It’s possible for a surgeon to get distracted by the wrong wound. The most dangerous wounds don’t always look the worst. People can get shot in the head and they’re leaking bits of brain from a hole in the skull and that’s not the fatal wound; the fatal wound is from another bullet that ripped through the chest. One patient a few years ago was shot in the face with a shotgun at close range over some money owed. He pulled his coat up over his mangled face and walked to the ER of one of Temple’s sister hospitals, approaching a nurse. She looked at him. He lowered the coat. The nurse thought to herself what you might expect a person to think in such a situation: Daaaaaamn. He was stabilized, then transferred to Temple. He lived.
The price of survival is often lasting disability. Some patients, often young guys, wind up carrying around colostomy bags for the rest of their lives because they can’t poop normally anymore. They poop through a “stoma,” a hole in the abdomen. “They’re so angry,” Goldberg said. “They should be angry.” Some are paralyzed by bullets that sever the spinal column. Some lose limbs entirely. During trauma surgery, when the blood flow is redirected to the brain and heart by an aortic clamp, blood goes away from other areas, and tissue in the lower extremities can die, causing gangrene, in which case surgeons must amputate the leg at higher and higher points, first at the shin, then at the knee, then at the thigh, to stay ahead of the necrotic tissue as it spreads. The femur bone may have to be disarticulated—removed entirely from the socket, and discarded. There was a woman several years ago whose boyfriend shot her in the leg. The bullet clipped the femoral artery and she bled. Goldberg was on call that day. She had to amputate the woman’s legs to save her life. “I’m so haunted by that,” she said.
Eighty percent of people who are shot in Philadelphia survive their injuries. This statistic surprises people when they hear it. They tend to think that when people get shot in the belly or the chest or the face, they die. But the reality is that people get shot and then they are going to survive, because trauma surgeons are going to save them, and that’s when the real suffering begins.
RAFI COLON WAS SHOT ONCE IN THE ABDOMEN WITH A 9mm handgun while defending himself from home invaders in September 2005. The bullet tore through his intestines. Trauma surgeons at Temple had to open his abdomen to repair the injuries, but fistulas developed, holes that wouldn’t heal, and until they healed, the incision couldn’t be closed. He spent the next 11 months in the hospital, immobilized in bed, with an open wound down the front of him that had the circumference of a basketball. It got to the point where it was a normal thing for him to look down and think, Oh, those are my intestines; there they are.
“It became second nature,” he told me recently over lunch at a Panera Bread in the Philly suburbs. “It wasn’t like a gruesome thing.” The holes in his intestines leaked stomach acid and burned away the surrounding tissues and skin, leaving less skin available to eventually stretch over the wound and close it. Colon learned to sop up the excess acid from his exposed intestines with gauze pads and later with a machine that sucked the acid through a tube. When his friends came to visit, they had a hard time looking at him. He messed with them once by asking a buddy to get him a Rita’s water ice, Philadelphia’s version of a snow cone. He knew what would happen when he ate it. The water ice was red, the Swedish Fish flavor from that summer, and 30 seconds after he swallowed it, the red water ice came oozing out of the hole in his intestine. His friends bolted.
Over the course of his long recovery, from the fall of 2005 into the spring and summer of 2006, Colon got a feel for the rhythms of the Trauma Service. Lying there in the bed, he occupied himself by counting the number of times each day that trauma codes were announced over the PA system. It seemed like the busiest times were Thursday, Friday, and Saturday nights. He’d ask the doctors, how many yesterday, was it 17? “They’d say, ‘No, 18.’” He could tell when the residents were stressed out by how many Diet Cokes they drank. There were days when the doctors were so busy with fresh traumas that they didn’t make rounds until 7 or 8 at night. “They would say, ‘Yeah, it was a busy day.’ I’d be like, ‘Yeah, I heard.’”
It ultimately took 14 surgeries to repair the damage done by one bullet. Temple’s surgeons stretched his abdominal wall closed with the help of some muscle from another part of his body and an artificial mesh. If you see Colon today, the only way you can tell he was wounded is that he walks with a minor tilt; he calls it “my Keyser Söze limp.”
Goldberg was part of the team of doctors who cared for him. They talked about muscle cars and sports. (She liked the Eagles; his team was the Giants.) He remembers that she was the doctor who would notice when he was feeling despair and let him eat a little something that the nurses wouldn’t necessarily allow, like a small chip of ice, or sometimes a piece of candy. He couldn’t eat normally—he was being fed intravenously—but “the fact that I could get a piece of ice, it was like heaven.”
She has gotten more sensitive over the years, she said. When you’re a young trauma surgeon, you’re developing skills, like how to put a bowel back together. Her medical training was all about learning to operate, to recognize the kinds of patterns that she now teaches to students and young doctors. I once saw her give a lecture to 11 medical students who had just completed their surgical rotation. Goldberg diagrammed anatomy and formulae on a whiteboard and asked questions about how the students would diagnose various hypothetical patients. But she also asked the students to share their experiences with patients and their feelings about those cases. One student spoke about stitching together the chest of a young shooting victim who had died after surgeons attempted to resuscitate him in the trauma area; the student’s first thought was that he was excited to practice stitching a chest, then he felt guilty for being excited. Another student recalled being surprised when a patient asked for his business card even though he was just a lowly medical student. “Yeah,” Goldberg said. “He trusted you.”
Often when Goldberg meets a shooting victim, it turns out she once treated a sibling, parent, cousin, or friend. “I’m a family doctor, a little bit, because I’ve been here so long,” she said. One day at the hospital, I saw her go on rounds, meeting with patients in the Surgical Intensive Care Unit (SICU) on the ninth floor. A sign on a bulletin board said WELCOME TO SICU! YOUR HEALING STARTS HERE! The letters were surrounded by gold stars.
Talking to patients seemed to energize Goldberg. She was alternately lighthearted and serious. The patients were uniformly docile and tired. They were on pain medication that slowed their speech. The first patient, shot in the neck, was a young man accompanied by his girlfriend, who sat next to him on the bed with an expression of concern. “When I was shot, I fell on my face,” he said. The second patient was older. A tube to drain fluids was snaking out of his chest. He held out a trembling left hand and smiled. “A little bit of the shakes,” he said. Goldberg told the man he was scheduled to be released the following Monday. He had been caught in some kind of cross fire. “We will miss you,” Goldberg said, “but there comes a day.”
“Cut the umbilical cord, huh?” he said, and laughed softly.