Working the trauma service can be feast or famine.\u00a0 Gunshot wounds, stabbings, auto accidents; their arrival at the hospital is sporadic and unpredictable.\u00a0 The ambulances are either coming so fast, dropping the latest shattered body off; or you are insufferably bored.\u00a0 Sometimes it depends on the day of the week, the time of day, the season of the year.\u00a0 We joke it depends on the phase of the moon.\u00a0 It is odd depending on random acts of violence somewhere in the city for something to do.\u00a0 But, it\u2019s just the way the trauma service works.\u00a0 You go about other routine tasks and wait for human disaster to arrive on your doorstep.\u00a0 There is a lot of disaster here.<\/p>\n

St. Louis, Missouri.\u00a0 It can be a dangerous city, depending on what part you are in.\u00a0 It is one of those middle American cities with a poor underclass.\u00a0 Detroit, Chicago, Memphis, they all have it.\u00a0 Lack of productive outlets and the innate human urge to \u201cmake something of one\u2019s-self\u201d lead young black men into the drug trade.\u00a0 With drugs comes guns and violence.\u00a0 Short of warfare, this is the most violent activity humans engage in.\u00a0 St. Louis is a little different from other cities I am familiar with.\u00a0 St. Louis also has East St. Louis.\u00a0 It\u2019s actually a different municipality across the Mississippi river in Illinois; but it\u2019s close enough and culturally similar enough to be thought of as belonging to the greater St. Louis area.\u00a0 East St. Louis has no police force.\u00a0 Enough corruption in city hall and a couple of big-time legal settlements against the city drove East St. Louis into bankruptcy.\u00a0 They had to sell city hall to settle one of the judgments.\u00a0 No city government means no police force.\u00a0 The state patrol cruises the highways but they never enter the city.\u00a0 Not their problem.\u00a0 Without a police force, what was already a crime filled enclave quickly turns into something like Dante\u2019s Inferno.\u00a0 Prostitution, murder, muggings are all out on open display.\u00a0 Day or night.\u00a0 Without knowing your way around, you take your life into your own hands just by strolling through downtown.\u00a0 The liquor stores, of which there are many, function like bank vaults.\u00a0 Instead of picking your selection off the shelf and taking it to the cashier, you go to a guy behind bullet proof glass and tell him what you want.\u00a0 He fetches it off the shelf behind him and gives it to you through one of those little one-way rolly drawers built into the counter.\u00a0\u00a0 But not before you give him your money.\u00a0 I tell this to people from other parts of the country and they don\u2019t believe me.\u00a0 That there is a lawless, frontier-Western-like city in the US, akin to Mogadishu, is disturbing news.\u00a0 The most unbelieving are from the country club set.<\/p>\n

The best trauma comes from East St. Louis.\u00a0 By \u201cbest\u201d I mean the worst.\u00a0 When the drug dealers and\/or gang-bangers shoot they mean to kill, not merely to wound or intimidate.\u00a0 That means a shot or multiple shots to the head and shots to the chest aimed at the heart.\u00a0 Depending on the level of the drug deal, the weapons used can be pretty sophisticated; customized assault weapons, basically.\u00a0 Tricked out Glock 19s, Bren Tens, Uzis, you name it.\u00a0 If there is a gang related shooting and the shooting victim manages to make it to the hospital alive and we are at all successful at keeping the guy alive, the fact the victim isn\u2019t quite dead makes it back to the rival gang responsible for the shooting.\u00a0 The gangs scan the newspapers for the name of the shooting victim to make sure they got their man.\u00a0 If we do our jobs well and the victim lives, the rival gang cruises the hospital looking for the victim to finish the job.\u00a0 Roving bands of young black men in the hospital is a sure sign there was a recent gang related shooting.\u00a0\u00a0 And they aren\u2019t there to deliver flowers.\u00a0 To combat this, the trauma service assigns an alphanumeric designation to the victim and we use that rather than the victim\u2019s name.\u00a0 Golf one, foxtrot twelve, etc.\u00a0 The doctors use it, the nurses.\u00a0 It\u2019s on the hospital chart and lab slips.\u00a0 We hide the patient in plain sight.\u00a0 Getting your patient shot again while he is in the hospital is not considered good form.\u00a0 I am, of course, describing life in an inner city teaching hospital.\u00a0 This shit doesn\u2019t happen out in the suburbs.<\/p>\n

Over time, a weird sort of ecology develops between the gangs and the hospital. \u00a0Enough gang members get shot and go to the hospital for the results of the shooting and subsequent medical care to make an impact back in the neighborhood.\u00a0 Some victims make it back and some don\u2019t.\u00a0 The \u201csome don\u2019t make it back\u201d part is obvious.\u00a0 They\u2019re dead.\u00a0 The ones that do come back is a different story.\u00a0 With the use of high powered weapons, enough damage is inflicted on the internal organs; no amount of modern, high tech medical care can return what was a previously healthy young man back to what medical people describe as \u201cfunctional\u201d.\u00a0 In other words, the ones that do make it back are sometimes too mangled, never to fully recover, or are in some state of intermediate medical care and don\u2019t quite act or look like they used to.\u00a0 This results in a bizarre combination of positive and negative feedback to the hospital.\u00a0\u00a0 New shooting victims come to the hospital making specific requests about how we deal with their trauma.\u00a0 The new victim has seen this enough times, to know what to ask for.\u00a0 They do it like ordering off a Chinese menu; one from column A and two from column B, but nothing from column C.\u00a0 The most frequent \u201cnothing from column C\u201d request is:\u00a0 \u201cNot the bag doc, anything but the bag\u201d; the bag in question being an ostomy bag.<\/p>\n

A bullet wound or stabbing to the abdomen often results in damage to the intestine.\u00a0 To repair the damage, the intestinal contents have to be re-routed to a surgically created opening in the abdominal wall called an ostomy.\u00a0 The ostomy, in effect, becomes the patient\u2019s new anus.\u00a0 The intestinal contents are collected in a bag the patient periodically has to empty when it becomes full.\u00a0 The diversion of intestinal contents can sometimes be reversed when the patient heals.\u00a0 Sometimes not.\u00a0 Going back to the neighborhood with \u201cthe bag\u201d can be problematic; especially when it comes to getting women.\u00a0 Having feces dangling at your side is a tough way to score points.<\/p>\n

Medical people who see this day in and day out over months or years become emotionally immune to it.\u00a0 It\u2019s just part of the job, we tell ourselves. The emotional immunity allows us to function and do the work.\u00a0 Every once in awhile something comes in that is just so awful, it sticks with you for a time.\u00a0 For me these are the botched suicides.\u00a0 Some teenage girl making a half hearted appeal for help by abrading her wrists with a butter knife isn\u2019t it.\u00a0 It is the truly despondent, desperate people taking a gun to their head and missing.\u00a0 The worst messes are made with shotguns.\u00a0 \u00a0Shotguns are meant to take a duck or a goose out of the air at 100 feet.\u00a0 At close range, or as is frequently the case in suicides, directly at the end of the barrel, the blast of shot acts with terrific force, shearing flesh and bone away in large chunks.\u00a0 Applied in the correct fashion through the brain, this leads to instant death.\u00a0 Incorrectly applied, it leads to shearing away a part of the scalp and skull and maybe a part of the brain.\u00a0 Or taking the entire face off.\u00a0 One fellow of recent memory did just that.\u00a0 He put the barrel of the gun under his chin rather than in his mouth.\u00a0 The blast was angled such that it took his lower face off; his lower jaw, part of his upper jaw, his tongue, his nose, part of the soft tissues of his throat.\u00a0 He had one big hole where his face used to be.\u00a0 His eyes, ears and brain, however, were intact.\u00a0 After the initial shock wore off, he was fully aware of what he had done to himself.\u00a0 He couldn\u2019t speak, of course, but he made it clear he wanted to be put back together.\u00a0 It was a given we would do that.\u00a0 We are doctors and that\u2019s what we do; if the insurance companies let us.\u00a0 My boss on the trauma service spent hours on the phone with the man\u2019s insurance company, dickering over dumbass things like whether we could get a psychiatric consult.\u00a0 The company\u2019s point was \u201cOf course he\u2019s depressed.\u00a0\u00a0 You don\u2019t need a psychiatrist to tell you that.\u201d\u00a0 \u201cYes, but\u2026 we would like to know if he is likely to make another attempt at killing himself before the plastic surgeons spend $200,000 and several hundred man-hours constructing him a new face.\u201d<\/p>\n

There are, of course, some parts of the brain that are more \u201cnecessary\u201d than others.\u00a0 Victims of botched suicides sometimes get into the brain with their bullets, but this is no guarantee of death.\u00a0 The frontal lobes are, in this regard, somewhat expendable.\u00a0 If, say, a person puts the barrel of a handgun in the mouth and the angle of travel for the bullet is, straight up, the bullet passes through the frontal lobes and only the frontal lobes.\u00a0 This results in the unintended frontal lobotomy but not death.\u00a0 To get at death with certainty, the bullet has to pass through the mid-brain or brain stem, neither of which you can live without.\u00a0 They are where the vital functions live, like breathing and making your heart beat correctly.<\/p>\n

If there is some grace to come out of such situations, it is the spouse that refuses to desert the despondent victim when they have every reason to flee their mate in horror.\u00a0 It brings me close to tears to see this. \u00a0Topics like this are difficult to talk about with lay people. \u00a0Doctors and nurses talk about it all the time amongst ourselves but try not to scare the larger public with it.\u00a0 It doesn\u2019t really go over so well at cocktail parties.\u00a0 Too, the emotional and psychological damage for the victims of trauma and their families can produce as raw a wound as any inflicted on the body.\u00a0 It is a separate type of anguish from physical pain and requires a different sort of healing.\u00a0 I\u2019ve never been much of a church-goer, but one thing that has impressed me over the years is the ability of spirituality to at least make a start into the emotional healing that necessarily must accompany the physical.\u00a0 Religion does indeed have a verifiable way to deal with grief at an emotional level.\u00a0 And what I mean by \u201cdeal with\u201d is offering the victims of acts of violence whose bodies have been torn apart never to be put back the same, some comfort, some consolation, some kind of emotional resurrection.\u00a0 \u201cThat God so loved the world, He gave his only son\u2026\u201d is an idea the mind can grasp and cling to when there isn\u2019t anything else. It certainly isn\u2019t for everyone, but when it does take hold, I have been much impressed by religions\u2019 ability to touch people in this sort of need.\u00a0 It offers insight into the meaning of suffering and how to deal with it.\u00a0 That some people find religious insight helpful to them in the midst of pain has been as much of an education for me as anything I ever learned in medical training about stopping the bleeding caused by bullets.<\/p>\n","protected":false},"excerpt":{"rendered":"

Working the trauma service can be feast or famine.\u00a0 Gunshot wounds, stabbings, auto accidents; their arrival at the hospital is sporadic and unpredictable.\u00a0 The ambulances are either coming so fast, dropping the latest shattered body off; or you are insufferably bored.\u00a0 Sometimes it depends on the day of the week, the time of day, the season of the year.\u00a0 We joke it depends on the phase of the moon.\u00a0 It is odd depending on random…… <\/p>\n