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

Gang Night

I was working the 7pm to 7am shift at Baylor’s ER and it was rumored to be “Gang Night” in Dallas. Why Dallas gangs felt the need to show their mettle on a hot & humid night in August was beyond me but….

Was “gang night” for real? We weren’t sure, but the idea of one particular night where opposing gangs from all over Dallas demonstrated their fearlessness and courage by cutting up and shooting one another caught my attention.

So, amidst the usual chaos and cacophony of the ER on a typical Saturday night, we were all on the ‘alert’ for mass casualties to hit the door at any minute.

Around two in the morning, I saw two, tall healthy-looking African American men dressed in hooded, bulky winter jackets enter the ER through our ambulance entrance. Based on their unseasonable dress, I just knew they had to be armed. They looked like they meant business.

Not one for confrontation, I surprised myself when out of nowhere ‘I got up all in their bidness’... “What do you want?” I sternly asked the biggest guy. “My son’s been shot.” He responded. I looked at the other guy who did not appear to be in any distress when he promptly unzipped his jacket and I saw the baby.

The child was about 9 months old. Snatching him, I ran next door into Trauma one. He was barely alive, with a single bullet wound that had entered his right chest and exited out his back.

The ‘story’ was that these two guys were babysitting when they decided to go out for a drive.

The baby was in the back seat of the car when “some mother-f!#*er started shootin’ at us.”

The baby survived. Hopefully his first GSW would be his last but - I kind of doubt it.

Five GSW's

It was about 5 am and the drama had died down in Surgery ER. Most all of our patients were in the OR, the ICU, transferred to an in house bed or were *OTD.

We were pretty well ‘done in’ and several of us had been sitting on stretchers, when the overhead page came from triage… “Surgery... Five *GSW’s on the dock.”

Hopping off our stretchers and steering them towards the front loading dock, we found five, well dressed women wailing in pain and anxiety, who had been shot multiple times and literally dumped at our front door.

Each nurse scooped up a patient and snagged a *PCA, intern and/or medical student. We headed for an available trauma room and got busy.

My patient was agitated and howling so loudly that any attempts to calm her fell on deaf ears. Ours. Her loud and incessant wail was heard throughout Trauma Hall. Calming her was necessary in order to deliver good trauma care and to improve her outcome but it was more important to do what we were trained to do. Oxygen, IV’s, monitoring and diagnostic studies were initiated. Exposing every square inch of her body was necessary to determine any unknown wounds or injuries.

It was at about that time that I learned my hysterical patient was going to be alright. I also learned that ‘she’ was actually ‘he’ and I was surprised to notice how my approach to calming ‘him’ was markedly different than how I attempted to calm ‘her’. Food for thought.

Word travels fast down Trauma Hall and the same discovery was being made at about the same time in each of the five trauma rooms.

Luckily, all five GSW’s were not mortally wounded and would be OK. Unluckily, their wives were on their way to the ER and our patients were getting a little nervous.

__________________________________________________________

*OTD - Out the Door
*GSW - Gun Shot Wound
*PCA - Patient Care Assistant
__________________________________________________________

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 

"The Knife and Gun Club" - Part 3

(See: Knife & Gun Club - Part 2)

As a staff nurse, my responsibility was not to contact family members. We had a clinical coordinator and chaplain to do that sort of thing. So I guess I was off the hook. But I did promise that I would “tell Cameron” and that bothered me.

I asked a couple of other nurses, techs and the ER doc what their opinions were of contacting family 'after the fact'. The general consensus was that I would be NUTS to even consider calling. Decision made. No phone calls to Cameron or any other gangster’s family members. This was a time to reinforce those ‘boundaries’ that I had been working on.

A couple of days later, while reading The Dallas Morning News, a story caught my eye about a young man who had been working the evening shift in Dallas when, on his way home, he became involved in a minor ‘fender-bender’. The cars were pulled over on the Dallas Tollway when a drive-by witness saw a tall, black man get out of his vehicle and walk towards two men who pulled out weapons and started shooting him. The man was a 29 year old named Michael Baxter (not his real name – although I clearly remember what his real name was) he left a wife and son.

The story continued to say that a few days before his death, Michael had spoken with his wife, Anna, and told her he felt that he had done what God wanted him to do in this world. She pleaded with him to talk about these feelings with their pastor and on the morning of his death, he did what she had asked. When he kissed her and their son good-bye on that afternoon, Anna said that she had a bad feeling about him going to work, but kept it to herself.

Michael was not a gangster.
According to his obituary, he was a hard worker and dearly loved by many.

Although, I would feel the tug on occasion to “tell Cameron”, I resisted the urge. I had no business in getting involved at this point. After all, these people had been through enough. What would I say to them anyway? Who was Cameron? A man? A mistress? Far too complex. Let it go.

And then, about six months after Michael died, I had a vivid dream. It was Michael’s voice and he simply stated his first and last name. That was it. I knew I just had to try to get in touch with his wife.

Next: Knife & Gun Club - Part 4