Wednesday, July 15, 2009

The Save



Dan J. Schmidt

I started medical school thinking I wanted to be a family doctor--someone who could work in a small town and deal with whatever walked through the door. But in our third year, when we received our first taste of clinical medicine, I found my surgery and ER rotations exciting. I was at our state's major trauma center, and I loved it. Fixing things gives me a thrill--and the power to save a life is even more alluring.

Each "save" felt like a miraculous triumph. Take the nineteen-year-old visiting Australian, stabbed in a random street altercation, his blood pressure dropping as fluid accumulated around his heart. Right there in the ER, he had his chest split open and his right ventricle patched by the very cool chief surgery resident.

But after several weeks of 5 a.m. surgery rounds and every-third-night call, I started to feel a nagging sense of unmet need, both my own and the patients'. To me, it seemed that the specialized care we were giving was excellent but fractured: No one was responsible for the whole person.

It was 8 a.m. during my third week of the rotation. The third-year resident had led us medical students through our rounds, and there'd been time for some drug-rep doughnuts before we headed down to the ER. At the nursing station, we joined those who'd been on call the previous night and were sharing their war stories.

"You shoulda seen what we just got!" said one of the students.

A twenty-something guy had come in with a near-amputation. "He cut off his arm with a Skilsaw!" (the powerful circular saw used by professional carpenters and builders). "He's down in the OR now. Orthopedic surgery thinks they can reattach it."

After the descriptions of the bones, the x-rays, the blood loss, I asked one student, "Which arm?"

She frowned. She didn't know. I looked at the x-rays. It was the right.

I caught the gaze of a third-year surgery resident and asked, "Do you know how hard it is to run a Skilsaw left-handed?" (It's a lot harder than scissors. I knew: I'd spent a year building condos before I'd entered medical school.)

The resident nodded. This injury was no accident.

That evening I heard the orthopedic surgery team talking about how happy they were with their neurovascular and bone-plating work. It looked like the patient's hand would be saved. But they were aware of his psychiatric risks: He was being kept in restraints until they could get a "full psych eval."

The guy was in the post-operative ward; when I'd gone around to check on my patients, I'd seen him. Straight black hair. Intense gaze. Cold affect. Girlfriend sitting at the bedside, then leaving in tears.

The next morning, the psych team came by to evaluate him. They started him on an antidepressant, but thought that he was no risk to himself.

Coming back from lunch that afternoon, I heard stat pages overhead, calling the chief ortho resident to a "thrash" on the post-op ward. Hurrying down the hall, I saw a bed barreling towards me, pushed by three residents. A nurse knelt on top of the patient and his bloody sheets, pressing her hands hard against his arm as they steered the bed into the elevator.

"What happened?" I asked the senior resident.

"He pulled it off! All that work, and he just pulled it off!" he raged.

Before the elevator doors closed, I heard him say, "Damn if we're putting this back on again! He'll get what he wants!"

And off they went, back down to the OR.

I went to his room. There were fine blood spatters everywhere, and a big, dripping arc across the far wall. The Filipina housekeeper quietly mopped the burgundy-stained floor, shaking her head.

A technological success. A medical catastrophe.

We had treated this man's injury, reattached his limb, evaluated his psyche--but not one of us had tried to care for the whole human being. It seemed that our academic and specialized-care system had accomplished a wondrous feat of technological prowess, but didn't foster a focus that could actually heal the patient.

Standing amid the gory mess left by a man I didn't know--a man who seemingly wanted not to be whole--I realized that I wanted to treat the whole person.

So I decided to stick with family medicine and left trauma and surgery behind.

A save still thrills me, although in family medicine they are thankfully rare. I get to keep my eye on the big picture. And I'm rewarded by a constant stream of quieter saves--the type 2 diabetic patient who loses fifty pounds, the alcoholic who's been dry for a couple of years now, the young single mother who's learning to raise her infant well.

These triumphs, bloodless but still lifesaving, keep me going.


About the author:

After seventeen years of practicing full-spectrum family medicine, Dan Schmidt now covers small-town practices on the weekends. Married, and with four grown daughters, he also fixes old cars and remodels houses--yes, sometimes using a Skilsaw. "I find that writing eases my need for reflection." This is the first of Dan's stories to appear outside of his Web site.

1 comments:

Cindy said...

Aaron, Very interesting. Treating the whole person seems logical. It that why you want to do family practice? Love ya, mom