I usually approach each post with the purpose of outlining an idea, lesson, observation or reflection. This particular post is merely for the purpose of remembering an experience that was profound in its own right.

Sweat began to seep through my scrubs as my body rejected the prison of lead that we are encouraged to wear for protection in the trauma bay. I had just removed my disposable gown when we got word that a second trauma was coming in: Level A, male in his 40’s, found down at the side of the highway next to a bicycle, unhelmeted, waxing and waning level of consciousness, 5 minutes out. I swiftly put on a fresh gown and assumed my position at the foot of the bed, trauma shears in hand. Our patient rolled in, offering only occasional answers to our questions; he told us his head hurt. It was decided that he should be intubated and quickly rolled over to CT scan. I stood in the room adjacent to the scanner with the trauma attending, it was the third level A trauma of the night and he had yet to be impressed. “Oh. Damn. Look at this,” our attending commented as he viewed the frontoparietal skull fracture that extended the length of the patient’s cranium. This particularly nasty head injury had, most importantly, resulted in bilateral subdural hematomas and bilateral subarachnoid hemorrhages, in addition to the skull fracture. For those readers less familiar with this terminology, there was a lot of blood, in a lot of places, compressing this patient’s brain. Bad news. Our patient was admitted to the SICU were I would have the opportunity to continue assisting in his care. It was 3 weeks into my SICU rotation, and I was enjoying the continuity of seeing patients in the trauma bay and then following them in the unit. What I wasn’t ready for was the degree to which I would see this case through.

From an educational perspective this case was a tremendous and challenging learning experience. The principles behind managing an individual with a traumatic brain injury can be summarized as follows: the cranium is a fixed, closed space which allows little room for bleeding and/or swelling. Primarily, the goal is to do all we can both medically and surgically to prevent pressures in the skull from getting too high; if this occurs, the brain can herniate through the base of the skull, resulting in death. We also aim to make sure the brain has adequate blood supply, despite the compressive forces. The concept is to use medical interventions to achieve specific parameters that function to minimize the metabolic activity of the brain…essentially the brain needs a tremendous amount of rest. Now, back to our patient.

The night that this patient arrived I happened to be on a 24 hour shift, and I observed him as he struggled through his first night. We were doing all that we were supposed to. He was in a quiet, dark room with the head of the bed elevated. His neurological status was being evaluated every hour. He was heavily sedated, his pain was controlled, he was given hyperosmolar therapy, kept normothermic, and had the appropriate blood pressures and ventilator settings. Despite this, his neurologic exam began to decline and another CT scan indicated that the bleeding had worsened. The neurosurgery team placed a device to monitor his intracranial pressures and then another device that could both monitor ICP and remove the excess fluid in his head. At this point the chances of a meaningful recovery after this degree of insult to the brain was minimal. In parallel to challenging medical aspects of this case, we were having a difficult time tracking down any family members. Eventually, one of our phenomenal caseworkers was able to make contact with the family; once as the bedside, their reaction to the situation was complicated. The family explained that this patient was an intellect, an accomplished historian on track to becoming a professor at a very prestigious university. It was revealed that sometime in his late 20’s he was diagnosed with schizophrenia. Instead of seeking treatment, he self-medicated with alcohol for years, and would ride his bicycle while intoxicated. Essentially, they saw this accident as…‘a long time coming.’ They also explained that the he greatly prided himself on his intellect; this was the aspect of himself around which he assigned the most value. His family explained that he would not want to live when the most important part of himself had suffered such tremendous injury. After some careful consideration, the family met with Gift of Life and consented for organ donation.

“This is a unique opportunity, Amy. You should definitely go.”  Me? Go?? To the organ procurement??? I was nervous. But I nodded vigorously and conveyed my enthusiasm to the team. I walked back into the patient’s room, physically navigating the forest of IV poles, while emotionally navigating this delicate moment with the patient’s family. I explained that I would be going down to the operating room with them. They were very kind. We waited for the transplant surgeon to arrive from another hospital while struggling to properly oxygenate our patient. Like a brass instrument with faulty pipes, I can still hear the sounds produced with every squeeze of the bag as we forced air into lungs drowning in fluid. We arrived in the operating room, which was a sea of unfamiliar faces. I introduced myself to the transplant surgeon who explained the events that were to follow: “First he’ll be sterilely prepped as we would for any surgery. All the instruments will be set up, he’ll be hooked up to the monitor, etc. Then, we will place a large drape over the body and another drape over the instruments. His head, of course, will be exposed. We will then invite the family in to stay their goodbyes. He will be extubated and disconnected from the ventilator. I expect death to come quickly for this man, but typically patients must die within an hour in order for organs to be procured. Once there are no signs of life, time of death will be called, the family will exit, the drapes will be removed, and we will get to work. For all of that you must stay out here with me. You either can be on the side where you withdraw care or on the organ procurement side, but not both. We don’t want there to be any conflict of interest. Any questions?” Conflict of interest? I thought to myself, realizing the surgeon probably wasn’t aware that I had spent the last week with this patient. I think we are beyond that now. I didn’t say anything.

Time of death was called within ten minutes. The surgeon and I entered the room and the first (and only) incision was made extending from the sternum to the suprapubic region. After sawing through the sternum, he cut through the superior vena cava and the descending aorta in order to place a catheter that would drain the blood. There was so much blood. Freezing cold saline was running through the patient’s veins as we battled against time for preservation. In these moments the experience became scientific and emotionless. It was the best anatomy lesson I had ever received. I was no longer the medical student squished against the foot of the bed during surgery, I was clamping the aorta, dissecting lymph nodes, and holding the heavy, fluid engorged lungs that only an hour prior we were trying so tirelessly to oxygenate. With a sense of abandonment born from the understanding that he was already deceased, I soaked up every opportunity for experience and knowledge. The kidneys were carefully removed by the surgeon and placed in ice water. At this point you may be thinking that the title of this piece is rather…insensitive or inhuman, which is fair. But with his face covered, and organs carefully resting in multiple places around the operating room, there was a powerful disconnect between body and human. The surgeon gave me the opportunity to close the body, I took my time to at least make the incision appear decent. We removed the sterile drapes and I viewed this patient as a whole; lying there, naked, with the pale yellow hue of an exsanguinated individual. I have seen people die, but this was different. This is what death actually looked like, and this I will never forget. 

I ripped off my gown, removed my face mask, and thanked the surgeon and Gift of Life team. As I made my way back to the ICU I took a moment to reflect and acknowledge the privileged position I am in; the position that allows me to care for patients and their families as they make difficult and selfless decisions to both preserve the integrity of their love ones, and make efforts to benefits others in the process. I allowed myself to reflect on and acknowledge the incredible trauma and ICU teams that work tirelessly everyday to save lives, as well as those who dedicate themselves to the exceptionally important job of helping those with mental illness.

Once I arrived in the ICU I printed out a new patient list and caught up with the team. It was only 8:00 pm and I was on my last 24 hour shift of my ICU rotation. I regrouped, ready to help those sick patients on our service. As I chugged a bottle of iced tea to replenish the fluid lost while sweating through each stitch in the OR, the trauma pager went off. Level A trauma. ETA 5 minutes. And off we went.  

**Some of the information has been changed to protect this patient’s privacy.

All rights reserved ©