“Broken”: A Doctor’s First-Person Story

Summary: Below, a story from Pulse—Voice from the Heart of Medicine, an online magazine that publishes true first-person stories and poems about the reality of illness and healing.

The story below raises some questions in my mind. Is this a case of humanity being trumped by the “technological imperative” –i..e, “if you have the technology you must use it”? Or was the trauma surgeon correct in reaching for the ventricular fibrillator, making a difficult, but necessary split-second decision to try to save the mother first?

On the other hand, he paid no attention to the chief resident. Was he too aggressive, too certain that he, alone, knew what to do?  Certainly, he wasn’t practicing medicine as a team sport. . .

Perhaps the answer is to look beyond the either/or. . . .See my comment at the end of the story.

I’d welcome responses from nurses, residents, doctors, medical students and patients.

To learn more about Pulse, click here : http://www.pulsemagazine.org/story.cfm?dropdown_us=1


 Jordan Grumet

I was a third-year medical student in the first week of my obstetrics rotation. The obstetrics program was known to be high-pressure, its residents among the best. Mostly women, they were a hard-core group–smart, efficient, motivated–and they scared the heck out of us medical students.

I remember the day clearly: Not only was I on call, but I was assigned to the chief resident's team. I felt petrified.

We'd started morning rounds as usual, running down the list of patients in labor. Five minutes in, my chief got a "911" page from the ER, located in the next building. This seldom happened, so instead of calling back, we ran downstairs and over to the trauma bay.

We walked into pure chaos. The patient was 27, in her last weeks of pregnancy and actively exsanguinating–bleeding to death. She and her husband had been fighting; apparently he'd picked up a kitchen knife and stabbed her in the neck.

As the ER physician and the trauma surgeon worked rapidly on the woman's neck, my chief readied herself to deliver the baby. She turned to me.

"Quick, get me a sterile gown and a scalpel."

Helping her to gown and glove, I could see the other physicians getting coated by the blood spurting from the women's neck. She'd been talking when she arrived by ambulance; she wasn't talking anymore.

The nurses were pumping blood into large-bore IVs in both of her arms, but the patient's blood pressure kept dropping. On the fetal monitor, we saw the baby's heart rate starting to dip.

My chief cleared her throat: "Okay, guys, we're gonna lose the baby if we don't do something fast!"

Without taking his eyes from the patient, the trauma surgeon said authoritatively, "We can't. If you cut her, she'll die. Give us a minute."

"It will take a minute-and-a-half to have this baby out," said my chief. She got no answer.

She stood poised over the patient's abdomen, arm raised, scalpel in hand and ready to pounce.

The patient's blood pressure dropped even faster, and the baby's heart rate plummeted.

"It's now or never," said my chief. Then the cardiac monitor began beeping.

"Ventricular fibrillation!" The ER physician grabbed the cardiac paddles and shouted, "Clear!"

With a sweep of his arm, the trauma surgeon moved everyone away from the table, then stepped back–and crashed into my chief. She fell to the floor, extending her arm to avoid slashing anyone with the scalpel.

The electrical shocks, delivered over the course of several minutes, didn't revive the patient. Her wavy cardiac tracing flattened into one long, straight line.

By then it was too late to save the baby. Its heart rate had been too low for too long, causing severe, irreversible brain damage. As we listened, the fetal monitor went silent.

The walk back to the obstetrics floor was eerily quiet. I wanted somehow to comfort the chief…to comfort myself…but I didn't know how. As we reached the nursing station, she slowly came unwound.

For the first hour, all she wanted to do was talk. She grabbed every resident and nurse who walked by, going over and over what had happened. If only she had disregarded the trauma surgeon, things could have been different…

Then she became intensely quiet. She sat at the table in the middle of the nursing station, her face contorting into a myriad of expressions as she mentally replayed the events. Occasionally she raised her right arm as if wielding the scalpel again.

Finally, she put her head down and started to cry–loud, disconcerting sobs. The staff and patients passed to and fro, largely ignoring her. No one seemed to know how to comfort such a strong, accomplished physician in her time of need.

And there I stood–helpless in a sea of sadness and pain.

She cried for what seemed liked hours. Then she picked up the phone, made a call, placed her pager on the table and left the hospital.

A few minutes later, an attending came in to replace her, to pick up the pager and to collect me.

The next day, my chief returned to work. She acted as if nothing had happened. No mention was made of the day before.

She finished the year and is now a well-known attending physician at a prestigious medical center.

I'll always remember that day as the day that medicine broke her–destroyed her innocence. To me, she seemed like a soldier who had witnessed her first death in battle. Would she ever be the same? Or had she lost a sacred part of herself forever?

I feel sure that this is what happened because I remember when medicine broke me–one lonely night, watching helplessly as a patient died in the intensive care unit. I'd bet that most of my colleagues have had similar experiences. We rarely talk about them, but you might get some answers if you asked our loved ones.

They would tell you how we changed over the course of our medical training. How one day we came home from work seeming different. How a young, eager, empathic man or woman gradually became angry, frustrated and often cold. How we started out suffering with our patients, but ended up suffering from them.

And that's the paradox of medicine. We enter this profession out of a passion to help others. But repeated exposure to the most agonizing situations causes pain that can make us retreat into a shell of cynicism or "clinical objectivity." There, we risk losing the softness, warmth and caring that sent us into medicine in the first place.

Now, years later, I know that some of us–the lucky ones–recover. For me, the anger and frustration started to reverse six years ago with the birth of my son. Gradually, I learned to tend the wounds that medicine had inflicted on me. Now I'm no longer so scared of being hurt. Now I can cry with my patients, not because of them.

And now I finally feel like the physician I'd always hoped to be–a little more caring, a little more loving and a little less afraid of what the future will bring.

In the end, perhaps this is a story about the ambiguities of medicine. Often, there is no “right answer;” doctors and nurses can only learn to accept the inevitable uncertainty, self-questioning,  guilt, and feelings of helplessness that cases such as these” inflict” upon the care-giver—the “wounds” of practicing medicine. At the end the author says: “Now I’m no longer afraid of being hurt.” He doesn’t say “Now, I can no longer be hurt.”  

About the author:

Jordan Grumet is an assistant professor at the University of Chicago and practices internal medicine in the Chicago suburbs. He writes as an outlet–in response to his often busy and sometimes stressful medical practice.

Story editor:

Diane Guernsey

14 thoughts on ““Broken”: A Doctor’s First-Person Story

  1. Powerful indeed. Definitely a story about the ambiguities of medicine. We can only judge because of hindsight. For example, what if the obstetric resident had ignored the trauma surgeon and delivered the baby, but then the trauma surgeon went on to berate her loudly and publicly for the mother’s death? Would the live baby have been sufficient consolation? Or would the guilt over the mother’s death and the humiliation of being actively blamed for it have produced the same emotional effect? We have no way of knowing.

  2. Wow. Reading that story . . .hurt.
    Hindsight is 20/20. We’ll never know if the outcome would have been different had the resident done the emergency C section.
    I agree with Dr. Grumet . . . when constantly faced with tragedies, bad outcomes, and stressed patients/families who take everything out on us, it is easy to lose one’s humanity in the practice of medicine/nursing.
    It happened to me when I worked in corrections. It took YEARS to get it back.
    One thing I do think; that situation required a crisis intervention team. Perhaps the answer is to have staff meet with such teams periodically to allow them to decompress and build better coping skills. Don’t know for sure. DO know I could have benefited from one on more than one occasion.
    Great article, one that needs to get as much exposure as possible.

  3. A very powerful story. And a rich example of the value of self-caring as a strategy for healthcare organizations. Where was the support for all those involved in this tragedy? We human beings can’t give what we don’t have.
    This clearly, unfortunately, is not an experience that rarely happens. Here is an opporutnity to create a supportive experience within the organization. In our recent research, we uncovered 5 dimension of self-caring that heal heathcare. Beyond personal practices (that’s just the 1st dimension), the 3rd dimension encompasses interactions with others and the 4th relates to policies. If self-caring was the focus of the strategy, support structures would be in place when medicine breaks the care-givers. What experience would be most supportive? Rather then the doctor left to cope, on her own, crying in the nurses station, would there be a “safe space” to go for a while, and would this time alone be encouraged and expected? Would there be someone dedicated to talk with those involved immediately after the trauma? Perhaps there would be a universal “code lavendar” chime so everyone pauses to send healing intentions, even if most of the staff is unaware of the particular circumstances. The opportunites are endless when viewed through the lens of primarily caring for the caregivers first by weaving self-caring into the fabric of the “beinginess” of the organization.
    The research is available at http://www.experienceinmotion.net.

  4. Oh, COME ON.
    She was “actively exsanguinating,” her BP was dropping despite nurses “pumping blood into large-bore IVs in both of her arms,” and she went into V-fib. Does anyone honestly think defibrillation was going to save her? Trying to get the baby at least made some sense. I can see why you asked the question the way you did, Maggie. The ER trauma doc must have been thinking with his equipment.

  5. Dennis does have a point. I agree that defibrillation was probably a waste of time. You can’t have cardiac output if you have nothing for stroke volume.
    We get so caught up in our own specialties that sometimes it is easy to lose sight of the big picture. I don’t think the issue is of “if the technology is there you must use it”, not from this particular case anyway.
    I think the issue is, the ER doc was focused on the mom, and the OB was focused on the baby, and neither was thinking of both.

  6. #1 Dinosaur,Panacea, Deb, Dennis, Panacea
    #1–You’re right, if the obstetric resident had managed to save the baby, the mother still would have died, and in all probabillity the trauma surgeon would have blamed her . . . Though when the case was reviewed, probably the consensus would have been that the mother couldn’t be saved . . . See Dennis and Panacea’s second comment above.
    Thank you. And yes, I do think everyone involved would have benefited from meeting with a crisis intervention team.
    And perhaps, after a week or two, a review of the case with an attending obstetrician and another trauma surgeon would have been helpful–if only to make it clear that it was an impossible situation in the sense that both mother and baby could not be saved–though perhaps, on reflection, the baby had a much better chance . . .
    Yes, the resident definitely needed a safe place to go where she could cry–with someone dedicated to (and trained in) talking to a doctor after a trauma like this one.
    Thanks for the link; I’ll read it.
    I’m not a doctor, but from the description in the story it does seem that the mother was in deep trouble and may well have been past the point of saving, whereas the baby could have been saved . .
    I’m guessing the trauma surgeon was simply doing what he had been trained to do–without consulting with or even really hearing the obstetric resident. And what he had been trained to do was to use the equipment–instead of taking a second to hear what other remembers of the team were saying. In other words, he had been trained to practice medicine as a team sport.
    I think you are correct– when each doctor is caught up in his own specialty, it is hard to think in terms of the big picture.
    This is one reason why doctors need to be trained to work as a team, so that in a moment of crisis, they automatically turn to and listen to each other.

  7. I work as a trauma attending. In obstetric trauma, the mother always takes precedence—-the single biggest determinant of fetal survival is mother survival. This is Trauma Surgery 101. Once the mother progresses to unsalvageability, there is some evidence to suggest that post mortem delivery of the baby can lead to meaningful survival, albeit at meager rates of success.

  8. I agree completely with buckeye. In a trauma situation, the best thing you can do to save the baby is do everything you can to save the mother first.

  9. A trauma service will often have the best “team” approach of anything I have seen in all fields of medicine. We can discuss encouraging “teamwork” in medicine, but nowhere is it more evident than it is on a level 1 trauma service. I would point the finger at awful lot of other fields before I would point at the trauma service. All teams need a leader or a quarterback and that falls on the trauma surgeon. Without such arrangement it will fall apart into an incoherent mess.

  10. Thank you for introducing me to Pulse. Reading about these types of “case studies” always puts things into perspective.

  11. Butckeye, Jenga
    Buckeye– As you know, I’m not an M.D. Nor do I play one on TV.
    But two other doctors on the thread seem to suggest that, given the amount of bleeding, and the fact that transfusion wasn’t working, the mother couldn’t be helped.
    (Even if I were a doctor, I wouldn’t know; I wasn’t there.)
    But it does strike me that a guideline which says that “the mother Always takes precedence”–a rule which tells trauma surgeons to ALWAYS follow this guideline is a mistake.
    In medicine, things are often just notthat cut and dried.
    Clearly, there are times when the mother is beyond hope and the baby might be saved . . . Those are the cases where someone needs to make the decision that the baby should be treated first.
    When wise people say that medicine is now a “team sport”–they are not thinking of football.
    Even in trauma medicine –where decisons need to be made very quickly– trauma experts say that we don’t want “quarterback” calling the plays. .
    See these studies: http://www.marylandpatientsafety.org/html/education/solutions/documents/Improve_Clinician_Perception_of_Teamwork_and_Communication_During_the_Care_of_Trauma_Patients.pdf
    These represent a small sample. Try Googling “trauma medicine” and “teamwork.”

  12. Maggie-
    Simply averring that a dictum of trauma surgery “must be a mistake” is not a credible argument, as I’m sure you realize. C-section is a bloody procedure. What if that expected 600 cc blood loss was the straw that broke the camel’s back and pushed the woman toward death?
    Here’s a power point I give once a year at my hospital for CME on obstetric trauma.

  13. Buckeye–
    As I stated earlier on this thread I realize that I am not an M.D. Nor do I play one on TV.
    I was responding to doctors who said that, given the circumstances, the mother had no chance.
    I reallly don’t know.
    And given the fact that none of us were there, it’s probably also hard for doctors reading this story to know.
    I should add that I’m a bit concerned about the rule that “the mother should always come first.”
    When I had I my two children, I have to say that if anyone had asked me (my doctor, my husband) I would have said: “Save the baby first.”
    At that point, I had enjoyed 29-32 years of productive life. My children hadn’t yet had that chance. I knew that my husband would be an excellent father, giving a child great love. And for a mother, the idea of losing a child during child-birth–this is a tragedy that most women never get over. . .
    On the other hand, if a child loses a mother he/she never knew, and had a good father (and probably, within a few years, a stepmother), she may not greatly suffer from the loss of her birth mother.
    In other words, it’s just not at all clear (to me) whether doctors should put saving the mother first–or just assess the odds, and try to save whoever has the best chance of surviving.