Thursday, September 1, 2011

Tenth Chapter

Tenth Chapter
In which our neophyte reaches competence, and we learn about trauma

   University Hospital, the employer of our subjects, is a Level I trauma center. Trauma is the leading cause of death for people ages 1 – 44. The leading causes of trauma in rank order are MVA’s (motor vehicle accidents), falls and assaults. Trauma is a surgical condition by definition. Trauma Centers vary in their capabilities, and are rated level I,II and III, with level I being the most capable. To be a level I center, a hospital must have highly trained and specialized surgeons, nurses and technicians on duty 24/7, as well as the equipment and facilities. It is very, very expensive. The metropolitan area served by University Hospital originally had three Level I centers, after two years only University Hospital had the resources to maintain Level I status. For the trauma victim, being treated at a Level I facility can raise the chances of survival by 25% or more. For those that reach a Level I center within an hour of injury, the odds go up even further.

   The trauma area is adjacent to the ER. There is an ambulance ramp that goes right up to the doors of the trauma area, and directly across the ramp is a helicopter landing pad.  Inside the doors are four stabilization/evaluation bays, and directly behind the bays are two trauma ORs. There is one trauma team in the center at all times, with a second team available in the hospital. A trauma team is made up of an Anesthesiologist, a Trauma Surgeon, a Trauma Resident, two ER nurses, and two OR nurses.

   A patient arrives, by ambulance or chopper, and enters into one of the bays. The most severely injured go right back to one of the ORs. Lines are placed, blood samples drawn, IV fluids and O negative blood administered as needed, the airway assessed and stabilized. O negative blood is used as it is the Universal Donor, and can be given without the time consuming need to type and cross match the patient’s blood. Even with a medical bracelet or “file of life” with blood type information on a patient, the O negative blood is used, as the teams have learned the hard way not to trust such sources of information.  A Foley catheter is placed into the bladder. These steps are the provenance of the anesthesiologist and the two ER nurses. While this is going on, X-rays are taken as needed. The Trauma surgeon acts as captain of the team, and directs the activities of the team as a whole. The OR nurses assess the patient injuries and prepare the appropriate instruments and equipment on the OR, the patient moves into the OR and surgery begins. In more extreme situations the patient skips the bays, goes right into the OR, and all this happens at once. 

   It has been almost two years since we first heard Cates story as a beginning nurse in the OR. Things have “clicked" for Cate, and she has earned the trust and respect of the other nurses and surgeons. It has not been easy. Dr. Syriani, famed surgeon to the deceased, had been particularly hard on Cate. Syriani was known for his lack of tolerance of beginners, taunting and ridiculing them. He had one day gotten Cate to the point of tears, and then crowed to the assembled team “Look! I made her cry!”, as if he had scored some kind of goal. Cate sucked it in and finished the case. She had learned not to give in to frustration and anger. And Syriani never bothered her again. He zeroed in on the scent of fear. That was the day things started to go better for her in the OR. When you get to the bottom, it all looks like up.

   Cate has just completed sixteen hours of classes and passed an exam so that she can take turns  covering the trauma center for the OR. She has had to learn the ABCDE of trauma. A= airway, B= breathing, C= circulation, D= disability, and E= exposure. Always in that order. B is no good if you do not have A, etc. There are detailed algorithms for each of these letters that Cate has memorized. She has practiced the techniques and interventions for each step. Airway is getting the air to the lungs. This could be by inserting an ET (endotracheal tube), tracheotomy, or cricothyrotomy (A large bore needle placed into the trachea just below the cricoid cartilage, and then air or oxygen blown in under pressure). Breathing is the chest and diaphragm, getting oxygen into the blood. This is done manually by an ambu bag (a cylindrical rubber balloon that attached directly to a mask, ET tube or tracheotomy tube), or mechanically with a ventilator. Circulation is the heart and vasculature, getting the oxygen to the organs of the body. There were several avenues of attack here: 1) Replacing fluids by crystalloids (saline, or other IV fluids) or blood products such as whole blood, plasma, etc. 2) plugging the leaks (control bleeding). 3) Reduce the volume to be filled. This last could be accomplished by the use of MAST (Military Anti-Shock Trousers), inflatable pants with three chambers, one for each leg and one for the lower abdomen.

The pressure of the MAST diverts blood from the legs and lower abdomen to the chest and head. Disability is the level of function of the brain and nervous systems. Exposure is getting the patient exposed and controlling his body temperature. Trauma victims are by definition thermally compromised. Clothing has to be removed quickly, using scissors that look cheaply stamped out of metal, but their serrated edges and large leverage granting handles can cut a copper penny in half easily. The nurses refer to these as “Rambo” scissors after the Sylvester Stallone movie character. Karen once got a complete set of leathers off a motor cyclist in about a minute. There are two basic means of warming the victims, by IV infusion of warmed fluids utilizing the Level 1 warmer/infuser, and the use of a Bear Hugger. The Bear Hugger is a sort of plastic and paper blanket that circulates warm air around a body. The Level 1 is a piece of equipment that can push a liter of fluid or blood into an IV line in less than a minute, and at body temperature to boot. Both were absolute necessities for the trauma rooms.

   Cate was in a state of adrenaline infused impatience, as this was her first solo in the trauma room, without a preceptor to back her up. Mercifully, the phone rang and Dr. Murphy, the trauma surgeon for the shift picked up the phone and listened. He hung up the phone and announced to the team, “We have a penetrating injury to the neck, an older male, John Doe, trauma scale 4 coming in. He was found unconscious on the sidewalk, no witnesses.The EMT's scooped him up and are coming straight here.” Trauma scale 4 meant unresponsive, very low blood pressure, low respiratory rate, very low pulse. The key thing here was the very low pulse. This told the team that the victim was in the last stages of shock. In the early to middle stages of shock the pulse becomes very rapid, the body’s attempt to make up for loss of circulating volume and pressure. As shock progressed, this compensatory mechanism also fails.  A score of 4 was the worst score in the scale, an indication that the chances of survival were poor. John Doe meant that his identity was unknown. This one was obviously a problem to be addressed in the first of the ABCDE, airway. The team leaped up and prepared the A list items, for placement of ET tube (also known as a breathing tube, to be inserted through the mouth), tracheotomy, or cricothyrotomy,(means of making openings into the windpipe) as well as peripheral and central lines, O negative blood and Normal Saline IV fluid. The other thought that occurred to everyone on the team was that the score of 4 plus a penetrating neck injury probably also meant hemorrhage of a significant portion of the victims blood, so Cate grabbed and opened the tray with vascular instruments, as well as the tray of basic instruments. Once an airway was established and ventilation accomplished, the next likely thing was going to be control of bleeding. 

   With a screech of brakes, the ambulance arrived at the door. The doors of the ambulance flew open and the EMT’s ran the stretcher into the trauma area. Murph waved them past the stabilization bays directly into the trauma OR. Cate took in the MAST trousers, and the victim covered in blood from the eyes all the way down the chest. One of the EMT’s was pressing a wad of towels against the victim's neck. The towels were saturated with blood and the EMT was covered in blood. Several things happened simultaneously: Kurt, the anesthesiologist, got a laryngoscope in the victim’s mouth and was suctioning large amounts of blood, saying “I can’t see a damn thing!” Chloe, one of the ER nurses was hooking the Level 1 to the IV line the EMT’s had placed. She cursed in turn as she saw that the line was running Lactated Ringer’s solution. This meant that blood could not be pushed through the line as it would instantly coagulate, the coagulation triggered by the calcium in the Lactated Ringer’s deactivating the anti coagulant in the bank blood. Only Saline should have been used. Blood would have been the best thing that could be given at the moment, because it could also carry oxygen as well as increase circulating volume. Crystalloids such as Saline and Lactated Ringer’s expanded volume but could not carry oxygen. She started the Level 1 pumping with saline.  Nan, the Other ER nurse was struggling to place another IV line in the other arm, hindered by the omnipresent blood which obscured visualization of the veins, and which also made everything slippery. Cate was mopping at the neck trying to clear the blood, so that she could see the wound and prep it with iodine solution. She couldn’t find a wound. Murph joined her in wiping at the neck with an artery clamp in hand, ready to clip a vessel. The blood was all dark, indicating a venous source as opposed to an arterial one. There was no wound!

   The monitors at the foot of the stretcher alarmed and flatlined. Kurt rammed the ET tube home, suctioned more blood out of it and attempted to ventilate with an ambu bag. The chest rose and fell. The monitor showed no heart activity at all, a condition called asystole. This is not a shockable rhythm, so the use of the defibrillator was out. Cate began cardiac compressions. Chloe took over ventilations with the ambu, synchronizing to Cate’s compressions. Kurt began injection of epinephrine (also called adrenaline) through the chest directly into the heart. A shockable rythm had to be established before the defibrilator could be used. Nan continued to struggle with the IV placement, finally getting it into the antecubital fossa in the inner aspect of the victim’s elbow. She attached it to the Level 1 and started it pumping O negative blood. Murph explored the neck, still finding no wound.

   The team continued their efforts for one minute, the held compressions and ventilation so that it could be determined if a shockable rhythm had been restored. None. The team continued its efforts. After ten minutes Murph called it. Every one backed away from the table looking at each other, their breathing and pulses returning to normal. Kurt ventured an opinion: “The bleeding must be internal, there being no wound. And from the volume of venous blood I suctioned out of the airway, I suspect that what we have here is a case of esophageal varices that eroded and bled.” Esophageal varices are varicose veins of the esophagus, a condition caused by a back up of venous blood from the liver, which in turn is caused by liver disease such as cancer or advanced cirrhosis. He continued, “The victim was expelling all that blood out of his mouth, and the EMT’s could not see that there was no wound, but from the volume of blood expected a vascular injury to the neck.”

   The team turned to removing the clothing from the corpse. Each item was inventoried and recorded. Nan was the one who found his wallet, a few cards and eight dollars in it. There was an ID card. Nan announced " This is no longer John Doe, his name was Harold Morgan. Could we please have a moment of silence in respect for Harold Morgan." Everyone stopped what they were doing for that minute.Then Nan, Chloe and Cate Washed the body and the corpse was respectfully placed in a shroud. An orderly transported the body to the morgue with a bundle of clothing and his meager belongings in a paper bag on top. Paper was used so that the clothing and belongings would dry out and not molder. Then they turned to restoring the OR to a state of readiness. Murph made phone calls; to the police, to the medical examiner, to the 911 dispatcher. He made an attempt to call the number found in Harold's wallet, but there was no answer. Then he began his paper work. To Cate fell the responsibility of filling out the rest of the rest of the records. Murph told them that they had done a fine job, that he could not have expected any better from the team. Everyone looked to the clock willing the hands to speed to the end of the shift. The autopsy report two days later confirmed Kurt's opinion.


babaybee_001 said...

Always enjoy the new chapters!

Orfyn said...

Thanks babaybee, good to have you as a regular reader!