Deep Trauma

“Ambulance in trauma bay five, GSW,” Sonya, one of the nurses, called breathlessly, poking her head into the break room as she flew down the hallway, pulling on a plastic apron over her scrubs.

“On it,” Riley replied, taking one last swig of coffee and darting for the door, though she was anything but enthusiastic to handle another gunshot wound. She hated guns and the careless, callous way they could end lives with just the slightest tug on the trigger and how, with so little effort, a firearm could destroy families and the tranquility of entire communities. She had recently told a medical student that she’d seen enough bloodshed from gun violence over the last few years to float a boat. And perhaps that was the reason GSWs were now her specialty.

Three minutes later, she was up to her elbows in it. “Where the hell are the trauma surgeons?” she exclaimed, holding pressure on the large-caliber exit wound between the gang tattoos on a dying teenager’s chest. The pungent metallic odor of an uncontrolled hemorrhage permeated the air as she packed the wound with sterile gauze to staunch the flow. The shrill tone of the patient’s monitor alarms issued an ominous warning that drowned out even the overhead calls for “all hands on deck in trauma bay five.”

“They’re still tied up in surgery. The operating rooms have been overwhelmed all day with injuries from the train,” Sonya replied, shouting above the racket. She snatched the intercom off the wall and alerted the blood bank to initiate the massive transfusion protocol stat.

“Good thing he’s already intubated. I’m glad you’re here, Burt,” Riley said, turning to the respiratory therapist at the bedside. He’d just taken over from the paramedics and was ventilating the patient with a bag device. “Keep his tidal volume low, will you?” Riley grabbed a surgical chest tray from under the counter and a sterile gown and gloves and threw them all onto a bedside stand. She scanned the monitors and the patient’s physical presentation for a few seconds before saying, “Looks like a tension  pneumo. What do you think, Burt? Does that trachea look deviated to you?”

“As bad as I’ve ever seen, Doc.” He cringed, reducing the pressure he was applying to the resuscitation bag and increasing the rate of ventilation. Riley listened to the teen’s chest with her stethoscope. Then, just in case the unconscious patient could still hear her, she bent down next to his ear, and in a soft but deliberate voice, she did her best to prepare him for what was to come.

“We’ll take good care of you, son.” Riley never knew the names of patients in the ER who were victims of violence. Calling the young man John Doe number 869 didn’t seem likely to build trust.  She tried to sound confident, “I’m going to place a tube between your ribs to help reinflate a collapsed lung. That’s going to hurt a bit, and you’ll need surgery soon to get this bleeding under control. But you’re going to make it. Hang in there, buddy.”

At that moment, a breathless intern from the trauma surgery service—who, in Riley’s estimation, looked like the tallest fifteen-year-old she’d ever seen—dashed into the room, ripping off his lab coat and tossing it into the corner as if he were a lifeguard about to spring into the kiddy pool.

“Where’s your senior?” Riley barked, eyes sweeping over his lanky form incredulously. She turned then to the nurse. “Sonya, grab a twenty-four-gauge chest tube ASAP.”

“Dr. Lim sends her apologies,” the intern announced, his long legs striding toward Riley with surprising confidence, given her obvious skepticism. “Our team is just finishing in the OR. They’ll be here soon. I’m pretty sure they’ll want an X-ray before anyone puts in a chest tube, though.” He pushed his way past the nurse to get a better look at the patient and inadvertently contaminated the sterile area she had just set up at the bedside.

“There’s a hook in the hallway for superhero capes,” Riley said, barely keeping her tone in check. The intern hesitated, his eyes finding the discarded garment on the floor. “When you’ve picked up after yourself, you can gown up if you want to help. But hurry, we don’t have much time.” Riley caught the sudden flush in his cheeks when he bent to pick up his discarded coat, and a deck of three-by-five cards tumbled out of his top pocket, scattering onto the floor.

“But . . . but you need to wait for Dr. Lim,” the intern insisted, visibly doubting Riley’s lead as he stuffed his pockets again. “We haven’t seen a chest X-ray, so what makes you think he needs a chest tube?”

At this, Riley lost her cool. “How long do you think this patient can tolerate a heart rate of a hundred and ninety and a blood pressure that low?” she snapped, tilting her head toward the monitors beeping wildly beside them. “The only thing we have time for now is action. Not X-rays and not discussion.” She grabbed a disinfectant swab and painted the intended tube insertion site between the dying teen’s ribs.

“Lung compliance is really decreasing, Doc,” Burt reported from the head of the bed, eyes wide.

“Sonya, I’m ready for that tube,” Riley announced as she extended her gloved hand. The nurse slipped the device, a small spear-like instrument, out of its protective sleeve and into Riley’s hand. A second later, Riley punched the tip of the chest tube between two of the patient’s ribs. She withdrew the inner core and set it aside, leaving a small rigid hose in place. A sudden woosh of air escaped from the youth’s chest, relieving the deadly airlock that had been crushing his heart and lungs from within. Then she handed the other end of the tube to Sonya, who attached it to a suction device that would help keep the lung properly inflated. Riley turned to Burt again. “Compliance improve any?”

“Like night ’n’ day.” He puffed out his cheeks in relief. Seconds later, the patient’s vital signs began to move in the right direction, though they were still unacceptable in Riley’s view. There had been just too much blood loss, she told herself as she began to secure the chest tube with a few heavy-duty stitches.

“What did you say your name was?” She glanced at the intern then, doing her best to improve her tone now that they had overcome the most immediate danger.

“Doug . . . I mean, it’s Dr. Hudson, ma’am.”

“Well, Dr. Hudson, put on the gown and gloves Sonya has been kind enough to set out for you. Then you can help her put on a dressing over this tube insertion site. Just watch that you’re cautious around the sterile field this time,” Riley added, giving Sonya a nod of gratitude and a look to counter the one she was getting in return—one that said, What am I, a babysitter?

Riley ripped off her bloody gloves and crossed the room to call the surgical suites again. She and her team had done what they could, including starting the massive transfusion protocol. But without surgical intervention to control bleeding, all that newly transfused blood would ultimately just end up on the floor.

As if on cue, the senior trauma surgeon and her team strode in; she breathed a sigh of relief as she laid eyes on Riley.

“God, I was hoping you were here today, Rye. I knew you would handle whatever it was—thank you, thank you,” she said, pulling on a pair of gloves to examine the patient’s wound, which Riley had packed with gauze.

“Thanks, Krista. It was touch and go there for a minute with a tension pneumo on the left, but I had good help from Burt and, of course, Sonya, who’s always a rock star in the worst cases. Every pair of hands helped.” The lanky intern glanced over his shoulder then from the bedside, where he was doing his best to appear useful while Sonya secured a large dressing around the chest tube site. Riley couldn’t help but draw a parallel between the look in his eyes and the one she so often saw in Indio’s when Artemis had just reminded him of his position in the pecking order.

Within minutes, the trauma team was whisking the patient off to the operating room, crimson transfusion bags swinging from the IV poles on the gurney and an entourage of support staff and medical trainees in tow.

Riley stood in the middle of the vacant trauma bay looking down at the pools of congealing blood at her feet, the victim’s shredded clothing—cut off to allow for thorough examination—and a myriad of surgical supply wrappers littering the floor.

She felt numb, as if somehow the world was a little slower and duller in the wake of all the commotion. She thought about all the resources being poured into saving the young man’s life and how long and difficult his recovery might be—and whether or not he would make it through surgery. And then there were the bigger questions, the ones she seldom deliberated because they could be so crushing. If the patient survived, would he just return to the same environment where he was bound to be a victim again? Would he, next time, perhaps be the shooter?

She headed for the break room, her head buzzing, hoping someone had had time to brew a fresh pot of coffee. Trauma cases were always such a paradox—emotionally draining but somehow also energizing. There was an indescribable peace, a flow of clarity best described as a singularity that came from navigating multiple streams of dynamic data in the middle of a disaster.

Today, she could honestly say her team had done well in their management of the patient’s injuries. There was no question they had all played a part in executing a lifesaving intervention. And for those things, she should have been grateful. But that’s not what she felt. What she felt was lucky, and that was cold comfort to anyone in her profession. Because no one was lucky all the time.