Trauma Blues

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Trauma Blues

He came to my office last Tuesday, asking for more pain medication. He had a couple of drains in his right side that should have been removed two weeks earlier, but he missed that appointment. Phone calls from my office went to a generic voice mail and messages went unanswered.

On Monday he finally called the office demanding to be seen immediately. My receptionist got him in at the end of the office schedule the next day.

It started a month earlier with a drug deal gone bad. Either he tried to cheat someone or they tried to cheat him, the story was never really clear. What was clear was that someone really wanted him dead.

He was shot twice in the chest, and once through the abdomen. Whoever shot him took whatever money or drugs he had on him and left him for dead. Instead he got lucky. The clerk at a convenience store nearby heard the shots and called 911. A police unit happened to be in the area and responded within two minutes. They found the kid (he’s only 22 years old) within five minutes and the paramedics arrived only five minutes after that. Within thirty-five minutes of being shot in an alley behind a strip mall, he was in my trauma bay.

We started blood and plasma. I put tubes into both chest cavities to evacuate blood and trapped air and checked for entrance and exit wounds. We had him in the operating room within fourteen minutes of arrival.

The bullet that entered his abdomen did the most damage. It shattered the right lobe of his liver, tore through the upper part of his right kidney, and clipped the lateral wall of his vena cava before traveling through the lower edge of his stomach, ending up in the muscle of his abdominal wall.

We fixed the hole in the vena cava, repaired the upper part of the kidney and cleaned up and drained the liver injury. Twenty units of blood and plasma, two hours of surgery and he was stable in the ICU. I went off service at that point and turned him over to the ICU Trauma Surgeon.

He spent two more weeks in the hospital before being discharged. Apparently he complained the whole time about his pain not being addressed despite huge doses of narcotics and an evaluation by the Pain Management specialists.

Then he started calling my office. Usually, trauma patients follow up with the trauma clinic at the hospital for their postop care. I will often see patients that I operate on in follow up, but usually only when they have an open wound or are going to need further surgery to address an ongoing problem. My staff directed him to the trauma clinic but he had various excuses as to why he couldn’t go. Never once was it his problem. It was always someone else who let him down or gave him bad information or didn’t do their job.

We went ahead and scheduled a follow up for about ten days after his hospital discharge, that appointment that he subsequently missed.

Since then I have seen him twice and my office has fielded many more phone calls. He hasn’t followed up as instructed, he has ‘lost’ or been unable to obtain his prescription pain medications time and again and the only time he can be relied on to call is when he runs out of narcotics. Not once has he acknowledged that he nearly died and voiced any appreciation for the team that saved his life.

This is the less rewarding side of a trauma practice. Trauma is a disease of the marginalized, the addicted, the alcoholic, the disenfranchised. In my experience, only about ten percent of traumas occur to regular everyday working folks who are blind-sided by a major injury. The majority of trauma patients have chronic underlying issues that make caring for them difficult and frustrating.

I find that as I have gotten older, my ability to make allowances for their behavior and tolerate their demands has worn thin. Perhaps it’s burnout, or compassion fatigue. Maybe I’m just tired of dealing with people who can’t or won’t take responsibility for themselves. My Chief used to say that if you want to be a hero, get a dog. I don’t necessarily want kudos for doing my job, but would like to feel that I made a difference.

Occasionally I am surprised. Occasionally, a life-threatening trauma is a transformative experience, causing a patient to take stock of their life and begin to make changes. But to distressing degree, all many patients find is pain, bitterness and blame. They can’t see that their actions had anything to do with their injuries and as quickly as they can, they return to the same behaviors that got them into the trauma bay in the first place.

I have written before about my role as a craftsman, about how I see the integrity of my work in the OR as an end in itself. A good outcome for the patient is a happy consequence of that effort to do my best, but is not the primary motive for that effort. Some days, that commitment to the work itself is the only thing that keeps me from being overwhelmed by the futility of dealing with the people I serve.

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