Out of Mind, Out of Sight

*This post contains graphic imagery that is not suitable for everyone, the image is attached at the bottom, please take appropriate discretion*

    I trained at a level 1 trauma center, and it did not take very long until I felt that I was "immune" to the types of things that would make others gag. Severed limbs, traumatic injuries, and gushing blood did not bother me in the slightest. Over time your training overpowers your natural responses and you approach these situations in a calculated manner. It's the only way, I was taught, to do the job because sitting and pondering the implications means you're not useful to your patient. I understand and agree with this notion in the majority of situations, and was happy to adopt it into my practice. Of course, if you've been reading this blog, you've noticed a certain pattern. Experience has continuously taught me that you'll never truly "see it all" and there are still cases that can rattle you. This story is regarding one of those cases. 

    First, I want to set the backdrop for this story. Let me start by explaining that when I started medical school, I matriculated with the intention of becoming an ophthalmologist. To acclimate myself to this future, I spent roughly 150 hours shadowing an ophthalmologist in the OR and in the clinic. So, as early as medical school, I was no stranger to surgical exploration and manipulation of the human eye. I had seen numerous traumatic injuries and was accustomed to the visceral reaction seeing a damaged eye produces. With that in mind, understand that this case and the context in which it occurred was enough to floor me for the remainder of my shift and beyond.

    Secondly, in the Emergency Department, strange things arrive at night. It is known, expected, and probably welcomed,honestly. The night-crew is a hardened set of veterans who, above all, get the job done. This case was no different and was a classic middle of the night  "drop in". We were prepared, but we were not prepared.

    Actually, the night was exceptionally busy, and I hadn't really had any time at all to think thoughts or feel feelings. My mind was running in bullet points and I was jumping from task to task  with as much efficiency as I could manage. I remember asking a nurse if she could accompany me for an exam and she said she needed some time. I told her I could be ready in 3,8,12, or 20 minutes, and whenever she was ready I would switch the order of things I had to do to accommodate her. This was that type of night. 

    So, like every other patient I had seen that night, I did not bother to fully read the documentation before I went in to investigate. This patient was a transfer from another facility, and had I read the documentation, I would have been introduced to this case in parts, lessening the shock. 

    EMS had wordlessly unloaded the patient from the stretcher onto the bed by the time I arrived. The patient had a bandage on his head but seemed otherwise content. Young, still dressed in street clothes, and in no apparent distress. What gives? My instincts were at odds with each other. On the one hand, he did not have the tell-tale signs of a chronically ill patient with an impending catastrophe, but on the other, there were subtle clues towards the magnitude of what was unfolding.  

    Whatever, no one has time for these mysteries and I began rattling off my introductions and open ended questions. How do you feel? Okay. Are you hurting anywhere? My eye. This was getting nowhere fast so I started to unwrap the bandages while I redirected the patient towards the salient points of his history. How did you hurt your eye? My hand. The conventional portion of the interview ended here because as he said this I had uncovered his injury. 

    This gentleman was young, about 30. He was very appropriate, tired as he should be because it was the middle of the night. He  gave off the same vibe that a child has when they approach you to confess doing something they shouldn't have. The shuffling, roundabout answers you get when they know you won't be pleased with their response. Over the course of the last several months, he had started to exhibit strange behavior. He recognized it as such himself, but kept on with it. He recognized that he was having auditory hallucinations and over time they started to gain power over him. The hallucinations demanded actions from him and he eventually relented. In this particular case, he had been convinced that his right eye was guilty of "lusting" and he felt that God was commanding him to remove it. He decided to use his hand and crush his eyeball in an effort to rip it out of his face. He was largely successful. Over the course of the medical transport, he regained lucidity and was fully aware of his situation. He would never see out of that eye again, and in fact, required surgery to complete the evacuation. He also understood that he had a serious problem on his hands, and from this point forward he would be struggling against these internal forces. I've attached a picture of this encounter, but the photograph does not fully recreate the horror of the situation. 

    We often describe accidents, injuries, or wrongful deaths as tragedies, which they are, because they rob someone of a family member, a career, or a future. This case was a tragedy in a slightly different manner in the sense that the victim was the architect of his own loss. He was blameless of course. This particular story is especially disturbing because it is troubling from every angle: the implications of a debilitating psychiatric condition, the horror of self-inflicted mutilation, and the loss of one of the most meaningful ways of interacting with the world. I think this is why it hit me like a brick wall, forcing me to reflect on it. It was a classic case of the insanity we sometimes see in the Emergency Department but will never truly be accustomed to.

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Severed and Indifferent

This post features graphic images. They are attached at the bottom. Not appropriate for children

It can take months to get accustomed to a new hospital. The Emergency Department is naturally a maze of people, rooms, and tools. You know the medicine, but every shop has its own flow, its own staccato rhythm that you have to learn and settle into. There are obvious skills to learn; where things are, what can be arranged, and which consultants to avoid. But there is a much more subtle pulse to each ER that needs to be measured if you're going to survive. Mastering this flow is extremely comforting, because you know that the whole department has your back when needed. I'm exceptionally bad at doing this, and it often takes me much much longer to settle in then most people. This transition is almost mandatory for you to be able to enjoy where you work, so I always have a...turbulent start anywhere new. 

And it was no different in this setting, it took a whole 6 months before I felt that the department worked for me and I worked for it. Together we were like an efficient machine, doling out patient care and heavy doses of sarcasm in equal amounts. I was fresh in this new found groove when I encountered this specific patient. 

It was an ordinary day, a blessing because ordinary days are extraordinary mostly, and we were moving patients at a respectable clip. Splints were applied, crutches were supplied, and wheelchairs arrived at regular intervals. This gentleman was not especially sick, he wasn't extraordinary in any way. His chief complaint was thumb pain, and thumb pain comes in exactly two varieties: extremely boring and slightly interesting. I've learned to expect the boring, so that when something slightly interesting shows up, you get to have more fun with it. This gentleman had essentially destroyed his right thumb. The most useful finger in his dominant hand. He'd applied a liberal amount of alcohol to the mundane task of operating a wood shredder, and was now sitting in front of me, far too comfortable for the injury he had sustained. He didn't let his injury affect his mood, smiling quietly as he soaked multiple layers of gauze dressing. I did my work, examined him and told him the next steps. 

There was a possibility that his thumb might be eligible for re-attachment. A chance, though slim, that he could come out of this situation with minimal dysfunction, but it required immediate transfer to a facility that could perform the procedure. After getting the patient's pain under control I presented the option to him, getting the necessary paperwork in order beforehand. I expected this to be a quick disposition, the patient would no doubt like to retain the function of his thumb. My own thumbs were working furiously, calling the appropriate hospital to arrange for transfer, because time was of the essence. 

Eventually, I came back to check on the patient, to confirm that medical transport was available and that the procedure was still a possibility. I told my nurse how to package up the destroyed thumb, and how best to get the patient transported over. I was saying goodbye to the patient for the final time and requesting his signature (while acknowledging how difficult that would be) to consent for transport. The patient looked apologetic, licking his lips as if he was preparing to tell me some bad news. He took off his baseball cap and held it in his good hand. He was not interested in the procedure. There was too much daylight left in the day, and...he really hadn't planned on being here this long. If it was alright with me, he'd rather that we complete the amputation have him on his way.

I started talking about how important thumbs are, how they really aren't like the rest of your fingers. You can't really be a movie critic without them, hitchhiking is impossible, and you look ridiculous in a pair of gloves. I started questioning his sobriety and decision making capacity, but ultimately he was able to verbalize to me that he really didn't value his thumb that much. He just wanted the bleeding to stop, and his wound to be closed so he could continue on his way. This was bizarre to me, but ultimately we reached a compromise. He would not allow me to transfer him to have his thumb saved, but he would allow a shorter transfer to a location that could perform a more cosmetic amputation. We were at an understanding, and he was on his way. 

This encounter was enough to sabotage our otherwise smooth operations that day. In medicine we deal in shades of gray, with only occasional chances at a "clean" kill or save. This was a chance at a clean save. A new injury with the potential for a poor outcome, but with appropriate management there was a chance to rectify it completely. The nurses, myself, and the rest of the department were on the same page, moving in a synchronized way to fix this tiny catastrophe; the only one not on board our soon to depart ship, was the patient. He wasn't having it.

I still think that there is no better seat from which to examine society then from the position of a healthcare provider. Even though a severed thumb no longer fazes me, I still have a strong reaction to the lives of my patients. My own life has been shaped by my particular circumstances, which are entirely different then the lives of others.  I have the privilege of seeing the truest cross-section of my society, and that ever changing picture continues to amaze me.