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Flesh & Blood

This patient was in a car wreck. That one was sprayed with bullets. The injured keep arriving—many of them mere seconds from death. It is the job of the trauma surgeon to keep them all alive. Dr. Gracie Dinkins tells what it's like

Making an incision into a person is what I call a dread privilege. Not in a negative sense but in an awe-inspiring one. This person has consented for me to do what perhaps no one else in their experience has done—to get on the inside of them. Literally. This person arrives as an utter stranger to me, and by the time they leave the hospital, we are more intimate than most members of their family but in a very different way. It’s a relationship that’s forced and artificial at first, but then usually it becomes deeper and grows to include their family, their friends, and people who come to see them. I have forged some of the closest, most rewarding friendships with people who’ve come in as trauma patients.

Trauma is the infliction of damage to the body: burns, lacerations, gunshot wounds, stab wounds. It can be intentional or unintentional, but the result is the same. My job as a trauma surgeon is about resuscitating, restoring, recuperating. But in another respect, it’s almost as if we’re dealing with a building. Pipes burst. Contents that should be contained within a cavity spill out. You have to scoop them up, clean things up, and patch the hole where the leak occurred. It’s a lot like plumbing.

A trauma surgeon is only summoned to the emergency room if the injury meets certain criteria. For instance, if it is to the upper torso—what we call the box—or is penetrating, a trauma surgeon has to be there within three to five minutes to decide if the injury is life threatening or is threatening a limb. We work in 24-hour shifts—that way, the hospital doesn’t have to relay a new patient’s information to another surgeon driving in. The specialists don’t have to stay.

I work at two hospitals, Long Beach Memorial and St. Francis, a Catholic hospital in Lynwood that all of a sudden got a big influx of trauma cases because Martin Luther King Hospital closed. We are just down the street. About 40 percent of the patients I see at St. Francis are for penetrating trauma. That’s your gunshot wounds, your stab wounds. We see a fair amount of assault. The severity score, if you rate the injury on a scale, is quite high. Three weeks ago I had four people arrive at once: One person was in critical condition with gunshot wounds across the chest. One had been shot in the abdomen, and two had been stabbed. Those last three were in semicritical condition. You have to triage a group like that very quickly and decide who gets to go first. Who do you call in for help? And how do you coordinate your trauma team—the doctors, the anesthesiologists, the nursing staff? That calls on your highest learned capabilities as a surgeon. They all made it, by the way.

I have so many patients who come in having shot themselves struggling to take their guns out of their pockets. Young boys. They carry a gun in their pocket, they get into a situation—it’s no longer an imaginary thing—they panic, struggle to remove the thing, and the gun goes off. You know what’s down there.

I used to make a study of bullets. There’s a whole science. The history of bullets, how they’re made, why they’re made the way they’re made. But I no longer pursue that. It got too grim. They’re meant to kill. That’s their purpose. A lot of bullets are not made to break bone. They’re made to hit the bone, which slows their speed and changes their direction as they ricochet off to softer material: heart, lung, tissue, intestines. They cause more damage that way. I’ve seen bullets wedged between the aorta and a large vein called the inferior vena cava, which basically kiss each other. The bullet just parked between them, and neither vessel was injured. If either had been, the person would have bled to death in seconds. So you just sit there and say, “God is exquisite.”

I’m one of four or five female trauma surgeons at St. Francis and the only female trauma surgeon at Long Beach Memorial. The trauma center at Long Beach is larger. It takes in children as patients, which is not the case at St. Francis. We get a lot of children—bus versus child, car versus child, bike versus child, and ice cream truck versus child. I have a special hatred for ice cream trucks. I think they should be outlawed. I have so many traumas from them, and the children hit by ice cream trucks are usually on the small side, so they get head traumas, which is not a good thing.

We get more of those during the summertime, when kids are out playing. Suicide attempts appear to occur more often during the holidays. Domestic violence goes up during the holidays, too. And we all dread a full moon on the weekend, because strange trauma comes in—normal people found in extremely unusual circumstances, like the respectable father, married with five children, who came in with a miniature baseball bat up his rectum. He put it there. We had to try to take it out downstairs in the ER. It had retreated up too far, so we booked him for the operating room. It was about 11:30 p.m. We’re ready to wheel him in, and he says, “Oh wait!” He jumps off the gurney and runs to the bathroom and evacuates the bat. I don’t have any scientific evidence, but it does seem like people are affected by the moon. That’s not really such a strange theory. We are 60 percent water.

I look at a person on a gurney, and I see a living being who is in various stages of distress—the clinical term is shock. Most of the time when you’ve been traumatized, you have some type of shock. The system has been hit with something it doesn’t expect. The reaction can range from mild shock to profound shock. I try to find out where they are on that spectrum, but I’m thinking about far more than that. I’m keeping an eye on the trauma staff to see that they’re responding appropriately. I’m thinking about whether this person might need surgery: Do I need to call for another diagnostic test? How much time do I have? If they come in and can’t talk to you because they have too much blood in their throat, I have to fix that problem and ward away death for a few more seconds or minutes or hours before I can proceed to the other systems.

If a person comes in and says “My girlfriend stabbed me in the chest,” I’m going to be more focused on making sure he doesn’t have a life-threatening injury within his chest cavity than on why the girlfriend stabbed him: Did he slap her first? Was she defending herself? Were children involved? Those questions are bubbling somewhere underneath the surface, but I don’t think they’re important at that moment. I could easily be treating hardened criminals. They are all my patients. They become almost like my children.

Some patients take one look at me and just cuss me out from my head to my toes. They’ve never seen me before. They’re usually under the influence of alcohol and drugs, and they’re belligerent. Fear automatically generates the wish to defend oneself, and trauma is your classic case: “I’ve been hurt—you’re not going to hurt me anymore. I’m not going to let you.” We have belligerent families, too, but the patients are my stars, so I pay attention to them. When they come in like that, I almost enjoy it, because it’s a challenge to me: I feel that I should have you be my friend before you leave this hospital. Of course, the goal is to resolve the trauma and get them going on their way, but if they come at you with belligerence, you have to give them kindness in return. When talking doesn’t work, you bring over a warm blanket. You do nursing—the stuff that you’re not taught and they tell you not to waste your time on. You’re supposed to spend time on diagnosis. But it saves me the need to call security and tie them down. I would say 95 percent of the time it works.

My grandfather was from Louisiana. His grandparents were slaves. He came west working as a Pullman porter, then lived in Victorville with my grandmother and tried to eke out a living with a chicken farm and several other farms. Nothing seemed to work, so he decided to strike out on a new path and immigrated to Liberia in the 1950s. My father went there with him as a teenager. He met my mother, who was a native Liberian, and got married. They shared a mania for collecting degrees. The only time we came back here was when one or the other of them had to have a master’s or Ph.D. in something. I was born in America when my father was a student at UC Berkeley. I left here when I was five and grew up in Liberia.

In 1979, we had what we call the Rice Riots. Rice is our staple. There was a shortage of it, and political unrest spilled over into the streets. I was in high school, and we had a coup d’état. Things went from bad to worse. In 1984, I came over here to compete in my first Olympiad, running the 100 meter. I was 17. I was going to university at the time. Liberia had only one university and one college, and that same year, 1984, both closed because of violence and unrest. That was my first real brush with death and dying. Several of my friends were killed. So in November of 1984, my father decided to scrape up the money and get an air ticket for me to move to L.A. I stayed briefly with an aunt who lives in Carson before moving onto campus at Cal State Dominguez Hills to finish up my BA in chemistry, then went to UC Irvine for medical school. I did my residency at Martin Luther King Hospital. Military trauma teams used to train at King, and they were busy.

My second Olympiad, in 1996, I did much better: I got to the quarterfinals in the 400 meter. I ran for Liberia again. Sydney was my last Olympiad. Sydney in September pours rain. So we all got sick. I did horribly. When I retired in 2004, I started developing athletes for Liberia, and that now is my second love.

I’m still learning: How do you produce a world-class athlete? It takes a minimum of five to ten years. The athletes have to bring a certain level of talent and dedication. They have to bring a certain mental capacity, the ability to block everything out. It is similar to being in a trauma bay, where everything’s bouncing off the walls and the patient is shrieking. At that point you say “OK, that’s fine, I’ll deal with you in a minute,” and you do A, B, C, D—airway, breathing, circulation, disability—which is your primary survey of the patient. It’s almost comforting to have that routine to cling to.

The injuries that set my blood pumping rather rapidly are those that allow you only a short amount of time to fix before they lead to death. Injuries to the box. And pelvic fractures are daunting because of the anatomy. The pelvis is a bony bowl that can be crushed from back to front or from side to side. The type of force that causes that sort of injury also causes major injury to the soft and malleable organs in the confines of the bowl. It takes up all of your mind. You don’t have time to think of anything else, but you must also think of everything else.

There was a gentleman who was hit in the head with a forklift, where half of his head opened like a coconut. While I was preparing him for surgery, other doctors would comment, “Why are you doing this? You know he’s going to die. This is a waste of time.” There was irreparable damage, but eventually he was watching sports games again. I must say, when I have a patient and they tell me “Oh no, all the king’s horses and all the king’s men…we’re not going to do this one, Gracie,” I just flog everyone and say, “More blood, more specialists! Come on, everybody,” and the patient winds up doing much better than everybody thought. That’s the reason I get up and go to work.

I’ve had two cases where I’ve had to amputate somebody’s limb. I did it to save their lives. One patient had a leg that was gangrenous, and the toxins from it were attacking the rest of him. The leg had to go. The other was an AK-47 wound to the leg, and he was bleeding out onto the table. I had no choice. Both of them went on to be vibrant, wonderful people. One of them is a poet. But I am a former athlete: You take off someone’s leg, and you can’t put it back on. I do not like doing those.

My work teaches me that you will be hurt at some point during your lifetime. My work has also taught me that pain can be an opportunity to bring creation out of chaos. A few years ago two policemen arrived at the ER with multiple gunshot wounds. One officer’s vital signs began to fail, so I had to cut through the chest and massage his heart in order to keep blood flowing to his brain. We were able to bring him back from absolute cardiac standstill. The downside of that was he had to retire from the police force. He was only one month out of the academy and really wanted to be an officer. The good side of that is his story touched millions of people, and he will continue to touch millions more people than maybe he would have ever done as a police officer.

I remember the patients that I’ve lost at least as much if not longer than the patients I’ve saved. I carry them around with me a long time. I had a patient who had a gunshot wound to his liver that developed into full-scale liver failure, and it was one of the most painful episodes I can recall in my entire life. The family was heroic, but there is a bitter feeling I carry around for far too long after I lose a patient. Afterward another doctor told me, “Every doctor carries around with him a small private graveyard, and he periodically repairs to that graveyard to grieve for the loss of a patient,” and I must say that applies to me. Deaths are not easy.

Trauma doesn’t just affect the patient and the patient’s family. It affects the doctor. If you lose that ability to be affected, that’s equivalent to losing a little bit of living. But when you have a feeling that you know is not going to be productive and you put that feeling somewhere to be dealt with at a later time—you have to in order to survive—you might forget on a conscious level that you experienced it. A lot of us would like to think that it sort of washes away and that it’s gone.

But I think that there is a residue, probably very faint, and over time it’s like a clean window that gets smeared and dusty because of all these experiences. Some people would call this burnout. Some people would call it callousness. Or just the inability to respond like you used to. I think that is something a doctor should be vigilant about—that’s why I try not to make work my life and pray often not to be callous—because building up a residue of defensiveness and callousness isn’t helpful. You miss clues that way. I also think you miss opportunities to grow and be blessed by a patient. I am more and more convinced that this is why God put me where I am, that I did not miss my purpose in life.

Photograph by Larry Hirshowitz

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