“PAUL, we’ve got a trauma red tag coming in.” Joanne, the charge nurse, put down the microphone to the EMS radio. “Gunshot wound to the chest.”
“Red tag” is shorthand for a patient who’s critically ill. It’s as close to dead as you can get and still warrant treatment. As the attending in the ER, I’d be in charge of the patient until the trauma surgeon arrived.
“Vital signs?” I looked up from a chart.
“Don’t know.” She walked toward the trauma bay. “All they said was ‘trauma red tag.’ They sounded pretty stressed.”
“How long has he been down?”
Joanne stopped. “You know everything I know.”
“Okay.” I held up my hands.
“I’ll call a trauma code and make sure the room’s set up.”
I walked with her to the trauma bay and checked the equipment I’d be using. I then discharged a patient and got another patient’s work-up started. Once the red tag arrived, I’d be too busy to get anything else done, and I wanted to clear out as much as I could before it got there.
The paramedics rolled in with a businesslike clatter. Barry gave the report: “Gunshot wound to the chest.” He handed Lisa an IV bag. “Fired a guy this morning, guy came back with a thirty-eight.”
“Damn,” Lisa said. “Where’s he work?” She’d been an ER nurse long enough to be casually curious about the circumstances.
“Insurance office,” Barry answered.
A firefighter pumped on the patient’s chest, while a paramedic squeezed the Ambu-bag, forcing air through a clear plastic tube going down into the man’s trachea.
“On three,” Barry said. “One…two…three.” They hefted the patient onto our stretcher. Barry pulled the green oxygen tubing from the nipple on his portable tank and tossed it to Joanne, who hooked it to the flow meter in the wall. The portable tank hissed loudly until Barry twisted the green knob on his tank, turning it off.
I pulled my trauma shears from the back pocket of my scrubs and cut through the blue oxford cloth shirt and tweed sport jacket. With each compression, blood bubbled lazily from a hole in the left side of the chest. “Bag,” I called, and I listened for breath sounds in the right side of the man’s chest as the firefighter squeezed the Ambu-bag. “Bag,” I repeated as I listened to the left side. “He’s diminished on the left.”
If air pressure builds up between the lungs and the inside of the rib cage, the lungs can’t expand. The increasing pressure also keeps the blood in the rest of the body from returning to the heart. The quick fix is to poke a needle between the ribs to vent the air that’s under pressure. A tension pneumothorax can be rapidly fatal, and you make the diagnosis based only on hearing the story and doing the physical examination. There isn’t time to get an X-ray, and a film of a tension pneumothorax is proof of inexperience or incompetence. I’d been an ER doc long enough to know this guy had one.
I glanced at Barry. “Did you needle him?”
“No, he sounded equal when we tubed him.”
“Probably went under tension en route.” I looked at Lisa. “Gimme a catheter.”
I swiped the chest with orange antiseptic solution, and poked the needle between the ribs on the right side of the chest. Air hissed audibly. I removed the metal needle, leaving the plastic catheter in place. One problem solved.
“Bag,” I said, as I listened to the left side again. “Better.” I draped my stethoscope around my neck. “Airway; Breathing; what do we have for Circulation?” I cut his khaki pants and underwear away and placed a gloved finger on the crease next to the pubic hair. “I think I’ve got a femoral pulse with compressions.” I looked up to the burly firefighter doing compressions. “Stop CPR.” The faint bounding under my finger ceased. “Nothing. Continue CPR.” Each time the firefighter pumped his heart, I thought I felt a pulse. “Lisa, how many lines do we have?” If he’d transected one of the major vessels going to or from the heart, he could’ve easily pumped his entire blood volume into his chest. He could use as much fluid as we could give him.
“I’m starting a second.” Lisa slapped the man’s pale, floppy arm.
“How much fluid has he had?” I looked at Barry.
“This is his second liter.”
I nodded that I’d heard. I didn’t want to open this guy’s chest. In ten years as an ER doc, I’d only done it on dogs, practicing. The trauma team would be there in a few minutes, and push me out of the way. But that was the only intervention that had any chance of helping him.
The idea is that with penetrating trauma to the chest, if you find a hole in the heart and plug it, you may be able to temporize until a surgeon can fix it. I’ve never seen it work, but in textbooks and on TV shows it looks easy. If I was in a tiny ER where there wasn’t a trauma team, it would be clear that I should go ahead and try it. Of course, if there was any hope of it working, it had to be done right now—not later. And the guy on my stretcher had no pulse. He was essentially dead. I had nothing to lose except my pride when the surgeons pushed me out of the way. “Get the thoracotomy tray,” I said, as I squirted orange antiseptic solution onto his chest.
“You’re going to open his chest?” Lisa looked up from her IV, her eyebrows raised.
“I’m hoping Ben gets here and takes over.” I tore the wrapping loose from the sterile tray holding the instruments, and put on a pair of sterile gloves.
Ben Smith, the trauma surgeon, walked in. “What you got?”
“Gunshot wound to chest. No pulse. Had a tension pneumo on the left when he got here. I needled it, still no pulse.” I pointed to the left side of the chest, wet and shiny from the antiseptic. “The only other thing would be to open his chest.”
Ben walked over. “You’re going to do it?”
“All yours, big guy.” I stepped back.
“Did he ever have a pulse?” Ben looked over to Barry.
“We were pretty sure we felt a carotid when we first got there.”
“Gimme a scalpel.” Ben popped on a pair of sterile gloves, looked over to me, and shrugged with his right shoulder. “We got nothing to lose.” He glanced up at the firefighter doing chest compressions. “Stop CPR.” In one long swipe he cut through the skin. The yellow fat splayed open. He tossed the scalpel onto the tray, wedged the tip of a pair of heavy scissors between two ribs, and cut first up, then down. “Gimme the rib spreaders.”
I handed him a bulky stainless steel bar with two paddles.
Ben wrestled the paddles into the incision, then turned a crank on the rib spreaders. The ribs gaped open further and further with each twist. He glanced at the firefighter who’d been doing CPR. “Don’t do any more compressions.” Ben didn’t want to take any chances of getting his hands squished between the patient’s sternum and backbone. He leaned over and snaked his hands into the chest. They made a slurping sound.
“The heart’s empty. Flat.” He frowned, his hands working inside the chest. “There isn’t a hole.” He pulled his hands out. “Look at what’s coming out of his chest. Looks like Kool-Aid.” A thin, watery liquid, barely tinted pink, dribbled out onto the stretcher. “Bullet must’ve tagged his vena cava. The IV fluid’s running out as fast as it runs in.” He shook his head. “There’s nothing we can do here. He probably bled out into his chest before EMS even got there.”
I shrugged. “Thanks for coming down.”
“So,” Lisa said. “Are we calling it?”
“Yup.”
“Time of death,” Lisa called out, “9:57.”
“Good job, team. We just didn’t have enough to work with.”
Ben slowly cranked the rib spreaders. The gaping mouth he’d made of the man’s chest closed. When he tried to pull the instrument out, it got hung up on the ribs. Ben levered the spreaders up and down as he pulled, like a man tugging a hatchet that’s stuck in a stump. When the instrument was free, he gently placed it on the sterile tray, tossed his gloves in the trash, washed his hands, and walked out to write a note in the chart.
A watery pink stain spread on the sheet.
I walked up to the head of the stretcher and looked at the man’s face. He had a receding hairline, with salt and pepper hair. Looked like a businessman. The bloody, shredded clothes looked like they’d come from an outdoors catalogue, full of photographs of healthy people wearing natural fibers. His yellow tie had a Windsor knot with a tight little dimple in the center. It was snugged up to the collar of his blue oxford cloth shirt, which gaped open from where I’d cut it up the center. This man looked as if he should’ve been in a photograph in a catalogue, smiling as he handed a set of house plans to a carpenter, or sitting behind a desk. He didn’t belong on a bloody stretcher in my ER, dead.
The hole in his chest was .38 inches in diameter. A red dot that was bigger than a quarter inch, smaller than a half an inch. “Looks like he was a nice guy.”
Lisa looked at me and blinked. “Huh?”
“You know.” I pointed to his clothes. “Doesn’t look like a gangbanger, or a biker or anything.”
Lisa nodded.
Several years ago, I took care of a woman who’d been shot in the abdomen while sitting on her front porch. Drive-by. She was scared. We got IVs in her, got her blood started, and the surgeons took her straight to the operating room. It was a satisfying case because the docs and nurses in the ER did our jobs quickly, and the patient seemed to have the same agenda we had—increasing her odds of survival. But a patient who gets shot while shooting someone else often brings the hostility of the conflict with him. If his wounds are life-threatening, the patient usually cooperates. But if it’s a gunshot wound to the leg or shoulder, the anger and bravado that got him shot is often still intact.
“Sir, can you tell me what happened?”
“What’s it look like?” The skinny eighteen-year-old scowls. “Motherfucker shot me in the leg.”
“Okay.” I take a deep breath, and let it slowly out. I’ve got an hour before I get off work. If a miracle happens, and I can get the films, and get a physician’s assistant to clean and dress the wound, I can get out on time and not have to dump this on the doc who’s coming on duty. “What did they shoot you with?” A wound from a high-velocity rifle causes more tissue damage than does, say, a handgun.
“What you think he shot me with?” The tough guy snorts. “A gun.”
“Pistol or rifle?”
“Pistol.” He smirks. “Does it look like I was out hunting buffalo?” He grins and cuts his eyes over to the nurse.
The nurse looks at me with a bored expression. “Want an IV?”
“Sure.”
“Naw, you-all can forget about the IV bullshit right here and now.” He shakes his head. “I got enough holes in me already without you sticking more in me.”
The nurse rolls her eyes. To the eighteen-year-old on the stretcher, it’s all a new thing. He’s seen it on TV, and now it’s happening to him in real life. But to the ER nurse, it seems like the billionth time someone comes in shot, or stabbed, and refuses an IV. She looks at me.
When I first started, I would’ve spent half an hour futilely pleading with the guy to let us do our job. Now I look at the nurse and say, “Document ‘patient refuses.’”
The girlfriend will arrive, pull out a cell phone, punch in some numbers, and start informing friends and family. As often as not, she’s our ally, and talks the tough guy into getting his tetanus shot.
If he’s sober, it’s easy: you make sure he understands the risks of refusing treatment, and give him the choice. Then you document that the patient had adequate decision-making capacity, and that he refused. End of discussion. If he’s drunk, you’re stuck because he isn’t competent to refuse treatment. Then it’s a round robin of pleading, cajoling the nurses taking care of him, asking the family or friends to help. And sitting on the stretcher, in the center of all this attention and effort, is the sullen, wounded, petulant King for the Day.
I stood at the end of the stretcher and stared at the dead man lying there, his cotton shirt and tweed jacket open and askew. This was an adventure he’d probably not been looking for. I stared at his face. He didn’t look scared, or stunned. As he’d knotted his tie that morning, had he thought about the guy he was going to fire that day? Maybe mentioned it to his wife at breakfast, as he ate a bowl of bran flakes?
Lisa and the nurses’ assistant rolled the dead man onto his left side to get him in a body bag. The bag, made of a heavy, translucent plastic, has a zipper running down its length. Lisa tied a tag to his toe, pulled the zipper up to the man’s waist, and tied another tag to the zipper. She looked back at me. “His wife’s here. In the Family Room.”
“I’ll talk with her in a second. Anyone call the coroner?”
She shook her head. “Don’t think so.” She spread a white sheet up over the body bag and tucked it up around the body’s shoulders, concealing the primitive colors of our failed resuscitation. After the wife had seen the body, all Lisa would have to do was pull off the sheet, zip the bag up over his head, and send the body to the morgue.
I stepped out to the nurses’ station and asked the ward clerk to page the coroner. While I waited for him to call back, I could talk with the man’s family. Lisa joined me, and we walked toward the Family Room. “Do we know his name?” I asked her.
“Stevens.”
The worst part of my job is telling someone that their husband, wife, son, or daughter is dead. A failed resuscitation leaves the whole team feeling empty and defeated. As I step away from the newly dead body, I feel a hard little nubbin of failure. I always tell the team they’ve done a good job, partly to honor their effort, but also to console myself. But at that point, the failure is circumscribed—it’s either a matter of imperfect technique, a limitation of medical technology, or the predictable result of working on an organism that’s too damn dead to bring back to life.
But when I go talk to a family, the tragedy becomes real and undeniable. This wasn’t an organism that had failed resuscitation, this was a person. A person with family, and friends. And I’ve found no words that can ease the pain of the people left behind. If I’m careful and lucky, the way I hand them this unwanted load won’t add to their burden. That’s the best I can hope for.
I was glad Lisa was going with me to talk to the wife. Lisa’s been an ER nurse for years. She’s usually direct, often blunt, but gentle when she needs to be. Lisa would stay with Mrs. Stevens after I told her that her husband was dead. That way, I could spring free and keep the other patients moving through the department.
I knocked on the door of the Family Room as we entered. It’s a small, windowless room, hardly larger than a closet.
A woman in a navy blue skirt and white blouse stood and looked me warily in the eyes. She clutched a crumpled Kleenex in her hands.
“Mrs. Stevens?”
She nodded.
I gestured to the chair she’d been sitting in, sat down in the one beside it, and faced her.
She sat without taking her eyes off mine.
“Your husband’s been shot…”
She nodded.
“And in spite of everything the rescue squad, nurses, and doctors could do, we couldn’t get his heart beating.”
She narrowed her eyes, and nodded again.
“I’m sorry, but he died.”
She closed her eyes tight. A tear squeezed from each. Her mouth clamped into a tight, pale line.
Lisa and I waited.
Mrs. Stevens gasped and started to cry.
I touched her shoulder, and she leaned against me, crying.
Lisa rubbed her back gently.
I’ve read articles and textbooks on how to break bad news. And I often remember how Dr. Nicholson, our obstetrician, told Sally and me that our daughter had Down syndrome. He spoke gently and clearly. Used simple words. He took his time, and allowed us to cry. A doctor’s demeanor at the bedside reflects who he or she is, but it also reflects techniques that have been learned, and I’ve tried to pay attention. I try to be like Dr. Nicholson.
I watch for cues from the family. If they’re shrinking back, shaking their heads, saying with every gesture and posture, “I don’t want to know,” I work around to it slowly, to give them time to prepare. If they’re fidgety, and look like they want me to get on with it, I do. As gently as possible.
On National Public Radio I heard a piece once about a woman who played the guitar for people as they were dying. She’d sit with the person’s family, next to the deathbed, and play quiet, restful pieces, to ease the journey. Must’ve been hospice patients. She said she played the person’s favorite piece, or pieces by their favorite composer. She talked about the peace, and beauty, the transcendence of the experience. I envied her. There are no candles in the ER. No Bach concertos for the guitar. Just unforgiving fluorescent lights and the squawking of the overhead pager. I can’t remember a death that was peaceful, beautiful, or transcendent. Death here is usually a noisy, hurried scramble through a harsh, industrial environment. The clock, like a huge hydraulic piston, relentlessly squeezes until I say, “Unless anyone has any ideas, we’ll call this one.” A nurse looks at the clock, and clearly calls the time.
“Did he suffer?” Mrs. Stevens wiped her cheeks with the palm of her hand.
Lisa gave her a Kleenex.
“No, he didn’t.” The certainty in my voice was meant as a kindness. But really, who knows how much we suffer as we die?
“Is there anyone in the family we can call for you?” Lisa held out another Kleenex.
“My son.” Mrs. Stevens started crying again. “He’s in California.”
“Is there anyone who lives close by?”
Mrs. Stevens shook her head and covered her face with her hands.
Lisa looked over to me and raised her eyebrows. We couldn’t leave Mrs. Stevens by herself, but we needed to get back to work. Lisa gestured toward the door with her head, letting me know I could leave and that she’d stay.
I wished there was something that would ease her pain, but I had nothing to offer but my presence. I waited. “Mrs. Stevens, do you have any other questions?”
She shook her head without looking up. “No.”
“I’ll be here for several hours. And you can call later. My name is Dr. Austin.”
I went out into the hallway, relieved to get away from the pain and loneliness of the Family Room, back to the clatter of phones ringing and monitor alarms chiming. Three empty stretchers were lined up against the wall; a security video camera stared at me from the ceiling.
I went to the bathroom, took a deep breath, and let it out. I splashed my face with cool water and dried it. Other patients and their charts were waiting for me in the rack. I walked back into the ER.
Someone had already moved the body to another room, to open up the trauma bay. A man from housekeeping was slowly mopping the floor. New suction tubing coiled above the clear plastic canister, and the countertops had all been wiped down with antiseptic solution, ready for the next red tag.
I walked to the chart rack, hoping for a patient with a problem I could fix.