In the trauma center, you don’t sign up to work on New Year’s Eve—you get stuck with it. Fireworks mishaps in the long hours leading up, gunshot wounds at midnight, car accidents at 1 AM… January 1 might be the deadliest day of the year, but the night before is an onslaught of crisis management and unpredictability. While it might be the least desirable time to be on-call for many surgeons, I like working New Year’s Eve. (I am doing it again this year.) Each year, I’m reminded of the profound intensity and relevance of my craft.
A lot of the injuries we see in the trauma center happen when the clock strikes midnight and people fire their guns into open air. Those bullets come down like raining lead, injuring and killing people. These days, it’s not as big of a problem as it used to be, thanks to local public service campaigns like Bells, Not Bullets and Bullet-Free Sky. But back in 2002, when I was a 27-year-old junior resident working at a trauma center in San Diego, stray bullets filled helicopters and ambulances with victims.
When the EMS teams would pick up someone with a GSW (gunshot wound) to the head, they’d make us aware of their condition en route to the hospital. This allowed our team of six—usually a trauma surgeon, an anesthesiologist, an x-ray technician, two nurses, and a specialized surgeon like myself—to be ready in the trauma bay, prepped to address whichever part of the body had been hit.
But one man in his late 30s, from one of the beach cities nearby, was different.
At 12:30 AM, TJ* drove himself to the hospital with a hole in his head. He walked up to the ER check-in counter and said he was stargazing when he had been hit by what he thought was a rock. “Toothpaste”—what he didn’t yet know was the white flesh of his frontal lobe—was oozing from his forehead. Despite the seriousness of his injury, he seemed completely unaffected. He had, after all, been able to drive himself in. The clerk took note and immediately alerted the nurses who called my team. Although TJ was composed, the ER docs rushed him to the trauma bay, where the sickest of the sick, in extremis, are managed by trauma surgeons.
Though the skin on his forehead was macerated from the entry wound, I knew from the lack of burn marks that he hadn’t been shot point blank. We had a conversation about where he was, what his name was, and what year it was, and he hit every answer in a timely fashion—the quickest test there is to establish brain function. There were no hints of any frontal lobotomy-type personality changes, as portrayed in the movies. This man was himself.
But the back of his skull was still intact, no exit wound, so I had a few things to figure out. First, the dangerous stuff: Where was the bullet, and what was its trail of injury? We wheeled him in for a computed tomography (CT) scan to find out if there was ongoing bleeding. The worst-case scenario would be a "talk and die," which happens when a brain injury goes undetected, leading to a coma, and then death. I knew TJ didn’t have a massive blood clot already. If he did, we wouldn’t have been able to go over his personal details. I just didn’t want to miss the one that would start small and blossom over the next few hours, slowly building up the pressure that would put him over the edge.
The scan showed us that the bullet had torn a channel through his right brain. His soft grey matter offered no resistance as it tumbled, undeterred, and lodged into the bone encasing his brain, about four inches above the top of his neck. It also revealed two golf ball-sized clots, one in his right frontal lobe (behind the forehead) and the other in his right occipital lobe (at the back of the head). When torn blood vessels release their contents into a confined space, the brain is the victim, its delicate tissue jellied by the pressure. If this was the apex of the blood clots, the brain could do away with the blood on its own, the way a bruise is absorbed over time. But if the vessels hadn’t sealed themselves off with their own naturally circulating clotting factors, I was ready to take care of it. This would require opening his skull and evacuating the blood, and singing shut the spurting blood vessels.
Unfortunately, the scan several hours later showed that both clots had expanded. With lead in his skull but no tear through his mind, TJ continued to engage me fully, so I spoke to him about the precarious perch he was teetering on. The clots were hours away from sending him into a coma and possibly brain death. We discussed the risks, benefits, and alternatives to surgery. Even with the damage done, he was lucid enough to give his informed consent.
At 4 AM, while being wheeled into the operating theater from the intensive care unit, TJ sneezed and brain sprayed out of his forehead. The sneeze had raised his intracranial pressure, and with the clots taking up ever more space, this was his brain trying to find a lower-pressure environment. The skull is nearly filled to the brim with brain and fluid, so if other space-occupying material is added, the pressure rises like a tense balloon. Liquefied brain exited its osseous cage into the atmosphere. This man was on the edge—he was about to talk and die.
I called the OR and simply said, “trauma craniotomy.” A team of nurses, anesthesiologists, and technicians were activated in minutes. Cosmetics rendered irrelevant, I shaved his head quickly with clippers, used no finesse to slice his scalp, and drilled ferociously to open his skull. The brain was tense and taut, so I punctured the thin shell of cortex hiding the blood-ball with a larger bore suction, and drove it directly into the middle of the clot. Large chunks of blood clot and ravaged brain came out. Although fresh blood isn't watery but gelatinous, the large suction was strong enough to make the core of this blood clot jump into its pull and into the canisters. The frontal lobe was immediately softer and deflated away from the inside surface of the skull. Now came the finesse.
I took care with the edges where the delicate boundary between the dark red clot and the pearly white brain would need to be dissected. Here, too, would be the remaining mesh of blood vessels that needed help closing with the burn of my electrocautery. I filled the crater with sterile water. And under the bright lights asked the anesthesiologist for a Valsalva—essentially, he manipulated TJ’s ventilator to recreate a sneeze. Under this increased intracranial pressure, my micro-welding of the blood vessels would be put to the test.
And then: nothing. No faint swirls in the crystal water. No blood. I quickly closed this section, and with a large syringe, filled the skull back up with sterile water to leave no room for trapped air. Then I placed the circular piece of bone back on top. This last step would keep air from remaining in his skull before the bone could be replaced. Air, too, can smash the brain—pneumocephalus—and it can be deadly. But not this time.
Although I hadn’t looked up for hours, I could see the sunrise leaking in from a thin, horizontal window near the ceiling of the operating theater. Night had turned to dawn, and one more lobe was in my plan of attack: the occipital lobe. It, too, fell with similar maneuvers, with the last step being the chiseling out of the bullet from TJ's skull. After the operation was completed, he was taken to the ICU, having had large swaths of his right frontal and right occipital lobes removed. I expected him to do well.
That 40-hour stretch, beginning early December 31 and ending in the new year, I performed five other operations and saw 23 other patients. But I remember TJ the most. Until he came in, I never imagined someone could survive a gunshot wound like that, let alone without colossal damage to his mind.
Months later, TJ drove himself into my clinic. On scans, those parts of his brain were still missing. They didn’t grow back—they never will—but the remaining brain, both fragile and resilient, continues to suffice.
*Names have been changed.