Patient Care

Call of Duty


 

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Dave Bowman, MD, doesn’t run anywhere anymore; it’s more of a fast walk. He doesn’t consider himself political, yet he does his civic duty and votes in every election. He’s not a big fan of vegetables, but he eats them to appease his wife and his conscience. Most important, Dr. Bowman doesn’t consider himself a hero. In fact, he doesn’t consider what he did that day any different from what he does every day in the hospital.

On the morning of Jan. 8, Dr. Bowman and his wife, Nancy, were thrust into the epicenter of one of the worst shooting rampages in American history. Dr. Bowman, a hospitalist, was the first physician on the scene outside the Tucson, Ariz., grocery store where a lone gunman killed six people and injured 13 others, including U.S. Representative Gabrielle Giffords (D-Ariz.).

“A hero is somebody, to me, who steps out of their element, steps up to the task that is needed, a task that is completely foreign to them, and steps up and helps people,” says Dr. Bowman, 61, executive director for IPC The Hospitalist Co.’s Tucson region. “A hero is not somebody who should be able to help in some manner and should be expected to help. … I don’t think nurses, doctors, firemen, EMTs get to be labeled as heroes. It’s what we should do, and gladly do, and in many cases took an oath to do.”

Even so, Dr. Bowman’s recollection of that frightful morning is a story laced with tragedy, courage, and hope. He remembers those who are “no longer with us.” He remembers his wife administering CPR and calling victims’ loved ones on their cellphones. And he remembers the brave men and women who not only subdued the shooter, but who worked together, selflessly, and in many cases with no medical training, to assist their injured neighbors.

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“It was a pretty traumatic scene. More for others than for me; I am supposed to be the doctor and can handle all that,” he says, pausing. “But they don’t teach this course in medical school.”

Shots Ring Out, First Thought Is Help

Born and raised 100 miles south of Tucson and internal-medicine-trained at the University of Arizona, Dr. Bowman became a hospitalist in 1998 and began working with IPC in 2000. He supervises a staff of about 90 providers, including more than 50 full-time hospitalists, serving two large community hospitals, rehabilitations centers, and skilled nursing facilities in the Tucson area.

Yet he knows who the real boss is in the Bowman household. He and Nancy, an ICU nurse, had just finished a brisk walk, eaten breakfast at McDonald’s, and stopped at Safeway to pick up some vegetables on the morning of Jan. 8. “I had the oatmeal. I was so proud of myself,” Dr. Bowman says. “And, as wives will want to do, she pushes the envelope and says she wants to stop by and get some Brussels sprouts. She hadn’t had them in 20 years, and I hadn’t had them in 45 years—since my mom stunk up the house with them. So we ended up at the Safeway, because the two things that keeps a marriage together are those two words: ‘Yes, dear.’ ”

The Bowmans passed by Rep. Giffords, her staff, and about 25 people in front of the grocery store entrance. They went to the produce department and had not been in the store for more than three or four minutes before shots rang out.

“I was 150 percent sure they were gunshots,” Dr. Bowman says. “I said to my wife, ‘Let’s go, Nancy,’ and she didn’t hear me. I thought she was right behind me. But she had gone over to the Brussels sprouts and I was still in mushrooms.”

Walking to the door, Dr. Bowman saw a woman rushing in and shouting, “They shot her. They shot Congresswoman Giffords.”

“I stepped out and stood behind a pillar until no more gunshots,” he says. “They’d actually already taken down the shooter as soon as he ran out of bullets. I looked around the corner to the carnage, as you’d expect, with Congresswoman Giffords the first person I saw right at the head of the line near the front door.

“Quite frankly, I stepped over people who were no longer with us to get to her. I got her turned around and moved off to the window; she wasn’t breathing real well. I worked on her airway, cleaning her airway with the young man [Rep. Giffords’ intern, Daniel Hernandez], who then held her for the next 15 to 20 minutes until the paramedics got her ready to go to the hospital.”

From that moment, Dr. Bowman says his training and instincts took over. More important, he went into field-triage mode, “which means you can’t do anything for that one. Can’t do anything there, this one is breathing and talking, not bleeding bad, good; still breathing, good, stay right there, I will be back. You go all the way up the line from person to person, seeing who you can and can’t help.

“The problem with field triage is that you really can’t stop and do a lot, like CPR, because then the rest of the people don’t have anybody looking at them. So you just keep moving,” he explains.

He says that while it was only minutes from the first gunshot to the time police arrived and secured the scene to the time paramedics were allowed to assist with the injured, it seemed like hours. Additionally, in his haste to help, Dr. Bowman had lost track of Nancy.

“I looked back and she was not there,” he says, adding she’d been swept to the back of the grocery store. “I kept working and I looked back and she had pushed [aside] the 17-year-old sacker who was acting as a security guard. … She came outside and started doing CPR on the first person she saw. I got up the line and there was a doctor doing CPR on the young girl [Christina-Taylor Green]. He was in the parking lot when the shots rang out; he threw his wife in the car and ran up to the little girl.”

Instinct and Autopilot

In a little more than 10 seconds, the gunman had fired more than 30 rounds and killed or injured nearly 20 people.

After he’d checked on all of the wounded, Dr. Bowman says he came upon four people holding the suspected shooter down. “One of them, I didn’t know it, was one of my colleagues, Dr. Stephen Rayle,” Dr. Bowman says. “I said, ‘Hold him, and I will send the first officer over here.’ ”

From there, Dr. Bowman says, he went back up the line of injured, checking for breathing sounds and bleeding, making sure every injured person was being attended to.

“People shot in the leg were holding a hand over a chest wound on the man or woman next to them,” he says. “It was one of those chaotic scenes that you try to make some kind of order to, by deciding who you can help and who you can’t.”

When the first paramedics arrived, Dr. Bowman directed them to Rep. Giffords and the 9-year-old girl. Soon after, there were enough EMTs on scene to attend to each of the victims.

“You are just on automatic,” Dr. Bowman explains. “Actually, after I dealt with the first two victims pretty quickly, Giffords taking the most time to just get her situated, I did stop and look out in the parking lot just to see if anybody was aiming anything at us.”

The most difficult part of field triage, Dr. Bowman says, is staying calm, organized, and “not losing it emotionally.” In fact, he ushered some shell-shocked bystanders away from the scene. “Some people will step right forward and say, ‘Can I help? I know CPR.’ Other people will just stand there and scream.”

Even tougher, he says, was watching his wife try to save the life of U.S. District Judge John Roll (see “Remembering the Dead,” above). “I finally had to go to my wife, pull her off of him, and say, ‘Honey, he’s gone. I need help with this lady who has been shot in the chest laying in the street,’ ” Dr. Bowman says. “Pulling them away is pretty hard. ... It was harder for her and the bystanders, because they were the ones getting right down close with the patient, talking to them, telling patients to ‘keep looking at me.’ That is a very close bond that develops. Field triage, you just keep moving.”

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Human Spirit, Cooperation, and Hope

One month after the shooting, Rep. Giffords was moving, talking, thinking, and recuperating at what her doctors at Houston’s TIRR Hermann Memorial deemed “lightning speed.” For Dr. Bowman, such news brings more than a sigh of relief.

“In truth, when I was first with her, she wasn’t responding,” he says. “She was breathing, although with a compromised airway. We got that straightened away and she had a good pulse. Daniel Hernandez, the young man with her, had some nursing training and was comfortable being with her.

“It was amazing to me, the second or third time down the line, just to look over to this guy, and he was watching for me, and he would nod and say, ‘We’re OK. She’s breathing, pulse is OK.’ I didn’t have to go back, and the third time down he said, ‘She’s moving, she’s squeezing my hand.’ ”

It was at that moment that Dr. Bowman felt the congresswoman, in spite of her severe head trauma, had a fighting chance. Others miracles were happening all around him. Each memory ceases to amaze the veteran physician.

“People who were injured holding somebody’s head in their lap because they were hit in the head and this person was hit in the chest,” he says. “It gives you hope for the human race. Those people, to me, were the heroes.”

Looking back, Dr. Bowman says, he’s played back the moment in his mind more than a few times, wondering if he did the right thing for every victim. He wonders how much he and his wife, the other doctors at the scene, and the bystanders really helped. Then, after a brief moment, he has the answer.

“It really took two weeks to really say that, when all the victims that had expired were dead at the scene, and everybody that got taken away made it and out of the hospital, it sunk in that we had made the right decisions,” he says. “Nobody died on the operating table because we didn’t pick up the gunshot wound to the back. It took two weeks to realize we did the right thing.”

Some of those answers will take many more weeks. Rep. Giffords, although she is on a positive path, still has a long road to a full recovery, and doctors are making no promises. “I don’t know how far she will make it or how long it is going to take, but there are some miracles out there,” Dr. Bowman says.

You’re a Hospitalist? You’re Ready

As a physician in the middle of a mass-casualty event, the media called upon Dr. Bowman to recount the events of the Tucson shooting. In more than a dozen interviews with local and national media, not once was Dr. Bowman referred to as a hospitalist.

“At the scene, when I kneel down, I am a doctor. Can you tell me what’s going on, can you talk to me? It goes no farther than that,” he says. “In talking with one of the interviewers, she asked, ‘What kind of doctor are you?’ I said, ‘I am an internist and a hospitalist, which is a doctor who works just in the hospital.’ They weren’t interested in that. When the cameras rolled, she said, ‘I understand you are an intern?’ I said, ‘No, I am an internist. Turn that thing off and start again.’

“That’s the level of knowledge you are dealing with, and that was a national anchorperson I was dealing with.”

It’s an all-too-common refrain for hospitalists around the country, but one Dr. Bowman and others like him have endured for years. It doesn’t bother him, and he says it shouldn’t bother others.

“Doctor or nurse was as far as it got. I can certainly understand that,” he says. “We explain what a hospitalist is every day. We’ve been doing it for 12, 13, 14 years, and people still don’t understand. It’s OK.”

What isn’t OK is hospitalist unpreparedness. In fact, Dr. Bowman says, his training as an internist and his years of HM experience played a pivotal role in managing the scene of the Tucson shooting. The first thing to do, in addition to remaining calm, is to keep your priorities straight and remember your ABCs.

Be ready. And, by the way, you are ready. You take care of a stroke patient in room one, take care of a gangrenous leg in room two, a diabetic with ketoacidosis in room three. The broadness, the generality of your training, you are ready to take care of a variety of things. You’re going to be able to help. Just be ready.

“It’s airway, airway, airway,” he says. “Without an airway, people don’t live. Then you are looking for bleeding, bleeding, bleeding. Then if they are talking, not a lot of bleeding and have a pulse, that is good enough for right now. So, it’s ‘Lady, just keep pushing on the chest right there on that wound.’ … I think, if you remember your ABCs, that’s all you can do in a field triage situation.”

Although the circumstances are less stressful, hospitalists are faced with make-or-break decisions every day, Dr. Bowman says. For example, it’s 4 p.m. and the day shift physician in the ED calls and says he has six admissions he’s been working on for the past three hours. “You, based on the info given to you, have to decide, Well, who is sickest, who do I have to get to first, who is going to the ICU?” Dr. Bowman says. “You do this triage thing in your mind as you walk to the ED. If there is any corollary, it’s the fact that you, as the hospitalist, get hit with a slew of patients all at once. They don’t come in one every 15 minutes like in your office for a blood-pressure check.

“Be ready. And, by the way, you are ready,” he adds. “You take care of a stroke patient in room one, take care of a gangrenous leg in room two, a diabetic with ketoacidosis in room three. The broadness, the generality of your training, you are ready to take care of a variety of things. You’re going to be able to help. Just be ready.” TH

Jason Carris is editor of The Hospitalist.

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