In the third year of medical school, on the second day on neurosurgery, I am assigned to shadow the resident Dr. Fernando Diaz and follow him to the University Hospital Emergency Room at about nine PM. An old man lies unconscious on the stretcher. He had taken out his garbage, slipped on the icy sidewalk, struck his head and didn’t wake up. Despite an operation–the first craniotomy I ever saw–he would die the next day.
I learned a lot from his case–how to evaluate the unconscious trauma patient, the steps of emergency brain surgery, quick evaluation and treatment of bleeding disorders. Yet, the big question, the Why, remained unanswerable. Why this time, after taking out his garbage thousands of times, walking on icy sidewalks every winter of his long life, why is this the last thing he does?
A couple of years later, a young woman walks across the New Haven green on a blustery Spring day. A limb breaks in the wind and falls, striking her on the head and knocking her to the ground. Rescue is called and she is brought to the ER but it is too late. She is dead on arrival.
Two years later, an eight-year-old boy is playing on the sidewalk waiting for his school bus on the busy Whitney Avenue. He trips and falls into the street in front of a garbage truck. Brakes screech, horns blow, but still there is a sickening thump. Traffic stops. An ambulance arrives and the boy is transported to the ER on a respirator. He was only a couple of years older than my oldest son and got hit in front of the preschool my son attended.
An act of God, according to the Wordbook dictionary, is a natural and unavoidable catastrophe. Most ER trauma cases are not acts of God. Someone pulls the trigger, someone gets drunk, someone drives too fast–and someone suffers an avoidable catastrophe.
But sometimes a guy just takes out the garbage. Or a woman walks across downtown green space. Or a kid plays while waiting for the school bus.
The hospital staff has a funny reaction to the acts of God. Everyone does their job, but I hear the murmurs and the whispers. He should have put salt and sand on his sidewalk. She should have waited out the storm before going for a walk. Kids shouldn’t play so close to the street. We blame the victim.
It is a defense mechanism. We want to believe that a catastrophe is someone’s fault. If we behave and others behave, we will be protected. Otherwise the world is unpredictable and dangerous.
But sometimes there is no one to blame except God.
I learned from the first case, I watched the second case, but on the third case, the kid hit by the truck, I was the senior neurosurgery resident directing his care. I saw him in the ER as the original resuscitation took place at nine AM. Even after oxygen and blood pressure were restored his exam looked grim. A CT scan showed no blood clots to evacuate, only a diffusely injured and swollen brain.
I called our director of pediatric neurosurgery and described the case. He asked me my assessment, and I told him it looked hopeless.
Well, almost hopeless.
We believed that young children shouldn’t die. We believed that maximum effort and state-of-the-art skill and knowledge would be rewarded. So we gambled with the almost and ignored the hopeless.
I placed an intracranial pressure (ICP) monitor to guide treatment, optimized the respirator rate and administered various medications to control brain swelling. By two PM, these measures had failed. Another CT again showed diffuse brain swelling. At three PM we took him to surgery to remove a large part of his skull so that even as the swelling increased his brain would not be compressed and the damage would be limited. But even as the skin sutures were placed, his brain continued to swell. The ICP went up again to dangerous levels, and then to levels incompatible with life. By six PM, the battle was clearly lost. The child would die. A catastrophe. An act of God.
This particular case affected me deeply. I had been part of surgeries that had in one way or another failed, and this was not the first person I had seen die, nor even the first child. Although always difficult and sad experiences, I had become inured. But somehow this case cracked my shell. Maybe because this time the victim looked too much like one of my own children.
So I buried myself in the paperwork; the demands for immediate hands-on action all day had outstripped the time available to document the required medical records. But mostly I didn’t want to talk to anybody. I was afraid if I had to talk, I’d cry.
I know what God told Job: Where were you when I laid the cornerstones of the universe? You’re just a man, you can’t understand the grand scheme of things. At the end of the book, God gave Job a new family. All very comforting and logical.
Until one is holding a dying child.
Then I want to know the Why.
And I if my sons were taken away by an act of God, replacement boys coming along a few years later might carry blessings, but the grief from losing the first two wouldn’t go away. As a matter of fact, I expect that the love I would feel for the replacement boys would carry a undercurrent of terror–the fear of another loss.
As I hid behind the paperwork in that pediatric ICU, the director of pediatric neurosurgery, the one who had been guiding and encouraging me all day, came and stood across the desk from me. “There’s someone outside to see you,” he said.
I respected this man for his knowledge and skills but didn’t trust him for emotional sensitivity. He made too light of difficult situations. He had been inured.
I shook my head; I was still afraid I would cry. Besides, no one came to see me; I was just the resident. Or worse, maybe the parents were waiting. I couldn’t face them. Not yet.
“Come on,” he said.
He stared me down, long enough that he knew I was in pain, and I knew he wasn’t going away. “Come on,” he said.
I got up and followed him. After all, he was my boss.
In the hallway outside the ICU stood a teen-age girl in a cowboy hat. Long, dark hair spilled out from under the right side of the hat, but no hair on the left, and maybe a hint of a scar in front of her left ear. She smiled, but it was crooked, and she leaned on one of those aluminum canes.
Then I recognized her. Six weeks previously, she had bled from something called an AVM, a congenital malformation, into the part of her brain that controlled speech and language. She needed emergency surgery to save her life, but the cost had likely been the permanent loss of speech and movement on the right side of her body. Two weeks later she was discharged to a rehab facility, aphasic and hemiplegic. Another catastrophe. Another act of God.
Now here she was, only a month later, walking with a cane–but walking already at just six weeks after her injury! If she could walk with a cane now, she might be able to run in another six months. Just to see her lifted my spirits. Could she talk?
The words were slow and overly round like her tongue was too big. “Thank you,” she said.
I don’t remember what I said. I remember I had to hide my tears, but now tears that held a measure of relief, hope, possibly joy.
Maybe it was a coincidence that this thoughtful young woman took this particular moment to say thank you. But maybe God sent a messenger to tell me that I couldn’t know everything He has to know, and I won’t know the outcome of many of the things I do, and the important thing is to trust Him.
I expect that God sent comfort to the parents of the child. Because God doesn’t just watch our suffering from on high. He gets down and dirty with us, and gets tortured and killed. The passion of Christ was a historic event, but I think in some cosmic or mystical sense that the crucifixion and the resurrection is also a continuing experience. When the kid gets hit by a truck, Jesus gets hit by a truck. When Jesus rises from the grave, the kid rises from the grave.
We believe God is good all the time until we face catastrophe. Then we wonder. But we do not have to wonder if God cares. In the Old Testament, He promises a time that He will wipe away all of our tears. In the New Testament, He weeps for the death of his friend, Lazarus, and again for the destruction that will come to Jerusalem. When the parents of a dying child weep, God weeps.
I understand now why the book of Job ends with his fortune and family restored. Those aren’t really replacement children. They represent the fact that for every “act of God” there is an act of mercy. He will dry your tears. Sometimes He will restore your fortune, sometimes He will send another child. Sometimes He sends a girl with a cowboy hat and a crooked smile.