Note: Details of this case have been altered to protect patient identities.

He was the first person I have ever seen die. I’ve seen people who were dying, almost dead, better off dead, and as good as dead, but he literally died right there in front of me. It was kind of subtle, really. Just looking at him, you wouldn’t have noticed at all. He was on a ventilator, so he didn’t really take a “last breath.

There was no change in expression, color, tone, or habitus. I saw no wisps of smoke rise up from his body and float toward the ceiling. All that happened was the flattening of the monitor’s beeps into a solid tone. And then he was gone. We already knew we had lost the battle for his life a half-hour before, but we all felt a fresh sense of sadness that this eighteen year-old boy would never see nineteen.

I should have seen it coming from the beginning. It was only my first night of call on trauma surgery, but even I knew that a page reporting “level 1: MPC vs 18-wheeler” can’t be good. When he came in he was still whimpering and moving all extremities except his right leg, which was lacerated all the way across his inguinal ligament with a rectangular gash that almost reached his mid-thigh.

There was no doubt his femoral arteries were destroyed. His pelvis was a wreck. On top of it all, he required bilateral chest tubes for a possible pneumothorax. When we got him to the OR, he started coding. The surgeons began their exploratory laparotomy, the anesthesiologist started running the code, and before I knew it I was doing chest compressions on a human being for the first time in my life. Who would have known my first experience with CPR would involve doing compressions a few inches from the transverse colon of my patient?

We never managed to stop the bleeding. He got seven coolers of blood (not bags, coolers), but he just kept bleeding. Eventually we had to ligate the common iliac artery in a last-ditch effort to stop the hemorrhage. It didn’t work. I think that’s when we realized all was lost. We tried a bit longer before closing him up as much as possible and heading to the S-ICU. Upon arrival the attending told everyone to stop the code and give 100mcg fentanyl. We washed off as much blood as we could, covered him with clean sheets, and stood back to watch for his wisp of smoke to rise.

A lot of questions run through your mind after you take care of someone who dies. Could we have done more? Did we miss something when he first came in? What if we had immediately put him in a pelvic binder? What if we had been faster in the ED? Did I do compressions well enough? Did we stop the code too soon? Should we have continued trying other surgical options?

A lot of these questions will probably be discussed in the M&M conference and will be more or less resolved. However, there are bigger thoughts I’ve been wrestling with after seeing someone die for the first time, thoughts that can’t be resolved at M&M.

I’ve realized that death is now a part of my life. I’ve realized that death is a process that I will actively participate in, save people from, and possibly even (God forbid) contribute to with a medical error. It is strange to think about death as something I need to get used to. I’ve realized that death can be dramatic and it can be subtle, sometimes even all at the same time. I’ve realized there are good and bad sides to death. It ends a life, but it also ends suffering. I’ve often heard death referred to as the ultimate enemy of medicine, and I’m not yet sure if I agree or not. After all, we’ve only just met.

Author

David Leverenz, M.D., Class of 2013