“Do you have a weapon? A gun or a knife?”
“A gun.”
I asked again. “You have a gun?”
He said nothing.
I tried again. “Do you have access to a gun?”
“Don’t worry about it, miss. Don’t worry about it,” he replied tersely, indicating that this would be his final answer.
“Gabriel, this is all very dangerous. This is one of those instances I mentioned before, where I have to break confidentiality. Anytime a young person mentions that they have access to a gun and may use it to cause harm, we have to speak with the social worker just to keep you safe.”
Gabriel didn’t move and didn’t say anything. I waited for any response or sign. He simply shook his head and froze.
“I’ll be right back,” I said.
I went outside and spoke to my supervising attending physician. I presented the case to her—residents must review all patient cases with their supervising attendings—concluding my presentation with my assessment that, given the disclosure of potential violence by firearm, I had to speak with the boy’s parents and the social worker. She advised me to proceed. I put a page out to Social Work and then went to the parents, who were waiting outside the examination room. I summarized for them the situation and my concerns.
They looked at me plainly, waiting for the question, waiting for clarification of why I was alarmed.
Now we were all confused. They were stumped by my concern, and I was puzzled by their untroubled stance.
We all went into the room to join Gabriel, who looked up at his parents.
“Miss,” his mother said to me, “if he has to defend himself, he has to defend himself.”
I paused. The statement was deceptively plain. I was horrified that his parent normalized what sounded like retaliation. It hadn’t taken long in my career for me to learn that violence often begets more violence. Each trauma alert, each young person we pronounced, each patient who, if lucky, left the hospital with a colostomy bag, tracheostomy, or wheelchair proved this point. I also knew firsthand that self-defense could make the difference between being memorialized or graduating, and that no child should ever be put in the position to have to make that choice. “Um, okay. This is a very dangerous situation. Anytime we receive information about potential gun violence, we have to get Social Work involved, to ensure everyone is safe,” is what came out.
“What are you saying, miss? Are you going to take our son from us?” the mother asked with the first hint of concern I perceived in her voice. The father slumped back in his chair, propped his head against the wall, and sighed, closing his eyes. Gabriel sat up in the stretcher. For the first time during this discussion with his parents, he looked me squarely in the face. His eyes were glassy with disbelief, the way I had looked at the two DC police officers who came to our door and said they would arrest my brother, too, after I had summoned them to stop my father’s violence. That night, they had communicated to my family that we were all implicated somehow, so all of us would have to pay.
Now, as I stood there looking down at this child, I knew how he felt. I knew that there wasn’t anything I could say or do to make him feel otherwise. We were all in this mess together, and none of us would leave feeling vindicated or clean.
“No, that is not the aim here. No one wants to take you away from your family. That will not happen here,” I stated, in a desperate attempt to clarify my intentions. As I stood there waiting for the social worker to arrive, I wondered why, in all my growing-up years, no physician had ever spoken to me alone, to ask if I was safe. Neither had a teacher, mentor, or other family member, for that matter. I wondered what might have transpired if they had. I imagine that I, too, would have felt reluctant and scared. I did know that it would have taught me a valuable lesson, one I would have carried with me for the rest of my life: There are adults who will protect another human being. This was something I had to learn later, on my own, once I finally left that house.
The ER social worker, Aisha, arrived and took her report. Aisha was as conscientious as she was fabulously accessorized. While she was undoubtedly a phenomenal social worker, she could have been a notable fashion blogger, too. Each day, she sported her pixie cut with a different selection of dangly earrings depending on her ensemble. How she adroitly walked the hospital halls during her entire shift in four-inch heels as if they were sneakers is still a mystery to me.
When she completed her consultation with the family, she pulled me aside to summarize her findings. She told me that these were hardworking parents who were doing the best they could. Mom worked full time at a grocery store, typically doing overtime to make ends meet. Dad was a janitor, working all hours of the night and day while doing contractor work on the side. They lived in a violent neighborhood riddled with crime. Drugs were sold on every corner, and you tuned out gunshots the way suburbanites tune out the crickets’ chorus at dusk.
Aisha placed her hand on my arm. Her tone was kind but resigned. She didn’t break a sweat, and her brow was unfurrowed. Clearly, this was a conversation she had with newbies like me all the time.
“Michele, when you’re at war, the rules are different. The members of this family, they’re soldiers in a way. They’re fighting for their families. The frame of reference in war is different. The atrocities of a war zone are a normal part of life, and you do what you have to do to survive, to make it out, to make it home.” She sighed. “You know these are really good people. None of this is right. Gabriel shouldn’t think it’s okay to use a gun. There are other ways, of course. And he shouldn’t feel he has to have a gun to feel safe at school. Schools should be safe. There are other ways for that, too.”
She sighed again, this time even more heavily.
“Oh, child,” she said, shaking her head. “Anyway, there’s no proof that this kid really has access to a gun. No one in his family has one, either. I’ll write up my report, and we’ll check on the family. There’s nothing else to do here.” She shook her head again and smiled. “Unless the ER can give these people jobs that are actually living wage and safe places to live.” She picked up her clipboard and began to walk away, and then turned to me and asked, “Can we do that, Doc? Lord knows, I wish we could do that. Have a nice day. You know how to reach me!” She waved, turning to see the next patient down the hall.
That was years ago now. I never found out what happened to Gabriel and his family. Yet his story, their story, haunts me.
Now I stood in the trauma bay at Montefiore, waiting to receive the latest trauma notification—all of us robed, gloved, and ready. The call had come in: two young men shot, one in the head, the other in an extremity. When trauma alerts like this one came in, I often thought about how the patient could be Gabriel or so many others like him. It was the beginning of my shift, so I would be taking the more seriously injured one. It’s common practice for the fresher doctor to handle any new critical patient. The other doc would head up the less serious injury, in Trauma Room 2, while my team and I were in Trauma 1. We figured the incident was gang-related, but then, that was almost a given.
As I stood at the head of the bed, I checked my suction and laryngoscope blade one last time. One tech was at the foot of the bed with trauma shears, to cut off all clothing for full exposure, so we could check for wounds. Another pulled out a C-collar, a rigid neck brace used to stabilize the cervical spine in any trauma patient where neck injury hasn’t been ruled out—just in case EMS didn’t have time to place one in the field. One nurse was on either side of the bed, each with an IV setup. The nurse to my right had fluids hanging, the one on my left had monitor leads and the code cart. There were two med students in the room, whispering to each other in eager anticipation. This was their first shift in the emergency room, and they probably already felt like they were in the middle of a popular ER reality show episode.
“Please, just let them get here,” I implored. Standing
there in the Trauma Room, I could practically feel the charts building up in the main ER. With a groan, I pinched the top of my mask snug to the bridge of my nose to prevent condensation on my face shield. I stood there thinking about all the things that could go wrong and how I could address them. What if the GSW was to the mouth, and I couldn’t intubate? What if it was to the neck, and I couldn’t even manage a tracheotomy? There are times, too, when the EMS notification is completely wrong. There was the time a GSW to the chest was called in that was actually a flesh wound to the arm. Who knows? Maybe the guy coming in was only grazed on his scalp.
Nurse Ramirez walked through the Trauma Room doors with an update. “Just a heads-up that y’all will only get the GSW to the head. The other male was diverted to Episcopal, since they’re in opposing gangs. The less craziness we have here, the better! They should be here any second.”
“Thanks, Chief,” Brian, one of the techs, replied.
We heard thunderous rattling at the ambulance entrance. Then EMS appeared, pushing in a gurney with two enormous black sneakers hanging off the edge, kicking in twisting movements. The legs were clad in jeans streaked crimson. Then a torso emerged—a striped shirt with blood dripping down the right side and bits of fleshy matter about the chest. Blood leaking from a pressure dressing to his scalp streaked the floor.
“Sorry, this was a scoop-and-run,” one medic announced, beginning his report. “Twenty-something-year-old man. GSW to head. GCS anywhere from thirteen to fifteen. It’s hard to tell because he’s agitated. Blood pressure one-ten over seventy, heart rate one-forty, saturating ninety-five percent on room air. We couldn’t get IVs. We couldn’t tube him in the field.”
They parked their gurney next to our stretcher and transferred the patient. One medic began to help Brian cut off the clothes as the other medic continued his stream of information.
“It was just madness at the scene. Sorry for the delay. There was a huge crowd and some fighting still going on. The police had to get us in and out as they secured the scene. Then we just drove like hell to get here.”
“What’s his name?” I asked as I looked down at the fallen giant on the bed. He had to be at least six foot four and probably 300 pounds.
“Friends said they call him Jay. His ID says Jeremiah; it’s with registration.” Jeremiah was enormous and thrashing and bleeding from his right scalp.
With swift precision, EMS and Brian cut off his jeans. Bloodstains on the legs, but no injuries. Next, they cut off his shirt. More bloody marks scarring his torso and arms, but no deformity, no injuries, no swelling. There was so much blood. We in emergency medicine do this work every day, but we never entirely numb ourselves to the impact of the body being rent apart to let rivers of life flow from arteries and veins. I couldn’t imagine a day when it wouldn’t be disturbing to see blood burst forth as if from a broken levee.
I could see no deformity to the neck. Jeremiah was breathing, he was moaning, he was emitting sounds of anguish. His GCS, or Glasgow Coma Scale, which measures a patient’s level of consciousness on a scale of 1 through 15, was somewhere near 15, which was reassuring.
Once he was fully exposed, the nurses placed the patient on the monitor and prepared the IVs. His blood pressure was technically “normal.” Given the stress he was under, that was a very bad sign. The constellation of fast heart rate and relative hypotension here signaled that he might have a life-threatening hemorrhage, not to mention the possibility of a catastrophic brain injury. The patient was flailing around, and the EMS guys and Brian grappled to get his legs down. The nurses called the med students over to hold down each arm while they placed one large-bore IV into each antecubital area of his arm, which in lay terms is the crease in the inner arm where the elbow bends. We needed venous access to stabilize him. It was like wrestling with Goliath—an agitated and confused Goliath.
“Jeremiah, Jeremiah, do you hear me?” I called to him softly, placing one palm on his left cheek while inspecting his head. The only wound, which was too much, was the section of his skull that shattered into his brain. Blood oozed from this wound in his right skull around matted chunks of tissue.
“Where am I? Christian! Mom!” he screamed out, thrusting his head from side to side, splattering blood around the head of the bed. His eyes were shut tight as he moaned and cried. A mix of tears and blood streamed down his dark cheeks. His skin was the color of deep mahogany, smooth and rich.
I placed my hands on each side of his head to coax him to stillness. Looking directly down at him, I asked, “Jeremiah, look at me. Can you look at me?”
His eyes cracked open and he looked behind my mask, past my glasses, and into my eyes.
“Can you help me? Please, please help me!” he cried.
“Jeremiah, we are going to help you. Try to be calm. Please try to be still so we can help you,” I chanted to him like a lullaby.
“Please, please save me! Moooommmmmm! Please, please save me,” he begged as he stared into my eyes.
“Jeremiah, we will help you,” I chanted, begging him to believe me, hoping we could both be soothed by my words.
Jeremiah wept. He wept in waves. He wept in howls that stirred the marrow. He wept from a place of pain much deeper than the GSW to his head, pain that hurt more than having bits of his skull shot off and lying on the sidewalk.
“Jeremiah, I am here to help you,” I said, gazing between the spaces of his tears as I placed my other hand on his shoulder.
“I’m going to diiiiiiieeeeeeee, I’m going to diiiiiiiieeeeee,” he gulped in great hiccupping wails.
“We’re here for you, Jeremiah.” I knew that my words were more important than the medicine I would push into his veins to dampen his consciousness and paralyze his muscles. More important than the breathing tube I would slide down his throat to take control of his breath. More important than the entire surgical team that had been activated for him.
I looked deeper into his eyes and moved my hand to his right cheek to cradle his face because I knew that he was correct. I knew that he was at a crossroads, that he was touching grace. I knew that no matter what he had done to end up in the ER, he deserved to be comforted right now.
“Dr. Harper, we have a line!” reported Trish, one of the nurses.
“Excellent,” I said to her, flashing a thumbs-up. “Let’s start with lidocaine 150 mg, then 30 mg of etomidate, and 150 mg of succinylcholine,” I said, requesting the medications that would relax him so I could perform an endotracheal intubation.
I grabbed my blade and looked into his eyes for the final time. “Now, Jeremiah, you’re going to sleep.”
After he slipped into unconsciousness I advanced the breathing tube into his trachea and the respiratory team attached the CO2 detector; we noted good color change, so they placed him on the ventilator. I tore off my bloody gloves to take my stethoscope and listen to his chest: There was good air entry bilaterally, another indicator the endotracheal tube was where it should be. The surgical team flooded the room and whisked Jeremiah off to the operating room. The techs and nurses had moved on to the next patient. EMS loaded up their truck for the next ride. The room was empty save for the aftermath of what had just happened: Monitor leads swung from their screens and plastic needle caps were strewn across the floor along with a mosaic of bloodstains and discarded gloves. I surveyed the scene and was reminded of how these resuscitation rooms are often the most tragic confessionals.
A police investigator came into the room, breaking the silence. He wanted to take my statement: How did the patient present? What was his condition on arrival? What had we done for him in the ER? What was his status when he left the ER?
I answered his questions, we finished the interview, thanked each other for our respective hard work, and stepped over debris to get back to our jobs.
Nurse Esteban met us at the door to say, “Doc, the OR called. That patient coded on the table and died.”
The detective heard him. “Okay, now it’s a homicide. Thanks, guys,” he said as he walked out of the department.
I looked up at Esteban, then I nodded and sighed. It wasn’t that I was surprised or confused—it was not surprising that a man who had been shot in the head would die. There was nothing confusing about a man crying out that he was going to die, proving that, in fact, he had perfect insight in that moment. No, my sigh acknowledged the moment he had had with himself and his life, with his blood and his tears, as he was absolved by the bright lights of the trauma bay. It was an understanding that no matter the hand we are dealt at the beginning of our lives, in the end, we face our actions alone. Jeremiah had called out for Mama and for Christian, but in our final moments, everyone we’ve honored or betrayed is, ultimately, not with us. We lie there alone, flesh and bone, soon to be only spirit.
It occurred to me that maybe Jeremiah was the Gabriel who had picked up a gun. Perhaps it wasn’t Gabriel precisely, because maybe he left the ER that day I met him and never touched a gun. Maybe Gabriel left the ER and survived to graduation and was strengthened by the challenges life threw at him. Maybe Gabriel finished college and was now mentoring his teenage sister. Or perhaps he was working toward owning his own business to improve not only his own life, but the lives of those in his family and community.
I suppose it’s a matter of faith whether or not we choose our starting ground before we’re born into this life. Some begin the journey on flat, grassy meadows and others at the base of a very steep mountain. One path, seemingly smooth, can make it nearly impossible for us to see the ditches and gullies along the way. The other, while painfully tough, can deliver what it promises: If you can navigate that path, you’ve developed the skills to scale Everest. It isn’t fair on many accounts; it simply is. And assuredly, both paths include uncertain terrain ahead.
As we place one foot in front of the other, we make choices at every step, no matter the terrain. When we reach the threshold that Jeremiah reached, we look back at our footprints and must face the results of our choices. Alone. In that recognition there is absolution. All deserve the chance to speak and be heard and be touched. If we’re lucky, we’re touched at every station along the journey, and if nothing else, then at the end.
The Beauty in Breaking Page 11