Between training and practicing, I have been a surgeon for almost 17 years. During that time I've seen a range of human drama, ranging from the patently absurd to the painfully heartbreaking. I am privileged to have shared some of my patient's and their families most intimate and challenging experiences that they have ever had. Some have made me laugh hysterically, some have made me angry and disillusioned, and some have made me cry like a baby. So read on and if anything moves you to comment, please do; I'd love to read your feedback.

Death is an integral part of trauma surgery. It is inevitable that a surgeon who deals with traumatic injury will be witness to countless episodes of mortality. For those that are able to cope and continue in the field, seeing patients die becomes second nature and after a short time the emotional component of seeing a fellow human being expire begins to fade. For the most part, trauma patients are adults. In the inner city, many trauma fatalities are young men involved in violent criminal activity. Often, it's easy to rationalize and almost de-emphasize the deaths of these young men as a coping mechanism. By keeping a "live by the sword, die by the sword" sense of justice about these violent deaths, many surgeons are able to cope and move from one trauma to the next with very little personal emotional injury.
For me, there are two scenarios that are still very difficult for me to cope with: The family session that takes place after a patient dies and the death of a child, especially by violent means. One of the most traumatic and vivid of these episodes happened in December of 1996 and will remain forever etched into my memory. I was a 5th year resident, team leader of my trauma team. We took call for 24 hours every 3rd day and our hospital, in the middle of South Central L.A.-between Compton and Watts, had a constant influx of patients injured by firearms. This particular day was a weekday, a Thursday. During the day, trauma is usually not very busy and gunshots don't start typically coming in until nightfall. The sun was out and the air was cool. The overhead operator announced: "code yellow-code yellow", indicating that a trauma patient was inbound to the ER. I rushed with my team to the ER so that we could get there and set up to take care of the patient. The routine was that the junior residents and students got IV fluids, IV catheters, blood tubes and other implements ready so they could go to work to help resuscitating the patient when they arrived. My main objective as team leader on arrival to the ER was to find out what kind of patient was on the way, the type of injury and the severity of injury, so that I could start to formulate a plan for organizing my team so that we could best take care of the victim. In severely injured patients, the first hour is crucial and disorganization and hesitation can mean the difference between a good outcome or a bad outcome in a patient on the edge of life and death. We arrived and my team started to busy themselves readying lines and blood tubes and catheters and other tools that they might need. I made a bee-line to the ER doctor who was coming in the room with a paper in his hand; he had just gotten off of the radio with the transporting paramedics and he had the precious pre-hospital information about the victim I needed to start planning. During the day, usually the report is a matter of fact: so and so age patient auto versus pedestrian complaining of leg pain, stable, etc. This time, the ER doctor walked in, paper in hand, and looked a little unsettled, a look that instantly made me feel uneasy. "6 year old male, GSW to the midepigastrium with no exit, pale, diaphoretic, blood pressure 70 palpated, ETA 5 minutes" Translated: little boy shot in the upper belly, in shock.... Now there was a palpable apprehension among the people in the trauma room. Larger IV sets were replaced with tiny pediatric sets and everyone was quiet, acutely aware that we were about to receive a potentially gravely injured little boy. I was nervous...the usual "live by the sword" safety blanket was about to be yanked from under my feet. I was going to have this little boy's life in my hands.

Oscar arrived after what seemed like a very long time. He was in a tall gurney, wrapped in a white sheet, small oxygen mask on his face, flanked by several firefighters and paramedics. Most children that come into the trauma room have been hit by cars, been in car accidents or in some other type of accident. Often, the little ones come in with the paramedics screaming and crying; Oscar was wide awake but was eerily quiet. I looked at his face and he didn't seem to have any fear in his eyes; he was also very pale, indicating that he was probably in severe shock, bleeding internally. Immediately, we began to work on Oscar, who was quiet, never cried, never complained of pain, awake the whole time, watching us intently. I forced myself to focus on him as a patient, not as someone's little boy who was critically injured by a bullet. I forced myself not to think of my own son who was 2 at the time and forced myself not to wonder what it would be like to see my son laying in Oscar's place. I had to remain objective to determine what we needed to do for this little boy. We started IV fluids, connected him to oxygen, hooked up cardiac leads and got vital signs. We undressed him and looked at his little body from head to toe. His body was perfect for a 6 year old except for the angry round red hole just under his wishbone in the top of his abdomen. There were no other holes, indicating that the bullet stayed inside him. We got xrays of his chest and belly....the chest xray looked hazy on the right, indicating that he had blood in his chest. The belly xray showed a stark white elliptical object sitting directly in the middle of the upper abdomen, a bullet; I estimated that it was a 9mm. I had an inkling of a sinking feeling in the pit of my stomach; the bullet was in an area I've referred to as the zone of death....the confluence of many large blood vessels and many important structures are right in the middle of the upper abdomen. It took us about 10 minutes from the time he arrived to assess him, get lines in, draw blood, get xrays, and place a tube in his right chest. Now we were ready to take him to the operating room, to further violate his little belly with our surgical steel to fix the damage that the bullet had caused. As we were rolling him out of the trauma room to the elevator that would whisk him away to the OR, I walked next to the gurney near his head as several of my team members pushed it. Oscar was still awake, alert and had yet to cry or make any overt noise. Instinctually, I looked at his face, his big brown eyes looking at me inquisitively and I reached down and stroked the top of his head and said "Oscar, are you ok?". At the time, I didn't know it, but he would then speak his last words to me; he looked up at me, without much fear, without much expression, and said "It hurts....".

In the OR the anesthesiologist hurriedly put him to sleep and we scrubbed him with iodine and I took a knife and made a long slit in his abdomen from just near the entrance wound all the way down to his pubic bone. Once I opened his belly, I found that the organs were almost completely obscured by blood. In an adult with a belly full of blood, at this point I usually reach as the scrub tech is handing me wads of surgical sponges, 10, 20, 30, sometimes 40 of them, to tightly pack the abdomen, in order to slow the bleeding and to clear the blood so that I can systematically explore to find the source. Oscar's body was so tiny that it took maybe 4 sponges to pack his abdomen. My heart was racing; instinctively I knew Oscar was in serious trouble....more than half of his blood had leaked into his abdomen. This was a sign that he had a big hole in a big blood vessel. I found the hole; he had a ragged tear in the portal vein, one of the largest veins in the body; the vein carries about 50 to 60% of all the blood that goes to the liver, the largest organ in the abdomen. My training kicked in and I focused on the vein, almost forgetting that it was a part of this stoic little boy who hadn't cried once. I got clamps on two ends, isolating the hole; fortunately (I thought at the time) it was sort of a tangential wound, it hadn't gone all the way through. Often bullets shred blood vessels so that the ends are hard to find. The vein was essentially intact except for this jagged hole which had been pouring his life's blood out of its surface. I was quickly able to sew the hole closed with fine suture. I removed the clamps and it wasn't bleeding anymore. I was about to breathe a sigh of relief, thinking almost jokingly to myself that I had performed yet another surgical miracle. I was about to explore the rest of the abdomen to see if the bullet had caused any other injury when the anesthesiologist told me that his vital signs were waning quickly. I looked up at the monitor, and my momentary sense of triumph melted away into horror...Oscar barely had a blood pressure and his heart was slowing to a crawl, a very ominous sign. I looked in his little belly and there was no more bleeding so my mind began to race, maybe the bullet had caused more of an injury in his chest than I thought. I had the nurse look at the chest tube collection and she said there was now suddenly a liter of blood there (this was close to half of his normal blood volume). There had only been a few milliters in there when we started. With alacrity I grabbed a regular heavy scissor and cut through the open upper part of his incision straight through his breast bone, flaying his chest wide open...he was so young and his bones so flexible that I cut through his sternum like paper....in adults it requires a saw. His heart, and aorta were exposed and I could see all of the big blood vessels that went to his lungs clearly....there was no bleeding.. My mind raced, wondering why, after this seemingly great save, was this young boy dying in front of my eyes. We began to pour more blood into his tiny veins and I watched his tiny heart go from a rhythmic beat to an unorganized quiver. I engulfed his heart with my hand and began to gently but forcefully massage it, trying desperately to push blood through it and in combination with the powerful drugs that the anesthesiologist was giving, make it start again, make Oscar come back to life. I tried for almost 40 minutes to no avail, until everyone in the room agreed, reluctantly, that we had done all we could. Oscar died at about 2:45, his tiny body split open from his pubic bone to the top of his chest, his organs profanely exposed to the harsh lights of the OR until I began to close his gaping incisions. Often, after we lose an adult patient on the table, everyone breaks scrub, starts chattering, talking about getting food or coffee or wondering how the rest of the night will be. With Oscar laying on the OR table, tiny, still and pale, the room was deafeningly quiet. Everyone seemed muted, perhaps stunned. There was no chatter, no talk of food or coffee.

The late afternoon sun was coming through the window when I emerged from the operating room; my scrubs were soaked with my own sweat, and also with some of Oscar's blood. I was still reeling from the impact of losing him on the table when I slowly began to realize that from the time he came until now, I hadn't seen any of his family...no mother, no father. I also realized that surely they were there now, waiting for news of how Oscar's surgery was going. The nurses at the front desk informed me that his mother was contacted at work and she was on her way into the hospital. I had a queasy feeling; I was going to have to sit down with this young mother and try to muster a professional but compassionate demeanor to tell her that her little boy just died on my operating table.

The mother arrived and it seemed that she could sense that we did not have good news for her. She was wringing her hands vigorously and tears were beginning to moisten her eyes as we led her into a quiet room near the recovery room, away from the noise of the rest of the hospital, a place we thought that would afford her as much privacy as possible as she was about to hear the worst news of her life. With me were two of my team members, mid level residents that helped me take care of Oscar. All three of us were about the same age; all three of us had little sons. I was already trembling, knowing that imparting this news was going to be difficult and painful, not only for her but for me as well. As we sat across her in the room that was dimly lit with the afternoon sun, I quietly explained what had happened to Oscar and told her with an audibly trembling voice that, while we had tried everything we could, Oscar passed away. At the end of the sentence, she responded with a crescendo cry which pierced me to the depthnof my soul; I bit my lip, trying to hold back tears as the urge to cry gripped me. She laid her head on the table and began to sob heavily and repeated, no, no, no, no. She looked at us, tears streaming from her eyes and said she wanted to see him. We took her to the recovery room, to the far end which had been sectioned off with rolling curtains to let her view Oscar in private. The three of us walked with her towards the gurney where Oscar lay, in a partially open body bag. She looked down on Oscar, tears streaming down her face, staining her work uniform and she reached down and cradled him, pulling him close to her chest; his arms fell limply away towards his sides. She rocked him back and forth and plaintively wailed "Oscar, please wake up, please wake up, it's mommy, please wake up". Seeing this, I couldn't hold back my tears any longer. My body was wracked with sobs and tears flowed freely down my cheeks. I looked at my two team members; they were crying as well. Normally, when I go through this ritual, informing family members of a death and standing with them while they view the body, I feel sad, but I can usually clamp my emotion down to a manageable level. Watching Oscar's mother try to wake her baby boy inside of the body bag, endotracheal tube still jutting from his mouth, cold, pale, already becoming stiff, I lost that control.

We walked out of the room and I felt drained and tired, as if I had run a marathon and lost a family member simultaneously. We still had 12 more hours of trauma call and I knew I would continue to dwell on Oscar for the rest of the night and that I would respond to other trauma victims with a mixture of sadness and even anger at the senselessness of their injuries. I looked out the window at the setting sun and I thought of Oscar's last words and I thought to myself, yes Oscar, it does hurt....

Welcome to the blog...

Welcome to my new blog....

In this blog I will expose the essence of my chosen field, general surgery, through vignettes and thoughts that I have culled and will cull from work. Sometimes names will be changed to protect the innocent (and often the guilty!) and to remain HIPAA compliant.