Peter Rhee - Trauma Red: The Making of a Surgeon in War and in Americas Cities

Serving humanity is a privilege and trauma surgery is a privilege.

To the people who made me who I am today: my parents and my wife, Emily. To my children, who were gifts from my wife.

To the military men and women who serve our greatest nation.

CONTENTS

CHAPTER 1

TRAUMA RED

T he sound of the gunfire had barely faded away when I got the text message on my phone: Heads up. Trauma red. Weve got ten GSWs coming in.

My first thought was, Oh, no, not now. Not today.

It was Saturday, January 8, 2011, my first scheduled full day off in weeks. I had just finished a thirty-six-hour shift the night before at Tucsons University Medical Center, where I was chief of Trauma, Critical Care, Emergency Surgery, and Burnsthirty-six straight hours of handling whatever sick, bruised, battered, bloodied, and near-dead humans the EMTs wheeled through the doors. Id had a couple of shootings, two stabbings, several traffic accidents, a pedestrian run over by a car, a guy who fell off his roof while trying to fix his air conditioner. We do medical emergency surgeries, too, for people who just cant wait, or who have waited too long, so I had done an emergency appendectomy and also cut out a cancerous tumor that had perforated the bowels of a guy who bragged to me that he hadnt been to a doctor in thirty years. In other words, it had been the typical day.

Trauma is a 24/7 business. I had been on call from seven A.M. Thursday until seven A.M. Friday, meaning Id had to handle all the patients who came through the door, and after that Id had to work another regular twelve-hour shift, so I hadnt gotten home until Friday night. Having a Saturday off was a rare event, and I was ready for some home time with my wife and kids. But first I needed a little me timeand that meant going for a run around the block. In my part of Tucson, in the mesquite-and-cactus-covered rolling hills north of the city, a block is about six miles around.

And now, shortly after ten A.M. , and just five minutes into my run, this: Trauma red, ten GSWs.

There was a lot of information in that brief message. Under the University Medical Center trauma activation criteria, a trauma code red indicated a patient or patients coming in with any of a variety of serious injuries: penetrating injuries to the head, neck, or torso; traumatic brain injury; amputation of an extremity; traumatic cardiac arrest; and so on. Trauma codes White and Green indicate progressively less severe types of injuries. The codes set in motion a series of steps at the UMC Trauma Center to ensure that the proper levels of staffing and resources are available to deal with them.

Ten GSWs was even more specific. GSW is short for gunshot wound. It meant that somewhere out there were ten people who had been shot, ten people who were in desperate need of someone who knew all too well what damage bullets could inflict on a human body, and, more important, someone who knew how to fix it. In other words, ten people in desperate need of a trauma surgeon.

I turned around and started running back home.

I picked up the pace a bit, but I knew I didnt have to sprint. Four years earlier, when I took on the job of creating a Level I trauma center at UMC, I had been determined to put together one of the best trauma teams of doctors and nurses and technicians in the countryand in my opinion, I had done just that. Other trauma surgeons were on duty, and I knew that until I got there they could handle anything that came in.

It wasnt as if we hadnt handled mass-casualty situations before. Even in Tucson, multiple gunshot victims were almost a Saturday-night ritual, and every now and then a chain-reaction pileup on the I-10 would flood the trauma center with a dozen badly injured people. Certainly in my fifteen years as a trauma surgeon, fifteen years in the urban battlefields of Seattle and Washington, DC, and Los Angeles, and as a forward-deployed US Navy surgeon in Afghanistan and Iraq, I had seen more than my share of individual and mass catastrophes. There was no reason to suspect that there would be anything unusual about this one.

Still running, I called my wife, Emily, and had the same conversation we had had so many times before.

Emily, sorry, but theres been a mass shooting, and I have to get back to the hospital... Yeah, I know its my day off, but I have to go... No, you dont have to pick me up, Ill be home in a couple of minutes. Could you do me a favor and put a clean set of scrubs in the car? Ill change on the way... Thanks... I love you, too.

I knew she was disappointed that I wouldnt be spending the day with her and the kids, but I also knew that she understood. I loved being a trauma surgeon, but for Emily, being married to one wasnt always easy. The job always came first.

I called in to the trauma center to get some more information. Details were still sketchy, but it appeared that a gunman, motive unknown, had opened fire outside a supermarket in a shopping mall, shooting into a crowd. A half dozen people were dead at the scene, and the woundedmaybe ten, maybe as many as twentywere on their way to UMC by ground and air ambulance. No word yet on the extent or the seriousness of their injuries.

The timing of the thing was actually pretty lucky. Dr. Randy Friese was just coming off his shift, Dr. Narong Kulvatunyou was just starting his, and Dr. Bellal Joseph was making the rounds and caring for the patients in the ICU, so we had three exceptional trauma surgeons on-site. The fact that it was a Saturday morning was also a plus. If the shooting had happened on a Monday morning, the UMC operating rooms might have been crammed with patients undergoing planned surgeries, and since you cant stop a surgery in progress to make room for another patient, no matter how great the emergency, we might have had to make do with the one OR that was always reserved for trauma cases. But since it was a Saturday, wed have plenty of empty ORs if we needed themwhich, as it turned out, we would.

I kept running. My phone rang again. It was RandyDr. Friese.

Im on the way, I told him. Moments after we hung up, the first patient from the shooting rolled through the doors. It was a nine-year-old girl.

Her name, as I would later find out, was Christina-Taylor Green. A bullet had hit her abdomen, piercing the main artery, the aorta. The first emergency personnel at the scene had performed CPR on her, but she hadnt responded. Unlike with heart-attack victims, CPR doesnt really help people who are bleeding to death; they need to get to a trauma surgeon, and fast. It probably was already too late for this little girl, but the EMTs kept trying, transporting her to our trauma center and performing CPR all the way. Maybe there was a chance.

Dealing with mass-casualty trauma victims is about making choicesoften life-or-death choices. The rule is simple. The most seriously injured patients who have a chance at living come first, the less seriously injured come next, and the dead and the certain to be dead have to be left to their fate. If you spend time and limited resources on those who cant be saved, it might cost the life of another patient who could be saved.

Its not an easy choice to makebelieve me, I know. In my career Ive had to make hundreds of decisions like that. Once in Iraq I had to look into the faces of twelve mortally wounded but still living men and declare them expectantthat is, certain to die. They were sent to a separate area and left untreated so I could help dozens of others who could be saved. Its something you train for and practice over and over, but in real life its not like the drills. You never get over it, and you never forget the faces. But there are times when deciding who lives and who dies is part of your joband if you think too much about what youre doing, you wouldnt be able to do it.