My First

Nathan Smith 

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Nathan Smith
 
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Year in Medical School: 3rd

Place of Birth:
Charleston, SC

Where You Grew Up:
Winston-Salem, NC

College: Bob Jones University

Major in College: Pre-Med

Goals (Medical School and Beyond): Cardiothoracic Surgery

Personal Philosopy on Life: "But whatever gain I had, I counted as loss for the sake of Christ. Indeed, I count everything as loss because of the surpassing worth of knowing Christ Jesus my Lord." Philippians 3:7-8

Favorite Quote: "I believe in Christianity as I believe in the rising sun; not only because I see it, but because by it, I see everythiing else." - C.S. Lewis

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I had just come from observing a CABG, a coronary artery bypass graft—something that heart surgeons do multiple times every day. One day, perhaps, I will be the one in whom a patient places his or her trust to use knife and thread, to expose them as no lover ever has or will, and to manipulate the thriving mortality within their breast for the chance of a few more years of life. The smell of seared flesh was still fresh in my nostrils, a by-product of surgical cautery, a tool for cutting tissue with minimal bleeding. It was an odd place for Michael Jackson to be passionately singing, yet he frequents that particular room via a few speakers and electronics. He sings melodies that thousands of unhearing ears receive while under heavy anesthesia, and keeps the surgeons and nurses subtly entertained while they perform yet another mundane open heart surgery.

A short walk down the hall brought me to an operating suite. There, a middle aged woman lay on her right side, completely naked. She was being swathed in alcoholic tinctures to minimize the risk of surgical wound infection. Her two sons were perhaps fifty yards away in another room, praying, talking, joking, weeping, bickering, encouraging, perhaps introspectively sitting while they awaited news of their mother’s operation.

The procedure was extremely gross—in the “gross anatomy” sense. One long incision began under her scapula just behind her left arm and extended diagonally towards her abdomen, passing under her breast and stopping just a few centimeters to the left of her navel. As the incision was opened, I marveled that her spine was not broken, so wide was the wound, so twisted was her body. Her shoulders were perpendicular to the floor while her pelvis and legs lay flat on the table. A short time later her lungs, stomach, spleen, intestines, and kidneys were pulled aside to expose the reason for the operation: a massive thoraco-abdominal aortic aneurysm. I would later learn there was a 60-80% chance for that aneurysm to rupture within the year, but at the time I only knew that she had a major problem.

The respect I’ve had for blood has always been high. I suppose everyone has a certain level of fear when they come in contact with the substance. The Israelite God Yahweh told Moses that “the life of the flesh is in the blood,” and consequently instilled the Jewish nation with respect and reverence for it. As a Christian, the fact that Jesus’ blood, His life, atoned for my sin adds a significant intrinsic-yet almost unconscious-value to blood in my eyes. My friends think that the mere sight of blood, to which I’ve become so accustomed in the OR, would make them faint. There in the operating theater I had no thought or inclination of fainting, but the sight of so much blood alarmed my developing surgical sense. Replacing someone’s aorta is bloody business, true, but her blood was flowing more freely than it ought to have been. Much of it goes into the “cell saver,” a device that cleans and reroutes surgical bleeding back into the patient via an IV. Though a significant amount spilled over the edge of the wound and down onto the floor my mind only touched on the mess in passing as I quickly glanced at the patient’s monitor: Blood pressure 70/40.

“Get her blood pressure up.”

The anesthesiologist injected something—as a 2nd year medical student I can guess it was probably epinephrine—but he overestimated the amount necessary. Her blood pressure sky-rocketed to 180/100, and a few arteries in the surgical field burst open, squirting small high pressure streams on the gowns of the surgeons. I had turned off Michael Jackson 10 minutes ago because of the intensity of the operation. A nurse asked me if I was praying when I opened my eyes after training my thoughts heavenward for a few moments on behalf of the patient.

170/98 — Still bad. 

160/95 — Better.

150/90 — Everyone was breathing easier and getting back to the operation.

120/80 — Perfect. This patient will pull through. “Thank you, Lord,” I whispered in gratitude for the answered prayers.

110/75 — Still no problems. I glanced only occasionally at the monitor now, since she was doing well.

100/60 — Surgeries often see patients bounce around a little, since surgical cutting and manipulation stimulates pain receptors which cause the release of catecholamines—stress hormones that, among other things, modify blood pressure. Besides, only God could anesthetically manage a patient perfectly under the knife.

90/58 — Where did this anesthesiologist get his training?

80/50 — A small hole had been found in her exposed lung. The resident sewed it up and then spread a small amount of bioglue on the wound while the surgeons paused and talked for a few seconds.

70/45 — Her heart rate was steady between 60 and 80, but her heart was beating weakly.

60/40 — The CT surgeon on the case reached deep inside her chest and began manually massaging her heart. Her blood pressure rose, and he paused after about thirty seconds. 59/38 appeared within two or three beats. Another 30 seconds of intra-thoracic-cardiac-massage, another 55/35. Again, one minute of massage, and another rise and fall in blood pressure.

Thirty minutes later, my own soul yearning with groanings that cannot be uttered, the surgeon abruptly called the resuscitation efforts off with a short “What time is it?”

Someone—I’ll never remember who—calls out, “11:01.”

“Time of death is 11:01.”

The patient’s heart beat—or perhaps I should say fluttered—maybe 5 more minutes as the arterial pressures slowly fell to zero. The patient was still splayed across her open casket, her skin pale as death. Not until then did I realize how much blood she had lost. The surgeon’s gown was soaked, his shoes full, and his socks saturated with her life. The resident grabbed a thick stitch and quickly sewed up the gaping wound, not bothering for the usual multi-layered closure. The nurses were chattering about the next patient, her two year old son, the church function, a joke heard yesterday. The patient just lay there, unhearing, unseeing, unfeeling, and lifeless.

“Nathan, you ok?” The surgeon was kind enough to remember I was in the room.

“Yes, sir.” I had already shed a few tears but quickly fought the rest back.

The less bloodied vascular surgeon came back from speaking to the family.

“How’d they handle it?” The CT surgeon glanced up at the returning team member.

“As good as can be expected—two sons.”

Did the patient misplace her trust in the surgeon? Wouldn’t she have still been alive right now if we hadn’t operated? Couldn’t the surgeon have placed her on ECMO—extra-corporeal-membrane oxygenation—and let her heart recover? How am I going to head back to school tomorrow morning and focus on classes? How do these guys do it every day? I had a few more hours to spend with the residents, and almost against my will my emotions became a little numb—a “coping mechanism”—and I went about my duties without an emotional response. The next few days, weeks, and months held an occasional tear for her, her family, myself, and perhaps for the surgical staff.

That night I turned to my Bible. “And the peace of God which surpasses all understanding will guard your hearts and minds in Jesus Christ,” Philippians 4:7. Terrible grief is endured by most families when a loved one doesn’t make it during a surgery, but I wondered if anyone ever paused to consider the surgeon. Most procedures are routine and generally successful, but bad cases happen often enough to be a significant emotional burden on anyone who truly cares for their patients. As I grappled with questions about life and death, about my own responsibility and my understanding of God’s sovereignty, something inside me was both shattered and rebuilt. My first patient death mattered, and it was proper for me to grieve, but I had an infinite Saviour-God who was there to help me bear the burden of responsibility. The surgical team had done everything in its power to save her, but ultimately God called her into His eternity. The scripture is clear that God’s ways are higher than mine—broader both in knowledge and purpose. “My first” brought me face to face with the reality that although I may not be able to find peace about her death, I could find peace in a God who assures me that He does all things well.

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Last Updated: 07-16-2010
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