“Code trauma. ETA 5 min.” The message flashed across my pager on a Wednesday during morning rounds. As I hustled downstairs to the trauma bay, I called ahead and asked, “What’s coming?”
“Mid 30s. Hanging. 10 minutes of CPR with ROSC. Intubated on the scene. Pupils fixed and dilated.”
“Damn,” I mumbled as I hung up. This was my third hanging in as many months. The other two had, predictably, not ended well.
I arrived in the trauma bay just as the patient was rolling in on a stretcher. The exam was consistent with what I would later describe to the family as a devastating brain injury. The CT scan displayed evidence of anoxia with impending herniation. The patient was admitted to the neuro-trauma ICU, but even 72 hours later, despite a GCS of 3T, continued to over breathe the ventilator.
Family arrived on Saturday morning and after I provided them with a brief update, asked “What’s next?”
Rather than launching into a discussion of prognosis and treatment options, I sat down to chat. I learned this patient had a long history of substance use, but had been clean for several years. I learned they had a long history of depression and that this was not their first suicide attempt. I learned they were spunky, difficult, full of life and “would never want to live like this.”
I inched closer to Mom and shared, “While it hurts my heart to say this, I need you to know that the likelihood of any sort of meaningful recovery is basically nonexistent.”
When Mom spoke again, she stated, with resolve, “Stop everything.”
And so began what I call “the dance of donation.” I have struggled with this many times: how can I best honor the autonomy of the patient, the grief of the family and the health and well-being of the greater community, including that of potential organ recipients? Over the years, I have had many mis-steps and have crushed several toes, but now, when families ask me “what’s next,” I reply truthfully: “Before we stop any treatment, donor services will approach you about organ donation.” While I realize every physician’s practice is different, for me, offering this “warning shot” feels genuine and kind.
The patient’s license indicated they were an organ donor and, after speaking with donor services, the family eventually chose to proceed with a donation after cardiac death (DCD).
Being present at a DCD is unlike witnessing any other death. It is always odd to invite family members into the OR, our secret and sacred temple. Dressed in ill-fitting white bunny suits, with blue bouffant caps on their heads and blue booties on their feet, they shuffle in like aliens, uneasy and awkward. For most people, witnessing a death is like traveling to a foreign country, where the local customs are strange, if not baffling. Witnessing a death in the OR is even worse – no one speaks your language and the land is cold and austere.
In this unknown land, I act as both the interpreter, translating the bells and whistles into simple words (“her heart is slowing down and the oxygen levels are falling”) and the tour guide, attempting to familiarize the family with local customs (“it’s okay to hold her hand” and “it’s okay to tell him you love him”), all the while keeping my eyes on both the patient and the clock. When faced with an impending death, I often counsel families that dying is like being born, that folks will often take their time and that ultimately, we need to be patient. In contrast, DCD – while terribly sad – is also terribly loaded. Everyone in the room wants the dance to cease. I have stood by as family members have fervently willed their loved ones out of this world within the hour, hoping to make some meaning out of the misery.
Once the heart stops, the music also stops and the dance comes to an end. The family is hurriedly escorted out of the room while the transplant team quickly scurries in through the back door, the two never crossing paths. The tempo is slow during this “no-touch” period, the requisite five minutes between circulatory arrest and declaration of death. And then the next dance, between scrub tech and surgeon, begins as steel meets skin.
The dance of donation reminds me that being a surgeon is holding space for both life and death. It is believing in science and praying for miracles. It is sharing the brutal truth and still maintaining hope. And it is smiling through your tears after leaving the OR, having just watched another surgeon hover expectantly over your patient, scalpel in hand, ready to transform loss into legacy, into life.