They parked their gurney next to our stretcher and transferred the patient. One medic began to help Brian cut off the clothes as the other medic continued his stream of information.

“It was just madness at the scene. Sorry for the delay. There was a huge crowd and some fighting still going on. The police had to get us in and out as they secured the scene. Then we just drove like hell to get here.”

“What’s his name?” I asked as I looked down at the fallen giant on the bed. He had to be at least six foot four and probably 300 pounds.

“Friends said they call him Jay. His ID says Jeremiah; it’s with registration.” Jeremiah was enormous and thrashing and bleeding from his right scalp.

With swift precision, EMS and Brian cut off his jeans. Bloodstains on the legs, but no injuries. Next, they cut off his shirt. More bloody marks scarring his torso and arms, but no deformity, no injuries, no swelling. There was so much blood. We in emergency medicine do this work every day, but we never entirely numb ourselves to the impact of the body being rent apart to let rivers of life flow from arteries and veins. I couldn’t imagine a day when it wouldn’t be disturbing to see blood burst forth as if from a broken levee.

I could see no deformity to the neck. Jeremiah was breathing, he was moaning, he was emitting sounds of anguish. His GCS, or Glasgow Coma Scale, which measures a patient’s level of consciousness on a scale of 1 through 15, was somewhere near 15, which was reassuring.

Once he was fully exposed, the nurses placed the patient on the monitor and prepared the IVs. His blood pressure was technically “normal.” Given the stress he was under, that was a very bad sign. The constellation of fast heart rate and relative hypotension here signaled that he might have a life-threatening hemorrhage, not to mention the possibility of a catastrophic brain injury. The patient was flailing around, and the EMS guys and Brian grappled to get his legs down. The nurses called the med students over to hold down each arm while they placed one large-bore IV into each antecubital area of his arm, which in lay terms is the crease in the inner arm where the elbow bends. We needed venous access to stabilize him. It was like wrestling with Goliath—an agitated and confused Goliath.

“Jeremiah, Jeremiah, do you hear me?” I called to him softly, placing one palm on his left cheek while inspecting his head. The only wound, which was too much, was the section of his skull that shattered into his brain. Blood oozed from this wound in his right skull around matted chunks of tissue.

“Where am I? Christian! Mom!” he screamed out, thrusting his head from side to side, splattering blood around the head of the bed. His eyes were shut tight as he moaned and cried. A mix of tears and blood streamed down his dark cheeks. His skin was the color of deep mahogany, smooth and rich.

I placed my hands on each side of his head to coax him to stillness. Looking directly down at him, I asked, “Jeremiah, look at me. Can you look at me?”

His eyes cracked open and he looked behind my mask, past my glasses, and into my eyes.

“Can you help me? Please, please help me!” he cried.

“Jeremiah, we are going to help you. Try to be calm. Please try to be still so we can help you,” I chanted to him like a lullaby.

“Please, please save me! Moooommmmmm! Please, please save me,” he begged as he stared into my eyes.

“Jeremiah, we will help you,” I chanted, begging him to believe me, hoping we could both be soothed by my words.

Jeremiah wept. He wept in waves. He wept in howls that stirred the marrow. He wept from a place of pain much deeper than the GSW to his head, pain that hurt more than having bits of his skull shot off and lying on the sidewalk.

“Jeremiah, I am here to help you,” I said, gazing between the spaces of his tears as I placed my other hand on his shoulder.

“I’m going to diiiiiiieeeeeeee, I’m going to diiiiiiiieeeeee,” he gulped in great hiccupping wails.

“We’re here for you, Jeremiah.” I knew that my words were more important than the medicine I would push into his veins to dampen his consciousness and paralyze his muscles. More important than the breathing tube I would slide down his throat to take control of his breath. More important than the entire surgical team that had been activated for him.

I looked deeper into his eyes and moved my hand to his right cheek to cradle his face because I knew that he was correct. I knew that he was at a crossroads, that he was touching grace. I knew that no matter what he had done to end up in the ER, he deserved to be comforted right now.

“Dr. Harper, we have a line!” reported Trish, one of the nurses.

“Excellent,” I said to her, flashing a thumbs-up. “Let’s start with lidocaine 150 mg, then 30 mg of etomidate, and 150 mg of succinylcholine,” I said, requesting the medications that would relax him so I could perform an endotracheal intubation.

I grabbed my blade and looked into his eyes for the final time. “Now, Jeremiah, you’re going to sleep.”

After he slipped into unconsciousness I advanced the breathing tube into his trachea and the respiratory team attached the CO2 detector; we noted good color change, so they placed him on the ventilator. I tore off my bloody gloves to take my stethoscope and listen to his chest: There was good air entry bilaterally, another indicator the endotracheal tube was where it should be. The surgical team flooded the room and whisked Jeremiah off to the operating room. The techs and nurses had moved on to the next patient. EMS loaded up their truck for the next ride. The room was empty save for the aftermath of what had just happened: Monitor leads swung from their screens and plastic needle caps were strewn across the floor along with a mosaic of bloodstains and discarded gloves. I surveyed the scene and was reminded of how these resuscitation rooms are often the most tragic confessionals.

A police investigator came into the room, breaking the silence. He wanted to take my statement: How did the patient present? What was his condition on arrival? What had we done for him in the ER? What was his status when he left the ER?

I answered his questions, we finished the interview, thanked each other for our respective hard work, and stepped over debris to get back to our jobs.

Nurse Esteban met us at the door to say, “Doc, the OR called. That patient coded on the table and died.”

The detective heard him. “Okay, now it’s a homicide. Thanks, guys,” he said as he walked out of the department.

I looked up at Esteban, then I nodded and sighed. It wasn’t that I was surprised or confused—it was not surprising that a man who had been shot in the head would die. There was nothing confusing about a man crying out that he was going to die, proving that, in fact, he had perfect insight in that moment. No, my sigh acknowledged the moment he had had with himself and his life, with his blood and his tears, as he was absolved by the bright lights of the trauma bay. It was an understanding that no matter the hand we are dealt at the beginning of our lives, in the end, we face our actions alone. Jeremiah had called out for Mama and for Christian, but in our final moments, everyone we’ve honored or betrayed is, ultimately, not with us. We lie there alone, flesh and bone, soon to be only spirit.

It occurred to me that maybe Jeremiah was the Gabriel who had picked up a gun. Perhaps it wasn’t Gabriel precisely, because maybe he left the ER that day I met him and never touched a gun. Maybe Gabriel left the ER and survived to graduation and was strengthened by the challenges life threw at him. Maybe Gabriel finished college and was now mentoring his teenage sister. Or perhaps he was working toward owning his own business to improve not only his own life, but the lives of those in his family and community.

I suppose it’s a matter of faith whether or not we choose our starting ground before we’re born into this life. Some begin the journey on flat, grassy meadows and others at the base of a very steep mountain. One path, seemingly smooth, can make it nearly impossible for us to see the ditches and gullies along the way. The other, while painfully tough, can deliver what it promises: If you can navigate that path, you’ve developed the skills to scale Everest. It isn’t fair on many accounts; it simply is. And assuredly, both paths include uncertain terrain ahead.

As we place one foot in front of the other, we make choices at every step, no matter the terrain. When we reach the threshold that Jeremiah reached, we look back at our footprints and must face the results of our choices. Alone. In that recognition there is absolution. All deserve the chance to speak and be heard and be touched. If we’re lucky, we’re touched at every station along the journey, and if nothing else, then at the end.

SEVEN

    In the Name of Honor