In vivo compressions

6-13-09 – Esmeraldas, Ecuador

It wouldn’t be a night out in Esmeraldas without a good gunshot wound. He came in around 11pm with a woodpecker’s nest through the side of his abdomen. Stuff like this is pre-approved for the OR, so off we went. A splash with the hands, a thwap of the gloves, a slice with the knife and we were in his belly – not looking good. His right kidney was like a kindergarten arts and crafts show but, again, that was the least of his problems. The most of his problems were shrapnel through a couple major vessels – namely the aorta and the vena cava. The trauma surgeon clamped off a few minor arteries but we were losing too much blood. Type O+. I’m type O+. I offered to drain a pint, but he needed more than that, so the case was on hold while the family ran to the blood bank on the other side of town. When his heart failed, we made a slice through the diaphragm and I put my hand up under his rib cage feeling for a organ bigger than a baseball, smaller than a softball, somewhere just to the left of midline. I found it and started squeezing. It was pretty amazing to see the monitor´s flat line pick back up again like a marionette. Eventually his heart took back over on its own right but only weakly, so I pressed it up against his rib cage with my right hand. With my left I counted down five intercostal spaces and inserted a needle between two ribs. As the plunger plunged, a drug called Atropine blocked the muscle’s parasympathetic nerve signals. In other words, it removed the heart’s brakes and the system sped up. The contractions got harder and harder but we were racing against time because he was still losing blood. In the end there was nothing we could do and he died on the table. On the way out of the OR I pictured the proud face on the other side of the trigger – some gang-banger a few blocks away, resting well, smirking. We are so awful to each other.

That was actually the third death of the night. The first two came in near simultaneously. We were trying to resuscitate a 73-year old diabetic woman when a young father barged through the doors cradling his four-year old and doing mouth to mouth. “Over there,” I yelled, pointing to the next table. I jumped over and he set the body down. The job is theoretically easy – airway, breathing, circulation, defibrillator – and in that order: the ABCD’s of life. I cocked his head back to extend his throat and open up his airway, but his jaw wouldn’t budge. That should have been a clue but I was not thinking straight. So I covered his mouth and blew into his nostrils – his chest went up and down with each breath but his body was cold, his arms rigid and, in case you have not figured it out, his clenched jaw was rigor mortis (when a body dies it stops making ATP, the gasoline of muscles – cut the gas and the muscles fibers can’t slide past each other, hence the stiffness). He had died on the way there.

I jumped back over to the first woman, now intubated, and took over on compressions. One and two and three and four… my orders were to count to 150 then listen for a heart beat – the ‘C’ in ABCD. But there was no ‘C’ and we had no ‘D’, and after a few rounds the doctor called the time of death at twenty-nine past the hour.


Around 4a we had the big morbidity and mortality talk, but I could hardly keep my eyes open. Over the previous few days I had written up a few thoughts, which I read, setting the stage for open communication. The front end was doctor-dominated - but in the end everyone contributed. Somebody commented that because we lack services, staff and speed, there really is not an Emergency Room – just a place to take cuts, burns and non-breathers in the middle of the night; I couldn’t disagree. We decided to make a few rearrangements – where to store tanks, how to give and receive orders - but time will be the test as to the effectiveness of our communication. After the others went to bed, Safadi threw on an episode of ER, subtitles in Spanish of course. He loves the series - mostly because it shows teams working together.

The rest of the cases that evening were pretty straight forward – mostly a lot of suturing. One guy came in with neck lacerations to his neck from a broken beer bottle. I was standing there getting ready to put in stitches when he pulled out a small piece of paper, opened it up and took a snort. “Are you insane?” I thought – but I couldn’t say anything because I was along in the room, didn’t know what the substance was, and didn’t want to get jumped.

Another patient came in helpless and ataxic (dizzy and staggering). “Take off your pants.” He took them off. “And your shirt”. It went too. “Now go sit in the shower for ten minutes”. He did. He did everything the doctor asked him to do – and would have easily given us his watch and cell phone had those not already been taken. Somebody gave him Escopalamina – a powdery street drug that affects one’s voluntary actions. It is used, of course, to rob people. The treatment involves exactly what I described, taking off the clothes and bathing – removing any residue and its lingering effects. You know the treatment worked when the patient realizes they are in a public shower in the skivvies and they don’t want to be. Genius… and hilarious.

I finished out the shift in the dining hall – shrimp empanadas for breakfast. I like the dining hall in part because I like eating, in other part because the people there are lovely. I like lovely people at the end of long nights.

-BH-