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The Bullet's Yaw

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000340950.69012.8d
Articles

Dr. Ballard received his medical degree from the University of Pennsylvania, and completed his emergency medicine residency at the UC Davis Medical Center in Sacramento. His writing credits include co-authorship with Angela Ballard of the award-winning travel narrative A Blistered Kind of Love: One Couple's Trial by Trail (Mountaineers Books, 2003) and contributions to Hoops Nation (Owl Books, 1998). He currently works as an emergency physician in northern California where he lives with his wife Angela, daughter Hayley, and Labrador retriever Gary. The Bullet's Yaw is available through Amazon atwww.amazon.com/Bullets-Yaw-Reflections-violence-unforgettable/dp/0595476481and through his web site,http://incisionanddrainage.blogspot.com.

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Chapter 2: Damage Control

My memories from that month in the fall of 2001 when Jeffrey Mains became my patient are an amalgamation of drab checklists blended with vivid snapshots of blood, guts, and gruesome violence. The checklists were the realm of the Trauma Nursing Unit (TNU) where I spent every other night doing 30-hour shifts, tackling work that I would have considered simple if it were not for the overwhelming volume of it. My responsibilities were mostly drudgery, but occasionally the monotony was broken by a trauma code, a “911” or “922” page that would send me sprinting to the trauma bay in the emergency department. These were moments of adrenaline, when a few minutes meant the difference, and inaction could mean death.

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Our trauma patients were a diverse group — the young and old, the rich and poor, the sober and drunk, the suicidal and homicidal, and the extraordinarily stupid and profoundly unlucky. Their injuries were as varied as their backgrounds — fractured arms, broken necks, bleeding spleens, leaking bowels, severed arteries, collapsed lungs, pierced hearts, and much more. Rarely did I learn the patients’ names. To me, they were all members of the extended Doe family with names like Ken Doe, Donald Doe, Rex Doe, Juan Doe, Cassius Doe, Dre Doe, or perhaps even John Doe.

During a “911” or “922” trauma resuscitation, as others assessed the ABCD of trauma's A-B-C-D-E algorithm, my responsibility was “E,” exposure, and I tried to ignore the nature and circumstances of the victim's injury and just focus on excelling in this role. The best way to cut off a John Doe's pants, I'd quickly discovered, was to make a short snip through the seam with my trauma shears and then grab each cut end and tear. I relished the sound of ripping denim or polyester, and raced the intern who was working on the other trouser leg, striving to reach the waistline first. The belt often caused a dilemma; it wasn't easy to cut through, even with my hardy trauma shears, and the fastest method was to unbuckle it and pull it through the belt loops. But if I attempted this, I had to be careful not to jostle the patient or I'd get a stern rebuke from the senior surgical resident. So usually, I'd wait for the other intern to stabilize the patient's hips while I tugged on the belt. In most cases, after “E” came the not-nearly-so-critical “F,” short for Foley catheter. This was a thankless task that I dreaded; it didn't matter if it were a man or a woman, the prospects for embarrassment were great. Finding a women's urethral opening, hidden between the vagina and clitoris, was tricky. To make matters worse, I always had an audience, and if I didn't locate the urethra, I quickly envisioned snickering faces around me — nurses and senior residents — who must have been wondering about my familiarity with the female anatomy. A man's urethra was easier to find, but the catheterization process was no less hazardous. It seemed to me that the tougher the guy looked, the more dramatically he reacted. Some bellowed mightily, others cussed my mother, and one young punk even flailed his fists at me. My final contribution to the trauma code was what we interns sarcastically called the “WB:” warm blankets. I'd hurry to the incubator in the main ER, and grab three or four thin, cream-colored blankets and drape them over the exposed and catheterized patient. Then, after only a few minutes of action, I was dismissed back to the TNU to continue my cycle of overwhelming drudgery.

When I first started with the Trauma Gold team, the trauma activation patterns seemed entirely random, but within a week or so, I discerned a daily injury schedule that had some predictability. Pre-dawn was usually quiet in the trauma bay; there's something about 4 a.m. that quells man's destructive tendencies, and for this I was thankful. As dawn broke on a weekday morning, though, we'd begin to see the victims of the morning commute. The nurses said that on winter mornings, when the Tule fog squatted over the Central Valley and greatly reduced visibility, rear-end fender benders were as plentiful as dirt, but even in early October, commuting casualties were plentiful. Fortunately, rear-end collisions are the safest type of vehicle impact, and many of these patients came in with nothing worse than a sore neck and an impending auto body bill. Mid-day patients, on the other hand, generally weren't so fortunate. These tended to be the occupational injury patients, and their wounds could be gruesome.

Sacramento is essentially a capitol town in a vast expanse of farmland, so I shouldn't have been surprised by the variety of agricultural and industrial injuries we treated. Even now, years later, certain injuries remain vivid. The farmer who rolled his tractor over his pelvis, crushing it into a half-dozen pieces; the migrant farm worker who was thrown from a ramshackle pick-up, and suffered eight broken ribs and a collapsed lung; the four-man crew with severe insecticide poisoning; the young man from the quarry who had been pinned under 800 pounds of granite for three hours, and the water treatment worker who slipped and fell 30 feet into a concrete tank, breaking both femurs before collapsing into sewage.

The late afternoon's business was no more palatable because this was when the injured children arrived. Despite what many parents (and the media) may think, school is a pretty safe place. It's after school that's dangerous. Bike accidents, falls from the monkey bars, failures to look both ways before crossing the street, and (this was always heart-wrenching) toddlers mistakenly backed over by a parent's vehicle in the driveway. Kids were magnets for mishaps after the final bell rang.

Suppertime brought an occasional reprieve. I attributed this to the fact that evening was the hottest time of day in the Central Valley. For those who haven't had occasion to experience it firsthand, I can unequivocally attest that Sacramento is positively broiling in the summer months. Not the heavy, thick-with-moisture heat of the East Coast, but an equally oppressive scalding desert heat, the type that might melt your leather car seat, or as in my minivan's case, cause your rearview mirror to come unglued and drop off the windshield. On the hottest of summer days, when ultraviolet light seemed to bore into my skull, paralyzing temperatures would peak around 6 p.m. That June, we had an early heat wave with a long series of 100-plus-degree days. California was facing an energy crisis, and there were dire predictions of widespread brownouts. Ads saturated the airwaves imploring residents to “Flex their Power” by setting the thermostat at 78 degrees and to be aware of unnecessary lights and other “watts going on.” Fortunately, the relative lack of humidity allowed for a nightly respite, and as soon as the sun set, we could open our windows and let the crisp air permeate the house. But as the city woke up in the cool night, the hospital became once again inundated with a potpourri of traumatic injuries, many of which were the result of high-speed motor vehicle collisions.

I grew up two hours west of Sacramento in affluent Marin County, and as a kid, I viewed Sacramento as a place that one traveled through (on the way to the mountains), rather than to. Viewed from Interstate 80, stumpy “skyscrapers” rise disjointedly over bland terrain and fail to inspire visions of a big city. Only the confluence of two rivers, the American and Sacramento, adds a touch of place, an explanation for this accumulation of roads, homes, and telephone poles. An infamous bridge, painted a strange sickly shade of gold, spans the Sacramento River near downtown, and is visible from I-80, but I found it far less worthy of rubbernecking than its neighboring Coors Light billboard which, that fall, celebrated “Raider Nation” with the well-contoured midriff of a cheerleader. After I officially moved to Sacramento, I discovered that my boyhood perception of the city was more or less spot on.

More than anything, Sacramento is a city that people drive through. Within its limits, two vast interstates intersect: I-80, which runs from the Atlantic to the Pacific, and I-5, which runs from Mexico to Canada, and at all hours, a steady stream of autos flows through the city, heading east, west, north, and south. At UCDMC, we saw the human carnage of their collisions. Compounding the challenge of managing the large volume of local car crashes was the influx of patients transported from afar. Because UCDMC is the only Level I trauma center in central California for hundreds of miles in every direction, critically injured patients were often helicoptered in from remote places, little rural towns with names like Galt, Cool, Weed, and Red Bluff. Many of the people injured in these obscure locales and transported to see us were victims of thrill-seeking endeavors gone awry: snowboarders with broken legs, people beat up from the feet up after being thrown from their all-terrain vehicles, and riders ejected from their horses. I recall one particularly gory calamity from the Sacramento River Delta, a water skier whose arm got caught in the tow line and suffered what is called a degloving injury. The force of the taut line accelerating against his arm caused his skin and muscle to be pulled completely off, like a glove, leaving behind nothing but bone and tendon.

Later in the night, the shootings and stabbings began. Sacramento may be surrounded by farms, but it has big-city crime with a multicultural flavor. I was initially surprised to learn that Sacramento is the most ethnically diverse metropolitan area in the United States, according to a Harvard study of 2000 census data published in Time magazine. But several nights in our trauma bay satisfied my doubts. We saw all different types of people shooting and stabbing each other, some in gangs, some not: Aryans like Joseph Ferguson, former Soviet state immigrants like Nikolay Soltys, Hispanics, Laotians, Vietnamese, Pacific Islanders, African-Americans, and just about any other color or ethnicity you could think of.

I estimated that about 90 percent of our late night visitors were intoxicated in some way: alcohol, cocaine, heroin, GHB, ecstasy, PCP, and methamphetamine — lots of methamphetamine (also known as meth, crank, or crystal). With time, it became easy for me to identify those flying on meth; their “accidents” always had a similar flavor, a combination of bizarre, stupid, and destructive acts. Methamphetamine addicts can also be easily identified by the presence of “Meth Mouth.” A combination of the drug's high acidity, its tendency to cause teeth grinding, to trigger cravings for high-calorie carbonated beverages, and its long duration of action have devastating effects on teeth. An addict with full-blown “Meth Mouth” has stained, rotting, and shrunken teeth (as if filed down for a dental crown) that often can be spotted from across the room. There was, for instance, the contractor who had nail-gunned his hand to a 2x4 while working in his poorly lit garage in the middle of the night and the woman with several cracked vertebrae who refused to lie still and shouted at me, “Yeah I'm on crank, but this is nothing. I can crank harder than this.” Some time later, I saw an article about a Portland-area man who, while high on methamphetamine, had shot 12 nails, each up to two inches in length, into his skull and somehow survived without significant injury. Unfortunately, self-inflicted wounds like this often appeared at 3 a.m., just as I was lying down for an hour of precious sleep: ice pick wound to the abdomen, steak knife to the heart, razor blade to the wrists.

From around 10 p.m. to 3 a.m. on the weekend nights, I spent most of my time in the trauma bay, leaving only briefly to retrieve warm blankets for the injured, drunk, and suicidal. I'd then return to the TNU to prepare for my morning rounds. Often, I was so numbed by fatigue and work that the horror of what I'd just witnessed wouldn't register for days, sometimes not until my wife looked at me sadly, and asked, “Did that really happen?” When I returned home from a shift on the trauma service, I was zombie-like, plodding around the house without purpose or slumped on the couch and utterly incapable of communicating in full sentences or engaging in the simplest decision-making such as what to watch on TV. It wasn't until weeks or months later that I realized how the consequences of the violence that I saw permanently altered my relationship with risk. Despite my wife's repeated urging, I continue to refuse her invitations to join her for a romantic horseback ride on the beach. I don't think I could find it romantic, not with the memory of the 17-year-old girl who I'd seen die in front of me from a massive head injury after being thrown from a horse. Likewise, I will never knowingly live close to anyone with pit bulls, not after seeing what such dogs did to a poor 7-year-old boy, grotesquely tearing and puncturing his body until it became a corpse. At one time in my adventurous years, I might have thought it exhilarating to jump out of an airplane, but any desire to do so was snuffed when I saw two young parachuters dead-on-arrival because of an equipment malfunction.

My most lasting trauma bay memories were spawned from the gory and the tragic, but there is one patient that I remember because of his creativity and his persistence. His name was Donald, and he was a carpenter, an epileptic carpenter, with a penchant for falling from great heights. Or, I should say, pretending to fall from great heights. I never learned Donald's exact age — he looked to be in his late 30s, but could have been much younger — but my colleagues made sure that I knew about his past. Years before, he had undergone major cranial surgery to remove a large seizure-inducing AVM, and the operation left him with a large, depressed defect in his blockish skull. At some point during his complicated recovery, Donald became hooked on an assortment of painkillers and sedatives, and, to make matters worse, his seizures persisted. At least that's what he led everyone to believe. He would often come to the ED and fake a seizure in the waiting room so that he could get a fix of his favorite drugs. When the triage nurses got hip to this act, Donald changed his tack, and figured out how to arrive in the ED as a “911” trauma code. The details were a little different each time, but the essence of his tale was pretty much the same: He'd suffered a seizure, fallen, and hit his head. Maybe it was while he was on a roof or on a ladder or while working on gutters or riding his bike. Oddly, there were never any witnesses, and it was never exactly clear who had called for help. When the paramedics arrived and heard Donald's account and noticed his misshapen skull (and Donald always made sure they noticed), they were alarmed. Someone who hadn't seen Donald before could easily mistake his misshapen noggin for an acute depressed skull fracture. He'd be rushed in Code 3, with the whole trauma team waiting in the trauma bay for the “head injury patient with a history of seizures.” The first half-dozen or so times he staged this, Donald received the whole battery of tests: x-rays, CTs of the head and abdomen, and a full rainbow of lab tests. Everything always came up negative (except the taxpayers’ bottom line because guess who picked up the bill?), and by the time it had, Donald was drugged, happy, and ready to go. Eventually, the response to Donald's cries of “wolf” became less urgent, and the senior EP or trauma resident would intervene before a full trauma code was activated. Whenever a paramedic report contained the phrases “depressed,” “skull fracture,” “seizures,” and “fall,” someone was dispatched to meet Donald at the door, and if no new injuries were seen, to downgrade the trauma. Donald, once he realized that he would be made to wait like all the other noncritically injured patients, would usually pull off his cervical collar, curse, and stomp out of the ED, only to try the whole stunt again a few days later.

On any given day, I had no idea how many critical traumas or new admissions I would have. This, combined with all of my other errands, suppressed my curiosity and drove me to maximize efficiency. In order to round on 30 patients each day, attend every trauma code, and perhaps catch a meal or two, I had to be supremely efficient. So I used every spare moment not spent gulping down a grease-saturated specialty from the cafeteria to prepare my notes for the next day. I kept 30 some pieces of blue-trimmed progress note paper stuffed in my long white coat, along with a collection of pocket medical reviews, laminated reference cards, and my green trauma shears. Scrawled on each piece of note paper were the patient's name, medical record number, and the outline of the “SOAP” note I was writing. The first time, as a third-year medical student, that I was asked to write a “SOAP” note, I was confused. I knew how to write a daily progress note, a brief recap of the past day's events, current vital signs, and physical exam. But what was a “SOAP” note? A cleansing of the medical record? Some type of cover-up for negligent care? No, it turned out that “SOAP” didn't stand for anything that interesting, but instead for the four elements of a proper daily progress note: Subjective, Objective, Assessment and Plan. Virtually all medical specialties that treat inpatients utilize the SOAP note, but while the practice is widespread, its execution can vary greatly. A SOAP note on the medicine service may be a several-page document, including a long list of medications, lab results, and an updated list of possible diagnoses. On the psychiatry service, it might be heavily weighted toward the Subjective, with a detailed description, for example, of a patient's belief that a monkey is lighting bottle rockets in the bathroom. On surgical services, SOAP notes were expected to be brief, unadorned, and devoid of interpretation. Consider the SOAP note I wrote on Jeffrey Mains for October 20, 2001.

  • S: Tolerating small amounts of p.o.. Ambulating with difficulty. Requiring decreased pain meds. “Restless” + Flatus + eating bread OK. No N/V.
  • O: Vitals: AVSS.
  • Resp: Lungs CTA B/L.
  • CV: RRR, no m, r, g.
  • Abd: Soft, NT. Wound dressing c/d/i.
  • A/P: 27 yo male with GSW to abdomen with enterocutanous fistula. Day 14/14 of antibiotics. Continue to advance diet as tolerated. Continue TPN as needed. Continue ambulate.
  • Continue IS.

I found this note in his medical record, and when I re-read it, I was reminded of how I rushed to prepare this and other progress notes, of how I scribbled while standing next to the radiologist, or while on the phone with a nurse. And I was not surprised that the brevity of this October 20 SOAP note belied the progress that Jeffrey Mains had made since the night he'd nearly died. As I later found, this story too had much more to it.

Trauma surgeons often refer to the peritoneal cavity as having “potential.” This is not a flattering description. It doesn't mean that the peritoneal cavity, like a rookie centerfielder, has the “potential” for greatness. Instead, it is an anatomical distinction, a potential space between organs. The peritoneum is a thin membranous layer that surrounds the stomach, intestines, and other abdominal organs and their blood supply. It has two components, a visceral layer and parietal layer, and the space in between is the peritoneal cavity. Because the intestines tend to expand and retract with the passage of food, the peritoneum is a stretchy covering, able to handle either Weight Watchers or Thanksgiving dinner. Normally, the peritoneal cavity is small, filled with only a tea cup's worth of lubricating fluid, but it can accommodate much more. In the case of a traumatic injury, blood may leak or pour into the peritoneal cavity, and if the bleeding isn't controlled expediently, shock and death can quickly follow. Jeffrey Mains was young, and his heart was healthy, so he was able to temporarily compensate for the loss of blood into his peritoneal cavity. But even the healthiest of hearts cannot work without blood. Like an engine when it runs out of its gas, a heart without blood will stall.

In the early morning of September 10, 2001, Jeffrey Mains was wheeled into a second-floor operating room. He was put under general anesthesia, given a breathing tube, and connected to a ventilator. Dr. Wisner, with assistance from his senior resident, Jeremy Benedetti, performed an exploratory laparotomy. The surgeons made a scalpel incision from just below the sternum to just above the bladder, and incised and retracted the underlying tissue and then entered the peritoneum. Inside was a bloody mess. Wisner and Benedetti packed the entire abdomen with dry sponges to soak up the hemorrhage, and then explored for sources of bleeding. The spleen appeared clean, uninjured. The liver had a large laceration, which was re-packed with sponges until the bleeding was controlled. There was a hole in the right hemi-diaphragm and a palpable bullet fragment in the superficial right chest that was removed, and held for the police as evidence. Then the surgeons “ran” the bowel, segment by segment searching for injury. The gut was bruised and bleeding from multiple sites and completely severed midway through the small bowel in the area of the jejunum. Sections of the large bowel, in the right colon and transverse colon, were also injured and dying. The dying and dead bowel tissue was removed and the interposing ends stapled, leaving Mains with a dead-end gut, like a road barricaded at multiple locations. As the operation progressed, the patient's temperature dipped lower, and the operative report notes that there was “increased ooze throughout the abdomen.” Mains was progressing from shock to coagulopathy, a common complication of traumatic injury.

Dr. Wisner decided to cease further repair and exploration, and attempt to stabilize his patient with medication to coagulate the blood. It was 3 in the morning, and he was not optimistic. In the waiting room outside the operating room, he met with Jeffrey's mother, Linda, and his uncle, Gary Kambestad. Hours earlier, Linda Mains had fallen asleep while watching the late news. Before she nodded off, she noted that the lead story was on a series of nearby shootings, and for a moment she worried about Jeffrey, but then thought, “He has to be at work early tomorrow. He's at home and safe.” At 2 a.m., she learned that Jeffrey was actually not home and not at all safe.

“Dr. Wisner told us that Jeff wasn't going to make it, that he had bled out,” Linda Mains recalled years later. “He told us that he was still alive but that it was going to be a long day and that we should go home, shower, and notify the family.”

On the morning of September 11, 2001, Jeffrey Mains, to the surprise of his nurses, family, and doctors, was still alive. Despite being in very critical condition, Mains returned to the operating room. His first surgery had been “damage control;” this one was clean-up. Liver packs were removed, sections of bowel reattached to one another with sutures, and the entire abdomen re-explored.

Mains woke up on September 12 in the SICU. He was confused and delirious, and the TV in his room didn't help: On it, a video of a passenger plane flying into a tall building was being played over and over. “I was so drugged up,” Mains later told me, “that I didn't know what was up or down, but I was hearing people and voices on the TV.” The atmosphere in the SICU and throughout the hospital was tense. Health care professionals attempted to continue their work and maintain their composure despite the shock of the terrorist attacks and the uncertainty of what the next target might be. When Linda Mains arrived at the SICU to visit her son, she saw nurses crowded around a TV in the waiting room, watching the news. “And I thought, ‘My god, all of those people will never get to see their families again.’ To be honest, I almost felt a little grateful about my situation.” For Jeffrey Mains, on the other hand, the circumstances were too much. Beset by agitation and panic, he thrashed on his gurney, and on September 13, loosened his hands from his restraints and pulled out his breathing tube. After that, he was kept deeply sedated for days. Visitors came and went hourly, his mother and uncle were there every day, and his sister visited frequently. High school friends, friends from the police force, ex-girlfriends, and a current girlfriend, the one who wanted a long-term commitment (but whom Linda Mains wanted to just go away) shuffled in and out of the SICU. Even Jeffrey's father visited once, but when Mains’ heart rate tripled under the aura of his father's words, his dad was asked to leave. The recovery, if there was to be a recovery, would be very slow.

© 2009 Lippincott Williams & Wilkins, Inc.