The ambulance called in the late afternoon with a 3-minute ETA on a multiple gunshot wound victim with CPR in progress. They managed to place an intra-osseous line and give him some IV fluid on the way, but salt water can't restart a heart.
After a flurry of activity, our team was ready when he arrived 4 minutes later. He looked like any other kid when they rolled through the doors - thin, muscular, a young face with a close-cropped scruffy goatee, a tattoo of some initials and a date on his left upper arm. What made him different was the absent look in his eyes and the medic sitting on him, pushing rhythmically on his chest. They yelled out some information as they transferred him from their stretcher to ours:
Twenty years old. Found barely breathing about 8 minutes ago, stopped breathing 7 minutes ago. Gunshot wounds to the chest, right arm, left groin. Asystolic.Dead.
A cursory glance at him revealed a gunshot wound to the left chest just above and medial to the nipple. Directly over where the heart is. The mortality rate for such an injury is very high, and when the patient comes in dead it approaches 100%.
This kid had only one possible chance, though I knew that chance was fleetingly small at best. I grabbed a scalpel - the big one. A splash of iodine on his chest seemed more for show rather than any possible actual antisepsis. I incised from his sternum all the way down the side of his chest to the bed. I inserted a Finochietto retractor and opened his chest wall as widely as it would go, cracking a few ribs as I went. The chest was full of blood, as was the pericardium (the tough membrane that surrounds the heart). The heart was twitching, barely moving. I grabbed the scissors and opened the pericardium widely. The heart was struggling, trying, but there was nothing to pump - it was empty. Nearly his entire blood volume was now on the bed, on the floor, on my shoes. I started squeezing the heart, trying to circulate what little volume he had left.
By this time others had placed multiple IVs, including a large-bore central line in his femoral vein. Blood was running into him as fast as the rapid transfuser would go. Epinephrine was injected.
The reason why the heart was empty was immediately evident - there was a hole in the left ventricle, the main chamber that pumps blood to the body. Everything we were giving him had drained right out. I plugged the hole temporarily with my finger, but when a bullet goes in, it must also come out. I found the exit wound on the back side of the left ventricle, and plugged it with another finger. Now the heart began filling.
And still I continued squeezing.
I shouted for some pre-loaded pledgetted sutures and repaired the anterior hole first, taking care to avoid the anterior interventricular vessels. This is a very difficult prospect as the heart continued to 1) move (weakly), trying to restart itself, and 2) bleed. Stitch, plug, squeeze. Stitch, plug, squeeze. I turned the heart over and repaired the posterior wound in the same way.
And then it started beating again. Hard. Rhythmically.
Above the din I loudly asked someone at his head to check for a carotid pulse. "I GOT A PULSE! I GOT A PULSE!" someone shouted back at me. I don't even remember who it was.
I checked my repairs - a tiny bit of oozing, but they were solid. As his heart started pumping away stronger and stronger I put my fingers on his neck and confirmed a carotid pulse. Ba-dum. Ba-DUM. For one ephemeral moment I thought he had a chance. Then my eyes went up to his - his pupils were blown. Fixed and dilated.
God. Damn. It.
My mind immediately started going over the possibilities - maybe we had been fast enough. Maybe the pupillary reaction would return. Maybe. More blood.
I went back to look at my repair, and the heart wasn't pumping nearly as hard. The epinephrine was wearing off. I looked at the monitor and his blood pressure was dropping. And then his heart stopped again.
Squeeze. Squeeze. Squeeze.
More blood, more epinephrine.
The transient moment had passed. I took one last look at the motionless heart, looked at the clock, and found myself pronouncing another young kid dead. It was about 6 PM. I had no idea where the previous 70 minutes had gone.
I can't say exactly why this loss struck me so much harder than most others. Perhaps it is because my best wasn't enough to overcome what I intellectually knew to be a fatal injury. Perhaps it was because of that brief moment when I thought he could be the 1% who survives. Perhaps it is because no one ever came for him.
I still don't know his name.