And who are they? Many arrived with their clothing torn off; EMS workers did not go searching for wallets. Because of their traumas, some will not even be recognizable to their families at first. One will turn out to be homeless, reportedly using the bus as a way to stay out of shelters.
In some ways, their identity doesn’t matter. In his career, Teperman has worked as hard on old ladies caught in gang crossfire as on the gangbangers themselves. The job is the same, whoever is on the table. In another way, it matters very much. Trauma is something that happens not just to the victims but to their families, and even to their doctors. Soon the circle of the accident will widen. Identifications will have to be made, survivors counseled. All of that will be complicated by cultural sensitivities. Some Chinese do not want to associate themselves with what may look to outsiders like an endemic gambling problem.
But before social workers can address all this, a second wave of instability swells.
A female patient with abdominal trauma enters the “triad of death”: hypothermia, acidosis, coagulopathy. (Her body temperature is low; her blood is acidic and won’t clot.) Dr. Kim, fresh from the splenectomy, opens the woman. She’s bleeding from the liver and elsewhere in the abdomen. He manages to control that flow, but there is a lot of nonsurgical bleeding, and her vital signs do not respond. She is still in the triad.
When Teperman was training, surgeons would have kept operating on a patient like this until she died. Or she might have died already, because trauma centers had not yet learned to transfuse separate blood components, which include clotting factors, as early as possible, nor to warm the blood as it came out of the fridge. With improved protocols in place, Teperman feels the patient has a better chance if they “temporize”; Kim packs the abdominal cavity with towels to stanch the bleeding, covers the opening with plastic wrap, makes a temporary closure with a suction device, and leaves the rest to nature “so she can live to fight another day.”
And that’s exactly what happens. With the damage-control procedure completed, the patient starts to reconstitute quickly. When the wrapping and towels are removed 24 hours later, she is fine.
But the woman who arrived hypotensive, and whose exact problems have still not been determined, lies dying on the table. She needs constant transfusion. The “Shel Saver”—the trauma service’s prized reserve of blood, named for Teperman—is empty. In all, hundreds of units are used. Teperman runs down the hall to the bank for more.
He has been cycling like this from the bank to the trauma bays to the operating rooms since he arrived hours ago. Now, as he returns with more units, he regrets not going to the gym as much as he used to. Winded, he simply throws the blood at his colleagues and drops to the floor.
On his knees outside the OR, he talks through the case with Melvin Stone, a critical-care surgeon, who then starts an emergency thoracotomy and blunt dissection of the aorta. But the procedure is tricky—in a nonemergency situation, it can take an hour—and the woman is about to die. Because Teperman often performed it on gunshot victims during the crack wars of the eighties, he scrubs in and takes over, finishing the job in less than two minutes.
Still, twenty minutes later, she’s coding again. Stone says, “Should we stop?”
Later, Teperman keeps replaying that moment. “An old professor of mine used to say when you’re a surgeon and a Jew, you’re guilty squared.”
They don’t stop, but she dies anyway.
When is a trauma over? By 1 p.m. Saturday the victims are cleared from the trauma bays and are being cared for elsewhere in the hospital. But for the doctors, is it when they get to leave? As soon as Cassidy, after fifteen hours on duty, feels that the surviving survivors are “tucked in,” she heads for home. But her car breaks down on the Hutch.
Teperman doesn’t get back to Hoboken until late Sunday morning, and then, just as his head hits the pillow, his phone rings again. Mayor Bloomberg is to hold a press conference at Jacobi in which he’ll plead for help in making a final identification. Teperman drives back, this time not speeding.
It might be considered a miracle, or at least a victory, that of the fifteen patients brought to Jacobi after the worst bus disaster in the city’s history, fourteen survived. (Four of the five brought to St. Barnabas, including the driver, survived as well.) But two patients remain at Jacobi months later; the homeless man is still homeless. And Teperman still grieves for the patient he lost.
“A surgeon should never take a bow except when his patients die of old age,” he says.
Even for those who were saved and sent home, Teperman is painfully aware that the trauma is far from over. There will be years of pain and procedures, disability and nightmares. In effect, what he and the rest of his team have done is save them so they can be saved by others, again and again, for the rest of their admittedly longer lives.