The Philadelphia Inquirer
March 5, 2006 Sunday
The young don’t want to die.
They fight against the blood spilling from their bodies, the oxygen draining from their lungs. They will twist and shout and beg someone — any of these strangers surrounding them — to save their lives.
Amy Goldberg, chief trauma surgeon at Temple University Hospital, knows this. She has seen it, dozens of times, usually young black men struck down on the city’s streets.
So it was on a recent winter night when police rushed in with an 18-year-old who had been shot once in the chest. His arms and legs flailed wildly as a team of doctors and nurses struggled to undress him and hold him down. He kept lifting his head, looking around wildly and trying to bite, despite one nurse’s efforts to keep him still. His appearance didn’t seem that dire: only a small amount of blood showed on his shirt and chest. There was no exit wound through his back.
His shouts were often unintelligible — sounding like, “no” and “stop” and “let me go” — but then he repeated one sentence in a clear voice: “I don’t want to die.”
Goldberg, 44, was in the middle of it, against the gurney and between the half-dozen doctors and nurses passing syringes, tubes and IV bottles over it. She was easy to miss, just pushing 5 feet, 2 inches tall, looking more like an intern or medical student than a veteran surgeon.
There was no doubt that she was in control here, instructing her team in a low, matter-of-fact, take-no-prisoners tone: “Pulse, pulse, pulse,” she instructed repeatedly. “Put a line in,” she told a surgical resident. “The blood. Where’s the blood?” she asked the room in general.
To the 18-year-old, whose struggles were lessening, she was more gentle. She placed a firm hand atop his head and said the words he needed to hear, “We’re going to take good care of you. You’re not going to die.”
‘Looking to do more’
Temple University Hospital is one of the busiest trauma centers in the state. It is also arguably one of the best: More than one Philadelphia police officer will tell you, “If I get shot, take me to Temple.”
Doctors here have a lot of practice with that sort of thing: According to 2004 data from the Pennsylvania Trauma Systems Foundation, Temple topped all other Pennsylvania hospitals when it came to the treatment of penetrating wounds — primarily gunshots and knifings.
But it’s not all guns and knives. It is the area’s number-one destination for fire and rescue squads. On the same night that Goldberg pushed her team to save the life of the bleeding teenager, she also treated a 79-year-old Chester County woman flown in by helicopter after falling and striking her head. She dealt with the fallout from two car accidents, one involving a pregnant woman, the other a 16-year-old with a broken back.
Variety is one thing that pulled Goldberg to trauma surgery. An anatomy junkie, she loves the idea that she can operate on a stomach one night, someone’s chest the next. As a child growing up in Broomall, Delaware County, she took apart broken watches and then painstakingly rebuilt them. Now she does the same to damaged humans.
She is determined to make a difference in people’s lives, even after they leave the hospital. She lectures. She scolds. She even yells. Keep living this life, she’ll tell some of her patients, and next time you might not be lucky enough to be here.
“I’m really looking to do more than what we can do medically,” she said. “One part is to take care of their injuries. The other part is the preventative part. Do they listen? I don’t know. I’m hoping they do. I know I’m going to keep trying.”
Surgery was critical
The 18-year-old, now strapped down and sedated in the emergency room, had been shot in the left side. Goldberg likes to say that what you do in practice is what you do in the game, and she and her team proceeded calmly, yet briskly, practiced from previous experiences. Breathing tube in. Fluids flowing. X-rays taken.
On the film, it appeared that the bullet had pierced the young man’s heart.
The most impressive cases — at least to nondoctors — seem to be the ones that involve the heart, Goldberg said. Not because they’re the most difficult, she explained, “but because it’s the heart.” There is awe surrounding the body’s blood-pumping center, the symbolic holding place of emotion. One’s heart can be damaged by so many things: love, loss, a bullet.
If the teen’s heart was damaged, things would be bad, but not necessarily deadly: Once, Goldberg said, she treated a patient who had two bullet holes in his heart. She sewed one wound, another surgeon handled the other, and the man pulled through.
“The guy lived,” she said, still marveling.
What was worse for this teenager on this night, further examination found, was the blood pooling in his chest. There had been no outward sign that it was gushing so. Its existence was discovered only when a chest tube was inserted.
Surgery was needed. Immediately. Goldberg’s team — two residents and a medical student — took hold of the gurney and hurried out the door.
“Don’t run down the hall,” she called after them, cognizant of the tubes, the breathing machines, the bystanders. “Don’t run.”
Minutes later, they had reached the operating room. The teenager’s heart had stopped.
A lecture is guaranteed
While doing a trauma fellowship in Baltimore 14 years ago, Goldberg was in the ER when a 16-year-old boy came in with a gunshot wound to the stomach. He died in front of her eyes.
But then the doctors resuscitated him. Using everything she had learned and every skill she had, Goldberg was part of the team that saved the boy’s life.
A month later, she saw him again in the hospital’s outpatient clinic. And the reality set in.
“It occurred to me this wonderful operation I had done was so inconsequential because what was this kid’s life expectancy? He wouldn’t live to be 20, 25, 30,” she said. “I don’t think I’ve forgotten that.
“We can take care of them medically, but what kind of influence do we have on them when they leave?” she asked. “We have to get this to stop.”
If this 18-year-old survived the night, he would likely receive one of Goldberg’s patented lectures in the morning. Colleagues say there is nothing like seeing Goldberg stomping her size-5 foot and waving a finger in the face of those who are towering over her, warning them that she never wants to see them in her clinic as patients again. She’ll tell them about Temple’s outreach programs and where to get help dealing with drug and alcohol problems, even take them to the morgue if she thinks it will have an effect.
The response from many of the patients is surprising: Even those who scowl seem to appreciate the attention.
“For the most part, the patients are happy that somebody has noted and cared to say something,” Goldberg said. “A lot of these patients are now given a second lease, and they probably know it, but by having this conversation and dialogue with them, it is now out there. And now it’s up to them to do something with that second lease.”
Some of them — too many of them — don’t do anything with that second chance. Or that third chance.
Goldberg recalls one teenager who survived his first gunshot — a chest wound — but barely. His second gunshot wound severed a major artery and he almost bled to death — but he pulled through. The third time he was shot, the bullet struck his head. He didn’t survive.
She had one patient, also shot in the chest and near death, who somehow lived and was sent home to recover. A month later, he was back again. Shot again.
“I said ‘Listen, you get shot again and the next time you’re going to die,’ ” she said. “They don’t get it that death is a permanent thing. They don’t see that on TV. They don’t see that on the streets, where their friends get shot and are OK.”
‘You can stop now’
The 18-year-old lay on a table in the middle of the operating room, the only still body in a room whirling with people: nurses monitoring his pulse and blood pressure and handing over instruments, doctors cutting open the young man’s chest and using an instrument similar to a car jack to keep it open.
His breathing, controlled by machines, was steady and slow, his pale lungs expanding and contracting in full view, his heart squeezed between them.
“We need as much blood as you can give him,” Goldberg said. “We need more blood, more blood.”
So much was happening, but time seemed to go so slowly. The doctors tried to stop the blood gushing into the boy’s chest, suctioning it out and soaking it up with cloths. They alternatively took turns compressing the teenager’s heart in their hands, willing it to fill up and start again.
Goldberg reached her red-smeared, white-gloved hands into the chest cavity and pulled out a small, bloody piece of metal.
“This is for the police,” she said, holding it up briefly. “It’s the bullet.”
She tossed it to the end of the operating table, near the boy’s bare feet.
“Oh, my God; oh, my God,” one nurse said, staring at the bullet before another took it away. “He looks so young.”
The teenager’s body was still, unresponsive, but the doctors kept working. Goldberg never left the young man’s side. She said his heart was cold so another physician poured warm saline on it. Goldberg supervised as they clamped the aorta to affect the blood flow. Her calls for blood were constant, and the medical staff poured unit after unit of fresh blood into the teenager’s body. Nurses squeezed blood-soaked gauze-like sponges so the vital fluid could be used again.
Nothing seemed to help.
Goldberg called for the paddles to shock his heart, and the doctors took turns holding the lifeless organ within the metal prongs while the others stood clear. They did this once, twice, five, 10, eventually 12 times. No reaction. They injected the stimulant epinephrine straight into his heart muscle. It didn’t flinch.
“You can stop now,” Goldberg said. “We’re going to have to call it.”
She said it quietly, but everyone seemed to hear. One nurse walked out of the room. Everyone else kept working — counting sponges, putting away equipment, examining the open wound to determine what had gone wrong. The machines kept whirring and beeping.
Roughly an hour and a half after the teenager had arrived at the hospital, kicking and screaming, it was over. His heart, as it turned out, hadn’t been damaged by the bullet at all. Instead, the largest vein leading to it had been sliced open by that seemingly insignificant piece of metal.
“It would have been easier to fix his heart,” Goldberg said.
The hardest part of the job
There is no good way to tell a family their loved one has died. Goldberg has done it dozens, perhaps hundreds, of times over the years. Each time is a separate agony.
“I practice over and over again,” she said.
She tries not to take her work home with her, she said, but each death stays with her for weeks afterward. She and her team break down what happened, try to figure out what they could have done differently or better. Despite having seen this so many times, she still remembers the details of cases from long ago.
“I guess every death stays with me in some way,” she said.
While the other team members sewed the teenager’s chest shut with black stitches, Goldberg walked out of the operating room alone. She took off her mask and gloves, pulled the coverings from her shoes, then began washing her hands. She scrubbed hard, until her skin was red.
“We’re going to have to tell his family their little boy is dead,” she said.
She wasn’t sure what she would say. Experience had taught her that people want her to be direct: They don’t want sweet words. They don’t want long stories. They just want to know.
Still, before the family arrived, Goldberg paced in the hall, her head down, wondering which words she would use. She practiced possible openings on another doctor. Should she give many details of the surgery? Should she talk about how he’d fought to live? Should she tell him how they’d fought to save him?
But in the end, when she met with the teenager’s stepfather in a small private room, she kept it simple. She looked up into his eyes, took his hand, and told the man that his boy hadn’t made it, that his boy wasn’t coming home.
“I’m very sorry,” she said.
About This Story
With the permission of Temple University Hospital, reporter Natalie Pompilio and photographer Elizabeth Robertson spent a night in the Emergency Department with chief trauma surgeon Amy Goldberg. Patient identities were not disclosed to protect their medical privacy.