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Open Thoracotomy

Schultz, Megan L., MD, MA

doi: 10.1097/ACM.0000000000002584
Teaching and Learning Moments
Free

M.L. Schultz is pediatric emergency physician, Children’s Hospital of Wisconsin, and assistant professor of pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin. She was a fellow in pediatric emergency medicine at the time of writing; e-mail: mlschultz@mcw.edu.

His heart looked much more like meat than I thought it would. Bloody, red, muscular meat. Like you could cut off a piece and grill it up for dinner. His lung had deflated, now a spongy pink mass clumped like a wet towel at the upper rim of his ribcage. His heart still quivered irregularly inside his chest. Pulseless electrical activity, we call this. PEA. I don’t know the medical term for the act of holding a man’s heart in your hands after he has died.

It’s an odd feeling going into work and knowing that your patients, the traumas that will come in by ambulance and by car skidding to a stop outside the emergency department doors, are not hurt yet. Your patients are not patients yet. Your patient is still at work, cleaning out the oven and wondering about his own dinner that night. Your patient is still driving home, talking to her mom on the phone and cranking up the radio to sing along to her favorite song. Your patient is still drinking a beer on his front stoop, reveling in the warm April sun on his back. Your patient has no idea that today is a day that is different from all the other days. Today is the day that will separate the before from the after. When you walk into the hospital, you have no patients. Your patient list is empty. And so you sit, waiting for your patients’ days to turn.

He was a big man, easily 300 pounds. He had tattoos covering his neck and forearms, nipples the size of half dollars. He had a black monitor fastened to his right ankle, and his jeans were soaked with urine. He arrived yelling, gasping for air, kicking both legs. Twenty minutes later he was dead, arms out like Jesus on the cross, eyes open, chest open, his face an unhuman gray. Over those 20 minutes, his blood had slowly drained out into his abdomen. How funny, how silly really, that the difference between life and death is just the misplacement of blood. The difference between kicking and cold depends on a vessel wall just a few millimeters thick. At what point was the misplacement of blood too much? At what exact moment did he die?

As a pediatric emergency physician, I have had 10 years of medical training. Yet there is still so much I don’t know. Why do some children fight off strep throat without a hitch, while others die of overwhelming streptococcal sepsis? How do some patients survive multiple gunshot wounds with nary a broken bone, while others succumb to a single bullet? Why do some babies die quietly in their sleep, never to wake again? Why do some teens walk away from car accidents unharmed, while others lose their arms, their minds, their lives?

I don’t know the answers to these questions. I probably never will. What I do know is that every one of my patients has shaped me in some small way. I have not been able to eat meat for 10 years. I always wear a seatbelt. I am a foster mom. When my favorite song comes on the radio, I crank it up. Embroidered into each of these myriad decisions is the memory of a patient, a story about a child. Because who among us knows when will be our last dinner, our last phone call with our mom, our last chance to revel in the warm April sun on our backs?

© 2019 by the Association of American Medical Colleges