Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (15 page)

J. T. loops his right hand around the heart and with your help plugs his middle three fingers through the hole you've got your fingers on. He presses his thumb over the fifth.

“I feel like I'm holding a bowling bowl here,” he tells you.

“Well, just don't let go,” you answer back. To Donna, “Get me some 0' silk. Lots of it.”

There are special techniques, special sutures to place in these situations, but you can't remember exactly how to do them. You'll have to improvise.

J. T. is now trying to do cardiac massage with his fingers still in place. He squeezes with his left hand, his right fingers still jammed into the bullet holes.

Donna opens packages of 0' silk by banana-peeling them over your thoracotomy tray.

You look around again and feel for the first time the tension in the room. Everyone there, including two police officers over by the ER door, is focused on one thing only, this man's open chest and the beating heart that you and J. T. hold in your hands.

You look down. I can't do this, you think.

But it all comes mechanically. You find yourself with a package of silk suture in your hands.

“I'm going to do this bullet hole first,” you tell J. T. “Let me anchor a tie.” You throw one quick stitch using the clumsy straight needle. It goes more easily than you thought.

“Okay,” you tell J. T. “Slowly, take your fingers out.”

“Christ,” he says. Now there's blood everywhere. You can't see anything.

“Sponges, guys. We need sponges.”

J. T. sticks his fingers back in the hole. You take another loop and then try to get one more, when J. T. suddenly says, “You got me.”

You look up at him. “Wha?”

“You got me with the needle.”

“Oh, for Christ's sake,” you say. But then you realize what that could mean. You stop dead what you are doing. “You need to scrub that.”

“That's okay,” J. T. says.

“No way,” you tell him. You are thinking now of one thing: HIV. “You know the risk is less if you scrub that wound. And this kid is a setup.”

There was a time when we all were not so afraid of blood.…

“It's all right,” J. T. says.

“No, it's not all right.”

J. T. doesn't even let you finish this brief sentence. “Just keep going.”

“I'm not going to risk your health over this.”

“Listen,” J. T. says angrily. J. T. never gets angry. You look up. He looks angry as well.

“I let go,” he tells you, “
then this kid dies.
Now sew up the goddamn hole.”

You duck your face back down, ashamed, and reapply yourself to the suture material. Your hands are shaking.

It's almost impossible to see. There's blood that just reaccumulates with every swipe of gauze. You make a guess for the next two loops, hoping you don't stick J. T. again. How could you have done anything so stupid?

You make a final loop. As you do, J. T. eases his fingers out of the way. The loops hold; there is a little leakage of blood but not much. You've nailed one of the bullet holes.

You cut the silk with the Metzenbaum, and J. T. gently massages the heart.

“I think we've got some blood circulating here,” J. T. tells you. “Heart feels fuller.”

So all the fluid you are pouring into this kid is starting to do some good.

“We've got a carotid pulse with compressions, guys,” Donna says, her hand on the kid's neck.

“I've got this one,” you say to J. T. “Go change your gloves and wash your hands. Donna can do this.”

Donna speaks from over your shoulder. “There's
no way
you are getting
me
to come
one inch closer
to that heart than I already am.”

“Just keep going,” J. T. says.

There is, you see, a technique to this. For the next hole you move J. T's fingers gently out of the way and pinch the hole shut with two fingers of your left hand. It's easier to sew now, although you can't stop that shaking. At least you are less likely to pop J. T. again.

You can see better now that neither of these entrance wounds is bleeding. You can keep the field somewhat clear of blood. The second one goes more easily than the first.

“Nice,” J. T. tells you. He lifts the heart somewhat to give you better access to the back side and you both bend down, peering at the holes J. T. has plugged with his fingers.

You realize now that if either of the bullets passed through the heart's septum, the wall between the left and the right ventricle, on its way out of the heart, you are sunk. There is no easy way to get at a hole
inside
the heart. Still, it looks as if they both exited through the bottom part of the left ventricle. Maybe this cat still had a few lives left.

You use the same technique to close the posterior lacerations. You pinch the bullet hole shut with your left hand and whipstitch with your right.

Once you close the last laceration, you let the heart fall away from your hand. The field stays fairly clear of blood. J. T. takes his hand away as well.

The heart just sits there quivering. It doesn't make sense until J. T. says flatly, “V-fib.”

The heart is fibrillating.

You are such a creature of habit that you don't believe it until you look up at the monitor and see the green electronic squiggle of ventricular fibrillation marching out across the screen.

“Well,” you say, “get the paddles.”

To defibrillate the heart, you pass an electrical charge through it, stunning the entire myocardium—the heart muscle cells—all at once. If the circumstances are right and you are very, very lucky, then the heart may restart itself in a normal rhythm. Usually in ambulances and ERs and such, you do closed-chest defibrillation. You pass the charge to the heart through the entire chest wall. Now, though, you have the heart entirely available, open right here in front of you. You can apply the electrical charge across the heart itself, so you need less voltage.

You use two long-handled paddles and position the two paddles so that the heart is between them. It's like holding a wad of Jell-O between two metal fly swatters.

J. T. attaches the paddles to the defibrillator cords. You take the handles and sandwich the heart between the two metal pads.

Twenty joules. Not much. Even so there is the sudden smell of burning flesh that arrives seconds after the first shock.

Everyone looks at the monitor. V-fib still.

“Again,” you say.

Another shock. More burning flesh.

“Epinephrine,” J. T. says. Adrenaline. “I'm going to give it intracardiac.”

Donna hands him the syringe. J. T. unsheathes the needle and jams it into the muscle of the heart. You can't give adrenaline any faster way.

J. T. goes back to cardiac massage. Everyone stands for a moment looking up at the monitor.

“Let's shock again,” he says.

You are ready with the paddles. J. T. slides the heart between them. Another shock, this time at 40 joules.

There is the flash and that terrible smell again. Out of habit, nobody watches the actual heart; everyone looks up at the monitor.

There is—after some jiggly artifact—normal sinus rhythm: rate 99.

“Just like on TV,” J. T. says.

You all look down at the heart, which is doing this weird shimmy as it contracts. It's
beating!
you think.

It is only now that you recognize that someone is shouting out in the hallway.

“Where's my patient? Where's my patient?”

The trauma doors swing open, and in comes Dr. Wu, the thoracic surgeon on call. He's a small, fierce-looking man, now wrapped in a wet trench coat. It must be raining, you think. Somewhere out there is a real world of night and rain.

“What are you doing?” Dr. Wu shouts before he even gets up to the bed. Dr. Wu is a character and not a pleasant one. He yells at the nurses and the patients, given any excuse. He throws instruments in the OR, he hectors the medical students, and when a patient goes sour, he shouts at anyone in his path. (He meets a mixed response to this, since no one can understand his English when he gets angry.)

However, he is a very good surgeon. You would want him to do your bypass surgery should it come to that.

Jesus, you think suddenly, and turn to Donna.

“Lidocaine. Bolus and drip.” That's to keep the heart from going back into fibrillation. You could kick yourself; you almost forgot. That one mistake could negate everything you've done so far.

You present the case to Dr. Wu as he peers down into the chest cavity. “A sixteen-year-old kid. Two through-and-through gunshot wounds to the chest. Both nailed the left ventricle. See.” You show him.

“You sutured!” Dr. Wu shouts.

“We had to do something.”

“Pledgets!” he shouts. “You sutured and you did not use pledgets!”

“Pledgets?” you reply stupidly.

“Cotton pledgets! You must have cotton pledgets to sew the heart. Where are pledgets?”

Donna, who is afraid of no one, wheels on him. “Dr. Wu, this is the ER, not the OR. We don't have pledgets down here,
so get over it
.”

Dr. Wu, sensing a dead end, immediately switches to another problem. “Who called OR? Is OR there? Where is Anesthesia? Why isn't Anesthesia ready? You people have gotten nothing done.”

“Dr. Wu…,” you say.

Donna is after him, though. “I'm sorry we haven't gotten anything done, but we
were busy trying to save this kid's life by sewing up the holes in his chest.
And if you quit having a temper tantrum because you got called in on an emergency case, then maybe you could help us out.”

Dr. Wu wheels around, his mouth open, ready to say something. He looks at Donna, closes his mouth, nods and tries again. Finally, he spits out the only thing, apparently, that he can think of. “I am going to scrub. Bring the patient to the OR.”

“Fine,” Donna says, arms folded. “You do that.”

You go back to the patient, basically thrilled to see Dr. Wu here no matter what his mood. At least he didn't ask you to cross-clamp the aorta.

That was the procedure that the photogenic doctors on TV were trying to enact. (“Do you see the aorta?” “Yes, yes, I see it clearly!”) The reality is this open chest, a bare beating heart and blood everywhere. To cross-clamp the aorta, you have to find it, and this means you have to root around in the darkest recesses of the chest. You remember the last time you did it—three years ago. That was another kid, nineteen, who was stabbed in the belly—complete transection of the aorta. After you resuscitated him, the young man went up to the OR. The surgeon repaired the aorta—a miracle—then the kid spent a month dying in the ICU. You remember talking to his gaunt, frightened parents, breaking the news. And then there was the death, finally, thankfully. Never again, you told yourself, no more miracles. And here you are again.

You realize that you faded out there for a moment. Donna is looking at you. “What now?” she asks.

The only simple part. “We take him up to the OR.”

“What about his blood pressure?” J. T. asks. You look up at the monitor. Systolic blood pressure of 60. Normal is over 100.

What now? You think and you realize you just don't care. You just want to get him to the OR.

“Let's restart cardiac massage,” you tell J. T. “At least until we get him upstairs.”

It takes a while to get everything ready. You have to transfer all the monitor leads to portable monitoring equipment, change the oxygen supply, sign and break down the chart. Meanwhile, J. T. is standing there, pumping the heart patiently. You change gloves and take over.

The little procession bangs out the door and down the hallway. You take over clutching at the heart. Clenching, unclenching, clenching, unclenching.

You have to take the front elevators. It's still before six
A.M
., so the back elevators aren't working yet. (They shut them down between midnight and six
A.M
. to save money.) You have to take one of the visitors' elevators up.

The bed just barely squeezes into the elevator cubicle. Everyone presses in around it. Bill presses the button for the fourth floor. This all seems pretty anticlimactic compared to what came before.

As the elevator levitates, you stand looking up at the ceiling, pumping away at the heart. Something occurs to you. A weird thought and you say aloud, “Maybe this kid will live.” Even you can hear the touch of disbelief in your voice. “Of course he's going to live,” Donna says. “He's nothing but a stupid, punk kid who, was out where he wasn't supposed to be, doing what he wasn't supposed to be doing. These guys always make it.”

You look sideways at her. It seems that as cynical as you have become over the years, you haven't gotten cynical enough to go that far, to feel that way. Then you remember J. T. and the needle stick. You nailed J. T. with the needle. No matter what happens to this patient, no matter how well he does, you would unravel the whole procedure just to take that needle stick back.

At the third floor the elevator stops. Everyone groans as the doors open; the OR is on the fourth. Standing in front of the door is a middle-aged woman, obviously waiting to get on the elevator. She doesn't look like one of the employees; she's dressed too nicely. Maybe she is an early morning visitor here to see one of the patients. What she sees with the elevator doors now open is a patient on a gurney with his chest pried open and you mashing on his bare heart while a motley crew of exhausted-looking health care professionals look on. Her mouth O's. She stands there frozen for the thirty seconds the door remains open. It closes again, and you ascend the last few feet to the fourth floor and the OR.

More anticlimax. Dr. Jan M. Radjike, the on-call anesthesiologist, wanders over, looking sleepy. Next to him an OR nurse stands waiting for you, arms folded, looking peeved. You feel for the first time a sense of relief, mixed with disappointment. Here is where you will pass the torch; you will go no further. The bypass pump technician waddles up. He scans the scene coolly; after all, he sees open chests and naked, flailing hearts every day. There are other nurses now as well, padding around in their blue surgical booties, surgical caps in place. Everyone looks grumpy and sleepy. No one wants to face this case first thing in the morning.