Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men
By John A. Rich, M.D., M.P.H.
Hardcover, 232 pages
The Johns Hopkins University Press
List price: $24.95
NOTE: The following excerpt contains subject matter that some readers may find disturbing.
1. Kari In Pain
The September morning was bright, and the Boston air held a crisp edge that confirmed that we had left summer behind. Before leaving for the hospital, I punched the switch on the coffeemaker and walked down the stairs of my Roxbury home to get the newspaper. I then sat at the dining room table, bathing myself in the warm sun, and sipped the thick, strong coffee in preparation for the day ahead.
It was my routine to sit and drink coffee as I scanned the Metro section of the Boston Globe to find out whether any young men had been shot or stabbed within the past day. This sometimes seemed a morbid task, but it was the only way I could think of to meet these patients and hear their stories. The paper was just a place to begin, but if I found nothing there, then a walk through the emergency room later in the morning would likely yield one or two young men whose injuries had occurred after the paper had gone to press or whose tragedies were not considered dramatic enough to report. I surveyed the paper with ambivalence. On the one hand, I was sickened by the near-daily shootings that killed or crippled young people in my neighborhood. These everyday tragedies motivated me to do the research I would need to understand it. On the other hand, news of a violent injury meant that there was another injured patient to include in my research. Learning of a shooting helped the research progress. Still, I had to reassure myself as I looked up and down the columns of print. "I don't make it happen," I told myself. "They'd get shot whether I was researching it or not."
It was of no use, I learned over time, to look at the front page or even the first section of the paper. Unless a group of black men had been shot or violence had spilled out into the street and injured someone else (generally assumed to be innocent), the shooting of a young black male was not news. Most often the story was nestled in the second section, tucked between the lottery results and a report about the usual deadlocks in the city council.
I thought back to the night before, when I'd taken a shortcut through the emergency room on my way home from the clinic. As I passed through, I saw my friend, Dr. Lenora Holloway, sitting hunched over a pile of papers. She flashed a small, troubled smile. She looked down at the forms in front of her and said with resignation, "This is one young man who is not going to make it to your clinic."
I recognized the form. It was the Massachusetts death certificate. It is a painful form to fill out, for all the obvious reasons. But each field must also be completed perfectly according to the instructions or an administrator will reject it and force you to fill it out again. Even using blue ink instead of black ink will get the form kicked back.
"What happened?" I asked her.
"Well, apparently this kid was standing at a bus stop on Dudley Street, and a group of guys pulled up in a car. They blew this kid away. We counted seven gunshot wounds, and he was pretty much dead when he got here, even though that's a short ambulance ride. We tried to revive him, but he was gone."
She turned her attention back to the form. She raised her modern black horn-rimmed glasses and set them against her short afro. I couldn't help but notice that she was a strikingly beautiful woman. I had known her since she stood out in her class at Harvard Medical School. Now that she was a secondyear resident, her eyes looked less bright and she seemed weighed down by the tasks of the day. But she, like most of us, had learned how to bracket her pain and emotions to get the work done.
Overhead, a voice announced, "Level 1 trauma. Gunshot wound. ETA 5 minutes."
Lenora looked up at me and shook her head while simultaneously stacking the papers and pushing them aside. "See? It just doesn't stop." She got up and joined the team of doctors and nurses who paused from treating patients with ear infections, dislocated shoulders, and out-of-control high blood pressure. There was little conversation as the team made their way to the trauma room. They had rehearsed this routine many times in the past and were primed from the young man they had been unable to save. Once in the room, each person took up his or her preassigned position.
I stayed in the hallway while Lenora moved to the right sideof the trauma table. She pulled on blue latex gloves and began readying a large needle and syringe that she would use to insert a central line. The other members of the team took their places as well. A nurse dressed in green scrubs stood at the left of the table and sorted through a cart that held vials of medication that might be needed to revive or sedate the patient. A large pair of shears hung from her belt. The position at the head of the table was reserved for the senior emergency resident, who took his place and began preparing the endotracheal tube that would be inserted into the patient's windpipe in the event that he was having trouble breathing. Other physicians and nurses stood in their places, preparing the various tubes and medications that were always a part of the resuscitation routine.
The table itself was perfectly prepared, with a crisp white sheet folded across it. Bags full of saline hung in place, and IV tubing draped down on either side. A large cluster of intensely bright lights hung overhead, making the room look like an operating room.
Over a loudspeaker, a different voice announced, "Trauma 1. One minute."
I looked to my left and saw an ambulance backing up to the sliding glass doors. The emergency medical technicians and paramedics unloaded the patient from the truck by pulling on the gurney and allowing the wheels to spring automatically from beneath the moveable bed. One of them was holding an IV bag while the other pushed the stretcher from the foot end. They rolled the bed through the automatic doors, where they were greeted by a nurse who listened to their quick description and walked briskly with them down the hall toward the trauma bay, where the trauma team waited.
On the stretcher, a dark-skinned man who looked to be about 20 years old rolled his head back and forth moaning through the oxygen mask covering his face. His eyes were wide open, terrified, glazed. A large plume of blood stained his oversized blue jeans. His pant legs were split cleanly up to the knee on both sides. A spotless Timberland boot hung off his left foot, but his right foot was covered only in a dirty white sock.
The nurse who was walking alongside the gurney leaned over and asked him in a loud voice, "What's your name?" The young man did not respond but continued to wag his head. Suddenly, he raised his shoulders off the stretcher, looking as if he was trying to get up. The nurse, pushing him down firmly with her hand on his shoulder, shouted, "I need you to lie down and cooperate with us."
"I'm cold," the young man said, garbling his words as if his mouth were full of stones. The nurse continued to move, businesslike, seeming not to have heard him.
The team of doctors, nurses, and technicians surged to the stretcher as it pulled up alongside the table. Each person grabbed a handle on the long narrow "back board" on which he was lying. The senior emergency resident shouted "OK, one, two, three!" and in synchrony, the team jerked the board and slid the young patient onto the table. The ambulance gurney was removed, and in a scene that has always reminded me of a pit stop at a motor speedway, the medical team descended upon the patient and began the sometimes gruesome work of saving his life.
The senior emergency resident placed his hands on either side of the man's neck and deftly slipped a foam collar around it to hold it steady. Simultaneously, the nurse to the resident's left pulled out her shears and finished the job that the paramedics had started. She cut off the patient's baggy jeans, boxers, and jersey and peeled them away, leaving him completely naked.
Once again the young man began to grunt and reared up off the table as if he were desperately trying to find something. A large male nurse stepped beside the table and pushed the patient's shoulders down to the bed. As soon as he touched the bed, the young man arched his back and made a loud retching noise. Suddenly, large clumps of blood spewed from his mouth and soared up and out over both sides of the table. The dark clots hung in the air as if suspended in slow motion. The large nurse restraining the young man had just enough time to react. He spun away and ducked so that the patient's blood splashed across the back of his scrubs.
"Did that get you?" the resident asked as he suctioned out the man's mouth with a clear plastic wand.
"I'm okay," the nurse responded, twisting to peer over his shoulder at the mess.
"I'm going to intubate him. Give him a sedative and paralytic." A nurse pulled two syringes preloaded with clear medications from the cart while the resident readied a lighted scope with a long silver metal tongue. The nurse injected the medications — one a powerful drug to induce a temporary paralysis, the other a sleep-inducing agent — into one of the IV tubes. The young man's body instantly went limp.
The large male nurse calmly placed a rubber mask over the young man's nose and mouth and began to squeeze the large oval bulb connected to it, forcing oxygen into the patient's lungs. He forcefully pumped the bag and watched the young man's chest rise with each squeeze. At the resident's cue, the nurse removed this apparatus — called an Ambu bag — and the resident leaned over the young man's now-flaccid body. He pulled back his jaw and inserted the long blade, designed to move his tongue out of the way and expose his vocal cords. He held the scope firmly and with his other hand slid the clear plastic breathing tube into the young man's trachea. The nurse returned with the Ambu bag, this time attaching it to the breathing tube. He pushed a few more breaths into the young man, watching to be sure that his chest was expanding, proof the tube was in the right place. Finally, he connected the tube to a ventilator. Rhythmically and easily, the patient's chest began to rise and fall, as the machine pushed oxygen into his lungs. The resident grabbed the stethoscope that was draped over his shoulders and popped in the earpieces. He leaned over and listened to each side of the patient's chest before announcing, "Good breath sounds on both sides," confirmation that the tube was properly positioned in the young man's trachea.
Once this was done and the patient was rendered completely immobile, an intense calm fell over the room. Lenora squinted with concentration as she swabbed iodine on the patient's chest just beneath his collarbone, preparing to insert a central line into the large subclavian vein in the patient's chest.
Another doctor surveyed the young man's body for wounds, calling out her findings to a nurse who recorded the details on a clipboard. Even from where I was standing several yards away, I could see the slight hole in his right abdomen that was oozing just a bit of maroon blood. With the help of several others, the nurse rolled the patient up onto his side to look for other wounds on his back. She seemed unsurprised to see a much larger wound beneath his right shoulderblade, evidence that the bullet had entered his front and exited his back. Yet another nurse prepared to place a lubricated tube — called a Foley catheter — through the opening in the patient's penis and into his bladder. Next, a technician rolled the large portable X-ray machine into the room and began to take films of the man's chest and abdomen. Lenora confirmed that her needle was in the patient's subclavian vein by pulling back on the syringe's plunger and seeing a flash of dark blood. She slid the large IV line — called a cordis — into the patient's shoulder and prepared to secure it in place.
Less than 30 minutes after the patient was rolled through the doors, he was ready to move to the operating room. The surgical chief resident, who had entered the room quietly during the chaotic drill, decided that surgery was the only way to explore and repair the bullet's damage. The team packed up the patient and wheeled him quickly out of the trauma room and toward the patient transport elevator. No longer naked but covered in a cream-colored flannel blanket, the young man remained motionless. His feet hung off the end of the stretcher and his ashen heels rocked with the motion of the gurney. I stood and watched as he disappeared through the automatic doors.
Having seen this orchestrated chaos a number of times before, I was coming to understand its logic. These emergency room providers were driven by a single goal: get the patient to the operating room as quickly as possible. To accomplish this goal, they followed a well-rehearsed set of protocols that have been proven to work. Their approach would have been the same no matter what type of trauma he had suffered. The same routine would have been invoked if this young man had been in a car accident, nearly drowned, or fallen from the roof of his house.
The principle that drives these actions is referred to as the "golden hour." It is widely believed among emergency medicine and trauma physicians that if a trauma patient like this young man can be assessed, stabilized, and transported to the operating room within 60 minutes of his injury, he has a much greater chance of surviving. While some dispute the evidence that led to the concept of the "golden hour," few can dispute the effect that it has had on trauma care. The treatment of trauma is arguably the most highly standardized and choreographed treatment in medicine. There is little room for variation or creativity in the process. As a result, every trauma patient gets the same assessment, the same tests. He could be the CEO of a Fortune 500 company or an escaped felon who had been shot by the police. The protocols, the treatment, the effort are the same.
Still, I had begun to believe that something different happened when the patient was a young black male. Several impressions struck me as I walked out of the emergency department to my car. The first was that in the rush to save this young man's life, very few words were spoken to him, and he said very few words in return. "I'm cold" were the only intelligible words that I could remember hearing the patient speak. But there was also a sense that in the minds of the doctors and nurses and EMTs, each of these young black males who were rolling through the emergency department at such a frightening rate was the same. With few words spoken, it was impossible to distinguish between a young high school student struck by a random bullet on his way to school and a hardened drug dealer shot in a gang war. The faces of my colleagues (and perhaps they could say the same about me) showed that we couldn't care about these things or make these distinctions for fear that somehow it would hinder our ability to do our jobs. But as I walked away, the image of this young black male propping himself up on the table, desperate to say something, stuck in my mind.
That image came back to me as I took another sip of coffee and read the following brief in the Boston Globe:
A young boy looked back at the spot in front of 1 Smith Street, where an 18-year-old Boston man was shot in the back during an armed robbery at around 6 p.m., yesterday. The victim was taken to Boston City Hospital where he was in stable condition last night, police said. Police are looking for a suspect who stole a gold chain from the victim.
From Wrong Place, Wrong Time: Trauma and Violence in the Lives of Young Black Men by John A. Rich, M.D., M.P.H. Copyright 2009 The Johns Hopkins University Press. All Rights Reserved.