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John Unknown WP 1017




It’s like something out of a horror film, or perhaps a nightmare. In fact, I had actually had a nightmare about something much like this earlier in the week. EMTs push the stretcher through the critical care hallway, but I don’t see their faces. I’m horrified but I can’t look away, much like an accident you drive by on the highway. I’m staring into the abyss that was his mandible, flaps of tissue gently beating as his body is pushed down the hall, blood dripping onto his mechanic’s jumper. The stretcher is pushed into a room, the EM resident ready to intubate, the surgery team with their scrub caps on.


EMS starts giving report. I hear them but am not listening. Instead I’m pulling out my trauma shears, walking towards the stretcher. Wondering how this man is breathing, wondering what made him do this, wondering how this gaping hole in his face will ever be repaired. His tongue flops to the right, unsupported by bone or tissue. He starts to cough, flecks of blood littering the air. The worst part of the entire situation is that the patient is mentating, eyes roaming. He is certainly in shock. Once the trauma attending confirms he is maintaining his airway and can breathe, a spell is cast over the room. Everyone vanishes. Nurses step away, residents call consults for plastics and ENT, attendings begin OR prep.


I’m at the side of the stretcher now. The patient and I lock eyes. His are piercing blue, worn, not afraid. I tell him softly that we’ll get him changed out of his clothing and into a clean gown. I start cutting him out of his jumper, my shears crunching through the thick cotton, blood streaking the blades. Not a stranger to the unknown patient, I check the pockets for a wallet, a license, some piece of identification. I find his worn brown leather wallet in his back right pocket. I learn his name. I ask him if he has a list of medications he’s taking and he fishes it out of the wallet. I start asking him other questions about his health without realizing he can’t verbally respond. He starts trying to mouth responses to me and I kick myself for being so stupid and inconsiderate. He can’t talk you idiot. Now that I know his name I touch his arm and say, “Give me one second, Mr. Smith.”


I burst out of the trauma bay, still trying to figure out if I’m leaving to help him or myself. My legs are shaking and I feel sick to my stomach. I ask a receptionist for a stack of paper and a pen, and then turn back around.


He’s still sitting there on the stretcher, alone. Someone has given him a suction tip so he can remove the clots of blood from his own throat. I approach the stretcher again, telling myself to put one foot in front of the other. Touch his arm. I hand him the pen and paper and ask him if there’s anything he wants to tell us. He writes down a phone number that I pass along to the social worker. His suction tip drops to the floor. I fiddle around and find another one, wrapping the tubing around the railing of the bed.


He taps my arm. I ask what’s wrong. He starts writing on the paper again, but this time it is a four letter word. P a i n. Tears well up in my eyes. I relay this information to the nurse, feeling powerless to provide him with chemical comfort.


Soon his family arrives and a meeting occurs. His daughter is crying, “I thought I got them all, he had the shotgun in the shed. He asked if bullets go bad.” The decision is made to proceed with surgery and before I know it I’m telling Mr. Smith that we are going to the OR, that we will take care of him. He nods once.


— —


In the OR he is intubated, we conduct a time out with the surgeon saying, “This is John Unknown WP 1017 and today we are going to irrigate and debride this jaw wound. Any questions?” In my mind I correct the name to Mr. Smith. We begin the procedure, removing bony fragments, cutting away damaged tissue. We re-wire what little remains of the left half of his mandible, begin approximating tissue for closure. Before I know it the bloody gaping hole of a jaw is repaired, a trach placed. It’s amazing how normal he looks. I’m left struggling, trying to reconcile the dissonance that is reverberating in my head. A repaired exterior. A broken mind.


Have we fixed anything?


— —


The next day we run the list of patients. He’s there, no longer John Unknown WP 1017. Mr. Smith, 81-year-old male, self-inflicted GSW to the face healing well s/p irrigation and debridement by ENT, trach placed. I don’t get a chance to see him that day, and instead plan to stop by the following morning to see how he is doing.


— —


I wander into the TICU and find the resident, wanting explanations. He shrugs, “Sudden asystole.”

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