The patient, a teenager shot on the streets of Richmond, came into the emergency room with a bullet hole in his abdomen and pleading for water.
“I want some water. Give me some water, please.”
His voice was strained but strong, loud enough to be heard over the commotion as doctors and nurses swarmed around him when the ambulance crew brought him into VCU Medical Center on a stretcher.
The night was young. Weekends usually are busy for VCU’s trauma center. This Saturday would be no different. By the end of the shift the next day, there would be two more gunshot victims, though not as serious as this one.
The patient’s question, “Am I going to die?” came later, on the way to the operating room.
Just minutes before, the trauma team had been paged to report to the emergency department. It was a code “echo,” the second-highest level of trauma. By the time the ambulance arrived, everyone was in place, waiting at one of the six bays set aside for trauma cases in the 72-bed emergency unit.
At least a half-dozen people swiftly moved to the patient’s side — surgery, emergency medicine and anesthesia attending doctors and resident physicians, trauma nurses, a paramedic and technicians. Others, including a chaplain and social worker, were nearby. VCU and Richmond police officers waited near an entrance.
Dr. Michel Aboutanos, a trauma and acute care surgeon and director of the trauma center, stood just outside the sterile zone, marked by a yellow line of tape on the floor. One of eight trauma surgeons at VCU, he was directing the response of the three teams — emergency medicine, trauma and anesthesia — as they worked to stabilize the patient. The residents — doctors getting specialist training — take the lead unless the case gets unusually complicated.
A lot was going on — too much for an untrained eye to follow. Clothing was cut away. Monitors connected. Intravenous lines placed. Doctors and nurses talked to the patient and moved their hands over his body, seeing the wound but feeling for injuries they could not see. Numbers, directions and orders were called out.
“Abdomen tender,” somebody said.
“Could you put a little piece of ice on my forehead?” the patient asked again. “Water, ice, anything.”
He had lost blood. Thirst could be his body’s response. The area around the wound was plump and swollen. The bullet from a small-caliber handgun had entered from the back and exited from the front.
“We need two samples for blood bank,” Aboutanos said. “We’re going to get a chest X-ray and then we’re going to go up, all right.”
“Up” is the fifth-floor trauma operating room, where Aboutanos and his team would repair the damage from the bullet. At that point, the patient had been in the hospital for about 12 minutes.
“Sasa, let him know what’s going to happen, please,” Aboutanos said to Dr. Sasa-Grae Espino, a surgery resident and one of the doctors working on the patient.
“We’re going to do an X-ray, OK?” she told the patient. “I will give you ice after we get this X-ray, OK? I need you to stay still.”
It looked like a jumble, a mess of movement. But it was planned and orchestrated — Life-Saving 101 in a level 1 trauma center.
The stretcher was moving toward the elevator when the patient spoke.
“Am I going to die?”
With all that was going on, his question could have been drowned out or left unanswered, but Aboutanos heard him and responded.
“You are going to be OK,” Aboutanos said. “You are not going to die.”
It’s a question Aboutanos has been asked many times, by other young men like this one who have been shot or stabbed. Sometimes it is when they are going into shock and a feeling of doom comes over them.
Or the patients realize just how serious their wounds are and that this could be it, the end. Had they not been shot and faced a life-threatening wound, they could have expected to live another 50 or 60 years — time to finish school, get a job, marry, have children, have grandchildren. Now there was uncertainty. Epidemiologists measuring the impact of premature death count those missed years as “years of potential life lost.”
Aboutanos needs the patient to be on board with the work that will take place over the next few hours in the operating room, through the night and next days in intensive care, and probably in the weeks and months to come in rehab. He has to manage not only their physical wound but also their psychological injury. There also is a medical reason to reassure the patient — his worry and fear could raise his blood pressure, which could accelerate bleeding.
“You are going to be OK, all right. You are going to be all right,” Aboutanos said, walking beside the stretcher as it headed toward the elevator. A city police detective was allowed to talk to the patient for a few seconds.
Before the elevator came, the trauma alert went off again. The teams got the alert on their pagers. A bicyclist who had fallen was being transferred from another hospital. Doctors and nurses moved around, preparing for the next case.
There are five level 1 trauma centers in Virginia. VCU Medical Center is one of them, serving a wide stretch of central Virginia.
Patients come by car, ambulance and helicopter with all kinds on injuries. People get drunk and fall down stairs. Cyclists and pedestrians get hit by cars. People get banged up in vehicle crashes. Workers fall from scaffolds, get mangled by machinery or burned by caustic substances.
In 2014, the VCU trauma center had 4,362 admissions. A third were injured in motor vehicle crashes. Eighteen percent were falls. Eight percent were burns.
Penetrating trauma — stabbings and gunshots — accounted for 6 percent of cases. It used to be a lot more, said Aboutanos, who first came to VCU in 1993 for a surgery residency, and when that was complete went elsewhere for additional training in public health and shock trauma. He has been back at VCU as a clinician, researcher and educator since 2002.
“At one time, we were Number 1 homicide per capita. That was a long time ago,” Aboutanos said. “It’s significantly decreased, but we still see it.”
In the late 1980s and early 1990s, Richmond was seeing one or two homicides a week, putting the city among the highest in the country in per capita murders. That has dropped significantly. The city had 44 homicides in 2014, still too many when compared to surrounding jurisdictions.
Aboutanos honed his skills during Richmond’s homicide epidemic. “It was incredible training. You do everything here. There’s nothing that you are not exposed to,” he said.
The impact of the killing was not lost on him, though.
One patient, he recalled, came in three times over the course of six months, each time with a gunshot wound. First it was the leg; the second time in the belly, Aboutanos remembered.
“He stayed with us for a while, ended up having a bag, an ostomy,” Aboutanos said, referring to a pouch worn externally to collect stool when the colon is removed because of disease or injury. “About four months later he comes back. Now’s he’s shot in the head. I watched him die in the emergency room, and I said, ‘What are we doing?’ ” Aboutanos said.
“I decided not to focus on one patient but to look at the bigger picture. So I did additional training in public health as a preventive medicine residency. I did two residencies at the same time. I wanted to look at how to prevent injuries, how can you prevent the very thing that we are finding every day.”
In the operating room, though, it is just one patient — and one life — at a time.
On this night, the teenager in the operating room still wanted water.
“You are going to be OK,” Aboutanos said again.
“Could you put a piece of ice, a little piece of ice, on my forehead, please?”
“Just a second and you’re going to be asleep,” someone said. “When you wake up, you are going to be OK.”
“Honey, what do your friends call you?”
“Are you going to give me some ice?”
“We will give you some in a minute. Breathe this air first.”
A mask was lowered over his nose and mouth.
In a minute, he was asleep.
Aboutanos was scrubbed and gowned. So was Espino. There was someone in the room to track and account for every piece of equipment and the supplies used. There was someone to keep the tray of surgical instruments stocked and replenished and to hand them to the doctors. There were medical students observing.
The operation took about two hours. It was search and repair. Espino used an electrosurgical device held like a pencil to burn open an incision down the abdomen. A retractorlike device was placed to hold the belly open. Then she and Aboutanos methodically examined organs — liver, kidney, intestines, spleen — and tissue for damage. The small intestine, the colon or large intestines and the liver are the most commonly injured organs in shootings and stabbings.
The spleen was bleeding and removed. The colon had the consistency of very soft rubber. It was examined a section at a time. The doctors spotted a hole.
The damaged section of colon was cut out. The ends were reconnected with sutures.
Bullets can bounce around inside and do a lot of damage. This one had done more damage than was first apparent. Failing to find all the damage can prove fatal. A missed hole in the intestines, for instance, could allow waste to leak into the abdominal cavity and cause an infection there or poison the entire bloodstream, leading to sepsis, which can kill faster than antibiotics can work.
Aboutanos was not fooled by the fact the patient, young and otherwise healthy, was not moaning in pain when he came in. His injury was life-threatening. His condition could turn on a dime.
“Young people fool you. When they are bleeding on the inside, they compensate. They look OK — their blood pressure is fine, everything’s fine — meanwhile, they continue to bleed. Then, suddenly, they stop compensating.”
Or, he said, putting it another way, they crash and die.
“All of these things — you don’t see it, but you’ve got to know it. That’s the problem with not doing this all the time. Not knowing what’s going to come,” he said. “If the team is not perfect, he loses. We all will lose.”
Aboutanos earlier had described how they decide what to do and when to do it. They’ve done it enough to know what works. There are established protocols among trauma surgeons borne out of experience. Some of what they do comes from what military doctors have learned from treating the wounded in the wars in Iraq and Afghanistan.
Number one is “we have to control the bleeding, control it fast,” Aboutanos said.
“We used to give blood products and now we give what we call 1-1-1, equal amounts of various blood products as if it’s whole blood. … We’ve learned that we give red blood cells at the same time we give what we call fresh frozen plasma, which is a solution that has all the components to help you clot, also at the same time we give you platelets.
“We aggressively are giving all the components at the same time.”
Often, as was this case, the transfusion is started while the patient is in the emergency room.
The bleeding also can be stopped by something called QuikClot, a mineral that is mixed with gauze and put inside the wound.
“It’s a product that will help to basically just stop the bleeding very quickly. The military also uses it,” Aboutanos said.
“Our Number 1 enemy is time,” Aboutanos said. “That’s really what we fight against. Every minute puts that person in jeopardy. How fast and how efficient and how accurate we must be in order to combat this enemy, which is time. Somebody may be looking OK but may be actually bleeding. You don’t know it, so we have to have the best technology to be able to quickly respond and do the appropriate tests to figure out what is going on. A lot of our patients cannot tell us what’s happening with them.”
The surgery was physical. The doctors and others were on their feet for more than two hours. They thought they had found and repaired all the damage. But the next few days would be critical. Stool spilled into the abdominal cavity, and even though quarts of saline solution were used to flush out the area, even a tiny bit of stool left could cause infection. The ICU doctors and nurses would be watching for signs of that in the days to come.
After the surgery, Aboutanos prepared to talk to the family, prepared them for what they would see — the patient with tubes coming from his nose, mouth and chest.
“You have to be honest with them,” he said. “You can’t sugarcoat it to them. You can’t give them too much assurance and he doesn’t do well.”
One time, breaking the news to a father that his son had not made it, Aboutanos said he had barely gotten out the words when the father punched him.
“I went flying,” he said. Then the father fell to the floor, sobbing. “He didn’t even know what he was doing.”
Other times, there can be no emotion, almost indifference.
“I think there is nothing worse for us than telling someone that their loved one died, and we do that so often,” he said. “It’s never the same. It’s never cold. You can be cold in the operating room. You can be a technician taking care of a person, and you have to be that sometimes. Then you have to open yourself when you come to the family.”
The doctors are not immune to feelings of loss and helplessness, either, said Aboutanos, 47, who is married and father of two young children.
A colleague shared this perspective: “ ‘You take care of a lot of people but only the dead stay with you,’ ” Aboutanos said.
The trauma team members also respond to each other when someone is taking a loss too deeply or sometimes even too casually.
“You cannot do it without the team. They know you. You know them,” Aboutanos said. “If somebody says, ‘I worked on this guy all night and I lost him,’ you have to have someone that understands exactly what that means to be able to respond to you.”
The response from surgeon colleagues is both emotional and technical, commiserating the loss but also probing for specifics of what might have gone wrong.
“You’ve got to be drilled down,” Aboutanos said. “What happened? What could you have done differently? If you think you did this right or wrong, and you have to admit that part if you didn’t do something right. And how can you improve the next time.”
As tragic as the situation with the teenage patient was, it presented an opportunity to help direct him down a different path.
“You see his attitude. If he stays with us, within a week or so that will be a totally different attitude,” Aboutanos said. “He will change. Like I talked about before, trying to catch them at this moment.”
For certification, level 1 trauma centers are required to have injury-prevention programs. At VCU, there are more than half a dozen such programs. One called Bridging the Gap targets inner-city youth ages 10 to 24. Program staff start working with the patient while he is in the hospital, in rehab and later goes home, for up to six months. Aboutanos or one of his surgeon colleagues will see the patient in clinic for follow-up. The social workers, psychologists, medical students and others will try to break the cycle of violence.
“Can you get in at that moment when they are vulnerable, where they want to listen to you?” Aboutanos said. “Once they realize that we want what’s best for them, then you can work on that trust.”