It can be difficult to fully appreciate the events that transpire on a busy transplant surgery service, and as a fledgling third-year student on my first rotation, I’d often find myself in stimulus overload — like a five-year-old who stops to look at every flower on a walk with their parents.
Morning rounds in the surgical ICU were typical, some sick patients getting sicker, others getting better. Transplant patients in particular often presented to the hospital with many complications in tow. Some of these patients were in the SICU before I even started the rotation, and remained there after I left eight weeks later. While situations like these were unfortunate, they provided me with the opportunities to learn both about acute management and chronic care of these unique cases. I was following a patient who had been admitted two months ago for a multi-visceral (kidneys, liver, stomach, small intestine and pancreas) transplant due to metastatic cancer.
After rounding on the patient with the transplant attendings, the next step was an organ procurement, which took place at a nearby hospital. Upon arrival at the site, I quickly learned that a middle-aged male had committed suicide and happened to be an organ donor. After walking briskly to the operating room, we were ushered into the back room as the family still needed their last moments with the deceased, and it is standard for the relatives to not see the surgeons who will perform the organ procurement.
After the family parted ways, we went in. I was only two weeks into surgery, my first rotation as a new third-year student, and so my welcoming party to the world of medicine was splayed-opened abdomens, organ transplants and now the face of a person who died by strangulation. I had never seen a strangulated face before; the lines of his face were distinct, a harrowing image that I will never forget.
I had barely begun to digest the emotional gravity of the scene when my mind was directed back toward the hectic race that is harvesting the deceased’s organs after turning off life support. A dead man on life support sounds illogical, but as long as the deceased’s heart and lungs work, organs can be perfused with oxygenated blood and kept alive, even if the brain is not. But time is key once that lifeline is cut off because the longer an organ is without blood flow, the less viable it is. And so, the cessation of the life support machine was akin to firing a starting pistol to begin a race, and once that pistol sounded, each surgeon rushed to their respective organ in a seemingly chaotic yet tightly controlled and coordinated dance.
With the procurement complete, the liver and kidneys in our possession were like fish out of water gasping for air, as the seconds ticked away on their viability. We raced back to our hospital via ambulance, siren blazing, weaving in and out of traffic as cars in both lanes parted ways to leave us a clear path.
As I sat in the ambulance amid the sound and the fury, I wondered: is there a universal balance in life? Is one positive somewhere in the world balanced by a negative? These kinds of thoughts didn’t last long, however, as we arrived at our hospital and I’m quickly pulled back into reality: “suction … dab … retractor … ” A medical student’s job in the operating room is minimal; hold retractors, cut sutures, hold the liver before placement into the patient. Yet the simultaneous normalcy yet absurdity of holding a dead man’s liver and transferring ownership to an alive man did not escape me, as I was paradoxically both shocked yet utterly unaffected. I realized that sometimes the gravity of a situation is diminished by the patterns we fall into.
After the procedure, the patient was moved to their post-op bed, and I was off to my next task, one final check-up on a liver transplant patient ready to be discharged. I assisted with her surgery, and had followed her recovery for the past week, and now she was ready to go home. In her was yet another tragedy in one balanced by the benefit of another, another instance of perhaps some kind of equilibrium at play.
Shortly after the patient left, there was a code blue — a patient emergency — the monotonous voice on the loudspeaker reading off each number to the patient’s room. My adrenaline increased with each successive number read. The final number announced left no doubt; it was our multi-visceral transplant patient.
This patient indeed had some problems earlier that day, including an instance of low blood pressure and some difficulty breathing. But, like many SICU patients, she was expected to have her ups and downs, and so I only thought of her new concerns as a temporary step backward within her lengthy process of recovery. As I made my way to the SICU, my stomach dropped when I passed by a family sobbing in the waiting room. I was wrong. The patient was pronounced dead just as I arrived.
The SICU is normally busy with staff buzzing about to their segmented activities, activities that bring patients back from impending death. But in this case, our patient took that final step from the boundary, outside of our grasp. But hospitals never stop, and so the normally busy and hectic energy of the SICU was there, but toned down to a muffled ambiance of background static, in a way putting a spotlight on the profound events occurring within this patient’s room. And as the numerous staff slowly faded out of the room, I couldn’t help but feel a spotlight on my own emotions that intensified as the view cleared, leaving the patient, in a state of disarray after an unsuccessful resuscitation. I had trouble connecting who I saw laying there to who I previously knew, and I felt a crushing sadness that I didn’t expect to feel, which left me confused. I was confused because I was tearing up over someone that I did not know that well. I expected to be sad, but not like this.
I checked up on her every day, and it became routine to the point where her condition became a standard part of my learning environment. But like how I won’t realize the gradual transition from student to doctor, I also cannot palpably recognize building rapport with a patient; it just happens through repetition and positive intention.
And so as I stood there, now with the attending as he explained the situation to the family, I struggled to think of something to say. The random backdrop of beeps, clicks and whirrs as the medical machines worked diligently, intertwined with the non-verbal to and fro of footsteps, provided an unsettling undertone, as a reminder of context and how medical care doesn’t just cease when something goes wrong.
Intravenous lines still pumped, vital machines still measured, and still I could not think of some inspiring wisdom to impart on the family, like they always somehow manage to in the television shows. I just hung my head low, defeated, and felt like I should head home. But it wasn’t even 3 p.m., and I realized that even after this event, the hospital would still be operating. The only thing that I could do in that moment was continue pace. Yes, I should grieve, yes, I should reflect and learn, but not now. My future patients would benefit from this introspection, but not the present ones.
And as sad as it was to see her go, I felt privileged to be sad, because I made an effort to build a relationship with someone, and then lost that which I considered to be valuable. And as long as I can feel that strain on my heart, I know I haven’t lost one of the main reasons that has driven me to pursue this line of work.
This day was an entire life of emotions condensed into less than 12 hours, and while I’m scared to go through that emotional roller-coaster again, I know that it is inevitable. My initial impulse to this fear is avoidance, and though I know that my training will help me better manage that burden, I often wonder: but at what cost? The same feelings that motivated me to write this are the same ones that may emotionally break me. At this point though, I have to assume that my fears and dilemmas are part of the training, and that over time I will learn to manage all of it. I certainly don’t want to turn back now.