Taboo

Preamble

I've been saving this draft I wrote long ago towards the end of my fourth year of med school, uncertain if I should share it. Was worried that I'd get in trouble for sharing something like that. It's probably unlikely, given that I'm not sharing any identifiable information about the patient or the personnel taking care of the patient. Plus, it's been so long ago... I doubt anyone other than myself remembered this incident. I've considered deleting it and just move on, but some things are hard to let go, and this is one of them. Sharing it now because it was so hard to talk about it when it happened then. Perhaps sharing it here now will allow me to see it in a new light, and put it to rest. So... here goes.

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My Emergency Medicine rotation was a memorable one, one that gave me some of the best and worst experiences in my clinical years as a med student. One particular incident left a deep impression on me, and I had to pen it down while it's still fresh in my head. On one of our on-call nights, my friend and I returned to the ED (Emergency Department) from a quick dinner break, only to find the red zone to be almost empty save for this one patient with the attending and a house officer huddling around him. The ED was divided into 3 zones - red, yellow and green (like the traffic light) - and patients were triaged to a zone depending on the severity/urgency of their condition: red being the most urgent/severe and green the least like a cold or a minor cut, with yellow in between with the potential of escalating to the red zone. As most med students can attest to, we usually like to be where the 'action' is, if not actually making ourselves useful during such occasions, at least watching and observing to learn a thing or two. And on that fateful night, a thing or two we did learn, indeed, albeit not what we expected.

A 60 year-old pedestrian was hit by a motorcycle, and was found unconscious on the ground for an unknown period of time. Upon arrival, he was found to have GCS of 8, with an active bleeding somewhere in the oropharnygeal region. He had no external wounds, no broken bones. His condition warranted a tracheal intubation to secure his airway before being sent for a CT scan of the head to rule out an intracranial hemorrhage. Unfortunately, none of these happened and he was not intubated until two hours later. Meanwhile, this man was bleeding quite profusely and we were tasked to suction the blood out of the cavity, as they tried to intubate him. I watched helplessly, worrying about him bleeding out. At the rate that he was bleeding, I was almost certain the blood being transfused could not keep up. It took another two hours to send him for the CT scan, because while all this was happening, his abdomen became increasingly tensed and swollen. The consensus was that there might be internal hemorrhage, but they couldn't seem to agree with the next step. It was between sending him for head CT only, or whole body CT scan. At this point it was close to midnight, the red zone started to get busy, the surgical residents who were called for consultation were reluctant to bring the patient to the operating room for an exploratory laparotomy to potentially stop the hemorrhage in the abdomen. Deliberate discussion took place, and then some, and in the end they decided they wanted a whole body scan. As all those were happening, patient's BP kept going down, his pupils fixed and dilated, and all we did was keep giving fluids and blood products. Bad luck had it that the CT machine in the ED wasn't working, so he had to be brought to the radiology department at another site, which was a long way away. It took us at least another 30 minutes to gear up before we were finally on the move to the other side of the building. Alas, as soon as we got there, the man coded, test was aborted, CPR was started while we wheeled the patient back to where we were 10-15 minutes ago.

It was of no surprise that this man died after an unsuccessful resuscitation; and everyone carried on with other tasks and patients as if it was just another death. Everyone except me. I was bewildered, stupefied, but most of all I felt helpless. Perchance when he came in he was already a lost cause, perhaps death was inevitable with the severity of his injuries, but we didn't know that for sure. Even if we did, shouldn't our job be to do our best to save his life, the emphasis here being 'to do our best'? I was upset not just because a person died that night, but that in every step of the way I felt we as providers could've done so much better. I didn't (couldn't) understand why everyone acted as if it was just another green-zone case, why there was zero sense of urgency, why certain decisions were made (and took so long at that), and why everyone appeared to be emotionless and moved on so quickly. Throughout the entire time no one contacted his family members, no attempt was made, or at least none that I know of.

I tried to understand what happened, and what could've been done differently to prevent this from happening, but I was stumped. This to me should be a case to be brought up during Morbidity and Mortality meeting, but when I asked the attending about it at the end of our shift, her reply to me was this, and I paraphrased: "... you will see things that are done correctly, and things that are handled poorly. Good and bad decisions, and behaviors/attitudes. Just learn the good ones, and ignore the bad ones..." For the second time that shift, I was baffled. Sure, yes learn the good and leave the bad behind. But what about the patients?! By not doing anything, aren't we silently consenting to the wrongful actions or behaviors? Does that not make us complicit? That morning I had trouble sleeping. I felt I've failed the patient, and I couldn't get rid of the guilt. As I eventually dozed off, I think I died a little inside.

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Afterthought
I still think about this man once in a while. I wonder if it's just me being the med student who was 'young' and 'innocent' and this was some kind of rude awakening to 'how things are' in real life. An initiation of sorts. Because how else do you explain why everyone who was working there acted so nonchalantly and went about their business? Maybe they felt something too, but had to hide it to be able to function. If everyone dwelled, then no work could get done. Maybe it's the culture to act tough and move on. Maybe like me, initially it got to them, but after a while if this kept happening, they just had to wall their emotions off, toughen up and learn to shut up and move on. Maybe they all felt helpless at some point, but believed that nothing could be done to change this and so they just accepted the way things were and learned to live with it. I don't know. These are just my speculations, because we weren't allowed to talk about it. Because pointing out some behaviors, actions, or decisions that might be questionable is forbidden, I didn't get to understand the root cause in that context. I doubt they really understood it either. It's such a taboo that you just learn to sweep everything under the rug and do your thing. If you want to survive, that's the modus operandi. 

My writing this and sharing it here wasn't intended to criticise or to let known how bad things are back home. Situations like these happen everywhere. The point is, there is a need to talk about it, to discuss and address the issues so that we can improve. Pretending as if it didn't happen won't prevent it from happening in the future, and then it's just going to happen again, and again, and again... We owe it to our patients to do our best, and make sure we do not repeat mistakes that can potentially cost lives. Primum non nocere, in English, means 'first, do no harm'. To do that, we've got to set aside the ego, and be willing to take the first step to talk about things that went wrong. I do not know if things will ever change back home, but I sure hope it will. One can only hope.