|SAN FRANCISCO CHRONICLE
GENERAL, LIFE AND DEATH AT SAN FRANCISCO'S HOSPITAL OF LAST RESORT/FOR TRAUMA TEAM, SAVING LIVES IS BOTH A SOCIAL AND MEDICAL MISSION
Mike Weiss, Chronicle Staff Writer
Wednesday, December 10, 2006
After 13 years doing trauma surgery at San Francisco General Hospital, Dr.
Andre Campbell knows just about everything there is to know about calamity, mayhem and long nights. On this Friday evening, when he was on call and tethered to the hospital until Saturday morning, his wife's leftover meat loaf -- his favorite -- represented an oasis, a pause to look forward to. So even though he was hungry, he put off eating it.
He was catching up on paperwork in his modest, cluttered office -- Campbell is General Hospital's chief of medicine and is also chairman of surgical education at UCSF -- when his beeper sounded about 7:30 p.m. on April 28. A shooting victim rode in an ambulance highballing it toward the Emergency Room three flights below. All through the hospital, the on-call trauma team hurried toward the ER.
A big man -- well over 6 feet, broad across the shoulders, with a deep chest where his frequent basso profundo laughs originate -- Campbell moved with deliberation. Panic, and the haste it engenders, is not a part of his emotional vocabulary. Emergency is his metier.
As usual, patients were lined up on gurneys to be seen in the ER; there was a second bottleneck on the third floor, of patients who were waiting for one of the 10 operating rooms. Like most of the other practitioners at the hospital, Campbell came to General to make a difference in the lives of the unfortunate.
This year, about 6,000 surgeries will be performed at General, San Francisco's only hospital to be certified as a trauma center by the American College of Surgeons -- a teaching and research hospital ready to perform emergency surgery round-the-clock. Whether you are wealthy or homeless, it is the place you will be taken if you have a serious car crash or are run over, or if your backyard grill explodes in your face. Or if you are shot, like James Hewitt.
The 14-year-old (his name has been changed to protect his privacy) was in shock, bleeding profusely and terrified when he arrived at the emergency bay. The emergency team ran him into a trauma room, lifted him unceremoniously off the gurney and ripped away his clothes. Amid the controlled chaos of shouted orders and questions, he looked up and saw a doctor bending over him, talking to him.
Campbell has a gap in his top teeth, and a long face marked by both gravitas and humor.
James asked, "Am I going to die?"
It was a question Campbell had been asked more times than he could count, and answering it never became less tense or terrible. There had been times, many times, when Campbell thought the outcome would be bad but his patient survived. There were other times, fewer but harder to forget, when a patient he expected would pull through died beneath his hands.
Seeing the fear in the eyes of this 14-year-old, Andre Campbell looked directly at him and rumbled: "I'll do the best I can."
"Am I going to die?" the boy wailed again, as he was wheeled toward the elevator up to the operating room.
It was going to be a long night. But saving lives is Campbell's job -- he does 15 or 20 surgeries a month. For a fleeting moment, he regretted not eating his wife's delicious meat loaf when he had the chance. He had ignored a lesson as certain as the swiftness with which laughter can give way to bloodshed on the streets: When you have a moment, inhale your damn food.
For as long as he has been at General, Campbell has worked beside the head of trauma surgery, Bill Schecter, who is 10 years older than the 48-year-old Campbell. Schecter embodies the work ethic and the mission of the hospital.
One day when a bunch of dog-tired young doctors who had not slept in 24 hours took the easy way upstairs and stepped into an elevator, Schecter shouted at them that they would regret it if he beat them by taking the stairs; then -- less than a year after undergoing a quadruple bypass -- he barreled up three flights, taking the steps two-at-a-time. The race ended in a tie.
Schecter makes the point that doctors, nurses, social workers, psychologists and technicians are all there because they choose to serve the poor, the afflicted, the ignored and the forgotten. If social justice still animated American politics as it did three decades ago, General would be a model institution. It is a place where a city that takes pride in its liberalism walks the walk.
"At this hospital, we are specialists in the surgery of poverty," Schecter said. "Treatment of acts of violence, complications of drug addictions, alcoholism and cigarettes, and treatment of advanced malignancies due to lack of access to medical care."
Or, as Campbell put it: "Everybody who stays here wants to be here another hundred years; everybody is fiercely dedicated to what we do. We're kind of tribal in defending the mission of the hospital."
It certainly isn't the money that attracts or keeps them at General. While surgeons make a very comfortable living -- Campbell earns well over $200,000 a year -- he could triple or quadruple it at someplace like Stanford Hospital.
Half the trauma surgeries performed at General are due to penetrating trauma -- stabbings or gunshot wounds -- and that makes Schecter righteously angry. "A gunshot wound is just a vector of a disease, like a mosquito carrying malaria," he said. "If you got rid of the bullets, you wouldn't have a disease. Our society is totally out of control, and I'm sort of like a social worker with advanced training. Some kid gets shot in Jerusalem, it's on the front page of every newspaper in the world. But a kid gets shot in San Francisco," he continued, "it probably doesn't even make the newspaper. You know why? Because fundamentally nobody gives a s
One day before James was wheeled into the emergency room, a 13-year- old girl underwent surgery after being hit by a stray bullet, Schecter said.
And the very next day, a 15-year-old boy would be operated on. But on the night of April 28, it was James' life that was in Andre Campbell's soft, long-fingered hands.
James was shot in a housing project in Hunters Point.
Ever since he was placed on juvenile probation in 2003 for joyriding in a stolen car, he had not strayed far from the apartment where his mother lived with her mother. James' mother, Paulette Spikener, did not have her own place, not since the boy's father, who worked for the San Francisco Housing Authority, had been gunned down in 2001 when he was 26 years old.
"When his father got killed," she explained weeks later, sighing, "he went from a good boy to a bad because he didn't know how to cope without his father. But after my son got out of juvenile hall he was in no more trouble. That turned him into a better boy. He wouldn't even get into no cars, he took public transportation."
The night he was shot was unseasonably warm. Just before suppertime, James and some friends were having a water balloon fight. In their high-spirited silliness, the middle school students tossed a balloon that splashed the wrong person. A few minutes later a red station wagon rolled up, and someone inside opened fire.
"Kid went down close to where his father was murdered," Campbell said.
"Problem with AK-47s is they explode in the abdomen. Basically, a bomb went off in his tummy."
While the teenager was being prepped for surgery and anesthetized in Operating Room No. 3, Campbell changed into his green scrubs, donned goggles, a face mask and a surgical hat, and pulled on heavy black galoshes. When he was a young resident at General, he later said, "I didn't care about blood," even in a setting where AIDS was widespread. "I just wanted to save lives. So Schecter said to me, 'You want to see your grandchildren? Put on boots.' " The memory made Campbell laugh.
He walked to the operating room, where the temperature was 60 degrees -- surgery is sweaty work. The massive hospital chiller had needed replacing for years, and in summer the ORs could be sweltering. Installation of a new $3.2 million chiller had at last been approved by the Board of Supervisors. That was just one of the difficulties faced by a county hospital like General. If a private hospital needed to replace its air-conditioning, it did it; but General had to go through a politicized budget process, competing with cops and firefighters for scarce dollars.
Campbell entered the starkly lighted operating room. The OR is a medical sanctum sanctorum and, within it, surgeons approach their work with distinctive styles. An essential part of the hospital's mission is to train medical students and residents from UCSF, and General's doctors are paid faculty of the university. Campbell teaches -- he heads a team that includes a surgical fellow, a resident, a medical student and nurses, and there is an anesthesiologist present as well. But he sees himself as "kind of like a concert director. I'm just conducting," he said, "while we convert chaos into order."
A surgical incision was made from just below James' sternum to just above his pubic bone, laying open what Campbell called "a slough of destruction," caused by a single bullet that entered James' right side.
His superior mesenteric artery -- the main artery to the stomach -- was blown up. The pancreas was severely distorted, and there was a bullet hole in the duodenum. Over the next several hours, Campbell cut away a 4-foot section of his right colon from his spleen down to the left colon, as well as his right kidney, which had suffered an irreparable wound. His liver was pulverized.
Because James was bleeding internally "like a fire hose," as Campbell put it, tremendous, sustained effort had to be made to stanch the flow, so the surgical team could see where it wasworking. If the surgeon accidentally tore James' bowel, toxins would be released that would kill him. "Bowel is very angry," Campbell said. "Punch a hole in it, it's the end of the world."
Some of the membrane Campbell was working with was tissue thin. So he had to be cautious, even delicate. But at the same time, the situation required physical boldness. Campbell handled the organs as bluntly as a butcher does lamb chops.
The bullet had fragmented and remained buried inside James. Trying to cut the fragments loose wasn't worth the risk. There were, Campbell said, an amazing number of gunshot wound survivors walking around with bullets, as he put it, "in their chitterlings."
James had also suffered a serious wound to his right arm, so a second surgery, a bypass of his brachial artery, was performed.
Well into the fifth hour of surgery, with countless stitches in him, James' ordeal was over -- for this night. They left the long incision open but protected. This was only the first of what would be many operations.
If James lived, that is. Campbell admitted to some pessimism. "I'm not sure if he's going to live or not," he said the next day. There were so many dangers. Blood loss. The death of an essential organ. Infection.
An exhausted Campbell changed from his scrubs back into his street clothes. His discarded battle galoshes were splattered with drying blood.
"You know," he said, "I became a doctor because I wanted to ride in on my white horse and save the day. Sometimes I can do that and sometimes I can't." He sighed. "Death was in that room, and you don't want that mother
-- in the room."
James Hewitt underwent two more surgeries in the next 48 hours.
"The reason he's alive," said Campbell, "is because he's 14. You're pretty much indestructible when you're a teenager. And he's going to have to be indestructible to survive this."
The eighth-grader lay in the Intensive Care Unit on the fourth floor of the hospital, much of his body swathed in bandages or penetrated by a tube or a line. His respiration, heart rate and blood pressure were being monitored, as was the oxygen in his blood; he was hooked to a ventilator that was breathing for him, 16 breaths per minute. He was being fed intravenously, and three additional IVs provided control for his agonizing pain, fluids to keep him hydrated and sedation so he would not thrash about.
"He'd be in a lot of danger without the sedation," said Carol Murray, one of the nurses who attended to James round-the-clock, as she prepared to take his temperature on the morning of May 2, four days after the shooting. "He'd try to climb out of bed. Being on a ventilator day after day, there's no way a human being with any strength is not going to fight against that, and fall and hurt himself."
Campbell prescribed vecuronium, a neuromuscular blocker that "paralyzed him," the doctor said. "I've got him on ice."
Because the fluids bloated him, James looked like a float in a Thanksgiving parade. He arrived at the emergency room carrying about 160 pounds on his 5-foot-10 frame, and now weighed 225 pounds. The only vibrant thing about him was his smooth, creamy brown skin. His brown hair was teased into caterpillar-like rows that were dyed orange and blond at their tips.
Like many practitioners at General, Carol Murray had been there a long time, with 19 years on the job. People found out quickly if the county hospital was the right place for them. If they had the commitment, they stayed. If not, they left.
Though James' eyelids fluttered at times, his eyes did not open, and Murray wasn't certain if he could hear her or not. Nonetheless, she talked to him.
"Hey," she said. "It's Carol. I'm going to take your temperature now."
Campbell was still uncertain if his patient would survive. "I've said yes and people die and I feel like a piece of crap," he said, laughing as he took on his conductor's role -- keeping everybody in the OR loose as preparations began for James' fourth surgery.
Campbell dominated the room. He liked to portray himself as an Everyman despite holding degrees from Harvard and UCSF Medical School, and for good reason.
His father was a Jamaican maintenance worker in Manhattan who did not finish high school, and his West Indian mother never made it to high school. "My mom," he said, "was a tough, take-no-prisoners kind of woman.
Education was most important. If I got an A, she wanted to know why it wasn't an A-plus."
Growing up, he remembered, there were "very few role models. You looked at TV back in the 1970s, there were no black doctors. Then I got a pediatrician who was a black doctor and I was like, wow."
His mentor, Bill Schecter, understood why Campbell brought a complex mix of humility, pride and drive to his job.
"A safe surgeon leaves his ego at the door," Schecter said. "You have to beware of the surgeon with misplaced confidence. Obviously, to do this work you have to have a big ego -- you can't cut people open unless you think you're pretty good. Nobody's totally mastered this. It's a constant struggle to avoid error."
Campbell examined the open wound. "Man, this is ugly. We got to plug that gash -- it's like yea big." The edges were a bright beefy red. Campbell went to a whiteboard and drew a diagram of James' innards for the benefit of the others in the OR.
The surgical opening in his abdomen was the shape of a football, but larger. Between operations -- Campbell anticipated there would be two a week for a while -- the gash was sealed by a mesh that cinched.
Today's surgery would serve several purposes. First, Campbell wanted to keep close watch on the devastated organs, while teaching the two surgeons-in-training in the room the techniques he had mastered. "All my little tricks," he said.
"Ever done a case like this before, Ed?" he asked a surgical resident, as he plunged his hands protected by baby-blue gloves into the wound. "Can we look at the duodenum," the first of three parts of the small intestine.
"Here it is," he said after a moment's search, partially lifting it. "Put your finger here, Ed."
Secondly, Campbell was monitoring any possible onset of infection. James'
bullet-damaged liver was covered with a green film Campbell didn't like; but it was a regenerative organ. "This is a toilet operation," he explained. "Wash him out and make sure nothing else is dead, or leaking.
We've got the bleeding under control."
Campbell was also inching toward the arduous task of closing James' gash a few centimeters at a time. "Everything depends on whether we can get him closed," he said.
The surgeon was pleased with what they had found, but James was by no means out of the woods. Most of his vital signs were improving, though Campbell was still worried about abscesses, or an infection, or pneumonia.
And it troubled him that James' heart rate continued to be elevated.
"I don't like that at all," Campbell said. The surgeon's eyelids were droopy and his voice hoarse. He was tired.
James' mother, Paulette Spikener, was barely able to function since her only child had been gunned down not a block away from the apartment where they stayed with her mother.
"It's really bumpy," she said. "First few days, I wasn't able to eat or sleep or concentrate right when my son was here fighting for his life."
She found it hard to look at him in the ICU, bloated, heavily sedated and hooked up to so many machines.
"She's scared to death," said nurse Murray, who talked to Spikener on the phone at least once a day.
"He's my one and only," Spikener said, during a visit. "Because I went through this with his father," who was shot to death when James was 10.
"Same deal." No one has been arrested for shooting either father or son.
Spikener is 35 years old and works part-time at a produce market in the Bayview. While she talked, sitting in the Intensive Care Unit, she picked at a packaged Hostess cinnamon roll and sipped from a Powerade Optimum.
Fearful as she was that her son would never make it out of the hospital, she was almost as worried what might happen if he did.
"Because every night there is shooting up there," in the Hunters View project, she said. "And next time he might not be lucky, like his friend Marcus, who didn't make it. This is like a never-ending war. I'm just trying to keep strong."
The danger to James -- who presumably knows who shot him -- was dramatized by another gunshot patient in the ICU. On May 4, that 21-year-old was seriously wounded while riding in a car with a friend who had given evidence in a gang-related murder case and been placed in witness protection. The friend was killed.
On the whiteboard where the names of ICU patients were written, James' and that other young man's did not appear. Instead there was the designation "R." This was a precaution against the possibility somebody might come to finish the job.
Even if James survived, there was a good chance he might return. Between 40 and 50 percent of teenagers shot once "come back here within a two-year period," said Dr. Rochelle Dicker, another trauma surgeon who studies the risks. "They feel completely trapped, and they don't know where to turn."
James developed a blood clot deep in his pelvis. If it migrated to his heart, it could cause a fatal embolism.
Campbell went to the radiology department on May 8. Radiology was a troubled department. Many physicians and technicians had quit, fed up with the antiquated equipment that was causing months-long backups. The hospital was pressing the Board of Supervisors for money and had been promised $2 million for salaries and up-to-date CT scanners and MRI devices.
Campbell told a radiologist, Dr. Derrick Allen, he wanted a filter -- an umbrella-like device to hold the medicated clot in place -- to be surgically inserted.
"Wow," Allen said, looking at the clot on a screen. "I can do it today.
That's more important than some other stuff."
The cost of caring for James was mounting. That wasn't Campbell's main concern, although as part of the hospital leadership he was deeply involved in the ceaseless struggle to keep General afloat.
"I don't give a s -- if he's insured," Campbell said, at first seemingly stunned that the question had even been asked. "His insurance status does not affect what I'm going to do for him. I'm going to do the right thing.
That's what our whole thing is here -- the guy in the bed. Anything it takes, any number of operations. I'm going to save him."
James was among the 21 percent of inpatients at General who lack medical insurance, including government coverage; the percentage is even higher among outpatients, 36 percent. For the most part, this financial gap is made up by a city subsidy -- $91 million of the hospital's $474 million budget in 2005.
Only 5 percent of General's inpatients and 3 percent of its outpatients have commercial insurance. The rest are covered by either Medi-Cal or Medicare, and neither government program pays the full cost of hospital treatment.
Eventually, the charges for James' inpatient care would climb to $1,078,613.19.
James' surgeries had become a geometry problem. "We're trying to bring the spread together, about 2 centimeters each time," Campbell said, holding up his hands to demonstrate. "Tighten it, pull it together. Part of it is closed nicely, but I'm not sure if I'm going to be able to mobilize it entirely or not."
The location of the entrance and exit wounds made it difficult to stretch the skin tightly across the gash.
As in any workplace, people in the OR talk while they work. During James'
operations, doctors discussed their vacation plans, gossiped about other doctors and debated the health care system.
"The only thing wrong with our health care system is capitalism," said Dr.
Andrew Infosino, an anesthesiologist, during the surgery on May 8.
"But it's inefficient capitalism," said Dr. David Aaronson, a resident.
"What I mean," Infosino said, "is it's perfectly market-driven for the big providers.
UnitedHealth and those people love it this way. Doctors think they're the big cogs, but we run the little service station, and they're Mobil-Exxon."
Campbell chimed in: "There's a lot of this stuff I don't understand."
"You're absolutely wrong, you do understand it," said Infosino. "For instance, cost benefit-wise, is it worth spending $500,000 or whatever for him?" He gestured at James, spread-eagled on the operating table, his eyes taped shut. "Or should it be spent on vaccinating people?"
"Problem is, in medicine, it's all about saving one life," Campbell said.
"Problem is, gotta tell his mama gonna let him go." He turned to a nurse, Kim Tucker, who Campbell knew lived in the Bayview but sent her teenage son to a high school in another city that she felt was safer.
"Kim," Campbell said, "don't you have some fancy-pants adhesive remover?"
There was an expression that surgeons used that Campbell liked. "You make a Frankenstein, you fix a Frankenstein." Of James, he said: "He's my Frankenstein." It was Campbell's way of saying that to practice medicine at General, you had to acknowledge your responsibility not only as a doctor but also as part of our society -- a society in which bullets were a disease, as Bill Schecter said.
On May 24 at 2 o'clock in the afternoon in Operating Room 3, Campbell decided that he would not be able to entirely stitch up the bottom of James' gash. He had been partially defeated by the geometry of gunfire.
Instead, he would cut some skin from the 14-year-old's thigh to graft over the gap.
Before the graft was complete, though, Campbell needed to leave for a Trauma Peer Review meeting where, he said, "the adults talk about the serious stuff we do wrong. It sucks being an adult." He asked a surgical fellow to complete the procedure.
Campbell removed his surgical gloves and goggles and started for the door still in green scrubs, mask and hat. At the door he paused. "I'm just happy he's alive," he said. "I wouldn't have predicted it at the beginning. We've got him all fixed now."
On many days, James' mother found it hard to look at her son in his hospital bed, unconscious and tethered by tubes and lines. But when Campbell called her and told her that he was going to survive, she hurried to the ICU and stood gazing down at her only child. She reached out and gently stroked his leg above the knee.
TELLING THE STORY
Staff writer Mike Weiss conducted more than 100 interviews and staff photographer Lance Iversen made more than 20 visits to San Francisco General to report this story.
The scene depicting James Hewitt's arrival at the hospital on April 28, and his initial surgery, was reconstructed through interviews with his surgeon, Dr. Andre Campbell, and with other nurses and doctors who were present. In addition, The Chronicle was present at three subsequent surgeries to repair James' wounds.
The account of James being shot on April 28 was reconstructed through interviews with his mother, with an anti-violence outreach worker who was on the scene at the time and with a spokesman for the San Francisco Police Department.
All the other scenes in the story were observed by The Chronicle.
BY THE NUMBERS: A TYPICAL DAY AT SAN FRANCISCO GENERAL
10: birth certificates are issued for newborns.
494: outpatient prescriptions filled, and 6,749 doses of medicine dispensed.
150: interpretations are made in 26 languages.
56: CT scans and 245 X-rays are made.
370: blood samples are drawn.
6,849: pounds of laundry are generated. 12,500: billing transactions are processed.
E-mail Mike Weiss at firstname.lastname@example.org.