Another call night in downtown L.A. It had not been a particularly eventful day: the usual offering of people hit by cars, falling off of things, and victims of man-made violence. Some injuries happen as a result of an accident, some as a result of carelessness, and of course many happen because of an intentional act. At about 1am the trauma pager went off; the text announced a “Level 1 trauma activation” which means the trauma is a high level trauma, the incoming patient could potentially die within an hour.

Getting up from watching a DVD, I grumbled to myself, semi-seriously thinking how rude it is of someone to get hurt and disturb my tranquil period between trauma victims.  I snapped back to reality and I called the ER on my portable phone as I walked calmly to get there. I asked them what the trauma run was and was informed by the triage nurse that the paramedics were bringing an unknown age male with approximately 7 to 10 gunshot wounds who had no signs of life in the field when they got to him but they were bringing him in anyway, presumably because of a hostile crowd.

Paramedics are in personal danger if the crowd perceives that they are not doing anything for a victim of violence; since most people that are shot and stabbed in Los Angeles are black or brown, that perception is that the paramedics don’t give a rat’s ass about saving black and brown people, especially if they’ve been shot. So instead of creating the possibility that they too will become victims of violence at the hands of an agitated crowd, they load up dead victims into the ambulance and cart them into the hospital where the physicians have the tiresome duty of pronouncing them dead.

When I heard what was coming, I was simultaneously relieved and annoyed. I was relieved because a DOA is a no brainer. No mental or physical energy has to be expended on a DOA: check the EKG leads, if they are flatline, the physician can authoritatively pronounce time of death and feel like Dr. Benton on ER, even if just for a moment. I was annoyed because I had to get up from my DVD to come and agree that someone was already dead. That may seem callous, but it becomes  like any other routine in life. Most trauma surgeons and ER doctors cannot count how many people they have pronounced dead. I am used to dealing with death, almost comfortable with it, and it tends not to be an emotional experience.

I arrived in the ER and we waited for the “patient” to arrive. 10 minutes had already passed since the call came in. To add further perspective, several studies have shown that victims of penetrating trauma that lose vital signs in the field and have a greater than 10 minute transport time remain dead 100% of the time. Everyone in the ER gets ramped up when a DOA or TFA (traumatic full arrest) is on the way to the hospital. Nurses and techs and even some ER doctors get really excited. They get excited when the patient comes in and has a blip of an EKG tracing and a penetrating injury to the chest because they know the trauma surgeon may be performing an ER thoracotomy … dramatically opening the chest wide to try to control bleeding and to attempt to resuscitate a dead patient. Called “cracking the chest,” this is a very graphic, uncontrolled procedure because it is a last ditch effort.  Surgeons are usually unmoved by these patients because we know that usually the only people who survive that require a cracked chest are those who have a single stab wound to the heart and a witnessed loss of vital signs; all of the rest die with their chests profanely ripped open in the crowded ER. So the surgeon becomes a trained seal at a show putting on a bloody performance for the tittering ER crowd. It is usually messy and usually a great waste of time.

The paramedics finally rolled in with the victim on the gurney; they were bagging him with a hand held ambu-bag and doing CPR. I thought in the back of my mind that they probably were not doing CPR in the ambulance and started right in eyeshot of the entry way cameras just to make it look good (I’ve seen them do this from vantage points where they didn’t realize anyone was looking; I don’t blame them, it is a total waste of time). They brought the victim in and transferred him to the ER bed; he was a mid 20’s appearing black man. His skin was ashen gray,  and his eyes were partially open in an empty death stare and his arms and legs flopped lifelessly as the paramedics slammed him unceremoniously down on the gurney.

When I get live patients, my senses are tingling and my mind is racing: as the trauma surgeon, I am in charge of the trauma team and I have to determine within seconds, if this patient is going to die in the next few minutes and if there is anything I can do to stop it. With patients that are already dead, I’m relaxed even nonchalant and I let all of the ER people twitter around and do their different tasks and the only thing I’m interested in is if someone has placed 3 EKG leads on the patient’s chest and shows me a flat line in all 3. This guy was dead and nothing was going to change that; I saw the flatlines and we pronounced him DOA.

After we pronounced him the excitement waned and people wandered off, doing paperwork, tending to other patients.  I looked down at the dead man on the gurney… he was a lean, fairly muscular man and looked pretty well groomed. His body was chiseled and almost perfect except for the 3 holes in his chest, 1 hole in his right lower abdomen and the 5 holes in his back and buttocks. I looked at all these little holes, the emblem of some intense anger or whatever emotion that caused whoever fired the missiles at him to do so. I have seen hundreds of guys in this condition but for a second this time, I paused and really drank in the significance of the violence.

I sometimes try to fathom what brings one human being to the point that he or she wants to take the life of another. I understand killing in self defense; I even understand violence inspired by passion as with infidelity and abuse. What I have never been able to understand is the manufactured hatred that is associated with gangs and street life. Many of the stories about reasons behind shootings are that they have to do with turf disputes or displaying wrong colors or being in the wrong neighborhood, or over some disrespect. It seems that underlying all of this violence is a self hatred, a feeling of despair over the aggressor’s lot in life. It is as if many people in the “hood” feel as if they are viewed by the rest of the world as insignificant, less important human beings than those who have money and the proper social status. It seems that these feelings run so deeply and are so central to the psyche of many young males (and many more females recently) that they manifest themselves as pointless rage. Consequently, this rage manifests itself as a wanton disdain and outright contempt for other’s lives such that the slightest of insults or the most casual wayward glance can lead to homicide. Intellectually, I have come to understand the root of the violence, but emotionally it always vexes me, makes me more angry than sad because it seems stupid and pointless and it seems that people should know by now how stupid and pointless it is.

I stood over the man’s lifeless body for an instant, and these thoughts went through my head and I felt a little bit of anger, anger that human beings are so careless with each other’s lives and that it happens time and time again. The feeling only lasted for a moment and then it burned away like morning dew when the sun rises and all I was left with was a desire to get back to the call room and finish my DVD.

Bryan Hubbard is a trauma surgeon. 

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