The bodies keep coming, p.11
The Bodies Keep Coming, page 11
Most died in the emergency department; some survived long enough to make it to surgery, where they died on the operating room table; the remaining survived surgery only to die in the intensive care unit.
I rarely perform ED thoracotomies because of these abysmal outcomes, and I sometimes critique my contemporaries for their eagerness to do them. Sometimes physicians operate out of the
“maximum resident bene昀椀t” mindset, as I also learned as a medical student, encouraging trainees to practice the procedure on people unable to refuse. In the throes of a futile emergency, I would not want a thoracotomy done to me or a member of my family for MRB. To this day, it is a dichotomy I have not reconciled.
But on that night, at that moment, in that room, the only chance for that cop to live was an ED thoracotomy. With a melodic clang, Vanessa dropped the thoracotomy tray on the bedside workbench as I positioned his left arm above his head, reaching past Dr. Waterson’s hip for the back wall. With my right hand I grasped the scalpel, and with my left I felt for the valley of soft tissue in the 昀椀fth intercostal space.
“Everyone, hands out of the 昀椀eld!” I ordered.
I can recite the steps of an ED thoracotomy like I can recite the alphabet, minus the memorable melody. I studied voraciously, internalized the teachings of my mentors, and watched intently whenever 100
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they did the procedure. I can perform the procedure only because I’ve had a lot of practice. My focus is always on the body before me. Not the bodies I have already treated and discharged, nor the ones likely coming later in the night. It is the body on the gurney in front of me that matters. And for years I had been perfecting this dis昀椀guring skill on the bullet-riddled bodies of scores of dying Black men and women lying before me. None of them had left the hospital alive. That reality changes a person.
In trauma surgery, heroism and futility often walk hand in hand, and sometimes it’s hard to know the di昀昀erence. But my duty is to always be a voice for humanity. Soaked in his blood, I cradled the police o昀케cer’s heart in my hands, trying to pump it back to life. It would not beat. I checked his carotid and his femoral pulses. He had none. Were it not for the ventilator, he would not breathe. The decision to end life-sustaining treatment—or death-prolonging treatment, depending on your point of view—falls to me.
“Before I call it, anything else we can do?” I asked Dr. Waterson.
“I agree. We’ve done everything,” she said.
“Does anybody think we missed anything?” I scanned the room, looking everyone in the eyes, so they knew I sincerely wanted their input. Before I call a death, any death, I give everyone a chance to speak. If you are in the room, I do not care if you are a medical student or an experienced attending physician. If there is anything we can do—any sign we’ve missed, any possibility left—I want to hear it.
I stopped pumping. I glanced at the digital clock on the wall and called the time of death, which Nurse Vanessa logged in the medical record. Other nurses turned o昀昀 the monitors, stopped transfusing blood, and removed the crash cart equipment. Nobody said a word while the frenetic pace slowed to routine post-mortem care. Only the high-pitched monotone on the cardiac monitor remained, along with the clicking from the mechanical breaths of the ventilator as the trauma team regrouped for the next patient.
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For the moment, this death was barely a blip on my emotional radar. I had been here countless times before. Besides, another patient in Bay 8 needed my help, and more were arriving in ambulances, their lights and sirens screaming. I 昀椀led away this death, thanked the team, and peeled o昀昀 my gloves to 昀椀nd blood coated my forearms, Rolex, and hands. There was so much blood that it slipped over the lip of the gloves at my wrist to coat my hands. After a quick wash in the sink, I 昀椀sted my white coat from the workstation chair where it rested and was on the move.
But two surgery residents cut me o昀昀 before I had both feet out of the door.
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9
“Dr. Williams, I’ve called all the residents in house to come help. What can I do, sir?”
It was Dr. Cole Jacobsen, a third-year surgery resident and not scheduled for trauma call that evening. He was sharp and would mature into a great surgeon. At the moment, he took the initiative to mobilize all the surgical residents in the hospital. Beside him stood Dr.
Luka Cyrus, the resident from SICU rounds earlier that day.
“Dr. Williams, how can I help?”
He should have been covering the Surgical Intensive Care Unit.
Those patients were sick, needed constant monitoring, and were also my responsibility during my night shift. But I did not question why he left his post because we needed all hands on deck. In my peripheral vision, I saw two more o昀케cers arriving, one on a stretcher and one on foot. The man, lying upright on a stretcher, appeared alert and stable.
A woman in uniform followed the gaggle surrounding him.
Pointing to the cop on the stretcher, I said, “Cyrus, that one’s yours.” Dr. Cyrus was a fourth-year resident and had plenty of experience running traumas. Less experience than Dr. Ashton, the trauma fellow in Trauma Bay 8, but more than Dr. Jacobsen the third-year resident who had herded all the available residents.
Within minutes we had received three gunshot victims, all of them cops. One I had already pronounced dead, one was across the hall 103
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in Trauma Bay 8, another had just rolled in, and several more were expected to arrive. How many more, we didn’t know. But having trained for multiple casualty disasters, I put several tasks in motion at once.
I had a mid-level resident, Dr. Jacobsen, calling for the backup trauma surgeon. I had a senior resident, Dr. Cyrus, assessing the third o昀케cer who arrived. In Trauma Bay 8 I had the trauma fellow, Dr. Ashton, treating the second o昀케cer who was obviously in critical condition when he arrived, hanging o昀昀 the stretcher and getting chest compressions.
That is where I needed to be.
♦ ♦ ♦
“Ashton, what have you got?”
“Gunshot to the chest.”
Ashton gave me a report on the critically injured police o昀케cer before us in Trauma Bay 8. He was in training to lead a crisis like this without any supervision, learning to make the time-critical, life or death decisions. As an attending, I tried to allow trainees autonomy to make medical decisions without jeopardizing patient safety. It was a delicate balance. Intervening too soon impairs training, and waiting too long can lead to patient death. Any indecision or misstep and I would quickly take over. I waited a breath for him to verbalize his decision.
Long enough.
“Ashton, he needs a thoracotomy.”
As the team launched into preparations for another ED thoracotomy, Dr. Cyrus, who should have been with the stable o昀케cer in another room, came into Trauma Bay 8.
“Dr. Williams, I think my patient needs a chest tube.”
“Is he crashing?”
“No, sir. He’s stable.”
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Standing over Ashton’s shoulder, I focused on his every move. He positioned the left arm, poured brown sterilizing 昀氀uid on the left chest, and reached for the scalpel. I stood beside him with the rib spreaders ready.
Surgery residents learn the technique of placing a chest tube within weeks of starting their 昀椀rst year of training, so I had no doubt Dr. Cyrus could do it unsupervised. Knowing when to do a procedure—and when not to—is the judgment residents gain from experience. We don’t do invasive procedures on patients who do not need them. (An ED thoracotomy is a maximally invasive procedure compared to a chest tube, which only requires an incision a few inches long.) My experience with Dr. Cyrus was that he was a dedicated resident who made excellent clinical decisions. For a chest tube, I trusted him.
“Okay, Cyrus. Go ahead and do it. Don’t wait for me.”
“Yes, sir.”
“And if his status changes, send someone to get me ASAP.”
Dr. Ashton’s 昀椀rst pass with the scalpel barely sliced through the skin and super昀椀cial layers of the 昀椀fth intercostal space. The second pass cut deeper, but still no entry into the thoracic cavity. I never enjoyed depriving a trainee of a procedure, but seconds matter.
“Ashton, give me the knife.” In one stroke, a crimson tide cascaded to the 昀氀oor as I handed the scalpel back to him. “Now curve the incision down to the bed—and don’t lacerate the lung.”
He did as he was told. I two-昀椀sted the rib spreaders, slipped the edges into the incision, and ratcheted it open.
♦ ♦ ♦
“If they arrive alive, they should leave alive,” is a maxim of trauma surgery. It is our goal and failure is not an option. But the inverse is also true: a trauma patient who arrives dead stays dead, with or 105
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without an ED thoracotomy. That means a thoracotomy is a clinical Catch-22.
As I’ve said, the chance of saving a patient with an ED thoracotomy is almost zero. It is also invasive and dis昀椀guring. The trauma surgeon who chooses not to do an ED thoracotomy will endure reproach from the zealots who ask, “Why didn’t you do a thoracotomy?” Then again, if you do a thoracotomy, you’ll su昀昀er indigna-tion from the restrained—I’m usually among them—who ask, “Why did you do a thoracotomy?”
At this stage of my career, I can “crack a chest” and cross-clamp the aorta in less than a minute. A few seconds later, I will have split open the pericardium, the leather-like covering encasing the heart, and hold that heart—their life—in my hands. If it is not beating, I can sometimes bring it back to life with bimanual massage, plug a hole spouting blood with my 昀椀nger until I repair it, inject epinephrine into the muscle of the left ventricle, or use internal de昀椀brillators to deliver electricity and shock it back to life.
But now, for the second time within minutes, I was pronouncing another Dallas police o昀케cer dead. I still wasn’t fully processing the facts: that we’d lost two police o昀케cers. I was thinking a few steps ahead to manage a worsening tragedy I knew little about, other than somewhere in Dallas, cops were being shot. Were they still getting shot? How many would we receive? Was my backup on the way yet?
More patients were coming, and the team had to move on. As I left Trauma Bay 8 to join Dr. Cyrus placing a chest tube on the stable o昀케cer, Jacobsen stopped me to say the backup trauma surgeon could not be found.
The trauma team ran smoothly despite the austere conditions. It was still early in the crisis; the team had drilled for this type of disaster.
Nurse Vanessa, a product of those extensive drills and preparation, wedged herself between Jacobsen and me.
“Dr. Williams, they say there may be bombs around the city.”
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“Bombs?” I echoed, trying to wrap my head around the idea of potential explosions in downtown Dallas.
“They’re not sure, but they’re concerned. Should we activate the Code Yellow?”
A Code Yellow sends a group page notification to all critical hospital personnel to come to the hospital without delay. In my six years at Parkland before the shooting, I could count on one hand the number of times I called for backup. But a Code Yellow? Never. Vanessa always functioned by the book, and she was not given to hyperbole. If there were truly bombs scattered throughout Dallas—well, you don’t need to be a trauma surgeon to know that would worsen the crisis. I needed more trauma surgeons—as many as we could mobilize—and I needed them as soon as possible.
“Call the boss and tell him we have a multiple casualty event with an unknown number of GSWs en route,” I told Dr. Jacobsen. “Let him know there is a report of possible bombs in the city and that we need all hands on deck.” With no response from my backup, more injured cops en route, and reports of bombs, I wanted him to know we were in the midst of an evolving disaster.
And in response to Nurse Vanessa’s question about whether to activate a Code Yellow, I said one word: yes.
Activating the Code Yellow resulted in a scene I could have never envisioned. We set up an incident command center run by a mix of clinicians and administrators, and we began transitioning the hospital to disaster operations. O昀케cers from the Dallas Hospital District Police Department donned body armor, grabbed AR-15s, and began patrolling the hospital. They stopped visitors from roaming the halls, controlled access to the emergency department, and secured all points of entry to the hospital.
By activating the Code Yellow, Parkland not only responded to a multiple casualty event; it prepared to defend itself from attack.
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10
Two cops were dead. A third had a gunshot wound to the chest but did not appear critical. We were expecting more to arrive, but for the moment, the third o昀케cer became my priority. He was sitting upright on the stretcher in his blue uniform, conversing with the team who were sticking needles in his arm veins, positioning him for x-rays, and asking about his medical history. He appeared stable as he talked with the nurses and techs. His partner, also in uniform, stood beside him at the head of the bed.
Dr. Veronica Morris, an anesthesiologist, gathered equipment and medications for possible intubation if necessary. She, like dozens of other doctors in the hospital, had left her normal post to come help.
There were so few Black doctors at Parkland that whenever I saw one, even during times of crisis, it left an impression. Dr. Morris and I exchanged a knowing glance, one communicating a lifetime of shared experiences. It’s like a mental handshake saying, “I got you.”
“Good evening, O昀케cer. “I’m Dr. Williams. I’m the trauma surgeon on call tonight.” Turning to the resident, I asked, “What’s the story, Cyrus?”
“Dr. Williams, O昀케cer Smith has a gunshot wound to the chest. I put in a left chest tube, which has put out over a liter of blood, and his pericardial FAST was equivocal.”
FAST is an acronym for Focused Assessment for Sonography in Trauma. It’s like doing an ultrasound on a pregnant woman, except 109
THE BODIES KEEP COMING
in trauma we use it to look for life-threatening, internal bleeding.
By saying equivocal, Dr. Cyrus meant he could not tell if an internal injury existed or not. And whenever I hear equivocal from a trainee, I default to the worst-case scenario—that there is a life-threatening injury. I have performed thousands of FAST exams, and I have taught the FAST exam to hundreds, maybe thousands, of trainees.
Sometimes subtle signs are recognizable only after years of experience. And truncal gunshot wounds, like the one to O昀케cer Smith, kept me hypervigilant. I processed what I knew: gunshot wound to the chest; patient alert, interactive, and appeared stable; equivocal pericardial FAST.
My internal alarms began to hum. “Let’s repeat the FAST.”
I scanned him and the monitors above his head and maintained an impassive facade, revealing nothing of my concern until I was certain. “I’m going to 昀氀atten the bed and have you lie down for a moment.”
As I engaged the lock to lower the back of the bed, I kept my eyes on him, watching for any change in his demeanor. Did he grimace? Have trouble breathing? Resist lying down? I also took a mental snapshot of his vital signs on the monitors while he sat upright, and watched for any change when he laid down.
Subtle changes in heart rate and blood pressure during this simple maneuver—transitioning a patient from sitting upright to lying flat—can speak volumes about what is happening inside a patient’s body.
Dr. Cyrus rolled the ultrasound to the bedside, powered it on, and applied clear gel to the notch below O昀케cer Smith’s sternum. We all stared at the fuzzy images 昀氀ickering on the screen. Dr. Cyrus slid the handheld probe across his chest as the four chambers of the heart came into view, then out, then back in again.
“See. Right there, Dr. Williams.” He pointed at blurred portion of the image. “I wasn’t sure about that.”
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I took the probe from Dr. Cyrus and maneuvered it to get a clearer image. I scanned the tubing from his chest draining into the pleuravac cannister on the 昀氀oor, now 昀椀lled with blood. Too much blood.
My internal alarms began to wail.
♦ ♦ ♦
O昀케cer Smith looked okay, but something was not right. The gunshot wound to the chest. The volume of blood in the canister. The abnormal ultrasound. We needed to move. And we needed to do it quickly.
More than a dozen extra surgeons were now in the emergency department. All were still in training except one: Dr. Gina Wallace, a plastic surgeon and classmate of mine from medical school. Gina was fully trained, board-certi昀椀ed, and capable of operating independently.
There was one problem.
“Willie, I haven’t done trauma in a while, but I’m here if you need help.” Gina addressed me by a nickname only my closest friends used. She was skilled at performing reconstructive surgery, not dealing with gunshot wounds to the chest and abdomen. I needed another quali昀椀ed trauma surgeon as soon as possible and did not want to draft her into something she might be unquali昀椀ed to do. Still, all surgeons do some training in trauma during residency. O昀케cer Smith could not wait, and I was the only trauma attending in the emergency department and unable to leave during a worsening multiple casualty disaster when more injured police o昀케cers were en route. I had no choice but to draft Gina as well as give the trauma fellow a battle昀椀eld promotion.
“Ashton, come here. Gina, I need you to take this patient to the OR with Ashton. He’ll help you get positioned for a left thoracotomy.
Just get him on the table. I’ll be there in a few minutes.”
