by Robert Lanz, LCSW
“On and on it went, lives measured in inches and seconds and deaths avoided by complete accident.” – Sebastian Junger, War
The 300-pound, heavily tattooed 20-year-old man could not have been a more stereotypical gangster: shaved head, baggy shorts, spotless high white socks. His voice was loud and his mood boisterous as he re-enacted for his family the incident that brought him to the ER. Latino gangsters who have been shot behave differently from their black and Asian counterparts in the ER. They tend to be much more cooperative with their medical careakers, are thankful and polite and generally make good patients. The level of respect they show for authority in the hospital is usually high enough that they don’t cause problems. Black gangsters, on the other hand, are much more likely to be rude and physically confrontational. They often do things detrimental to their treatment such as calling a member of the lifesaving team a motherfucker and kicking him. Asian gangsters act as if they are not really there. They are essentially cooperative, but don’t interact much with staff. Their demeanors are cold and distant, but not as hard as those of the blacks. On the other hand, the Latinos getting patched up are frequently warm, funny and openly expressive of their appreciation.
In the interest of being inclusive, I have seen a few white gangsters in the ER, but usually, they are guys who associate with the black or Latino gang in their neighborhood and take on the cultural attributes of that group. Under police questioning, black gangsters who have been shot by someone they know either lie in a hostile manner or say something stupid like “Fuck you, I ain’t telling you shit, motherfucker.” Latinos often act contrite, look the police right in the eye and lie in a nice way. The cops know they are lying, and the gangsters know that the cops know it. It’s part of the game. Asians are as remote with the cops as they are with us, and usually won’t give up the name or gang affiliation of the guy who just tried to kill them. Of course, this reluctance to include law enforcement is also part of the game we are familiar with, and we know there is a good chance we will soon see more victims who’ve been shot in retaliation.
When the cops showed up to talk to that night’s victim, the enormous guy who had taken two small caliber bullets to the back, it was like old home week. The victim called the officers by name and denied knowing the identity of the shooter, whose face had been covered by a bandanna when he ran up in the video arcade and cut loose with a couple of rounds. This was a total lie, of course. The shooter yelled his gang name before shooting just so the victim would know exactly who shot him. The game. Two points for the opposition. But weak points, as the victim didn’t suffer much of an injury: a broken blood vessel that required a CT scan and angiogram to try and determine if the leak to his artery was great enough to require surgical intervention.
The investigating cop, an old friend, told me that only the day before, the victim was lamenting the fact that despite being in the gang a long time, he had never been shot and was hoping someone would remedy that situation. His goal was either to be put out of his misery (gangsters love a good send-off even if they are the ones being sent off) or to survive without too much pain so that he could display the red badge of courage. He would finally have achieved one of gang life’s highest status symbols, getting shot and surviving (the others being hard time in prison and killing another gangster without being caught).
Being shot twice and being able to go home the next day was the ultimate macho move, and the victim was brimming with pride. His parents were there, vowing vengeance, his girlfriend was there, displaying dramatic concern, and his homeboys were already busy setting up a retaliatory strike. The game. It’s a family game. I can hear the kid bragging already, “Those putos from Villa are pussies, had to run up and shoot me in the back and they still couldn’t hurt me.” This was the night of his life, his graduation. Everyone was so proud.
It’s hard to tell if these guys are so depressed that they actually look forward to dying. I would consider weighing three hundred pounds at twenty years old a sign of depression, but then it can also be a sign of a guy who sees no future for himself and who only lives in the present. In his culture, his obesity and his depression are acceptable, so long as he is willing to die for the gang. The gang would accept him no matter what his emotional condition is. My guess was that a guy like this was really unhappy and had no perception of a potential emotional rescue. His behavioral escape, which might be defined as a form of mental illness (dysthymia—low level depression), actually becomes an acceptable behavioral trait. Nobody really cares how he feels about himself, only that he acts a certain way with his gang. The problem is, this guy had found a totally dysfunctional cultural treatment for his depression, and in the short term, it worked because it is reinforced by anyone who is in the game with him. It follows that, if there is no attention paid to his negative behavior, it only reinforces what he already believes about himself, that he is a worthless person. He’s in too deep. The game claims another one, and there’s no way out.
While I was sitting thinking about the game, the charge nurse came running to my office, “Bob, we’ve got a two-year-old going south in Room Four, get the parents out of there.”
I quickly did just that, leading them to the anteroom to my office, where bad news is delivered, so that when the family screams out in emotional pain they can have some privacy. It also keeps their reactions from causing panic in the other patients, who are already anxious enough.
The young couple appeared to be warm and loving parents, and they told me that the kid had been sick, like kids will be. He threw up a couple of times the day before and started with a little diarrhea last night. They thought he had the flu or something and that it would pass. Made sense. Except that in the case of sick kids, not everything makes sense. The child had a high fever and mother said he had been having episodes of diarrhea all day. He was slightly lethargic, but still interacting with his parents. We could tell pretty quickly that he would have to be admitted and re-hydrated for a couple of days while we figured out what was wrong with him. Was it a virus or was it bacterial?
As is usually the case, we called the in-house pediatrician, and he came down and made arrangements to admit their child. The nurse went into the room to start an IV but was having trouble finding a vein. Kids have small veins anyway and they can be hard to hit. Some people have what are called “slippery” veins, which are difficult to puncture and dehydration causes diminished blood volume and veins all but disappear. This kid’s circulatory system was shutting down from lack of fluids right before the nurse’s eyes, and during one of her attempts to establish the IV, the boy’s blood pressure dropped unexpectedly, making it even more difficult to get the line started. With rapidly decreasing blood pressure, the child then went into respiratory distress, which slowed his heartbeat, further collapsing what was left of his veins. We were losing the kid, and the nurse called for a Code procedure. The team responded.
It was my responsibility to get the family out of the immediate area because the flurry of activity is generally too much for them. The doctors find hovering parents distracting. Sometimes the parents freak out and get in the way or make the atmosphere more emotional at a time when it needs to be the most clinical. It’s amazing for me to watch a resuscitation attempt on a child, because I know that most of the people on the team have children, and I know exactly what they are thinking and feeling, yet it doesn’t seem to get in the way of their judgment.
That night, the team was even more focused, because the new in-house pediatrician, with whom no one had been in a code situation before, was so directed, so calm and so polite, it was almost unnerving. The team quickly placed a tube down the little boy’s throat and into his lungs and attached a bag to it which would be used too force air into him. A nurse began the chest compressions that would move the blood in and out of his heart until we could get the heart stimulated into performing that function on its own. The body can tolerate this sort of artificial respiration and circulation for only so long before the lack of oxygen begins to cause brain damage, so there is always a sense of urgency, not just to save a life but to ensure that the life you save can continue to be one of the highest quality. Sometimes people get saved so they can lay around on a machine for a long time. Sometimes they return to normal. The longer it takes to get the heart and lungs working on their own, the worse the prognosis is, something everyone in the ER is aware of. I am amazed at how well the team does under these circumstances.
A two-year-old child whose life is slipping away is one of the most difficult things ever to watch. There are at least ten people around the bed doing CPR, loading medicine, putting lines and tubes in every part of the kid’s body. A doctor cuts deep into his legs and neck to try and find a suitable vein for all the fluids he needs. Another doc does an intraosteous stick three times just below the knee in which fluids are injected into the bones because sometimes that is the last place where acceptable circulation can be found.
This was taking what seemed like forever as the nurses took turns doing chest compressions, the most gut-wrenching of all the tasks being performed. They take turns, not because, as with adults, it is really hard physical work to make a child’s heart compress enough to move blood through it, but because it is it so emotionally draining it can’t be done by anyone for more than a few minutes at a time. The flurry of activity involved in drawing blood, getting results and trying to give the right amount of various drugs to correct the metabolic imbalance is amazing to follow. Calculating the child’s weight, blood pressure, heart beat, if he has one, and respiratory rate, and then figuring the dosages and getting them right, places everyone on the firing line. Mistakes can be fatal ones. Why anyone would want to put themselves in that position on a regular basis is beyond my comprehension, yet it doesn’t seem to make those who do it crazy or emotionally void the way one might think it would.
My job, in these situations, is to sequester the family, make frequent trips between the anteroom and the code room and provide updates and progress reports. If we are not making progress and the team thinks it is likely the child will die, then my job is to prepare the parents for that. I deliver the information little by little, so when the doctor comes in and delivers the bad news, they will have had some chance to warm up to the idea.
As the code progressed, I knew that was going to happen tonight. The news grew worse, going from, “We’re not able to get his heart to respond to the medicine and he’s still not breathing on his own” to “He’s very sick, right now we aren’t sure what will happen” to “Nothing seems to be working yet. There’s a chance he might not live” to “We are down to our last attempts and he isn’t responding, we don’t think he will survive”. It developed into a moment in life where nothing really makes sense to the family and probably never will again. Life is both all too clear and a blur at the same time.
Before the situation had gotten grave, and the parents were certainly smart enough to see that was coming, they asked to be with the child if he was going to die. This is one of the hardest calls I ever have to make. Even when it involves an old person at the end of life and the regular ER physicians are running the code, they don’t like the way the presence of family members heightens emotions when they have so many intellectual decisions to make. On the other hand, the family has a right to be with their loved one at the moment of death, and it appears that doing so has a lasting beneficial effect.
But that night, it was a child and he had been dying for forty minutes. His parents couldn’t stand the chorus of bad news any longer. They asked directly to be in the room with the child to be able to offer encouragement, to take some hope from something—anything. I let them into the room. The doctors who didn’t know me were a little anxious about this, but the head nurse, my oldest dearest friend in the ER calmly took the parents to the bedside. They were able to hold the child’s hand and keep calm and try to encourage the child. The teams just worked around them and none of them gave off any bad vibes, so I left to see some other patients who had been waiting for me.
Within minutes, things changed. The nurse found me and told me the doctors had become upset by the parents’ presence and wanted them out of the room. As far as I’m concerned, the doctors are the captains of the ship, the social worker is the director of public relations and the patients and families are paying guests so there is always a lot of conflict on these issues. The child is the doctor’s patient and he has a right to be in control of the child’s care as long as he has the responsibility. My patients are the families and I have to do what I think is best for them. We fight about this. Sometimes I win, sometimes I lose.
I was able to get the parents back to my office for a couple of minutes, but they wanted to be as close as possible to their dying child, so we stayed in the hallway with the door open. This was a workable compromise for both the parents and the ER team. At the one-hour mark, the level of anxiety was as high as I’ve ever seen it. Most codes don’t last nearly that long. In an hour, we have either stabilized the patient or have given up and pronounced him. With a child, there is almost always a perceived need to work longer, and the team continued. At an hour and twenty minutes, all of the stimulating drugs and acid balancers took hold momentarily. The child’s heart beat on its own when CPR was halted. There was a slight blood pressure, so slight it could only be heard through an electronic, amplified stethoscope. The monitor clearly showed that the heartbeat was not a good one, but after an hour and twenty minutes, any heartbeat was encouraging. I know from experience these little reprieves often take place. I also know that usually, they don’t last very long and the team is back to square one. Still, the parents have a right to know about any positive developments, so they were told. They, quite naturally, grabbed onto this as a sign the child might improve. Who wouldn’t? Even an old hard ass like me wanted to believe it. We all wanted the ordeal to be over for the child, for the family, for us.
Within three minutes the boy’s heart stopped beating and we started CPR again. The parents descended to new lows and I fell with them. I hated being the messenger, the only person they could get any hope from at the moment, the one they clung to in desperation. I was just as desperate for any good news to give them. The reality was that after this much CPR with minimal oxygen to the brain the child would not survive no matter what we did, and if he did survive it would be the worst thing for him. We all knew that but didn’t give up.
We finally stabilized him with a very weak heartbeat and very poor pulse. His pupils were so sluggish they were barely moving, a sign that brain circulation has been compromised significantly. We all knew the child was dead, if not in heart, at least in brain, but we admitted him to the hospital and when the child went upstairs I knew—we all knew—he was going to die. All except for the parents. They still thought he was going to get better. They needed him to get better. But he didn’t. He died slowly over the next twelve hours, no pain, a peaceful passing and I was glad I didn’t have to be there. That was something for the day shift social worker. I’d had enough of that for now. I’d had enough of that forever.
After the child was taken upstairs, I talked to the new pediatrician who had run the code.
“Hey, good code. You stayed calm and centered in the middle of all that. I thought you really did a great job”.
He responded, “Thanks, I wish we could have done better.”
The outcome could have been better, but the team could have not performed any better. Its the hardest thing of all, to see the team play so well and lose so big.
On the way home I was thinking about the gangster with the dysfunctional gang culture, reflecting on all the pain he will cause to himself and others, about how much time, money and effort it will cost to take care of that pain. It occurred to me that a great cosmic mistake must have been made that night. Otherwise, how was it that the wrong kid was going to die?