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I Hit the Aorta

Op-Med is a collection of original articles contributed by Doximity members.

I hit the aorta was flashing in my mind. 

Pulsatile blood spewing from an injury? Must be arterial.

Management? Midline laparotomy.

Complications? Ischemic injury to any surrounding organ including brain (stroke), heart (heart attack), liver, kidneys, lower extremities—the list was long.  

I was infinitely prepared for this clinical vignette on a test. 

The reality of a lethal surgical complication was like looking back at a sinking ship, recognizing the iceberg, and watching as the water quietly rippled, swallowing the ship piece by piece … while you searched for a solution isolated in its innards. 

I felt my mind glaze into a frozen, terrified, infantile space even as my hands moved quickly. A volcanic plume had erupted over the OR bed and the entire room was split between running to safety and collecting trays of instruments to control the smoke. But the smoke was pooling blood. Gurgling from the suction collecting my patient’s blood was the background symphony, my team and I moving in concert, packing the abdomen with lap sponges.

General and vascular surgery were en route. Scrub techs were bringing large, medieval-looking clamps into the room. Clamps for the largest blood vessels in the body. Trauma clamps. What happened to the last person who had needed these clamps? Did the clamps know what the outcome would be? Would they feel it when they clasped the sinews of the vessel? Did they gamble — or were they honest clamps, knowing the truth of the outcome the second they were applied?

I was floating outside my own body, watching us carve the abdomen open on a routine, meant to be minimally invasive case. Anesthesia was pushing fluids into thin veins, calling for backup, placing new lines. I heard someone from behind the drape say, “I can’t get a blood pressure,” and I felt my heart migrate into my eardrums, reminding me of how very alive I was. I felt wet tears under my glasses, soaking my surgical mask. This moment isn’t about you, I told myself. I needed to be composed, focused, at my best. I could hear the thoughts collecting in the back of my head, I wish this didn’t happen, I wish it happened to me instead, I wish I could just disappear. I snapped back into reality — I didn’t have time to think or feel.

The case lasted eight hours — or did it just feel like eight hours? Maybe it only actually lasted several hours?  Neighboring surgeons saw me outside the OR afterward and said kind, humble words. “If you’re not getting complications, you’re not operating enough,” they said. 

But had they felt for a pulse inside of her abdomen? Had they prayed to God that her mental capabilities remained when she awoke — that she didn’t have a stroke, that her legs still worked? Other surgeons said, “It’s not your fault. These things happen.” You weren’t there, I thought. You didn’t see it. You don’t know whether it was avoidable or unavoidable. You don’t know if it was all my fault. You don’t know. 

She woke with a tube in her throat in the ICU instead of in the postoperative bay. She woke with a gash from her pubic bone to her sternum instead of with crackers, apple juice, and two laps to walk around the nursing station before discharge. Did we warn her enough? When we said that the risks include death, did we say it quickly and with a smile, like car salesmen? Or did we stop; did we give a moment of pause for death?

I was at her bedside in the ICU when she woke up, confused and afraid, but grateful to be alive. Had I looked in her eyes like this before? Had I known that she had brown freckles deep in the amber? Did she know what I was saying with my eyes? How deeply sorry I was? 

When I was in high school, I remember telling my family doctor that I wanted to be a physician but I was afraid of getting HIV from a patient. He told me: “If you’re afraid of the kitchen, don’t become a chef.” I thought his words were callous then. Now, I stood in front of her family, piecing together the story of what happened, stumbling over phrases like “known complication” and “hopeful outcomes,” wondering what happens if a chef can’t cook. Or worse: what if the chef is afraid the meal will kill people? What if I was unwittingly the Typhoid Mary of the OR?

The white coat was so new that it lay stiff across my shoulders at the white coat ceremony. The words of the Hippocratic Oath felt exhilarating. I would have the privilege of caring for others. Yet at that moment, with her family, I felt its true weight, the adrenaline of being a novice worn off. I didn’t realize that in addition to being a promise, it was a mirror, questioning you about your own ability. Do I hurt people? Do I help people? Is intent enough? Or do outcomes dictate one’s worth as a caregiver?

The right things were done. The hospital reviewed the case, questioned the details, the measures taken, the reactions. A Morbidity & Mortality conference was held: What did you learn? Did you learn? What next? All questions answered, all answers questioned. They didn’t ask if I was sleeping. They didn’t ask if I saw her when I closed my eyes. They didn’t ask if I was having trouble operating because I kept seeing red every time I was about to make an incision. They did ask how I was. I’m fine, I said. That’s the right answer, right?

It’s been a year. She’s okay. She followed up. Can she read our eyes? It’s all there. More than 300 cases later, and I still carry the flash of red in my mind; it's like a scar along my palm that I trace my fingers over sometimes. I hear of a trainee with a major complication and I call him. I tell him my story. I tell him how he’ll question whether he should ever be allowed to touch another human again. He asks, “Will I get over this?” I say: You will. It’s now written into your story. It’s not the end or the beginning, but just a part of it. It won’t go away, it’ll feel raw when you recall it, but it’ll be followed by other stories, which will help the pain. It will be a clamp on a bleeding vessel in your heart that you will feel give way, sometimes; you will feel the pain intermittently, but the clamp will hold. It won’t give way. It’ll stay there until you are ready to release it, to feel the entirety of the injury, and to share it. Like all scars, it will heal but never be completely erased. It will serve as a memory in place of a vignette. 

Image: Surapol USanakul / shutterstock

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