Maya J. Sorini

My pager exploded with sound in the frigid operating room. The message just said “AAM, 40’s, stab, eta 15.” I was in surgery with the trauma attending while she worked on a run-of-the-mill abdominal gunshot wound from earlier in the afternoon. The calls that day had been nothing special: a relatively minor car crash, this gunshot wound, and now a stabbing.  Standard fare on a weekday in St. Louis. I left the OR to strip off my mask and bouffant cap as the attending pulled off her gloves and instructed the senior resident how to proceed until her return. We took the elevator to the emergency department (ED) together and she strode ahead of me into the trauma critical care bay while I adjusted my clipboard, stuffed as usual with data collection forms for the clinical research study I was working on.

In a shrill symphony, everyone in the trauma bay checked their pager again. I was expecting another patient, a car crash or a gunshot wound, but the page was about our stab victim. His heart had stopped.

In my three years of trauma research, I had seen very few stabbings serious enough to cause cardiac arrest. Gunshot wounds? I’ve lost too many to count, but I can’t remember a stab patient dying. That’s the thing about stabbing someone: it’s a difficult way to kill them unless you get lucky (or unlucky, as the case may be). Whenever gun enthusiasts suggest that outlawing firearms is akin to making knives illegal, I try to impress upon them the force required to push a knife through a person’s ribcage. I make my hand— balled up as if around the hilt of a blade— come down hard towards their chests to show how close you must be to stab someone. I use words like “manage,” “get through,” and “bones” to evoke the integrity of our thoracic cavities. Then I hold out my index finger. I remind them what they already know: even a toddler can pull a trigger.

We got ready for the crashing patient, who came careening through the ED doors with the emergency medical technicians (EMTs) doing chest compressions kneeling on his stretcher.  The senior EMT told us the story: an African American man had been stabbed by his girlfriend in the shin. When they got to him, he was sitting in a liter of blood.

I could picture the scene. Once while resuscitating a critically injured gunshot wound patient, a nurse opened a blood bag so forcefully that the entire liter of red cells burst up and out, coating his shirt, the walls, the ceiling, and the floor. Not long after, I watched surgeons try to staunch the bleeding spleen of a man found in the street riddled with bullets. They cupped their hands and bailed out the blood from his abdomen so they could see the source of bleeding and clamp it. We lost him on the table. I learned then that when blood puddles, it has an impressive surface tension, so that it seems to stand up in a layer above the floor. The edges will start to clot first, as the liquid evaporates, but it can take hours for a large puddle to become congealed.

Our stab patient had been talking and cooperative in the ambulance until he slowly crashed. The paramedic intubated him, started CPR, and gave epinephrine in an attempt to restart his heart. All the while, the EMS team infused clear fluids to stall the effects of volume loss as best they could, since they don’t have blood on board the ambulances. After transferring the patient to our ventilator and replacing the EMT giving compressions, the first thing our trauma team did was tighten a tourniquet around the patient’s thigh.

Because I have taught dozens of “Stop the Bleed” (STB) classes, which certify bystanders to stall life threatening bleeding, I am a tourniquet enthusiast of the highest order. The military has proven that applying a tourniquet is the most effective way to stop arterial bleeding in an arm or a leg, but some outdated biases against the practice prevail. People used to think of tourniquets as a necessary evil: something that stops bleeding but kills off limbs, and should therefore only be used when absolutely necessary. This is wrong. A leg can go for hours with a tourniquet on before needing to be amputated, and tourniquets are the best way to keep patients with severe extremity injuries from bleeding out. I taught those classes for many reasons, but one was looming and selfish. I had lost too many. Too many that could have lived another fifty years. Patients whose injuries had no right to kill them. I love tourniquets because they stand tall between patients and death, saving the save-able. When so many are beyond help, you learn to lean on the ones you can save.

In our STB class, we teach our students that if blood soaks clothes, starts to puddle, or spurts, they should put a tourniquet on the victim immediately. A liter of our patient’s blood was on the floor. This patient came in without a tourniquet on. I cannot reconcile these two facts. I have taught children how to put tourniquets on, even known a high school age student who saved her brother’s life with one after he was stabbed, but these EMS professionals missed the single most important step when a patient is bleeding. An adult man can only lose two, maybe three liters of blood before he is at risk for hemorrhagic shock.

Our patient was in hemorrhagic shock. I watched as the ED resident worked furiously to get more access to the patient’s bloodstream. The nurses struggled to place intravenous lines in the dying man, so we brought out the intraosseous (IO) gun. They cleansed the patient’s upper arm and bored a needle through his skin, muscle, and humerus.

Inserting an IO requires a nail-gun-like device to puncture a patient’s bone deep enough so that fluid can be pushed through its marrow into the bloodstream. Punching an IO line for access is not the preferred way to deliver fluids in a hospital because it can only be kept patent a short time, and is a relatively invasive form of bloodstream access.  We are forced to use them any time a patient is dying too quickly for us to drop a central line, despite their drawbacks, because the less blood volume a patient has, the harder it becomes to find and infuse through a vessel. Getting an IV into a bleeding patient’s peripheral vein is like putting a needle into a deflated balloon.

Once they had access and had exhausted the ED’s supply of donor whole blood, the team activated the massive transfusion protocol, which prompts the blood bank to bring boxes full of blood products to save patients in shock, like ours.

Hemorrhagic shock, the kind our patient was fighting, occurs when someone loses so much blood that they can no longer transport enough oxygen to their organs, which begin to shut down as they suffocate.  The brain, our most resource-hungry organ, stops functioning quickly without enough oxygen and sugar from flowing blood, so patients going into shock become confused, anxious, and slip out of consciousness.  Once someone has passed out, the clock starts ticking on their other organs.  The liver, kidneys, heart, and lungs all require oxygen too: the longer someone stays in shock, the less likely it is that we will be able to bring them back. I have seen patients in hemorrhagic shock need hundreds of bags of blood products to become stable.

In the chaos of the resuscitation effort, someone came in with blood gas results. When the doctors and nurses heard our patient’s pH was at 6.75 (far too acidic), the panic in the room intensified. They loaded him with a base called bicarb, red blood cells, plasma, saline, and more epinephrine, all while continuing CPR. After a few tumultuous minutes, his heart started beating again.

Just because his heart beat, though, didn’t mean all that much. Certainly, it was better than the alternative, but a patient with his level of hemodynamic instability is far from predictable.

It did give us time to assess the patient’s stab wound. The trauma surgeon unwrapped the compression bandaging around the patient’s calf, which was downstream from the tight tourniquet and therefore cut-off from blood flow. From where I stood taking down information, it looked like someone had stabbed a screwdriver straight into his tibia. With the puncture visible, the doctors loosened the tourniquet to gauge the damage.

As soon as circulation returned, a glittering arc of blood flew through the air from the patient’s shin onto the linoleum.

The image still rattles in my head. The blood shooting up, then falling to the ground: a different sort of St. Louis arch, a new landmark of our city. We are a land of punctures, a leaking town, where blood spurts in the North while sprinklers whir West in the suburbs. When I was the researcher responding to trauma pages, it seemed like I watched a Black man die once a week. I never tallied it up, never even tried to count the dead or the dying.  I forget details of the cases, once so shocking, as the impossible was repeated in our patients over and over again. Even with all those memories, the swimming pools worth of blood I’d seen, I had never seen anything quite like this.

Except in simulations, you rarely see a clean, single, straight wound. The stab almost looked planned, as if some anatomy professor had engineered this dramatic arterial bleeding effect for a group of wide-eyed medical students. Most of our gunshot patients had injuries to the easier-to-hit chest, belly, and flank, and car and motorcycle crash victims tend to be crushed not punctured. It may sound counterintuitive, but complete severance of an artery in the limb, like what happens during a traumatic amputation from crashing a motorcycle, may actually be better news for a patient than a puncture wound. Arteries are pressurized like a firehose, so that if they are completely transected, they recoil back towards the heart. The muscles and connective tissue can partially compress the retracted artery, which leads to less catastrophic blood loss. A punctured artery, on the other hand, doesn’t retract. It stays patent, meaning the blood is still pushing through at pressure, and the blood shoots out the hole. One thing I say at most STB classes is, “remember, our goal is to keep blood inside bodies.” A liter of blood on the floor. One fifth of his body’s blood spilled in his home. How much leaked in the ambulance? How much did he lose in this harried room? Were we giving him enough blood to make up for all we had lost?

The doctors re-tightened our patient’s tourniquet and continued working to stabilize him. As the team kept infusing blood and monitoring the patient, his heart stopped again. They re-started CPR, pushing blood through his body from the outside in.

CPR looks insane because it is insane. A person pushes down with all their might rhythmically, cracking sternal cartilage and breaking ribs, doing with hundreds of pounds of external force what the heart does with a muscle the size of a fist. CPR is also not particularly successful: less than 15% of patients will have their hearts restart using this procedure.

Desperately, the doctors pushed more epinephrine, gave more blood, gave more bicarb, drew more labs, charged paddles ready to shock. But they couldn’t use them, because they require the heart to be fluttering to work.

His heart never moved again. There was simply too much damage from the minutes when his depleted blood couldn’t carry enough oxygen for his organs to survive. He was a relatively young man and in good shape; his organs and our team put up a fight. But I knew the statistics from teaching them. If you get a tourniquet on before shock, survival from severe extremity bleeding is about 90%. If you get the tourniquet on after shock, it drops to 20%. One in five will live.

The attending pronounced the patient dead less than an hour after he was wheeled in. A single injury to the shin had felled a grown man. As the attending and I walked back up to the operating room together, I watched her eyes slide blankly over the linoleum while she shook her head.

“He shouldn’t have died.”

In the operating room, my mind still flashed with images of our patient’s blood shooting through the air. Bathed in the scent of cauterized flesh, I tried over and over to make myself believe he was dead. To know it. But I couldn’t. The blood was frozen in its arc. It had become a permanent landmark.

Maya J. Sorini is a narrative medicine scholar, essayist, medical student, and award winning poet. Her first collection, The Boneheap in the Lion’s Den, won the 2023 Press 53 Award for Poetry. Maya has a master’s degree and has taught in Columbia University’s Narrative Medicine program, and continues to work as a freelance Narrative Medicine workshop facilitator. Her work has appeared in many arts and medical journals, including JAMA, Intima Magazine, and Doxy’s Op Med. Maya currently attends Hackensack Meridian School of Medicine and lives in Bergen County with her grandmother.