Shaheen Timmapuri looked down at the small child being prepped on the operating table. Who would shoot a 3-year-old boy? And more important: Could she save him?

The young surgeon didn't have the time to process what had happened: The toddler had been shot twice in the back by an intruder while sleeping in his parents' bed.

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She needed to focus. This was damage control.

Get in. Find the injuries. Stop the bleeding. Get out. And do it all before the child arrested or became so unstable she and the trauma team at St. Christopher's Hospital for Children wouldn't be able to revive him.

At 6:37 that Monday morning, the team of surgeons led by the 34-year-old Timmapuri began the surgery on the gunshot victim, who was young even by the standards of Philadelphia - one of the nation's most violent cities.

This was like no other shooting victim Timmapuri had treated in 12 years of medical training or in the four months she'd worked as an attending at St. Chris.

Using a scalpel and cautery, a resident sliced down the middle of the boy's abdomen, from his sternum to his pelvis. The surgeons pulled open the incision and packed the abdominal cavity with large surgical sponges to stanch the flow of blood.

Timmapuri knew from an X-ray that the bullets had passed through the boy's 33-pound frame. She knew from the CT scan that he had a hole somewhere in his colon and an injured kidney.

The clock was ticking. Timmapuri had to move fast if she was to save Amin from bleeding to death.

'Level 1 trauma'

It started while Timmapuri was asleep at home.

Shortly after 5 a.m. on Monday, Dec. 1, Betsy Grund stood outside the trauma bay at St. Christopher's, chatting with a colleague.

The small emergency room was nearly full, but quiet after a busy night.

At 5:12, Grund and rest of the ER staff heard the radio beep, followed by the call from Philadelphia Emergency Medical Services: "Trauma transport, 3-year-old, gunshot wounds to back and side. ETA three minutes."

The doctor in charge called a Level 1 alert - the full trauma team including X-ray technicians, nurses, surgeons, and the ICU and OR staffs.

Timmapuri's pager woke her up. "Level 1 trauma."

The surgeon jumped out of bed, threw on the scrubs she had laid out the night before, and ran to her silver Acura. As she raced up Fifth Street to the hospital, she wondered what she'd find.

What had been hit? Had a bullet gone into his chest? She prayed she would get there in time.

At 5:15, Amin, wearing only a diaper, was carried into the 20-by-18-foot trauma bay and gently placed on the table by an EMS medic.

The little boy's eyes were open, but he didn't make a sound. He was in shock.

Grund and a dozen other medical personnel crowded into the room. Police and firefighters watched from outside.

Amin was the 871st trauma patient admitted to the children's hospital this year. He was the 19th gunshot victim, but most of the others were much older.

This was different. This was a toddler.

Grund and her colleagues worked quickly to get a breathing tube in, put IVs in both arms, and start pushing fluids and medicines into his small body.

They checked him for injuries, from head to toe. An X-ray to ensure that the breathing tube was properly placed showed that the bullets had passed through the boy, but little more.

There was blood in his urine.

Timmapuri arrived at 5:35 as the team prepared to take Amin for a CT scan. She examined him quickly as she walked beside his gurney into the scanner room.

Despite everything, Amin was relatively stable. Maybe the bullets had passed through without causing major damage, she thought.

Two bullets

The CT dashed that slim hope. Contrast dye used for the scan was pouring out of Amin's colon, and a cloud appeared where his left kidney should have been.

Timmapuri didn't need to see any more.

"Let's go," she said.

They wheeled Amin to the elevators, up a floor, and directly into Operating Room 4.

It was 6:05 a.m.

In the ER, Timmapuri had heard that the boy had been hit in a home invasion and that his parents had also been shot.

She pushed back that thought and focused on the task at hand: Save this child.

The surgeons began systematically to check for damage. They started on the right side and quickly moved to the left, where the two bullets had pierced the boy.

A bullet had passed through his colon. Stool had spilled out of the wound.

Though working fast, Timmapuri made sure to clean the area well, to minimize risk of infection.

After cutting the colon free of the abdominal wall, the surgeons stapled the colon closed on both sides of the wound - simultaneously cutting out the damaged tissue.

Behind the colon, the kidney was shattered.

As Timmapuri examined the organ to determine whether it could be salvaged, the surgeons found yet another bullet hole in Amin's small intestine. They stapled it closed.

They found a hole in his diaphragm, the muscle between his abdomen and chest. Timmapuri decided to leave that for a later surgery.

She knew she could come back another day to reconnect the intestine and colon - if Amin lived that long.

Her job this morning was to fix what she could and get her patient out of the OR and into the intensive-care unit, where he could be stabilized.

The left kidney continued to bleed profusely, but the right one was fine. Amin could live with just one. Timmapuri decided the damaged kidney had to come out.

After it was removed, the surgeons had a better view of Amin's spleen. It had been hit, too.

It was a lot of wreckage for two bullets.

A radiologist called the OR. The CT scan showed that a bullet had shattered a vertebra and injured the boy's spinal cord.

That injury wasn't life-threatening, and there was nothing Timmapuri could do about it right now anyway. She had no time to worry about whether the child, who hadn't yet been potty-trained, would be paralyzed.

But now Amin was becoming more unstable. His temperature was dangerously low, despite the efforts to warm the blood and fluids being pumped into his body. His blood pressure was dropping.

The boy's heart was working too hard and at risk of failing.

At 7:12 a.m., anesthesiologist Roy Schwartz injected epinephrine through an IV to improve Amin's blood pressure and prevent a cardiac arrest.

Timmapuri looked back at the spleen. The spleen is especially important for children fighting off infection. Kids who lose the organ must take antibiotics for years.

It was bleeding too much, and the boy was teetering.

The surgeon decided the spleen had to come out, too.

Once they finished, the surgeons repacked the child's abdomen with surgical sponges, and put a drain on top - and another drain in his chest. They left him open, his abdomen covered with a large bandage.

At 7:22, 45 minutes after the first incision, they rushed Amin down the hall to the intensive-care unit.

Timmapuri knew that if he survived, the boy would need more surgery in the next 24 to 36 hours.

A child's strength

While Amin was in surgery, ICU nurse Doug Konzelman was getting ready.

As soon as the child arrived from the OR, Konzelman took his temperature. It had fallen to 90.5 degrees, 8 degrees below normal.

It was critical to get Amin's temperature up to prevent his heartbeat from becoming erratic or stopping and to help his blood clot.

In the OR, Amin had received three units of blood, plus a unit of platelets, but he needed more fluid. All told, he had lost about 60 percent of his blood, and his wounds were still oozing.

Konzelman focused on warming him up.

Timmapuri considered her patient, and what to say to his family.

Amin was in critical condition, and he was unstable. It wasn't clear he would survive, and if he did, there was the spinal-cord injury. It was too soon to know whether he was paralyzed.

Timmapuri walked down the hall to the waiting room. Dozens of Amin's relatives and family friends had converged on the hospital after learning about the shooting. There were not enough chairs for all the people waiting.

As she walked in, someone told her Amin's mother had died.

It was almost too much for Timmapuri to comprehend. The overwhelming damage to the boy and his family infuriated the young doctor. It was so unfair.

She found Yolanda Payne, the boy's paternal grandmother, and began to go over his injuries.

Timmapuri urged the family to have hope.

"Children are strong, resilient," she told Payne.

The surgeon had often been amazed by what her young patients could withstand. She hoped the boy, whose grandmothers called him Samson, would have the strength of his biblical namesake.

He needed it.

Timmapuri swallowed back her feelings, held back the tears.

There was too much to do.

Back in the ICU, she went over Amin's surgery and her plan with the doctors and nurses.

She wished she could pick him up and hug him, but that was impossible.

Still, she stroked his forehead, held his hand.

Even while he was sedated, she wanted him to know someone was watching over him.

She stayed with him for hours. She couldn't bring herself to slip away to check on her other patients, or grab a cup of coffee and a soft pretzel, until 11 a.m.

Amin remained unstable, but by 4 p.m. the surgeon was more confident he would survive. Unfortunately, the spine experts did not boost her spirits on that front.

She held out hope.

It wasn't until later, when Timmapuri was driving home, that she cried.

She called her parents, who live in Hamilton, N.J., where she grew up. Her mother is a family physician. Timmapuri needed to vent.

She was physically and emotionally exhausted. Once at home in her Washington Square apartment, she turned on the news to see if the shooter had been caught.

She was disappointed.

Sleep did not come easily that night. She could not stop thinking about Amin.

Would he be able to walk?

A pinched toe

The surgeon woke up early on Tuesday, Dec. 2, and checked on Amin as soon as she arrived at the hospital.

He looked better.

The boy still needed medication to stabilize his blood pressure, but Timmapuri was confident he would make it. She wanted to get him back to the OR to finish the operation.

It wouldn't be that easy. It took three more operations over the next week before she could completely close Amin's abdomen.

He did well. Most of the wounds would heal.

On Friday, Dec. 5, four days after arriving at St. Christopher's, Amin's breathing tube was finally removed and his sedation reduced.

Timmapuri watched his legs carefully. She pinched his toe.

He didn't move his legs, a bad sign.

Timmapuri knew there was little chance he would walk again, but she tried to hold on to hope.

She fought to get him into Shriners Hospital for Children for rehabilitation.

She would hope he could overcome the odds and one day walk. He had the strong support of his grandmothers and extended family.

She looked down at the little boy. She had saved his life.

She wondered if that was enough.

Coming Tomorrow

Samantha Houston's death, and the injuries to her son Amin Payne Jr., show the broad reach of street violence in Philadelphia. Even the bedroom of her own home was no sanctuary for her and her children.EndText

Contact staff writer Josh Goldstein
at 215-854-4733 or jgoldstein@phillynews.com.