Howl into the Wind
A ritual to mark the passing of a human spirit.
You cannot know what will turn out to be your best day, or your worst, until you have lived all the days of an experience, or of a life. Only then can you line them up to compare, scrutinize side-by-side, and identify the highest of the highs and the lowest of the lows. I am 51-years old now, and odds are that more days of my life are behind me than ahead. Nevertheless, I hope thousands remain before the time will come for me to judge. Thankfully, my medical training ended over 2 decades ago — that period of my life is complete. During those years, there were many bad days and low moments. But one stands alone as the very worst.
Summertime is busy on the orthopedic trauma service, and this sunny, warm day in my 2nd year of residency is no different. In the late afternoon, the airlift nurses radio ahead to tell us their helicopter is in-flight, bringing a 12-year-old boy who was hit on his bike while trying to cross a rural, 2-lane road. He started into the street without realizing the truck that just passed had a trailer attached, and he was struck at high speed. His dad is a volunteer firefighter who we later learn was a first responder at the scene, arriving to discover his own son sprawled unconscious on the road. Even now, I still flinch when I see a trailer hitched to a truck, remembering this boy and his father, and wondering whether a day goes by without him recalling this horrific image.
Waiting in the ER, we are forewarned that he has a large wound on his back, and his condition is unstable — blood pressure dipping dangerously low, heart rate quickening in compensation to meet his body’s oxygen demand. They have intubated him in the field. Once he’s wheeled into the trauma bay, the team rolls him for me to inspect his back. The wound is massive, flesh peeled away from his neck to his ribs. We take a chest x-ray and after a few minutes for processing, the tech returns, hanging the film on an illuminated view box on the wall. It shows fractures of the clavicle and scapula — collar bone and shoulder blade — straightforward injuries in isolation, but the combination is ominous. It indicates that at the time of impact, his arm was pulled away from his body with enough force to break these bones that connect his arm to his torso. It’s called a “scapulothoracic dissociation.” Even though the arm is still attached, it is equivalent to a forequarter amputation — a devastating injury that is lethal 10% of the time. The fractures themselves are not deadly — the major threat is from internal damage to the large arteries and veins in the arm and chest. We work diligently and quickly, starting multiple intravenous lines, manually squeezing bags of fluid so they will flow rapidly into his bloodstream trying to make up for the volume he has already lost. Despite the most extraordinary of measures — medications to bolster his heart, electric shocks to restart it after it stops, and finally, cutting his chest open to do manual massage, he dies in our hands.
After a “code is called,” meaning the resuscitation stops and time of death is announced, an eerie silence sets in — a sharp contrast to the chaos and frenzied activity moments before. The trash strewn about makes the scene look like the aftermath of a rock concert, countertops and floor littered with wrappers from IV tubing and bandages and sterile gloves. Often there is blood, soaked in gauze pads and towels, congealed in pools underfoot. The residents and nurses slowly disperse to continue their work, seeing other patients or charting. Even unsuccessful encounters like this require documentation, more detailed in fact, recounting every step to be sure nothing was missed that could be construed as an error, and sorting through potential lessons for what could be done differently next time. The housecleaning team comes in, and the boy’s body is taken to a private room in the back of the ER for the family to visit before being sent down to the morgue. Ahead of their arrival, a junior resident removes the IV lines and breathing tube and hurriedly sews the chest closed with ropy suture, trying to conceal the assault of our failed efforts.
Half an hour later, I’m on to the next consult — another 12-year-old boy who has broken his leg playing soccer. We are in the hallway, because the ER is so busy there are no exam rooms available. His dad stands beside him, while he sits on a gurney with his leg dangling over the side to allow gravity to help re-align the fractured bones. I crouch in front of him to apply a splint, and they pepper me with questions about how long he’ll be on crutches, when he’ll be back walking, running, playing soccer. Over the thrum of activity, I hear the shrill sound of a woman wailing. Without turning to look, I know this is the mother of the boy who was hit on his bicycle. As they pass directly behind me, she is inconsolable, supported by loved ones who mostly carry her down the corridor. I sink to my knees, momentarily frozen by the piercing siren of her grief. Once they are gone and I can no longer hear her, I resume putting on the splint. I can feel this father staring at me, though he says nothing. When our eyes finally meet, I want to tell him what fate has stolen from another family tonight. I want to shake him gently by the shoulders and say, “Her child died, a boy the same age as yours. Today, you are the lucky ones.” But of course, I can’t, and I don’t say these things.
Later that night, one of the orthopedic trauma fellows¹ stops by the ER to see if anything is brewing before she heads to the call room to sleep. I’m at a desk catching up on paperwork, and she asks how I am doing. I look at her, confused, not sure what she means. She mentions the 12-year-old who had died and says she knows these things can be hard. It is the only time in my 5 years of residency that a colleague will ask if I am okay. I am training to be a surgeon and have bought into the myth that I should be stoic and strong. I shrug and thank her and tell her I’m fine. After 25 years, I can begin to admit that, perhaps, I wasn’t. I’m not.
My practice now is composed primarily of elective surgery in healthy patients. I haven’t been a witness to death for many years. Recently, I checked on a 16-year-old who was ready to be discharged from the hospital. She struggled with post-operative pain and with anxiety that fueled the pain, but she had turned a corner after five days and was now ready to go home. When I arrive on the pediatric ward, a team is crowded in a room, two doors down from hers. I immediately recognize the urgency and focus — a patient is in distress. It’s impossible not to be curious and worried and want to rush in, but it’s a violation of privacy, since this is not my patient. And my resuscitation skills are rusty after all this time, I know my presence would be more hindrance than help.
I continue instead to my patient’s room and talk with her mom who is oblivious to what is transpiring 30 feet away — she chatters about her frustration with the dosing schedule of her daughter’s medications and updates me on each step of her physical therapy, even though I’d read the notes and written the protocol. She double-checks discharge instructions and asks again when her daughter can return to dance, which we’ve discussed countless times and she already knows will be months away. I want to interrupt her, not to shame her, but to press “pause” on the looping track in which she is caught. I want to shake her gently by the shoulders and say, “A child is dying right now. Today, you are the lucky ones.” But of course, I can’t, and I don’t say these things.
When I emerge, the eerie silence is familiar, unmistakable. The curtains of the other room are pulled closed, the lights turned low. Members of the team, doctors, nurses, a social worker, and child “life” specialist, stand around, not speaking, but not wanting to leave. They mill about in a fog, faces fixed with the shock of disbelief. When you get up for work in the morning, events like this are not penciled into your day planner: 3pm, the child in room 601 will die. When you go home in the evening, words are not adequate when your partner asks, “How was your day?”
Seeing the dazed, devastated expressions of this pediatric team instantly evokes a heavy empathy — I recall the feelings of powerlessness and failure that follow these experiences. I worry for them. And I worry for critical care colleagues in this pandemic who encounter death repeatedly each day, yet dutifully soldier on. There is suffering inherent in tending to the suffering of others, and I wonder why we have no ritual for this. In a hospital, where we care for and attempt to facilitate healing in others, why do we not have a practice to acknowledge the pain and trauma that comes in the course of our work? Some may argue it’s not appropriate to have a communal rite, since we don’t all share the same beliefs, and it’s more important to be politically or religiously correct. But I would do it differently now, at least for myself. In my town, there is a place along the waterfront where a pedestrian overpass hovers above a set of train tracks. When a train passes below, you have no choice but to clutch the chain link fence with both hands to avoid being blown back by the force of the wind. The cars are so close, it gives the illusion they will snare your shins and carry you away. If I had it to do again, each time I witnessed the passing of a human spirit, I would come stand in the middle of this bridge. When the train horn blares, I would hold on tight and howl like the mother of the boy on the bicycle.
¹ A “fellow” does not signify gender; it is the status of someone who has completed residency and is pursuing additional subspecialty training.
