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2005-03-03 - 12:19 p.m.

I lost my first patient when I was 21 years old. I was a field medic in the Army at the time. She did not die on the battlefield. She died on the grass in front of the dorms.
I joined the Army a few months after graduating high school. Despite a poor academic showing throughout high school, once I began medic training in the Army I became a focused, voracious student. My first tests came back with high marks. Soon afterwards, I found myself thrust into a tutoring role. I am not sure how much I helped my classmates, but they kept showing up for more. . .
I graduated in the top 3 % of that medic training class. I soon found myself in a new environment. My new assignment was a light infantry battalion at Ft. Campbell, Kentucky. The status of being somewhat special in a safe training environment was gone. I had been assigned to a unit that spent a great deal of time on maneuvers and focused keenly on physical fitness, neither of which I could claim as a strong point. Their focus on education was minuscule at best.
Over the years, I paid my dues in �Field time�, or time spent out on maneuvers. I no longer automatically dreaded them once I began to set aside the physical discomforts and concentrated on learning the skills and teamwork that our more experienced sergeants and officers were trying to instill in us. With a lot of hard work and a bit of grumbling, I struggled to pass my Physical Fitness Tests.
My first three years of active duty passed quickly. I began attending the occasional CPR class and refresher course to maintain my civilian license. I even went so far as to get a CPR Instructor license. Through one of these classes, I landed a position as an assistant instructor for a medical training class my last year of active duty service.
In Army lingo, the class is �Combat Lifesaver� training. There students learn many skills beyond the first aid foundations everyone learns in Basic Training. Adult CPR, how to start intravenous fluid administration, first aid for broken bones, cuts, and burns; how to properly move someone who is hurt, and how to begin care for someone who is injured in a chemically contaminated area were just a few of the topics covered by this class.
I began that job in the February, one year before I was to leave the Army. The duty was not hard, seeing as to how I became exempt from field duty as soon I took on the teaching assignment. The day to day routine became just that: routine. The teaching duty became a welcome relief from the constant field exercises, but my impatience for the end of my service grew with each passing day. I wanted to go home. I took the special duty assignment for granted.
I also drew �Sick Call� duty before my teaching duty each day. �Sick Call� was the first-line clinic that the medics conducted near the dorms to see and treat minor illnesses and injuries. �Sick Call� began at 5:30 A.M. I routinely woke at 5 AM to get there on time.
It was in this setting that I lost my first patient.
The sun still slept when I woke May 1st, 1996. The day would eventually dawn warm and bright, with a few fluffy clouds drifting lazily across the sky to provide shade. As I was on a teaching assignment and had to be ready work a full hour ahead of the normal schedule, I enjoyed conducting my physical fitness training (or PT) on my own.
I left the weight room of the small dorm gym that morning, sore from the workout and still not quite awake yet. As I headed back to my dorm room to shower and change, I had my head down, lost in thought. The morning was sticky and hot, the sunlight streaming down on my back, warming my sore muscles.
I had a vague awareness of my immediate surroundings and not much else. I glanced around at the people streaming back to their dorm rooms after PT. My gaze rested briefly on a group of people lying down on the grass in front of the dorms three buildings over. As lying on one�s back was quite the common occurrence during PT, doing sit-ups and such, I did not give it much thought. Not even breaking stride, I turned back to studying the ground.
Some of my dorm mates, artillery specialists, were walking towards the dorm a little behind me. One of them looked past me and asked:
�Hey, Doc! What�s up with that person on the ground over there?� indicating the knot of people in front of the dorms three buildings over. �Doc� is the moniker that infantry troops use to refer to medics. I returned my gaze to the group of people indicated and saw that indeed only one person was lying flat on the ground. At that distance, it appeared to be a young woman.
�I don�t know.� I said, as my attention focused on the still figure. �I�ll see what�s up,� I added over my shoulder as I began trotting over to the cluster of humanity on the grass in front of the dorms.
As I drew up to the crowd, I asked what had happened. A young African-American woman lay on her back, eyes closed and not moving. A higher-ranking member of the group was holding her legs up at a 45-degree angle by her feet. He was trying to get blood back to her head.
�We got back from our run and she said she wasn�t feeling good,� said the man holding her feet.
�I went into the bathroom with her and she got sick,� said a young Hispanic woman to my right. �She said she felt a little better afterwards, but when she came back out, she said she felt dizzy and passed out!�
�What�s her name?� I asked.
�Phelps,� was the reply from many voices.
I knelt on her right side. Calling her name, I began shaking her by the shoulder gently, and then a bit more forcefully, trying to rouse her. Her head flopped limply as I realized she had not passed out. I bent lower and, putting my ear above her nose and mouth, listened for her breathing. I looked towards her toes to see if her rib cage rose and fell. I neither heard nor felt anything. I grew anxious and calm simultaneously.
�She�s not breathing!� I stated as I tilted her head back. Then, pinching her nose and lowering her jaw, I placed my open mouth over hers and breathed into her. Her chest rose and fell. Sweat began to drip off my forehead.
Her windpipe was clear. The acrid taste of her vomit stung my lips and nose as I inhaled and breathed into her again. Again, her chest rose and fell. I began to tremble softly as the reality of the situation sank in.
I wiped my mouth against my sweatshirt sleeve. As the adrenaline dumped into my bloodstream, my heart pounded with nervous energy. A loud rushing sound began in my ears. I quelled my stomach, which was threatening to rebel, by pure willpower. I took a deep breath and refocused my mind on helping her.
I pressed the fingers of my left hand against her neck. I felt nothing. Keeping my eyes and ears by her nose and mouth, I reached down her arm and sliding my fingers under her watchband, trying to feel for a pulse there. I squinted and blinked the stinging sweat out of my eyes as I willed her heart to beat. Again, I felt nothing.
�I don�t feel a pulse; somebody double check me, please!� An older man knelt on her opposite side and repeated my actions. I held my breath, hoped, and prayed as the sun beat down. My face flush and my head swimming, I wished for her to live. He quickly looked up at me and shook his head.
�I don�t feel anything, either!� he said, breathing faster as the situation dawned on us both.
�Alright, start compressions!� I directed out loud, unconsciously following the training I had drilled into the heads of my student. It did not occur to me to ask if this man knew CPR or not. But, to my surprise, he ran his fingers up the inside of her ribcage, found her sternum, and placing his hands correctly over her heart, he began counting in time with his compressions. I resumed breathing for her.
Someone had left to call the ambulance. My fellow rescuer and I switched off performing chest compressions every minute, trying to conserve our energy. We did not know how long it was going to take the ambulance to arrive. I was sweating freely as the lights and sirens drew closer. Numbness displaced the pain in my back and shoulders.
The ambulance pulled up beside us. The paramedic came running over. He was an older man, with a moustache and glasses. He looked somewhat apprehensive. We quickly related what happened to her. The paramedic and his assistant packaged her onto the stretcher and got her into the back of the ambulance. He motioned for the two of us to climb aboard as well.
We got in and after the people outside closed and locked the doors, we sat back and watched them work on her as we sped towards the hospital. The ride there and the hour spent in the waiting room passed with agonizing slowness. Members of her unit flowed into the waiting room and began pacing the floors and questioning the staff at very short intervals. The rising tension in my gut was preventing me from sitting still. I paced with them.
The stages of acceptance of death begin with denial. Anger is next, followed by bargaining, acceptance, and then finally mourning. In the Emergency Department Waiting area, I began bargaining. I would give up a year off my life in exchange for her making it. In my mind, that was the deal I ultimately cut with God.
God doesn�t make deals.
After the longest hour of my young life slipped away, the ER doctor walked slowly out from the back, head down, scrubs darkened with sweat, drying his hands.
He called us over to him. We followed him to a more private area of the waiting room.
�I�m sorry� he began, and one of the young women began sobbing. �We tried everything we could, but we were unable to get her heart beating again.� More people began crying, myself included. �I�m sorry.� The doctor concluded. �You can go inside and say goodbye if you like.�
I went in with two other people. She looked asleep, with the exception of the breathing tube jutting out of her mouth and the large intravenous line going in under her collarbone. Tears slid unchecked down my face. I touched her cheek and whispered �goodbye� to the person I couldn�t save.
It was 9:00 A.M.
�I�m sorry,� I blurted out, not knowing what else to say. Back out in the waiting area, I stopped some of the nurses that worked in the Emergency Room. I recalled the events to them and asked them if there was anything more I could have done to save her.
They listened attentively, and after I finished, reassured me that I had done everything possible, and correctly. I was seeking absolution, and none was forthcoming.
I do not remember how I got back to headquarters, but I soon found myself in front of my company�s first sergeant. The company first sergeant is the highest-ranking enlisted member of the unit. They are not a commissioned officer, but are effectively an assistant commander. They deal with the day-to-day operations of the unit and can promote as well as punish.
As I had been directly involved with the death of a soldier, Army criminal investigators would be coming to speak with him soon. Even thought I had been attempting to save her life, a death had occurred, and the Army would be asking �why�. Knowing this, I related to him the events of the morning. He asked me if I had done everything I could and if I did so correctly. I said yes.
�Good job, Villarreal. Get cleaned up and go to work.� It seemed insanely abrupt, indifferent, and cold. Damn it, somebody had just died! But looking back, keeping me occupied was the wisest thing he could have done. I left his office and somehow made it to the Combat Lifesaver classroom an hour later, showered, shaved, and dressed for the duty day.
It was 10:00 A.M.
I wandered about the classroom in a daze. I realized that someone was speaking to me.
�Are there two breaths before a pulse check, or just one?� a student asked me. Mechanically, I began teaching the student on a mannequin what I had done to a real person two and a half hours ago. The irony was palpable, settling into my stomach for the rest of the day. I do not remember much of the rest of that day.
I stumbled through a numb fog for the next two weeks. I would repeatedly second-guess myself at work. I obsessed at replaying the resuscitation in my mind, trying to find some way I could have saved her. The �What-If� game, as it is colloquially known. I could not fall sleep without having nightmares of almost being able to help people, and then watching them die at the last moment.
I needed help.
Grief councilors were at her unit, and their first sergeant was kind enough to invite me to participate. I needed to be with people that knew her. I cried and listened with them as they related stories about her. I felt a crack begin to form in the shell of misguided guilt I had surrounded myself with. The pain began lifting from my soul.
They held her memorial service the following week. It was raining outside as I walked towards the chapel. I was late due to an assignment that ran over. I walked around to the front of the chapel as the honor guard began the 21-gun salute. The crack of the rifles electrified my skin. I jerked spasmodically. A cold, empty hole sprang into being inside me as I stood transfixed in the rain.
From inside the chapel came a raw howl of agony. It came from her friends as the shock of the gunfire broke down their last emotional barriers. Military tradition designed it that way. It lets the grief flow freely.
Life went on.
One morning, two months later, I stood in front of my company on the grass. The rest of my unit stood at attention. My company commander pinned a medal onto my chest. The unit commander of the young woman I had helped had put in the recommendation for me.
A letter of appreciation from her unit accompanied the medal. I numbly saluted my captain and received the medal with a minimum of words. The lump of dead bronze thumped against my empty chest as I received the subdued congratulations of my platoon-mates.
I left the Army January 13, 1997. As I left my dorm room the last time, I laid a rose at the spot where she fell. I said a silent prayer for her, and then one for myself. I walked away, the frozen grass crunching under my feet. I never looked back.
I celebrated my 22nd birthday July of that year. Around that time, one of the members of her unit e-mailed me an obituary from her hometown paper. The funeral was delayed as her parents didn�t immediately have the money to pay for a formal memorial service. She died of the same congenital heart defect that killed her brother six months before she died. She was born the year before I was.
I recall that memory whenever I am having a bad day at work in the Emergency Department. I especially rely on the realization that when we lose patients, we must then turn to the task of taking care of the next patients: the family of the deceased. I remember how I felt when I lost a stranger. I remind myself that these people just lost a father, brother, mother, or a sister. It doesn�t matter who: the result is the same.
I would like to say that I have learned patience, respect, and to not take people for granted. In truth, I am still learning these skills to this day. I do not know everything there is to know about medicine, and I never will. What I do know is that people are why I do this, and that the right approach to people, guided by some hard-earned perspective, makes the difference between just doing a job and genuinely caring for someone who needs your help.


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