Who's Trauma is it Anyway?

My last day as a resident at the Stanford emergency department fell on a Friday night. With only a few hours to go before the 7 am change of shift and I began slowing down. In a matter of seconds that tiredness snapped away as I listened to the radio call from the EMTs, "We've got two 16 year old females, ejected from their car, travelling at speeds over 100 mph, one is combative, we are seven minutes away." In the next few minutes our trauma bay turned into what seemed to be a standing room only event as more and more people poured in and prepared for the incoming patients. The following day I would describe this story to a friend who was not in medicine and she was shocked to hear about the number of people that respond to a trauma like this. Since there may be more people as surprised as my friend I hope to describe their multiple roles as I retell the story here.

In this trauma it was my role to intubate the patient. With a motor vehicle collision (MVC) at high speeds and a person behaving abnormally, even if they are not having trouble moving air through their trachea, the patients often need to be intubated. Since they will likely need a CT scan of the head an uncooperative or agitated patient will need to be paralyzed and intubated thereby permitting the CT scan and possibly getting to the cause of their agitation (maybe a head bleed).

I steered around two nurses to get to the head of the bed and set up my intubation tools. These tools consist of an oxygen mask for initial ventilation, a laryngoscope to open the throat, a tube to place in the trachea and allow for ventilation, a suction device, as well as a back-up device in case the airway is difficult to access. The nurses are crucial. They play a vital role in knowing how to get the machine moving and accomplish most of what needs to get done. By that I mean they will start the IV, keep records of our actions, setup up the vital sign monitors, and physically move the patients where they need to go. Though they will also help with the intubation I was setting up, a respiratory therapist (RT) is also needed to manage the patients airway after intubation. It is the RT who puts the patient on the ventilator or continues manually ventilating the patient as they are moved to the CT scanner. If you lost count during this description we are currently at 6-8 people for the two traumas surrounding a gurney the size of a small twin bed.

There at the head of the bed I played through possible scenarios to prepare myself for the intubation, moving my hands in rehearsal. During this time more people entered the room still in preparation for the two patients. I didn't notice. It is much like getting used to a subway that runs outside of your house. Trauma surgery arrived with a team of one intern (a role I filled a few months earlier as I rotated through their service), an second year resident (R2) who was working overnight in the surgical intensive care unit (SICU), a fourth year resident, and an attending who happened to be the chief of trauma. Now our count is up to 14 people if you include the emergency department attending and the third year resident. And, the two girls have not even arrived.

As emergency department physicians our role in these major traumas is initial stabilization and assessment. Trauma is also there to help assess and treat the patient. In the trauma bay we may transfuse blood to a hemorrhaging patient or release air from someones lung with a chest tube. Or, for example, trauma may take the patient to the operating room if they have a liver laceration. Other specialties may also be called as needed for pelvic hemorrhages or cranial bleeds or broken bones.

Ready for action I was surprised to see the first girl rolling in and conversing with the EMTs. She did not seem very combative. With an obviously clear airway she was probably able to sit still through the CT scans she was sure to receive. At that time I noticed that the pediatrics team was also there. They respond for patients under the age of 18 and are especially good at interpreting vital signs (which can be very different for children) and adjusting drug dosages for different ages. Also, a pediatric trauma usually means more concerned adults and more people worriedly watching. Some of them don't necessarily have a role but respond to the trauma nonetheless. At that point it takes a strong voice to run the trauma.

Not long after the assessment of the first girl began and I started packing away the intubation kit I heard the screams bend around the corner. The second trauma was rolling into the trauma bay. I remember getting calmer as the noise increased and brought the intubation tray to the second bed, weaving through various teams. She was combative, shouting, blood in her mouth, not responding to commands but she was able to move all her extremities and respond to pain.

Our second patient needed to be intubated and the nurses prepared to push the paralyzing drugs when the trauma attending shouted for us to stop. He wanted vital signs first. He wanted to make sure we didn't drop her blood pressure any further with these drugs if it was already low. He was right. That is where the additional eyes benefit the situation by putting the whole scene into context. So, we waited until we were confident she could handle the drugs, pushed the medications, and I suctioned the blood out of her mouth and inserted the tube without any complications. Still her oxygen levels were dropping on the monitor so we looked at the chest xray and saw one lung that looked okay and one that was more white than it should be. The senior trauma resident began preparing to insert a tube into the chest when another attending stopped him. The tube used to intubate the patient was inserted into the righ bronchus, missing the left bronchus, and causing the left lung to collapse, and it only needed to be withdrawn a few centimeters to correct the problem. The second xray looked much better.

She was taken to the CT scanner and found to have an intercranial hemorrhage. Neurosurgery brought her to the operating room to correct treat her. Back in the trauma bay the crowd had already dissipated as everyone scattered to return to the always full emergency department and patients. As for the girl, you are now in the same predicament we often find ourselves as emergency physicians: not knowing what happened next. It is important for us to follow up on the patients we see to inform and improve our practice. Next time I am at Stanford I will look up her file and can post it in the comment section if you are interested.

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The Next Step

My wife recently asked me “How do you deal with death on a daily basis?” I tried to answer this question as best as I could, but ended up stumbling over my thoughts. I wanted to convey my feelings about the personal effect death can have on anyone who is exposed to it routinely. Working in an Emergency Department, the tendency is to push the thought of death to a far corner of your mind and leave it there. It may be common for a Nurse, or Doctor to think “Oh, I’ve seen that before, that is too bad, but it is busy, and this is just part of my job.” I would guess that on a deeper level, amidst the everyday flux of life and hectic work in the Emergency Department, the people we see in the last stages of life effect us in ways we cannot comprehend. After working in Medicine, and in the Emergency Department specifically, I think death has the potential of metamorphosizing itself within the human psyche: from a grim notion tucked into a dark corner, to an absolute gift that has the ability to change us immensely during life. I believe those who find themselves accustomed to death are given a unique opportunity to embrace this gift. I have found myself being cognizant of the way people die.

Sometimes death is sudden. Trauma and experiencing the sudden death of a patient is one of the hardest, gut wrenching experiences I have endured as an Emergency Department Resident. The familiarity of trying to save someone who has endured a life ending traumatic injury and being unsuccessful makes death that much more palpable. These are people like you and I who moments earlier were living life: working, biking, swimming, surfing, driving, and skiing. They were someone’s husband, wife, father, daughter, girlfriend, boyfriend, or boss. They are dressed like you or I-in sweats, biking gear, a suit, a dress. You catch a glimpse of their belongings: a purse with a cell phone, a hair scrunchy, a backpack with books, a bottle of water. Reminders of things that were. There is a flurry of activity around them-you hear the Paramedics report, you assess the injuries, you do everything you can. The finality can be a short, quick ending. Other times the struggle is prolonged, mostly by us. All that is left is an empty shell. Now they are gone.

Sometimes patients die alone. They come into the emergency department and seemingly have no one. No relatives to call, no contact information, we may not even know their name. Sometimes they are elderly, from a nursing home, and the closest family is a plane ride away. Sometimes they are found on the street. Sometimes they live alone- did anyone know they existed? It is hard for me to imagine that we will be the last comfort they may have. How can you be given such a charge? You try everything to save them, but when it becomes apparent you cannot-how do you help someone with the transition from life to death? I have seen nurses hold their hand, or stroke their hair. I have seen Doctors become teary. I pray we did not let them pass alone.

Sometimes patients are ready to die. Patients with cancer or other terminal illnesses may come to the Emergency Department if their condition has suddenly worsened. Having worked as a Family Practice Resident prior to working in the Emergency Room, I had become familiar with helping patients with terminal illness and families transition towards dying. In many cases all efforts are made to treat the illness. When efforts fail, institutions like Hospice provide invaluable care for patients and families making this transition.

I recently met a patient named John. He was 45 years old and was diagnosed 6 months ago with metastatic Melanoma-a rapidly spreading form of skin cancer. He had been receiving treatment for his cancer for 3 months, and his condition had worsened. He was brought to the Emergency Department because he was having tremendous difficulty breathing (the cancer had spread to his lungs). I remember asking him “John, what can we do for you.” He replied with a glimmer in his eye and a small smile, forcing what little energy he had left, just to speak: “Nothing man, I’m ready for the next step.” He passed 5 minutes later.

These words stuck with me, “I’m ready for the next step.” I cannot imagine being truly ready for the next step-not yet anyway. So back to the question: How do I deal with dying? I live everyday to the fullest, stirred by the people we have tried to help in the Emergency Department. They are with us on some level every day. You have to pull them from the far corners, and realize they could be anyone of us at anytime. Life is so precious, we have to respect it, this is their charge: We are alive: the woman on her bike that I pass on the way to work, the elderly woman in the grocery store, the homeless man on the street, my wife and son laughing on the couch. We cannot take life for granted.

I would love to hear your thoughts or personal experiences about death, or the passing of a loved one-your experiences can help us all embrace life.

Sean Donahue

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