Speed and Skill Saved Boy
By Tamara Jones,
The doors to the Bowie Health Center had just been unlocked, and Tom Lyons was catching up on paperwork before the usual parade of cut fingers, sore throats and headaches began. Mondays have a bad reputation with emergency room doctors, and Lyons knew the small suburban ER he ran would be bustling soon enough. He was savoring one last cup of coffee when he heard someone shout for him in the hallway.
We've got a gunshot wound!
Lyons hurried to the trauma room. It would not be the first time some hunter had shot himself in the foot, or kids had mishandled a BB-gun. What he found waiting there instead stunned the 50-year-old veteran of emergency medicine: a boy slumped in a wheelchair, blood soaking the front of his white football jersey, his face alarmingly pale.
The boy was conscious and alert, but in shock. His aunt, a quick-thinking nurse who had rushed him to the nearest medical help rather than obey a 911 operator's instructions to wait for an ambulance, said he had been hit outside Benjamin Tasker Middle School, a mile and a half down the road. The boy was just 13. It hurts a lot, he told the doctor. Lyons recognized the fear in his eyes.
It was the look of abject terror some people get when they know they're close to death.
This boy knew.
In emergency medicine, the first hour after a devastating injury is called "the golden hour," when every minute counts in the battle to save a life. Survival depends mightily on whether doctors can stabilize a patient during those 60 minutes, keeping vital signs steady. Airway, breathing, circulation. The ABCs of major trauma. Don't let the blood pressure plunge or the heart jackhammer.
Lyons found a bullet hole the size of a pencil eraser in the upper-left side of the boy's abdomen. The blood bubbled as air gurgled from the hole, signaling a sucking chest wound, the kind expected in a combat zone, not a schoolyard. Blood was pooling in the boy's lungs. Lyons knew getting him to a hospital was not an immediate option. He would never last the 13 miles to Prince George's Hospital Center. As a free-standing ER affiliated with the hospital, Bowie Health had resuscitation equipment; it got a fair number of heart attack and stroke victims. Lyons put the boy in the cardiac room.
Meanwhile, a nurse switched on the intercom and called the outpatient surgical center next door to Bowie Health. Gunshot. We need help! A surgeon, anesthesiologist and several nurses raced through the hallway connecting the two buildings. Lyons would later marvel at how a quiet urgent care clinic had been instantly transformed into a full trauma unit.
The makeshift team administered drugs to sedate and paralyze the boy, and rolled him over on the exam table. There was no exit wound. An X-ray showed fragments scattered like confetti through several major organs. The bullet had exploded like a small grenade inside the child.
"He had six or seven life-threatening injuries," Lyons said.
The doctors put the boy on a ventilator, forcing air into his damaged lung. A chest tube was inserted to drain the blood flooding his lung and chest cavity, and three intravenous lines were run. The boy's parents arrived, the mother in hysterics, and Bowie's cheery waiting room began filling with police. That the boy might be the latest victim of the sniper terrorizing the region did not immediately dawn on Lyons. "Things were happening so fast, we were just thinking about what to do next," he recalled.
An X-ray revealed damage to the boy's spleen, a large spongy organ prone to hemorrhage when injured. The boy was in danger of bleeding to death, but Bowie had no blood bank. Just two units of O-negative -- the universal donor -- on hand for extreme emergencies. Lyons grabbed both bags. ABC, thought Lyons, then get him the hell out of here so someone can operate.
The Golden Hour Runs Out Twenty minutes had passed -- the golden hour was slipping away fast.
Once the boy was stabilized, Lyons got on the phone to Children's Hospital. "There was no question where to send him," Lyons said. "He needed the best." The boy's distraught family was reassured, too; the aunt was a nurse at Children's.
Lyons's call was routed to a communications command center, where the dispatcher activated a code known as Trauma Stat. Pagers instantly beeped on the belts of 18 surgeons, emergency doctors, radiologists, respiratory specialists, anesthesiologists, nurses, runners to ferry blood and lab work, social workers, even hospital administrators. A text message advised them that a 13-year-old was en route with a gunshot wound to the chest. Maryland state troopers were transporting him via helicopter from Bowie Health.
One of the computer screens in the command center flashed flight information: Six minutes for Trooper 2 to fly from its base at Andrews Air Force Base to Bowie, and seven more minutes from Bowie to Children's. The medics on board also would relay the boy's vital signs and condition when they were in the air. Because of weight restrictions on helicopters, family members are not allowed to ride along. The boy's family would have to drive the half-hour to Children's, calling for updates on a cell phone along the way.
The trauma team gathered in an emergency room hallway at Children's to wait. Michael Holder was the attending ER physician who met the chopper on the eighth-floor helipad and caught a first glimpse of the boy. The young doctor felt a surge of emotions -- shock, outrage, sorrow.
Downstairs, Stephen Teach, the associate chief running the ER that morning, presumed that his young patient was the sniper's latest victim even before TV news bulletins reported it and the police converging on Children's confirmed it.
"I knew in my heart," Teach said. "The ante had just been significantly raised: A child had been shot."
The boy was admitted to Children's as a VOV -- victim of violence. For his protection, he was assigned an alias, which became the name all staffers would use, and which anyone seeking information about him would have to know. A bogus file was created in the computer system to throw potential hackers off the trail. And in this high-profile case, because the boy was considered a witness and therefore at risk, uniformed police officers stayed within reach of him at all times. Hospital security and admissions clerks at both entrances also were told to be on alert. The ER was locked down.
Holder and Teach were happily surprised by the heroic efforts of Lyons and his team. "Bowie did an amazing job of stabilizing him," Teach recounted. Much of the work they had expected to do before sending the child to surgery had already been done. His vital signs were as good as could be expected, but the boy still was losing vast amounts of blood and in imminent danger of organ failure.
A handful of gunshot wounds come through the Children's ER every month, but in his five years there, Teach could not remember ever having seen a wound from a high-powered rifle like this. "It's not like a big body accepting the force," he explained. "It's a little body accepting that force."
Physiologically, children are different -- not adults in miniature. Their hearts are generally strong and resilient, but their lungs are smaller. For adults, cardiac arrest is the most common danger in a major trauma. For children, it's respiratory failure. Machines were breathing for the 13-year-old now.
In the ER, the trauma team spent about 15 minutes examining the boy and doing what they could to control the bleeding before sending him to the operating room. A uniformed Prince George's County police officer followed the gurney and stood guard outside the OR.
It was a little past 9 in the morning. The boy had been shot at 8:08.
The golden hour was gone.
Damage Control Martin Eichelberger was called out of a skin graft on a young burn patient to perform emergency surgery on the gunshot victim. The 57-year-old chief of pediatric surgery at Children's quickly paged the department's vice chairman, Kurt Newman, who was so surprised to see the digital message that the news stopped him mid-sentence in an administrative meeting. Newman was patched through to the OR and could tell by his longtime partner's tone that this was bad.
We've got a gunshot wound. I need your help.
Newman bolted for OR-2. A portable X-ray in the ER had given the surgical team a generalized overview of the boy's wounds, but time was too critical to spend getting the three-dimensional view a CT-scan would provide. Eichelberger wouldn't really know what he was dealing with until he got inside. The question now was whether to open the chest or the belly. He had a fifty-fifty chance of being right.
"If there was a gunshot wound to the heart, we had to do something quick," Eichelberger recalled. "If he had gunshot wounds elsewhere, then we had more time." He opened up the chest, making a foot-long horizontal opening between the ribs.
The doctors had no idea whether the bullet had been designed to come apart and spray shrapnel inside its victim, or whether it had fragmented after hitting one of the boy's ribs, which was broken. But even an initial glance inside the 13-year-old told Newman that "this was a bad, bad gunshot wound. What is incredible is that this kid didn't die at the scene."
Once a patient has lost 20 percent to 25 percent of his blood volume, the blood pressure will suddenly plummet and the body's organs will go into crisis. Controlling the massive bleeding also was imperative to prevent brain damage, since blood carries oxygen to the brain.
Seeing no damage to the heart or its lining, the surgeons swiftly moved to clear the blood around the left lung, which appeared to have sustained most of the injury.
The anesthesiologist, Ramesh Patel, suddenly spotted blood in the breathing tube, which could spell disaster if a major blood vessel around the lung had been hit and the bleeding could not be controlled. Eichelberger quickly ruled that out. Still, the lung had been badly ripped and lacerated by the bullet fragments.
"There was a lot of blasting," Newman observed. "The lung really looked like it had been smashed."
Fortunately, the lung -- especially a young, healthy lung -- has "an amazing capability of healing itself," Newman explained. Eichelberger decided against removing any part of the lung. The team tamped down the lobe with damp sponges to slow the bleeding and kept moving. Judging from the X-ray and the likely trajectory of the bullet, the doctors knew that they had only just begun.
There was a lot of bleeding in the abdomen, too. The surgeon's scalpel now sliced the boy open vertically, from just under his sternum to his belly button.
"It was like some sort of bomb had gone off in there," Newman said.
The diaphragm had two holes in it, one of them fairly sizable. The liver was badly torn, and the tip of the pancreas had been hit, too. The team was relieved to see that the boy's kidneys and the major blood vessels around them had been spared, but the whole front of the stomach gaped open. Not only was the wound itself severe, but his system would have been contaminated by the stomach's contents as well, putting the boy at even greater risk for infection.
"On the positive side," Newman said, "we were not encountering anything that couldn't be handled. There was a lot of optimism. We were developing a sense that these are all fixable problems, that there was a solution for everything."
Operating rooms must be kept warm to facilitate blood clotting, and Eichelberger's tendency to perspire through his surgical hat was a running joke with him at Children's. Tough surgeries were "two-hatters." Now Newman shot a look at his friend and announced the obvious:
Marty, this is really a five-hatter for you.
Next stop was the spleen, which produces some white blood cells, filters out old red cells and returns needed iron to the blood. Soft and porous, the organ is nearly impossible to repair, like trying to sew wet Kleenex. One member of the team questioned whether there was not some way to save it. Eichelberger glanced at Newman. "I'd take that out," Newman confirmed. Medication could compensate for the loss of the spleen. Removing it would also alleviate some of the hemorrhaging. It seemed as if every time Newman looked up, they were hanging another bag of blood to pump into the boy.
The team moved on to the pancreas. "It's a tricky one, a finicky organ," Newman said. "In surgical medicine, there's a saying: Eat whenever you can, sleep whenever you can, and don't mess with the pancreas."
Splayed across and behind the stomach like a fish with a large head and long tail, the gland secretes digestive juices, neutralizes stomach acid and releases hormones that regulate glucose levels in the blood. The surgical team stapled off the bit of damage to the tail.
Most of the dozens of bullet fragments riddling the boy's body were tiny, not even visible to Eichelberger as he worked. When the doctors did happen across a shard that could be removed without further insult to an organ, they dropped it onto a piece of gauze to save for police.
Focusing on the liver, the surgical team meticulously stitched up the shrapnel wounds. Though badly gashed, the liver was salvageable. Like the lung, the organ was capable of healing itself, and could regenerate whatever was lost within a matter of weeks.
Finally, the surgeon confronted the boy's most challenging abdominal injury: the stomach. The entire front wall was blown open, but fortunately the stomach was not bleeding. Removing all or any part of the stomach would obviously impact the young patient for the rest of his life. Eichelberger, nationally renowned for pediatric trauma surgery, thought he could avoid that. He showed Newman the injury and described how he would sew it shut in two layers.
As they were closing the stomach, it occurred to Newman that the biggest fragment -- the thumbnail-size piece of bullet lodged in the chest -- might be important evidence for police investigating thesniper attacks. Normally they would just leave it in place. But a different thought popped into Newman's head: We wanna get this guy. Now Newman went back to scrutinize the X-rays more closely. It did not look as if the fragment was in the abdomen or chest cavity. It appeared to be outside, in the chest wall.
Eichelberger called for a fluoroscopy machine to more precisely pinpoint the fragment's location. The giant C-shaped arm was positioned over the boy and began shooting continuous X-rays that flashed images on a monitor. Newman was right: It was in the chest wall. Using two clamps to lock in on the area, Eichelberger made a tiny incision and popped out a half-inch-long piece of gnarled lead.
Experienced in preserving chains of evidence in criminal cases, Eichelberger designated Newman as the point man, dropping the fragment into a cup and passing it to his partner. Newman logged it and took it outside to the waiting police.
He was perplexed to find officers from both Montgomery and Prince George's counties waiting. Both wanted the evidence. Calls were made, and after waiting 10 anxious minutes, Newman turned the fragment over to an agent from the federal Bureau of Alcohol, Tobacco and Firearms. A hospital pathologist examined the shard and stipulated in writing that it had been removed from the boy. An ATF agent sealed the cup in a special baggie, tagged it and took it away.
Ballistics tests later confirmed what authorities had suspected all along: The boy was the victim of the one-shot sniper.
With the 2 1/2-hour operation winding to a close, police asked the medical team for more help. They wanted to know the boy's height and the distance from the soles of his feet to the entry wound. Could the surgeons tell what position the boy had been in when he was hit? They also wanted the clothes that had been cut off the victim.
Back in the OR, Eichelberger gave Newman the high sign.
The boy was not out of the woods yet, but they had done what they could for now.
Newman, himself a father of two young children, felt relief but something else, as well, as he gazed at the small, wounded figure on the operating table. Fear.
"That could have been any of our kids lying there," he said.
Watching and Waiting A week after becoming the sniper's ninth victim and one of only two survivors, the boy remains in the intensive care unit, heavily sedated, in serious condition. Doctors are hopeful for a full recovery with no long-term disability, though it is still too soon to rule out major setbacks, such as infection, recurrent bleeding or organ failure. "We're in a critical phase with this youngster," Eichelberger said. "There is a lot of luck involved here, and I hope I'm a lucky surgeon." The boy's family describes him as a fighter.
At the Bowie Health Center, Tom Lyons feels relief but the heart-tug of depression, as well. How, he wonders, do you begin to fathom someone "hunting a kid like a deer"? He passes Tasker on his way to work each day, and the innocence lost is not merely imagined but spelled out in block letters on the marquee outside the middle school, where usually there would be word of Halloween dances or science fairs.
Now it offers the number of the sniper tip line.