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“We should have known he was dying,” my Attending said to me with a somber look on her face. “These young guys always fight you when they are getting ready to die,” and that’s exactly what Rodney did-he fought us. One minute the picture of perfect health, the next, gone-his only memory the steady beep of a heart monitor, a trail of blood leaving the trauma bay. Rodney died in the operating room.

“We can’t get him controlled,” the trauma nurse yelled as the young man, bucked, and sat upright on the gurney…” “What is his blood pressure?” I screamed, “It is stable in the 120s,” my surgical counter- part replied. Two nurses had to lie across him just to keep him still. He continued to buck, trying to sit up…”Rodney it’s OK, you are in the Emergency Room, you have been shot in the arm,” I tried to call him down. The paramedics had just called us 15 minutes ago-“a single gun-shot wound to the left upper arm, no other injuries, his vital signs are stable, we are working on an IV, we’ll be there in 5 minutes…”

It was my day to manage the trauma victims who arrived at the Emergency Department. I was going to treat Rodney with the same level of suspicion, and caution as I would any other trauma patient who comes into the Department: “Trauma patients are all guilty until proven innocent from an injury standpoint,” one of my mentors, and a great trauma surgeon, had once told me. Rodney was no exception.

When he arrived to the trauma bay, his left arm was covered in blood. He immediately was consumed by the trauma staff: taking his clothes off, working on IVs, getting warm blankets. We ensured that his airway was patent…”Rodney, I’m Doctor Donahue, do you know where you are right now?” “I’m at the hospital,” he replied in a calm, strong, yet frightened voice.” Next I turned to his breathing, I listened to his lungs-his right lung sounded muffled, but he was still moving air…”his breath sounds are diminished on the right, “ I yelled, “ can we get a chest x-ray now, and prep for a chest tube…” I could not piece it together, he had been shot in the left arm, apparently no other wounds. He had strong, fast pulse in all limbs, and he had a great blood pressure, but he was becoming increasingly more agitated. “Let’s make sure we have IV access on him,” I yelled.

“Where in the hell am I-let me go! LET ME GO!!” He swung wildly at one of the nurses. It had been just one minute; Rodney was changing in front of our eyes. He seemed almost like a caged animal. Was he on drugs? Did he have a head injury we did not know of? What was he trying to tell us? “Let’s quickly look for any other injuries I yelled.” My surgery colleague and I quickly assessed for any other wounds… only one wound to the left upper arm. I listened to his lungs again-this time I could not hear anything on his right side. The surgery Resident immediately prepped Rodney’s right chest for placement of a chest tube to evacuate any blood, or air which may have collapsed his lung. It was taking three nurses to hold him down-something was seriously wrong.

“Is that his pulse,” I asked in disbelief. His heart rate was now in the 30s…it had been 120 not fifteen seconds ago…”What is his blood pressure?” The trauma surgeon screamed….”we don’t have one,” a nurse replied. Rodney had stopped fighting us. “We need to open his chest,” the Trauma Surgeon commanded, “get me the thoracotomy tray!” In an instant the Surgery Resident had inserted a chest tube in Rodney’s right lung, and I assisted the Trauma Surgeon with the thoracotomy- a procedure to open the chest cavity, and to assess for injuries to the heart, aorta, and other great vessels. Over 2 Liters of blood spilled out from his right lung- mystified as to why Rodney continued to bleed, we struggled to decipher where the bullet had gone?

Once we had his chest cavity open, we discovered his heart was empty, there was no blood inside of the chambers, and it was barely squeezing. It was obvious he had bled a lot. The surgeon clamped the aorta below the heart in order to maintain blood pressure to the heart and brain…blood continued to pour out of his right chest, and from above his heart…”I can’t tell where this is coming from, I just can’t tell…” I can still hear ringing in my ears.

Rodney was whisked away to the Operating Room. He died 10 minutes later. The bullet had entered Rodney’s left chest cavity through his left shoulder, coursed behind his left collar bone, and major arteries on that side-somehow avoiding all major vital structures. It ultimately transected his right Carotid Artery before lodging in the deep muscles of his neck. He was bleeding to death in front of our eyes. In his own way he was telling us he was bleeding to death. I do not think we could have helped him any better. Frustrated and sad are the only words which come to mind. Standing in the trauma bay after he left I felt completely numb. The monitor made the only noise in the room.
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About the Author

The Stanford Emergency Room is the center of emergency care at Stanford University.