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.

How the ED (Emergency Department) Works

Ambulance image via Shutterstock

The Emergency Department is one of the most active and exciting parts of the hospital because it is the hospital’s sieve. The ED physician determines
whether an injury or complaint is life-threatening or not and then treats or admits the patient to the hospital if necessary. Someone usually comes in by
ambulance or private vehicle with a general complaint — referred to as the chief complaint — such as “stomach pain,” “chest pain,” “leg pain,” or “shortness
of breath.”

But occasionally, the first assessment of this chief complaint begins outside of the emergency room. Paramedics or emergency medical technicians who bring
the patient in by ambulance identify someone clearly in need of medical attention. Outside of the hospital they take the patient’s blood pressure, heart
rate, breathing rate, and temperature (collectively known as vital signs). These measurements indicate the seriousness of the situation. For example, if a
patient looks pale and sweaty, and his blood pressure is 80/40 (extremely low), this indicates the need for emergency treatment. However, if a patient calls
for an ambulance but has normal vital signs and looks healthy, then he can wait a bit longer for medical care, and the ambulance does not rush to the
hospital.

When the patient arrives in the emergency room, he will see a similar setup at many different institutions (I can testify to this because of my days spent
as an emergency medical technician in New York City, where I saw the emergency rooms of many hospitals). The doctors and nurses sit at an open station with
computers in the center of the circular or semi-circular room. The patient beds stand on the outer edges of the circle in small slots separated from each
other by curtains and, in some cases, by an actual wall. Usually, a patient is hooked up to a machine that continually takes vital signs and projects them
onto a screen facing the doctors and nurses.

Once the nurses bring a new patient back to a bed, the resident physician assigned to that bed asks one of the medical students to go see the patient. We
have ten minutes to interview the patient about the chief complaint and do a focused physical exam, which means we only ask about and examine bodily
systems that relate to the chief complaint. If a patient has chest pain, we do not ask about or examine the foot.

Difficulties abound with this assignment. First, some patients come to the ED and want to have all their problems taken care of, which is impossible to do
in a short period of time. Additionally, the ED is only meant to handle emergencies. Someone who has a broken leg, for example, may also want to talk about
a muscle sprain in his shoulder — but a sprain is far less concerning and does not need immediate attention. Second, some patients want to have a long
conversation with a medical student or physician. They may feel lonely at home, or have a difficult social situation, or just want to chat. And while we
must listen to the patient, these conversations may be irrelevant to the chief complaint. Moreover, other patients with life-threatening problems arrive
regularly and need an ED doctor more urgently. Finally, some patients come seeking pain medications because of an addiction, or some may malinger (faking an illness for some type of secondary gain, like getting out of school
or criminal prosecution).

Dealing with these kinds of patients is integral to the art of medicine in the ED. The methods we were taught in first and second year
about how to manage disease and what questions to ask tend to dissolve when dealing with human beings who have different motivations for coming in to the
ED. We need to understand those motivations and, occasionally, quickly work around them in order to address a patient’s life-threatening
illness.

After we see and examine the patient, we tell the resident what we think the diagnosis is and what lab tests or imaging we want to get. The resident then
sees the patient briefly and tells the attending physician his or her plan for the patient. The attending finalizes the plan for the patient and the
resident executes it. All this might be clearer with an example from my own experience.

During one of my shifts, a patient presented to the ED with severe back pain. He could not sit still, and cried out every few seconds. He squirmed on the
stretcher, moving his legs up and down, tearing sheets off the bed and clenching his hands to his chest while grimacing. Watching someone in pain is
extremely difficult and can even cause the observer to feel pain. And
there is no question that I felt incredibly sympathetic for this man — so much so that I didn’t want to disturb him by asking him questions and examining
him.

This is another difficulty in the field of medicine. We need to perform certain exam maneuvers or tests even though they cause the patient pain and
frustration. But it can be so difficult to bring oneself, especially in the student role, to swallow that difficulty and foist the necessary exam onto
the patient. How could I bear to push on and examine this man’s back when I knew this would cause immense discomfort? With difficulty, I continued the
interview and briefly palpated the spot on his back that hurt.

Once I finished the interview, I thought about a differential diagnosis. A differential diagnosis is a list of possible diagnoses for the patient given the
signs and symptoms the patient is presenting with, usually listed from the most likely to least likely. This gentleman with left lower back pain, for
instance, had a differential diagnosis list as follows:

1. Kidney stones

2. Herniated disc

3. Pulled muscle

4. Kidney infection (pyelonephritis)

5. Spinal abscess

6. Appendicitis

This list may not be complete, but it gives a sense of the kind of approach a physician takes to a medical issue. And as the physician questions the patient, the list changes. A doctor might ask if this particular patient had his appendix removed. If the answer is yes, then appendicitis comes off the list. A
practitioner uses interview questions and physical exam maneuvers to narrow the list down to one or two very likely diagnoses.

As for labs or imaging tests, these are only done to rule out or in diagnoses after narrowing down the list of possibilities with an interview and physical
exam. This man most likely had a kidney stone, as his presentation of severe back pain with an inability to sit still is a classic demonstration of this
pathology. Therefore, a urinalysis (examination of the urine) or CT scan (an imaging study to look for the stone) was integral to the diagnosis.

After deciding on this, I presented the patient to the resident. Across the field of medicine, medical students, residents, and attending physicians
present patients to each other in a standard format with an ordered listing of information. This information includes the age of the patient, history of
the chief complaint, relevant past medical history, physical exam findings, and a plan for the patient’s care. This gives all medical professionals a
concise, relevant, and standardized summary of the situation. In this case, for example, I might present the patient to the resident by saying this:

“Mr. B is a 44 year old caucasian male with a relevant past medical history of previous kidney stones, here today with a chief complaint of severe back
pain. The pain began five hours ago while showering with no apparent preceding incident. The pain is only better when the patient brings his knees up to
his stomach but otherwise remains severe. The pain is sharp and unilateral on the left side and does not radiate anywhere. The patient took ibuprofen
earlier, but that has not helped. He reports no blood in the urine, no difficulty urinating and no change in bowel movements. On physical exam, the patient
is extremely tender to palpation on his left flank but the exam is otherwise normal. My differential diagnosis includes kidney stones, pyelonephritis,
herniated disc, pulled muscle, spinal abscess, and appendicitis. I’d like to get a urinalysis and CT scan of the kidneys, ureters, and bladder, and give the
patient morphine for pain.”

That’s not a perfect presentation (and at the time mine was far less comprehensive), but it is the kind of formatted presentation that doctors look for
when they see a patient who has severe back pain.

If the ED attending physician is unsure of what is going on or how to treat the problem, the resident usually calls a consult. If the patient is bipolar,
for example, the ED resident calls a psychiatrist to see the patient in the ED and possibly admit the patient to the psychiatric ward in the hospital. If
the patient presents with a stroke, the resident calls a neurologist, who treats and admits the patient to the stroke service. While emergency medicine
physicians are excellent at figuring out what might be going on and whether it is serious, and while they are meant to know a little bit about everything, they
don’t know as much about specific problems as a specialist in that field. Therefore, it is not the ED physician’s job to treat everything neurological,
psychiatric, or cardiac in nature. It is the ED physician’s job to determine who needs to see which specialist physician, and to treat those urgent problems
that they can treat.