the Break in the Acute Care Surgery Coat of Armor

The thing about acute care surgeons is that we always show up with our invisible coat of armor. Over years of training and experience with grittiest and most tenacious role models and mentors guiding our way, we become resilient. We learn to provide timely and high-quality care to all those in need whether it’s 2 am or 2 pm, whether it is a weekend or a holiday when everyone we love has some respite, whether its a pedophile from the federal penitentiary or the sweet old lady who reminds us of grandma who needs us to help urgently, whether it is a slam dunk easy case or the risk of mortality is high in the best case scenario. We do this despite the momentary cost to our physical or emotional health because that coat of armor shields us.

Often we are where the buck stops when patients are complex. When our colleagues need help figuring out the culprit on their differential diagnosis or an extra set of hands they call us.  Can’t figure out if the nausea is from an intra-abdominal source, call acute care surgery. Can’t figure out if the source of florid sepsis is GI perforation, call acute care surgery. Can’t figure out if this skin exam is consistent with cellulitis or necrotizing soft tissue infection, call acute care surgery. Can’t figure out if the airway pressures are rising due to abdominal compartment syndrome, call acute care surgery. Urgent central venous access, call acute care surgery. Difficult airway, call acute care surgery.

Like every town’s fire brigade, we are there. We show up whether or not there is a fire to be put out because someone was concerned enough to ask for help. We have chosen our specialty because we are committed to helping not just our patients but our colleagues, in even the most inopportune circumstances. To do so, we truly function as a family. I may not have chosen to be friends with them outside of work but at four different jobs with a team based approach to emergency surgical care, I have alway loved and cherished my team members like family. It’s like wedding vows. We are in it together and would lay down across rail road tracks to help each other do right by our patients.

In these unprecedented times surrounding COVID-19, from preparations to actual care of extremely critically ill patients, this family’s invisible coat of armor has started to crumble.  Our ER, hospital medicine, and medical intensive care colleagues still need us for those vexing matters that are routinely part of our work responsibilities. However, we may or may not be able to offer these patients with the inflamed organs or perforations the same kind of care that we might have as recently as two weeks ago. We might have to offer something that is likely non-inferior. It may be non-operative or operative in the old fashioned way we did it long before fiberoptic cables and robots.  These alternative decisions might be because we have to be proactive about using supplies. They might be because asymptomatic carrier rate is high and we need to protect the surgical and anesthesia workforce. They might be because we simply don’t have the physical space to provide surgical care. Meanwhile, given our critical care expertise we are, of course, available for managing patients whose only known issue is COVID-19. We understand ventilator management, and ARDS, and reversing I:E ratios, and proning. We have put young previously healthy patients on ECMO before. We remain here – day and night – to help. We are searching for scarcer and scarcer PPE so we don’t miss a beat when you need us.

All of this is happening for each of us on the front lines including EM, IM, and MICU all day every day (even while others might be figuring out their new normal mostly at home) while our families are struggling from social isolation in general, from knowing we are in the direct line of fire, or seeing how preoccupied we are with being prepared given so much uncertainty. Like our other front line colleagues, there is no down time for acute care surgeon, even those who have been put in the “bullpen” at home in case we start losing faculty to COVID-19. Because being out of harms way means that someone else is in harms way, the moral distress of sitting out is paradoxically crippling. On top of this worry for work family, where ever we are stationed, there are a dozen relevant emails before the crack of dawn. Multiple remote conferences to stay up to speed. At best you a catatonic shadow in the lives of your real family when they truly need you – the medical person in their life – to have no breaks in the armor. Some of us, have gone to extreme measures of isolating in separate quarters within the home or in entirely separate locations from our loved ones – the ones’ whose snuggles and kisses are such a critical part of our day to day resiliency when things are at baseline.

When you play so many key day to day safety net roles across a health system when things are acute care surgery “normal,” the extreme abnormality of COVID-19 is a serious hit. There are so many moving pieces that we must be totally on top of.  From where to enter the hospital, what to don where and when, where patients will be cohorted, whether surgeries can be performed, where overflow ICU beds will be, how to protect our trainees… the list goes on and on. Each bit of uncertainty, each disruption to our typical decision making or daily practices, each pang of guilt or worry regarding the work family or the home family, along with the constant use of brain power to keep us COVID-related issues is physically and mentally exhausting even before you’ve passed that soviet-era temperature checkpoint to start your day at work.  It chips away at the invisible shield of armor that usually shields us. So we have to figure our other ways to be resilient in these trying times because our usual mechanism is failing us.

But there is a fire somewhere and we are needed. I am sure that in sickness or in health we acute care surgeons will figure it out.

RBG is everything!

Originally posted on heelskicksscalpel.com

I finally made it to a showing of the Ruth Bader Ginsburg documentary This week. Despite my long absence from the blog, RBG so resonated with me that I felt compelled to tell you why.

Ruth Bader Ginsburg the woman and RBG the documentary is everything.

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(source: https://www.americanprogress.org/issues/race/news/2016/10/14/146171/say-it-aint-so-ruth-bader-ginsburg/)

I expected a thorough retelling of the life a remarkable woman. A quiet but fierce jurist and principled judge. A trailblazer among women and the strongest of advocates for equal rights. But I got so much more.

I didn’t anticipate that this was the kind of documentary that would make me cry. But I did. More than once. In fact, I cried several times.  I shed tears of sorrow as the documentary follows the Ruth Bader through the grief of losing the bookends of her life, her stern but loving mother at age 17 and her soulmate since age 18 Marty Ginsburg.  I welled up with tears of pride seeing her, just one of seven women in her law school class, making the Law Review,  successfully arguing before the nation’s highest court for equality across genders in all domains of personal and professional life, and then telling of her struggles, of her sex’s struggles, including the struggle to exercise control over our own bodies before the Senate Judiciary Committee when she was under consideration for a seat on that same court. I cried the happy tears inspired by true love and affection. First, there was the adoration in Joe Biden’s eyes as he listened to Ginsburg’s testimony during her nomination hearings. Then there was the remarkable, heartfelt, and genuine friendship between Ginsburg and her ideologic foe Antonin Scalia. I mean to watch them have fun together and share in their love of opera was truly such a wonderful and tear worthy thing. And, woven throughout the documentary was the once in a lifetime, made for each other that the Ginsberg shared. Every word that Marty said about his dear wife as a wife, a mother, or a professional made me squeeze my own husband’s hand a little tighter as I dabbed my eyes. It’s the kind of love, mutual respect, and balancing of inherent traits through open dialogue that leads to lasting marriages. The Ginsburgs had that.

I also did not imagine that I was going to a comedy but laughed plenty during RBG. I giggled at the site of a rather serious pint sized woman occasionally not taking herself so seriously. There are multiple cuts of Ginsburg working out her burly trainer wearing her ‘Super Diva’ sweatshirt. It’s just the cutest/most badass thing to see her bust out real push-ups (“not the girl kind” which is the only sexist moment I caught in the whole film). There a multiple different times when Ginsburg’s prowess, or rather lack thereof, in the kitchen comes up. She is able to heartily accept her failings as a cook as others in her family mock her for it. While the sharing of memes and addition of music to video of Ginsburg in relation to her being dubbed the “Notorius RBG” are humorous, the really hysterical moment is when Ginsburg details who she and the Notorius BIG have a lot in common. It should surprise no one that Ginsburg is not an avid television connoisseur. Thus, watching her laugh at impressions of herself that are wholly unlike her in real life are ridiculously funny. Seeing Ginsburg in costume to do bit parts in real operas, sometimes even composing some of the speaking parts, is funny as well. And, who wouldn’t crack up learning how Ginsburg accessorizes her robes with collars based on the content of the judgment to be rendered.

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(source: https://www.vanityfair.com/hollywood/2018/05/rgb-documentary-about-ruth-bader-ginsburg-is-surprise-box-office-hit)

I did expect, however, to feel anger and to be sure the RBG delivered. I was angry that Ginsburg had to fight so many battles on behalf of others who simply did not stand a chance in a system rigged to favor white men. I was angry that Ginsburg had to battle so many double standards to rise to her current position. I was angry that she has had to dissent on a number of key SCOTUS decisions, such as reversing voting rights protections or guaranteeing equal pay for equal work, that are taking our nation back to place resembling more the America of her childhood than the America in which I should feel that there is nothing to hold me back from being as accomplished as my male counterparts. There’s not much more to say. Anyone who is a thoughtful human would feel anger at this. In this regard, the documentary is pretty straight forward. Ginsburg has spent a lifetime fighting to make our nation a more fair and just place for everyone and she’s currently not on the winning side of the battle. It’s sucks. And it makes me really angry.

In the end, RBG was not just about anger, laughter, and tears. It was a playbook on succeeding as a woman in a man’s world. It was about grit, tenacity, and hunger to do good paired with a great mind. It was about giving permission to a generation of ambitious women to have a home life distinctly unlike that which has historically been most valued and expected in our society. It was about enduring love between two opposites driven by mutual respect and admiration. It was about the legacy of a principled woman of profound intellect who was not afraid to stand up and speak. We should be like RBG. We should be everything. The battle wages on and we need to be everything.

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An Open Letter to My Elected Officials on Firearms and the Deaths Trauma Surgeons See Daily

An Open Letter to My Elected Representatives

February 23, 2018

Dear Elected Official:

As a trauma surgeon and one of your constituents, I was heartened to hear that you are reconsidering your views on how to protect Americans from the ravages of our national gun violence epidemic. I am writing to share my first hand experiences along with known facts about widespread use of guns in the US today. In my line of work I am all too familiar with the lethal potential of firearms, especially when coupled with a cavalier attitude that many legal gun owners in America have that they or their families are somehow immune to the deadly power of guns. While every life I save is a privilege, my greatest success as a trauma surgeon would be to significantly reduce the number of people who need my care. Injury prevention is as fundamental to my work as is operating. In the case of firearms-related injury, there is much work to be done. I hope my perspective on the morbid consequences of Americans’ unfettered access to firearms will be helpful as you consider what should be done to protect each and every one of us from a death that is truly 100% preventable.

As a trauma surgeon, I have held countless ounces of brain matter in my hands while examining a self-inflicted gunshot wound. Occasionally, someone shoots themself in the chest, aiming at the heart. Most often, however, the suicide victim points a gun, legally purchased by themself or a family member, at the temple or roof of the mouth aiming at the brain. At such close range, despite my expert skill in trauma care, the damage is far too severe to reverse. It is a uniquely American reality that homes across the nation, occupied by residents experiencing deep depression, are also filled with firearms acquired for sport, hunting, or presumed personal protection. Of the nearly 96 Americans who die a firearms-related death in the US daily, nearly 59 die as the result of suicide. People with suicidal thoughts are three times more likely to succeed if they live in a home with a firearm. Furthermore, while 9 out of 10 suicide attempts with a gun are successful, only 1 out of 10 attempts by all other means succeed. To be sure, we as a society need to lift the stigma on psychiatric disease and enact policies that increase our nation’s mental health workforce and require both insurance companies and hospital systems to treat mental health conditions like any other illness. However, given that the leap from suicidal ideation to death by suicide is shortened by the presence of firearms, we must also take steps reduce access to firearms in US homes.

As a trauma surgeon, I have felt the anguish of too many parents who learned that their child was dead from me. Occasionally, the child was a teen who, in the absence of strong public education, housing security, and hope for an economically sound future, turned to a life of gang warfare in our urban centers. But more often, a child’s death has been deemed in our societal discourse an “accident.” Yet, the presence of the firearm used in the “accident” is in fact very intentional. Our fellow citizens routinely purchase these deadly weapons and keep them in their homes, thinking they are for defense, sport, or hobby. I wish I did not know the horror of a child killed “accidentally” by a sibling, a friend or even themself, but I do. The adult gun owners in each of these cases would swear to be well-versed in firearm safety. But, having seen that child lying cold and lifeless in my trauma bay, I know that they were overconfident in their ability to safely store their firearms. Nearly 1,300 American children die of gunshots every year. Worldwide, of all children who die this way, the US accounts for 91% of them. And, despite the characterization of our nation’s urban centers as the source of the majority of our dead American teenagers, it is important to note that only one in five teens who suffer a firearms-related death was involved in gangs; the vast majority of firearms-related deaths among teens in our nation are, in fact, due to suicides and these supposed “accidents.” Certainly, we should address the problem of urban violence among our youth and the illegal firearms trade that makes it so easy for them to kill each other (recalling that all illegal guns were at one point legally acquired). And, as the number of children lost in school shootings impossibly rises, we absolutely should address the pervasive issues affecting our boys today which might make any one of them turn against their classmates with lethal force. But these efforts would not be nearly enough given that the vast majority of children killed by firearms in the US die in settings with legally acquired guns one “accidental” death or suicide at a time. We must reduce the widespread presence of firearms in American homes and we must stop giving those who choose to keep deadly weapons near their children a pass when their carelessness results in a death.

As a trauma surgeon, I have also taken care of too many people, most often women, who have been shot dead in an act of domestic violence. When my patients have been beaten (by hands or weaponized object such as a bat or pipe) or stabbed (by weaponized knife or bottle) by their abuser, I have a realistic chance to heal them of their physical and mental wounds and get them to a safer place. However, firearms make it too easy for the abuser to become a murderer and I am robbed of the opportunity to end the cycle of domestic abuse in a positive way. Of all women murdered in this country, 45% are murdered by someone who supposedly loves them. This risk of intimate partner violence spans all sociodemographic groups but women residing in homes with firearms are 5 times more likely to be murdered by their abuser than those whose abusers do not have easy access to a gun. To be sure, we need as a society to address the root causes of domestic violence in the US and expand services nationally to help people in abusive relationships leave. However, it is clear that easy access to firearms is the major cause of domestic abuse fatalities; we must at the very least put a halt to how easy it is for abusers to acquire guns.

As a trauma surgeon, I have been fortunate not to have to care for victims from a mass shooting event; but I have trained repeatedly for mass casualty response. Years ago, we used to prepare for something like a bus crash or a building collapse; these days we prepare for shooters. Sadly, I have had to learn from the experiences of my fellow trauma surgeons in places like Newtown, Orlando, Las Vegas, and Fort Lauderdale. There is no glory in caring for victim after victim arriving with bullet holes, only grief; and then one must have the fortitude to bury the grief and move on to the next victim. Often, however, the grief is not from the patients coming into our trauma bays. Rather it is the eerie quiet in the empty bay picturing all the lifeless bodies that never needed to come to the trauma center. We have seen over and over in our country the highly lethal mix of angry people (some with true mental illness but most simply filled with rage) and easy access to firearms, typically legally acquired by self or family member. Surely, reducing overall access to firearms must be part of the equation in improving our collective right to life, liberty, and the pursuit of happiness while we are at school, the movies, and other public venues.

As a trauma surgeon, I have also trained for active shooter events because sadly, in additional to training for years to become the highly skilled professional that I am, I must now also be prepared to get shot in the line of duty as a healthcare provider. From 2000 to 2015 in the US, there were 241 hospital-related shootings. This statistic really hit home when cardiac surgeon Michael Davidson was shot dead in his clinic by a disgruntled family member whose mother had died of a known complication of major heart surgery. He was around my age. His wife was a college classmate. He was killed by a volatile man who lived in my community just 40 miles away. Complications are a part of what we do as surgeons no matter how expert we are, or how much caution we exercise in doing our work. To live in fear that my own death might be the consequence of my professional efforts, because so many of my patients and their families are legal gun owners, is something that my years of training simply did not prepare me for. Here again, the lethal combination of rage and access to firearms is painfully apparent. To be sure, we must make efforts to understand why people come to hospitals prepared to kill – whether it is a critically ill loved one or a physician who they see as responsible for a complication; but, we cannot simply continue let the answer to rage be grabbing one’s readily available firearm.

As a trauma surgeon, I can also provide some insight into the “good guys with guns” concept that people sometimes put forth as a solution to our nation’s gun violence epidemic. As evidenced by the seasoned hunter who shot off his reproductive organs cleaning his rifle or the experienced officer who shot himself while moving firearms from one cruiser to another, I have seen that even the most highly trained “good guys” sometimes don’t understand the power of their guns. Furthermore, the few times that I have been the one to care for a fallen police officer has taught me that even the “best of guys,” armed, well-trained, and experienced, can be taken by the actions of an enraged person with a gun. I was not on call recently when an officer shot while responding to a domestic altercation was brought to our trauma bay; my partner’s efforts to save his life proved to be futile. I can hear the wails of the grown men in blue who lost their partner that night as if I had been present because, sadly, I have heard those wails before. They are somehow even more haunting than the cries of a parent who has a lost child. To be sure, criminals intent on killing will find a way; however, in the decade leading up to 2016, 537 US police officers were killed by a perpetrator wielding a firearm. In contrast, those attacking with a knife, a bomb, or fist/strangle caused just 26 officer deaths in the same time period.  It seems clear that even the “good guys” are not immune to rage-filled persons armed with guns. Therefore, seriously limiting access to firearms will necessarily make more of a dent in our nation’s firearms-related death epidemic than arming others who are unlikely to respond quickly enough to make a save or, worse, might accidentally shoot themselves or someone else.

As a trauma surgeon, I have also seen the impact of high-powered military style assault weapons. As an interested professional, I have deliberately read reports on the autopsies of so many killed with such weapons in our nation’s most recent mass shootings. While all firearms are manufactured with the purpose of maiming or killing, make no mistake about it: the destructiveness of high velocity missiles that can be fired multiple rounds at a time makes semi-automatic assault rifles like no other gun. These kinds of weapons cause tissue damage that is unfathomable, leaving unrecognizable parts that were once part of a living, breathing human. Regarding ownership of such deadly weapons for the sport of hunting, I would argue that if you are such a bad shot that a bow & arrow or a shotgun does not suffice, then you should buy your meat from the store and take up a new hobby. Having seen firsthand what these assault weapons do, I see no reason why any civilian should have access to them for any purpose.

I am grateful that you have taken the time to read about my experiences. Based on my vantage point as a trauma surgeon, and as a concerned citizen, I have several suggestions that I hope will protect all of us from dying from a gunshot(s).

  • Firearms buybacks for those who simply no longer want to live subject to the possibility of the kinds of death I see daily
  • Deny gun permits to those with any history of domestic abuse, restraining orders, anger management issues, school suspensions, animal torture, and the like which all point to tendency for moments of rage
  • Mandate biometric trigger locks so that only the one legal owner of any firearm could use it, and not a thief, or a child, or a suicidal family member
  • Regulate firearms use and liability as we do with automobiles through required firearms training and testing and insurance to cover death/injury/anguish should anyone else get struck by a bullet from your gun
  • Allow survivors and states to sue gun manufacturers for wrongful death as we do for other consumer products (e.g., swimming pool drains, fertilizer, toys, airbags)
  • Prosecute adults whose negligent storage of a firearm leads to “accidental” death at that hands of a child
  • Ban the manufacture and sale of high velocity semi-automatic weapons and multiple rounds of ammunition along with a mandatory buyback of all such weapons followed by fines or jail time for those later found to be in violation of such laws

Again, I am heartened to know that reducing the burden of firearms related death in our society is among your legislative priorities. While I am not an expert in any such policy issues, as you have read, I am sadly an expert in people who die with bullet holes and buckshot wounds. Please do what you can to rid me and my colleagues of these horrific images and make all of us safer.

Sincerely,

 

Heena P. Santry, MD MS