Luck of the Draw

By Tony Dajer|Tuesday, June 01, 1993
I hit the ER entrance before the triage nurse had even left her seat, propelled by the adrenaline pulse that surges through an emergency room when an unannounced, critical patient staggers in. Blood--shockingly red and soaking through a wide expanse of T-shirt--splashed into view. Above the shirt a young Chinese face wore the wincing, near-defiant look of a mischief-maker who has just tossed a cherry bomb into a crowd and knows all hell is about to break loose.

It did.

Gunshot wound! the triage nurse yelled.

Stretcher! I barked.

Nurses and residents dropped everything. High-decibel orders bounced off each other, feet pounded, equipment banged. In a flash a clump of white uniforms had settled the young victim onto a stretcher and was bustling him back to the trauma slot.

The slot is a miniature operating room, its narrow walls lined with defibrillators, chest tubes, IV sets, and cut-down trays stacked with surgical instruments. We took several pairs of shears and cut away every stitch of the kid’s clothing. Wide rivulets of blood caked his right arm, so a nurse shoved large-bore IVs of saline solution into his left. I wove my way to the business end of the stretcher and grabbed the sides of his head. No visible injuries there.

Can you breathe? I hollered, upside down, just inches from his nose.

He looked up at me.

Yes, I can breathe.

What’s your name?

Johnny.

Okay, Johnny, everything’s going to be all right. Just tell us where it hurts and where it doesn’t.

Am I going to have to spend the night in the hospital?

I was taken aback. Why, of course. You’ve been shot.

Well, you can at least let go of my head, he huffed. I caught the anger in his tone. Heck, the poor kid’s probably scared out of his wits, I thought, then hurried to do the rest of my exam.

His neck was unscathed, but when I lifted his right shoulder and looked behind it I found--between the right shoulder blade and the spinal column--the ugly, puckered hole where a bullet had gone in. Because the human lung fills most of the chest cavity and reaches as high as the collarbone, my first thought was that the bullet must have nicked his right lung, causing at least part of it to collapse. The lung is attached to the wall of the chest by a thin double membrane called the pleura: one layer of pleura is stuck to the lung itself, the other to the chest wall; the layers are separated by a thin, fluid-filled space. This arrangement gives the lungs the freedom to slide back and forth over the wall as they expand and contract but makes it exceedingly tough to pry them off the wall. If air or blood gets between the layers, however, it breaks that strong but delicate bond and the lung collapses like a stuck balloon.

So I quickly placed my stethoscope beside Johnny’s shoulder blade. But instead of the echoing silence of a collapsed, useless lung, it picked up the reassuring sibilance of air flowing in and out. Still, he needed a quick chest X-ray to make sure air or blood wasn’t building up inside, signaling an imminent collapse. If the lung were to collapse, our young patient would need a plastic tube inserted into the chest cavity to evacuate any accumulated air and blood. If there was a lot of blood, we would operate immediately.

I sized up the bullet hole again. Despite evidence to the contrary, I still figured the bullet had to have hit the top of the lung. And there were other possible complications. I eased Johnny back, then scanned his chest. The exit wound glistened dully in the meaty part of the shoulder muscle, oozing black, thickened blood. I knew that a tangle of arteries, veins, and nerves arched just beneath that bulge. Damage in this part of the shoulder could result in paralysis or massive blood loss.

I pushed two of my fingers into the palm of his right hand. Squeeze my fingers, I urged. hard.

Sure, he replied.

Suddenly I felt my finger bones cracking.

Um, okay, I grunted. Very good. You can let go now.

He grinned.

I felt for the pulses in his wrist. They were bounding. Which reminded me of something.

What’s his blood pressure? I asked Jenny, the heads-up nurse who had already put in the two IVs.

One twenty over 80, she answered without looking up. Not bad, I thought. Those certainly weren’t the numbers of someone hemorrhaging to death. But hemorrhage in young people is treacherous. They can maintain a normal blood pressure even after losing a quart and a half of blood--almost a third of the body’s total volume--because their still-springy arteries automatically narrow to keep the pressure on. If the volume isn’t replaced and bleeding continues, however, a point of no return is passed. The body goes into shock: blood pressure nosedives, cells are starved of oxygen, and vital organs begin to shut down. And, ironically, all this happens with much less warning than it would in an older person, whose body doesn’t compensate as well.

Better to have too much blood volume than not enough, I thought. I looked at the bags of saline hanging over Johnny’s head. In many cases a little extra fluid does just as much good as a blood transfusion, and it’s much quicker: it takes a long time to type and cross-match blood to be sure the patient won’t reject a transfusion.

Jenny, I called, those IVs are wide open, right?

This time she did look up. As wide as the manufacturer lets me crank them.

Just checking, I answered, smiling.

She smiled back indulgently.

I continued my visual sweep down Johnny’s body. Chest, abdomen, legs--no injuries.

Okay, everyone, let’s turn him over, I said.

Four pairs of hands wedged themselves under torso and limbs.

Gently, now. Roll away from me.

The teenager’s right side lifted off the stretcher like a board. I ran my hands down from the back of his head to the soles of his feet. Nothing.

Looks like there was only one bullet. Right shoulder, entry and exit wound, I announced.

Everyone breathed a sigh of relief.

Right on cue, the X-ray technician appeared in the doorway, pushing a portable machine with a cathode-ray tube dangling off a mechanical arm.

This the gentleman who needs that X-ray? he drawled.

This is the one, I answered. Do your stuff.

Briskly, he slid a film cartridge behind Johnny’s back.

X-ray! All clear, he shouted.

As I joined the flock of white coats scurrying out of the room to protect future generations from radiation, I glanced back and caught the disdainful look on our patient’s face. Jeez, it seemed to say, I just stopped a bullet, and you guys are worried about a little X-ray?

Johnny, the interceptor of that slug, was 19--which qualified him as the latest statistic in the United States’ deadliest epidemic among kids his age and sex. Firearms kill more black teenage boys than car accidents, and more teenagers overall than cancer and heart disease combined. What’s worse, while other death rates have been declining, from 1989 to 1990--the last year for which statistics are available--the number of teenagers killed by guns soared by 24 percent.

In the annals of medicine, one feature makes this epidemic unique. Historically, great plagues have swept across national borders, making a mockery of these artificial partitions. But the firearm epidemic is extremely respectful of lines drawn on a map. Epidemiologists say that the risk of being murdered with a handgun is five times greater in Seattle than in the near-identical city of Vancouver, not far over the Canadian border. Why the difference? There are tighter gun-control laws in Vancouver.

Even within the United States, municipal borders can be effective barriers. For instance, in the District of Columbia private citizens were prohibited from buying or possessing handguns in 1976; soon afterward the rate of gun-related homicides and suicides dropped by 25 percent. But the rates in neighboring counties in Virginia and Maryland kept on rising.

As the incidence rates rise, so does the severity of the incidents themselves. In 1982 only 5 percent of gunshot victims at Chicago’s Cook County Hospital had been hit by more than one bullet. By 1991, with the proliferation of easy-to-buy assault weapons, that rate had quintupled.

But even a single round can kill, and with assault weapons that’s especially true. In medical terms, the difference between being shot by a handgun or by a high-velocity assault rifle is catastrophic.

As a volunteer physician in Nicaragua, I scrubbed on plenty of gunshot-wound cases. One I’ll never forget: it was the case of a 17-year- old who’d had too much to drink and begun harassing a young militiawoman. She tried to push him away but he kept on coming. Finally she unslung her AK-47 assault rifle. This got his attention and he started to run away, but she had already opened fire. She hit him with just one round in the midback.

The viciousness of an assault rifle lies in the high velocity and bounce of the bullet it fires. In flight, the round is designed to tumble rather than spiral through the air, and it strikes at crazy, ricochet-prone angles. So after it enters the body, it caroms wildly, blasting through the body like the pieces of a hand grenade instead of traveling straight through. In this boy’s case, the single bullet finally exited just below his right rib cage. Friends of his watching nearby threw him in the back of a truck and raced down from the mountains. Two hours later, he arrived at our hospital.

We poured blood and fluids into him, rushed him to the operating room, and opened his abdomen from sternum to pubic bone. Immediately an overpowering stench of feces and clotted blood filled the room. The damage we found was stunning--that one AK-47 round had perforated the boy’s colon, small intestine, duodenum, pancreas, and stomach, shredded his liver, and almost severed the main blood vessels to the gastrointestinal tract. Though the surgeon and I sutured like mad for three hours, it was like the Dutch boy’s nightmare: every time we plugged one hole we discovered two more. The 17-year-old died on the operating table.

The 19-year-old in front of me hadn’t been shot by an AK-47. He probably had no idea of the bloody havoc such a shot could have inflicted inside his chest. Then again, I thought sadly, maybe he did.

The X-ray technician was done taking his films, and the surgeons had arrived. We all trooped back into the trauma slot.

Johnny, I said, these are the surgeons. They’re going to take a look at you.

He eyed them warily. I’ll be fine.

Lori, the chief surgery resident, went straight to Johnny’s right shoulder and began examining it. Let us be the judge of that, okay? she said.

With gloved hands she inspected the wound front and back, then back and front. She turned to an intern. This’ll need some debridement-- the surgical removal of foreign materials, like clothing fragments, and damaged tissue--and we’ll give him a dose of antibiotics now.

She directed her attention back to the shoulder. Is that film back? she asked no one in particular. Just then the X-ray technician with the perfect timing returned. Like an actor holding the name of an Oscar winner, he paused dramatically and then announced, Lung looks fine.

Almost unbelievingly, we threw the X-ray up against the brightly lit view box on the wall and clustered around. The lung did look fine. So did the collarbone and shoulder blade. Lori whistled. Jesus, she said. It missed everything. Everything.

She walked over to the lucky patient.

You’re going to be fine, she said. We’ll just admit you to the hospital for observation and antibiotics, and you can go home in a day or two, all right?

I want to go home now, he replied.

Huh? Lori stepped around to face him directly. You can’t go home now. Wounds like this can get infected. You could start bleeding again. Your lung could collapse. All kinds of bad things could happen.

Johnny raised his eyes to the ceiling, as if counting the tiles. I need to go home, he said firmly. Now.

I walked up beside Lori.

Johnny, don’t be ridiculous. You were very lucky, but you’ve also lost a lot of blood. Nobody just goes home after being shot.

More tile counting. He would have crossed his arms for emphasis except there were two IVs in the left, and the intern had already begun debriding on the right.

Someone mentioned that Johnny’s mother and girlfriend were in the waiting room, so we brought them in to plead with him. No dice. He was over 18, he informed us, and he could damn well sign himself out of the hospital. So we made a deal.

How about letting us finish cleaning the wound, I said. He nodded. And will you promise you’ll take your antibiotics and come back at the first sign of any trouble?

We’ll see, Johnny answered.

Two hours later the skinny young man walked out the same double doors through which he’d come. The only difference was a bulky shoulder dressing under which he seemed to be listing to starboard.

Lori had come down to the ER to oversee the departure. Maybe he had an appointment he couldn’t refuse, she remarked as we watched him go. Gangs can be sticklers for punctuality.

What are those lines in King Lear? I ventured. ‘How sharper than a serpent’s tooth it is / To have a thankless child!’

Nah. Reminds me more of Superman, she sighed. The kid’s 19. Nineteen-year-olds all think they can leap tall buildings in a single bound. She shook her head. But this one--well, he’s definitely not faster than a speeding bullet.
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