Monday, September 24, 2007


Trying to save someone's life while simultaneously trying to respect their wishes often isn't as clear cut as it should be. The easiest choices are made when a patient isn't capable of making them on their own, and you're the one that has to make decisions for them. It gets real confusing when they appear to be fully with it and decline your help.

Sometimes, you ignore them and do what you think needs to be done. Knowing when it's appropriate to do something like that... well, that's a tough decision to make. A very tough decision.

A middle aged man was brought into the trauma bay after a botched suicide attempt. He decided to use a shotgun to kill himself. After finishing his suicide note, as he was making his way to the bedroom he dropped the gun, which subsequently discharged a load into his abdomen.

His daughter, who was in the house, found him and called 911.

Although he was initially knocked unconscious, he was fully awake by the time EMS brought him to the hospital. The patient was, amazingly, still alert, fully coherent, and screaming at us to leave him alone and let him die, threatening us with everything from bodily harm to a lawsuit if we did otherwise. His daughter was in a heap in the corner of the room having an emotional meltdown. His wife circled the ER yelling at us to save her husband while simultaneously verbally abusing her dying husband. My junior resident was holding pressure on that bleeding abdominal wound with a towel, as two nurses were trying to tie down the man's arms, with one holding his legs down. The ER doc was struggling to get a sedative in the patient while getting spat on by the patient.

I had rushed to the ER to be greeted by this scene, and I stood there for a minute, wishing I could be anywhere else.

The ER doc asked me what I wanted to do. Morally and ethically, we're bound to the wishes of a patient in a normal state of mind. The confusing factor in this case was that this patient, despite his apparent trauma, appeared fully alert and mentally capable of making decisions for himself.

Although I made a decision and gave out an order to the nurses in less time it took me to take a couple of breaths, I agonized over that decision in my head for what felt like an eternity.

So against his wishes I sedated him, with him screaming at me that he will certainly kill me. We then quickly took him to the operating room. Removed his destroyed spleen and kidney. Removed the disintegrated parts of his colon and small intestine. Transfused multiple units of blood to replace what's already been lost and what I was continuously losing as we operated. Created a colostomy. And several hours later, wheeled him into the ICU.

He spent several weeks in the ICU chemically sedated and paralyzed, slowly recovering from his injuries. He had several set backs, which required two more operations. And during that time, I had rotated off of the service and handed over the care of this patient to another resident.

I had kept up with his progress with occasional updates from the other residents. Then I heard he was being moved out of the ICU and onto the surgical ward.

I decided it was time to go see him. The last time I saw him awake was in the ER. And I recalled the exact last words he said to me with inhuman rage as I sedated him, "I'm going to fucking kill you if you don't let me die."

I looked into his room and saw him in bed watching TV with a blank stare. A corner of his room was full of get-well cards and balloons. He was holding the hand of his wife, who had fallen asleep in the chair by his bed. He slowly turned to look at me as I entered the room.

Patient: You're the asshole that I saw in the ER.

[sigh] I knew this was going to be tough. He looked a lot thinner. I looked at this abdomen, a mess of an open wound covered in bandages from the recent skin graft. It's not easy repairing a shotgun blast from such a close range. The last month of recovery hadn't been easy for him. And he still had a long road ahead of him before he would be fully recovered from this. His eyes caught mine looking at his colostomy. I broke off the gaze.

Me: Uh... yeah. That was me.

We both looked at each other in silence for a very long time. A thousand thoughts fluttered through my head. All of a sudden I became aware of my hands, hanging loosely by my side. Not sure what to do with my hands, I eventually stuffed them in the pockets of my white coat after fidgeting with them for a bit.

Me: Sorry. [What do you say in this situation?]


Patient: [softly] Thank you.

I didn't ask what he meant, and he didn't elaborate either. He extended out his hand, and I shook it. Whether he was accepting my apology for disrespecting his wishes, or whether he was thankful that I did and saved his life, I will never know.

But we both knew that enough words had been said between us. I wished him well and walked out of his room, as he slowly turned his gaze back to the TV screen.

Nobody said this job would be easy.