What Trauma Docs Know
At Chicago’s most intense ERs, the degree of mayhem rivals that of a war zone. Working there can take a heavy toll — and yield immense rewards.
Call it a dubious distinction, but Chicago is one of the best places in America to get field experience as a trauma surgeon. The city’s Level 1 trauma centers — hospitals specially equipped to handle the most severe injuries — treat a staggering volume and variety of patients, including, most notably, victims of so-called penetrating trauma, typically gunshot and knife wounds. In Chicago, such cases constitute nearly 30 percent of all Level 1 trauma admissions, compared with 4 percent nationwide. And then there’s the constant stream of those injured in the accidents and oddball misadventures one might expect in a city of three million people.
Chicago talked to a dozen practicing or recently retired trauma surgeons, each affiliated with at least one of the city’s six Level 1–certified hospitals: Advocate Illinois Masonic Medical Center, Northwestern Memorial Hospital, John H. Stroger Jr. Hospital, Mount Sinai Hospital, Ann & Robert H. Lurie Children’s Hospital, and University of Chicago Medicine/Comer Children’s Hospital. Speaking anonymously, these doctors talked candidly about, among other things, what it’s like to operate on a 2-year-old shooting victim, what happens when violence spills into the trauma bay, why you should really wear a motorcycle helmet, and how best to handle a severed limb. The observations and stories below, presented in the doctors’ words, reveal much about our city — and about the fragility and resilience of human life.
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I. “EVEN THE BEST OF US WOULD CALL IT ORGANIZED CHAOS.”
The blood bank only has so much blood, so do you pour it into one patient who has a very minimal chance of surviving, or do you save it for a relatively survivable injury? These are the decisions that weigh on you.
We got a guy who was in the basement of one of the high-rise construction projects downtown. An industrial drill bit—about six feet long—fell from the fourth floor and hit him. It went in the top of his head and came out his cheek. Went through his hardhat and pinned him to the ground. They had to use a welding iron to cut the drill bit, because they couldn’t pull it out of the ground. That probably saved his life, because it heated the rod, and so it stopped bleeding. He actually made a pretty good recovery. He had some ongoing difficulty with word finding and a little weakness in his right arm, and that’s about it. But his brother was standing next to him in the basement when this happened and went into some sort of catatonic state and never came out of it. Two years later, he was still institutionalized. You talk about a visceral reaction to trauma.
At a hot-dog plant in the city, a guy got his arm shredded through the meat grinder. I love hot dogs. I’m a hot-dog connoisseur. But I didn’t eat hot dogs for a month after that.
Your body is plumbing, electricity, and structure. Bones are the structure, electricity is the nerves in your brain, and plumbing is the blood vessels that supply oxygen to your tissues. Broken plumbing is going to kill you first, unless you get shot in the brain. I’m a glorified plumber at the end of the day.
It’s the visually impressive injuries—like the amputations or near-amputations, the people who have been impaled, with objects sticking out of them—that get everybody’s attention, but it’s not always those injuries they’re going to die from. They’re going to die because they don’t have an airway, or because they’re bleeding. You take care of those things first.
If you make it here with a pulse, the chances you’re going to leave alive are about 98 percent.
They put places on lockdown now if they bring in a gang shooting, because they figure there’s going to be some type of retaliation, and part of that retaliation maybe is to try and take out the doctor trying to save the gang member.
There was a gentleman who was in custody. I’m not sure what he did. There were four police officers around him. He was cursing out my nurse—a senior nurse who has been here for 30 years. She can connect with anybody. He was egging her on: “Bitch!” Calling her a motherfucker, everything. But she kept her composure. Later I walked in to get my morning report, and she’s sitting at his bedside holding his hand and they’re talking.
There’s an old saying that there’s the golden hour for trauma: That first hour is the most important for a patient, because that determines whether they live or die. But that was more for, like, blunt trauma—people falling from horses or whatever. Now they’re trying to coin the “platinum 15 minutes.”
The trick in a busy trauma bay is to look at a patient, decide whether he or she is dying in front of you. The way you make that decision is basically trauma poker: You’re looking for the tells that their body, the remarkable machine of the human body, is compensating to keep them alive, or refusing: heart rate, respiratory rate, blood pressure, the color of the skin. The body, if you listen, will tell you what’s going on.
I teach my police officer medical staff tactical medicine, and more liberal use of tourniquets has been a big deal. They save lives. Even if your tourniquet’s on for a longer period of time, it typically will not cause damage. And if it does, it’s life over limb, right?
You don’t want to put a severed limb on ice directly because it can freeze or damage the tissue. You want it in a moist gauze on ice.
Dead for us is called triple zeros: no pulse, no breathing, no blood pressure. We just had a guy come in who was triple zeros. One of my fellows took him in the OR, opened his chest, started internal CPR, squeezing his heart, cross-clamped his aorta to shunt the blood to keep it between his heart and his brain. Basically the iliac vein was torn in half by a bullet. She tied that off, got control of the bleeding, gave him back about 30 units of blood. She resurrected a dead man.
The volume and intensity of cases here, you pretty much don’t see that anywhere else. I have a friend who’s in a surgeon in Hawaii, and she was like, “Oh, I got one person stabbed in the chest in the last three years.”
As much as we try to keep it organized and calm, I think that even the best of us would call it organized chaos.
When I was a resident, someone came in who was shot and died, and the trauma surgeon found an ID card on him. So he got the family’s number from the police, called who he thought was the wife and was like, “Look, I’ve got some really bad news. This happened, that happened.” And the lady’s like, “No it didn’t, because he’s standing next to me.” And the doctor hears her say, “Hey, that jerk who stole your wallet got shot.”
The scope and the scale of what happens in a community when it’s a child who’s injured far surpasses what typically happens when it’s an adult. When a kid comes here, it’s not just the family that shows up. It’s the family and the family friends and the pastor and the school who are all suddenly involved in this trauma.
I tell new residents, “You’re going to see a lot of death here.” And it’s abrupt, which is far from the norm of what you see at most hospitals.
Most patients figure out that we’re here to help them. The ones who don’t: We’re not going to tie them down. If they want to leave, they can leave. If they’re really dying, they’ll be unconscious quickly enough.
There may be a faction or someone at a summer barbecue who doesn’t get along with someone else, and the whole party gets sprayed with bullets. That’s a very common story. The triage system tries to spread it out, but sometimes you may have the entire party—both factions—in your trauma bay. The perpetrator may be a gurney away from the others. When the family shows up, the tension is palpable. Occasionally we have to escort people through the back door.
There’s always a way to de-escalate. If you can’t de-escalate, that’s what drugs are for.
You run into families who say, “You’re not doing everything you can to save them. You just want their organs for somebody else.”
If you really want to make a difference and want to be the most badass trauma surgeon you can be, you would stay in Chicago.
One of the reasons trauma runs such a high risk for malpractice is the fact that the patients were fine 20 minutes before we see them, and then they’re dead. People will want to blame somebody.
Trauma surgeons are all like surgical MacGyvers. No two patients are ever the same, no two injuries are ever the same. This is not like doing a hernia or taking out gallbladders every day.
II. “NOBODY GETS SHOT JUST ONCE ANYMORE.”
We’ve seen some unusual bullets of late. There’s a “RIPeople,” as we’ve started calling it—a Radically Invasive Projectile. It hits and splits off into multiple pieces. They go in different directions so it creates secondary injury.
Younger patients are ridiculously resilient. They can be shot like 20 times, you give them 50 units of blood, and they walk out of the hospital.
Before, it was just the kids in the gangs or whatnot getting shot, but now it’s babies, innocent bystanders. Three weeks ago, we had a blind gentleman who was walking to the pharmacy, got shot in the back, then died. Literally a blind guy going to the pharmacy to get some medication.
Although a 16-year-old looks like an adult, they still want their mommy. Or they’re still afraid of getting an IV. Or they like to watch cartoons or hold their stuffed animal.
We used to see a fair number of shotgun injuries. I can’t remember the last one I saw, which is good. I hate those. You can’t keep track of all the pellets.
I’ve learned how to reconcile a lot of the violence that we see—even the 16-year-olds that die. But when you get a 2-year-old who gets shot by a stray bullet, it’s very hard. It’s still the only thing that emotionally impacts me.
The most common question we get asked is, “Did you take the bullet out?” We don’t take the bullets out. If they’re in our face and we find them, great, but unless they are in certain places like joints, we don’t go looking for bullets. They’re like splinters: They work their way out eventually.
We’ve seen a significant uptick in semiautomatic weapons. Nobody gets shot just once anymore. Everybody is shot four or five times. And when you get shot five times, you have five times the likelihood of hitting something critical.
With the larger magnum types of weapons, we don’t see those victims. Those just go right to the medical examiner.
I’d say twice a month I’ll have some kid come in with an injury to his penis or testicles, his knee, and his big toe. And he’s like, “Some guy shot me.” And I’ll look at him and go, “No, you put the gun down your pants, pulled the trigger accidentally, and shot yourself.”
I don’t necessarily want to take away anybody’s guns. But can we stop shooting one another? That’s what I would like.
There was a child who was brought in because he collapsed on a basketball court. What actually happened is someone shot a gun straight up into the air somewhere, nowhere near him, and the bullet came down on him and killed him.
Sometimes I get this feeling that people might be talking about violence from a cocoon. They’re sort of like, “Oh, I’m so different.” You’re really not. Because we’ve seen the insides of a lot of people, and they’re all the same.
I took a gentleman into the operating room for a gunshot wound, which looked like it was going to be through his aorta. I opened him up, and what I thought was going to be his aorta ended up being his vena cava, because everything was backward in him. Anatomically. He was a genetic anomaly. He was built backward.
Usually there are two holes, an entrance and exit. This one time in the OR, we flip the stomach over to find the exit hole, and all of a sudden, blood just starts welling up. A second wound, an inferior vena cava injury, had been contained, but as soon as we moved the stomach, it just exploded on us. So I stick my thumb in there. I literally couldn’t move my thumb for 30 minutes.
We had someone shot multiple times. We gave him like 30 units of blood the first 24 hours. He had what’s called a retrohepatic IVC injury. It’s the big vein that goes to the heart. And when it’s behind the liver, it’s pretty much impossible to get control of the bleeding because you can’t move anything, so they essentially bleed to death and go into multiorgan failure. I didn’t leave that night. We just kept on giving him blood, and after 48 hours I’m like, “Oh my God, I think he’s going to make it.” And then he died. I remember talking to his family, and they’re crying, and I felt like crying with them.
III. “STUPID HUMAN TRICKS.”
July 4 is a busy night. St. Paddy’s Day. Cinco de Mayo. Those are the days you come to work and kind of brace for the worst. If you haven’t eaten dinner by 8 o’clock, you can probably forget it.
On the first snowy day, people forget how to drive.
We call a car accident a “crash and injury,” because a large majority of what we see is preventable. We haven’t called them “accidents” since the ’90s.
Any holiday where everyone’s out drinking, having fun, it’s just a matter of time, 12 hours or so, before people start getting shot, people start falling, people start drunk-driving.
We had a significant uptick in injuries during the whole Cubs championship season. I saw people sitting on a third-floor window ledge drinking beer. I saw people on all types of industrial equipment at a construction site across from Wrigley Field. I took pictures, sent them to the person on call, and said, “Here are your next trauma patients.”
When you get a bunch of people together and mix it with alcohol, you’re going to see interpersonal type injuries—or what I like to call “stupid human tricks.”
I remember one case with a homemade firework made out of PVC pipe. What did they expect? PVC isn’t strong enough to hold the explosive. It just blew apart, with molten pieces of plastic embedded in the patient.
Any day that’s a big day at the bar is a big day at the trauma center.
We’re a more bicycle-friendly city than we used to be. But being bicycle friendly has significantly increased the number of bicycle crashes that we see.
Two pieces of advice for cyclists: One, beware the car door. The other is: helmet, helmet, helmet! Eighty-five percent of fatal crash victims weren’t wearing a helmet.
People falling off the L platform and getting electrocuted on the tracks: That’s almost guaranteed during Lollapalooza.
Everybody says, “It’s going to be 80 degrees today! Beautiful!” And we know it’s going to be hell here.
Back when all that divided the northbound and southbound Lake Shore Drive was two yellow lines, we used to get six to 10 devastating head-on collisions every year.
On a regular basis, we have inmates at the county jail throwing themselves off the decks or eating bolts and screws so that they can get a trip to the hospital. Usually there’s a reason behind it: They want a visitation, or they want the contraband they can get at a hospital, or there’s a big game on television, or because it’s just a bit more of a comfortable place.
Trauma surgeons are grateful for bad weather.
Back in the Michael Jordan era, every time they won the championship there was brutal violence citywide. Now when the Hawks won their Stanley Cups, there was a lot of partying but very little injury.
You get “frequent fliers.” Someone comes in, they’ve fallen from drinking, they have a head bleed, you send them to rehab, and literally six months later they come back and you’re like, “I know this person. I know the scar on their head.”
I have always maintained that there should be a mandatory organ donation card for motorcyclists.
Someone not wearing a motorcycle helmet, they literally come in with brain matter coming out of their skull. Just totally smashed like an egg. Someone wearing a helmet: The helmet’s broken, they might have a little bit of bleeding in the brain, but they’re OK.
During a Bears game, things are sort of quiet. Then the game ends, and it picks up.
The average age of admission to a trauma center is about 22. It used to be 90 percent male. Now, it’s only like 84 percent male. Women are becoming as stupid as men.
IV. “WE DID EVERYTHING WE COULD.”
The one thing that always haunts you is when they come in and say, “Don’t let me die.”
If they start talking about how they have children and they need to live to raise them, that’s bad, because those are things that can really get to your emotions. And if it gets to your emotions, it may affect your decision-making.
It’s hard to tell someone their kid is dead, and I do that almost every time I’m on call.
The older I am in my career, the more affected I am by people dying, which I think should be the opposite.
It’s easy to become hardened. It’s very easy to treat people with disrespect, even unknowingly. So the test that I demand of residents is, “Would you treat your mother like this?”
Most of the female trauma surgeons I know in Chicago don’t have kids. Some people can have it all. Personally, I can’t. I have a cat and I have a husband.
You just go in and as quietly and compassionately as possible say, “I’m very sorry, but your loved one has just died.” You actually say “died,” you don’t say “passed.” And you leave it at that.
A surgeon isn’t the end-all, be-all. You can be wrong. You can make mistakes. The most important thing is, if you make a mistake, you have the humility to recognize it and just fix it.
Even if they’re getting shot or in gangs, they’re grateful to us, I’d say, 95 percent of the time.
The first time I ever told a patient’s family the patient died, when I was a second-year resident, I literally got knocked unconscious. It was a 16- or 17-year-old kid who got hit by a fire engine while riding a bike. When I went out and told the family, I had the mother in front of me, and I had the brother over here, and I had a friend of the patient over on the other side. The mother and son started to hug each other, crying. I wasn’t paying attention to this other guy. He just wound up and hit me. Just punched me in the face and knocked me out cold.
Every year I get a text on Thanksgiving from one of the big gang leaders in Chicago. He says, “Doc, thank you. I wouldn’t be here without you.” He’s been shot twice since the first time I took care of him.
Whether they were or weren’t in a gang should have no bearing on how I care for a patient’s injuries.
I think a lot of us, if not all of us, rarely will approach a family in an acute situation without somebody else in the room and without being very mindful of where to exit in a hurry.
A shaken baby comes in, and “Who did it?” is the question that everybody wants to have answered. As a medical professional, I don’t care. It doesn’t matter to me.
People react differently. I had somebody throw a chair at the picture on the wall in the quiet room. He was just whaling on it. It didn’t even crack. Until that time, I didn’t know it was plastic and not glass.
The amount of post-traumatic stress syndrome in trauma surgeons is underrecognized. It’s something we don’t talk about.
I had this one guy. It was pedestrian versus auto. He came in, and his eyes are fixed and dilated, he has no blood pressure, he’s bleeding from every orifice, he broke his arms and legs, he broke his pelvis, he had injury to his intestine. We take him to surgery, I give him an ostomy, we pack him for bleeding, I give him like six units of blood in the first 24 hours. I’d normally do 24-hour shifts, but I stay there 30, because I just keep on pushing blood. So then I go home, and I come back the next day and I can’t believe it: He’s still alive. We take him back to surgery five more times. And literally this guy, he walked out of the hospital into rehab and then a year later he writes this note saying, “Thank you, doctor, for saving my life.” That’s the best feeling in the world.