Shotgun Trauma: Whodunit?

Receiving a Trauma patient...back in the day.

It was 1991-ish at around 5:30 am when the 'Bat Phone' rang. The phone itself was red with teensy photographs of a gun and knife taped to the handset and it was our hotline to Biotel - a centralized Emergency Dispatch center. in Dallas, Texas. " male, multiple gunshot wounds, Code 1, Priority 4, five minutes out”, cautioned dispatch. This was bad.

A five-minute ‘heads up’ was a blessing.

Our patient arrived alive. Oxygen, fluid resuscitation, blood and diagnostics were all being done simultaneously. He was shot with was not just a simple handgun but, a shotgun. A shotgun typically uses a ‘shell’ and when fired, shoots a number of pellets which is why his abdominal x-rays looked like stars in the night sky - almost too many pellets to count from the multiple shots. His injuries were devastating and he was drifting in and out of consciousness. The ER doc made it clear to me that he would not survive.

Suddenly it seemed as though everyone lost interest in this case except for me and a cop who was left sitting in the corner of the room, making notes. He told me that when our victim left for work that morning, someone was waiting for him, across the street, with a shotgun.

My patient would most likely die soon. I maintained his blood pressure (and consciousness) with blood transfusions and oxygen, while waiting for the surgeons arrival. This was before we had designated Trauma Response Teams, Trauma Centers, Trauma Case Managers and the like. This was how it was done. Hard to believe.

I didn’t know how much longer my patient would remain conscious, so it was critical to me that family be given the opportunity to be with him. I opened the door to 'The Family Room' where it was filled with distraught family members and friends. The doctor had explained the gravity of the situation and they were clearly heartbroken. His parents. siblings and friends came forward to be at his bedside. Recalling the tearful, anguished sobs, followed by prayers of strength and validations of love, it was a powerful moment and told me how much this man meant to everyone. The only person who had not stepped forward was his wife. She, still in her nightgown, wearing pink sponge curlers in her hair and staring blankly overwhelmed by grief.  I asked everyone to leave his room in order to provide the couple privacy. 

She stood beside him with tears streaming down her face. She didn’t speak a word and barely moved. He told her that he loved her. She did not respond. After a few minutes I brought her back out to the waiting room where she was comforted by her friends and family.

My patient died that morning. He was 28.

A few weeks later, while out shopping, I saw a familiar face in the store but just couldn’t place him. So, I approached him and said…”You look so familiar, do we know each other?” He paused for a moment and then said, “You’re the nurse.” I nodded. He said, “I’m the cop.” The cop from my patient's trauma room.  I asked, “So did ya'll find out who did it?”

I was totally unprepared for his response,

“His wife", he said.

A promise of  $500.00 to kill her husband - to be paid when she collected from his Life Insurance policy.

It just affirms the fact that you can't judge someone in our business.

#TheIsolationJournals - Write about when you were dead wrong about somebody

ER 101

In 1983, a doctor that I had worked with suggested I transfer to the Emergency Room at Baylor. I had planned a lengthy tour of Europe and would be gone for a couple of months, so transferring sounded like a good idea. I secured my transfer to the E.R. before leaving for my trip.

When I reported to the E.R. for my first day of duty, I was all bright-eyed and bushy-tailed (so to speak) and didn't get why the E.R. staff weren't exactly thrilled when introduced to me by the nurse educator. I certainly didn't miss the subtle eye roll and yawn when they were told about my (non-ER) nursing experience and I was blown away by the blatant rudeness of a more experienced E.R. nurse when she snapped "get me a real nurse" after I had entered the room where a patient wasn't doing so well.

In the eighties, nursing academics began discussing how ‘nurses eat their young’, a phrase used to describe an epidemic of how many times 'seasoned' nurses would not be kind or helpful to new or young nurses but rather, teach through intimidation, fear and bullying. Believe me, those nurses were most definitely in the ER and gave me a new understanding into the naming of 'nurse sharks'. That being said, without any ER experience, the truth of the matter was that I knew I had to ‘prove’ myself and that I needed them more than they needed me. Fortunately, the practice of 'nurses eating their young' has gone by the wayside. Nurses are generally more supportive and helpful to the newbies.

I accepted the challenge of Emergency Nursing and did my best to present myself as a self confident, skilled and knowledgable nurse and made every effort to befriend even the most bloodthirsty of nurse sharks. Humor helped alot and I learned that when you swim with sharks you'd best not let them see you as bait.

The following are just a few of the new terms and phrases that I had to learn ...

ER Vocabulary

• ABC – Airway, Breathing, Circulation


• Biotel – a central communications center that is staffed with nurses, doctors and paramedics who communicate and advise with various ambulance services. They are also responsible for designating the hospital that receives the patient based upon predetermined criteria.


• Bat Phone – a red telephone in the ER that is a direct line to/from Biotel


• Blunt Trauma – hit with a baseball bat or crunched in a car wreck


• Code - normally a respiratory and/or cardiac arrest but there were many 'codes' used in the hospital. If someone "called a code" it could mean starting or ending CPR


• C-Collar – Cervical Immobilization Collar – neck brace


• DFD – Dallas Fire Department (and ambulance)
  Code 1 – lights only Code 4 – lights and sirens
  Priority 1 – easy Priority 4 – see train wreck


• ETOH – Blood Alcohol or just alcohol as in “ETOH abuser”


• FB – Foreign Body


• GCS – Glasgow Coma Scale


• Gomerade – 1 liter of Normal Saline with Multivitamin, Folic Acid and Vit B12 added – used for ETOH abusers (gomers) - Now the term is "Banana Bag" - much more politically correct.


• GSW – Gun shot wound


• LP – lumbar puncture (spinal tap)


• LOC – Level of Consciousness


• LOL/LOM – Little old lady/man


• MVA – Motor vehicle accident


• MVC – Motor vehicle collision/crash … around 1995 MVA was changed to MVC. According to the Board of Trauma Surgeons “There are no accidents. Every crash is preventable.”


• MCA/MCC – Motor Cycle Accident/Crash


• POPTA – passed out prior to arrival


• Pit – the ER


• PTA - Prior to arrival


• Penetrating Trauma – stab wound, projectile wound, gun shot wound, puncture wound etc.


• Ruptured triple A – see train wreck (ruptured abdominal aortic aneurysm)


• Ruptured ectopic – see train wreck (ruptured pregnancy gestating in a fallopian tube)


• SW – Stab Wound


• Thumper - A mechanism used to deliver chest compressions to a patient in cardiac arrest


• Train wreck – any really bad trauma or pt in really bad condition.


• Tox Screen – Blood or urine specimen to determine presence of opiates, amphetamines, cannabis etc.  

Knife & Gun Club - Part 1

"The Knife and Gun Club" - Part 1

Circa 1990, I was an ER Nurse at a hospital situated in a (less than) desirable neighborhood of Dallas, Texas across the street from an apartment complex referred to “The Projects” - a government assisted  apartment complex for the very poor where many occupants were armed to the teeth. See ER 101

Consequently, walk-in or dump-off trauma was commonplace. The ER Team was expert in managing 'penetrating' trauma as Gun Shot Wound's (GSW) and Stab Wounds (SW) were fairly routine.

The majority of our patients originated from The Projects but an additional source of blood and guts was from 'The It'll Do' nightclub located about three blocks away from the ER and notorious for late night stabbings.

The “Knife and Gun Club” would kick off on Thursday nights (payday) around ‘closing time’ (2 am) and continue until Sunday evening. Most of the victims were drunk or stoned, poor and under-educated.  I was told a long time ago that the ‘club’ name began by way of the differentiating members. The weapon of choice and modality of maiming and/or killing were determining factors on whether or not you were a member of the ‘knife club’ or the ‘gun club’. Divided by nationality, American citizens could legally purchase a gun to shoot one another. Undocumented aliens, were unable to legally purchase guns, so knives were the preferred mechanism of assault. Who knows?

It took me years to learn how to create strong boundaries between the patient and myself without losing my sense of compassion for them. After all, many of our ER clients were not the nicest of people.

The secret was to view their reality separately from mine and treat them as I would want my own brother or sister to be treated. It was the healthiest way for me to deal with some of the most horrific people and witness some of the most disfiguring trauma. But it took some time to get there as they don’t teach you this stuff in nursing school.

It was just after midnight on a Friday and “The Knife and Gun Club” was running full tilt. The ‘Bat Phone’ rang and we were told to prepare for an unconscious, hypotensive male with multiple GSW’s to chest and abdomen.

Within minutes, the patient arrived by DFD. An African American male, wearing a African print “doo-rag” and jeans, he was bloody and appeared lifeless. I could tell just by the look of him that he was a gangster.

Next:Knife & Gun Club - Part 2 

"The Knife and Gun Club" - Part 2

(See Knife & Gun Club - Part 1)

Trauma One was stocked with everything needed for a rapid trauma resuscitation … including a machine to transfuse massive amounts of blood and fluids within minutes, a chest ‘cracking’ tray (used for - just what you would think), an abundance of sterile tubes, needles and catheters used for placement in patient’s heads, hearts, chests and nether-regions. Trauma is brutal, no doubt about it and many times, invasive procedures are performed without anesthesia. The life-saving procedure itself trumps pain management. Thankfully, most trauma patients tend not to have memory of their ER experience and that I believe to be and example of God’s grace.

The trauma team converged on this guy. Multiple gunshot wounds to the chest, abdomen and legs. Doctors, nurses and techs all had, literally, a piece of him. Within sixteen minutes of his arrival to our ER, he was stripped, assessed, monitored, had two tubes that were as big around as some garden hoses inserted into each side of his chest with 'auto-transfusers' attached. Auto-transfusers collect blood coming out of his chest into special sterile, filtered containers so that when they fill, his own blood can be transfused back into him. A foley catheter, multiple IV’s, arterial blood, and other diagnostic blood and urine samples were sent, a quick chest xray and before I knew it, he was out the door (OTD) and en route to the O.R. Although central pulses (groin and neck) were present, at no time were we able to find a peripheral pulse (arms) or get a blood pressure.

What happened to me during those sixteen minutes were the strangest that I have ever experienced with any patient in this shape. It didn’t (and still doesn’t) make sense.

As I was preparing to start my gangsta’s IV, I looked at his face. It's a reflex to warn someone that you're about to shove something sharp into them. Normally, when a trauma patient is so profoundly in shock, they are unable to make eye contact with you but this trauma patient did. “What’s your name?” I asked, not expecting a response. His affect was serene and peaceful. His reply, calm and almost musical, “Michael” he said.

I looked up at a tech who shrugged his shoulders and raised an eyebrow as if to say “go figure”. I then recited a fairly standard statement that I would usually give to frightened, less critical, alert trauma patients…”Michael, I want you to know that we are here to help you, you're in the hospital and you will be feeling better soon. Don’t be afraid OK?”

Much to my surprise, Michael looked straight at me – all the while being poked and prodded (remember the chest tubes?) by strangers and said “What’s your name?” This was a first. I told him my name was Joan. “Joan.., Joan.., Joan” he said slowly. Then he actually smiled and said, “I know where I am and I know where I’m going. I’m OK. I’m not afraid.” I asked him if he was in pain and he said he was not. Knowing that he may not survive, I asked him if we could call anyone for him. He smiled again and said “Cameron, tell Cameron.” I asked for Cameron’s phone number and unbelievably he gave it to me. I had the ER tech write it down.

Michael made it to the OR but died 'on the table'. Should I call his family? Do I call Cameron? Do I really want to get involved with a 'gangster's paradise', so to speak?

Next: Knife & Gun Club - Part 3 

Snakebite

It was in the early 90's and I was an ER nurse at Sunnybrook Health Sciences Center in Toronto, Canada.

Sitting at Triage early one Sunday morning, my mind dulled by inadequate sleep the night before, I was interrupted by a young man of the ‘skin-head persuasion’ who was in a panic. “Ya gotta help me!” he shouted. “I've been bitten by a Black Naja Cobra" He showed me his very swollen finger. A red bandana was tightly wrapped around his wrist as a tourniquet. I didn’t know a lot about snake bites back then and had no idea of what a "Black Naja Cobra" was, but I did know that if the bitten area has a gross local reaction, and the snake was called a "cobra" - you've got yourself a big problem.

As I was taking him back into the ER, I learned that ‘Randy’ raised “Black Naja Cobras” as pets and he was "helping" one of them to "him shed his skin" when he was bitten. He didn't happen to have any anti-venom as he procured these snakes illegally from Africa and the seller did not supply him with any. “You know how it is”, he said. I didn’t. I'm no snake expert but I would think snake-lovers everywhere should have some basic rules like Rule #1 - Do not help a venomous snake shed its skin - they 've being doing it for centuries alone. Rule #2 - If you own venomous snakes, and if you must help them shed their skin - have anti-venom available.

Supportive treatment was initiated including oxygen and IV Fluids. When I got the ER doc’s attention, orders for tons of blood work spewed - chemistry, hematology, clotting panels, bleeding studies and ABG’s. Black Naja Cobra…was its venom neurotoxic, hemotoxic, cardiotoxic or what?

At the time, our doctor could choose from text, microfiche or expert resources. He called The Metropolitan Toronto Zoo and knowing that the chances were slim anybody who knew anything about anything would be at the zoo on a Sunday morning, he explained the situation then asked the zoo operator to get a hold of the person in charge of exotic snakes. Within a few minutes, the 'snake person' called back and following a brief conversation, the appropriate anti-venom was secured and The Metro Toronto Police were alerted to deliver it to us.

I got pulled from Triage.

Randy’s blood work had come back and we found out that his pet's venom had a profound anticoagulant effect. His clotting mechanisms were failing rapidly.

When the anti-venom arrived, the ER doc turned to me and casually said, “OK, Joan, go for it." Trying to disguise the 'edge' in my response to that ridiculous statement, I said"How?"

Clueless on how to administer this stuff, we found the directions in the box.

Anti-venom or ‘anti-venin’, (as it was labeled on the packaging) was to be administered via IV drip and based on kilograms of body weight. The anti-venom was derived from various species of cobra. I clearly remember myself and another nurse having to draw up at least ten vials or so and mix them in 500 ml of NS. A skin test was to be performed first in order to check for a possible allergic reaction. “And if he's allergic...then what?’ I asked. The doc ordered steroids and benadryl and told me to skip the skin test as we would have to wait an additional twenty minutes for results to be read accurately. I began the drip. The anti-venom would infuse over thirty minutes and then repeat blood work would be collected.

The response to the anti-venom was truly remarkable. By the time the infusion was completed, Randy’s post anti-venom blood work had improved significantly and within a few hours, it had returned to normal limits. Unfortunately, his finger had become blackened and necrotic. I learned later that week that Randy had lost his hand secondary to gangrene. Plastic surgeons said that the tourniquet he had applied to his arm might possibly have slowed the transport of the venom but that it caused pooling of it in his arm and worsened the tissue damage.

That same day, as I was wheeling him out of the ER, Randy was repositioning himself on stretcher and that’s when I saw the back of his head. Although at first glance, his head appeared clean-shaven, it wasn’t until he sat up that I noticed the hair on the back of his head was shaped in the form of a cobra’s head.

Nice.