by Pamela Grim
For the people in the ER though, the first responders, this was “heads up” time. It starts the moment after an ambulance calls in a trauma and it extends until the doors slide open and the patient is revealed. No matter what the paramedics told you on the radio or, in this case, tried to tell you, you never really know what is going to roll through your door until it actually does. That's when the victim of a gunshot wound to the chest turns out to be someone who was shot with a twenty-two and the bullet bounced off his clothing. Or a simple facial burn from a mishap with the oven turns out to be someone whose face has melted down to a third-degree burn so severe it exposed cartilage. It might take twenty minutes for the paramedics to cut a drunk driver out of his crashed and burned motor vehicle, but he turns out to be fine, ready for discharge in no time, while the person he hit, someone in a Volvo, no less, who is up and walking at the scene, turns out to have a dissecting aortic aneurysm and dies on the operating table. There is just no telling.
I stood to the side that day, not a player. Murray could be very peculiar about who participated in his code. I knew all the moves, though. Sudesh stood at the head of the bed checking the intubation equipment: the plastic endotracheal tube, a syringe, a wire stylet, a little lubricant; the stuff that saves lives. After this, he turned on the suction, and when it wouldn't work started poking at the plastic tubing, looking puzzled. Murray stood off to the side, arms folded, head bent, chin resting on his chest. He was mumbling; I couldn't hear what he was saying, and it was probably just as well.
That was when, apropos of nothing that I could see, Sudesh turned to Donna and said, “You know, this is not a real life.”
“You're right,” she replied. “This is not a real life. This is a test. If this had been a real life, you would have been instructed where to go and what to do.”
Sudesh turned away, shaking his head wearily. Ted laughed. (This was his third double shift in a row.) Sheila rolled her eyes. I can remember everyone in the room that day, or were they at another resuscitation? Was Sudesh on the night before and Sheila on day shift and had she already left? And Donna? Why do I remember Donna when I didn't work with her until years later? As I think back, what I remember, more than anyone I knew or anything that happened, is the pervasive sense of exhaustion, of being up for hours and hours, days and days, weeks, months. Exhaustion was like dust, settling over everything. You felt as if you had to swim through the day; the drag coefficient of even the littlest gesture made you ponderously slow. You even thought slowly. The whole world seemed darker than you ever remembered it—and the memory of the real light had almost vanished. And with the exhaustion came the phantoms of emotions, monstrous feelings, panic, terror, paranoia. Sudesh, standing by the bed, looked punch drunk, bedazzled by the suction equipment. This was his eighth twelve-hour shift in a row.
“Tune in tomorrow, whiny guys,” Ted said, “for another episode of Days of Our Lives.”
Murray turned on everyone. “Would you all be quiet!” he shouted. Then he glared at me, but he said nothing.
From outside in the ambulance bay we could hear the backup buzzer. The paramedics would be rolling in any second.
“All right, all right, all right. Let's go, let's go, let's go,” Murray shouted at everyone, even though there was really nothing anyone could do.
Four paramedics swept in, one doing chest compressions, one holding an IV aloft, another bagging the patient and the last wheeling the cart. They all looked terrified. The victim's head was swathed in bloody Kerlix. Blue sweat pants, T-shirt. Man? Woman? The belly was massively distended.
“Twenty-two-year-old shot in the head, we think times two. She had a pulse when we got there, but we lost it. It was a big-time bloody mess in the field.”
“Breathing?” Sudesh asked.
“Agonal, at best. I'm not sure.”
“Wait a minute, wait a minute.” It was Murray. He had moved over and now stood in front of the hospital gurney, blocking the paramedics' way. He raised his hand. “What's this?” he shouted, pointing at the swollen belly. He glared down at the lead paramedic as if whatever it could be was all his fault.
The paramedic took a deep breath. “She's pregnant.”
“Pregnant!” Murray shouted. “Pregnant! What do you mean pregnant!” He stood nose to nose with the paramedic, waving his hands.
One of the other paramedics, the one holding the IV bag, leaned forward and said directly to Murray, enunciating each word carefully, “She's—going—to—have—a—baby—In two weeks. She's term. And she doesn't have a pulse.”
Murray turned back and shouted, “Would you all be quiet!” again. He turned to Donna, “We need anesthesia down here; we need OB; we need pediatrics—neonatal, we need…” He stopped, apparently having run out of things to need. He turned back to the patient and stood for a moment staring at the abdomen. Everyone stood silently watching as Murray leaned forward and put his hands on the belly. He looked as if he needed to touch it to believe it. Only then did he step aside so that the paramedics could get through.
“Come on, come on, come on. What the hell, what the hell are you waiting for?”
The paramedics looked wrung out. Sweat was dripping from the forehead of the paramedic doing chest compressions. “She's lost a bunch of blood. We've got two IVs in her, but we can't keep up, she's still bleeding like stink. We tried tubing her but the scene wasn't secure; nobody knew what was going on, just who had the gun or what. The family was making a big scene, so we had to just run with what we had.”
“Did you get a blood pressure at all?” Sudesh asked.
“Nada. But that's not to say…”
Everyone shifted around to help move the patient off the gurney. All I could really see now was her sweat pants and cheap white sneakers covered in blood. Sheila leaned over and started attacking the sweat pants with her trauma scissors before they had even moved the patient off the cart.
“Hold CPR. Hold CPR,” Murray shouted. “Hold CPR. We need to roll…She needs…Side, side. She needs a side.…We need to turn…” In a panic nobody knew what he meant. (It's a simple thing; you want to position a pregnant woman so that the fetus and uterus don't cut off the blood supply to the lower body.) Finally Drew, another resident (didn't I know him from some other time and other place?), pulled the patient's arm, rolling her to the side of the cart. But with this it became almost impossible to do CPR. There was a clumsy minute while everyone tried to figure out what to do. Imagine the chaos of desperation, a room full of people all scrambling to try to save a life but having to contend with reality: not enough room, not quite sure where to stand, a falling IV pole, IV lines everywhere, monitor leads, head bleeding (and you are aware, as you fumble, that each drop of blood on the floor is bringing the patient just that much closer to the end of the line). There seemed to be no way to brace the patient properly. Finally someone wedged a few towels under the backboard and the medical student was told to crawl up there and get started with chest compressions. He did so, his face white as a sheet. The woman's Kerlix-bound head lolled to the side; blood was everywhere.
“What did you have on the monitor?” Murray demanded of the paramedics. He wasn't quite shouting now.
“Mostly idioventricular, I think. She didn't flat-line on us.”
“Who shot her?” someone asked—a rotating intern who didn't know any better.
“Shut up,” Murray said, his face right up next to hers. “Who the fuck cares who shot her? We're not here to play detective.” He turned and addressed the room at large. “Somebody set up for a central line.”
Donna leaned over the head. “Oh, jeez,” she said. “Guys, I think I see brains here.”
“Let's get her moved. Let's move it. Move, move, move.”
Everyone did the best they could.
“One…
“Two…
“Three. Let's go, let's go, let's go.” Murray paced back and forth in front of the bed. He looked like a coach on the sidelines fuming at a referee's bad call.
“Drugs!” He was shouting again. He leaned over the paramedic who was trying to catch the IV bag on one of the overhead hooks. Murray pointed, his finger a hairbreadth from the paramedic's chest. “Drugs?”
“Epi. That's all we've given her.”
“Do we have a pulse?” Murray shouted. “Do we have a pulse?”
Drew came forward saying, “Hold CPR.” When the medical student paused, he palpated the neck of the patient. “Nothing,” he said.
“This woman has no pulse” Murray said through clenched teeth. “We've got to get that baby out. Where's OB? Page OB overhead.”
“Keep your shirt on,” Donna told him.
Sudesh moved up to control the airway. He stood, ET tube and laryngoscope poised, ready to intubate, except that the paramedic managing the Ambu bag couldn't move out of the way; he was trapped in a snare of monitor leads and IV lines. Murray paced back and forth in front of the cart, talking to himself, his nervous tic animating his face. He put on the characteristic Murray posture, head down, arms wrapped around his chest and hands buried under his armpits. This was Murray's style. He could stand brooding or pace back and forth like this throughout an entire code, listening to everyone and following the code more with his ears than with his eyes. Even so, all the while he paced he looked more like any one of the schizophrenic walkers we had patrolling the psychiatry ward. More than that, he looked like a caged animal. He even growled as he walked.
Donna and Ted started doing the routine stuff: hooking up the monitor wires, strapping on the blood pressure cuff (not that, at the moment, there was any blood pressure to measure). Defibrillator, drug box. Eileen checked the IVs and got set to start another, a large-bore one for the blood we would need if the patient showed the least signs of life.
This was it, the golden hour. In emergency medicine this may be the only chance you get to save a life. Sixty golden minutes, each is an opportunity won or lost, each weighs in with the question Live or die? Live or die? Questions synchronized to the ticking of the clock. Can't get an IV in? The patient will die. Can't get the patient intubated? Dead, dead, dead. Can't find the cause of the hypotension? Don't make the diagnosis of a ruptured aortic aneurysm? Get the central line in too late? Drop a lung? Don't recognize within the slobbering, comatose drunk before you the massive intracranial bleed? More than one of these? Then the patient dies. And the pressure is on you, big time. It's because of you that the game gets won or lost. But the question is, how long can you play the game with stakes like these.
Murray stopped pacing. “Where's trauma surgery?” he shouted. “Where? where?”
“Here,” an intern said as he walked in through the sliding glass door. “What's the problem?”
Murray bore down on him.
“Where's the rest of your team?”
The intern looked around uncomfortably. “They're on their way,” he said. “I think.”
Murray pointed. “Well, she's got a bullet in her head. It would sure be nice if trauma could make a guest appearance.”
The OB-GYN intern followed the surgery resident in. I knew him. He was a sweet guy but easily baffled. He also looked like he had not made it through puberty. This did not help matters.
“What's going on?” he asked me in a don't-have-a-clue voice.
“She's shot in the head,” I told him.
He looked around at me. “And you called OB?”
“She's pregnant,” I said.
“How pregnant?”
“Real pregnant. And she's a full arrest.”
“Oh,” he said. “Jesus.” He took a sharp breath in and exhaled slowly.
Murray was still pacing. “Where's OB?” he demanded of no one in particular.
The intern visibly shrank back. “I'm here,” he said.
“Well.” Murray bore down on him. “Where's pediatrics?”
The intern shrank back further. “I don't know.”
Murray pointed. “There is a woman here and we don't have a pulse and we are doing CPR and she is pregnant. She's going to have a baby and she's not pumping any blood to that baby. You've got to get that baby out.” He leaned over the intern, prodding him with a finger. “Call your senior down now.”
Ted had connected the patient up to the hospital monitor.
The surgery intern raised his hands. “Hold CPR, please. Checking for a rhythm here.”
Everyone paused and stared at the monitor screen, waiting for the artifact to settle out. And there it was, a rhythm of sorts, slow and broad-based. Her heart was at least going through the motions.
“Do we have a pulse?”
Sudesh was still fumbling with the intubation gear. He reached out and massaged the woman's neck again, looking for a carotid pulse. “Nothing,” he said.
“Epinephrine,” Murray shouted. “Come on, come on.” He wheeled around, looking for the OB intern. “Where's your chief? Where is your chief?”
The intern was on the telephone. He raised the receiver so Murray could see.
“We need fluids,” Murray shouted, again to no one in particular. “We need a central line in her.”
The surgery intern nodded. “I'll do it,” he said. Then he looked at the patient. “Where?”
“Where, what?” Murray said.
“Where do I put the line in?” He motioned toward the patient. He was right to be puzzled. The head of the bed was packed with people. It would be hard to find room enough to get to her neck or shoulder.
“I don't care where you put it,” Murray said. “Just put it in somewhere.”
The OB resident called out from where he stood by the phone. “My senior wants to know if she has had any prenatal care.”
“I don't know,” Murray shouted. “She's been shot in the head. She can't talk.”
The intern's mouth O'd. The enormity of the situation had finally gotten through.
“C-section…” he breathed into the phone. “Crash C-section.” He turned to all of us. “We need a c-section tray.”
From somewhere next door in the storage room Sheila shouted back, “I'm looking for it.”
At the head of the bed Sudesh had succeeded in intubating the woman. He and the respiratory therapist were trying to tape the tube into place. He motioned for me to come over and help bag. (Or did he? Do I remember this right?) I must have put some gloves on (or was this before we all took the HIV stuff seriously?) and grabbed at the Ambu bag. This was my first close-up view of the woman's head. A matted collection of blood-soaked dressings were plastered over her forehead and held in place by layers of Kerlix.
“Let's see what we have here,” Sudesh said.
“I found the tray,” Eileen shouted.
Sudesh slipped off the bandage as if it were a hat. Beneath was the forehead with a bullet hole. A clean shot. A hole the size of a dime that was oozing blood.
This is the dead end of violence, unstylized and unshorn. An argument, a flash of gunmetal and its result is a hole in someone's forehead. I thought of all the gunshots casually exchanged between the hero and the villain on a television show. That was the fantasy; this was the reality of a stray shot or two.
Blood and edema had already swelled the area around the wound.
“See any brains?” Donna said, leaning over.
“No,” Sudesh said. “Not yet.” Then, “The paramedics said they heard two shots…”
The patient's right eye was swollen, puffy. “Two shots,” Sudesh said again. He touched the hole in the woman's forehead. “Shot number one.” Then he palpated the right eyebrow with his gloved thumb and lifted the lid. The globe of the eye was gone; there was nothing there but an oozing pool of blood and egg white-like tissue.
“Bingo,” he said. “Shot number two.” He called out to Donna, who was recording. “Two gunshot wounds involving the face,” he said. “One midline on the forehead; the other into the orbit. The forehead one's an entrance wound, I think.” He palpated the rest of the scalp. “I've got another bullet hole here, guys. Back of the skull, occiput. Maybe
an exit wound. It's big, really big.” He pulled what was left of the bandage out, lifted the woman's head as best he could, and bent down, peering at the back of the skull. “Guys, I think we are talking brain matter here.”
“Hold CPR,” Murray shouted. We all looked up at the monitor, waiting for the artifact to fall away. And there it was, a narrow complex rhythm, a sinus rhythm. Rate: 120.
“Do we have a pulse?” Murray thundered.
Sudesh massaged the patient's neck again. “Maybe,” he said. “Thready. Someone get the Doppler.”
“Should I hold CPR?” the medical student said, pausing on an upstroke.
Murray turned to him and shouted, “God damn, you don't hold CPR until I tell you to hold CPR and I'm not telling you to hold CPR until this woman has a certified blood pressure.”
The medical student, looking stricken, resumed CPR.
Murray pointed to me. “We need two units of O-neg blood, right now.”
I surrendered the Ambu bag and went over to the phone to call the blood bank. Another medical student was standing close by looking somewhat sick to her stomach.
“Blood bank,” I said, pointing. This is the medical tradition: scut flows downhill. “Now.”
She dashed out past two police officers who now stood in the ambulance bay doorway looking on with a sort of noncommittal curiosity. I went over to them.
“What happened?” I said, or rather, whispered, so Murray wouldn't get upset. “How'd she get shot?”
The first officer shrugged. “Gang stuff. Somebody had a beef with her brother.”