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.

Olfactory Adjustments

There’s no question that one of the most difficult things to get used to about the hospital is the smell — or, rather, the smells. This is especially true on a surgery service where many patients undergo multiple operations. Some need a leg or foot amputated. Others need open abdominal surgery and can’t control their bowel movements afterwards. Some patients’ intestines cannot absorb fat, leading to oily stools which give off their own distinct and foul odor. And still others have abscesses, or deep bacterial infections, which need to be cut and drained. It’s impossible to know how to react to the offending smell. Mostly, in the presence of these stenches, I control my desire to run from the room and, stoically, attempt to breathe through my mouth. But the smells are potent and dehumanizing. Empathy for these patients is difficult to find when one’s visceral desire is to sever the olfactory nerve which transmits smells to the brain. One encounter in particular is burned into my memory.

The Emergency Department had called the surgical team to see a patient who had a deep abscess. An abscess initially develops with some kind of break in the skin: an insect bite or a cut. And these infections are usually caused by specific bacteria called Staphylococcus aureus, though other bacteria can be involved. Our body’s immune cells wall off the infection, thus creating a pocket of pus and inflammation. Because it is walled off, antibiotics can’t reach the site of infection, so the only treatment in most cases is an incision of the abscess, draining of the pus, and allowing the incision to heal. If the abscess goes untreated, the infection, despite being walled off, can still spread. Some of these bacteria infect and consume flesh and produce gas as they disseminate.

The patient in the Emergency Room had a severe abscess that was far advanced. He had noticed a fever and some tenderness and redness in his lower abdominal area a week earlier but had not thought much of it. As the week went on, however, this area of redness grew and he decided to come to the ER. I felt awful for this young man who had assumed whatever this was would go away.

On entering his room, the smell hit me. There is nothing comparable to it. It took every effort to restrain myself from coughing — my sympathetic flight response had been turned on: my heart began to beat faster, I began to sweat, and I wanted to run. Never in my life would I have guessed that such an uncontrollable visceral reaction could occur because of a smell.

Alas, this seems to be a common theme throughout the history of medicine. Louisa May Alcott, author of Little Women, volunteered as a nurse during the American Civil War and wrote Hospital Sketches, a compilation of reflections on her time in the hospitals. She explains exactly how it feels to deal with the potent smells: “The first thing I met was a regiment of the vilest odors that ever assaulted the human nose, and took it by storm. Cologne, with its seven and seventy evil savors, was a posy-bed to it; and the worst of this affliction was, every one had assured me that it was a chronic weakness of all hospitals, and I must bear it.”

Our patient’s skin in the affected area was lucid. I could peer through into his body and I watched as air bubbles and pus percolated in the tissue. Because of the diffuse infection, he had to be taken to the operating room immediately in order for the dead tissue to be cut out. This was the only possible treatment — even with the medical miracles we possess, the scalpel is often still the best treatment.

In the operating room (OR), we put our masks and gowns on and the nurses coated the front of our masks with Starburst-scented cream to overpower the stench. We were like Alcott: “…armed with lavender water, with which I so besprinkled myself and premises.” Four of us — two medical students and two upper-level surgical residents — huddled over the patient’s body, cutting away skin and fat and flesh as warm pus poured out of the infected area, which overpowered the smell of Starburst, rendering our substitute for lavender water completely useless. But, there was no “out” here, no excuse to leave the OR. It had to be done, as the situation, in Alcott’s words, “admonished me that I was there to work, not to wonder or weep; so I corked up my feelings, and returned to the path of duty, which was rather ‘a hard road to travel’ just then.”

Thankfully, the patient ended up being ok — no vital organs were touched by us or by the bacteria. We had come very, very close to the inside of the pelvis with its reproductive organs, but all was safe and well. However, the smell lingers in my memory. Now, whenever I encounter an unpleasant smell in the hospital I compare it to the abscess. No smell is quite as awful and dehumanizing as the shock of the first one. Perhaps it was the unexpectedness of it that caught me. And, of course, I remember Alcott and what she must have faced in an understaffed, overburdened Union Army hospital in 1862. Her words admonish me that I am here to learn and help where I can and not to wonder or weep.