Healing

“Eagle in 5!” It’s 7:35am, my shift just started, and I welcome this surprise. I am not supposed to say this, I know — a trauma patient flown to the hospital is hardly a surprise to be welcomed, but as an intern at “The Temple of Trauma”, this is what I yearn for every day I get out of bed at 5:30am and head to the emergency room. This, I learned with time, is as close as it gets to what I hoped medicine would be when I made the premature decision to become a doctor. I was 8 and, to my grandmother’s bafflement, 24 hours of bitter boldo tea did not manage to cure my appendicitis, my mother took me in her arms to be operated at my town’s local hospital. When I finally woke up from anesthesia, I remember looking up to the surgeon from my hospital bed and realizing that he was far from an ordinary man, he was a superhero. My school breaks left no doubt that I had always wanted to be a superhero and, secretly, maybe still do.

It would not be politically correct for Superman to admit he loves crime and bad guys, but we all know that a world in peace does not need men in uniforms beyond boring theme parks and mildly entertaining movies. Similarly, a world without tragedy is no place for trauma surgeons, and “Eagle in 5!” is here to remind us that this world remains in agony, and there is no time to philosophize about it — we jump from our seats mid-sentence and place our soon-to-be-cold coffees on the table in an urgent and anxious choreography. If life had a soundtrack, the apex of Vivaldi’s Winter would be on, its frantic violins making us wonder how chaos and order can coexist in such a harmonious way. In anticipation to the rescue helicopter landing on the roof above, it takes 45 seconds for the 8 of us, young residents and interns, to leave our unfinished ordinary tasks in the doctors room — taking notes on our computers, discussing our cases or just waiting for the next patient to walk in while sipping on some coffee — and rush to the Eagle room right across the hallway, grab a yellow gown from the pile nearby, put on a pair of purple gloves, fit our goggles, assume our positions, and wait. We are joined by four nurses and technicians who halted their paperwork and blood sample management in response to the magic three words. The three attendings, the only people in the room over 40 and decently dressed in suits embroidered in authority, are the last to the scene, walking from the comfort room with the tranquility of someone who has done this hundreds of times and will not get their hands dirty.

The “Eagle room” feels small, sterile white and silver, designed to fit exactly (the) one critically injured patient, the trauma team, the dozens of compact tool boxes and medical supply drawers and one short ladder — moribund patients do not climb to their beds in the Eagle room, but doctors frequently have to, I found out intrigued a couple years ago. Every day, when we take on a shift, we gather just outside that room and are assigned one of ten roles in the trauma team. Today I am M2. That means I stand to the right of the patient’s chest, next to the ladder we hope we will not need, and perform assessments and procedures. I like how close to action I am. It’s T-4min and I mentally rehearse my part as a team of three rushes to the helipad to bring the patient to the trauma room. As soon as they get back, I will place two fingers on his neck, where the carotid is, and wait for 5 seconds until I feel whatever life he has left pulse under my fingers. I will follow by touching each side of his chest with my stethoscope on a hunt for breathing sounds. I wonder what I will hope to find this time. If it turns out silent, I will be forced to resort to a chest tube, which requires reaching the lungs through skin, muscle and pleura. The thought excites me, and I secretly hope my stethoscope does turn out silent, so I can be more needed and fulfilled. I will continue the standard protocol, checking his abdomen for tenderness secondary to internal bleeding, and looking for wounds, fractures and spine injuries. In less than what it takes a burger flipper to prepare a Big Mac, I will know how likely this patient is to survive and how long it will take until we can finish our coffees.

I am ready, I thought. I look around and give some of my closest friends an anxious and excited half smile. We are all ready. For what, I wonder? A late night Eagle would probably be carrying a drunk stabbed at a bar in the suburbs, a reckless driver who crashed into a lamppost at 90mph, or the victim of a shooting in the favelas. Weekday afternoons almost invariably carry poor, hard-working motorcycle riders caught in the blind spot of poor, hard-working, tired truck drivers. Late nights or early afternoons, Eagles are always flying around the victims of this world in agony. But what does a Saturday morning Eagle bring? Nothing exciting happens on Saturday mornings, usually swamped with long rounds and endless bureaucracy, none of which is tragic enough to top pre-med students’ lists to become a doctor. I wonder why the Eagle Team doesn’t give us a summary of the case before they land. Maybe they don’t want to spoil the surprise, or maybe this another thing someone needs to fix in Medicine.

I hear the transport bed’s metal wheels aggressively and loudly punching the stone floor outside the trauma room. My expectation grows.

Art critics usually describe Guernica as hard to read, confusing, chaotic. There is death and dying everywhere, and we are thrown right into the middle of the action. Characters are fragmented, unshapely, discontinued. It takes some time for our eyes to adjust to the sheer feeling of graphic violence of the scene and start seeing and hearing the figures — the explosions bursting in destruction, the dagger tongues fighting the fire, the soldiers fallen beside their broken swords, the mother screaming with her lifeless baby in her arms. The dark brush strokes are said to be heavy, textured, charged.

Trauma surgeons are taught to skip the eye adjustment period and systematically and unemotionally read their cases. I first see the shiny silver reflective blanket covering his body. Shiny silver is not a sign of fortune in trauma. I see a blood-tainted breathing tube screaming “he can’t breath” — perhaps his airways were crushed or his lungs are filled with blood. As the bed rolls into position, I finally see him. It’s hard to recognize the boy behind all the injuries, blood, and broken facial bones, but I can tell that he is young and has the brown skin of a common lower middle class Brazilian family. He is innocent, I judge by what is left of his clothes, his modest haircut and the slight frown of his immature youth.

“Unidentified 14 year-old male. Frontal collision with a car while riding a bike without a helmet on the highway”, loudly, firmly and calmly announces the Eagle doctor in his air force-style suit. He doesn’t seem impressed, concerned, or even excited. Tragedy is cauterizing, I guess. They are always unidentified. Not because no one tells us their names, someone at the scene usually does, but because names are unnecessary distractions in our protocol. They always have an age — 14-year-olds are not supposed to die, and I know we will do whatever it takes to save this one. Frontal collisions are synonymous to misfortune. On a bike. Without a helmet. At highway speeds. Disaster.

Pulse. “Present, weak and slow”, I report loudly to the student taking notes and the senior resident leading the team. My stethoscope reveals reduced sounds, no chest tube for now. “Starting fluids and massive blood transfusion”, I hear the nurse almost sounding distant. Abdomen is tense. Probably some internal bleeding. Pubic symphysis is stable. Multiple abrasions. No major sources of external bleeding. Multiple facial bones fractured, exposed fracture on left leg, already immobilized by Eagle Team, ready for full-body CT. “Heart rate is dropping!” “ Blood pressure is dropping!” “My son! I wanna see my son!”, shouts a weeping female voice from the hallway — must be the mom, how did she get here so fast?

“No pulse, let’s start CPR!”

The absence of a pulse, frightening to most, dampens our symphony. It simplifies our algorithms, narrows our focus, and even reduces the amount of people required in the room — we can feel the entropy dropping as we reorganize around the new protocol. I am first in line for compressions. Bee Gees go in my head before I start hearing the less exciting “tóc-tóc-tóc-tóc” from the metronome reminding me to keep my beat at 110bpm. I can feel the broken ribs cracking in and out with every compression, but that’s business as usual. Beyond the machines beeping, the metronome tóc’ing and the mom crying outside, the room is silent — focus.

I’m sweating, I feel as I quickly jump off the small ladder so my colleague can climb back on during my 2-minute rest. I take 10 seconds to breathe and look around again. The three attendings still removed from the scene in their spotless dark suits and dry skins, catch my eyes. They are discuss something. It’s grave, I read their eyebrows wondering what comes next.

“Thoracotomy box!” Dr. Krane injects entropy without hesitation as he takes off his blazer and puts on a sterile gown and gloves. This patient is going to die. The emergency thoracotomy this Professor seems committed to performing is an act of desperation hard to justify through pure logic. It means opening up a patient’s chest in order to access his heart with the hopes of preventing exsanguination — all done not in an operating room, but in the emergency room, sometimes with other patients around, and without concern for infections or other cosmetics, because we can deal with those later, but we are yet to come up with a way to handle bloodless bodies. The procedure can only be performed in high complexity hospitals with the resources to clean up the mess that invariably ensues. Success rates are extremely low.

I wonder what Dr. Krane is thinking as he dissects skin and muscles to find a motionless heart. I wonder what brought him into medicine. I wonder if he still secretly wishes he could be Superman on the rare occasions he plays with his 12 year-old son. I wonder if he sees his son on Unidentified 14yo or hears his own wife on the mom weeping outside. I wonder if he actually believes he can do anything to prevent this tragedy from coming to the end no one hopes for but everyone sees coming. I wonder if he is so pointlessly unwavering because he knows that in a few minutes he will have to deliver the news to the mom, and having gone farther than reason advises will make him feel better. I wonder how it is possible that over 30 years of frustration have been unable to teach him how to deal with the powerlessness that death implacably imposes on all of us.

All is red. Dark, thick red. As I massage the heart, someone clamps the aorta with a metal clip, cutting blood supply to all but the brain — we double down on our desperate measures. We never manage to find a bleeding from the heart or any major blood vessel, it must be hiding from us somewhere else. I can barely follow or understand what we are doing anymore. I try to focus on the metronome, making sure I don’t let my fatigue get me out of rhythm. I try to focus on the depth of my massage, making sure I effectively pump whatever is left of Unidentified 14yo's blood to his brain, which allows us to keep our mission alive — technically.

What is our mission? I wish I could silence the mom outside, not by preventing her from doing the only thing she can to tell us how much she wished her son had not left his room today, but by preventing her from losing her second son to a car accident on that same highway. I wish I could somehow inject life back into this heart I am touching through the thin latex of my gloves. I wish I could amend Unidentified 14yo’s fractured bones. I wish I could amend his broken relationship with his mom so she can morn her son without the guilt of not having kissed him on the cheek before he left to hang out with the friends she didn’t like. All of this I can only wish in retrospect. When my hands were feeling the fibers of Unidentified 14yo’s heart, I didn’t know about his brother, Unidentified 16yo, who had died in almost identical circumstances two years ago. I din’t know that he was constantly fighting with his mom or that he had the kind of friends parents usually dread. I didn’t know if he was happy or even wanted to live. I didn’t know whether, in the unlikely event that we managed to keep him alive, he would become president or a gang leader. All of this I only found out when it was too late to factor into my decision making — or cloud my judgement —, when I finally delivered the news to the mom. In a way, I wished I had never found out — I didn't want to be reminded of the person behind the patient the next time Eagle landed and I came across an Unidentified teenager broken in pieces. It was not up to me to be the arbiter of life and to deliver divine justice or worldly happiness to those who deserved one or the other. That’s why I did not need to know the names, the stories, the relationships, the accomplishments, the crimes, the charities, the feelings, or the sufferings of the bodies I served.

Just two days ago, Unidentified 40yo was brought to the emergency room in cardiac arrest. It was his birthday and he drowned in the pool during the party — he was too drunk to swim. It took us 25 minutes to bring him back and he was not happy. He was not happy with his bruised and sore chest from CPR. He was not happy with the food. And he was definitely not happy with the fact that all of his family and friends saw him drink to near-death on his birthday — he never admitted he had a drinking problem, we got that from his wife. Most importantly, he was unhappy with his life and he hoped total darkness, purgatory or perhaps heaven, if he was so lucky, would’ve been better alternatives. He was unhappy with his bitter wife and her annoying complaints about his drinking habits. He was unhappy with his inability to connect with his son and daughter, or to inspire them on any level. He was unhappy and blamed us, especially me who saw him everyday, for bringing him back to a life he did not deem worth living. I resented his ingratitude and abbreviated my exposure to him to the bare minimum necessary to keep my records decent. I wondered what was the point of saving a middle-aged miserable guy from a death that could mercifully spare him and his family from his existence. And I wonder what is the point of pretending we are going to save Unidentified 14yo.

It is 8:43am — I know because someone just finally announced the time of death.

I’m exhausted. Everyone is. There is not a lot of movement in the room. I sit on the small ladder by the body, his right hand hanging from the bed. “I will not use the knife, not even on sufferers from stone” is how the Hippocratic oath prohibits surgery, consistent with the Pythagorean view that surgery was a lesser trade, closer to butchery than to healing. Today I feel like a butcher. My own hands and arms are coated in blood, I feel its metallic smell. The floor is covered in dark red half-dry pools encrusted with used tissues and needle caps. Unidentified 14yo’s chest is still open, I see the motionless heart I was touching a few seconds ago. His body is bruised, broken, notably crooked.

I still hear the mom outside, the violence of her initial sob replaced by the weariness of a fatigued lament — crying in desperation is exhausting, maybe she gave up too. I remember my mom taking me to the OR a decade ago. I discover the tightness in her chest, the lump in her throat, her strength in finding an encouraging smile to give me while she worried that my fear was not really unwarranted. I am not a superhero after all. There is no life to fight for, tragedy to remedy or bones to amend. I remember my mom meditatively reciting a heartfelt proverb a few years ago, “when parents die, they are buried in the ground. When a child dies, they are buried in the parents’ hearts”. This grounds me, pulls me back from my contemplation. Unidentified 14yo cannot be buried in his mom’s heart like this. In my first real act of compassion, I start cleaning up the mess, not as a doctor, but as a son.

I take on new white gauze and softly start restoring Pedro’s body, a son at last. I close his mouth and spend some time zealously caressing his face. I cross his arms on his chest. I take on new white sheets and cover him so he looks in peace. I look around trying to make sure this place looks less like a butchery. I wish I could dim the bright white lights that assault our eyes, or replace with wood some of the shiny silver metal that accentuates the coldness and sterility of this room, or somehow make it a shelter for someone who desperately and helplessly needs to be embraced, comforted and consoled. When everything is ready, I take Mom to the office and hear her tell the stories of Pedro and João, her anguish preventing her from making sense most of the time — the message is so clear, no logic is needed.

* * *

Most people will say they became physicians to help people. It only takes a couple hours observing doctors’ behaviors to realize that this is rarely the case. Maybe this noble ambition is intentionally pasteurized through training or accidentally cauterized through the torture of repeat exposure to tragedy and suffering. Maybe Medicine is just more about a doctor’s answer to his childhood fantasy than his patient’s need for care. Maybe it is more about wealth than healing. More about excelling over technical challenges than overcoming suffering and misery. Even in mental health, it is about chemistry more than it is about purpose or meaning. It is about closely following protocols so that you never get sued. It is about not having the ethics committee breathing down your neck, rather than righteousness or virtue. Some say that the true art of healing is lost, abraded by market dynamics and bureaucracy. I wonder what made the Medicine of Saint Luke, “Doctor of Men and Souls”, different from mine. I wish I could say I came into Medicine to help moms love their sons more deeply, fathers have more time with their daughters, dying grandparents have more peace, siblings few less pain, and children thrive. I did not. It took a few moms crying over Unidentified Pedros, my own father’s sudden heart attack, and my aunt’s 15 years withering to cancer for me to realize what true care means. Caring takes infinite shapes and forms, only a small fraction of them requiring a white coat. Caring is a late night visit after work. Caring is your favorite ice cream. Caring is placing my hand on yours, gently giving you a hug, hearing your childhood stories, laughing at your jokes, crying with you, understanding when pain makes you bitter, calling your mom to let her know how surgery went, making your parents feel proud of your strength, talking about life and what comes after even when I am not sure myself, praying for you and praying with you. It took me a long time to remember that when I was 8, awe was not all I felt in that hospital. I also felt fear of the shiny silver blade that was about to dissect my skin. I felt angst and loneliness when my bed was rolled into the OR and I tried as hard as I could to reach my mom’s hand with mine so she could come in with me as she always did when things went wrong. Our hands never reached, and only a decade later did I make out her heavy look into my eyes when I woke up from anesthesia the following day — the almost imperceptible but unmistakable tension in her face finally dissolving into relief. I felt the warmth of my friends when they visited and tried (fruitlessly) not to make me laugh because it hurt when I did. I felt joy when my favorite aunt brought me my favorite ice cream and walked (very) slowly with me around the hospital. It took me a long time to remember that all of this is healing and there is no Medicine without it.