Wednesday, March 21, 2007

Dissecting the Dead and Saving Lives

Dissecting the Dead and Saving Lives

How can a dead person be of any benefit to the practice of Emergency Medicine” my first year medical school advisor asked me in 2001. “Well”, I said, “It’s like knowing the answer before asking the question.” I was sure that working at the Medical Examiners office in New York City during my one free summer in medical school would be useful whether or not I pursued an Emergency Medicine residency. When a young man who had been stabbed in the chest arrived at the Bellevue Emergency Department, where I am now a third year resident, I remembered that conversation and a summer spent performing autopsies in the cold, bright basement at 520 First Avenue.

“Trauma in the slot”, a voice rang out. I was taking a history from a patient with a headache. I dropped the chart and ran into the Critical Resuscitation Unit. EMS brought the patient in. “We have a 30-year-old man with a stab wound to the left chest, blood pressure 60 over palp, heart rate 120.” I performed a needle thoracostomy and we heard some air rush out from the catheter. Blood pressure was still 60 over palp. We immediately established large-bore access and ran 2 liters of normal saline into his veins. Moments later, the fourth year resident shouted, ”No pulse!” This is not good, I said to myself.

During the middle of my summer internship at the Medical Examiner’s office, I assisted on a homicide autopsy. The police report featured nothing unusual: a verbal dispute turned deadly when the perpetrator plunged a knife into his victim’s chest. The decedent arrived straight from the hospital. His body lay on a steel table with an endotracheal tube, fresh defibrillator burns, and ECG leads still attached. The image of the knife buried in the decedent’s chest and poking out of his back is seared in my memory. Our job was to determine the cause of death. This hinged on whether the pericardium and heart were violated or a major vessel was severed. After dissecting the mediastinum the answer became very clear. The knife penetrated the right ventricle, the pericardium was filled with clotted blood, and the heart was unusually empty. The patient died of pericardial tamponade.

I thought of that autopsy as the fourth year resident hollered, “Get me the thoracotomy tray.” With a firm sweep of the scalpel and twist of the rib spreaders, the victim’s heart came into view. It wasn’t beating. She made an incision into the pericardium and found a sac full of blood and clot. She removed the clots, located the source of bleeding, and stapled the lacerated myocardial edges together. Our patient had pericardial tamponade and survived, unlike the last case of tamponade I saw. He was one of the lucky few to undergo an ED thoracotomy and live to tell about it.

As a medical student, my experience at the Medical Examiner’s office allowed me to connect what seemed abstract in textbooks to the practical and concrete aspects of clinical medicine. I developed a clearer awareness of the physiologic mechanisms that separate the nuances of life and death so frequently seen in the Emergency Department. More than anything, I gained insight and knowledge about life while understanding more about what causes death.

As an emergency medicine resident at Bellevue Hospital, I do everything I can to find answers that will save lives. Though I am immersed in the emergent effects of disease on life, I am grateful that I had a summer to learn about death. It provided a head-start by giving me the answers before I knew the questions.

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1 comment:

jasonryz said...

Extraordinary it!