One Night In The ER



I was on  call for unassigned patients that night.  Our rural hospital at the northern tip of California was a bastion of modern medicine.  I was a newly minted Family Practitioner, fresh from residency and the newest edition to the staff.  Our county, appropriately named Del Norte but pronounced by we gringos as Del Nort, had just five Family Practitioners and one General Surgeon to handle whatever nature presented.  This took  a certain modicum of courage and confidence and perhaps a fair dose of naivety.  But even now in reflection I think we did an admirable job with the resources at our command.

But that night I was faced with a situation whose memory has lasted vividly these long years.  The ambulance called us to prepare for a dire arrival.  An eighteen year old was coming in with a chest wound from a 357 magnum pistol.   He was conscious and his vital signs were stable.  My immediate reaction was to call in the surgeon and he appeared within minutes, calm and collected as always.  I greatly admired the great skill and judgement he consistently displayed and it gave me an instant sense of relief that he would be there to manage what I feared might be a catastrophe. He had served a tour as an army surgeon in Viet Nam.  He was no stranger to gunshot wounds and I relaxed a bit knowing he would lead and I would assist.

And so we waited with a composed sense of anticipation preparing the supplies and gathering the nurses, the respiratory technician and lab staff we would inevitably need. The blood bank was put on alert for we would surely be tested with our limited inventory. The boy was being transferred from Brookings Oregon some thirty miles north of our town of Crescent City.  The story would emerge later about the circumstances of his shooting. He had been down in the Brookings harbor with some friends hanging out and having fun.  Apparently another car load of boys showed up and there was bad blood between the groups.  Billy approached the car and kicked the door. One shot rang out and the young man dropped to the ground as the car took off.  Now Brookings is not a violent place, far from it.  It is sleepy, prosperous and cleanly.  It would be a nice town in which to retire with its stately shoreline homes.  That this sorrow was approaching our ER from that direction was in itself a shocking surprise.  But one must be prepared for anything that comes your way when one takes on the mantle of ER doctor.

Soon we heard the sirens and I could see the flash of the red and orange lights in the receiving bay.  I rushed out to greet the paramedics.  They were wheeling in the gurney with two IV’s of normal saline running full open, one in each arm.  And then something strange happened.  A handsome young man lay calmly on the gurney.  He looked at me with a smile and said “Hi”.  His curly blond hair and clean cut looks took me by surprise.  His preppy dress and demeanor was not at all what I expected.  The encounter seemed more like the greeting from my waiter on summer break who was working at a fancy restaurant.  His color was good, though there were a few beads of sweat on his brow.

We got him into the trauma room quickly and removed his clothes.  He was smiling and passing pleasantries while we worked, his bright perfect teeth freely displayed.  I saw the dime-sized wound just below his right collar bone and my stethoscope revealed markedly reduced breath sounds on the right.  There was a dull thud on tapping the chest wall with my hand on that side compared to the bright sounds on the left.  The chest X ray confirmed the large quantity of blood that was accumulating on the right.  His blood oxygen was starting to fall and he began to hyperventilate somewhat.  His heart rate was accelerating.  There was no time for a specific blood match.  We had two lines of Type O negative blood, the universal donor type with the lowest chance of transfusion reaction, running full open with pressure applied by blood pressure cuffs around the infusion packets.

The surgeon quickly inserted a chest tube on the right and a profusion of bright red blood began to fill the vacuum bottle.  His blood pressure was maintaining an adequate level and his breathing eased as we administered oxygen by nasal cannula.  All the while he watched us work with a calm demeanor that conveyed confidence in our competence.  He did not complain of pain or cry out.  Not once.

As the surgeon and I entered the elevator on our way to wash up and prepare for the surgery he turned to me and tersely said ” He’s gonna die”.

I was shocked.  I was expecting him to be saved.  He was talking to us.  He seemed relaxed.  Didn’t we have things under control?  Hadn’t we gotten to him soon enough to stop the bleeding and send him home in a week or so?  But the surgeon knew how such things went and the limits of the resources in our small rural county hospital. His battlefield experience had shown him what could and could not be done.  We said no more as we scrubbed in and changed into surgical gowns, masks, shoe covers and gloves.

When we entered the OR he was already intubated and unconscious. The nurse anesthetist was administering oxygen with an ambu bag.  As we approached his side taking our places and getting ready to open his chest, his pulse rapidly faded and then ceased.  It all happened so fast.  Though a hardened  veteran of scenes of death, I was shocked.  It was indeed hopeless.  We could not resuscitate him despite our desperate efforts.  He was young and virile and bright and now he was dead.

I relate this story to you some 35 years after it occurred but I can still see it clearly now as I saw it then.  Some scenes never leave you.  It was with sorrow that I heard of the outcome of the shooter’s trial.  He was acquitted on the grounds of self defense.  I ask you how someone as promising as Billy could be justifiably gunned down for kicking a car.  I saw this boy and would have been proud to call him my son.  I felt wounded when I heard of the verdict. True I was not at the trial but I felt our souls had touched at the moment of his farewell.  I was convinced he could not have been a mortal threat.

Justice was not done that day.