Small: Life and Death on the Front Lines of Pediatric Surgery

6 | Battlegrounds to Playgrounds

battlegrounds to playgrounds By the time the four-year-old boy arrived in the emergency room, his heart was still beating, but his body was broken beyond repair. His mother had left him for just a minute to answer the phone in their Harlem high-rise apartment. And that was all it took for him to scramble up to the ledge and tumble, headfirst, out the unscreened window to the sidewalk four stories below. A short time later Dr. Barbara Barlow was opening the abdomen of her critically injured patient in a Harlem Hospital operating room. His liver was cracked, his spleen was ruptured, but those were the easy parts. She could fix those. What she couldn’t fix was his brain. When kids fell out of windows they all landed on their heads, and in this case, the bruising and swelling in his brain would lead inevitably to brain death. She was too late for this little boy, the most recent casualty from the neighborhood. The only way she could have gotten to him in time was if she had kept him from crawling out in the first place. The thought nagged at her, and it would not go away. Barlow would continue to witness a constant stream of carnage in her new job as the first full-time pediatric surgeon at Harlem Hospital—gunshot wounds, stabbings, and falls from windows. It was 1975 and she had just finished two years of learning the craft of pediatric surgery in an intensive fellowship that concentrated on congenital anomalies and childhood cancer. Before that she’d battlegrounds to playgrounds ( 85 ) spent the better part of a decade operating on sick and injured adults in the Bronx, but this torrent of life-threatening injuries to children was something new to her.1 She had never worked in Harlem, though, a place where drugs, violence, and poverty were as pervasive as fog rolling off a harbor in winter. The 1970s have been described as possibly the worst period in the history of Harlem, a time of hitting bottom by nearly ever measure imaginable. Harlem had the highest death rate in New York City courtesy of the glum trifecta of homicide, suicide, and alcoholism. The infant mortality rate, well above average in the late 1960s, doubled in the 1970s.2 Children openly sold drugs on street corners and joined the ranks of organized crime. There were no jobs and a quarter of families were on welfare. Businesses were shuttered, and three thousand apartments per year were being lost to decay, arson, and abandonment. No matter your age, your color, or the dreams you held close to your heart, if you were growing up in Harlem your chances of being felled by a major injury were more than twice the national average. Every day trauma ripped families apart, leaving only jagged edges where siblings used to be. Like it or not, Barlow was in the middle of a war zone. She was willing to operate all day and all night to try and save pediatric trauma victims, but she also began to contemplate what could be done about the relentless gush of wounded blanketing the stretchers in the emergency room. Barlow realized she needed to step back and consider the bigger picture. A new approach was in order. If she were really going to help the children of Harlem, she should be figuring out a way to prevent injuries from happening in the first place. Was it even possible? If so, what would it take? She had no idea, but she knew she had to try. In the trauma business one learns early about the finality of getting to a patient too late. The first time I saw it, I was an intern ( 86 ) s m a l l on the trauma service. Early one morning, a young woman on her way to work was rear-ended by an eighteen-wheeler. She arrived at the emergency room in shock, her blood pressure dangerously low. A trauma surgeon and I wheeled her straight up to the operating room, as fast as we could move, past hallways crowded with patients on their way to elective tests and procedures, their faces creasing with concern as we barreled through. We skipped the rituals of scrubbing and prepping, pulled on our gowns and gloves, and hustled to the table. The trauma surgeon quickly threw down sterile towels, grabbed...