“This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong.”
Atul Gawande

     I left our orientation meeting convinced that Kaczanek was crazy, but as it turns out, he was entirely correct.  The first time I witnessed a patient death in the operating room, I was the intern scrubbed in on a case with the senior resident and one of the attendings.  An attending surgeon, also known as a staff surgeon, is a qualified physician responsible for instructing and overseeing surgical residents. The procedure involved a standard aortic aneurysm repair performed on a sixty-eight-year-old male patient.   I had seen him in pre-op, to make sure his labs were all in order and he’d gotten his antibiotic.  His wife was with him, and they were chatting and joking about some upcoming trip with their grandkids.

      In the OR, the anesthesiologist put him to sleep and got all the lines and the epidural in place.  Jessie, the senior resident, made the incision.  I retracted the bowel out of the way while she carefully dissected through the tissue to expose the aorta.  An aortic aneurysm is a dilation of the aorta with buildup of atherosclerotic plaque along the walls.  Chunks of the plaque can shear off and lodge in the arteries of the legs, causing blockage and damage.  Sometimes so much plaque builds up that not enough blood can flow through the aorta to the lower body.  Sometimes aneurysms that are large can spontaneously rupture, so the patient bleeds to death.  To prevent these terrible problems, we clamp the aorta, cut out the dilated, diseased part, and replace it with a gortex tube. 

     This aneurysm was pretty big, about eight centimeters, and very calcified.  Things were going fine.  Jessie had gotten to the superior edge of the aneurysm and dissected the tissue around it so she could slide a clamp across.  Dr. Davol double checked everything and was happy with the exposure and location for the clamp.  Clamping the aorta can induce some pretty significant changes in blood pressure, so he let the anesthesiologist know we were about to cross clamp the aorta.  Jessie carefully slid the clamp across the aorta and gently closed it under Dr. Davol’s close supervision, exactly as she had done numerous times before.  But this time, everything instantly changed.  The abdomen filled with bright red blood, overflowing the sides and spilling onto the floor.  The monitors started beeping furiously.  The anesthesiologist jumped up to stare over the drape, muttered “Oh, shit”, and started calling for blood.  Dr. Davol shoved his hand up towards the top of the abdomen, trying to compress the aorta higher up.  It must have torn when the clamp was applied, so if we could clamp it above the tear, it should stop bleeding.  I suctioned blood as best I could, while they tried to expose the aorta just under the diaphragm to get a clamp across.  My heart was pounding as I watched blood just continue to roll out of that abdomen.

     “You need to stop that bleeding, he’s losing his pressure, I can’t keep up,” the anesthesiologist informed us.  He was running liter bags of fluid through the IV as fast as the nurse handed them to him.  Someone came running in with two units of packed red blood cells, which he promptly hooked up and then yelled for more.  He was trying to make up for the blood that was being lost but couldn’t get it in fast enough.

“His pressure is dropping!  We’re in the 50’s.  You have to get control of that bleeding,” he barked at us.

     This did nothing but irritate the whole surgical team.  With blood streaming out of the abdomen and drenching our shoes, we were very aware that we needed to get control of the bleeding.  It was painfully, blatantly obvious to us that we needed to stop that bleeding. [Jennifer 1] 

     Dr. Davol managed to get a clamp across the aorta high up in the abdomen, and the bleeding slowed down, but not before the patient went into cardiac arrest.  CPR was initiated as we tore down the drapes and did a thoracotomy to try and clamp the aorta up in the chest.  As a last, desperate attempt to control bleeding from the abdomen, the chest can be opened, the lung pushed out of the way, and a clamp can be placed across the aorta up near the heart.  This stops flow through the injured area while preserving blood flow to the heart and brain.  As the incision went into the chest cavity, blood poured out onto the floor.  Dr. Davol placed the clamp across the aorta near the heart.  But the heart was literally empty.  He tried open chest cardiac massage, and the anesthesia team continued pushing blood and fluid and drugs for about twenty minutes.  No one in the room was ready to call the code, to say he was dead.  Dr. Davol finally stopped and backed away from the table.  Jessie continued to pump the heart, calling for the defibrillation paddles again.  She wasn’t ready to give up.  Dr. Davol told her it was over.  She defibrillated the dead heart again.  The anesthesiologist put his hand on her shoulder and shook it, as if to jolt her into reality.  She stepped back.   The monitors remained flatlined.  The heart lay there, eerily still.  

     Dr. Davol slowly stripped off his bloody gown and gloves.  For a moment he just grasped his face in his hands in silence.  Then he took a deep breath, bracing himself for what was to come next.  He slowly went out to talk to the family.

    It’s hard to describe the feeling in the OR when someone dies completely unexpectedly.  Everyone is so geared up during the code, and there is so much activity, everyone is busy doing something.  Once the decision is made that there is no chance of recovery of cardiac function, the code is stopped.  Suddenly nothing is happening.  Silence.  Stillness and quiet.  No more rushing around, no shouting instructions, nothing to be urgently done.   No one really knows what to say or think.  Utter disbelief envelopes everyone, making it hard to actually do anything, because you don’t quite believe it’s over.  It seems as if everyone is waiting for the heart to just spontaneously start again or something.  For a patient to die during a routine elective case was intensely disturbing for the whole team.   Jessie just stood there in her blood-soaked gown, wondering out loud over and over, “What the hell happened?  The aorta was soft, the clamp went on just like it always does.  What the hell happened?” 

     The autopsy showed that the aorta had split along the posterior wall all the way up into the chest.  He lost his entire blood volume into his chest and abdomen in about five minutes.  Jessie was profoundly shaken up by this for a while.  She felt responsible, like she had caused this nice old man to die.  Which, in fact, she had.  Just like Dr. Kaczanek had predicted.

---

 [Jennifer 1]Make this less narrative. Show – don’t tell.