Amazing shift in the ED. Unbelievable. We had been having a medium paced day. The med student was doing the heavy lifting and I was keeping up with charts and chatting up the patients. 9:30 pm passed and a little bell rang in my head--shift's over, everyone coming in now belongs to the 10pm guy. Great--wrap up three or four outstanding dispos and be home to potty break the dog and see the Beautiful Biscuit twenty minutes early. Ten minutes later the medics call in--gun shot wound to chest, coming to us. I half listen to the radio until I hear the guy is in agonal respirations. Then I stop the med student's presentation and go to the radio room. Young guy, found down in a pool of blood, apparently one through and through gunshot, and--here's the vital part--agonal respirations and (they think) pulses. Question: 1) Does he go to a trauma center? 2) If he comes here, do I crack his chest? The guy deserves a trauma center. Surgeons in house, plety of docs to manage the initial resusc, OR ready and prepped, etc. But he'll never make it to one. We're twenty to thirty minutes from County USC, and twenty to thirty minutes to UCI, and about the same distance to Arrowhead. Ah, California, your miserable Trauma/Emergency infrastructure--what madness is this? So, the medics want to bring him here and I feel that we're honor bound to take him. And if we're going to take him we have to do it right. Vitals in the field, penetrating chest wound, and loss of vitals....the textbook says crack the chest. My ex-residency director made it clear all those long years ago--never crack a chest in the community: the guy will die, you'll be holding the bag, and you don't want to be the last hands on a corpse. But in the absence of a state wide legitimate trauma system we need ER docs who are willing to do it all. So I ready myself to crack the guys chest and wait. Wait and prepare. We get all the equipment together--chest tray, chest tube tray, central line, intubationn equipment, O- blood, rapid infusers, four IV's stripped and ready, goggles on, gowned up, double-gloved. I run through the various options and plays ahead of me. Sirens in the distance, and I feel myself tightening up and getting ready. It's a great, great feeling. They roll the guy in, doing compressions and wiith blood burbling out of the EOA tube jammed in his mouth. Okay. Do compressions and give me the rib spreader. I take a flimsy little scalpel and make a sternum to gurney incision in his chest wall. Big guy and only on my second sweeping cut do I hit the ribs and trace my blade through the intercostal muscles. Rib spreader ready (I've never used it) and I wedge it in place. Crank, crank, crank and with a pop and snap I'm looking through a bloody, meaty, ragged edged hole into this guy's chest. Big pink wet floppy lung rises and falls. I shove it out of the way with the back of my right hand and dig in with my left to find the heart. There it is, the motionless avocado sized piece of muscle just above the spine. I pull it towards me--pericardium tight on the heart itself--no blood to evacuate. I make my incision, paralell to the axis of the body to lessen the chance of hitting the phrenic nerve (an odd nicety considering the gravity of the situation.) I nick the myocardium on my way in. I examine the heart and run my fingers over it--no holes. I cup my hands around it and compress while I think about the next move. Have to clamp the aorta. Shit--never done that before either. The great nurses have started lines and pushed epinephrine and atropine. I take these odd long curved hemostats and push them in to the cavern of this guy's chest. No, this won't work. I picture the anatomy and put my right hand in until I'm feeling the spine. There's something meaty above the spine. I slide the hemostats in my left hand in, along my right hand and clamp the shit out of the meaty thing above the spine. What next? Central line. It's busy at the head, and he's got a GSW right by his right subclavian. I go for a cordis in the left fem--hit it blind on the first shot. Feed the line in and call for the saline that we have prepped--we're filling this guy with fluid. We have blood on the rapid infuser and saline going in on pressure bags. The nurse is doing internal compressions. We stop, reassess, and I see the heart twitching and shivering. It's hanging out of the hemithorax, a grey-pink yellow veined egg shaped organ, nude, exposed, glistening and twitching under the lights. We'll haveto defibrilate this. Internal paddles (I've never done this) and guess that we should go for 10 joules. I cup the heart in the paddles and call "Clear". Thud--the heart starts beating. We give more epi and now the guy has a carotid pulse. And now what? It never occured to me that we might get to this point. Return of pulses?! I ask them to call the trauma surgeons. Cardio-thoracic responds. She has all sorts of good reasons for not getting out of bed and coming in. The guy probably won't live. I agree-but my job is to get pulses back and call the surgeons. This is a job for trauma surgeons--I agree, and we're calling them also. Angrily she agrees to come in to "help the trauma surgeons". We call trauma--they don't even bother to speak to me, they just tell the nurse its a job for thoracic and they refuse to come in. We call general who is in house, but, unfortunately, working on the bowel perf I gave them an hour earlier. What a surprise--I crack the chest on this unsalvageable victim, get his pulses back, and there's not a god damned surgeon who will have anything to do with him. Why take on the liability? The guy will probably die anyways, right? I put a chest tube on the right side and in thirty seconds a liter of blood pours out of the chest tube. I call for the re-infuser. I intubate the guy. A hard, hard tube to make--swollen oropharygeal tissues from previous attempts and chords constantly obscured by the blood pouring up out of this guy's airway. We push it a little further, but without surgeons willing to help this guy is already dead. When the heart slows on us and when it stops I push epi once and then canvass the room and call it. We almost did it. I'm glad we tried. I feel better about myself for going big and doing everyhting possible. My ex-residency director was right, of course, it was pointless and I did nothing but expose myself and my team to blood borne diseases and lawsuits. Still, if you call yourself a doctor you gotta try. This guy had one hope in the world, and what if I had given up on him? I don't mind failing, but I would have been ashamed to not be willing to try. It looked like a warzone. Knee deep in bloody sheets and discarded papers and plastics--the detritus of a full bore code. All of us covered in blood--I'm bloodied up to the elbows and have blood spattered on my goggles and face mask. The left lung and heart lay hanging there motionelss under the lights. The med student is just on cloud nine. She was part of something unbelievable. She held a human heart in her hands and helped keep it pumping. She says flattering things to me and I think I can say that she will never forget what we did tonight and what she saw me do. I wish my mom had seen this. She would never have been able to believe her son was doing this. It would amaze her and, I hope, make her proud. U-561