HOSPITAL COURSE: The patient arrived and after a full trauma activation with the team already in attendance in the emergency department a left angiocatheter was placed in the second intercostal space and an interosseous access was already placed. Upon arrival simultaneously an airway was established by first bagging the patient and then placement of an endotracheal tube. IV was established via the right EJ and the heart rate was noted to be 120. There was a good palpable femoral pulse. A Foley catheter was placed. Soon after this the pulse was lost and chest compressions were started. A chest x-ray showed opacity of the left lung and a chest tube was placed on the left side with return of blood but no rush of air. ACLS protocol was being performed concomitantly. A left thoracotomy was performed and a #10 blade scalpel was used to make a generous incision. The curved Mayo scissors were used to open into the pleural space from the table to the sternum. The heart had no spontaneous mechanical movement and the aorta was crossclamped. There was good ventilation of the left lung with a small air leak. It should be noted that the entry site of the gunshot was at the midsternum and the exit on the posterior shoulder with a laceration on the upper chest of unknown etiology. The right external jugular vein access was lost and a right subclavian Cordis was placed by myself using the Seldinger technique. There was return of good venous blood and infusion of blood products and crystalloid continued through the Cordis at a higher rate. With this higher rate of infusion the heart began to fill and a spontaneous electrical wide complex rhythm was noted. Cardioversion was attempted at 30 joules with a continued wide complex rhythm. Between these therapies CPR was continued at all times. The patient was then brought to the operating room where after prepping the chest with Betadine and continuing compressions the patient was draped and the thoracotomy incision was continued across the midline to the right side. It should be noted that in the ER ultrasound of the pericardium and the abdomen showed no pericardial tamponade or intraabdominal free fluid. The clamshell was completed. The pericardium was opened. There was no blood here. There was no fluid in the right chest. There was a large hole through the right lower lobe of the lung and a Satinsky clamp was placed on this to obtain excellent hemostasis and control air leakage. There continued to be bleeding from the posterior mediastinum. The heart appeared uninjured by the bullet. Using a Deaver retractor the heart while still performing cardiac massage the posterior mediastinum was exposed showing moderate bleeding but the source of the bleeding could not be identified. Concomitantly there was a moderate amount of blood from the endotracheal tube. The aortic crossclamp was left in place. After failure to obtain any spontaneous cardiac rhythm the code was called at 11:02 a.m.