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Last Night in the ER

There is so much that I love about the practice of Emergency Medicine, and very little that I truly despise and would change if I could. Last night, however, I had one of the fortunately rare cases that causes me to ever-so-briefly stop and re-consider my career choice.

This case involved a young woman (I'll call her "Christine") who had been riding on the back of a motorcycle driven by her boyfriend. He lost control and “laid the bike down” at a high rate of speed. No other vehicles were apparently involved. As the motorcycle slid across the harsh pavement, Christine suffered a complete amputation of her left leg above the knee and a severe crushing of her pelvis. Her rapid blood loss sent her quickly into shock. The rescue personnel (including our amazing Life Flight helicopter crew) responded quickly and began immediate resuscitative care. Unfortunately, she was in a relatively remote location when the accident occurred, but the flight crew packaged her and got her to us as quickly as possible.

As Christine was brought into our ER trauma room, she was amazingly awake and alert, and very lucid. She was frightened and in a lot of pain, suffering from both psychological and physiological shock. We moved quickly to assess and treat her injuries, and as the physician in charge of the initial resuscitation, I tried to calm her and reassure her. It was clear that she was very severely injured and would be going through major interventions in an effort to save her life. I, therefore, made the decision to sedate her, temporarily paralyze her and to take over control of her airway and breathing (a procedure termed "Rapid Sequence Intubation" or "RSI") in an effort to reduce her pain and to put her lungs and respiratory muscles at rest, thereby easing some of the work her heart needed to do. As I was about to put her to sleep, I bent over and gently spoke into her ear, “We’re going to take good care of you.”

Taking control of Christine's airway and breathing went flawlessly, and we rapidly poured blood into her veins in an effort to replace what she’d lost on the pavement and into her broken pelvis. We then moved her as quickly as possible to the operating room for care by our trauma and orthopedic surgeons. She was, however, still in shock as she was moved out of the ER.

A few hours later (and, for me, many ER patients later), the trauma surgeon came down to the ER to give me the very sad news that Christine had died in the OR. Her injuries and her shock were just too severe. I had just a few moments to pause and reflect before moving on to the next ER patient who needed our care.

We deal with death regularly in the ER, and every ER doc learns to deal with it in his/her own special way. I like to think that I have a healthy approach to dealing with patients at the end of life, and I feel that I am pretty good at helping family members and loved ones work through the initial phase of dealing with their loss. In Christine's case, however, there was no family for me to speak with, and the only “loved one” was her boyfriend who had been driving the motorcycle. His injuries were much more minor, and he’ll eventually make a full physical recovery. I’m not sure what his ultimate emotional injuries, scars and recovery will be however.

So, the part of Emergency Medicine that I truly despise? It’s those times when I bend over and whisper into the ear of a very sick or badly injured patient, “We’re going to take good care of you,” and, despite all my best efforts and the efforts of the very talented people with whom I work, those turn out to be the last words that person hears in this life...

Stay alert and stay safe.
- Dr. Bob
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.