Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.
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New Year’s Eve 2017
I woke up in a motel 75 miles from home, with a dead dog and a nasty head cold. I was on call for two hospitals that day, and there were eleven patients I had to see and some who would need surgery. I sat up in bed and nudged Lucy with my foot. “Time to get up, LazyBones.” She didn’t move. I reached down to shake her awake and felt how cold and stiff she was.
Lucy was old for a bulldog. We’d had nearly ten good years together, and I’d begun to fear she would die soon. I wrapped her in an old sheet I got from the housekeeper and placed her on the back seat of my Jeep then drove to the hospital. She lay there all morning as I rounded on inpatients, saw a new patient in the emergency room, and scheduled surgery for the day.
I took her to the crematory between operations. The gentleman who operates it out of his home in the country was kind, but not overly solicitous. He told me that the fee was based on weight, and took Lucy into the back of the shed which served as his office. Returning a moment later, he informed me the cost would be forty-two dollars.
I handed him my credit card, and burst into tears as he handed it back. He hugged me lightly and gave me a handful of tissues for the road.
An hour later, I was elbow-deep in the tangled intestines of an elderly woman who was suffering from acute ischemia of the gut. She was already gone in shock on arrival to the hospital, and without surgery would certainly have died.
It was a busy day. I removed a gallbladder full of stones and a rotten appendix. I inserted a chest tube into a pedestrian who’d been struck by a car, and drained an abscess resulting from intravenous drug abuse.
I met with the family of a very ill and severely debilitated man who were struggling with whether to place a feeding tube and keep him on a ventilator, or “let Nature take its course.” They felt he’d “had a good life” and decided not to continue aggressive treatment. The breathing tube was removed, medication supporting his blood pressure was stopped, and I sat with them as his heart ceased to beat.
I went back to the motel, put a frozen dinner in the microwave, and changed into sweats and a T-shirt that- like most of my clothes- were covered in dog hair. Exhausted as I was, it was hard to sleep without Lucy curled up at my feet.
My mother has OCD. And 12 cats. This combination was responsible for the nightly ritual known as “counting cats”. We were a family of five in a standard three-bedroom ranch style home in El Paso, Tx. My two sisters and I dreaded bedtime. I, for one, had been known to slink off to bed early just to avoid participating. Before you judge, let me describe the scene to you:
”Bedtime!” my mother announces. We all know what that means. My sisters and I crowd into the one full bathroom in the house to brush teeth, wash faces, apply moisturizer, and whatever else our toilette entails. The cats, of course, scatter to the four winds.
Everyone changes into pajamas, and it begins.... each cat must be located, it’s location reported and confirmed. Don’t even try to pretend you’d found one when you hadn’t. If your veracity was at all in question, someone would be sent to verify your claim. Woe be to the prevaricator! Not only would they be punished (lying was the greatest evil in my mother’s mind), but when the cat you said was inside was actually left out all night, suffering a cruel death at the mercy of the elements and/or the coyotes, upon your shoulders is where the blame would firmly rest.
Those of you who know cats will understand when I say I’m convinced they took sadistic glee in finding impossible hideaways at this time of night. The cat who sat on your homework all evening, the one continuously howling for cream in the kitchen, the one snoozing peacefully on the sofa, the one biting your toes under the dinner table, the one who’s so old and fat it lays in the same spot in the hallway twenty-three hours a day- all disappear.
“None in my room!” cries Tammy, the middle sister. Her room is neat and tidy- nothing out of place. A cat could not go unnoticed in there, even under the bed or in the closet (Standard Search Protocol).
”I found Juby in my room!” reports Tara, the youngest. She and Juby have a special bond. They’re each the youngest and the smallest of their litter. Make of that what you will.
“Prince is in the bathroom,” says my mom. Prince, an affectionate, languid, long-haired Persian mix who’s favorite hiding place is the towel closet, is the reason every time I get out of the shower and dry myself, I’m covered in fur.
Four cats down, eight to go. The search continues.
“I’ll check the laundry room,” I announce. Just then, Katie, a shy calico we found living in the woodshed with her newborn kittens (whom we obviously took in), leaps down from the shelf above the washer, narrowly missing my head, and darts past me. “Katie’s here!”.
The only kitten of Katie’s we were unable to find another home for was Marilyn. Now a full-grown, cotton-haired white cat whom we suspect is deaf, and who is perpetually covered in mats due to an aversion to self-grooming, resides primarily under my bed. She’s called Marilyn in honor of Miss Monroe, due to her lush white fur and habit of lounging about and gazing provocatively at anyone who passes. Don’t try and touch her though; she bites. I spot her (without touching her) lying in the far corner under my bed.
Someone has located Kelly, a large, fluffy, motherly calico, asleep amongst the couch cushions. That leaves only “The Boys”, who are likely outside.
Once my mother is convinced every room has been thoroughly scoured, she heads for the front door to round up the stragglers.
“Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!” she calls.
And again. “Heeeeeerrrrre KittyKittyKittyKittyKittyKitty!”
Nermal comes sauntering in. He heads directly to the kitchen, expecting a treat. Tara obliges him with a saucer of milk.
My mother continues to call for several minutes, then enlists me to take over.
Reasoning that perhaps they simply couldn’t hear her well enough from the doorway, I venture out onto the porch. Standing under the porch light, I begin to call.
“Heeeeeerrrrre KittyKittyKittyKittyK.....AAAAAHHH! Stupid bugs! Heeeeerree KittykittykittyKITTY! Help!!!”
The porch light has attracted the usual array of moths and June bugs, and now there’s a June bug entangled in my hair, buzzing frantically near my right ear, its creepy little legs crawling on my scalp. I’m generally considered the least squeamish and the boldest of the family, but June bugs are my Kryptonite. As I dance around yelling for help, Keaton ducks past me and scratches at the front door. Tammy opens the door and he runs in. She manages to get the bug untangled from my hair and takes over the cat calling.
Back in the kitchen, I trip over Nala. “Where did you come from?” I ask him. He mewls at me, indicating the empty milk dish.
“All right,” says my mother as she comes into the kitchen. “Who’s not here?”
I run down the list with her: Juby, Sugar, Pepper, Prince, Kelly, Katie, Marilyn, Nermal, Keaton, Nala. Only two missing.
Momentarily, Tammy opens the door for Shadow. “Just Cowboy left to go”, she reports.
Cowboy is a rogue and a rambler: a large, lanky, orange tabby who prowls the neighborhood from dawn to Last Call. There have been a few nights we finally gave up and let him stay outside (against my mother’s better judgment and ability to sleep). When he does come inside, he sleeps in my bed- curled up on my pillow just like when he was a tiny kitten. I feel a particular fondness and a responsibility for him, so I volunteer to brave the porch again, thinking maybe he’ll come for me if no one else. This time, though, I avoid the June bugs by turning off the light. Cats can see in the dark anyway, right?
After another twenty minutes of calling with varying tones, pitches, and ululations, he appears. I scoop him up in my arms, kissing his head and scolding him for causing so much worry.
My mother announces it’s now truly time for bed. All is well. Until tomorrow night......
The pager went off at 6:42 pm. "Full Trauma -- ED 6"
I hurried down the stairs and into the Trauma Bay. Several team members were assembled around the room
"What have we got?", I asked.
"24 year-old male, GSW to the chest. CPR in progress". (GSW = Gun Shot Wound)
"Get the thoracotomy tray. Have we called Blood Bank?"
"A box of blood is on the way. EMS three minutes out."
We heard the stretcher coming down the hall. A moment later, the unconscious patient was lifted onto the gurney. Nurses and techs went into action: placing EKG leads, starting additional IVs, stripping off blood-soaked clothing.
"What has he had?", I asked the medic.
"This is liters two and three of lactated ringer's. We've given epinephrine twice. He's in PEA."
I felt for a pulse at the carotid artery and there was none.
The monitor showed an electrical rhythm but there was no pulse, likely because there was insufficient blood in the vascular system to generate an adequate blood pressure.
"Rapid infuser is ready," said the trauma nurse. "How much blood do you want?"
"Hang a unit of cells and keep it coming, alternating with plasma every two units."
Meanwhile, I had opened the surgical tray and grabbed the scalpel. With one long, smooth stroke, I made an incision along the upper edge of the fifth rib from sternum to armpit, slicing through skin and fat down to muscle. I traded the scalpel for scissors, cutting the muscle between the ribs to enter the chest cavity. I could see pink lung tissue inflating and deflating with every squeeze of the AMBU bag.
The chest compressions were obscuring my view of the pericardium, the tough sac that contains the heart. When they stopped, I could see it was distended with blood which was crowding out the heart so it could not fill and pump. I cut a hole in the pericardium with the scissors and blood rushed out- over the lung, out of the chest, off the gurney, and into my shoe. There was clearly a large hole in the heart or one of the large vessels associated with it.
"More blood! Keep it coming!”
I took up the scalpel again and extended the incision across the sternum and onto the right side, an exposure known as a "clam shell". I now had access to the entire chest cavity, which was held open by a Medieval-looking instrument called a "rib-spreader".
The heart was not beating, and it was flaccid and flat- EMPTY. Blood was pouring out of a hole at the junction of the inferior vena cava and the right atrium. I put a finger over the hole. The heart filled and began to beat weakly.
With my left index finger on the hole, I took the suture in my right hand and started sewing. Meanwhile, the nurses continued pumping warmed blood into the veins. As I completed closing the hole, the heart began to beat more strongly. The monitor showed a rapid but normal rhythm. Blood pressure rose. A sigh of relief went around the room.
"Call the OR- we'll have to take him down and get him closed. Do we have an ICU bed ready? Let's get a set of labs. Warm blankets, please. He'll need a Foley catheter and a nasogastric tube."
We'd done it. Life saved.
"Family is in the consultation room," said the Chaplain.
I looked down at myself. I was a mess: arms smeared with blood to my elbows, scrubs soaked with blood from chest to knees.
"I'll have to change before I talk with them."
Someone ran to get me a clean set of scrubs and I set about washing up at the sink.
"Pressure is falling again!", announced the trauma nurse.
I turned from the sink.
“Check for a pulse. Give epinephrine. How much blood has he gotten? Do we have labs yet?"
The respiratory therapist read off the numbers. They indicated sufficient blood volume and oxygenation, acceptable acid/base balance and electrolyte levels.
I looked back at the heart. The sutures were intact and there was no bleeding. The heart was full, but barely beating. I began rhythmically squeezing the heart between my hands to augment its contractions. Soon, they ceased. Medications to stimulate heart activity were administered, I kept pumping, and we spent another twenty minutes working with no recovery of spontaneous heart function.
"We've lost him.", I said.
I continued manually pumping the heart while verbally running down the list of what had been done so far, what the current status was, then polled the room.
"Is there anything more we can do? Can anyone think of anything we've missed?"
No one could.
"I believe we have reached the limits of what we can do, so I propose we discontinue resuscitative efforts. Are there any objections?"
There were none.
"Time of Death: 7:51 pm.”
Musings on my travels and experiences as a Zen practitioner, trauma surgeon, and citizen of the world.