By Birdstrike M.D.
It was intern year of my Emergency Medicine residency. I was on my trauma surgery rotation and working at least 100 hours per week (pre-ACGME regulations). To say that I was burned out and sleep deprived would be an understatement. It was three weeks into residency and I had done nothing but change dressings on my Chief resident’s patients’ putrid decubitus ulcers, run to get gauze packets, perform rectal exams, “RETRACT!”, and be the butt of senior resident jokes. I had learned so few real skills in procedures or anything else that I was seriously ready to quit at this point, but in way too much student loan debt to do so. I can’t tell you how many times I prayed for this guy to end up blind, impotent and in an adult diaper. My supervising resident, Chief “Violate” … I’m sorry, let me rev up my French accent, Chief Violetté was infamous for getting his first two surgical residencies shutdown due to his generally abusive nature, not to mention his penchant for being an exquisite jerk at the perfect moment. At his program’s ACGME site visit, when he was asked why he logged 168 work hours three weeks in a row during his first surgery rotation, his response was,“I wanted to work 170 hours, but when I got to 168, there were no more hours left in the week!” I must say, despite being a bastard with no equal, old Chief “Violate”(as I will refer to him from now on), made me take my game to another level.
It’s Saturday night. I’m on call. I’m dead asleep, and let’s just say I’m feeling a little “pukey” and abso-friggin’-lutely exhausted from having a little too much fun the night before at the local nursing school graduation after-party. I hear this insanely loud pounding on my call room door and our medical student is screaming, “Wake up! Wake up! The Chief’s got an intubation for you! He wants you in the trauma bay in 30 seconds!!” In a deep circadian haze, I run down to the trauma bay, and Chief Violate grabs my ear, pulls me into trauma room 1 and says, “I’ve got a procedure for you, big boy.” I look down at the patient on the stretcher and see a pair of boots, blue jeans, a belt, a man’s tattooed chest, a perfectly normal neck and … a bloody stump of a partial-head pouring out blood like a lawn sprinkler. As my sphincter tone increases rapidly to diamond cutting levels, the Chief puts a Mac 3 in my left hand and a 7.5 ET tube in the other, pushes me to the head of the bed and says, “You’ve been whining about not getting any good procedures, so cock, lock and get ready to rock, tough guy!”
To everyone’s shock and amazement, the guy is alive! He’s conscious! Choking on blood he screams, “Finish me off! Finish me off, and put me out of my misery, you bastards!” Apparently, instead of pointing the shotgun at the back of his throat towards his brainstem which would certainly have been instantly fatal, he put it in his mouth and pointed upwards, tearing off his upper teeth, maxilla, nose, eyes, forehead and frontal skull, leaving the key parts of his brain intact.
As my heart rate creeps up to near SVT levels, the Chief painfully flicks my ear and says, “What the hell are you waiting for? Intubate him, All-Star! Don’t worry. This will be the easiest airway of your life.” Only having intubated sedated animals and rubber dummies and never having intubated any patients that shot their faces off before, clueless, I begin to make my move. “Just wait ‘till he takes a breath, and shoot for the bubbles. You can’t miss,” says the Chief Violator. Trying to see beyond the blood splatters on my face shield, I realize he has a very good point. What intubation can be easier than one where you can literally look down the patient’s airway without any “face” to get in the way? I wait. He takes a breath. Out comes a bubble and in goes my tube. Score! First life saved: “check”. First intubation: “check”.
“Alright, cowboy. Nice intubation. Are you ready for the hard part?” says the Chief. Not believing that there could possibly be a “harder part” I answer, “Yes”. “Now it’s time for you to go tell his family the good news and the bad news,” the Violator-in-Chief shoots back. “There’s good news? What the hell is the good news?” I ask. “The good news is that he shot his face off,” he says. Even more puzzled, I ask, “What’s the bad news then?” The Chief’s answer, “The bad news is that he’ll probably survive. Good job tonight, bro. You da’ man. The trauma service is yours tonight. Only call me if someone needs an operation.”
I walk alone to the family consult room, take a deep breath, and open the door. Standing there is a pretty young woman, the patient’s only daughter, not likely more than a few weeks over the age of 18. She is strangely expressionless, stoic almost. “How’s my dad?” she asks. I am oddly more anxious about breaking the news to her, than I was actually during the trauma code. “He shot himself,” I say. Showing no emotion, “Is he alive?” she asks. “Yes he is,” I answer. “Is he going to make it?” she asks. “It’s too early to say, he has terrible injuries to his face and head. He’ll be in the ICU indefinitely. I’m very sorry, that this has happened,” I answer. Expressionless, she says, “Thank you,” and walks away without asking to see him.
After my heart rate drifts back safely below SVT range, but not before I can go to the bathroom to check my underwear to see if I unloaded in my pants during the trauma code, it becomes clear that faceless John Doe is anything but a “John Doe” to us. According to his chart, he is a “frequent flyer” to our ED for various drunken, disorderly and violent acts. In fact, 6 years before as a medical student, the Chief himself had sewn his now missing face back together after it was fileted open multiple times by the police after resisting arrest. The crime: rape. The victim: his then 12 year-old daughter.
After a few hellish weeks, bloodied, blind and in agony, his condition worsens. A family conference is called. The only one in attendance other than the ICU team: his only daughter, now of adult age in control of his fate. They discuss his prognosis: grave, at best. The options, they explain, are as follows: 1) To keep him alive, intubated on life support, in a painful living hell, or 2) To extubate him and let nature take its course, which will likely bring death quickly. They explain to her, that to be aggressive, to keep him alive in this state would likely be nothing but futile and immeasurably cruel, and that most certainly he will die anyways, but in much more prolonged agony. They also explain that to extubate him would mean that he will likely die quickly and painlessly, that this is by far, the more humane option.
The ICU team had talked amongst themselves beforehand, all knowing that years earlier he had cruelly and repeatedly raped her. In a way that they never had before, they secretly hoped that she would ask them to make him suffer and choose the cruelest of all fates for him, to keep him alive and prolong his suffering and agony. Certain, and secretly hoping, that she would bring him to justice by keeping him alive and instructing them to prolong his “prison sentence” of pain and living hell, they decided that either way, they would respectfully follow her wishes. They anxiously wait for her answer.
“Extubate him,” she says. “Let him die.”