He died an hour after we left the hospital; as the night ICU resident said, just long enough for him to be the one in charge, and the one who has to answer for everything in M&M. Two of the other medical students told me he kept bleeding all afternoon and evening, blood pouring out of his abdomen, chest, and scalp lac, as fast as it could be pumped back in through the Level 1 infuser, and from a cell-saver pump which was scavenging RBCs from the chest and abdomen drains. His family was still hanging on, and would not give consent for him to be DNR, so when his pressure dropped for the last time, they coded him for 20 minutes before calling it. If there was one more thing to feel bad about, that would be it; I wish we had had time to persuade his family not to put him through that last piece.

After I left the hospital yesterday, I thought all the way home, and in my sleep too, about this man – if there wasn’t anything we could have done that would have changed the outcome, or at least held death off for another day or two. I think there were two big things we missed: 1) the heavy abdominal bleeding, and 2) his hypothermia, which eventually caused an irreversible coagulopathy. The first one, I think the attending maybe should have caught. There were at least three branch points, where the team failed to notice or act on signs: when the fast ultrasound was done, right in the trauma bay, five minutes after he got there, it was read as equivocal. Maybe that should have led to a DPL right then, and we would have gone to the OR immediately. Maybe he wouldn’t have bled as much. And then, all the while we were getting ready to go to CT, his pressure kept jumping around wildly. Later on, it was noticed that every time he received a heavy fluid bolus, or a transfusion, his perfusion would improve for about five minutes – duh. That, I can understand us missing; with so many different people hanging fluids and measuring vitals, it’s not unreasonable to have missed that correlation. But then, in CT, when free fluid was found in the abdomen, I don’t know why the attending and the chief were so nonchalant about it. I mean, isn’t any free fluid in a trauma patient an indication for surgical exploration, or at least immediate DPL? Why did they waste time, going to the ICU, putting him in a bed there, putting two chest tubes, before doing the DPL?

That part, I only wondered about at the time. But the second thing, the hypothermia, I knew what was happening, and I should have done something. See, the first day of the rotation, Dr. French took us around the OR, and explained every single bit of the equipment. I was kind of bored; “oh, I know this already, I’ve been around ORs for two months, I know the ropes.” But I didn’t know, what he explained about temperature control: that when a patient’s temperature drops below some number (95 F, I think), they become wildly coagulopathic, and start bleeding out of every pore. Trauma patients are especially susceptible to this, because they’re already in shock, and they’ve got even less covering on than a patient who comes in electively. So; when we were in the trauma bay; and when we were in CT, I kept touching his feet (being too dumb to be allowed near his head), and thinking, “Boy, he’s cold, I wonder if we should do something about that.” Then in the OR, things moved so fast, no one put any of those warm-air blankets on him. And as they were digging in his abdomen, his intestines out all over the field, that’s one more way to cool off. I remember touching some loops of bowel (again, not being anywhere near the real action), and thinking, “This stuff is cold, as cold as that dead man I saw the other day, this is going to be a problem.” (The only helpful thing that was happening was the Level 1 infuser, which in addition to pushing things faster than fast, also heats them to above body temperature first.) So I knew what was happening, when maybe no one else had time to think about it. I thought, maybe there was nothing I could do; but I could have. In the trauma bay, and CT, I knew where the warm blankets were kept; I should have split off from the rest of the team, with or without permission or instructions, and gotten tons of blankets on him. In the OR, I should have gotten up the nerve to ask the anesthesiologist (who was busy trying to keep his pressure above 80) if we shouldn’t put an air blanket on him.

Bother, bother, bother. I knew, and I didn’t do anything.

So I was kicking myself all night, and this morning; and I didn’t dare ask that chief or attending, whether there were any things we had missed. Then, this afternoon, as I was working with the ICU resident who had him in the afternoon, and we were talking about his coagulopathy and hypothermia, I asked what he thought. He said, no, the surgery didn’t do anything major to stop his bleeding, it wouldn’t have helped to have gotten in sooner; and he would have been in shock and cold even before he came in, so blankets wouldn’t have made enough difference to change the outcome. So that’s some better.

So now I have this discussion with myself: In spite of it maybe not making a difference, I don’t trust that attending’s choices. I think he was indecisive, and missed things; it’s one thing for me, and the residents, and even the chief, to miss things; but he should know better than us. And he was changing his mind, and delaying people from taking action on the chief’s decisions. And then there’s that other attending, the woman, who swore my patient had pancreatitis, and he didn’t. And she swore this other lady had cholecystitis, and she didn’t, she had ulcers. She forced the team to admit and treat them with those diagnoses, against the initial recommendations of the intern and resident. But, there are just as many times when the residents are wrong, and the attendings right. So how am I going to manage, when I’m a resident, and I strongly disagree with the attending? If I could be certain I were right, I would be happy to get into a nasty argument, to try to do what’s best for the patient; but I can’t be certain. So I suppose one must do as all the residents do, take whatever the attendings say, and try to explain to the patient and family when there’s a mistake or delay. I hate being the one to talk to the patient, when someone else is responsible for their pain continuing.

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