by Studs Terkel
ER
Dr. John Barrett
He is Chief of the Trauma Unit at Cook County Hospital, Chicago. He still has an Irish brogue.
In 1966, the Trauma Unit here was actually the first of its kind in the nation. It’s dedicated to people who, more than being sick, are injured—patients who have been subjected to what we call intentional injury, violence. It’s gunshot wounds, stabbings, personal assaults. Other trauma centers see patients who predominantly are victims of unintentional injury: automotive wrecks and falls. Our experience here has been inner-urban, lower-socioeconomic groupings; predominantly young, predominantly male, and predominantly penetrating trauma: gunshot wounds and stabbings.
I AM THE THIRD of four sons. My father was a mail carrier, my mother was a dressmaker in Cork. The family really struggled to make sure that all of the sons went to university. My two elder brothers did science—chemistry and physics. I wanted to do something that was scientific in nature but more people-oriented. There was really no family tradition of medicine, but medicine seemed to fill my criteria. I can recall my eldest brother, Frank, saying, “This is a terrible waste of time—you don’t have to be intelligent to be a doctor.”
It’s not as if it’s rocket science. There’s nothing terribly difficult to understand in medicine, there’s just an awful lot of it that you have to remember. I always wanted to be a general practitioner. In my final year of medical school, I did a rotation with the then-professor of surgery, and I loved it. At the end of the rotation he said, “Well, Barrett, what are you going to do?” I said, “Well, Mr. Kiley, sir, I’m going to be a general practitioner.” He looked at me and said, “Barrett, there’s the makings of a great surgeon lost in you.” So that’s why I decided to do surgery. I realized that what I really, really enjoyed was the injured patient. It’s such an acute event: the patient is perfectly healthy, then something traumatic happens, and within a matter of seconds they are injured. They’re a great surgical challenge because they’re bleeding, they generally need surgical intervention. The epitome of those patients is the gunshot wound. Despite all the terrible things you hear about Northern Ireland and all the violence, where I was in the South we saw no gunshot wounds. I actually had to come to this country to see gunshot wounds.
I have found that surgeons have a certain personality. They tend to be very action-driven, very egocentric, frequently overconfident—especially trauma surgeons who will act very quickly with a minimal amount of information. That may not be the person you want to be your lawyer or your priest, but that’s the person you want to be your trauma surgeon. They tend to be supremely confident in themselves, and that’s why many people don’t like them. They tend to demean other people. It goes with the territory because you have to be damn confident in yourself if your job is to start cutting people open at the drop of a hat. People, when they hear that you’re a surgeon, they immediately look at your hands because they imagine there’s something unique about the surgeon’s technical ability. That’s not true at all. People have said you can teach educated apes how to operate—I’m not sure if that’s true—but it’s the decision-making process, not the technical stuff.
If you ask me to talk about life and death, the first thing I would think of is my patient. You begin to realize there’s not a sharp distinction between life and death. When is a person alive and when is a person dead? We have, for instance, patients who come in who are clinically dead: their heart has stopped beating, they are not breathing, their pupils are fixed and dilated. But we have them. The Chicago Fire Department paramedics are excellent—they get them in here fast. They’ve been without vital signs for a short period of time. You can still resuscitate some of them, you can bring them back . . .
Was it two weeks ago?—we had a man who was stabbed in the heart, came in clinically dead. We immediately opened his chest, released the pressure from his heart, sewed up his heart, and he actually recovered. He can’t have been dead because we got him back, but he was clinically dead. It’s not a very firm line; there’s a gradual blending from where you’re alive to where you’re dead. The people I see who are dead are in general young people who have suffered a calamitous event—they’ve been shot. You try your best. They’re either dead when they arrive or generally die fairly quickly after they’ve arrived. You can’t resuscitate them. The first thing that strikes me about it is, it seems such a waste . . . You’re looking at a human body, and as a surgeon you know its intimate details: the anatomy and the sinews and the arteries and the veins, and they’re now dead. This wonderful perfect machine is now no more. It’s frequently the smallest thing that has killed them. A stab wound to the heart will kill one person and it won’t kill the next. It seems to be such a capricious thing. What I really think a lot about is when children die. When adults die from trauma, you feel they have some degree of responsibility insofar as they chose to be in that place at that time. When a child dies, you think: Why did that happen? Five minutes’ difference would have changed the entire course of events. And parents ask you the same thing: “Why did it happen, doctor?” You try to explain: “He was shot, we did the best we can.” That’s not the answer they want. They want to know why this person who was awake, alive, and healthy this morning is now dead. You don’t have that explanation as a surgeon.
The first thing I feel, I feel angry, angry that they died, that I haven’t been able to save them. To me it’s almost like a personal defeat. I know in a logical sense that’s not true. I didn’t shoot them. It wasn’t my fault that there were guns on the street.
Remember how I characterized the surgeon? The surgeon is supremely self-confident. We whip them back from the jaws of death, we have the scalpel, we have the decision, we have the technology, and we have a system in this hospital that’s supposed to save them. But you can’t save them all. We don’t lose a lot, but we do lose them. So initially I feel angry. That passes fairly quickly because I then say to myself: What could we have done that we didn’t do? Actually, we talk about it as a group: Could we have acted quicker, recognized this quicker? Because even though this particular patient is dead, we may be able to improve care for the next patient. Then I think: What a waste! A total, absolute waste. Especially now. I’m fifty-five years old. It makes you think about your own mortality. We really don’t realize what a precious gift life is. We take it for granted. I’ve always taken it for granted. My children are growing up, my daughter is going to college this year, I’m growing older, and I’m surrounded by people who are brought in, some of whom die. It is a very, very fragile thing we have that can disappear. The stuff that you worry about . . . Are you going to get the house painted? The basement floods occasionally. My God, the car keeps breaking down . . . It’s all so trivial . . . We should really realize that the greatest gift we have is time, and that means you’re alive.
When the patient comes in, you might see someone who’s covered in blood. I don’t see someone covered in blood, I see somebody who has technical challenges. A gunshot wound to the chest with hemothorax, we need to get a chest tube in, determine the rate of bleeding, and make effective interventions. So right then and there, I’m not thinking great philosophical thoughts—I’m in a mechanical, operative mode. You just go boom, boom, boom . . . It’s like a very organized, choreographed dance. But then at the end, he dies. Then you say, “Let’s look back at the dance. Did we do something wrong, could we have done something better?” You do tend to become a little philosophical as you grow older. I’m convinced that the solution to all this violence is not surgeons. We need to somehow prevent it.
I come from Ireland, a country that has national health insurance. Every resident is insured. I’m an American citizen and I love being one, but I can’t understand why we can’t ensure that every resident of the country actually gets adequate health care. I’m so happy to work here at the County Hospital, because that’s part of our mission statement: We will not turn you away. People refer to us as the hospital of last resort. I think that that’s
a very noble thing.
People say, “Why did you stay?” It’s so perfectly logical to me. Here’s what I wanted: I wanted to be a surgeon who dealt with patients who required surgical intervention. Those are gunshot wounds. I also want to be able to teach people. I think it’s important that you pass on your skills. And to even do a little research, to maybe improve the care of the patients. Patient care, education, and the research, all three things I’m doing here. The money isn’t the greatest, and there are frustrations working in the public sector—but compared to what I’ve gotten out of it, I am one of the most fortunate people that you’ll ever meet. I would actually pay money to do this job. They pay me to do what I love to do.
When you lose a patient . . . I think every doctor has their own way. It’s not something they teach you in medical school, and they really, really should. Physicians and health-care people in general need to have a far greater degree of sympathy toward their patients, toward the patients’ family. No one ever taught me how to talk to a family and tell them that their loved one was dead, especially in a trauma situation. It’s one thing if a patient has, say, cancer and they become ill and then they die—it tends to be a process. You get to know your doctor, you finally realize the end is inevitable, you may have time to talk to your loved one.
Trauma is different. What happens in trauma is this eighteen-year-old leaves the house in the morning, perfectly healthy. Then the mother gets a call at two o’clock, it’s the Trauma Unit at Cook County Hospital: “Your son’s been shot. Please come in.” When she walks in, she’ll see me. She doesn’t know me, she’s never met me before, and I am now going to tell her that her son is dead. So how do I do it? The first thing that I do is I try to put myself into their situation. What they want to know is, is he alive or is he dead? I think you need to tell them that. Some people start telling them about he was shot and he came in and we did this and we did that. They’re really trying to impress the family with the work that they did to save him. That’s not what the family wants to know: they want to hear if he’s alive or if he’s dead. That’s what I tell them. I say: “You don’t know me, I’m Dr. Barrett, I’m the senior surgeon here tonight.” They won’t even remember my name. Sit them down. Sit down with them. Look into their eyes. If you can, hold on to them and say, “It’s bad news.” And they’ll say, “Is he dead?” Or they just look at you. You have to use the word, you have to say it: “He’s dead.” If you say he’s “expired,” he’s “passed away,” they don’t hear that. You have to say he’s dead. Then, then they react. They generally go into disbelief: “No, no, it’s not true—I can’t believe it . . . How could it happen . . .” Or they say, “It can’t be him. Are you sure?” All you do then is you just let them grieve. I think it’s actually helpful for them to come and see the body. I think that’s important. He’s all covered in blood, there’s tubes in him. That doesn’t matter. They want to see that person, they want to see that face. I say to them, “It’s OK to hold him, if you want to kiss him, if you want to talk to him.” I think it’s important to do that because, afterwards, they’ll go through that scene in their mind over and over and over again. “I remember the night they called me from the County and I came in and this is what happened, and that is what happened . . .” It’s very important to put yourself into their shoes, but you’ve got to say the word “dead.” You’ve got to give them the finality of it.
I ask residents, “How would you do it?” They’re trying to explain to the family what they did: “He came in, we intubated him, we did this, we gave him blood, we gave him CPR.” The family isn’t even listening to that! They’re not listening to it. After you’ve said he’s dead, they won’t listen to anything for a long time. Once they’ve calmed down, it’s important to tell them the absolute truth. “I don’t know what the circumstances surrounding the shooting were, but as far as I can tell, he was unconscious very rapidly after he was shot. He never regained consciousness. I don’t think he suffered.” Just tell them the truth, it’s always the best thing.
When you die, you die. Your body rots. Everyone knows that. There’s no argument about that. But there is a spirituality to us. If you want to call it a soul, you can call it a soul. I think of it more as the thing that allows us to choose to do good or evil. You kind of fall on one side or the other. You tend to be on the side of the good or the side of the evil. You can personify this as being God and the Devil. You can call this spirituality your soul, or not your soul, but whatever it is, I do believe it continues after your body is dead. I’m not sure that thing that’s going to exist after I’m dead would say to itself, “I am John Anthony Patrick Barrett and I remember everything about John Anthony Patrick Barrett”—I don’t think it’s that simple. I do believe in an afterlife, but I don’t believe that it’s up there in the clouds somewhere with angels flying around beating their wings, and God is an old geezer with a long beard.
Let me try it a different way. You do things that live on after you. Each of us, as we pass through life, influences others. You leave behind you a legacy of things you did and people you influenced. So even if you don’t believe in a life after death, you’ve had an influence. And people say, “I haven’t had any influence. What did I do? I worked in a steel mill all my life, I didn’t actually do anything. Got married, had a few kids . . .” Well, you did—you had an effect as you went through life, and it was either a good effect or an indifferent effect or a bad effect. That effect continues on. I have two children, and they’re going to have influences on people and they’re going to do things. I’m also a teacher: I’ve taught lots of people, hundreds, perhaps even a thousand people that I have influenced in a very fundamental fashion. Many of them are now surgeons themselves. There’s little pieces of me that exist in all of that. So even though you’re dead, you’re not gone.
If you said, “What do I think makes me different from other surgeons?” the short answer is I don’t know . . . But I will tell you I think it’s a word called “empathy.” I have the ability to think and feel like the other person. I don’t know where I got that, but it’s something almost instinctive. Maybe that’s what doctors need to have. If doctors are supposed to comfort, you’ve got to understand that the person is suffering; you’ve got to kind of live in your patient’s shoes. I don’t care if you’re a Hindu or a Jew or an atheist, it’s all fine to me. I certainly don’t believe that there’s only one true religion and one true God and only one way of getting to Heaven. If you believe in your particular belief, I respect that. You’re gonna get to Heaven every bit as fast as I am, and in fact even faster probably.
I remember the first dead person I ever saw—my mother’s father. I would have been probably four or five years old. I remember a big commotion in the house, getting dressed up and washed and cleaned and being on my best behavior. He was laid out in a morgue. I recall the body. He was in the casket. It was an open casket, and he didn’t look like granddad. It was this pale waxen look—it wasn’t him. The second one I ever saw dead was in Ireland. I think I was probably eighteen or nineteen years of age, and I was out on my bicycle. There was a guy who had crashed his motorcycle into a car. As I arrived at the scene they were getting the body out—and he was dead. And they were getting him out and I remember he was covered in blood. I haven’t thought about this in a million years. I remember, as they took him out, he had his watch on. I remember the second hand of his watch was still ticking. Why do I remember that? I think it was the thing that I talked about before. He was fine, and now he’s dead . . . but his watch is still going on.
If you had been born a hundred years ago, Studs, you wouldn’t have lived this long. Yet you’re still living a very productive and fruitful life. There comes a time when we really do have to balance that, though. Now, how do you make those decisions? These are actually not decisions that your doctor alone can or should make. Especially those of us who are technologically driven. If you were dying from something that I think I can cure by operating on you, I am going to t
ry and convince you to have the operation. You may have a totally different perspective on life. I think medicine needs to acknowledge that. Sometimes it’s not the patient, it’s the patient’s family who say, “I want everything done.” How much of that is driven by them because they want to be able to say afterwards, “Well, we did everything”? It makes them feel comfortable . . .
It isn’t a huge problem in trauma because we really do try to do everything, because the patients are young. But if I am at the stage where I’m absolutely convinced that the patient is going to die but I can keep the patient alive longer, I think what you need to say to the family is not, “What do you want me to do?” What I say to them is, “If the patient in the bed could talk to us, what would he say, do you think? You know him, he’s been your son or your husband. You know his approach to life. What do you think he’d say?” Then they begin to think: What would he say? They’re surrogates. I don’t want to know what they want to do because they’re filled with guilt and anguish, and half of them want to do this and half of them want to do that. I want them to tell me what they think he would do.
Then there’s the question about physician-assisted suicide. I can understand the sort of logic that says the patient is in absolute agony, the patient wants to die, and they want me to help them to die, but I don’t subscribe to that. I think there’s a huge difference between pushing someone into a river and having them drown, and seeing someone in the river drowning and doing nothing, letting them drown. If you look at the cases of physician-assisted suicide, man, you’d better be damn sure that you’re doing the right thing. You need to be damn sure. I mean, surer than capital punishment. You need to be sure that whatever it is the patient has is totally incurable and cannot be relieved. You’re dying because you’re in intractable pain? We can take care of it, I mean, we really can. This feeling that they’re turning to say, “Kill me, doctor . . .” They’re not depressed? There’s nothing we can do to help that depression? I don’t think I ever personally would feel so confident that I would do that.