A Race to Stop the Bleeding

Leroy Eppright was the kind of patient who makes surgeons break out in a cold sweat.

When paramedics rolled him into the trauma center at Martin Luther King Jr./Drew Medical Center in July, Eppright was pale, clammy, thrashing like a drunken man -- signs that he was in the last stages of bleeding to death.

For Eppright and other shooting victims, the complexities of trauma care can boil down to this issue: blood loss, and how to stop it in time. As the Los Angeles County Board of Supervisors weighs the proposed closure of the King/Drew trauma center, his story, reconstructed from interviews and records, illustrates a key part of the equation.

Eppright, 19, arrived at King/Drew with barely a liter of blood still in his veins. He was in shock, with a 9-millimeter bullet lodged in his torso.

Trauma surgeon Dr. Bryan Hubbard gave the lanky youth on the gurney one look and uttered an oath to himself.

Eppright was tall, with large brown eyes, a boyish face, sparse sideburns.

Growing up in South L.A., he had always been easygoing and shy -- often glancing down with a wide, bashful grin instead of speaking. His father was black, his mother a Latina. After graduating from Crenshaw High School, he worked for the city Recreation and Parks Department, tending plants. But he was of an age, background and race that mark him as among the country’s highest-risk individuals for violent death.

Eppright never saw who shot him, never even saw a car. He had been walking with friends near Crenshaw Boulevard and Slauson Avenue. The bullet was like a blast out of the dark: He started to turn, then was thrown to the ground and was lying on his side on someone’s front lawn. Police say they know no motive for the attack.

There was a brief, sharp pain. Then his left leg went numb, and a strange warmth crept over it. A woman was telling him not to move. He felt panic rising and willed himself to stay calm.

French doctors gave a name to the tendency not to immediately feel the agonies of a serious injury, said Donald Trunkey, professor of surgery at Oregon Health and Science University. They called it “wound shock,” and it is caused by the release of endorphins -- morphine-like compounds -- to mask pain long enough to allow an escape.

The bullet hole was not quite the size of a quarter. But under the skin was a catastrophe.

The slug had pierced Eppright’s lower back just above his left buttock, leaving behind a swath of shredded tissue. It had punctured his large intestine and ripped through a nerve before settling near a pelvic bone.

Some of the largest vessels in the body pass through this area, carrying blood between the torso and the legs.

Eppright had no sense of a bullet in his body. But he was beginning to feel cold.

Ten minutes after the 911 call, paramedics from Los Angeles Fire Station 66 were at his side.

Shortly after, he was staring up at the light in an ambulance ceiling, listening to voices around him.

One pleaded in his ear: “Stay awake! Try to stay awake!”

But Eppright felt heavy, sleepy. His eyes kept closing.

Confronted with massive blood loss and a dwindling supply of oxygen, the body begins to shut down in stages, sacrificing parts of itself to survive, said Trunkey, the Oregon surgeon. First, blood supply is cut off to the skin, then to the muscles, then to other organs as the body tries to maintain a flow to the heart and brain.

The ambulance reached King/Drew in 17 minutes. When Eppright was rolled into the trauma bay, 39 minutes had passed since his shooting.

Hubbard, waiting with his trauma team, saw that Eppright had, he said, “what I call the death look”: sickly pallor, moist skin.

Eppright was struggling, talking incoherently, trying to sit up.

Though unconscious, he had entered a state of agitation common to patients who are beginning to lose oxygen to the brain. It is a sign that the body senses death is near and is letting loose a last fight-or-flight reflex. Some of these dying patients become so belligerent that they rip out tubes and fight doctors.

Hubbard felt a stab of apprehension. No time to spare, he thought.

The first hour after a severe internal injury has been dubbed the “golden hour” by surgeons -- the time in which they have the best chance of saving a patient from bleeding to death.

The key is getting them quickly into surgery. Medics and paramedics, however skilled, can’t do the trick. Their role is mainly to supply fluids and transport the patient, because they can’t stop the bleeding. Usually, only a surgeon can do that.

Most-Dreaded Wound

In the operating room, Hubbard moved quickly, noticing little about Eppright except his buttery complexion. He wondered in passing if the young man was black or Latino.

He focused on the wound, the kind Hubbard dreads most -- those frustrating gunshot wounds to the pelvis, where large vessels are buried in hard-to-see places. Half a dozen people worked on Eppright, everyone moving at once. A nurse splashed iodine on his skin -- no time to sponge carefully. They gave him hardly any anesthesia; he was too close to death already.

Hubbard lifted a scalpel and cut a long slit in Eppright’s abdominal wall. He worked quickly to seal off his abdominal cavity, packing the sponges tight.

Next, clamps. Nothing else would matter if Hubbard couldn’t stop the bleeding. He peeled back the pink membrane lining the abdominal cavity, then cut the punctured colon loose and flipped it over to see beneath.

Much of Eppright’s lost blood lay in a jelly-like mound, a little bigger than a softball. More blood was pooling around the mound. It was coming so fast that Hubbard could hear a hissing noise, like water spurting from a garden hose.

Hubbard found the aorta and clamped it. But the bleeding continued. Where was the tear?

He peered deeper into the pelvis, a narrow, awkward recess. Hubbard found the top half of Eppright’s broken iliac vein, flapping loosely into empty space. But the bottom half was nowhere to be found.

It had retracted, like a rubber band, into the bowl of the pelvis.

Eppright’s bleeding was relentless. Hubbard and his assistant wielded sponges in their forceps -- on and on -- trying to find the tiny, flimsy stump of vein that was causing so much havoc. The blood flowed -- and was vacuumed and put back into his body, warmed and cleaned by a machine. He had arrived at King/Drew with only about 20% of his normal volume of blood. He would eventually get more than 10 liters, nearly twice the entire volume in an adult’s body.

Machine-infused blood -- whether your own or a donor’s -- can save your life. But it is a poor substitute for the real thing. It doesn’t clot, and it strains the immune system.

Hubbard knew he was running out of time. The longer surgery drags on, the less the patient’s blood clots. After a while, it starts seeping everywhere, thinned to the consistency of Kool-Aid, and the patient enters a downward spiral -- dying, in part, of cold.

If you don’t plug the dike, no amount of donated blood will help. “Eventually,” said Hubbard, “the bleeding wins.”

At last, Hubbard found what he was looking for: a pearly-white, slippery stub, half the width of a finger, poking up from the base of the pelvis. It was the vein, the tiny, ragged end of it -- hard to grip, too fragile to pull.

Hubbard pounced. But the vein kept slipping out of sight. Each time he got close, curtains of blood would obscure it. Hubbard tried again. And again.

As a surgeon, you know every delay puts the patient closer to death, he said. But you can’t rush. It’s like threading a needle -- as fast as you can.

As Hubbard struggled, Eppright’s mother, Bertha Mirich, sat alone in the trauma center waiting room, praying. She was praying for her son -- and for Hubbard’s hands.

It took Hubbard some 40 minutes. Finally, his clamp fastened around the frayed stub. The gushing stopped. He let out a long breath.

During the surgery, he had not felt tired. But walking out, he said, he felt drained.

Homicide death in Los Angeles comes three ways, said Hubbard. There is the quick death with a bullet to the brain or heart. There is the slower end that comes to those who bleed to death.

Then there’s the slowest death of all -- by organ failure or infection after surgery.

Eppright now faced the third danger. He was out of surgery. But his blood wasn’t clotting and it seeped from a thousand microscopic places. His organs were in bad shape. Bacteria from his colon had leaked into his abdomen.

Lessons Learned in War

Modern trauma medicine developed over the course of several wars.

During the Civil War, 80% of soldiers wounded in the abdomen died, Trunkey said. Advances came with the two world wars. But the biggest strides came in Vietnam. Helicopter transports and mobile surgical units meant that bleeding soldiers were rushed to surgery. Death rates from abdominal wounds dropped to about 5%.

Much of the change can be summed up in one word: Time. Get a patient into surgery fast, doctors learned, and death rates plummet. The faster the better.

Two years ago, a group of researchers from the University of Massachusetts and Harvard published a study estimating that without improvements in medicine since 1960 -- particularly in trauma care -- national homicide figures could be triple their current levels.

The location of a high-level trauma center closer to where victims are being injured is one of the most significant of these improvements, because it allows them to be operated on quickly, said one of the researchers, Anthony Harris, a sociologist at University of Massachusetts Amherst.

Trauma care in Los Angeles consists of a cooperative network of 13 trauma centers, paramedics and a triage system. Each trauma center formally serves a particular area. But practical difficulties mean patients are frequently shunted to neighboring trauma centers.

A traffic jam on the Harbor Freeway, for example, or a flurry of retaliatory gang shootings in one part of the city can quickly render the boundaries moot.

One principle for decision makers in Los Angeles to consider is the need to “allocate your resources close to the area of highest incidence of injury,” said another of the researchers, assistant surgery professor Stephen Thomas of Harvard University.

In L.A., shooting victims are concentrated around King/Drew.

For example, Southeast Division, the closest LAPD precinct to King/Drew, has had about 300 gunshot victims this year, more than three times as many as Harbor Division, nearest to Harbor-UCLA’s trauma center, and nearly four times as many as Hollenbeck Division, nearest to the trauma center at County/USC.

California Hospital, a suggested replacement for the trauma center at King/Drew, is a few blocks southeast of Staples Center, at the northeast edge of this zone. It is very close to some areas with high numbers of gunshot victims. But the hospital nearest to the center of the shooting zone -- and therefore closest to the largest numbers of shootings -- is King/Drew. It also handles the highest proportion of gunshot injuries of the county’s 13 trauma centers.

Operate or Wait

Hubbard met Bertha Mirich outside the operating room and chose his words carefully. “I always paint the grimmest picture possible,” he said. “If you say they are going to be great, then they die.”

It was 6 a.m. Mirich went in to see Eppright. She couldn’t hug him because of the tubes and a warming device covering his body, a kind of air-filled electric sleeping bag.

So instead she touched his face with both hands.

For hours the bleeding wouldn’t stop. Hubbard knew he had a choice: Operate again in hope of finding another tear -- a risky step. Or wait. He waited. “There is no science to it,” he said. Just instinct.

It worked. The second day, Eppright blinked awake in a haze.

Some time after, Hubbard chatted with him, his patient alert and smiling. Hubbard remembered something he had heard in medical school: “Surgery is a miracle.”

Eppright went home after about a week. He could barely lift himself off the couch. Extreme lethargy is common in such patients, a result of the wear and tear on organs from the chemical cascade of shock.

His stomach could take only liquids at first. He dropped from 175 pounds to a skeletal 135. He couldn’t sleep, suffered headaches and felt an excruciating burning sensation in his left leg, caused by nerve damage.

A week or two later, he called his mother at work to tell her he had a high fever. He had an infection and returned to King/Drew for a second operation.

In recent weeks, nearly three months after the injury that took a split-second to inflict, he has finally begun to walk without a cane. The bullet remains in him.

Almost dying “makes me think twice about where I want to go and who I hang out with,” he said. “I want to go back to school now.” He knows what he wants to study, he said. Botany.

He is expected to recover. But he still can’t sleep, still lies on the couch when the phone rings, still feels burning pain.

“It is terrible to be shot,” Eppright said. “So terrible.”