“Our mistakes should neither be forgiven nor forgotten. Otherwise, we’ll make them again.” – Yousef Nabeel.
“Beep… Beep… Beep“
I woke up to the sound of my pager bleeping. It took me a few seconds to realize where I was, the Emergency Department’s doctors’ room, or lounge as it was officially called. It was a small room that contained nothing except for a single bed and a rusty closet in addition to a plastic table that had a water boiler and a Nescafe jar on top. The room smelled of coffee, every doctor’s best friend. I had just put my head on the pillow and lied down less than ten minutes ago. Every time I think I can escape and get a few minutes of precious sleep, I get awakened by a nurse paging me, hardly ever for an urgent matter. I thought of calling to ask what the matter is but I had lost all hope for sleep that night. I glanced at my watch to see that it is almost five in the morning. I had lost track of time. I was yet to get used to these night shifts. I washed my face and headed to the ER where I was doing my first rotation of the internship year.
“Dr. Yousef, hurry,” said Alice, the head nurse of the ER as she saw me approaching. “What is the problem?” I asked, still sounding sleepy. “RTA victims have just arrived. Man with his wife and two daughters,” she said, jolting back my senses into me. RTA stands for Road Traffic Accident. “Page Dr. Mazin immediately and page the surgical on-call too,” I said as I ran toward the room she pointed at. Unfortunately, I was not prepared to deal with what was inside of it.
“Dr. Yousef Nabeel. What happened?” I said as I entered the room. I was able to hear the wailing even before I came close to the room. The wailing was coming from a lady in her early forties who was crying her heart out. “Ya Allah, Ya Allah,” she kept on saying. A man in his mid fifties was pacing around in his place saying over and over again, “Oh please God, save my daughter. Save her.” There was a young lady in the room too, probably my age. She was sitting on the chair at the distant corner and seemed to be in shock or lost in her own world. The man had a relatively large bruise on his face. The upper part of his thobe was torn apart and he had multiple lacerations on his shoulder, chest and left arm, none seemed particularly dangerous. The two ladies were disheveled but seemed to be fine with the exception of minor bruises and lacerations on whatever showed from their bodies. The reason for their concern was the girl lying on the bed in the middle of the room.
“Doctor, please help my daughter,” the father shrieked at me when he first saw me. She was unmistakably in a bad shape. It was the first trauma case I have ever encountered and I was not prepared. I did not know what to do. I froze in my spot for a couple of seconds before I shook my head and said, “Inshallah khair. We’ll do the best we can. Just keep praying for her.” “Karin, please take the family and check on their vitals and see if they are complaining of anything,” I addressed the nurse that was present. “Please go with the nurse and someone will be there with you shortly to check on you,” I told the father. “We are not going anywhere until we are sure that Amal is fine,” he said, firmly. I turned my attention to the girl because there was no point of arguing with a worried parent.
“ABCDE; Airway, Breathing, Circulation, Disability, Exposure,” I was thinking rapidly in my head as we were taught. She had a neck collar on. Do we do the head-tilt/chin-lift maneuver in this case or not? I wondered. I just opened her mouth and looked to see if there was anything obstructing the airway. I did not see anything. “Okay, good,” I thought. Her chest was rising up and down but on auscultation, her breathing sounds were muffled on the right lung. Her oxygen saturation was decreased. Her blood pressure was very low and I could barely feel her pulse. She had clearly lost a large amount of blood whether it’s from the openly fractured arm of hers or even worse, internally. Her limbs were cold.
“Insert two large bore IV cannulas and give her a 500ml bolus of Ringer. Send for CBC, Type & Cross Match, U & E’s.. umm.. PT and PT too,” I told the nurse then asked the family, “What is her blood type?” “A+,” the mother replied. “Do you have a document that proves that?” I asked her. “Yes, it’s written in her medical ID card,” she replied. “Tell the blood bank to send four units of Packed RBC’s of A+ immediately. Tell them we have an actively bleeding patient,” I ordered the first nurse I spotted outside the room because Karin was busy with the IV lines. “Quickly, please,” I yelled.
“ABCDE,” I repeated it silently. Disability, I did not check for that. I looked at the girl and she was obviously drowsy. “What’s your name?” I asked. She mumbled something incoherent. “Can you lift your arm?” She did not move a muscle. I pinched her left hand and she withdrew it away. “What is her GCS? There is something missing,” I thought to myself. Shit. My mind went blank and I could not remember the details of the scoring system. It did not matter anyway. “E is for exposure.” I started taking a quick look at her body to see the extent of her injuries. “Her lower limbs suffered only minor abrasions. Her right arm has an open fracture. Her right lung has muffled breathing sounds but the left lung and arm are relatively fine. Her face is bruised but other than that…” My thoughts were halted when I noticed blood oozing from the back of her head. I turned it to the side to see that there was gauze completely draped in blood and soaking. The paramedics must have had put them there. How did I not know there was an injury to the back of her head? Just as I was inspecting it, I heard the vitals monitor’s loud alarming sound.
Her blood pressure and her oxygen saturation were dropping to dangerous levels. “Where is Dr. Mazin?” I yelled. What am I supposed to do? They did not prepare us for any of this back in medical school. I took the Basic Life Support course more than a year ago. What did they tell us? My mind was racing but my body was frozen in its place. “Call a code,” I almost shouted at the nurse that entered the room that moment. She ran out to give the order. “Please leave the room,” I told the panicking family. “I can’t work with you around. Please get out so I can help your daughter better.” They left the room unwillingly and the mother’s wailing became loud again after it has subdued a while ago. “Code Blue. Code Blue. Emergency Room. Adult Code Blue. Emergency Room,” I heard the operator’s voice delivering the message through the overhead speakers. “Where is that blood? Damn it.” I was losing my self control and starting to panic myself. The nurses came with the crash cart. They did not teach us how to use the defibrillator before! I was sweating profusely as the nurses stared at me expecting me to run the code. “Don’t you understand? I don’t know anything,” I wanted to yell at them. Luckily just then, Dr Mazin entered the room.
“What is going on?” he asked. “RTA victim. Open fractured Humerus. Apparently severe injury to the back of head. Muffled breath sounds on her right lung. She was given 1500ml Ringer so far. And as you can see, patient is coding,” I filled him as he was instructing the nurses on what to do. “What is her GSC?” he asked me. “I do not know,” I said. “What about her abdomen? You did not say anything about it.” “I did not check her abdomen. I’m sorry,” I said with shame building up inside of me. How did I forget to examine her abdomen? He gave me a look as if to say, “An apology does not make up for incompetency.”
I stepped aside and watched as he tried to save Amal’s life. Everything switched into slow motion and the sounds mixed together until there was no distinct sound except for that of the vitals monitor. Her heart flat lined. I saw Mazin doing everything that is medically possible to keep Amal alive. I looked at him with admiration and wished in myself that it was me doing all of that. For nearly thirty minutes, he was trying to spare Amal’s family the tragedy of her loss. Unfortunately, there was nothing he could have done. She passed away. “Time of death: 5:41,” he said mournfully then paused for a second before leaving the room.
“I’m so sorry. We have done all that we could but she was severely injured. We tried to save her but it was her time. I don’t know what to tell you. My sincerest condolences. May Allah grants her entry into His heaven. May Allah grant you the patience and strength to make it through,” I heard Dr. Mazin delivering the horrible news to Amal’s family as I watched from afar. Her mother screamed in a way that I know for a fact that I will never forget in my life. Her father’s eyes were widely opened in disbelief in a clear state of shock. Her sister broke down in tears. I just watched. Her mother and sister could not hold themselves standing anymore so they sat on the ground and continued sobbing. The father tried to hold his composure. “La hawla wla gowat ella bellah,” he started saying over and over again. He had an empty gaze in his eyes and he was looking directly at nothing. He was shaking his head every now and then. I just watched. There is no dignity in death. It strips you down of all that you are and leaves you bare with nothing except for your beliefs. “Rabby Ajerny fy mosebty hazeh, Rabby ajerny fy mosebty hazeh,” he was saying. I wanted to tell them that I was sorry for their loss but I did not.
I just watched from afar like a coward. If I were brave enough I would go to them and tell them that I have failed them and failed their daughter. I should have been more prepared. I should have known what to do. I should have acted quicker. I should have been a better physician. My heart ached for them. I felt my eyes tearing up so I stepped outside the hospital for a moment. Guilt was devouring me and I needed to escape. The walls were closing in on me. Perhaps the air will cool down this fire inside of me. “It is my fault,” I thought to myself. It is my fault. It is my fault.
To be continued…
PS. This is the first chapter of a new story that I am working on. Don’t get excited yet about anything. I’m still not sure that it will evolve into something big but it’s a beginning nonetheless and Layla started as a single chapter one night two years ago. I hope you enjoyed reading this post. As always, comments and feedback are much appreciated. Thank you.