Prepare
On a warm spring evening in a New York City public hospital, the slow pace of a Sunday call shift was interrupted when the in-hospital trauma notification system chirped out the details of a patient in transit, “This is a Level 1 notification, 28 year old male multiple GSW to the chest en route to hospital, BP 90/palp, HR 130, unresponsive, ETA 5 minutes.” The trauma team assembles and we prepare for action. Roles are assigned, we’re gowned and gloved, the rapid infusion device is primed, and the procedural team stands ready to secure the airway and establish IV access. As the trauma chief resident I stand at the foot of the bed and review a few technical details of how to organize the resuscitation with my attending as we wait.
Action
The patient arrives: a healthy well-groomed male who looks almost my age, he’s wearing jeans and a T-shirt that are cut away in seconds. As the airway team intubates, an ominous trickle of bright red blood from 2 holes in his left chest is noted. I nod to my attending and I signal a team member to get ready for a chest tube. Another person auscultates, another nod, and we begin to position the patient with his left arm taped high overhead. The tube goes in successfully. The trickle of blood from the bullet wounds abates and is diverted as a river of red gushes through the transparent tube, its warmth palpable through the thick plastic. A transient improvement in his vital signs only lasts a few minutes. A massive transfusion protocol is underway but his blood pressure continues a downtrend. He loses a palpable pulse and the Trauma Attending taps on the thoracotomy instrument tray, “Open the chest, NOW.”
The next several minutes seem to pass in slow motion. I evacuate a large pericardial hematoma but his ventricles are empty and he’s already lost too much blood, we go to open cardiac massage, he codes, regains pulse, codes several more times and ultimately all resuscitation attempts fail. After his time of death is pronounced, the crowd of people thins out from the trauma bay, and a sense of stillness and silence returns to the night. A loud shriek and hysterical cry pierces the air moments later as his wife standing just outside receives the news. I’m quickly closing his thoracotomy incision with a running suture before she is allowed in to see her husband. As I’m finishing the wound closure his left arm drops back into the field of view. A bright and colorful beaded bracelet adorns his wrist, with the words “I LOVE YOU DAD” held together on the string. Those of us still in the room see the bracelet, and we shake our heads in silence.
Plan for the future
At 7 AM the next morning the surgical teams are gathered for Morning Report where we discuss the cases from the weekend. The “ED thoracotomy GSW patient” is the leading case we review. We ask what we could have improved in the trauma bay. Could we have done a better job with personnel management? Was there a limitation on the blood or systems resources we might have needed to give this young man his best chance for survival? Is there data to guide how we should respond to this trauma scenario that could help us perform better in the future? We discuss the pre-hospital environment and the actions taken by first responders. We focus on what we can improve as clinicians, and the conversation extends no further.
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A few weeks later on a Monday morning in Washington, DC, over 300 surgeons are seated in a large hotel conference room. Arranged by the American College of Surgeons, this conference is unlike other academic meetings. The focus is political advocacy, working to promote current or future legislation that is relevant to the practice of surgery. The American College of Surgeons, through its own political action committee, has a presence on Capitol Hill that is established and well-versed in the lobbying process. They’ve been vocal on a range of issues from abolishing the Sustainable Growth Rate formula and advocating for surgeons during health reform in the Obama era. This year a central focus is on the issue of gun violence that has risen to a fever pitch in America following major mass casualty events like the shootings in Las Vegas, NV and Parkland, FL. The importance of trauma systems preparedness in the wake of these events is particularly well-recognized by the surgeons in attendance, and the sense of purpose in advancing this agenda is palpable.
We spend the day educating ourselves on the issue of gun violence in preparation for in-person advocacy efforts. Experts on the subject frame the issue within the current political context and simplify the message that will be delivered. Our goal is uncontroversial and straight-forward: to clarify existing regulatory language to allow the Centers for Disease Control and Prevention to research firearm-related injuries. It becomes apparent that legislative advocacy at this level is a well-oiled machine. A lobbying consultant group has been hired to organize our attack on the elected representatives. We’re split into state and regional groups based on practice location. There’s a mobile app complete with meeting times with senators or congressional representatives and walking maps to guide us, all of which is updated in real-time. Charter buses are arranged for transportation from the hotel.
The next morning, we descend upon Capitol Hill as a sea of suits and whitecoats carrying customized stationary folders. We break out into our groups and head to individual representative offices, ready to deliver the policy statements and bring a voice to the issue of gun violence that plagues communities across the US. But with each meeting, the hope of enacting meaningful change through this advocacy process seemed to dwindle further. We didn’t physically meet a single elected representative. Instead, the conversations took place with staff members in their respective offices. Our delivery was smooth, empathic, data-driven and actionable. The responses received in return ranged from “we support you, please keep this conversation going” to “unfortunately we can’t bring this up in this climate, the last representative that brought up this issue lost their seat when they were up for re-election.” The congressional staff member would scribble a few bullet points on a notepad, accept our policy memos in a folder, shake our hands and provide an empty thank you. I walked out onto the National Mall to find stale heat on a quiet afternoon, with a sense that no tangible impact had been made.
As surgeons we are uniquely positioned to speak up about gun violence. Whether during training or in practice, we are part of the select few in society who have felt the splash of warm blood onto our hands or heard the cries of family members who have lost their loved ones to death and disability as a result of senseless gun violence. From our clinical mentality we will always be bound to the concepts of preparation, action, and planning for the future. We will continue to hope we might one day curtail the epidemic of gun violence in our country. Until then, our surgical community will stay focused on what we can do as healthcare providers to control the damage that has already been done.