Unspeakable Acts

by Sarah Weinman

  Goldberg was part of the team of doctors who cared for him. They talked about muscle cars and sports. (She liked the Eagles; his team was the Giants.) He remembers that she was the doctor who would notice when he was feeling despair and let him eat a little something that the nurses wouldn’t necessarily allow, like a small chip of ice, or sometimes a piece of candy. He couldn’t eat normally—he was being fed intravenously—but “the fact that I could get a piece of ice, it was like heaven.”

  She has gotten more sensitive over the years, she said. When you’re a young trauma surgeon, you’re developing skills, like how to put a bowel back together. Her medical training was all about learning to operate, to recognize the kinds of patterns that she now teaches to students and young doctors. I once saw her give a lecture to 11 medical students who had just completed their surgical rotation. Goldberg diagrammed anatomy and formulae on a whiteboard and asked questions about how the students would diagnose various hypothetical patients. But she also asked the students to share their experiences with patients and their feelings about those cases. One student spoke about stitching together the chest of a young shooting victim who had died after surgeons attempted to resuscitate him in the trauma area; the student’s first thought was that he was excited to practice stitching a chest, then he felt guilty for being excited. Another student recalled being surprised when a patient asked for his business card even though he was just a lowly medical student. “Yeah,” Goldberg said. “He trusted you.”

  Often when Goldberg meets a shooting victim, it turns out she once treated a sibling, parent, cousin, or friend. “I’m a family doctor, a little bit, because I’ve been here so long,” she said. One day at the hospital, I saw her go on rounds, meeting with patients in the Surgical Intensive Care Unit (SICU) on the ninth floor. A sign on a bulletin board said WELCOME TO SICU! YOUR HEALING STARTS HERE! The letters were surrounded by gold stars.

  Talking to patients seemed to energize Goldberg. She was alternately lighthearted and serious. The patients were uniformly docile and tired. They were on pain medication that slowed their speech. The first patient, shot in the neck, was a young man accompanied by his girlfriend, who sat next to him on the bed with an expression of concern. “When I was shot, I fell on my face,” he said. The second patient was older. A tube to drain fluids was snaking out of his chest. He held out a trembling left hand and smiled. “A little bit of the shakes,” he said. Goldberg told the man he was scheduled to be released the following Monday. He had been caught in some kind of cross fire. “We will miss you,” Goldberg said, “but there comes a day.”

  “Cut the umbilical cord, huh?” he said, and laughed softly.

  Goldberg descended to the eighth floor to meet with another gun victim. She knocked on his door and said hello in her friendly voice. There were two large men inside the room in T-shirts and shorts. She assumed they were his family, but when she entered, the men rushed over to her and said that the patient was a suspected shooter himself. They were plainclothes cops, guarding him.

  “I don’t want to know,” she said. “It’s better if I don’t know.”

  She went over to the side of the patient’s bed as the cops watched. She said she was Dr. Goldberg and she wanted to explain what was happening and help him if he needed anything.

  He looked young. He seemed afraid. There was an open wound in his chest, a vertical incision from below his nipples to his belly button, rising and falling with his breath. Surgeons had needed to remove one of his kidneys, his spleen, and part of his stomach to repair the damage of the bullet and save his life. After the surgery, the tissue swelled, which happens sometimes, and they couldn’t immediately stitch the incision closed, so they had to leave it open. The edges of the wound were pink and raw.

  Goldberg reached out and held his left hand in her hand while telling him what organs he’d lost.

  “You don’t need your spleen. You do need your kidney,” she said. “But luckily, God gave us two.”

  He nodded slightly. She asked how he was feeling. All he said was, “Pain.”

  Goldberg said they would try to help with that and rubbed her fingers across his hand in a gesture of tenderness.

  THE KEY DISTINCTION FOR GOLDBERG ISN’T INNOCENT or guilty, it’s rational or irrational. Gun violence is irrational; there’s no pattern to it. Police statistics show that shootings decrease in the cold winter months and pick up when the weather warms, but any given trauma shift in the winter can be busy and any shift in the summer perfectly quiet.

  Goldberg has always found the senselessness of violence frustrating, and when she was promoted to chief of trauma 15 years ago, she started thinking about how to engineer some control, to help patients “above and beyond just being a trauma surgeon.” She imagined a comprehensive approach to prevent shootings and keep patients from showing up in a trauma bay in the first place. She knew this would involve talking to people in the community, but she also knew she was a flawed messenger. “Who’s going to listen to this white Jewish girl say that guns in the inner city aren’t good for you? Nobody’s going to listen to me say that. I wouldn’t listen to me.” She went looking for help, and found Scott Charles.

  A big, energetic guy with glasses and a master’s degree in applied positive psychology from the University of Pennsylvania, Charles has been working to reduce youth violence since 1988. When he was growing up in Sacramento, two of his older brothers were shot and his sister committed suicide with a gun, and at 19 one of his best friends was shot and killed. He moved to Philadelphia when his sociologist wife got hired by Penn, and two years later, he joined a nonprofit that designed service-learning projects in public schools. Some of his students from North Philly started collecting the stories of families who had lost children to gun violence, which is how Charles made the connection to Goldberg—Temple had treated one of the victims, Lamont Adams, a 16-year-old from North Philly who was shot and killed in 2004 after a false rumor was spread about him.

  Goldberg hosted a tour for Charles and his students, inviting them into the trauma unit and explaining what gun patients experience there. She was immediately impressed by the way he dealt with the kids. She told him she’d create a new outreach position for him at Temple, that she’d get up “in people’s faces” until she made sure it happened.

  “She said, ‘Don’t go anywhere else,’” Charles recalled. “‘I’m going to write you a check for one year of your salary. If I don’t get this position for you, you can cash the check, it’s yours, and take another job.’ And I was like—this white lady’s crazy. My wife was like, who’s this lady who keeps calling you at eleven o’clock at night? ‘It’s this crazy doctor.’”

  Charles accepted, joining Temple in August 2005, and since then he and Goldberg have developed a suite of ambitious programs in collaboration with other Temple doctors and staff. “The thing that allows us to do so much of this is she carries a big stick,” Charles said. “Who was going to get in her way?”

  There are three programs aimed at preventing violence before it happens. Cradle to Grave is an expansion of that first tour Charles took at Temple. He brings groups of kids and adults into the trauma area and shows them how surgeons save gun patients. He has his own copies of the various surgical instruments for demonstration purposes, removing them from a travel bag: chest tube, rib-spreader, hammer, Lebsche knife. He introduces the visitors to Goldberg if she’s available. He tells the story of Lamont Adams, asking a volunteer to pretend to be Lamont and then placing a circular red sticker on the location of each of Lamont’s 24 bullet wounds (entry and exit). On his chest. His abdomen. His thigh and arms. And most disturbing of all, the two bullet wounds on his hand, a sign that Lamont was trying to shield his face from the bullets at close range.

  Charles also runs the Fighting Chance program, a series of training sessions for community members, where doctors show people in neighborhoods how to give first aid to gunshot victims, to apply tourniquets and stop blood loss in the seconds immediately followi
ng a shooting, before the EMTs or police arrive. Recently, Charles has also become a sort of Johnny Appleseed of gun locks, handing them out to parents who want to keep their children from getting hurt in accidents. He keeps boxes of them at the hospital and distributes the locks with no questions asked. Sometimes he lugs them to subway stations and offers them to commuters.

  That’s prevention. Temple has also created an intervention component, called Turning Point, where shooting victims get extra counseling while they’re still in the hospital. “They come in, they’re very scared,” Goldberg said. “‘Am I gonna die? Where’s my mom?’ Then, as soon as they would recover, they would not be so scared anymore, which maybe wasn’t good.” So if a victim is between 18 and 30 years old, he’s offered a series of supports in addition to the usual visits with Charles and a social worker. Temple asks the patients if they want to talk to a trauma survivor. And they are given an opportunity to view a video of their own trauma-bay resuscitation. (The surgeries in the trauma area are videotaped for quality control.) About half say yes. Charles shows them the video. They get psychological counseling for any PTSD symptoms, as well as case management services to help them get high school diplomas or jobs.

  Turning Point was initially controversial within the hospital. Some doctors thought it was cruel to show patients videos of their own surgeries, especially patients who had done nothing wrong. But Goldberg argued that she wasn’t judging anyone’s past or even asking about it. “The only way I know how to deal with a problem is, let’s break it down. Let’s try to educate,” she said.

  Breaking it down has involved doing science. Goldberg and her team have needed to gather data about questions that have never been rigorously answered, a common situation when it comes to gun violence. For instance, when a paramedic first finds a gun or stabbing victim, nobody knows if it’s better to administer IV fluids and put a tube down the victim’s throat on the spot, or if the medic should simply race the victim to the hospital. Trauma surgeons have long suspected that the latter option is preferable—most shooting victims actually arrive at Temple in the back of police cruisers, a practice the cops call “scoop and run”—but there has never been a long-term randomized study.

  So Temple launched one. It’s called the Philadelphia Immediate Transport in Penetrating Trauma Trial (PIPT), an elaborate undertaking that has involved close coordination with emergency personnel and also dozens of community meetings where doctors explained how the study works (over the next five years, some victims of penetrating trauma will receive immediate transport and some won’t) and how people can opt out of the study (by wearing a special wristband). In that same spirit, Goldberg has been gathering data on the Turning Point program. For years, patients have been randomized into a control group and an experimental group. One group gets typical care and the other gets Turning Point, and then patients in both groups answer a questionnaire that quantifies attitudes toward violence.

  In November the hospital published its first scientific results from Turning Point, based on 80 patients. According to Temple’s data, the Turning Point patients showed “a 50% reduction in aggressive response to shame, a 29% reduction in comfort with aggression, and a 19% reduction in overall proclivity toward violence.” Goldberg told me she was proud of the study, not only because it suggested that the program was effective, but also because it represented a rare victory over the status quo. Turning Point grew out of her experience with that one patient in 1992, the three-time shooting victim who died the third time. It took her that long to get the authority, to gather the data, to get it published, to shift the system a little bit.

  Twenty-four years.

  EACH TIME I WENT TO THE HOSPITAL, I ASKED GOLDBERG what else was going on with her aside from work. She usually talked about running. She likes to run along the Schuylkill River while listening to music and thinking about nothing at all. She competes in a few half marathons a year.

  I never learned much about Goldberg’s personal life. She lives alone in an apartment in Center City. She has a rowing machine there and access to a treadmill in the building’s gym. Her religious faith is still strong—it’s not that she goes around talking about it, she told me, it’s just that she has worked for 30 years in trauma and seen a lot of death, and it’s hard to do that and not feel something about God. I noticed one day she was wearing a white Lokai bracelet, a ring of plastic capsules said to contain mud from the Dead Sea and water from Mount Everest. “The highs and the lows, to stay even-keeled,” she said. “I probably need ten of them, five on each hand.”

  The major nonrunning events in her life tend to be awards ceremonies. She has reached the point in her medical career where people gather and say nice things about her, and there are plates of olives and prosciutto. Her med-school alma mater, Mount Sinai in New York, recently invited her to give a special lecture at Grand Rounds, a hallowed medical tradition. On March 16, Temple threw a party for her “investiture,” a ceremony where she passed from being merely the chair of surgery to being the George S. Peters, MD, and Louise C. Peters Chair of Surgery. Endowed chairs at universities are a big deal. Past colleagues from all over the country came to speak about her qualities. One compared her to Teddy Roosevelt’s famous Man in the Arena, “whose face is marred by dust and sweat and blood . . . who spends himself or herself in a worthy cause.” (“Or herself” is not actually a part of Roosevelt’s quote, but the guy modernized it for Goldberg.) She gave a brief acceptance speech focusing on the importance of teamwork to medical excellence. She said she used to dream about being a sports coach, and now she’s coaching the next generation of surgeons. As she once put it to me, “One of us can’t give perfect care. But together, maybe, we can give perfect care.”

  One of the speakers at the investiture called Goldberg a “realistic idealist,” and when I saw her later, she said she’d been thinking about the phrase. At first it surprised her that people saw her that way, but she realized it captured something true. “When I get angry, and hurt,” she told me, “it’s because I can still be a little naïve.” Even after all this time, the sense of horror she first experienced as a resident treating gun patients has never completely gone away.

  One evening when I was at the hospital, I saw what she meant. Two shooting victims came in, a man and a woman, about two hours apart, and were quickly patched up. The man was shot twice, in a wrist and a thigh—four holes, not life-threatening. The woman was shot once in the thigh with a small entry wound but no exit wound—a stray bullet that struck her while she was walking down the street. In the trauma bay, the surgeons taped a paper clip over the entry wound so they could identify that spot on the X-ray. Goldberg wheeled the monitor over to show me the X-ray image: paper clip and bullet. “Very small,” she said, pointing to the slug, “like a .22.” As so many other patients do, the patient asked the trauma surgeons if they were going to take the bullet out, and the surgeons explained that they fix what the bullet injures; they don’t fix the bullet.

  They left the wound open to prevent infection and put a dressing on it. “We’ll probably send her home tonight,” Goldberg said. “Isn’t that awful?”

  She meant it as a strictly human thing. There’s no medical reason for a patient to be in a hospital longer than necessary. The point was the ridiculousness of the situation. A woman gets shot through no fault of her own, she comes to the hospital scared, and if she’s okay, Goldberg says, “It’s like, here, take a little Band-Aid.” The woman goes home, and for everyone else in the city, it’s as though the shooting never happened. It changes no policy. It motivates no law. In a perverse way, the more efficiently Goldberg does her job inside the hospital, the more invisible gun violence becomes everywhere else.

  Which is why she pours so much of herself into the outreach programs, the scientific studies, and any other method she has of finding control and making the problem visible. Then, as always with Goldberg, she does her call shifts. “We care,” she told me once. “We’re gonna be here. We’re gonna be here.
We’re gonna be here, and then you know what, we’re still gonna be here. And then we’re still here. That kind of thing.”

  The last time I saw Goldberg, I was eating breakfast in the hospital’s basement cafeteria, one corridor away from the morgue, where bodies are kept, pending transport. It was at the end of a relatively quiet overnight call shift in late March. She walked in with a coffee, looking calm and fresh. The forecast showed rising temperatures. The crust of snow on the sidewalks would soon melt, the days would lengthen, people would leave their houses to enjoy the weather. Spring was coming, and the shootings would pick back up.

  Originally published by Highline for HuffPost, April 2017

  Checkpoint Nation

  By Melissa Del Bosque

  Laura Sandoval threaded her way through idling taxis and men selling bottles of water, toward the entrance of the Cordova International Bridge, which links Ciudad Juárez, Mexico, to El Paso, Texas. Earlier that day, a bright Saturday in December 2012, Sandoval had crossed over to Juárez to console a friend whose wife had recently died. She had brought him a few items he had requested—eye drops, the chimichangas from Allsup’s he liked—and now that her care package had been delivered, she was in a hurry to get back to the Texas side, where she’d left her car. She had a three-hour drive to reach home, in the mountains in New Mexico, and she hated driving in the dark.

  Sandoval took her place in the long line of people waiting to have their passports checked by US Customs and Border Protection (CBP). When it was her turn, she handed her American passport to a customs officer and smiled amicably, waiting for him to wave her through. But the officer said she had been randomly selected for additional screening. Sandoval was led to a secondary inspection area nearby, where two more officers patted her down. Another walked toward her with a drug-sniffing dog, which grew agitated as it came closer, barking and then circling her legs. Because the dog had “alerted,” the officer said, Sandoval would now have to undergo another inspection.