Should ER Doctors Treat Bodies or People?

Megan Kalata is the first of the students to meet her second dead patient. She’s on trauma surgery, just a few weeks into her clinical year.

The trauma pager goes off – GSW [gunshot wound] to the head ETA five minutes. Megan, a petite woman in her twenties who clips her shoulder-length brown hair in place, races with her team to the emergency department. In transit, the surgery resident preps her, in a shorthand fashion. “Just so you know, people who have gunshot wounds to the head generally don’t survive.”

Duly warned, Megan arrives at the trauma bay as it fills with more than a dozen people. The room smells of latex gloves, industrial cleaning supplies, and the sweat pearling up on the clinicians despite the odorless air conditioning.

Megan moves away, huddled together with a classmate in an out-of-the-way corner of the room to watch the teamwork. A bullet’s entry point requires little skill to observe, but the skilled people in the room know the distinctive destructive paths different kinds of bullets carve inside the cranium. They know how to work determinedly, and together, to stop bleeding and prevent further damage to the brain. The hospital has a reputation as one of the best and fastest trauma centers in the country, but this time, the team is moving with less speed than expected. Watching the half-speed clinical bustle of the trauma team, Megan catches a peculiar energy. The clinicians are behaving, she senses, as if their work will soon be over.

Confirming that hunch, the team calls the students up, like rookies off the bench to finish off a rout, to stand at the center table. Her friend does chest compressions for a full two minutes, then Megan takes over. Megan’s resting expression is a smile that involves her whole face, while masking her resolute determination. Megan places the heel of one hand over the sternum and interlaces the fingers of her other hand to keep them off the patient’s chest. Then she presses down and up, down and up, worrying about whether she is doing it right.

Gregg Chadwick, 24/7, oil on linen, 2019. Used by permission.

A resident reassures her. “If the table is too high and you’re too short, or if you get tired, step out of the way and I’ll take over.”

A nurse helps her keep time. “OK. Go, go, go.”

She feels bolstered by the staff’s encouragement, even as doubts creep in.

“I don’t know how time works when you’re doing that,” Megan said, “but after thirty seconds or a minute, that was when they stopped everything and said, ‘OK, we’re going to check one more time for a pulse,’ and asked if anyone could think of anything else they could do differently.”

Megan is the last person to attempt resuscitation, the last person to lay hands on the patient before he becomes, through a physician’s declaration, a corpse.

“I think as a med student, in the back of your mind, you know that no one’s ever going to really let you do anything bad or wrong, but you’re also nervous. Whatever you’re doing, whether it’s closing a patient’s skin or doing chest compressions, you have this thought of ‘Who decided I could do this? Who let me in here to do this?’ But also: ‘I really want to be here doing it and I want to do a good job with whatever it is.’”

This day, the it is practicing CPR on a patient in his final moments.

Afterward, as the nurses clean up and the resident physicians file paperwork, Megan speaks with her classmate. They both noticed the same thing.

“The patient had a gunshot wound to the head, but he also had a gunshot wound to the hand that was through and through. I had been thinking, what were those last moments like for him? Was his hand up by his head? Was there one gunshot or two gunshots? But either way, no one was paying attention to the patient’s hand, and the hand was laying over the side of the bed with blood pouring out of it. And I got blood on my scrubs because it was just pouring out of the hand and because it was not something that anybody was caring about when this person had this gunshot wound to his head.”

The bleeding hand was not the it. The blood on Megan’s hand was not the it. The violent death of the patient – the heartache it would bring, the generations it would fracture – was not the it.

“I didn’t feel as sad as I would have thought that I would when seeing someone die. Then I felt kind of guilty for not feeling sad about it. But I didn’t know this person. I never saw him, never talked to him, didn’t see this person open his eyes.”

Megan learned how you can maintain emotional distance while gaining clinical skills on a dying person, even as he bleeds on you from a hole in his hand where a bullet passed through.

Maintaining emotional distance is one of the central lessons of medical training. For at least the past century, we have taught it before any other lesson. When the sociologist Frederic Hafferty observed medical training, he found that the first lessons of medical school occurred in the cadaver lab. A student’s first assigned patient, Hafferty observed, was a cadaver, and it socialized the student to the doctor’s role. That dead patient was also the patient with whom she would spend the most time for her entire career, the patient she would know best. But what would the student know? Not their hopes, their failures, or their sorrows like those of a friend. Not even their name, their rank, or their identifying number like a prisoner of war. A student would open a body and leaf through it to see how it resembled an anatomy atlas. Students learned to locate problems within individual people, explicitly the patient, but implicitly in themselves. Medical culture, Hafferty wrote, implicitly encourages students to “locate the source of their troubles in their own personalities rather than in the structure of the educational experience.” Medical schools use psychological language, which students adopt, to describe their enculturation as an internal reality (what they feel and think), rather than an external one (what they do, how they spend their time). A student’s minutes, hours, days, weeks, and months became subsumed into medical time in windowless cadaver labs before they learned to subsume their lives into the hospital. By the end of the lab time, a student dismantled her cadaver into her first textbook and built herself into someone who could focus on the skills necessary to resuscitate a trauma victim even while he was becoming a corpse underneath her hands. Medical education changed her into the kind of person who, after breaking open the body like a favorite text, will later perform invasive exams, becoming dirtied by its bodily fluids, and yet maintain emotional distance. That is what medicine has wanted from physicians for the past hundred years, to know the failing body intimately, to face death directly, all while retaining clinical equanimity.

We gain from equanimity – the composure and even temper – when a physician prioritizes a patient’s needs above her own in difficult situations. We lose from equanimity when a physician is so composed that she becomes distant from her own interior life, the people in her life, and the people she meets as patients. Dosing medical students with the right amount of equanimity is the challenge for medical schools: enough for a student to respond to a trauma, not so much that they become traumatized by the work. And the places that deliver medical school’s strongest doses are the cadaver lab and the trauma bay, the places where a sick person becomes an it, where a person becomes a textbook that can be seen, done, taught. This is the textbook of the body.

Occasionally, though, a student finds herself in one of those places and personhood intrudes, and she needs to know more, needs to be something more than merely composed.

Not long after seeing her second dead person, Megan was called to see what would have been, in an earlier medical era, her third dead person.

A bad car accident brought five people into the hospital. Megan was assigned to the person most grievously injured. The team spent six hours with the patient in the operating room, and Megan says, “It was touch and go with her for a long time.” Trauma surgeons can save people who surely would have died only a few years ago, and in this case, after all their overnight effort, the patient survived. Megan recounts that as she was finally leaving at the end of her shift that morning, “we walked past the SICU waiting area, and there were maybe thirty-five or forty people, all sitting there, all there for her, and crying and praying and talking to each other.”

It hit her. All night, she was with their loved one, on the same floor, separated by one corridor and her clinical distance. As she closed the physical gap, the clinical distance collapsed as well. She wanted to go to them, comfort them somehow. But the rest of the surgical team was headed out the door in search of scant sleep.

Megan recognized their response as professionally sound: they saw it many times before, and they would see it many times again, so they blocked it out to stay emotionally steady. Emergency physicians and surgeons talked about their work’s shifting “D/B,” or death-to-beauty ratio, and admitted that getting on the wrong side of the ratio could pull a physician down. Megan followed the team out the door.

For most med students, that would be the story’s end. The patient would remain an it they encountered during trauma, whose family keeping vigil they would walk silently past.

But Megan is different, so it was the story’s beginning. The patient survived the night, and Megan added her to her list of longitudinal patients. She learned the patient’s name: Esmeralda. As Megan followed Esmeralda through her stay in the hospital, Esmeralda became visible to her, familiar, known. She knew Esmeralda across time, how she lived, whom she loved, whom she worshiped. The textbook of the community.

When Megan compares her response to those two trauma patients, she names the felt difference between mourning a person and mourning an it.

“I felt a lot more emotion with her because we were there with her all night and saw her family crying. Then she was a patient that my team kept following, so we were checking on her every day, and then I met some of her family members and learned more about her. She is a single mom and has two kids.”

The clinical year transforms every medical student into a particular kind of physician. How it changes you depends on how you learn to work with other people. Pathologists see death’s premonitions in tissue samples. Trauma surgeons tragically feel death take over a body under their hands. Primary care practitioners attend to a person who slowly sickens and dies. Medical students decide what relationship they desire with death, an uncommon decision for people their age. They need to know the body, but they can also know more. Knowing more about Esmeralda impacted Megan’s response. Megan saw her as a mother. Then she thought about the victim, nameless to her, with the fatal gunshot piercing his head and hand.

“I felt kind of guilty not having that same emotion for that other person. So, yeah, guilty.” Megan wanted to transmute that guilt into a resolution, to be the kind of physician who knew the body well but could also be close enough to her patients that she could know them as people, even share some of their emotions. She wasn’t quite sure what kind of physician training she would seek in the Match, which assigns doctors to a specialty. Since Megan wanted to know her patients and be known by her patients, she was learning from a physician who had found a way to teach students from two textbooks: the textbook of the body and the textbook of the community.

Excerpted from Progress Notes: One Year in the Future of Medicine by Abraham M. Nussbaum, MD. Copyright 2024. Published with permission of Johns Hopkins University Press.

From the artist: 24/7 is part of my series of artworks in honor of the brave nurses, doctors, and health care workers fighting daily for our lives. I was brought up in a US Marine Corps family and learned the phrase "Run to the guns" as a kid. This is what these dedicated health care workers do. Artworks are on permanent display at UCLA School of Nursing.