Wednesday, January 05, 2011

The World Keeps Spinning

The Road // La Carretera
Originally uploaded by Dark Botxy
or, Death doesn't take a holiday.

Nowhere is the fact that there is no holiday from illness or death than within the walls of he hospital. There are no holidays from tragedy. The world keeps spinning, life keeps marching forward and death keeps putting a halt to all those best-laid plans.
I recently started back on the inpatient palliative care service. Our first new consult came in fairly early in the day and my attending and I began to scope out the situation.
At first glance, the situation was ugly. A young man, involved in a car crash the day before, transferred to our hospital after a "prolonged extrication" from the vehicle. The trauma surgery team's note laid out injury after injury. Multiple broken bones - jaw, cheek, arm, pelvis, thigh, ribs. Internal injuries - liver damage, bowel damage, ruptured spleen that had been removed. Most dire, though: massive brain injury. Part of his skull had been removed to allow his brain to swell. The skull now tucked safely away inside his abdominal cavity, awaiting the time when (if) his brain would shrink back down to fit within the skull and the portion of bone could be replaced.
It's unusual for the trauma service to consult our service; much less consulting us within the first 24 hours of a patient's admission. This creates a dynamic in which we're never quite sure where we are going to fit into the plan of care or how extensive of involvement we can expect to have. My attending and I arrived in the surgical intensive care unit and "met" the patient for the first time. He was, of course, unresponsive. Machines breathing for him, tubes entering and exiting his battered body, a leg pinned in weighted traction, his head wrapped in gauze.
Taken in isolation, the situation is bad enough.
Then, the story of this man and how he became our patient, and what his family was experiencing adds layer upon layer of sadness.
He and his fiance and their dogs had packed up their car early in the morning heading out for a 1200 mile drive across the country to visit his family for the holidays. They were about an hour into the two day trip when the wreck occurred. Hit head on when another vehicle crossed the median of the interstate. The vehicle rolled over. The dogs were killed. The fiance suffered major injuries, too. Our patient, though, was the worst injured of the humans from either vehicle.
His family, those thousand miles away, got the phone call we all fear. Themselves out visiting friends, they were three hours from their own home when the phone call came to them. They went immediately to the nearest airport, nothing but the clothes on their backs and their wallets, purses and cell phones with them. As quickly as they could and at any monetary cost, they flew here.
We met this family, first at the patient's bedside, and then sitting down with them along with the surgery attending managing his care. It was the first time they had a chance to meet face to face with a physician to be given the list of injury after injury, and the news that, in terms of his brain, this young man couldn't be much closer to death.
Life, hanging in the balance.
Hanging by a thread.
Holiday or no holiday, a young man, a good young man, lays near death. His family, a good, loving family, has their world crashing down around them.
I met with them again this morning, delivering them no good news. I asked them if they had any questions, and concerns - a question I always feel ridiculous posing, since of course there are concerns, and questions, how do I even begin to know how to answer the question most looming, the question of, "why?" But this lovely, gracious family, through their tears and terror, smiled kindly, and thanked me for my time and support. "We don't even know what questions we ought to ask," his mother said.
Medically, I know how grim things look, and I think they understand, too. Of course, they hold onto hope, "we're still hoping for the best" they say.
With his sister sitting in the room, holding on to hope most tightly of all of them, I cross a line that we rarely get to cross in medicine, but often must in palliative care. I speak from my heart. I tell her we are in a situation when my heart makes me need to say what I'm about to say.
I know this must be horrible, I tell her, looking in her eyes. I know you are holding onto hope, and you have to keep doing that. If he were my brother, and I were in your shoes, I would want someone to tell me that this is the time I need to tell my brother I love him, and anything else that is important for him to know. I'm not asking you to let go of your hope, but he may not have another chance to hear these things form you, or for you to say these things to him.
There are tears in my eyes as I finish my sentence.
There are words I'm leaving unsaid. Things I know aren't fair for me to let her know.
That her brother is the same age as my own brother.
Young, healthy men.
My brother, like her brother, a good young man.
As I'm trying to prompt her to tell her brother she loves him, I begin letting the thoughts come too close to home - he could just as easily, just as randomly, just as tragically BE my brother. A flash of my family in a room, surrounding the bed of my brother enters my mind.
Stop. You can't go to that place. Put the wall back up. Quickly.
patient's family. I leave the room, letting them cry together.
Afterward, I make my mind move away from the place too close to my heart and try and keep it a safe distance the rest of the day.
On my way home from work, though, I called my brother and we exchange a few bits of conversation. I tell him, "It's important for me to let you know that I love you, and am so happy you are my brother." I feel my voice cracking. Knowing this rare and random expression of sisterly love probably has my brother freaked out keeps me from getting more emotional lest I totally rock his world. I tell him I have a very sick patient who is his age, that he has a sister, and that I want to make sure he knows how I feel, now, when he can appreciate it fully.
He says,"Ah. Well, I love you, too."
So, this holiday, amidst the usual holiday traditions and chaos, let's all make time to tell our families we love them. That we are proud of them, are better because of them, or whatever it is you would have them know.
I hope this family has a chance to do this now, not only with the patient, but with one another.

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