By Alison Stuebe
The first thing I see is his tatoo -- "GANGSTA," etched across his abdomen in 4-inch high letters. He's a 27-year-old African American male with multiple gunshot wounds, stretched across the table in the trauma room amid a swarm of residents and nurses. A baggy pair of jeans, casually belted at the hips, comes off with scissors. There's no pulse anywhere, and someone starts CPR, while another resident listens for breath sounds.
I'm at the other end of the table with the foley catheter, the medical student's designated job. I've placed a couple of these in the operating room, and it's pretty simple -- clean the opening of the urethra, lubricate, and in goes the catheter. Keep pushing until you get urine out. This time, the catheter stops, with no urine to speak of. I try again, and again, continuing to flail. The male nurse across the table is annoyed. "You gotta pull up on the penis!" he tells me. I'm getting nowhere, and he grabs the tube from my hands.
I take over for the resident doing chest compressions, and some 30 seconds later, they tell me to stop. He's got a pulse. Things are looking up.
Neurosurgery arrives to evaluate the situation -- an x-ray of his head shows a bullet in his brain, across the midline. There's some debate as to what to do -- scan his head, or go straight to the operating room. His belly is swollen, like an over-inflated balloon, bulging with blood. We've already transfused 4 units -- nearly two quarts-- and he's barely got a pressure. There isn't time for a scan.
There's more scurrying as we load all the IV's onto his stretcher. He's wheeled to the elevator with a flock of nurses, residents and techs in masks and water-resistant gowns trailing behind. I take the stairs, and catch up with one of the residents outside the OR. I ask about his prognosis.
"Slim to none," I'm told. "And slim just walked out the door."
"So why are we taking him to the OR?"
"Because he's got a pulse and a pressure, and if we don't operate, we're killing him."
In the OR, the night staff is rounding up equipment. "Another autopsy under anesthesia?" the scrub nurse quips. Nobody responds.
I find the two surgery residents in the hallway, putting on plastic aprons, the kind the staff wears in the cafeteria. When I ask why, I'm told, "Why do you think?"
One of the nurses is cleaning off the abdomen, swirling orange betadine over the tatoo. Someone drops off a cardboard box with eight more units of blood. Minutes later, we open. His abdomen is bulging, and we cut gingerly. The tension inside his belly is the only thing keeping blood inside his vasculature -- when cut through the last layer of tissue, his pressure is going to plummet.
"Ready for the bloodbath?" the resident asks. Anesthesia gives us the ok.
Blood pours out over the incision, running down both sides of his body. I suction as fast as I can, but it keeps welling up, spilling onto the floor. The chief resident reaches down into his belly, grasping for the aorta. We put a clamp across it, trying to stop the bleeding. That's where we are when the senior surgeon, just finishing another case, comes in to view the carnage.
"What are we doing here?" he asks. "Are we just screwing around?"
He takes over, slicing open the chest cavity and prying the ribs apart. I find myself wondering why the lungs are pulsing so much. Then I realize the throbbing thing is his heart.
The surgeons discuss their options, and try an atriocaval bypass. They round up the equipment, cut open the heart and run a plastic tube into the vena cava, the vein that brings blood back from the lower half of the body. If the bullet hit the cava close to the heart, this should bypass the leak. The tube is in the right place, but the overflow continues.
Now, the attending looks for the vessels that go to the liver, trying to clamp off flow there and isolate the leak. Someone remembers I'm in the room, and says, "Alison, what is he doing?"
"Exsanguinating?" I stammer.
They are not impressed. I'm told that this groping for the liver is called the Pringle Maneuver.
From behind the drapes, anesthesia reports that there is something coming out of the gunshot wound to the head. "I think his brain is leaking out," they say. "And there's blood coming out of every oriface." He's been transfused 12 units by now -- more than a gallon -- diluting away the proteins that should allow his blood to clot.
The Pringle Maneuver is unsuccessful, and the attending steps back. "Let's call it," he says. It's 1:15 am. The surgeons resume pawing around in the abdomen, looking for the source of the bleeding.
They keep digging for a few minutes, after he's technically dead. I'm watching the thing that's the heart, which is still contracting regularly. People start to drift out of the room, and the attending goes off to find the parents, who are waiting in the emergency department.
The resident closes the incision. I cut the ends of the suture as he ties knots, and I'm silently thankful I haven't been asked to sew. We're done in 20 minutes. His belly, with the greenish-blue lettering, the blood, and the meticulous line of purple suture, has the look of an album cover. The middle G in "GANGSTA" is aligned perfectly, still legible, if a little scrunched by the stitches.
We disband, and I wander down the hall in search of paper to write the expiration note. One of the residents is washing down his plastic clogs in the sink. When I return, a nurse stops me. "Could you take off your shoe covers?" she asks. "You're tracking blood through the hallway."
I apologize, pulling off my blue plastic shoe covers and scrubbing the soles of my sneakers in the sink. It's 1:49 am. I need to get some sleep.