Gimme Shelter

23 Jan 2019

By Alyssa Brown

        “It’s just a shot away, it’s just a shot away,” blared the music in the OR.   There was a flurry of hands and spurts of blood. But I should start at the beginning of the story.  I hate to say that there is something exciting about getting called in to the hospital in the middle of the night.  Logically, I know that means something bad is happening to someone else, but it makes my heart beat a little faster and my adrenaline rush to know I can potentially help.  I had been following a surgeon at a local hospital all Saturday. We didn’t have any cases so we both went home to rest at 3pm. We agreed that she would call me if anything came in.  She always rolled her eyes when I asked her to do this because she thought I should probably just get some sleep and enjoy my weekend. I got a text from her at 8pm, and it said, “Seems like a quiet night, so unless something changes, let’s meet at 8am to round.”  She had uttered a jinx by saying it was a quiet night. I decided to go to bed early and turn my phone up loud just in case.

        At 1 am, I sat straight up in bed; my phone was playing its loud jangling tone.  I didn’t recognize the number, but I went ahead and picked it up after rubbing some of the crust out of my eyes.  “We have a case. You don’t have to come in, but if you do, come through the ED, and I’ll prop the door open so you can get up to the lounge.  Be here ASAP if you’re coming, this case needs to go fast.” I quickly woke out of the fog. Before I even responded, I was pulling on a pair of scrubs.  I grabbed a pair of diet colas and a granola bar before half-jogging out the door.

         It was pouring rain and there was a chance of the roads flooding that night.  I didn’t think about it as I tore down the road probably a little too fast.  My mind kept rifling through the possibilities of the case. She hadn’t revealed any details, but I knew that it probably wasn’t an appendix, which is usually not a middle of the night emergency operation. It was definitely not trauma because the small hospital was not a trauma center.  I thought might be a gallbladder, but that can usually wait until the morning as well. I whipped my car into the ED parking lot. I walked into the front door of the ED and past all of the security and staff, and I shimmied through a door into the staff elevator. I slid through the propped open door to get into the PACU and down the hall to the lounge.  I took a deep breath before walking into the lounge.

        I found the surgeon curled in a chair, covered in a blanket fresh from the warmer.  She was reviewing the patient’s chart. I handed her the diet cola that she didn’t remember she needed. She was scrolling back and forth through a CT scan.  She told me to throw my stuff in her locker and look at the CT. I wadded up my white coat and crammed it into the top of the locker and hurried back out. Without turning, she said, “What do you think of this CT?”  My brain was still foggy with sleep, so I wasn’t sure what I was looking at, but it looked like there was a lot of bright contrast sitting in the peritoneum, which I knew wasn’t good. She began to fill in the details to add color to the black and white CT scan.  The patient was an elderly female who fainted that afternoon. By that night, a CT scan had been done in the Emergency Department, and blood was visible in the abdomen. Radiology reported a possible splenic artery aneurysm that had ruptured. That’s when the surgeon had gotten called.  It was her turn to try to make this patient better.

        She looked at me, and said, “We are going to get in there, get out, and pray that we can patch it up enough for her to make it through the night.”  As if on cue, the intercom screeched to life and said, “We’re ready for you.” The surgery floor always seems to be so full of life during the day, but at night, it almost seems haunted.   There are empty beds, empty carts, and you can only hear your own breath and sometimes the hum of a rogue machine. We walked down the hall towards the OR. I had seen her work her magic before, but not on a case like this.  She was usually bubbly and talkative as we strolled to the OR, but tonight she was quiet. She knew that the odds were not in her favor. She was the last chance to save this woman.

        The patient was moved into the room seamlessly.  The gloves and gowns seemed to appear on the surgeon, like a quick costume change, and everything seemed to quicken.  The surgeon strode over to the table and stepped up onto two step stools. As I stepped up to the table, my mind began to wander.  I thought to myself that this could be my grandmother, or someone else’s. It is easier once the face is covered to not think of these more emotional details of the patient.  It is easier to keep distance when they are just a case or just an anonymous patient on the table.

         Before I got too deep into these thoughts, the surgeon called for a #10 blade and traced it down the middle of the patient’s abdomen.  The suction was shoved into the fresh wound as we went. Blood began to run down the sides of the drape. When we could finally see the abdomen open before us, there was dark red, firm blood pooling throughout. Everything and everyone was at the ready.  Hands seemed to just know exactly where to go. Nothing was fumbled. There was a steadiness to the surgeon’s voice, with urgency but without harshness. The aneurysm of the vessel was hiding within the yellow clumps of fat. It stubbornly did not want to give away its position.  The surgeon began to pack the abdomen with laparotomy pads. She was shoving them down into the crevices and cracks of the abdomen to soak up any extra bleeding. We would leave them there. She dug and dug for the stubborn aneurysm, and finally decided coming back was a better option.  The patient would be closed another day, but for today, she would leave the operating room with a new vacuum-sealed abdomen. The surgeon asked for lab values. The anesthesiologist recited them to her, and I could see her begin to frown even from under the mask. They did not sound good, but we had done all we could do for the night.  Hopefully she would make it through the night.

        We stepped out of the OR and peeled off our blood-covered gowns. I looked down and realized that blood covered my clogs because, as usual, I had forgotten to put on shoe covers.  It was 3am. We agreed to meet back at 7am to round and check on the patient. I was exhausted. I was also worried that the patient would not make it to the morning. She was in a precarious state, and I was not sure if we could pull her back from that cliff edge. I came home and kicked off my clogs and fell asleep in my scrubs.

        The sleep came quickly, but my alarm came quicker. I was already tense about seeing the patient. I wandered through to the OR lounge where the surgeon was still staring at the CT from the night before and some new lab results.  I could tell from her expression that it was not looking good. She didn’t turn to me when she said, “We’re taking her back to the OR.” She stood and quickly paced down the hall; I didn’t ask where we were going because I knew this was not the time for questions.

        Eventually, we ended up in the family room of the ICU.  The family members were standing there clutching coffee and speaking in hushed whispers.  They quieted more when we appeared. The surgeon said, “We are happy she made it through the night, but she is going to need another operation this morning to keep her alive.  I cannot promise anything. Her chances are not good, but we will do the best we can.” Somehow, the family did not look surprised, or maybe they were still in a state of shock from the night before and hadn’t yet absorbed this new information.

        The surgeon began to assemble the team.  She listed them like a batting order—her surgical partner, a hematologist, a critical care specialist, anesthesiologist, and a first assistant.  The patient was full of tubes, hoses, and wires, so it was difficult to move her to the OR floor. We crammed into the elevator and hoped that nothing bad would happen on the way there.  Once in the OR, there was a flurry of activity. Things were going to go quickly again. The critical nature was weighing heavily in the room, but everyone there knew that it was a Hail Mary, and this team was the final chance the woman had to live.

        There is nothing quite like a surgeon in a critical case.  There is nothing wasted in their movements or words. The team worked like a machine.  It was like everyone knew what the other would do before they did it. The wound vacuum came off, the staples were removed, the abdomen was opened again.  It seemed as though time stood still. It was only 8am.

        “The floods is threat’ning, My very life today, Gimme, gimme shelter, Or I’m gonna fade away” wailed Mick Jagger.  It sounded like someone had turned up the volume. I could see the surgeon clipping vessels and saving this woman on the table as the song seemed to get louder  Two surgeons working together to fix this. Music makes the OR feel special, magical. There are sometimes indescribable moments in the OR that don’t seem quite real −a suspended disbelief, where miracles seem to appear out of the ether.  I thought for a second, there is no way that she isn’t going to make it off the table, not with the feeling that was filling the room. The room collectively sighed as the surgeons began to navigate the patient back from the brink. The bleeding was controlled, and everything was working perfectly.  Before I knew it, the case was over. The bubble of magic had burst, and the patient had survived another hour. As we all began to strip off our masks and gowns, someone pointed out that it was an all female team. There were leaders, but it was a group effort rather than a single person who saved this patient’s life, at least for a while longer.

        After the surgery, we continued to make rounds, but kept coming back to the patient. We kept wandering by her room to talk to her family and update ourselves on how she was doing.  By the afternoon, she remained stable. She was not awake or out of the woods, but her lab values and vital signs were improving. This was my last day with the surgeon because I had to go back to my normal rotation Monday. I finally went home.

        I woke up Monday and started my first day of a pediatrics rotation.  I kept thinking about the weekend patient, though, and I was worried.  How was she doing? I was afraid to ask. I was afraid to hear that she had passed.  I thought of texting the surgeon, but I did not want to bother her after an arduous weekend.

        That night, I heard my phone buzz, but I didn’t think much of it.  I finally checked, and it was from the surgeon. My heart dropped into my toes.  I was afraid to open it. I knew before reading it what it would most likely say.  It said, “She went into pulseless electrical activity this afternoon, and we never got her back.”  I responded that I was sorry, and I knew she had done all she possibly could. She had given it her all.  She responded, “Thank you.” For one of my first times during third year, I felt like the physician had the same feelings about the patient’s death as I did.  We were both hurting. I could tell she was grappling with what she could have done differently. She didn’t blame the other team members. She assumed full responsibility.

        Still, when I hear the song “Gimme Shelter” on the radio, I think of that patient, that night, and the magic of the operating room.  Some nights all that is left is a Hail Mary for the patient, but sometimes, the miracles do happen, and sometimes the true miracle is keeping them alive long enough to say goodbye.

Alyssa Brown grew up in Chattanooga, TN.  She went to Centre College for a B.S. in Biology and minor in History.  She fell in love with surgery after seeing her mentor perform an anoplasty during the first year of medical school.  In July, she finished her third year of medical school and wandered off the beaten path to get a PhD, before finishing her MD.  She is receiving her MD degree from University of Louisville School of Medicine, and her PhD in Biomedical Engineering and Physiology at Mayo Clinic School of Biomedical Sciences.  She is currently working on research projects involving pediatric ulcer disease, diaphragm sarcopenia, and benign breast disease. She currently works as part of the AWS Blog Subcommittee and AWS Instagram Subcommittee.  When she is not being a black cloud, you will probably find her in the pediatric surgery OR, baking sweets and pastries that she saw on “Great British Bake-Off”, or off on an adventure. You can find her on Instagram @alyssabrown1013 and Twitter @Alyssa_B_MDPhD

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.

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