Just Here Trying to Save a Few Lives: Tales of Life and Death from the ER (26 page)

“What did you have on the monitor?” Murray demanded of the paramedics. He wasn't quite shouting now.

“Mostly idioventricular, I think. She didn't flat-line on us.”

“Who shot her?” someone asked—a rotating intern who didn't know any better.

“Shut up,” Murray said, his face right up next to hers. “Who the fuck cares who shot her? We're not here to play detective.” He turned and addressed the room at large. “Somebody set up for a central line.”

Donna leaned over the head. “Oh, jeez,” she said. “Guys, I think I see brains here.”

“Let's get her moved. Let's move it. Move, move, move.”

Everyone did the best they could.

“One…

“Two…

“Three. Let's go, let's go, let's go.” Murray paced back and forth in front of the bed. He looked like a coach on the sidelines fuming at a referee's bad call. “Drugs!” He was shouting again. He leaned over the paramedic who was trying to catch the IV bag on one of the overhead hooks. Murray pointed, his finger a hairbreadth from the paramedic's chest. “Drugs?”

“Epi. That's all we've given her.”

“Do we have a pulse?” Murray shouted. “Do
we have a pulse?”

Drew came forward saying, “Hold CPR.” When the medical student paused, he palpated the neck of the patient. “Nothing,” he said.

“This
woman
has no
pulse”
Murray said through clenched teeth. “We've got to get that baby out. Where's OB? Page OB overhead.”

“Keep your shirt on,” Donna told him.

Sudesh moved up to control the airway. He stood, ET tube and laryngoscope poised, ready to intubate, except that the paramedic managing the Ambu bag couldn't move out of the way; he was trapped in a snare of monitor leads and IV lines. Murray paced back and forth in front of the cart, talking to himself, his nervous tic animating his face. He put on the characteristic Murray posture, head down, arms wrapped around his chest and hands buried under his armpits. This was Murray's style. He could stand brooding or pace back and forth like this throughout an entire code, listening to everyone and following the code more with his ears than with his eyes. Even so, all the while he paced he looked more like any one of the schizophrenic walkers we had patrolling the psychiatry ward. More than that, he looked like a caged animal. He even growled as he walked.

Donna and Ted started doing the routine stuff: hooking up the monitor wires, strapping on the blood pressure cuff (not that, at the moment, there was any blood pressure to measure). Defibrillator, drug box. Eileen checked the IVs and got set to start another, a large-bore one for the blood we would need if the patient showed the least signs of life.

This was it, the golden hour. In emergency medicine this may be the only chance you get to save a life. Sixty golden minutes, each is an opportunity won or lost, each weighs in with the question Live or die? Live or die? Questions synchronized to the ticking of the clock. Can't get an IV in? The patient will die. Can't get the patient intubated? Dead, dead, dead. Can't find the cause of the hypotension? Don't make the diagnosis of a ruptured aortic aneurysm? Get the central line in too late? Drop a lung? Don't recognize within the slobbering, comatose drunk before you the massive intracranial bleed? More than one of these? Then the patient dies. And the pressure is on you, big time. It's because of you that the game gets won or lost. But the question is, how long can you play the game with stakes like these.

Murray stopped pacing. “Where's trauma surgery?” he shouted. “Where? where?”

“Here,” an intern said as he walked in through the sliding glass door. “What's the problem?”

Murray bore down on him.

“Where's the rest of your team?”

The intern looked around uncomfortably. “They're on their way,” he said. “I think.”

Murray pointed. “Well, she's got a bullet in her head. It would sure be nice if trauma could
make a guest appearance.”

The OB-GYN intern followed the surgery resident in. I knew him. He was a sweet guy but easily baffled. He also looked like he had not made it through puberty. This did not help matters.

“What's going on?” he asked me in a don't-have-a-clue voice.

“She's shot in the head,” I told him.

He looked around at me. “And you called OB?”

“She's pregnant,” I said.

“How pregnant?”

“Real pregnant. And she's a full arrest.”

“Oh,” he said. “Jesus.” He took a sharp breath in and exhaled slowly.

Murray was still pacing. “Where's OB?” he demanded of no one in particular.

The intern visibly shrank back. “I'm here,” he said.

“Well.” Murray bore down on him. “Where's
pediatrics?”

The intern shrank back further. “I don't know.”

Murray pointed. “There is a woman here and we don't have a pulse and we are doing CPR and she is pregnant. She's going to have a baby and she's not pumping any blood to that baby. You've got to get that baby
out.
” He leaned over the intern, prodding him with a finger. “Call your senior down now.”

Ted had connected the patient up to the hospital monitor.

The surgery intern raised his hands. “Hold CPR, please. Checking for a rhythm here.”

Everyone paused and stared at the monitor screen, waiting for the artifact to settle out. And there it
was,
a rhythm of sorts, slow and broad-based. Her heart was at least going through the motions.

“Do we have a pulse?”

Sudesh was still fumbling with the intubation gear. He reached out and massaged the woman's neck again, looking for a carotid pulse. “Nothing,” he said.

“Epinephrine,” Murray shouted. “Come on, come on.” He wheeled around, looking for the OB intern. “Where's your chief? Where
is
your chief?”

The intern was on the telephone. He raised the receiver so Murray could see.

“We need fluids,” Murray shouted, again to no one in particular. “We need a central line in her.”

The surgery intern nodded. “I'll do it,” he said. Then he looked at the patient. “Where?”

“Where, what?” Murray said.

“Where do I put the line in?” He motioned toward the patient. He was right to be puzzled. The head of the bed was packed with people. It would be hard to find room enough to get to her neck or shoulder.

“I don't care where you put it,” Murray said. “Just put it in somewhere.”

The OB resident called out from where he stood by the phone. “My senior wants to know if she has had any prenatal care.”

“I
don't know,”
Murray shouted. “She's
been shot in the head. She can't talk.”

The intern's mouth O'd. The enormity of the situation had finally gotten through.

“C-section…” he breathed into the phone. “Crash C-section.” He turned to all of us. “We need a c-section tray.”

From somewhere next door in the storage room Sheila shouted back, “I'm looking for it.”

At the head of the bed Sudesh had succeeded in intubating the woman. He and the respiratory therapist were trying to tape the tube into place. He motioned for me to come over and help bag. (Or did he? Do I remember this right?) I must have put some gloves on (or was this before we all took the HIV stuff seriously?) and grabbed at the Ambu bag. This was my first close-up view of the woman's head. A matted collection of blood-soaked dressings were plastered over her forehead and held in place by layers of Kerlix.

“Let's see what we have here,” Sudesh said.

“I found the tray,” Eileen shouted.

Sudesh slipped off the bandage as if it were a hat. Beneath was the forehead with a bullet hole. A clean shot. A hole the size of a dime that was oozing blood.

This is the dead end of violence, unstylized and unshorn. An argument, a flash of gunmetal and its result is a hole in someone's forehead. I thought of all the gunshots casually exchanged between the hero and the villain on a television show. That was the fantasy; this was the reality of a stray shot or two.

Blood and edema had already swelled the area around the wound.

“See any brains?” Donna said, leaning over.

“No,” Sudesh said. “Not yet.” Then, “The paramedics said they heard two shots…”

The patient's right eye was swollen, puffy. “Two shots,” Sudesh said again. He touched the hole in the woman's forehead. “Shot number one.” Then he palpated the right eyebrow with his gloved thumb and lifted the lid. The globe of the eye was gone; there was nothing there but an oozing pool of blood and egg white-like tissue.

“Bingo,” he said. “Shot number two.” He called out to Donna, who was recording. “Two gunshot wounds involving the face,” he said. “One midline on the forehead; the other into the orbit. The forehead one's an entrance wound, I think.” He palpated the rest of the scalp. “I've got another bullet hole here, guys. Back of the skull, occiput. Maybe an exit wound. It's big, really big.” He pulled what was left of the bandage out, lifted the woman's head as best he could, and bent down, peering at the back of the skull. “Guys, I think we are talking brain matter here.”

“Hold CPR,”
Murray shouted. We all looked up at the monitor, waiting for the artifact to fall away. And there it was, a narrow complex rhythm, a sinus rhythm. Rate: 120.

“Do we have a pulse?” Murray thundered.

Sudesh massaged the patient's neck again. “Maybe,” he said. “Thready. Someone get the Doppler.”

“Should I hold CPR?” the medical student said, pausing on an upstroke.

Murray turned to him and shouted, “God
damn, you don't hold CPR until I tell you to hold CPR and I'm not telling you to hold CPR until this woman has a certified blood pressure.”

The medical student, looking stricken, resumed CPR.

Murray pointed to me. “We need two units of O-neg blood, right now.”

I surrendered the Ambu bag and went over to the phone to call the blood bank. Another medical student was standing close by looking somewhat sick to her stomach.

“Blood bank,” I said, pointing. This is the medical tradition: scut flows downhill.
“Now.”

She dashed out past two police officers who now stood in the ambulance bay doorway looking on with a sort of noncommittal curiosity. I went over to them.

“What happened?” I said, or rather, whispered, so Murray wouldn't get upset. “How'd she get shot?”

The first officer shrugged. “Gang stuff. Somebody had a beef with her brother.”

I looked at them both expectantly.

“Boom, boom,” the other cop said. “That's all we know.” “Where'd she get hit?” the first officer asked me. I touched my forehead and then my eye. “She gonna make it?” the other asked.

“Not a prayer,” I told them. “You may as well go ahead and notify your homicide detectives.”

“Yeah?” the cop said skeptically. He looked up at the monitor. “But she's still got a heartbeat…”

I shrugged. “You're right; she does have a heartbeat.”

“Well, then she's not dead yet. We're not supposed to call homicide until they are officially dead.”

The medical student doing CPR was flagging, I could see. He was sweating like the paramedics had been. His glasses kept sliding to the bridge of his nose and he'd try to nudge them back into place with his shoulder so he wouldn't break his CPR rhythm. Nobody made a move to replace him. Nobody but me even noticed.

The OB intern came back from the phone. “My senior is in the OR,” he said. “He'll be down as soon as he can.”

Murray pointed at the patient. “
Now
! I want that baby out
now.”
He grabbed the intern's right wrist and he stuck something—I think it was a pair of trauma scissors—into the intern's hand. Then he dragged, literally dragged, the intern over to the foot of the gurney and pointed with his other hand.

“You
are OB. This is your responsibility. I want that baby out and
I
want it out now.”

The moment of truth. The intern peered up at Murray, then at the patient, then back at Murray, as if trying to calculate which was the most frightening. The answer was clear: Murray.

The intern's lips moved but he said nothing. Perhaps he was praying.

“Come on,” Sudesh said,
sotto voce.
“You can't know less than me.”

Meanwhile Murray turned and surveyed us all. “Where's neonatal? I told you to stat page neonatal. Where the hell is the team? Hell, team, hell, team, team. Where?”

As if on cue, the doors to the main ER opened. The medical student who had gone to fetch the blood now came back in carrying two units.

“Where's neonatal?” Murray demanded of her.

The medical student looked around, bewildered.

“Never mind,” Murray said. “At least you got the blood.”

Sudesh opened up the OB pack. I edged over; I had never seen an emergency C-section before (or since). I had only the vaguest idea of what needed to be done—but then, obviously, so did the OB intern. The trauma intern, now joined by his resident, peered over from where they were suturing in a femoral line. They looked equally baffled.

“I'd open with a ten-blade,” the trauma resident told the OB intern.

Sudesh left the head of the bed and was now standing next to the OB intern trying to help. He sorted through the equipment in the C-section tray, poking at the retractors, Kelly clamps and forceps.

Eileen had dumped a great brown pool of Betadine on the woman's belly. This was the only gesture toward sterility. We all knew it didn't matter. The mother had been lost from the very beginning; the problem now was to save the child.

“Go,” Murray shouted. “Go,
go, go, go, go.”

I looked over at the OB intern, who was standing with a scalpel in his raised right hand, staring down at the woman's belly like a high diver staring all the way down to the water so far below.

“
Do it,”
Murray shouted. He was standing at the intern's shoulder.

The intern cut a curved incision along the lower boundary of the woman's belly, exposing a deep layer of fat. Immediately this fat herniated through the incision as a result of the pressure transmitted from the chest by CPR. It was eerie-looking, almost as if the belly was breathing in and out.