The trauma pager buzzed shortly after noon. LEVEL 1 PED, it said—a pedestrian struck by a car. I followed Goldberg to the ER, and she disappeared behind a windowless set of double doors, into the trauma resuscitation area. A few moments later, she emerged and waved me inside.
The trauma area is a rectangular room with three bays, each of which can accommodate two patients side by side when it’s busy. It’s an organized place—there are small trays on wheels for different surgical procedures, each tray holding a particular complement of instruments—but the tubes and cables snaking from poles and machines make it feel a bit chaotic to the untrained eye. The goal of a trauma surgeon is to limit the amount of time that a patient spends in a trauma bay, to stabilize the patient until he can be transferred for a CT scan or to the OR for surgery. The temperature in the room feels about five degrees hotter than in the rest of the hospital. The air doesn’t seem to move.
The pedestrian was awake but silent. This concerned Goldberg because by all rights he should have been screaming in pain. He looked to be in his late 20s. He had black hair and his shirt had been removed. He spoke Spanish. There was a laceration above his right eye and a small amount of blood on the sheets near his head. Goldberg and about 20 other doctors and nurses in blue scrubs clustered around him, checking vital signs, asking questions. Goldberg wore purple latex gloves. She tapped lightly on the patient’s left forearm with one hand. The arm was broken.
“No dolor?” she asked in Spanish. No pain? He shook his head. “Really?” she said. “No?”
Goldberg walked over to another doctor and said, “So are you troubled by the fact that he’s not screaming? He has an arm that’s so freaking broken and he’s not screaming.” She frowned. “I’m troubled by that.”
The patient’s vital signs appeared stable, but Goldberg was worried about internal bleeding. A lack of pain could indicate a hidden injury. He needed a CT scan.
Staff wheeled the patient out of the trauma unit and into a nearby procedure room for the scan. Goldberg took off her latex gloves and threw them in a biohazard trash can. Two police officers had been observing from a distance with pens in hand and notepads open. One of the cops, a large man with a buzzcut, got Goldberg’s attention by saying, “Doc.”
“I’m Goldberg.”
The officer asked what the police should put down in their report for the patient’s condition. She said “critical.” This has been Goldberg’s policy for years, she explained to me as she exited the trauma bay and walked down a hallway toward the CT scanner. “I always make the patients critical until I know they’re fine. It’s a jinx thing.”
Goldberg is superstitious. On days when she’s on call, she shaves her legs. She can’t say why, she just started doing it years ago and now she will not deviate. She’s been wearing the same style of tan Timberlands for 15 years; her current pair, given to her by a colleague when she became chair of surgery, has the Temple logo inked on the heels. She parks her gray BMW in the same spot every time. “It’s so hard to take care of patients without making mistakes that you need every edge.” She recently hired a sports psychologist to talk to the residents about strategies for peak performance. Visualization. Positive self-talk. Breathing. For most of her career, she has stopped at the same Dunkin’ Donuts to order a large coffee with cream and two Sweet’N Lows. A few years ago, the store stopped carrying Sweet’N Low, so she bought a box and left it there; they keep it under the counter for her. “It’s pink,” she told me once. “Sweet’N Low is pink, Equal is blue, Splenda is yellow. And that is how you have to build a good system, believe it or not. So nobody makes a mistake.”
In the hallway next to the ER, she opened a door, and I followed her into a small, darkened room where six young doctors sat at computers. A window looked into the bay next door that held the CT scanner. “Billie Jean” played at low volume from a tinny speaker. Goldberg watched through the window as staff moved the patient from his gurney onto the bed of the machine. He cried out. Goldberg said, “That seems more appropriate.” Now they gave him some pain medicine. She looked at me and winced. “He has a broken humerus. I mean, you can feel it.” She streaked the thumb of her right hand against her fingers. “It’s one of my least favorite injuries. You can feel the bones rubbing together.” The CT scan showed some clotted blood in the patient’s head, appearing on the screen as patches of white. Goldberg ordered some additional scans.
When a shooting comes across the trauma pager, the code is GSW. There were no GSWs that night, only assaults. One patient was an older man who had been beaten up and complained of stomach pain. Another had been stabbed in the abdomen during a fight. His assailant was brought in, too, in handcuffs, a white-haired man in a red T-shirt, his left eye bloodied and swollen shut.
The injuries weren’t life-threatening. Goldberg attended to the patients in the trauma unit. When she wasn’t there, she went on rounds, taking the elevator up to the eighth and ninth floors to check in with patients recovering from earlier traumas. She walked fast from one place to the other and I would lose her sometimes behind corners and doors and she’d have to double back for me. These are busy shifts even when there aren’t a lot of fresh traumas coming in. During a down moment, Goldberg mentioned that she was thinking about scaling back her call schedule now that she’s chair of surgery, with large administrative and educational responsibilities. “I’ve been doing this 30 years,” she said. “Do I need to be on call? Do I need to do Saturdays?”
The pager stayed quiet overnight and through late morning, when Goldberg’s call shift ended. I arranged to return and shadow her again on her next shift, in two days. I left the hospital before lunch. The following morning the trauma pager blew up. LEVEL 1 GSW TO CHEST. LEVEL 1 MULTIPLE GSW TRANSFER FROM EPISC [Episcopal Hospital]. LEVEL 1 SECOND GSW MALE.
GOLDBERG DIDN’T KNOW MUCH ABOUT GUNS OR GUN violence until she got to Temple. She grew up in the quiet Philadelphia suburb of Broomall. Her father owned a dairy business in the city; her mother was a schoolteacher. She was an intense kid who really believed the religious ideas she was learning at Jewish summer camp “in a big, bad way.” When she was 11, she woke up to see a light through her window and feel a tremor underfoot, and she wondered if it was God’s doing.
She went on to study psychology at the University of Pennsylvania and medicine at Mount Sinai in New York. She particularly loved anatomy. “It’s a miracle,” she told me. “The creation of a person, you know. It’s the heart beating and the lungs bringing air. It is so miraculous.” Surgery, for Goldberg, was a way of honoring the miracle. And trauma surgery was the ultimate form of appreciation, because a surgeon in trauma experienced so much variety. She might be operating on the carotid artery in the neck, or the heart in the chest, or the large bowel or small bowel in the abdomen, or the femoral artery in the thigh, at any given moment, on any given night.
In her first or second year of residency at Temple, when she was in her mid-20s, she helped treat a young boy who had been shot in the chest by his sibling who picked up a loaded gun that was lying around. The doctors couldn’t save him. The senselessness made her so angry. Goldberg listened as a senior resident informed the boy’s mother. “I’m sorry,” the resident said, “he has passed.” The mother didn’t react; she didn’t seem to understand what she had just heard. Goldberg spoke up. “He died. We’re so sorry. He died.” It was a lesson: be direct. “You have to find a very compassionate way of being honest,” she said.
She finished her residency in 1992 and decided to stay at Temple, and the feeling of wrongness only intensified. There was a teenage boy in August 1992 who was shot in the heart. His heart stopped beating. Goldberg revived it. He lived. But some weeks later he came in again, with a shooting injury to his brachial artery, in the upper arm. He almost bled out, almost died again, but the surgeons got him back, again. “And then of course the third time he came in, he was shot through the head, and he was dead,” Goldberg said.
She started thinking that Temple sh
ould find a way to intervene—to try to talk to patients while they’re in the hospital so they would never need to come back. But she didn’t have the authority yet. She was just a trauma surgeon, a good one, and getting better. She had good hands and good judgment and a methodical approach to the craft. And as 5 years stretched into 10, and 10 into 20, Goldberg built up a deep well of experience in doing the things that are necessary to save the lives of gun victims, the things that are never shown on TV or in movies, the things that stay hidden behind hospital walls and allow Americans to imagine whatever they like about the effects of bullets or not to imagine anything at all. “You think you know what happens here?” Scott Charles asked me. “Because I thought I knew. But there’s nothing that can prepare you for what bullets do to human bodies. And that’s true for pro-gun people also.”
The main thing people get wrong when they imagine being shot is that they think the bullet itself is the problem. The lump of metal lodged in the body. The action-movie hero is shot in the stomach; he limps to a safe house; he takes off his shirt, removes the bullet with a tweezer, and now he is better. This is not trauma surgery. Trauma surgery is about fixing the damage the bullet causes as it rips through muscle and vessel and organ and bone. The bullet can stay in the body just fine. But the bleeding has to be contained, even if the patient is awake and screaming because a tube has just been pushed into his chest cavity through a deep incision without the aid of general anesthesia (no time; the patient gets an injection of lidocaine). And if the heart has stopped, it must be restarted before the brain dies from a lack of oxygen.
It is not a gentle process. Some of the surgeon’s tools look like things you’d buy at Home Depot. In especially serious cases, 70 times at Temple last year, the surgeons will crack a chest right there in the trauma area. The technical name is a thoracotomy. A patient comes in unconscious, maybe in cardiac arrest, and Goldberg has to get into the cavity to see what is going on. With a scalpel, she makes an incision below the nipple and cuts six to 10 inches down the torso, through skin, through the layer of fatty tissue, through the muscles. Into the opening she inserts a rib spreader, a large metal instrument with a hand crank. It pulls open the ribs and locks them into place so the surgeons can reach the inner organs. Every so often, she may also have to break the patient’s sternum—a bilateral thoracotomy. This is done with a tool called a Lebsche knife. It’s a metal rod with a sharp blade on one end that hooks under the breastbone. Goldberg takes a silver hammer. It looks like—a hammer. She hits the top of the Lebsche knife with the hammer until it cuts through the sternum. “You never forget that sound,” one of the Temple nurses told me. “It’s like a tink, tink, tink. And it sounds like metal, but you know it’s bone. You know like when you see on television, when people are working on the railroad, hammering the ties?”
“It’s just the worst,” Charles told me. “They’re breaking bone. And everybody—every body—has its own kind of quality. And sometimes there’s a big guy you’ll hear, and it’s the echo—the sound that comes out of the room. There’s some times when it doesn’t affect me, and there are some times when it makes my knees shake, when I know what’s going on in there.”
Now the chest is open, and Goldberg can work. If the heart has stopped, she can try to get it beating again. This may involve open cardiac massage—literally holding the heart in her hands and massaging it to get blood flowing up to the brain again. If there’s bleeding in the cavity, she can control it by putting a metal clamp on the heart or on the lung. She can also clamp the aorta, the largest artery in the body, so that instead of the blood going down into the bowels, where it’s needed less, the blood goes up to the brain.
“These crossing bullets are just so challenging,” she said. “Where is the injury? Is it in the chest? Is it in the abdomen? You’re down there, looking, and sometimes you find it, and sometimes you don’t. And sometimes it just really hurts as you work your way through.” She meant that it hurts when patients suffer. Hurts them and hurts her.
There are some gun victims who die quickly, right there in the trauma bay, or soon after being transferred up to the OR. Others develop cascades of life-threatening complications in the following days that surgeons race to manage.
Goldberg said she saw a movie a few years ago that captures what it’s like to operate under these conditions. It was a documentary about the 33 Chilean miners who were trapped underground for months in 2010. “They interviewed them all. And the miner that had the hardest time down there was the youngest guy. Not the oldest guy. It was the youngest guy. And they said, why? Why did you have such a hard time? And he said, God and the Devil were with me.” Goldberg thought that was perfect. “That’s what I had been searching for, for years, in how you feel in the operating room. God and the Devil are with you. You start a case. A young person. Shot. They come in talking. You go upstairs. They have this devastating injury. The Devil. You suck. You’re gonna kill this guy. You call yourself a good trauma surgeon. You’re the worst. And you just plow ahead and plow ahead and plow ahead. You find what’s injured. You control it. God. Oh, you are the best. You’ve done a great job. Then you’re working. You find another injury you didn’t expect. You suck, you suck, you suck.”
It’s possible for a surgeon to get distracted by the wrong wound. The most dangerous wounds don’t always look the worst. People can get shot in the head and they’re leaking bits of brain from a hole in the skull and that’s not the fatal wound; the fatal wound is from another bullet that ripped through the chest. One patient a few years ago was shot in the face with a shotgun at close range over some money owed. He pulled his coat up over his mangled face and walked to the ER of one of Temple’s sister hospitals, approaching a nurse. She looked at him. He lowered the coat. The nurse thought to herself what you might expect a person to think in such a situation: Daaaaaamn. He was stabilized, then transferred to Temple. He lived.
The price of survival is often lasting disability. Some patients, often young guys, wind up carrying around colostomy bags for the rest of their lives because they can’t poop normally anymore. They poop through a “stoma,” a hole in the abdomen. “They’re so angry,” Goldberg said. “They should be angry.” Some are paralyzed by bullets that sever the spinal column. Some lose limbs entirely. During trauma surgery, when the blood flow is redirected to the brain and heart by an aortic clamp, blood goes away from other areas, and tissue in the lower extremities can die, causing gangrene, in which case surgeons must amputate the leg at higher and higher points, first at the shin, then at the knee, then at the thigh, to stay ahead of the necrotic tissue as it spreads. The femur bone may have to be disarticulated—removed entirely from the socket, and discarded. There was a woman several years ago whose boyfriend shot her in the leg. The bullet clipped the femoral artery and she bled. Goldberg was on call that day. She had to amputate the woman’s legs to save her life. “I’m so haunted by that,” she said.
Eighty percent of people who are shot in Philadelphia survive their injuries. This statistic surprises people when they hear it. They tend to think that when people get shot in the belly or the chest or the face, they die. But the reality is that people get shot and then they are going to survive, because trauma surgeons are going to save them, and that’s when the real suffering begins.
RAFI COLON WAS SHOT ONCE IN THE ABDOMEN WITH A 9mm handgun while defending himself from home invaders in September 2005. The bullet tore through his intestines. Trauma surgeons at Temple had to open his abdomen to repair the injuries, but fistulas developed, holes that wouldn’t heal, and until they healed, the incision couldn’t be closed. He spent the next 11 months in the hospital, immobilized in bed, with an open wound down the front of him that had the circumference of a basketball. It got to the point where it was a normal thing for him to look down and think, Oh, those are my intestines; there they are.
“It became second nature,” he told me recently over lunch at a Panera Bread in the Philly suburbs. “It wasn’t like a gruesome thin
g.” The holes in his intestines leaked stomach acid and burned away the surrounding tissues and skin, leaving less skin available to eventually stretch over the wound and close it. Colon learned to sop up the excess acid from his exposed intestines with gauze pads and later with a machine that sucked the acid through a tube. When his friends came to visit, they had a hard time looking at him. He messed with them once by asking a buddy to get him a Rita’s water ice, Philadelphia’s version of a snow cone. He knew what would happen when he ate it. The water ice was red, the Swedish Fish flavor from that summer, and 30 seconds after he swallowed it, the red water ice came oozing out of the hole in his intestine. His friends bolted.
Over the course of his long recovery, from the fall of 2005 into the spring and summer of 2006, Colon got a feel for the rhythms of the Trauma Service. Lying there in the bed, he occupied himself by counting the number of times each day that trauma codes were announced over the PA system. It seemed like the busiest times were Thursday, Friday, and Saturday nights. He’d ask the doctors, how many yesterday, was it 17? “They’d say, ‘No, 18.’” He could tell when the residents were stressed out by how many Diet Cokes they drank. There were days when the doctors were so busy with fresh traumas that they didn’t make rounds until 7 or 8 at night. “They would say, ‘Yeah, it was a busy day.’ I’d be like, ‘Yeah, I heard.’”
It ultimately took 14 surgeries to repair the damage done by one bullet. Temple’s surgeons stretched his abdominal wall closed with the help of some muscle from another part of his body and an artificial mesh. If you see Colon today, the only way you can tell he was wounded is that he walks with a minor tilt; he calls it “my Keyser Söze limp.”
Unspeakable Acts Page 23
