The Trauma Unit is aptly named, not only because it describes the pathophysiology underlying the patients’ stay but because it identifies the experience of those involved. For families and loved ones, it is often a series of “worst days” punctuated with the immeasurable hope that the inhabitants will regain a sense of normalcy. Occasionally, hope prevails.
As a medical student on clinical rotations, learning in a community-based program has its perks. I may not always have the opportunity to work with residents, but being one-on-one with attendings is an unparalleled learning experience—especially at a safety net hospital rife with pathology.
Still, the intimate environment of my program does not insulate me from the more brutal moments on a trauma rotation. Instead of a large team of residents and fellows bustling from room to room while rounding, it was only my attending and I telling the young parents that their teenage daughter had been declared brain-dead days after a motor vehicle crash. I struggled to look at them as they cried silently...so I looked at her, our patient. Seeing just her face, she would seem peaceful. In fact, you’d hardly know she had multiple operative facial fractures. In truth, she was mangled, with rods and bars from external fixation devices holding her limbs together and tubes weaving in and around her. I chanced a glance at her hospital ID bracelet. She was younger than me, younger than my little sister.
And yet, this was just another day on the trauma unit, and rounds proceeded as usual. This was not the first time we’d lost one of the patients I was following either. Like the infamous House of God, I had my own “Yellow Man”—only she was my “Yellow Lady” with fulminant hepatic necrosis, asking every day over her valved trach when we’d let her go home. A couple days later, I arrived for a night shift to find she’d been transferred to hospice. I never got to say goodbye.
There was something distinctly different though about my young patient from the motor vehicle crash. I wasn’t sure why, as I’d never even really met her. She’d been hypotensive enough in the field that she likely arrived to the trauma bay already brain-dead. When I found out her parents had opted to proceed with organ donation, I was eager to observe in the operating room. Thinking back now, I imagine I’d hoped that maybe glimpsing inside may reveal why she’d seemed special.
It was the busiest operating room I’d ever seen, with entire transplant teams hailing from all over the state. Each of them buzzed around the huge operating suite, making preparations. They brought residents, their own scrub techs, and alien devices for securing the organs in transport. This organ procurement procedure was the talk of the day among the OR, and as an aspiring surgeon I felt incredibly privileged when the lead physician offered me the opportunity to scrub in.
I don’t profess to be an expert or anything near it in the OR (yet). But there are certain things, phenomena that would otherwise seem bizarre to outsiders, that become oddly familiar and routine in the operating room: seeing frankly necrotic viscera, holding the lifeforce of a person’s pulsating aorta, or watching waves of peristalsis, for example. Touching a beating heart, however, is always thrilling. Only here it held a note of cognitive dissonance: this seemingly strong, healthy heart in my hands was now associated with death.
Brain death is, of course, a legal definition of death. But in the circumstance of organ donation, the doctors make sure to keep oxygenation up and blood pumping in these already dead patients long enough to preserve the integrity of the organs. Knowing this did not ease the procedure. Once they clamped the major blood vessel supporting all the viable organs, the teams flipped into overdrive. They flooded the body with preservation fluid and liters upon liters of ice to reduce metabolic demands and preserve as much of the soon-to-be-transplanted tissue as possible. The rapidity with which the surgeons adeptly procured the organs was nothing short of miraculous. Yet, with all the flurry that this orchestra of surgical personnel had mustered they were gone twice as fast. It was essential that they arrived in time to appropriately transfer each organ into their respective recipients. But when they suddenly departed, it left our formerly bustling, cacophonous operating room eerily quiet.
There were only three of us left behind. One, the circulating nurse, was staring on from the side and stifling tears. Two, the scrub tech methodically gathering up the surgical instruments. And three, me. We wouldn’t be closing her wounds like normal, so there were no instruments, sponges, or inventory to count. There was no anesthesia. There was no surgeon. She still had ice filling her now empty abdomen. The surgical tech grabbed morgue sutures and told me “You should go. You don’t have to stay for this part.” But I did have to.
Her parents had already said their goodbyes upstairs and said they did not want to hear or see any news until her ashes were returned to them. The trauma team had already taken her off the sign-out sheet 3 days prior. The massive academic transplant teams came and left, hardly learning her name. Everyone had left her. In truth, it was nauseating to see her the way she looked then and part of me wanted to intellectualize the whole experience. But it wasn’t about me, and I knew I owed it to her to stay. “Needle grabber and pickups?” I asked.
They were able to harvest almost all possible organs for donation.
Her heart went to a young adult with cardiac amyloidosis. Her fractionated liver went to 4 separate people. Her lungs went to a COVID ARDS patient. And samples of other tissues went to research labs all over the country in the name of advancing scientific research, and potentially helping find treatments for endless other diseases.
She saved more lives than some physicians ever will.
Facing death is an experience not unique to surgery or trauma. It is something we have all seen as medical professionals and will continue to confront, battle, and sometimes even cease hostilities in the hopes of constructing a “good death”. I found this particular encounter with death to be traumatic, enlightening, sorrowful, and rewarding all at once. It’s been challenging to process. As in my personal struggles, I have found comfort in the pages of my favorite book:
Many that live deserve death.
And some that die deserve life.
Can you give it to them?
Even the very wise cannot see all ends.
I never had the privilege of seeing her open eyes, hearing her voice, or even seeing her alive….and yet, she is one patient I will never forget.
Dominique Catena, MS3, Florida State University College of Medicine
1Shem, S. The House of God, 46-47. New York: Berkley Books, 2019
2Tolkien JRR. The Fellowship of the Ring, 78. London: HarperCollins Publishers, 2020.