Ep. 16 — A God-fearing trauma surgeon struggles to cope with human atrocity in the wake of a mass shooting / Dr. Alan Tyroch, Chief of Surgery and Trauma Medical Director, University Medical Center of El Paso.
His grades were so poor that Dr. Alan Tyroch almost didn’t get into medical school. But the stubborn Texan was not about to let something as mundane as bad grades get in his way.
Fueled with frequent, sometimes heated, conversations with God and blessed with sheer grit and perseverance, Dr. Tyroch not only fulfilled his dream to become a trauma surgeon, but also helped develop University Medical Center of El Paso’s top-notch trauma program.
Tyroch’s motto, “You play like you practice,” came true on August 3rd, when the medical center was flooded with victims of a mass shooting in which a gunman, armed with an AK-47, killed 22 and wounded more than two dozen people at a local shopping center.
Fresh from a recent city-wide disaster drill involving mass casualties, Tyroch says everyone, including the housekeeping staff, worked as a unified team to save as many lives as possible.
Tyroch says he’s acutely aware of and working to allay the post-traumatic stress that many medical personnel, including on his team, experience in the aftermath of these types of events.
But despite his own nuanced understanding of “good” and “bad” deaths, developed over nearly two decades as a trauma surgeon, Tyroch says he still fights the outcome when a patient dies on his watch.
Chitra Ragavan: Hello and welcome to When it Mattered, a podcast on how leaders are forged in critical moments and how they deal with and learn from adversity. I’m Chitra Ragavan. This episode is brought to you by Good Story, an advisory firm helping technology startups find their narrative. My guest is Dr. Alan Tyroch Chief of Surgery, Trauma Medical Director and Chief of Staff at University Medical Center of El Paso. Dr. Tyroch also is professor and founding chair of the Paul Foster School of Medicine’s Department of Surgery. He’s an appointee on the governor’s emergency medical services and trauma advisory council. And an active member in the Regional Advisory Council on trauma and emergency healthcare.
Chitra Ragavan: Dr. Tyroch was in the unenviable position of helping to direct and manage the trauma care after the August 3, 2019 mass shooting in El Paso, Texas, in which a 21- year old gunman armed with an AK-47 killed 22 and wounded more than two dozen people in a local shopping center. Dr. Tyroch, welcome to the podcast.
Dr. Alan Tyroch: Thanks for having me.
Chitra Ragavan: Tell us a little bit about yourself.
Dr. Alan Tyroch: Sure. Well, first of all, I’m a fifth generation native Texan and extremely proud of it. I’m from Czech heritage. My families came here from either Moravia or Bohemia, which no longer exists, either in the 1850s or 1870s. Depends on what side of the line. Either my mom or dad side. So I grew up in Texas, and very proud of that. I grew up actually in Central Texas. I was born in Temple, Texas. Then when my father retired from civil service at the VA hospital there, he moved us to my great grandfather’s farm. The same farm that my mom was born at. She was actually born at home.
Dr. Alan Tyroch: That’s where I grew up. I went to Texas A&M for undergraduate. I got a degree in microbiology. I was interested in the sciences. I decided I wanted to be a doctor but actually before that I couldn’t decide. “Should I be a veterinarian, or a doctor. Do I want to take care of animals, which are easy to handle. They don’t argue or do I want to take care of humans.” That’s what I wanted to do. To be honest, my grades weren’t the best. I was not the worst in class, but I wasn’t the highest either. I struggled to get to medical school. It was clear I was going to have a super high battle to get into medical school at the time. I even decided at one point that this is just not going to happen for me.
Dr. Alan Tyroch: I went to apply for a PhD. I was still living in College Station at the time doing some research at the tech scene in a medical school in biochemistry, but I went to University of Texas in San Antonio to apply for a PhD program. I interviewed there and even then I sort of made the comment to the interviewers like, “Well, I want to get into medical school, but my grades aren’t that great.” And he said, “Well, your grades aren’t that great, but you probably shouldn’t say that when you’re trying to interview for a PhD. When you’re looking at something else.”
Dr. Alan Tyroch: I did my interview, they said, “Well, we’ll get back with you.” I remember getting in the elevator. There’s like four medical students in the elevator with me and I looked at them, I’m like, “Dang it. That’s what I want to be. I don’t care. I want to do that.” So I drove home. It’s about 100 miles. It was raining cats and dogs. Typical spring thunder shower season in Texas. You could barely even drive. You couldn’t see despite the windshield wipers and there is lightning, thundering. I just started crying saying, “I want this. I got to do this. I got to figure out how to do this.” And I remember even praying to God saying, “God, if you can get me to be a doctor, I promise you I will be the best I can do to take care of the patients.”
Chitra Ragavan: A very dramatic moment.
Dr. Alan Tyroch: It was actually. It really was a dramatic moment. It might be a little bit too melodramatic here but it really did happen. When these back roads in Central Texas nearly part of the East Texas area, driving through there. Nothing but pastures and cows. All of a sudden the rain quits, blue skies and I said, “You know what? I’m going to make this happen somehow with the grace of God.” So I tried to get in medical school. I took my MCAT. The scores were not that good. I was able to interview at a couple of programs. Did not get accepted. And I said, “You know what, I’ll just try again.” I did that and I got in the next year. I went to University of Texas Health Sciences Center, which is in Houston, Texas, worked hard. Once again my grades were average at best. But as they say, what do you call the person that’s last in your class in medical school, you still call him a doctor.
Dr. Alan Tyroch: I graduated medical school. I did not match into surgery and that was something I really wanted to do. I went to the Texas Heart Institute. I saw where Denton Cooley was operating, one of the world class cardiothoracic surgeons. That’s what I want to do. I want to be a surgeon but I did not match in a category of a spot. Which means that gives you a guaranteed five years if you’re doing a good job in a residency program. Didn’t get in but I did a preliminary year in general surgery at Baylor College of Medicine there in Houston. Predominately, had been top hospital. The chairman of surgery at the time was Dr. Michael Debakey, who was the premier surgeon. Everybody knew he was, I mean the guy operated on kings and queens and all type of dignitaries, very hard program. Went through that year successfully, would not ever want to repeat it again because it was not fun, but it was one of the most exciting years of my life.
Dr. Alan Tyroch: I got accepted for a second year position in Phoenix, Arizona under Dr. Stone, who was the chairman there. A very well recognized trauma surgeon in his day. I finished up in 1995. I met my wife, my future wife at the time, when I was in residency, she was an intern. She was an internal medicine resident. I told her, “If you’re going to marry me, we’re going back to Texas.” Because all native Texas go back home at some points, it’s kind of a homing instinct. She was okay with that, but I had an interest in trauma and critical care. So I went to California at UCSF and Fresno, California and did a two year trauma critical care fellowship. And like I said, I wanted to get back home. So I interviewed around in Galveston, in Houston, some other places in Texas and also looked at El Paso.
Dr. Alan Tyroch: At that point in time, the state of Texas was trying to develop a trauma system. So all of the larger hospitals, especially the county hospitals, and the academic institutions were becoming trauma centers so they asked me to, if I wanted to be the trauma director here. And I said, you know what, first of all, there’s a lot of … they needed a lot of work the program needed a lot of work. It was on life support to be honest. Financially as well as clinically at the time. This was in 1997. And I said, “I don’t know how to be a medical director, I know how to operate but I don’t know how to be the administrator and take care of the direction of it medically or non-clinically.” But a job fell through in Galveston, I said, “I need to get a job, I got a young wife and a two-year old son at home I got make some money because I’m in debt and stuff.” So I said, “I’ll take the job.”
Dr. Alan Tyroch: I can’t make it any worse than it is. I can’t screw it up any more than it currently was. So I took the job thinking I’ll work here three or four years, get some publications, and move on to a bigger program but I quickly fell in love with the place. El Paso is a cool place to live. People are friendly. The medical school that we have, which was at that time, a regional campus, it’s part of the Texas Tech system. And I heard rumors that we were going to have our own separate medical school here in El Paso at some point in time. And also at that time, the current regional chair of surgery, Dr. Saul Stein was stepping down he asked me if I would be the interim chair surgery while they did a nationwide search for another chair.
Dr. Alan Tyroch: I started doing it for him anyway, going to all the meetings and stuff in his place, and I said, “Sure, might as well do it.” So I did it had no desire to be the chair but they brought a couple of guys to interview here. I said, “I don’t think I could work for these gentlemen. I like my job. I want to stay here.” I might as well put my name in the list of candidates and I did that and I guess nobody else wanted the job at the end of the day and they gave the job to me and I became the chair of surgery here in 2002. Afterwards, we became a separate medical school in the Texas Tech system that was in 2009 and afterwards, we actually grew to be a separate Health Sciences Center in the Texas Tech system.
Dr. Alan Tyroch: The mothership is in Lubbock, Texas, but it had regional campuses in Odessa, and Amarillo and El Paso. So then now we are a separate medical school, a separate Health Sciences Center, and growing by leaps and bounds and so is the Department of Surgery, so that’s sort of my story at that point. I’ve been the chair surgery for about 17 plus years here, as well as the Trauma Medical Director at the level one trauma center, which is UMC of El Paso.
Chitra Ragavan: So you’ve helped develop this trauma program that saved so many lives on August 3rd. Tell us a little bit about the program and what’s an average day and night like when you’re on call and the range and types of cases you see in general.
Dr. Alan Tyroch: Sure. Well, first of all, UMC is a county hospital. County hospitals see all types of stuff. We also live on the border of Mexico with Juarez which is what we call our sister city. There’s the Rio Grande that separates us. Half the time there is no water in the Rio Grande, its dry but we have a Rio Grande and it’s a large city there 1.7 million. El Paso is about 850,000 population growing very quickly. So we see all types of stuff when we were here. When I first came here, our trauma census, our average mission would be five or six patients a day and you’ll trauma admissions at just under 1300 patients that we would admit, we are now admitting over 3000 patients we take care of adults, we take care of kids. We have a lot of geriatric trauma patients we cover now 1.3 million individuals over a 43,000 square mile radius in Texas in southern New Mexico. We’re a regional referral center for trauma but we also cover very surgical specialties.
Dr. Alan Tyroch: When we’re on call, we may take care of somebody that has an abscess, what we call butt pus, which means they have pus around the rectum. If I see one or two of those a day we take out one or two Abby’s appendectomies a day but we see a lot of trauma. Just the other day we had a lady that got stabbed in the back of her head. The knife actually lodged into the back of her skull went into her brain, terrible head injury, a lot of car wrecks, a few shootings, a few stabbings. 92% of what we see is blunt trauma either due to people crashing their motorcycles, crashing their cars or doing silly things like riding ATVs, and a lot of falls.
Dr. Alan Tyroch: A lot of older people, that are falling, that’s sort of like the growing trend. So we see a lot of that. So a little bit of everything but we’re not a knife and gun club like let’s say in Baltimore, or in Chicago, it’s mostly car wrecks that we try to injure ourselves.
Chitra Ragavan: So on that Saturday, August 3, when the shootings began, you were actually out of town at first, which made it all the more difficult for you to direct the triage efforts. Where were you and what were you doing?
Dr. Alan Tyroch: Yes, so full disclosure, I was in Las Vegas. My mother in law was celebrating her 90th anniversary. So her children got together a couple months before and said, “How can we celebrate this with her.” And it was on her bucket, we got the bucket list. She wanted to go back to Las Vegas. She wanted to go to Circus Circus which probably would not be on my top five list, maybe my top 10 list of places to go to in Vegas to spend the night. I’d probably go to Caesars or somewhere else but that’s where she wanted to go. Because that’s where her kids and her and her husband went. When they were younger, they would go there. The kids I don’t know if you ever been in Circus Circus, but it’s first of all, it’s very old, sort of decrepit. I shouldn’t say that but it is.
Dr. Alan Tyroch: It’s got like a Midway inside, they got like a carnival type atmosphere. They got entertainers and stuff. So that’s where we were staying. That Saturday morning, which was August the 3rd, I remember waking up, for whatever reason I was in a very melancholy mood, and I’m usually not, but I just was. There was just some darkness, I just had that feeling. I finally got out of bed, took a shower and everybody else was half asleep are still sleeping. I just cruise down to the basement at Circus Circus and used my voucher so I can get my free breakfast buffet. I had my breakfast buffet, I’m sitting in there and then I got a text on my phone saying active shooter, Walmart and whatever the street address was.
Dr. Alan Tyroch: To be honest, we get those fairly frequently, maybe once every month or so. It’s usually nothing, it’s either somebody that was walking around that looks suspicious, but not real or it was just a guy that shot off a gun for some reason. We like to shoot guns in Texas but this time it was real. I call the nurse in charge of the hospital. We call them the AOD administrators, the day I call and I said, “Kennedy, Is this real?” And he goes, “Yes, we’re getting four to five patients maybe more.” I immediately texted the trauma surgeon on call Dr. McClain and the trauma surgeon who was coming off a call, Dr. Alex Rios Tovar at Texas that we’re getting five victims, maybe more.
Dr. Alan Tyroch: I immediately texted the chief, the CEO of the hospital and the trauma program director and I told him, basically text the same thing. So then I call it back the AOD and said, “Give me an update.” This is like not even two or three minutes. He says, “We’re getting 10 plus patients. It’s an active shooter. They may be three and there’s multiple victims at the scene.” I texted all the other surgeons that were not on call. I said, “I need you at the hospital.” Even my surgical specialist, including my pediatric surgeon, because I heard there was going to be some kids coming. That was initial thought there was kids coming. So I said, “Mary, I need my PD surgeon there.”
Dr. Alan Tyroch: I also called the orthopedic surgeon, I said, “You’re in charge of ortho. You guy you’re in charge of pediatric surgery. I’m out of town. I’m coming in as soon as I can. So please take care of things.” I call the person in charge of the blood bank. I said, “I need you in the hospital to help coordinate that stuff.” Then I ran upstairs to the hotel room, and told my wife, “Get me back to El Paso.” She didn’t know what was going on. I said, “Turn the TV on.” And she did and they saw that and she started making arrangements and I was in my not even jeans, just some shorts and a T-shirt. Didn’t take my luggage or anything. I just jumped in a cab and went straight to the airport. Didn’t even have a flight yet, but somehow I got to the airport.
Dr. Alan Tyroch: She had already made, my wife had made arrangements on Southwest Airline. I tell you what, you can go through TSA very easily or fast if you want to, and I made it happen. I said, “I got to go. I look like a crazy man but I got to go. There’s been a terrible event in El Paso, I got to get there.” By then some of the people had already started hearing that something was happening and the passengers all just moved out of the way and said, “Get him to the front of the line.” I got to the front of the line, got to the place where you wait for the plane and like typical airlines, now there’s 30 minutes delay.
Dr. Alan Tyroch: I finally get on the plane. We’re still sitting on the tarmac. I’m making phone calls, and texting people getting updates, and they’re telling me now maybe 60 victims. Turns out it was 47 total. They were pretty close at the time because when you get these kind of events, there’s always so many rumors and things like that. So, they tell me “Okay, it’s time to turn off the phone.” I got off the phone after I made my last phone call and think, “Oh my God, it’s going to be a long trip.” Even though it’s really not that far from Vegas to El Paso. It’s about an hour and 20 minute flight and I finally told myself, “Okay, there’s nothing you can do now. Just say a prayer and take a nap because you’re going to, it’s a long haul.”
Dr. Alan Tyroch: As I told people, these things are you start off as a sprint, but it becomes a marathon. I tried to take a nap and it was not a very restful nap. Then I woke up and we’re landing in El Paso and soon as the wheels hit the tarmac, turn my phone back on and I have 56 texts coming “Oh my gosh, I can’t even go through all these texts.” And just as many emails and I quickly scan and saw which one’s important. Just immediately after that the CEO of the hospital called as I was getting off the plane, he says, “I need you to do a press conference.” And I said, “Okay, I just landed.” Let me go the bathroom. My bladder is about to rupture. I didn’t have time to go the bathroom in Vegas and go find my car and then I couldn’t find my car in the parking lot because my wife drove to the airport for us.
Dr. Alan Tyroch: I wasn’t paying attention and by luck, I was able to find the car. Took off to the hospital, put some scrubs on and got a quick debriefing and then did the press conference with the hospital. That was sort of how the Saturday started for me in El Paso when I got back home.
Chitra Ragavan: What’s it like when these shootings happen and the injured start pouring into the hospital? What do you do? How do you triage and what’s the process like?
Dr. Alan Tyroch: Sure. Well, first of all, you have to practice. You got a drill for these things. You can’t just make this up on the fly. We did a citywide disaster drill in October of last year. Every hospital participated. EMS, the police, the fire department, and what it was, was an active shooter with over 100 plus victims at the airport and they brought victims to all the hospitals. So we did a really good job practicing for that and you know, practice is not like the real thing but I always tell people, “You play like you practice.” And I’m the biggest critic of every one of our disaster drills, like, communication was bad. We didn’t do this, we didn’t do that but I tell you what.
Dr. Alan Tyroch: When I saw what happened on Saturday, people did an incredible job. So many people stood up and took leadership roles and made things happen. Fact that we had practiced these things over time helped a lot but they really did an incredible job, not just the doctors and the nurses at our hospital. Same thing at the Level Two trauma center across town, they took 11 victims and the people at the scene, EMS and police, they did a very good job triaging these patients, and I must say going back to what was going on in our Trauma Center, just everybody pitched in and took care what needed to be done including the housekeepers.
Dr. Alan Tyroch: We may forget people like that, but that’s one of the things that I kept hearing from the group afterwards at our debriefing. The trauma bays were all full, we moved the patients out, went to the ER, housekeeping just jumped in and they cleaned up the room got the blood out all the stuff that had to be cleaned. So for the next victim, and then they went to the OR where we had four operating rooms running at one time. It’s just, everybody pitched in. You have to realize with active shooters, the event happens so quickly. It’s almost like a textbook. Everyone plays out like a textbook and it’s the same thing in El Paso. It happens quick. You get a mass of patients.
Dr. Alan Tyroch: One or two of the patients will probably come in first by private vehicle, not even by ambulance and that’s actually what happened here. Our first patient came in by a private vehicle. It was a police officer who brought the guy in, but then the EMS started bringing patients in two ambulances. Immediately, they all went to the Operating Room and I think we did eight. They did eight surgeries that day here at our hospital and those were all done within four hours but the fast it was all happening so quickly and we did a good job that day. I was so impressed and so proud of the team.
Dr. Alan Tyroch: I don’t know if you know that the yesterday one of my faculty actually testified in Congress regarding gun violence and he did an amazing job and I was just so impressed. It was so emotional, how he did it and he carried himself so well. He actually was there that day, he actually was post call and ran back to the hospital and he saw the victims and he operated just like all the other surgeons and people.
Chitra Ragavan: Now I understand you know, I was reading an article that describe how you actually do this and this process of doing the bare minimum you need to keep them alive and then you ship them out of the ER so you can get the next victim in and get them and then you bring them back and you patch them up for the final thing. How does that work? What’s it called? And how does that work?
Dr. Alan Tyroch: Sure. Well, first of all you do triage. It’s a French word meaning to sort that gets done at the same, which means more critical patients go first to the hospitals and then once they hit the emergency department of the trauma center, we triage them again. The most severely injured patient goes to the operating room first or whatever needs to be done. Some people need to have procedures done in the emergency department like chest tubes to decompress a collapsed lung that could kill the person quickly or they’re there bleeding to death. We need to stop the bleeding and then we take them to the operating room.
Dr. Alan Tyroch: We do something called damage control surgery in the OR, and that was sort of learned by the military. That’s the only thing that’s good from war, surgeons and doctors learn how to take care of injured patients from war. So what we do is, we stop the bleeding and we stop the leakage of poop in the intestines, a stool, or we plug the holes in the stomach so they don’t have their gastric contents leaking, so they don’t get severe peritonitis. We go in quickly, do that, don’t even close the belly up. We have things called vacuum, wound vacs. That’s an artificial abdominal wall that has suction on it.
Dr. Alan Tyroch: We put those on the patient, and then we put in the critical care unit and a lot of these patients are so unstable, that we need to further resuscitate, we need to warm them up, give more blood products, more fluid, various medications. That’s what’s called damage control surgery. We got one guy that comes in he’s massively injured either from a car wreck or a shooting, we’ll do that but you have to be even more cognizant of doing that when you have multiple victims. Everybody wants to have the best care possible for that one patient but when you got multiple patients coming in, you kind of take care of a lot of people and you got to control the bleeding.
Dr. Alan Tyroch: That’s what they did that Saturday. I didn’t participate. They did. Then on Sunday, the next day, we came back and we did five operations on that Sunday. Three of those were patients I had the open abdomens that we came back and did further surgery. The orthopedics operated on Sunday on some really bad fractures, because this guy really did some damage to these people, unfortunately, with the gun and the bullets he used and then on Monday, even more surgery. These patients having multiple surgeries over the subsequent days, not just on Saturday or Sunday, we still have one patient still in the hospital.
Chitra Ragavan: So it was a really difficult weekend for you and your team and one of the things people don’t realize or talk about much is that even for the medical team, there’s an element of PTSD afterwards. When the adrenaline wears off. I know you yourself experienced it and I’m sure your team probably experienced that. What happens? And how do you handle that?
Dr. Alan Tyroch: Sure. As I was mentioning earlier, you start off as a sprint, but it becomes a marathon. So you need to rest. First of all, when the work is done, go home. Let somebody else take over. So like, on that Sunday, the guys that were working on Saturday, and they were actually to be scheduled on the on call again. So I said, “You stay home till one o’clock, I’ll take care of this with some other guys. We’ll take care of that.” So we did that but the adrenaline does wear out and at some point, it impacts you. I’ve talked to the trauma directors. I’ve heard people give talks on this from the Paul shooting in Orlando, the terrible event that was in Vegas, the Fort Hood shootings that happened twice unfortunate at their military base. I’ve heard the people talk and that one thing they tell you is it will impact your faculty, it will impact your residents.
Dr. Alan Tyroch: It’ll impact the nurses as well as EMS personnel and the police. Because you’re going to have guilt feeling like well, I could have done more. You’ll start second guessing yourself and you just see so much tragedy. We’re used to dealing with death, and we see that every day but as you mentioned earlier, there was 22 people that died that day. It was 25 people that had severe injuries. Some of them really are life changing that will never be back emotionally or physically. It’s been shown in even literature that a third of surgery residents will suffer PTSD up to even six months after the event. So what we do is and that’s what we did, and we actually talked about that as part of our disaster drills. Don’t forget the after effect.
Dr. Alan Tyroch: We had counselors come in. We met as a group, like my department, all the residents and faculty got together and started talking about the event. It was led by one of the psychologist and that was very helpful. We also offered professional counseling on a confidential basis. They need it. We did that, the hospital did that. We even came together as a University on that Tuesday afterward, about 150 people just to debrief just to talk about it, and also say there’s support out there for you. It’s okay, you’re going to have moments where you’re going to feel just really sad, and it does happen. It actually happened to me, didn’t happen to me on Saturday, but on Sunday, it was a busy long day cleaning up but then all the politicians started showing up.
Dr. Alan Tyroch: I had to be distracted from my clinical duties to take care of the political stuff. Also remember, even though you’re taking care of these victims, the usual work that we typically see in a level one trauma center and County Hospital, people still come in. On Sunday we had somebody with appendicitis, we had somebody with an abscess need to be draining, we have the usual number of car wrecks and general surgery problems. ER was dealing with heart attacks and strokes. So you’re still being distracted. You’re getting pulled physically for that, but you’re also being pulled emotionally dealing with this other stuff.
Dr. Alan Tyroch: That’s one thing we face. I even talked to the medical examiner the other day, and it impacted his team with the PTSD. I know EMS has been impacted, so they have counselors. So it’s a real thing, the PTSD, the emotions, but it got to me even on Sunday. I was walking in my car, is like late in the evening, I was by myself and all of a sudden I just want to start crying. Just thinking, “Oh my gosh, this was our town.” I never thought … I always told people we’re gonna have a disaster. You always be ready, but I never thought it will be a mass shooting.
Dr. Alan Tyroch: The day before I was looking at Vegas and I was driving just touring Vegas was thinking, “Oh my God, how did these people deal with this?” The next day it was us. And we’re getting in the cab getting to the airport, I said to myself, “It’s our turn now.” I was like, “Oh my gosh, what a crazy thought.” I would never thought I had to say that to myself, but it really was. That Saturday night when the dust settled a little bit, my counterpart at the level two Trauma Center, Dr. Flaherty, texted me, says, “Alan, now we’re in that exclusive club, meaning we had to deal with the mass shooting here in our own city.” I was like, “Wow, that’s really true.” And that’s how we sort of support each other.
Dr. Alan Tyroch: That’s one of the things we’ve been doing since and all of us, is supporting each other. It also got to me when I was driving home on Sunday to see the on Interstate Ten. We had these traffic signs everybody has, says, go slow, wet roads where every sign had “El Paso strong.” I remember seeing it in Vegas when they had there’s a “Vegas strong.” It’s been in other places now it’s El Paso and I knew that was being beamed across the whole state of Texas because these signs are not really centered to a city. The whole interstate system has that nice thing oh my gosh, everybody in Texas is seeing that which is sort of supporting though.
Dr. Alan Tyroch: I got so many calls and texts and emails supporting, saying, “What can we do to help you so that was sort of nice.” That’s that part.
Chitra Ragavan: You talked to me earlier about this really interesting thing that you tell your residents, this idea if when you are in this kind of job, that sometimes you will have what you described as good deaths and sometimes you have bad deaths. Can you talk a little bit about that and why that is helpful to understand?
Dr. Alan Tyroch: Yes. There good deaths and they’re bad deaths. First of all, everybody dies and we have to rely, especially as surgeons, because we have to do a lot of stuff to make people better. Sometimes we have to actually, we’re pretty invasive with our surgical procedures. Every time I operate, I can always look back saying, I could have done a better job or this could be done differently but anyway it went well. I’m going to give you an example of a bad death for me at least it really it was a rough one.
Dr. Alan Tyroch: It was a Thanksgiving weekend. 16 year old girl came in was in a car wreck. Her blood pressure was good but she was very tachycardia which means her heart rate was very fast. Her pulse was fast. She was very pale, which is already telling me she’s bleeding internally. She’s wide awake, crying, saying, “I don’t want to die. I don’t want to die.” And I reassure her, “I’m not going to let you die.” Rush her off to the operating room. I opened up her abdomen. A rush of blood. She probably had lost three or four liters of blood already. This is despite us pouring in blood products into her. I see a massively injured liver. It was shredded, and we grade liver injuries of one to five, five being bad.
Dr. Alan Tyroch: Hers was a big time five. Basically she tore the liver off of her inferior vena cava, which is the big vein that goes to the heart and I did every maneuver I could do to fix that and stop the bleeding. I had an excellent chief resident with me. This guy knew how to operate and we did everything under the sun. I went through every thing I learned, and she still died in the operating room. Then afterwards, I need to go talk to her father.
Dr. Alan Tyroch: And then everybody warns me that the father thinks the daughter’s fine because the pre-hospital people told him she was fine that she was talking and alert and unfortunately the people in the ER had also told the father that. So now I’m the one that has to go tell the father, “I’m sorry. You’re innocent little 16 year old daughter, who you just saw earlier today is dead.”
Dr. Alan Tyroch: That was not a good death. That bothered me for so long but you what I tell my residents? “It’s okay to feel bad because if you don’t feel bad, when things like that happen, there’s something wrong.”You got to have that one to one connection with the patient or their family because if they don’t feel bad, you’re just a technician at this point but I remember after I went and told the father who just didn’t want to believe me like, “I want to go see my daughter. I know she’s still alive. Go back and fix her.” And I go, “I’m sorry, I can’t do that.” He goes, “But everybody told me she’s fine. She’s going to go home in a couple days.” I said, “I’m sorry. She’s passed away. We did everything we could.”
Dr. Alan Tyroch: I stormed outside of the hospitals like two in the morning, I remember it was cold outside. I just sat down on a bench and I remember. I don’t know what the star was not even the planet. It was so bright. I just kept looking up there and I said, “God, I can’t believe you let this girl die. She didn’t do anything wrong. She wouldn’t drink. Why don’t you let this innocent little girl die. This teenager. She had everything to live for.” I said, “God, I told you if you let me be a doctor, I would do my best. I did my best. And she still died. I’m mad at you.” I’m a little emotional. I’m sorry. This always bothers me.
Dr. Alan Tyroch: It took me weeks. I said, “I can’t talk to you for a while.” Then three or four weeks later, I can talk to God again. Well, it’s actually a pretty good relationship. I can tell him, “I’m mad at you.” So that was pretty cool. That was a bad death but once again, what did I learn from that? I did everything I could. Even in retrospect, we present our deaths at something called an M&M, morbidity and mortality conference. Everybody said you did all the right things. I knew I did all the right things, because I even went back and reviewed the literature. I did all the right things, but it was a bad death.
Dr. Alan Tyroch: If I’m going back to the gentleman that … Actually about to get the interview and testified in DC yesterday, he talks about the patient he couldn’t save in the trauma bay. She had lethal injuries, but he says, “I still live with that. Why could I have done it differently.” We all told him, “You did everything right. People die.” To him, that’s a bad death but I know and he knows in his heart and back of his mind, he did the right thing. I’m going to give you a couple of good deaths if we have time. Here’s the first one. Hopefully there’s statute of limitations out there.
Dr. Alan Tyroch: I was in a resident I won’t say where exactly either in California or Arizona or Houston. This lady was hit by a car. She’s what people call a street person. A transient. Her whole body was just all messed up. We couldn’t save her in the trauma bay, we declared her dead. And the hospital personnel put her in a body bag. They put her off in a corner. Nobody around, there’s this one area the ER, actually it was in the operating room that nobody hangs out. They were waiting for the medical exam or pick up the body later in the morning. This is like probably at four o’clock or so in the morning when I got involved again.
Dr. Alan Tyroch: This guy comes in he says, “That’s my wife. We didn’t officially get married but I gave her a ring and she’s my everything. I want to see her. I know I want my ring back, he says but problem is I can’t bury her. I had no money. We both live on the streets but I love my wife. Can I see her?” He says, they all tell me I can’t go see her because she’s now at the medical examiner or the coroner’s office and I said, “Come here with me.” So we snuck into a back door. Nobody was around in that room, I unzipped the body bag. He looked at her, started hugging her and kissing her. It was just him, me and the lady that was dead. And he grabbed her hand, holding her hand and he says, “They’re not going to give me this ring.” He says no place that she can be buried. We’re going to cremate her and then I’m not going to see her again.
Dr. Alan Tyroch: I said, “Here.” I pulled the ring off that lady’s hand and gave it to him, zipped her back up and that was that. It’s very, very sad, a very good death because I saw the love between the man is this lady. Tell you what, If I do this now they get probably me written up and get all kinds of trouble back then. But that’s what I did. Another, I guess, a good death that there’s so many on but this one rings true too. This lady was in her 90s. She somehow got burned, she had burns like 90% of her body, which means that’s a lethal burn injury. She came in, no family. She was in such bad shape.
Dr. Alan Tyroch: I said, “We’re not even going to transfer her to the burn center.” Which is 350 miles away. There’s no point in doing that because I knew she was going to die in the next few hours and so let’s just make her comfortable. Then out of the blue, a young guy came probably in his 30s he said, “This is my grandma. I’m all she has. She’s outlived all her other family. She’s lived all her friends. I just want to sit with her.” And we sat there. He and I for about an hour and a half, maybe longer in the ICU with her. She’s completely out, unconscious. We were giving her morphine for pain.
Dr. Alan Tyroch: He would just tell me stories about how his grandma took care of him. She was like his surrogate mom and I just saw the love and the passion or the compassion that he had for his grandmother and I sat there with him. I just felt I couldn’t leave this man because I just saw that. That that that was a good death. There’s one more I just thought about. I always give this one to the nurses. I always want to hear stories when they come and join us. I used to meet with them for a couple hours. We had a gentleman came in. He was in a car wreck. Actually, I think it was a motorcycle crash. He had broken his femur and shattered his spleen and he was going in and out of consciousness because he was in such bad shock. The paramedics told me that he told him just before he arrived, that he is a Jehovah’s Witness and to not give him blood, no matter what.
Dr. Alan Tyroch: By the time he got to me, he was unconscious but I felt pretty comfortable with what the paramedics told me that he couldn’t get blood. So we took him to the OR took out his spleen, stabilized his broken leg, took him back to the ICU and his blood pressure was terribly low. His heart rate was very, very fast. This is somebody that I would give blood to. I can guarantee you that this man would survive and probably gone home in about five or six days.
Dr. Alan Tyroch: His wife shows up and says, “He is not a Jehovah’s Witness, give him blood.” His other family says, “No, he is.” The nurses say, “Just give him blood.” I said, “I can’t. I have to honor this man’s wishes even though I don’t agree with it because I know if I gave him blood he’ll survive.” His wife was so mad saying, “I’m going to sue you on and on and on.” An attorney calls says, “You got to give him blood.” I said, “We got enough information that that’s what he wants. That’s his wishes. He’s an adult, I have to honor his wishes, even though I don’t agree with it.”
Dr. Alan Tyroch: As I was meeting with his wife again, she’s still yelling at me. The nurse runs and says he woke up. The wife and I go and see him and I asked him the question that says, “Listen, I really need to give you blood.” He shakes, he said, “No.” I said, “Listen, If I don’t give you blood, you’re going to die. I’m going to be honest with you, you’re going to die and you’ll die tonight. Do you understand.” And he acknowledges that he understands that and so we respected his wishes. He passed later that night.
Dr. Alan Tyroch: Then I get a phone call from his wife and think, “Oh my God, I don’t want to hear this phone call.” She calls me and tells me, “Dr. Tyroch, I was mad at you. I didn’t want you to do that but when we went and saw him and I knew that’s what he wanted, and I thank you for honoring him by doing what he said. Not what I wanted even though he died.” That was in an odd way a good death because you have to respect the autonomy, autonomy of a patient do what they want, not impose what I want. Yes, my job is to educate them, tell them what is right and best for them but the end of the day, it’s them. I thought that was one of my good deaths even thoguh it’s painful was I knew we could have saved that man and he was young.
Chitra Ragavan: You also have to deal with some complex situations where the people you treat have probably done some really bad things and yet you have to treat them like you would treat anybody else. Briefly how do you reconcile that?
Dr. Alan Tyroch: Well, that’s one of the things about trauma first of all. You have no idea what’s going to come through those doors. car wrecks, gunshots. 99 year old person that fell off their wheelchair or a nine year old kid that was playing football and has a head injury and you don’t know what. When you start your shift, you have no idea what you’re going to be doing in the operating room. So you better be able to be a jack of all trades sort of in surgery at that time. But you do take care of all types of characters. We get a lot of people that have mental problems. Obviously a lot of people that have run afoul of the law.
Dr. Alan Tyroch: Some people that aren’t the nicest people in the world, some of those the sweetest souls of the world too but here’s an example for that. Many years ago, this guy, shot his wife. He wasn’t a nice guy. It was clear he had a bad criminal record. He shot his wife, you could actually put your hand through her chest. It was that big of a hole. The type of gun he used. This was many years ago. The cops shot him. So we tried to save his wife next door, she had lethal injuries. So immediately after I took care of try to take care of her, pull the curtain, he’s next door in the other trauma room operating on, taking care of him and people were going, “Just let this jerk die.” And I was like, “No, we don’t judge.”
Dr. Alan Tyroch: Our job is take care of the body take care of the person. We are all were all saints and sinners at times so that’s that’s how we try to as trauma surgeon as any other physician and nurse. We’re not supposed to judge because nobody’s perfect and that’s one of the things I like about trauma. You get all kinds and you have no idea what’s coming in that door.
Chitra Ragavan: So looking back you know at all this adversity you face to become a trauma surgeon. All those bad grades all those rejections, what do you think are the principal lessons you learned from that and how those challenges helped you get to where you find yourself today and I think you’re very happy where you are today doing the work that you’ve always wanted to do.
Dr. Alan Tyroch: I’m actually very happy. I got the best job in the world. When I was growing up, I either wanted to play for the Dallas Cowboys or be a guitar player in a rock band but none of those was going to work. I can’t even play any kind of sheets and music. I’ve no idea and I was not big enough to play football. When I played, I was pretty good, but not big enough. I was fast but not big. I guess I had do something else. I get the best job in the world. If I want to go make money, there’s a lot easier ways of doing that. Just this week, I was on call starting on Monday morning 8 AM. I didn’t get home until 7 PM on Tuesday night, but I had so much fun during the time.
Dr. Alan Tyroch: I get up in the morning excited like, “What’s the challenge today?” And you got to love your job and you got to be persevering. I tell the residents, “When you’re on call, the surgery resident, be the best, don’t be good, be great.” There’s always somebody smarter than you. There’s somebody always xxx just better than you. But that’s okay. Be the best doctor in the hospital when you’re on call. Because if you’re trying to be the best doctor, when you’re on call, hopefully the other persons that are on call today will be the best doctor, or the best nurse, or the best whatever that’s taking care of these patients. Treat the patient as if it’s your mom or your grandma.
Dr. Alan Tyroch: Would you want your grandma treated half-assed? No, you don’t. So do that. I know I’m not the best surgeon in the world. I’m really not. I don’t think I am technically the best but I know the patients know when I go there, I’m going to give 110% and that’s what I try to ingrain in my residence and my junior faculty and I got an incredible number of amazing faculty, young and old, they had the same mindset. Go there. Don’t be good, be the best that you can be. And that’s what we’re trying to instill in our Department of Surgery.
Dr. Alan Tyroch: To be the best Department of Surgery in the southwest. I tell people you know, El Paso is the sixth largest city in Texas. We’re actually the 19th largest city in this country. We cover a big area. Why can’t we be good? When I came here, we were a small surgery department. Worked hard, put out good residents, taught the medical students well but now I want us to be bigger than that. I want us to be strong academically, strong clinically, be a regional academic referral center for the Department of Surgery and just do the best we can. Ir’s exciting. It’s fun.
Chitra Ragavan: This has been a great conversation. Dr. Tyroch, thank you so much for being on the podcast.
Dr. Alan Tyroch: Thank you. Thank you for letting me talk to you this morning.
Chitra Ragavan: Dr. Alan Tyroch is Chief of Surgery trauma, Medical Director and Chief of Staff at University Medical Center of El Paso. Dr. Tyroch was in charge of directing and managing the critical care of the August 3, 2019 mass shooting in El Paso, Texas.
Chitra Ragavan: Thank you for listening to when it mattered. Don’t forget to subscribe on Apple podcasts or your preferred podcast platform. And if you like the show, please rate it five stars leave a review and do recommend it to your friends, family and colleagues. When it Mattered is a weekly leadership podcast produced by Goodstory, an advisory firm helping technology startups find their narrative.
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