Unimaginable Grief: Reflections on the Newtown Film

Originally published on heelskicksscalpel.com

I grew up in a home with the subtle lingering sorrow of parents who have lost a child. An older brother I never got to meet.

I have dear friends who have lost their children. Mothers and fathers who will never be the same.

I am gripped with grief every time I enter a windowless family waiting room to tell a parent that their child is dead. I often wonder how they are doing now, months or years later. How do they move on the way my parents and my friends who have lost children have moved on?

This is the hardest thing I ever do in my job. I operate on beating hearts. I cross clamp aortas. I whip out spleens 20 minutes skin to skin. But this, this is the hardest thing I have to do as a trauma surgeon, telling parents their child is dead. 

Last night at a trauma surgery professional meeting we were privileged to watch the Newtown Film documentary with the filmmaker and an ER physician who provided care that day and is a Newtown resident. It was a gut wrenching story about the evolution of grief.  It followed the parents who lost their children in this particularly gruesome and entirely preventable way. The grace and dignity with which they tackled life after 12/14 was remarkable, inspiring, and heartbreaking. It followed the teachers, the students, and the first responders who saw and heard what was simply unimaginable in even our worst nightmares…until then. Until 12/14/12.

Carnage: 20 dead first graders. 6 dead educators.

We are having myriad civil discussions at this meeting on what we as a profession can do to reduce firearms injuries. To be sure it’s a careful line to walk in our current societal climate. Avid readers of this blog already know where I personally stand on this issue based on my experiences as a trauma surgeon and the fact that I am human.

But today, today I just can’t get my mind of those dead children. They were loved and cherished lives filled with infinite potential. A lone gunman whose mother thought it appropriate to have a semi-automatic weapon and multi-round bullets in her home took them all away.

They didn’t stand a chance. Not with that weapon. Not with that kind of ammo. All gunned down in <5mi.

How many of us wave good bye to our little tykes, back packs all snug on their shoulders, expecting them to return home at the end of the school day? My own child was a sitting in a first grade classroom not too far north of Newtown, CT on that day. Any of us could be these parents experiencing unimaginable grief.

I am once again listening to the words of Lin Manuel Miranda from Hamilton to try to buoy me through these emotions as a mother, as a surgeon, as a human with a soul.

In ‘It’s Quiet Uptown’ Eliza who has lost her son to gun violence sings:

There are moments that the words don’t reach.

There is suffering too terrible to name.

You hold your child as tight as you can

and push away the unimaginable.

The moments when you’re in so deep,

it feels easier to just swim down.

There are moments that the words don’t reach.

There is a grace too powerful to name.

We push away what we can never understand,

we push away the unimaginable.”

Her husband Alexander sings:

“If I could spare his life,

If I could trade his life for mine,

he’d be standing here right now

and you would smile, and that would be

enough.

I don’t pretend to know

the challenges we’re facing.

I know there’s no replacing what we’ve lost

and you need time”

The chorus repeatedly adds:

“They are trying to do the unimaginable.”

The Newtown Film chronicles a community trying to do the unimaginable. While I cried through most of the film watching the grief unfold, the most powerful moment for me was when David Wheeler who lost is son Ben was testifying to a CT legislative task force. He said “The liberty of any person to own a military-style assault weapon and a high-capacity magazine and keep them in their home is second to the right of my son to his life.” That line took my breath away like a sucker punch to my gut.

The Newtown Film is powerful and difficult to watch but I hope that all of us Americans- parents, teachers, first responders, policy makers, legislators, and professional organizations – all of us  see it.  With this film, I hope that the national dialogue will become less contentious as we realize that no one, no parent, no school, no community, should ever have to suffer such imaginable grief.

Trauma Surgeon’s Ballad by Lin Manuel Miranda

Originally posted on heelskicksscalpel.com

Like much of America, my family is currently obsessed with everything Hamilton on Broadway. We jammed to the sound track all summer. The season culminated with a late August trip to the show which I described on social media as the best day of my life. Seeing the show, the actors, the set, and choreography, come to life with lyrics we had all memorized was such an amazing experience.


I cried.

Part of that was pinching myself that it was actually happening (NB: Tickets now that the original cast is gone are not that hard to find on resale sites but still cost quite a bit above face value.) And the other parts were one particular segment that just cut into my soul when I saw the character of Aaron Burr singing it.

I sobbed.

Let me provide you context. Burr is an orphan who is in love with a married woman. He has decided that with everything he has gone through, all of the losses he has suffered, he is willing “to wait” for the woman he loves. As someone who was taught to hate Burr by her high school history teacher who was a Hamilton scholar, this humanization of Aaron Burr was a bit off-putting at first. But the reason I simply could not stop the tears while experiencing the song with all of my senses as the show was not about the forbidden love story behind it, rather is was the commentary on death.

“Death doesn’t discriminate

between the sinners

and the saints,

it takes and it takes and it takes

and we keep living anyway.

We rise and we fall

and we break

and we make our mistakes.”

These words resonate so strongly with my trauma surgeon’s soul. We provide care indiscriminately, irrespective of race, socio-economic status, mechanism of injury, insurance, etc. And we lose people. Sometimes they arrive lifeless; sometimes our efforts fail. When that happens we are broken. We wonder if we could have done anything differently; did we make a mistake? But we have to go on “living” because there are more patients waiting. Some of them are sinners while others are saints and it doesn’t matter we treat them all the same. Then we wait for the next patient to arrive.

The title of the song is Wait for It.

The Hamilton sound track is still more or less played in a continuous loop in my home, in our cars, on my runs. And every time I hear this song I cry. I can’t help it. It simultaneously breaks my heart for all my patients who have died and provides me reason to keep coming back to this very emotionally challenging and physically exhausting profession. I know it was not Lin Manuel Miranda intent to write this segment of music (the lyrics and the accompaniment which is haunting) for the trauma surgeon in me but that has been it’s effect and I am so grateful.

And as for the burnout that is particularly rampant in my specialty, despite the tears from this particular song, the overall experience of seeing the show on Broadway was truly one of the happiest days of my life – a perfect way to spend a weekend off and return to work refreshed and ready to wait for it

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.

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.
**Men be like the ladies and cull your closets seasonally; donate to your local trauma center.
***If any Kohl’s or Target folks are reading this consider donating items or gift cards to your local trauma center.

Defining “Mommy Friendly”

Originally published at heelskicksscalpel.com

I had a familiar conversation the other day with yet another female medical student.

“I really loved surgery!” she said, “but I was concerned about the lifestyle so I decided on _______________.”

Lifestyle, it turns out, almost always seems to be code for having a family (maybe it’s just the kind of students who are apt to seek me out as I have yet to encounter someone who is concerned that a surgical career will hamper their aspirations to compete in triathlons or become national fencing champions or write books for the general masses–I personally know surgeons who manage to work full time and do all of these).

The other day, I came across yet anther discussion board on what advice to give to women in search of “mommy friendly” medical specialties. There were lots and lots of suggestions, some were full time jobs with predictable hours and others were part-time jobs but not one of the suggestions was a surgical subspecialty.

Not. A. Single. One.

Sigh. This makes me sad for my chosen specialty and for all the promising young women who will not go on to realize their potential as amazing surgeons.

I would be lying if I said that surgery is lifestyle friendly. In fact, anyone who has followed this blog for more than a millisecond knows that many of our daily woes outside of work arise from the demanding hours and high stress of our career choice. But the question is: What does mommy friendly even mean? This is not the same as the “mother’s hours” often noted as selling points in help wanted ads. There may be ways to go really part-time or certain very specific specialties that enable a woman to only have to be at work when her kids are at school I suppose. But I have to believe that mommy friendly is about more than just the hours.

I know, I know. You are just waiting for me to launch into the cliche of it’s quality, not quantity. But I won’t.

Because the truth is I wrote all the words above nearly 500 days ago. It turns out I never finished because I don’t know what mommy friendly means when it’s used as an adjective for a career.

Since I first wrote the beginning of this blog post, I have spent well over a year of my life as a surgeon and a mother. I even wrote an open letter to young women with the same opening line evidently having forgotten about this draft. That letter, now read more than 15 thousand times, doesn’t define mommy friendly either.

Paid maternity leave. Private pumping rooms. Childcare. A promotion clock that doesn’t penalize for maternity leaves.

To be sure any work place can provide these but do the amenities in and of themselves mean the associated profession is mommy friendly? Not if the backhanded comments or outright displays of resent persist. Often, the culture of the profession is at odds with these progressive work place policies. And these replies on what medical career to choose clearly indicate that the culture of medicine has not caught up to modern times.

Luckily, however, not every one is reading the same message board. And so this week across the country a whole new crop of women begin training as surgeons. They are less a minority and more just reflective of the demographic of modern surgery. Hopefully, they will all become surgeons (there is still some attrition in our programs nationally) and some will become mothers. And my hope is that, together with the men they are training with, they will foster a culture in which is it no longer necessary to ask if surgery is a mommy friendly.