Running a Trauma Code in the ED

Hospital image via Shutterstock

The paramedics flying the patient in by helicopter called the Emergency Department charge nurse and described the patient: a 40-year-old male in a construction accident with
deep lacerations (wounds) to the left leg. The moment between the paramedics’ call and arrival was only a few minutes.

During this time, the ED notified the
trauma surgery team that a patient may need surgical care and classified the trauma as level 1 (a level 2 trauma is less urgent). As the ED
notified the trauma surgery team, the ED nurses and an ED resident prepared the trauma bay, which is just a larger patient room in the ED. They kept IV
fluids at the ready; the blood bank prepared to get the patient blood; the resident placed an intubation kit at the stretcher side (if the patient is
unconscious and cannot breathe on his or her own, the resident places a tube down the patient’s throat in order to get oxygen into the lungs); an oxygen
mask was set to deliver oxygen; we medical students placed blankets at the bedside; and everyone put on gowns, masks, and gloves. The whole scene was
chaotic, not least because of the sheer number of people involved: multiple nurses, an ED resident, a general surgery resident and/or an acute care surgery
fellow, a trauma surgery intern, a pharmacist, medical students, and an x-ray technician to take immediate imaging if needed.

As the paramedics rushed the patient in on a stretcher (yes, just like in the movies), they recapped the patient presentation for the healthcare team and
provided slightly more detail about the mechanism of injury. A construction worker accidentally dropped a chainsaw onto his leg. The metal edges
of the saw cut through the patient’s left shin and thigh.

I don’t usually find blood upsetting. During surgery, I had no problem in the operating room watching the surgeons explore bowel or try to stop bleeding
from a severed artery. Objectively, I comprehend that it is gruesome, but it doesn’t induce an intense visceral reaction. However, this particular event was
absolutely disturbing. The metal blades cut the left shin so deeply that only half of the bottom leg was attached to the knee. The tibia and fibula bones
jutted out of the skin over large, severed arteries and veins. Muscle and tissue clung to the leg by a few strands of skin as blood seeped from the wound.
On the upper thigh, the damage was less intense — the saw tore through the quadriceps and the lateral leg muscles. Some of the superficial muscle hung off
the wound, which bled much less severely. This sounds horrible, but the sight of this, akin to some kind of horror movie, was not so affecting until one
pairs it with the fact that this patient was conscious.

His screams were charged with fear and intense pain, while he lay in a completely strange place with no family and no shortage of doctors and nurses and
paramedics aggressively intruding on his personal space. I thought of this passage from Tolstoy’s The Death of Ivan Ilyich: the screaming “was so
terrible that one could not hear it through two closed doors without horror…. ‘Oh! Oh! Oh!’ he cried in various intonations. He had begun by screaming ‘I
won’t!’ and continued screaming on the letter ‘O.’” For this person to experience all this commotion and pain while also realizing the possibility of losing
his leg must have been overwhelming.

But the struggle to provide medical care went on and the trauma assessment began. The upper-level surgery resident stood at the foot of the patient’s bed
directing the healthcare team and the ED resident stood at the head of the stretcher making sure the patient could breathe. The nurses, meanwhile,
confirmed that two IVs (one in each arm vein) were in place and working so that they could deliver blood, fluids, and pain medication as needed. The upper-level trauma surgery resident began with the primary survey, which identifies life-threatening injuries to the patient. For instance, an injury to the patient’s throat
or mouth that prevents the patient from breathing is an immediate concern. The resident scrutinized the vital signs and quickly assessed
for other urgent issues: airway (is the patient’s mouth clear from obstruction?), breathing, circulation (major blood loss), disability/neurological
issues, exposures to toxins/environmental control. We frequently use the mnemonic ABCDE to remember this. The nurses completely stripped the patient of
his clothing during this examination, for the sake of thoroughness.

If the patient is not on the verge of dying, the trauma surgery resident begins a secondary survey and fastidiously examines the patient head to toe for
other, perhaps less urgent, signs of bruising, bleeding, or anatomical abnormalities caused by trauma to bones or tissue. The hospital staff roll the patient
onto his or her side in order to get a clear view of the back and buttocks. The surgical intern usually performs this part of the exam, hollering out any
abnormal findings to a nurse who stands outside the room, documenting the patient’s injuries to a computer. The resident also performs a FAST exam (Focused Assessment with Sonography for Trauma), where he or she uses
ultrasound imaging to search for blood within certain parts of the abdomen, chest, and pelvis. It is a quick and effective way to assess whether a patient
is bleeding internally and needs immediate surgery.

The healthcare team did a secondary survey as the patient continued to groan and scream. Because of the severity of the injuries to different systems, the
trauma surgeons, orthopedic surgeons, and vascular surgeons all came to assess what kind of surgery this patient needed. After a quick huddle with the
attending physicians, the nurses wheeled the patient straight to the OR, never to be seen or heard from by me again. The one aspect of this patient’s
prognosis that I do know is that the surgeons thought they could save this patient’s leg and its function, which is demonstrative of the
miraculousness of modern medicine.

In the early seventeenth century the great English poet, cleric, and lawyer John Donne
reflected upon sickness and health in a book called Devotions upon Emergent Occasions, after battling illness
himself. In it, he wrote that “we study health, and we deliberate upon our meats, and drink, and air, and exercises, and we hew and we polish every stone
that goes to that building; and so our health is a long and a regular work: but in a minute a cannon batters all, overthrows all, demolishes all….” There
is nothing quite like a trauma to reinforce Donne’s observation about how fragile our condition remains; being struck by a car or being in a construction
accident shoves us off the tenuous tightrope of health on which we walk. Here, a healthy patient in the prime of his life was nearly destroyed by poor
fortune.

This is also an example of losing track of a patient’s outcome, which is so common in medical school and residency. I’ll never know his whole story — as
I’ve written, this is something that contributes to cynicism in medicine.

And another thought on this trauma: a Chinese proverb states that “no man is a good doctor who has never been sick himself.” This certainly sounds
right. How can one understand a patient until experiencing his pain? I disagree, though. We know that many who see other people in pain experience pain themselves. But
further, the power of human empathy can be surprisingly vast. True that nurses, students, and doctors may not directly feel the pain of a sharp metal edge
slicing through flesh, but can we not comprehend the horror of this? Can we not, in an admission of never wanting something like this to happen to us,
experience in a small way the terror of such an event? An empathetic emotional response is enough to prime healthcare workers to take great care of a
patient. The potential problem in medicine, then, is not what the Chinese Proverb suggests. The possible outcome is that when we see people like this every
day, the once-astonishing horror becomes treated as a daily experience.

Death and ‘The Death of Ivan Ilyich’

There is much in Leo Tolstoy’s frightening and brilliant story The Death of Ivan Ilyich that is relevant to my previous post about CPR in the hospital. The novella concerns an upper-middle-class judge, Ivan Ilyich, his rise within the Russian legal system, and his subsequent death. Tolstoy describes Ilyich’s unremarkable and vapid professional and personal life — his accomplishments are not long-lasting and he despises his wife and cares little for his family — and contrasts this profoundly with Ilyich’s lingering march toward death.

I’d like to focus on two of the interesting points that Tolstoy makes about death. First, death itself is only a concern for the dying, while others are insouciant, opportunistic, or burdened by the obligation of dealing with a friend’s passing. Upon hearing of his death, Ilyich’s legal colleagues first thought “of the changes and promotions it might occasion among themselves or their acquaintances.” And one friend complains about traveling to the funeral: “…but they live so terribly far away.” Perhaps even more disturbing, “the mere fact of the death of a near acquaintance aroused, as usual, in all who heard of it the complacent feeling that, ‘it is he who is dead and not I.’ Each one thought or felt, ‘Well, he’s dead but I’m alive!’” Again, Tolstoy emphasizes the disturbing frustrations Ivan’s friends felt: “But the more intimate of Ivan Ilyich’s acquaintances, his so-called friends, could not help thinking also that they would now have to fulfill the very tiresome demands of propriety by attending the funeral service and paying a visit of condolence to the widow.” This haunting view of human nature should make us all cringe — how lonely death is and how cruel is the human response to it!

On that night I helped perform CPR, were those of us surrounding the dying patient in the hospital feeling as insouciant or feeling as burdened as Ilyich’s friends? Though Tolstoy’s dark view on such matters may hold true in some cases, I think that experience on the night shift was completely antithetical to Tolstoy’s understanding. In the hospital room, the feeling was not one of an obligation or burden. The attending physician kept CPR going because he wanted to give this young woman every shot at coming back to life. Then, he hurriedly tried to get in touch with the patient’s family, trying cellular numbers, home numbers, and even work numbers, to tell them what had happened. He covered up her chest with a blanket out of respect for her. And when he called the time of death, the palpable silence in the room was telling. There were no words to account for this process. In some ways, silence was the appropriate response. Nobody complained about other chores they had to do, or about the paperwork that had to be done or how much time they spent trying to resuscitate this patient.

Tolstoy also writes about the experience of dying, which makes up a large part of the novella. Ilyich sees death on the horizon and his inexorable march towards it. “In the depth of his heart he knew he was dying, but not only was he not accustomed to the thought, he simply did not and could not grasp it.” Ilyich attempts desperately to ignore death: “The pain did not grow less, but Ivan Ilyich made efforts to force himself to think he was better.” Towards the end of this process, Tolstoy describes Ilyich’s reactions: “[He] wept like a child. He wept on account of his helplessness, his terrible loneliness, the cruelty of man, the cruelty of God, and the absence of God. ‘Why hast Thou done all this? Why hast Thou brought me here? Why, why dost Thou torment me so terribly?’ He did not expect an answer and yet wept because there was no answer and could be none.” This is compounded further by Ilyich’s regrets about the life he led: “And the further he departed from childhood and the nearer he came to the present the more worthless and doubtful were the joys.” These moving passages summarize the dreadfulness of Ilyich’s confrontation as Tolstoy drags the reader through this horrific scene. During the last few days, Ilyich screams continuously, which is “so terrible that one could not hear it through two closed doors without horror.” And it is only when Ilyich admits to himself that his family would be better off with him dead (“It will be better for them when I die”) instead of watching him die, that he is freed from his pain and “in place of death there was light.”

Interestingly, Ilyich initially approaches his final minutes the way those who do CPR approach death, the way Dylan Thomas wanted his father to approach death, and the way so many people encouraged Christopher Hitchens to approach his cancer — with rage and a desire to do battle. Ilyich clings to false hope and attempts to confront death. In the end, though, he mitigates his suffering and the suffering of others only by submitting peacefully to his inevitable passing. Does this mean one must always allow death its victory, and must even pursue death, through means like euthanasia, when one is in intense pain? No, I think Tolstoy’s point is far more nuanced than that. Ilyich does not commit a form of suicide; he merely accepts his fate, which is when his pain and fear disperse. A good analogy might be the kind of care the field of medicine provides to terminally ill patients. We now attempt to provide comfort and care for the dying through hospices, institutions which give nursing care and pain medications to those with terminal illnesses in order to make their passing a comfortable rather than a painful struggle. This method is increasingly common and improves patients’ quality of life at the end in certain instances. (I will write more about hospices and issues related to end-of-life care in coming posts.) And this does not invalidate the option for a fight when it is appropriate and when something can and ought to be done. For those other than Ivan Ilyich, like the woman in the hospital on that night, there is still the hope of being saved. This option we must pursue no matter how difficult the pursuit is, so that, to borrow from Tolstoy, in place of death there is life.