My first patient’s death was on a Saturday.

        I was sitting in the EMS room at a large hospital for my second clinical shift with three classmates and our clinical preceptor, working on paperwork. I was finishing up the chart for my second patient when the intercom sounded for a Shock 1 patient. I put my pen down mid-sentence and left the room without asking for permission. Shock 1 patients are uncommon, even in major metropolitan hospitals, and these cases offer invaluable learning experience. The chart I was writing could wait; I wanted to see something cool.

        The shock rooms were only 50 feet away from the EMS room, but by the time I got there, a crowd of people was already outside the door. Nurses, scrub techs, residents, orderlies, and surgeons were putting on gowns and gloves, smiling and joking with each other. My classmates and I went through the adjacent shock room to avoid the crowd of people and filed onto the observation deck, a small platform in the back of the room roughly the size of a dining room table. By the time we had arranged ourselves so that we could all see, the emergency room staff had taken their stations. There were at least 30 people in the room.

        A few seconds later, a crew of firefighters and paramedics burst into the room, pushing a gurney. One of them was walking alongside the bed, pumping on the patient’s chest. It was the first time I had ever witnessed CPR on a real person.

        The doctor running the code shouted orders, and people sprang into action. Every single person had a job. Two residents assisted the paramedics and moved the patient to the trauma bed. Three nurses attached EKG leads to the patient’s chest. Another nurse drew blood. One of the doctors checked the carotid pulse, while the senior resident checked the femoral pulse. The trauma surgeon shouted for ultrasound, and a resident whispered to us that the patient’s spleen was shattered. The firefighter standing next to the patient continued CPR.

        With the ultrasound complete, some of the equipment was moved out the room, and I finally got a clear view of the patient. He was in his 40s, with dark skin, closely cropped hair, and a broad face. He was a large man, and his feet nearly stuck off the edge of the trauma bed. He had been intubated, and he had dark red blood all over his chest and abdomen. I noticed a puddle of blood on the floor to his right, and looked at his arm to see if it was the source of the hemorrhage. His right arm wasn’t there.

        While I frantically whispered to my colleagues that he didn’t have a fucking arm, where the hell did his arm go, one of the paramedics started to give a history. “43 year-old male found down in the park after being shot while riding his bike. Was unconscious but breathing when we arrived, we got him in the rig and started patching holes when he crashed on us. Intubated him and started compressions en route. Been down for about 12 minutes.”

        Who gets shot while riding a bike? Who shot him? Where had he been shot? Was he going to surgery? And how in God’s name had his arm been blown completely off? I had so many questions, but it was not my place to ask them in that crowded shock room.

        The fact was, this man was dead. He had died in the back of an ambulance in the park, he had been dead when doctors and nurses took over his care, and he was still dead now. He had not had a pulse for over 12 minutes, and even if the trauma team did succeed in getting his pulse back, he’d probably be brain dead.

        The trauma surgeon had evidently reached the same conclusion and ordered the firefighter to stop compressions. He checked a carotid pulse one last time, and with no pulse to check, he stopped resuscitation efforts completely. The surgeon looked at his watch, then announced it to the room.

        Time of Death, 1857. 

        And that was it. The nurses removed the monitor leads and pulled a sheet over the man’s face. The surgeon snapped off his gloves and left the room, residents and interns following suit. My colleagues and I also left the room, still whispering to each other. The firefighters gathered their equipment and followed us back to the EMS room. As we left, I saw a janitor with a mop go in to clean up the blood on the floor.

        In five minutes, I had gone from writing a routine chart to watching someone die. He was a nameless face, just another casualty in a busy metropolis. To our preceptor, he was an excellent teaching tool, and she quizzed us over CPR protocols, cardiac rhythms, gunshot wounds, and trauma assessments for the next half hour. The team of
medics filled us in with more details about the case, and we asked them all sorts of questions. I never did figure out what had happened to his arm.

        Then we moved on. I finished my chart, received excellent marks, and went to find another patient to interview. My colleagues finished their paperwork, and someone figured out how to work the coffee machine in the break room. The firefighters left with sirens blaring, off to another emergency. Somewhere in the ER, a nurse found the man’s family, and somewhere in Houston, a wife and son and mother and brother had their lives destroyed. After our shift was over, my preceptor drove us to get ice cream in the Village. We didn’t mention the man who had died in the shock room even once.

        It didn’t really hit me that I had actually watched someone die until I got home. I put on pajamas, climbed into bed next to my partner, and stared at the ceiling for a while. My partner asked how the shift had been and if something was wrong.

        “I watched someone die today,” I whispered.

        He seemed shocked and asked if I was alright, if I needed anything, if I wanted to talk about it.

        I was alright. That was the problem. I didn’t feel traumatized, or shocked, or sad. I had watched a human being die, and I had gone out for ice cream with my colleagues four hours later. The doctors and nurses in the shock room hadn’t been affected either. He was just another patient who didn’t make it. That was all.

        So why was I staring at the ceiling, picturing his face and the pool of blood on the floor? If I hadn’t been in that shock room, I wouldn’t have even known he existed. But for somebody else–for his family–that night would forever be the worst night of their life.

        How had I not been prepared for this in class? Surely our instructor had lost patients before. How had he not taught us to treat patients as people, to recognize that they had lives just as complicated and messy and beautiful as our own? We were taught so many things about life, but nothing about death. We were taught logic and rules and calculations, but nothing about empathy and compassion and grief. Those must be learned on our own.

        Whenever I tell this story to my friends, they look absolutely appalled. “You really saw someone die?” they ask with surprise.

        “Yeah, I did,” I say. “It’s part of the job.” Then I usually change the subject.

        What I don’t say is this: It’s the most fucked up part of the job. It’s fucked up that we get sent to the hospital as students to watch people die. It’s fucked up that human lives are used as teaching tools, and it’s fucked up that the doctors and nurses in that room didn’t even take a moment to think about the person that died in front of them. We should not be taught to see someone as a patient. We need to be taught that they are people, that we are caring for people with hopes and dreams and vibrant lives. I will never be convinced otherwise.

~~~

        I’m in this field because I like it, even the slow shifts. But getting dispatched to a good trauma call when you haven’t had anything in three weeks? Damn, that’s hard to beat. Trauma calls are what get me through slow campus shifts. When I run into my colleagues in the office, we always swap stories about patients who wrecked their bikes or fell down a flight of stairs, not the third sprained pinky of the week. We’re addicted, desperate for another hit of the adrenaline we felt the first time the tones went off. We take what we can get. Trauma doesn’t need to be bloody. Sometimes all it takes is something new.

        Then again, sometimes the blood is a bonus.

        It was a year later, and once again, we were lounging in the EMS room at the hospital. I was done with my charts, so I was talking with our preceptor about our upcoming exam. The intercom went off for a Shock 1. We beat the trauma team to the shock room and crammed into the tiny gallery in the back, fighting for the best view.

        The firefighters pushed in the stretcher, and an older woman was transferred onto the hospital bed. She was unconscious, but alive. A paramedic reported that she had been in a car accident, and they had extricated her from beneath the dashboard. Her heart had stopped once in the ambulance, but they had resuscitated her.

         The trauma team started their typical assessment. She was already intubated, so an anesthesiologist connected the ET tube to the hospital’s ventilator. Nurses removed the patient’s clothes, exposing her chest and abdomen. She was covered in bruises, some of which clearly showed the outline of her rib cage. Part of her rib cage moved inwards when she inhaled–something called paradoxical movement. This was flail chest, something I had only read about.

        The trauma surgeon used an ultrasound to assess her internal organs. I had a view of the monitor, but I didn’t understand what I saw. I found out afterwards that her abdomen and chest were full of blood.

        Right at that moment, as I peered over the railing to see the ultrasound, she coded. The monitors blared their alarms, and I recognized ventricular tachycardia on the cardiac monitor. The trauma team lept into action, and once again, everybody had a job. The closest firefighter started compressions, nurses started an intraosseous line in her leg, and the anesthesiologist started preparing medications. The trauma surgeon, however, pulled over a cut down tray. This hadn’t happened during the last arrest I watched. They were going to open her chest, right there in that shock room.

        The trauma surgeon shouted to halt compressions, then in one smooth motion, he sliced the patient’s chest open. He made a long, horizontal incision, from the center of her chest down to the table. The resident mirrored him on the other side. They used a bone saw to split her sternum. The surgeon jammed a retractor under the top half of her sternum and pulled upward, hard. Her chest opened like the hood of a car.

        This procedure is called a clamshell thoracotomy. It’s a common trauma technique used to expose the entirety of the chest cavity in the event of cardiac trauma. It allows the surgeon to see the entire heart and both lungs, hopefully giving him access to the injury of concern. In this case, the patient had broken almost all of her ribs, and one of them had punctured her heart. This resulted in pericardial tamponade, in which the sack surrounding the heart fills with blood and prevents the muscle from pumping. It explained why her heart had stopped. The surgeon needed to drain this blood and plug the hole in the heart or the patient would never regain a heartbeat.

        My colleagues and I watched all of this with gaping mouths. We were staring directly at a human heart. I felt my own heart start pounding. We had just watched a surgeon crank open a chest, as easily as you might shuck an oyster. Such scenes were reserved for Grey’s Anatomy and true crime documentaries. I was an Advanced EMT student, just barely 20 years old. This was so fucking cool. One of my colleagues became nauseated and closed her eyes. I took advantage of her revulsion and moved to where she had been standing, which had a better vantage point.

        As I watched, the surgeon stuck his hand in the chest cavity and started massaging the heart. This had the same purpose of CPR–to replicate a heartbeat–but it was futile. He had discovered a second puncture, with a rib slicing into the aorta. He had thrown several stitches, but with a vessel that large, blood was pouring out faster than he could stitch. Heart massage was a last ditch effort. The surgeon massaged the heart for about three minutes, then seemed to acknowledge the large pool of blood on the ground. He shook his head and pulled out his hand.

        Time of death, 2041. 

        They lowered the patient’s chest back down to where it belonged and removed her ET tube. A nurse pulled a sheet over her body. Then we left.

      I wasn’t as shocked by this death as I had been with my first. I should have been. It was arguably the most violent thing I had ever watched. I was just in awe that I had gotten to witness such a procedure. I had seen a human heart.

        When I mention that case to my colleagues now, some of them had similar stories. Surgery in the shock room is not as uncommon as you might think. My friends talked about how they got to touch the heart after the surgeon called time of death. This made me jealous. Why did we have to rush out the room when we could have seen something, touched something cool?

        That is a fucked up thought. I’m saying it outright–no one outside of the medical field would be jealous of their coworkers for something like touching human organs. No one in their right mind would question why we left the room and left her body in peace. I think about that case all the time. I wonder if I’m secretly a psychopath, if I have some fascination with trauma that can’t be satisfied. I have to remind myself that I’m not, I’m just naive. We aren’t wrong for being fascinated by blood, I’ve learned. There’s something about the unspoken taboo and privilege behind it that just draws us in. We see things that no one else gets to see. The things we see are part of being human, like it or not.

        There’s a reason why we go to the hospital for our shifts and observe in the shock rooms while people die. We learn from death. We learn from real experiences, tangible experiences. We learn from stories of other people’s mistakes. If we don’t prepare for trauma in a controlled setting, we will freeze up when we witness it on our own. And when that happens, people die.

        The nature of this job requires us to look past the bloody horror and see underlying mechanisms and pathophysiology. We are taught to see humans as a collection of biological features–blood, organs, bones–rather than people. This is simply necessary. If we constantly stop and take time to acknowledge the human life lost on our stretcher, coping with the aftermath becomes impossible.  In order to be prepared clinicians, we make sacrifices. Perhaps the cost of our sky-high tolerance for trauma is that we lose our sense of humanity.

~~~

      We have no true preparation for this job, despite sitting in a classroom for months on end. We learn about bleeding, trauma, and death in a controlled setting that fails to adequately replicate what we will really see in the field. Our instructors purposely omit the hellish nightmares they have experienced. Our preceptors do not tell us of the times they have struggled and suffered. We are expected to navigate the learning curve on our own, then we’re shocked when our colleagues burn out and kill themselves. We do not talk about the things we see enough. I am very fortunate that I am able to discuss my experiences and learn from them so I may move forward to help the next patient. Many of us are not so lucky.

~~~

      The events in this narrative are based on my memory of real-world situations. However, to protect patient privacy, all names, dates, and identifying details have been changed. Any resemblance to persons living or dead is entirely coincidental and unintentional.