As
I conclude the first half of my final year of general surgery residency, I
begin to reflect on my experiences over the preceding half-decade of my life
and even the training before that. While
I currently rotate on the Trauma service for the last time, I am reminded of
why I am proud to have chosen to train in surgery. Trauma is an important part of what we do,
and caring for the injured patient requires more than meets the eye. I learned this early on.
I
can distinctly remember my first trauma experience, the devastating injuries,
and the heroic measures it requires to try to save a life. While rotating on my surgery clerkship as a
third year medical student, our team was called to a trauma activation. The
patient was a frail octogenarian who was severely injured in a high-speed motor
vehicle collision. She was quickly diagnosed
with various injuries in trauma bay: broken ribs, a collapsed lung, a broken
femur, and internal bleeding. She was
rushed immediately to the operating room and - as the student who responded to
the trauma- I was allowed to scrub in.
After immediately entering the abdomen, the attending surgeon and chief
resident worked furiously to identify all of the injuries and control the bleeding. In the process the woman lost her pulse. I was instructed to immediately begin chest
compressions – something I had only ever practiced on a dummy. As I forcefully shoved on her chest and her
broken ribs pressed against my closed fists, I could see the anesthesia team
working frantically to re-start her heart.
The attending surgeon ripped her diaphragm and began to massage her
heart, yet still she did not respond and quickly passed away on the operating
room table. By this time her son had
arrived. Informed of her death, he
immediately wept – surprised, confused, angry.
This is just one of the memories I
recall from that time and on my clerkship I saw the wide breadth of skills
acquired and scenarios encountered by a general surgeon. Now, with a little more experience under my
belt, I feel that all of the skills of surgery are encompassed in Trauma. I see this every day. It starts with the operations. As a trauma surgeon you may be expected to
operate on the heart, the chest, the abdomen, the pelvis, blood vessels, or
extremities—all of which have happened in the seven weeks I have been
rotating. Furthermore, we perform a full
range of bedside procedures from endotracheal intubation, emergency surgical
airways, tracheostomy, bronchoscopy, endoscopy, central line insertion, tube
thoracostomy, and diagnostic peritoneal lavage.
We manage wounds and burns, both thermal and electrical—which are
different entities. We interact with
various consultants daily including neurosurgery, orthopaedics, vascular
surgery, plastics, and rehabilitation specialists. We must manage the
recommendations of our physical therapists, nutritionists, pharmacists, and speech/swallow
pathologists. We ‘re expected to adapt
to situations ranging from the emergencies of the trauma bay to the complex
care of the ICU patient. We also must
deal with the pre-existing medical conditions that our patients enter the door
with. Not merely technicians, we often
become the short-term primary care provider for these patients (who may not
have had medical care in years, if ever).
In addition to their injuries, this means managing conditions spanning
from diabetes to depression. The job of
a trauma surgeon also involves informing and improving the community, which we
accomplish through outreach, domestic violence prevention, gang intervention,
HIV screening, and substance abuse support.
But
the skill set runs deeper. Arguably the most
grueling - and perhaps important - interaction we have is with the family members
of the injured patients we treat. Unlike
chronic illness, malignancy, or other conditions for which patients and their
families’ have had time to digest, trauma is an unexpected and shocking event. The last time a mother saw her son he was
awake and speaking to her. Now she
arrives to hospital to find him unconscious with a ventilator breathing for him
and tubes leaving every orifice. It is in
this setting that we must use our other skills that are not as apparent as our
scalpel - but just as powerful: empathy, reassurance, honesty.
I
recently had the opportunity to help a family come to terms with the imminent
death of their terminal loved one. We
were able to ensure that all of his family from across the country could make
it to his bedside. The family decided to
withdraw care and we were able to provide the patient comfort and dignity with
his ultimate breaths. I think about the
stark contrast of this scenario to the unfortunate woman from my medical school
experience. In both situations the
patient expired, but the endpoint was really quite different. For all of the uncertainty that this field
can bring, trauma surgeons are truly equipped to handle it all. This requires channeling from all of the
skills I have acquired over the last few years.
No other aspect of my surgical training truly encompasses this in the
way that Trauma does.
from Vikram
Krishnamurthy, M.D.
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