Numb to the Violence: Five Years as a General Surgery Resident

I’m not one for written reflection. I certainly don’t keep a journal. But I made a point to write down the date—July 28, 2018. This was the first day that I saw a patient, victimized by insensible violence, die in front of me.

At the time, I was a surgical intern. My job on the trauma service was to complete the primary survey. The role of the primary surveyor is to perform a rapid head-to-toe assessment of the trauma patient and report critical findings to the team leader. It’s a job that nearly every surgical intern in the country is familiar with. On July 28, the emergency department took report that a motorcyclist was coming in after sustaining a gunshot wound (GSW) to his right arm. When the patient arrived to the bay, it became clear that the report and the reality of the situation did not align. I could see that he had been shot in the head; his extremities were uninvolved. The patient was an approximately 40-year-old African American male who was still wearing his helmet and leather jacket, which was engraved with letters from his motorcycle club.

I immediately felt his neck for a carotid pulse and there was none. The next moment is the one that has stuck with me. I cut the chin strap and removed his helmet and there was gray matter from his brain oozing out to the side of the bed. His pupils were blown. His time was over. That particular night we didn’t even observe a moment of silence. I didn’t talk to anyone about what we had had witnessed. We kept it moving because we had to. We had other patients to attend to, other families to break bad news to. I got a brief report from one of the officers on scene who stated that someone rolled up beside the guy at a stop light and shot him in cold blood. The police unfortunately had no leads. Maybe he was in the wrong place at the wrong time, or maybe he had it coming?

That event in isolation was enough for me, as it would be for most people. I had a couple of dreams about the event in the first few months after it happened; I have always been able to recall the face of that patient in my mind’s eye. Since that time, there have been other similar situations. In fact, I have cared for two to three hundred victims of gun violence since starting residency. Some encounters have been more serious than others. I’ve operated on many of these patients. Many of them have died. I’ve always rationalized that emotional toughness is part of the job. Surgeons need to compartmentalize their emotions so they can be effective. Plus, I have grit. I’m in the Army. I was raised not to be soft. I’m fit for this.

My thoughts and recollections about the aforementioned event became less frequent over the last few years. I became more accustomed to death, dying, and insensible violence. A lot of my numbness to what was going on around me resulted from the fact that I was just too busy to stop and process anything. I had operations to read about and learn how to perform, papers to write, and presentations to put together. You know, more important things to do.

Flash forward to a week ago. Now, I’m in my fifth post-graduate year and serve as the chief resident on the trauma service. I run things, or at least that’s what I tell myself. There was another call that came in overhead in the emergency department. This time the medics were reporting that they were bringing in an eighteen-year-old who had shot himself in the head. Per report, the boy had not had pulses for 10 minutes and the team was still 7 minutes out. I knew what to do. I told the team to start CPR upon arrival if the patient was still pulseless. We would quickly check his cardiac activity with bedside ultrasound, and if he had no cardiac activity, we would call time of death. Regretfully, this is exactly how things played out. This time we did observe a brief moment of silence, and I praised the team for a well-run code. The patient didn’t want to live, anyway. It was just past 4 o’clock in the morning, and in all honesty, I was somewhat relieved that this wasn’t a GSW that required a trip to the operating room. I was tired and just wanted to go to bed.

The next day, I woke up to a text from one of the interns asking me if it was a wild night. My first thought is that it wasn’t anything out of the ordinary. The intern relayed to me that one of the third-year medical students on the trauma service reached out to her and said that she had cried her whole drive home. About what? Then it hit me. I was that guy. The guy who was too caught up in his fatigue and sea of tasks to recognize the brand-new medical student standing in the corner having her own 2018 moment. She had literally just started her clinical rotations and barely felt comfortable taking a history and physical. Yet, here she was, watching a cool cadaver roll in with a self-inflicted GSW to the temple. There was no recognition of the tragedy, no discussion about this kid’s life, and no debrief. We kept it moving, just like we do.

After hearing about how much this situation had shaken the new medical student, I immediately thought back to July 28, 2018. I ended up calling her to talk about what had happened. I assured her that what went down was not the slightest bit normal, and she should not accept it as such. Most people will live their entire life and never see anything remotely as heinous. Outside of the medical field, or perhaps the military, such an event would be met with intense emotional reaction and likely deep reflection. I recounted to her some of my stories as a surgeon in-training, and she seemed relieved that she was not alone and that there was someone she could talk to.

The point of this story isn’t about me calling the third-year medical student after the fact. I was the goat in this situation. I missed my opportunity to make a difference in real time. I also don’t pretend to have easy answers to some of society’s most complex problems, such as the uptick in gun violence that has occurred over the last several decades. My goal in recounting these stories is simple—I want us to work on defining a new normal in medicine and surgery. We need to acknowledge the violence, death, and tragedy we see and have an open and frequent dialogue about the trauma we experience as providers. By supporting each other, we can help to stave off the numbness and create an environment of compassionate care. I’m certain we can do better.