The author of this piece is a surgical resident in Pennsylvania and this column, along with her painting (above) was published in the June 10th edition of the New England Journal of Medicine.

To say that the Covid-19 pandemic has changed all our lives dramatically is an understatement. The population of North Philadelphia is no exception. In a city where gun violence was rampant before Covid, bloodshed has only increased with the upheaval of the structure of everyday life. Over the past year, there have been more than 2200 shooting victims and 500 homicides in Philadelphia, reflecting increases of 54% and 40%, respectively, over 2019.1,2 In November 2020, while completing a trauma rotation, I witnessed the aftermath of such violence. One boy, along with many others from that time, will always haunt me.

When he arrived in the trauma bay, he was alive. He had been shot in the chest. I immediately started working to gain access to his femoral vein as another doctor monitored his airway. His legs were kicking as he screamed, “Help me! Help me!” As I focused on securing the central line, I noticed that the nurse holding his legs down no longer needed to apply as much force. His writhing had slowed, then stopped. I looked up at the head of the bed, where the trauma chief and the attending stood, and glanced down just in time to see the light in the patient’s eyes go out. “Don’t leave, don’t die. We’re here,” I pleaded silently.

Everything happened so quickly, like a choreographed dance. The urgency in the room was palpable. Everyone had a role, and all those roles were equally vital to the objective. One resident was intubating the patient. The chief resident took a scalpel to the left chest, just caudal to the nipple, curving cranially as he drove the knife to the bed. He saw me beside him and handed me the scissors. I opened the chest to find blood, as another resident placed a chest tube on the right. Blood sprayed out under pressure. I knew what that meant. I wielded the metal mallet and hammered the bladed bar across the sternum, extending the thoracotomy into a clamshell. We placed the Finochietto retractor, opened the pericardium, and cross-clamped the aorta. Blood was everywhere.

I scooped blood and clots out of his thorax to identify the injuries. And there they were. An 8-cm hole blown through the right atrium and a 10-cm hole in the posterior inferior vena cava. We did our best to clamp the holes and attempt cardiac massage. The clamps were not big enough. They would not hold, as blood leaked around them during attempts to squeeze the heart. We started sewing urgently, in an attempt to stop the bleeding and pump the heart. Even with our best efforts and several transfusions, there was no bringing him back. He had left us. What I saw before me was a teenager covered in his own blood, his chest flayed open in the attempt to save his life. The dance was over, and it had not been fast enough.

The attending called out the time of death. The room had quieted, and the teams shuffled out. I stayed, alone with the shell of a human, left to close the chest that I had opened. I closed his eyes and covered his lower body in a blanket, then began meticulously sewing his chest closed with silk.

When I was finished, I trudged to the locker room to change my scrubs – my pants were soaked in dark blood. I was shaking from the adrenaline crash, and my eyes were swimming with tears. As I pulled off my scrub pants, I realized the blood had seeped through to my skin. A nurse in the locker room looked at my shins in horror and brought me chlorhexidine wipes, a gentler solution than the bleach wipes I was using to scrub away the blood. I knew I had to pull myself back together. I knew my pager could go off any minute for the next trauma. I walked the halls and did what was required of me to finish my 24-hour shift. I felt numb as I walked out to the garage the next morning. I called my sister on the drive home, and I finally let myself fall apart and cry. “I am a surgeon. I am supposed to be able to stop bleeding.”

Over the course of the 6-week rotation, I was involved in seven emergency thoracotomies in patients with gunshot wounds. It was difficult, but over time I found peace in the quiet after each procedure concluded. I gently closed the patients’ empty eyes, covered their bodies, and sutured. Somehow, in making that closure perfect while I thought about their too-short lives and the loved ones they’d left behind, I felt that I was honoring the victims. Looking back now, I think that maybe in choosing to take on the task of approximating the skin of those corpses, I was really trying to put myself back together. I had been changed by what I had seen, and I knew it. I spent time coping outside work by painting a picture of that first boy (see image). I let myself feel the pain again with each stroke of scarlet paint across his body.

I wanted others to know about these violent deaths. I wanted people to know what I had gone through, what I had seen. I wanted them to understand it on a deeper level than the statistics they read in the news reports.

As I attempted to tell the people around me, however, I realized it was too heavy, too painful. It made them uncomfortable. My brother, an Army Ranger, who had recently returned from deployment overseas, pulled me aside. “We signed up for jobs where we see horrific things,” he said, “so that those we love don’t have to see them.”

Later, I was recounting the gory details of my rotation to one of my attendings, explaining how angry and frustrated I was. This was not what I had signed up for, I told him.

“Yes, you did,” he assured me. “You just didn’t know it.”

His response will stay with me, along with the faces of so many patients in their final moments. I am certain that no one can fully prepare for what they will encounter in medicine, nor what the profession will require of them. I certainly did not foresee the coming of a pandemic before starting this career. The reality is that we are often witnesses to the lowest and darkest moments in many of our patients’ lives. Residency takes from us in myriad ways; above all, it demands our time. I now know that it is paramount to set aside time to cope with loss and death — not only for our immediate well-being, but also for our self-preservation. Three years into my career as a surgeon, I am beginning to understand the true gravity of what I signed up for.