Self-Inflicted

“Not again,” we all silently sigh when the page comes through. He arrives under lock and key and stays that way no matter what our plan. Every trauma surgeon and nearly every resident has previously participated in his care over the years.

He has a life sentence.

The abdomen is socked in. There is no more retrieving the foreign bodies piercing his abdominal cavity. We have been there and done that. If something is visible on the outside we can pull it out. Now we just have to hope whatever was injured causes a process that walls itself off and does not cause too much physiologic compromise.

But what about the psychologic compromise? He does not wish to end his life; that much is clear. But he is looking for escape. The lure of the secondary gain is strong. He has admitted to us:

The food here is better.

The nurses are cute.

I don’t want to be near the pedophiles.

With our incarcerated patients, it is not our place to address these cries for help. We can’t imagine the fortitude it must take to clandestinely acquire a sharp object and then meticulously drive it through the abdominal wall into whatever organs lie beneath; but, we must stay focused on the anatomic issues and potential complications.

He is screaming at us now. The guards tell him to calm down. Now it is his words that pierce our ears:

You have to cut me open.

Please put me to sleep.

I am not a bad person.

As trauma surgeons we view all patients as equal. They all deserve the same compassion and high standard of care no matter what the circumstances of the injury, no matter what the personal status of the patient. We never, not ever, inquire as to the circumstances of the crime(s) for which the patient is serving his sentence or how long the sentence is. None of that matters. He is our patient and we provide him the best care possible.

Today the best care possible is to provide minor bedside care with local anesthetic to remove a foreign body. To calm him down I take his hand while the residents work. I lock his eyes so he will stop trying to see their sterile field. I ask him about himself. I am not sure why but it seemed like the natural thing to do.

He tells us where he grew up. He describes his childhood. He takes a sentence to describe his crime and then speaks more in detail about how the next 37 years of his life sentence led to today. He says:

I wasn’t always like this.

I used to be normal.

Now, this is the only way I know how to cope.

The self-inflicted stab wound will be fine. No hospital food needed. No bedside care from nurses needed. But before he goes back to his bunk with the pedophile, I tell him that we are sorry things turned out this way for him. We wish him luck trying to cope better but we fear he won’t be that lucky.

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Hero

A colleague of mine was recently questioning her capabilities having lost yet another patient who had arrived nearly lifeless after being shot. She was despondent over the nation’s overall complacency about our gun violence epidemic giving her far too many opportunities to fail or succeed as a trauma surgeon. Truthfully, neither quick decisive action nor expert surgical skill was enough to repair that much damage. Not in the hands of any trauma surgeon.

As trauma surgeons we bring everything we have–every ounce of energy and drive, countless years of specialized training, and an ever expanding armamentarium of medical technology to fix broken bodies–to our work but sometimes we simply feel like failures, both unable to save our patients and unable to move the dial on policies that might ameliorate gun violence.

Here are the words of support that I offered to my friend: a compassionate, highly skilled trauma surgeon who without hesitation took a hemorrhaging gun shot wound victim to the OR to try to save his life:

“The grief is understandable. For your patients. For your community. For our society. You have a skill set that makes you brave enough to even try, my friend. As a trauma surgeon when you hear audible hemorrhage you run toward it, just like the police run into the gunfire or the firefighters run into the flames. Each and every patient is lucky to have you and your strength; their families will be grateful for your efforts and empathy no matter the outcome. Don’t be too hard on your self.”

Having been raised in a culture of morbidity & mortality conferences where we scrutinize every decision and every action preceding a death or complication, having a chosen specialty whose goal is to salvage badly damaged bodies, and living in a world where these patients keep appearing in our trauma bays even when we speak up about gun violence, this self-doubt is common among us.

But sometimes we just needed to be reminded we are heroes who have chosen to run toward the audible bleeding so we can get up and go back to work the next day.

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The Dignity of Pants

“Please don’t cut off my pants,” he pleaded. “I am homeless and they are my only pants. Please.”

He could say these words as we were conducting our initial assessment in the trauma bay so at least he was hemodynamically stable with an intact airway at that moment in time. However, he had arrived seconds earlier with potentially life threatening injuries as a level 1 trauma activation. Based on the location of wounds that were visible on his torso this was a real possibility so we needed to quickly conduct our secondary assessment. That meant rapid exposure by taking the trauma shears, one on each pant leg from my assistants, as we examined him from head to toe, front to back, in every crevice or crease that might hide a wound.

I looked him straight in the eye and said “Don’t worry. We will get you a pair of pants but right now we have to take care of you.”

Straight in the eye.

He relented. How could he not? The pants were already cut off even as I made eye contact. The process takes just seconds in the hands of a coordinated trauma team.

He was a very polite young man. He didn’t yell or kick or scream. He followed all of our instructions. He quietly told us his health, social, and family history. He told us he was scared. His life story mirrored that of many of our trauma patients: food insecurity, lack of affordable housing, few resources for education and job training, addiction, interpersonal violence, an endless vicious cycle. He was caught in that cycle and it was obvious that he was heartbroken to be there. He wanted a better life and tonight in the trauma bay, without his pants, he had failed once again to break it.

I always say that I was attracted to a career in trauma surgery because I am part surgeon and part social worker. In reality neither I nor the social worker employed by my hospital to help patients in need of socioeconomic support have much to offer our patients with these very real struggles. The policy level changes and investments that would bring grocery options, better schools, safe and affordable housing to our most underserved areas are not in our control. Even for those patients who want to make a change there are too few addiction treatment beds and job training programs. While these issues are clearly predictors of health, they are managed partly (addiction services) or entirely (basically everything else) outside of the healthcare system.

Yet every day we see the ravaging effects of socioeconomic insecurity on our population’s safety and well-being when they become our patients. We open the trauma bay doors and provide the full armamentarium of modern medicine to save a life acutely while feeling powerless to save lives at the societal level*.

We finished examining and working up our patient. He was not going to die that night and could be discharged. Discharged where? It was 3 in the morning. The social worker could give him the address of a shelter in town. There might be a bunk free. She could refer him to addiction treatment. There might be an available bed. A local non-profit might intervene in the light of day if we could make the connection. But we had no way to guarantee that this man, who was lucky to be alive, would not simply just slip back into his otherwise unlucky life after discharge.

Oh, and there weren’t even any pants to give him. The social worker’s closet of donation was empty of men’s pants it turns out**.

This was not something the trauma team to could bear. We might not be able to provide our patient with better groceries, housing, or addiction treatment to this man who in all of his words and actions as our trauma patient showed us a deep hope to be in a better place in life; but the least we could do is provide him the dignity of a pair of pants to head back into his unfair reality.

So we pooled our cash on hand, asked him what size he wore, and waited until the local Target and Kohl’s opened***. The next morning the light in his face and the sincere words of gratitude when he saw his new jeans and a back up pair of track pants and shorts felt like as much of an accomplishment as stabilizing the unstable patients who had entered the trauma bay earlier or the exploratory laparatomy we had done.

“Thank you. Thank you. Thank you,” he said. “I really need these. Thank you.”

He needs so much more. But this was the least we could do.

*NB: Most trauma centers do provide targeted injury prevention like helmet, seat belt, or firearms safety education through small investments or grant funding but these typically address to specific injury mechanisms rather than social policy.

heenaSTAT

Health & Humanity from the Lens of An Acute Care Surgeon

Category: Health Disparities