Technology has evolved considerably since my first years in the Medical Center and, as we all know, the speed of that evolution is itself increasing. Today any reasonable 10-year-old can remember a time before the first iPhone. I can myself recall an even worse epoch when there were no cell phones at all, not even flip phones. In those days, I knew the location of every single telephone booth there was along the corridor between my house and the hospital—and along both sides of the road–because when my beeper went off, I had to find a pay phone in a big hurry to call in. This made for skittish driving when I was on call. And not just me: I know of accidents–one of them grimly fatal–that occurred when a colleague’s beeper went off on the drive home, or on the drive into work, and good road safety was challenged by the programmed, urgent need to find a telephone.
That programming was intense. My beeper had the exact, pulsing, intrusive sound of a microwave oven, which meant that at times it was hard to reheat coffee, warm soup, or toward the end even comfortably enter the cafeteria because–if I wasn’t self-consciously keeping myself in check– the sudden beeping from the microwave would send a surge of adrenalin through my system, and I was automatically prepared to take flight. We all were. In any given gathering–during lunch, grand rounds, in the break room–you could always see examples of twitchy people checking their little machines, and then quietly dashing for the exit to return the call.
To tell you the truth, all that electric excitement takes its toll. It is not always easy to confront trauma whenever the need may randomly occur. You try to get used to it, and certainly over time you have plenty of opportunity to practice toughening up, but defenses are imperfect. When you least expect it, something zings through, or sometimes you’re breached even when you think you are ready for it. Much of the failure in bedside manners arises from the personal compromises clinicians make between the instinct to care for a person—who may be hemorrhaging on the floor—, and the requirement to remain objective, and not be over-run by emotions. Often that compromise dictates the sort of medical setting you chose to work in. For myself, I preferred to treat adults; children wiped me out.
So I was prepared for the worse when, on one rotation, I was summoned to a medical floor to evaluate a 13-year-old boy who had shot himself in a botched suicide attempt. He had gotten into another argument with his older brother, and in his distress he went into his father’s bedside table to sneak out the police revolver there, and shot himself with it.
Among the many bad choices implicit in that desperate act, two stand out with particular irony. First, he chose a gun with a very large caliber: the weapon could have put a slug through an engine block. And second, he elected to position the barrel of the gun under his lower jaw, pointing upward, whereupon he then pulled the trigger.
As you can tell, he was very seriously wanting to die, but what he accomplished was a partial frontal lobotomy. The bullet went through the roof of his mouth and then out the top of his head with so much force that the damage of the slug itself was relatively concise–or at least it was non-lethal. From the neurosurgeon’s point of view, things could have been worse.
The concussive force of a weapon that size, however, inflicted massive secondary trauma. It wasn’t the bullet that inflicted the most damage, but the size of the blast itself. He blew off much of his lower jaw–his mandible–, so that the stump of his tongue was hanging unsupported from the back of his mouth. His upper lips were still charred black, and the shock wave as it traversed up through the back of his face, blew its bones outward, and pushed his eyes almost from their sockets, so that they bulged in the perpetual expression of surprised horror.
I should have read the medical chart at the nurse’s station before I entered his room–no one told me he had shot himself in the head, not his chest or something–but in truth I don’t know if it would have done me much good: I took one stunned look at his face, caught the expression in his eyes, and burst into tears. It was not one of my best moments at all: the last thing I wanted to do was make him feel any worse, assuming that could have been possible. There are better ways to demonstrate your empathy than weeping in front of your patient—which goes back to what I was saying before about managing your own emotions. Suck it up.
My embarrassment and chagrin helped me regroup: pretending I had a cold, I blew my nose, and started to engage him in something, anything. The referral question was whether he was depressed: a logical question, given both the reason he was there to begin with, and the widespread assumption that he could not be thrilled about his current prospects. He couldn’t speak, of course, but he had his facial expressions, he could write, he could draw, he could perform all manner of non-verbal tasks: everything between completing games of tic tac toe (a basic display of strategy), to responding to different versions of this logical relationship: if A=B, and B=C, then A also =? For example, if a large circle is associated with a small circle, then a large square would be associated with…what? You can communicate a great deal of what you have on your mind, and about how well your mind is working, without ever uttering a word. Just point to the picture that solves the logical relationship.
What he had on his mind was not really what folks were expecting. The executive portions of his thought were disconnected from the other elements of his cognition, and as a result he was not thinking coherently at all about his life, its sorrows, what he was going to do next, and so on. Instead, he was fundamentally agitated, unable to concentrate, and impaired in his ability to integrate what had happened to him, even though technically he knew most of the details. The quality of his thinking bordered on the delusional. There was nothing wrong with his memory, nothing terribly wrong with his intellect per se, but he could not put all the details together intelligibly. It was something like visiting a library after a major earthquake: none of the information was missing—all the books were still there on site—, but its arrangement was drastically compromised, and so nothing could reliably be located, no two things could be conjoined into a whole understanding. It was a disaster. What he was really feeling, therefore, was overwhelmed, not depressed. He was perpetually unable to grasp the import of events, or display reliable insight.
This portrait I am providing here came after I made multiple, subsequent visits after that first introduction. I kept coming back. In time, his surgeons were able to refashion a jaw for him out of one of his ribs that, with the implant of prosthetic teeth, was able to function pretty well. Problem solved, the surgeons were saying, everything works. We have a success here, they kept telling me with their rote faith in mechanical solutions. Surgeons just make the best Americans.