Sunday, September 02, 2007

First on the scene

Even before I wanted to be a doctor, I used to imagine being the first person to arrive at some great tragedy, saving the day with my Boy Scout first aid skills. I've learned a lot of first aid since then, all the way through ATLS and ACLS, but still, I've never had to use it outside of the hospital. I'd never seriously considered it even, for despite the nature of my job, there was still a division between me at work, being a doctor, and me at home, being a 20-something guy with a cheap car and a nice stereo.

Until last week.

I had the unique opportunity, late one night after dropping a friend off at her apartment, to be the third person on the scene of a rather horrific motorcycle accident. When I pulled over and ran up to the site, I did have a vague idea that "I might do something good here," but it was shattered when I saw the one victim. Even though I'm not a surgeon, it didn't take medical training to realize there was nothing I could do for the dead man, who had hit a retaining wall while traveling maybe 100 miles an hour. (He had passed me moments before, and my last uncharitable thought as he sped over the hill was "he's going to get himself killed driving like that.")

The guy who got there ahead of me was taking a pulse when I ran up, and he looked up at me and said "I'm an ER tech, and I don't think there's anything we can do." I looked at the double amputation, the blood all over the road, and the apparent high neck fracture, and responded "I'm a doctor. And there isn't." We called 911, of course, but there was no bleeding to stop, and the EMS guys called him dead on the scene.

Two things stuck with me from that night. One, I called myself a doctor, claiming a certain level of expertise, intentionally. And I didn't feel inappropriate doing so. I also watched, with part of my mind amazed at the change, as the seven or so bystanders now on the scene seemed to relax. I think they all needed to know that there wasn't anything to do, and they felt bad not doing something, despite the horror of the situation.

Two, even as I called myself "doctor" I felt a bit guilty for not doing anything. This bothered me for quite some time actually, until I realized that it is actually my job to make that kind of call. It is my job to take the information I have about a patient, compare it to the knowledge I have of my abilities and resources, and decide how to proceed. And here I had few resources to use on a patient with two major arteries severed and no longer bleeding, implying he had exsanguinated. I think I made the right call, but it still was painful not doing anything while waiting for EMS to arrive.

The crowd started to drift away, having had their fill of voyeurism. The victim's fellow motorcyclist (who had missed the retaining wall and come back) knelt by the body, nearly hysterical. The guy didn't look more than 18 or so, and I realized, with a bit of a start, that I was moved myself. Oddly reassuring, because, having seen so much death in the MICU and CCU lately, I was beginning to wonder if I was losing the ability to really care about my patients.

There are at least two ways of caring, I think. It is possible to be emotional and tearfully connected to another. But this form of caring does a physician little good in an emergency, and that is where I demonstrated, at least at first, another kind of caring, in bringing my assessment of my talents to bear on the situation. There is time for emotion after all the action has been taken.

I'm not sure what this kind of perspective means to my life as an internist. Internists are supposed (especially by surgeons) to be the hand holding type, remaining emotionally connected with patients always. Perhaps I am that on some level, but I think this is why cardiology, and especially interventional cardiology, appeals to me. It will allow me to apply my internist's mind to an emergent situation like that faced in surgery. And if I go that route with my career, I will need that perspective on caring.

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