Body Trauma
Page 5
• A specialist, say a neurosurgeon, isn't available to care for a head injury. Does the local doctor attempt to place burr holes in the victim's skull to evacuate the life-threatening blood clot? Or does she send the patient to the closest trauma center knowing he may not survive the trip?
• The local surgeon feels he can handle the injury himself despite the presence of injuries to three or more major organ systems. Is there anyone around to fight his ego-driven, ill-advised care plan?
• The local surgeon doesn't want to be bothered by what she expects to be a time-consuming patient with no insurance. Does she dump the victim on the other hospital in town? Or is the ER doctor who works for the hospital trying to dump this "self-payer"—a euphemism you might hear in the ER back room for what are called street bums, slimeballs, dirtballs—on the nearest trauma center? Who blows the whistle on the hospital?
• The local HMO says not to transfer the patient—it doesn't have a contract with the trauma center and wants its own surgeon to handle the case. Does the HMO administrator pressure the doctor into agreeing the injuries aren't really severe enough to warrant transfer? Do life-threatening injuries go undetected by the undertrained HMO physician?
• The local aging surgeon dislikes the young stud trauma surgeon at the local trauma center. Does he refuse to transfer the patient or do it in a sloppy manner with inadequate information sent with the patient?
There's no end to clinical chaos.
When a trauma victim reaches the local hospital, a lot of decisions must be made in a hurry. The ER doctor, unlike his pre-1980 predecessor, is trained to provide immediate trauma care. But not complete trauma care. That's where the trauma team comes in. This is one of the hottest areas of debate in trauma care. When a big crunch comes into the emergency room, it is manned by ER residents and surgical residents. Who takes care of the patient? Well, the ER resident physically in the ER when the patient comes in can perform an initial assessment. Should he put in the various tubes? The surgical resident is better at it and can open the chest if necessary. The surgical resident has the good hands. So what happens?
Conflict.
All the way from the trauma room's bloody floor to the executive offices of the chairpersons of the departments of surgery and ER medicine, there is conflict about who should do what and to whom. Somehow it gets worked out. At least for the moment.
Thus, the trauma team or the emergency room doctor involved in the initial assessment of the trauma victim must:
• Rapidly assess the victim's condition, including vital signs—blood pressure, pulse rate, respiratory rate and temperature
• Stabilize and resuscitate the victim and treat life-threatening injuries immediately
• Decide if local (hospital) management is appropriate
• Arrange for transfer and transportation to higher level trauma center if local care is not adequate
• Be responsible for the transfer
The Level I Trauma Center
In chapter one we discussed the requirements for each level of care designated in the national trauma care system. Each level depends upon the local availability of doctors and technology. Linked by the needs of the trauma victim, these hospitals refer to each other when patients are triaged according to the severity of their injuries. In the field, the paramedic or EMT assesses the victim, calls the hospital and describes the injuries. As well as giving the hospital lead time to prepare for the victim's arrival, this communication also launches the triage process itself if several injured people are involved.
Lesser injuries may be sent to the local hospital where such things as chest tubes may be placed, fractures set and uncomplicated abdominal and head injuries observed. Victims of multiple organ trauma are usually taken directly to the nearest level I facility unless resuscitation in a smaller hospital is warranted first.
The different levels of trauma care described in chapter one are being integrated nationally into a regionalized plan of trauma care. The American College of Surgeons over many years has worked diligently to improve the plight of the trauma victim in America. Hardly complete, the aim of all states is to create a network of hospitals that function as parts of a universal care plan. In some geographical areas, trauma care is fine-tuned. In others, it is all but absent.
Next we will look at what is available at a top-notch level I trauma center.
The Trauma Room
Readily accessible in all level I trauma centers is a specially equipped room kept open for major injury cases. It isn't used to suture lacerations or to bandage abrasions or to reduce and cast fractures. This huge room (Figure 5) has two or three operating room tables and is filled with resuscitation equipment, including an oxygen source, ventilators, suction apparatus, emergency surgical instruments and emergency cardiac medication and other equipment stored in wheeled carts. The walls are lined with drawers laden with suture material, sponges and surgical instruments as well as equipment used in the diagnosis and treatment of rapidly evolving, life-ending problems. Oral airways and endotracheal tubes are on standby ventilators, and suction equipment is available for swift resuscitation. IV poles prepared with bags of lactated Ringer's and tubing are ready to be connected to large-bore catheters the surgeons will immediately place in the victim's arm veins on arrival in the trauma room. IV fluid resuscitation represents an essential part of the surgeon's first line of treatment.
Nurses specially trained in the immediate care of the trauma victim wheel the patient into the room from the ambulance or helicopter with the help of the paramedics who transported the patient from the field. There is no record taking, no search for identification, no asking for a history—the traditional steps in diagnosis. These critically ill patients are rushed into the trauma room, and, after assuring the cervical spine (neck) is protected with a rigid collar (it was probably applied in the field), an airway is established, ventilation started with an Ambu bag by hand or with the ventilator and IV lines placed and fluid rushed into the victim. As members of the team accomplish these initial tasks, the trauma surgeon, surgical resident or ER doctor goes through the first of the four steps in trauma care, which I'll describe in a moment. To avoid missing a life-threatening condition, these four procedures are always followed
in the same sequence regardless of the patient's condition.
In part two, you will become familiar with twelve nasty chest injuries that can kill the victim immediately or within hours of injury. It is the doctor's responsibility to make certain that the trauma patient doesn't have any of the "dirty dozen"—or, if present, that they are treated swiftly to reverse their lethal potential.
When these victims arrive in the emergency room, they represent the second wave of traumatic disasters. The first wave of killer injuries
occurred in the field right after impact, terrible wounds that snuffed out life before anyone could respond. When death occurs within minutes or seconds of impact, the traumatic wounds sustained are usually:
• Severe laceration of the brain stem resulting in immediate cessation of breathing
• Severe laceration or contusion of the brain associated with massive increased intracranial pressure (on the brain) and compression of vital centers
• Transection or smashing of the spinal cord high in the neck with damage to the nerves to the diaphragm—death results from complete inability to breathe
• Laceration of the heart or aorta (off of the heart) or any other major blood vessel, causing immediate loss of blood volume, shock and death by exsanguination
The Four First Steps in Trauma Care
Out in the field, your hero should use these same steps in assessing the victim of a traumatic injury. Whatever the setting, the sequence of steps is always the same—unless you want an injury to be missed.
Step One: The Primary Survey
In the ER, the doctor who first evaluates the victim follows these steps. The trauma surgeon, for example, arrives at the side of the stretcher and begins this qu
ick drill. As the doctor makes his initial assessment, nurses start IV lines and remove clothing to permit careful examination. It all happens at once.
The trauma surgeon's initial brief examination is performed to identify life-threatening injuries. The elements of the examination are to:
• Establish an airway
• Make certain victim is breathing
• Check pulses and stop any major hemorrhage
• Look for head and spinal cord damage, surface wounds, chest injuries, abdominal tenderness or any other findings that suggest hidden injuries
Step Two: Resuscitation
• Place two large-bore (caliber) IVs in the arms—usually forearm
veins—or legs if needed. If neither is available, use neck veins (this is called a central line). Last choice is a "cutdown" on an ankle vein.
• Administer lactated Ringer's IV solution as fast as possible, anywhere from two to ten liters in the first hour. Place IV bag inside pressure cuff for faster infusion of fluid in cases of severe shock.
• Draw labs (blood tests) to cross and type for blood transfusion and to determine specific organ function, body chemistries and blood count.
• Place a nasogastric tube to decompress stomach, a Foley catheter in the bladder to measure urine output (and thus judge how much fluid and blood to administer) and, in the ICU, special lines to measure blood pressure (arterial line) and heart function (Swan-Ganz catheter).
• Emergency surgery, either in the ER or in the OR, may be part of the act of resuscitation; nothing short of operative intervention will save the victim's life. In the ER, the surgeon may open the chest (cut between the ribs on the left) and suture a bullet or stab wound to the heart (25 percent of these warriors will live to fight another day). In the OR, any surgery designed to halt massive hemorrhage may be needed to catch up on blood volume.
Step Three: The Secondary Survey
With lines in place and life-threatening injuries treated for the moment, the trauma surgeon now goes back and starts to examine the victim all over again. A meticulous head-to-toe evaluation is carried out to check for broken bones, dislocations and deep soft tissue injuries. Appropriate x-rays will now be performed with extra films taken of areas of concern based on this second exam. Also, if no injury mandates a rushed trip to the operating room, CT scans and other special x-rays may now be done.
Regardless of the types or pattern of the injuries, in all multiple-injury victims the following x-rays are performed routinely:
1. Chest x-ray—Any evidence of the "dirty dozen"?
2. Cervical spine x-rays—Fractures or dislocation of neck vertebrae?
3. Pelvis x-rays—Fractures? How many?
If the original abdominal examination reveals significant tenderness, or if the tenderness seems to be increasing on subsequent examinations, the trauma surgeon will perform a test called a peritoneal lavage. This involves placing a plastic tube into the abdominal cavity through a tiny incision near the belly button and infusing saline solution. The peritoneal lavage test is positive and leads to emergency abdominal surgery if:
• Frank blood comes out of the tube when first placed in the belly— something is bleeding massively.
• Feces comes out of the tube mixed in the saline—it means the colon (large intestine) is ruptured.
• Bile comes out in the fluid—gallbladder, liver, bile ducts or duodenum (first part of small intestine) are ruptured (perforated).
• Many red or white blood cells are present in a sample of the saline when examined under the microscope.
Note: If the abdomen is swelling up before the surgeon's eyes in the ER, no test is required as the assumption is that massive bleeding is occurring in the belly. An urgent operation is mandatory, so a peritoneal lavage isn't needed.
Step Four: Management of All Major Injuries
After a detailed secondary survey of the victim, the trauma surgeon knows what's wrong or has a high index of suspicion for certain injuries. Specific operative or nonoperative treatment may be started or further tests may be ordered to chase additional diagnostic possibilities. Injury severity and the need for specific organ support determine what happens next. Basically, the patient goes to the OR or the ICU. With lesser injuries, some trauma patients may go directly to a surgical floor for careful monitoring. Which floor depends on the injury: "neuro" floor for a head injury, orthopedic floor for a fractured femur or a general surgical floor for lesser degrees of both. For patients who do not require a surgical intervention, observation becomes the name of the game.
It is at this point when conflict may arise among members of the surgical team. Does the trauma surgeon repair the torn bladder, or should a urologist be called in? Should the trauma surgeon fix the fractured femur or ask for assistance from an orthopedic colleague? Is the chest injury severe enough to warrant the services of a thoracic surgeon, or can the trauma surgeon handle it herself? Who repairs the child's torn bladder—a pediatric urologist or an adult trauma surgeon? Or an adult urologist or a general pediatric surgeon?
Turf battles rage all over the country. Somehow it gets worked out and excellent care is provided in a timely fashion. Despite the conflicts, trauma care in the U.S. is becoming consistent and more universally available.
Trauma surgery is almost never elective, not unless the patient is well down the road to recovery from the original night of horror. Follow-up operations are usually undertaken to fix broken bones, remove screws and pins, debride (clean away) dead tissue from open wounds or place skin grafts on beds of burned flesh. This sort of follow-up surgery may be performed more leisurely than the chaotic emergency procedures. Nonetheless, the mood in the operating room during surgery for the first big crunch and subsequent surgery is never casual.
Before writing an authentic operating room scene, you need to know who works in this hallowed and horrid corner of the hospital. Who are they? What do they say? What is the mood in surgery? Does it change when things get tense? Who's in charge? Also, you need to have a handle on the equipment.
First, who is the trauma surgeon?
All surgeons other than those whose specialties you recognize— orthopedics, neurosurgery, plastics, urology, vascular—are general surgeons. Not general practitioners, not primary care docs. A general surgeon is the board-certified surgeon most people refer to when they say "surgeon." A general surgeon does everything except the more complex and specific procedures done by specialists. In some circumstances, and in many small communities, the general surgeon performs all of the basic duties of the specialist, referring the complex cases to a larger medical center.
A trauma surgeon is a general surgeon with five years of residency and extra training or a fellowship in trauma surgery. Able to perform a variety of lifesaving operations as well as the usual general surgical procedures, the trauma surgeon sees all major injuries admitted to the hospital through the emergency room. Of these creatively smashed-up souls, only about 15 percent require a major operation.
Other than the lifesaving kinds of things done in the trauma room that you've already learned about, the remainder of the trauma victim's surgical care is rendered in the OR, the surgical ICU and on the surgical floors. Unlike elective cases where a specific procedure is prepared for and a defined area of the body shaved and prepped with specific instruments picked and sterilized, in trauma cases the victim's status is unknown. The surgeon expects and often finds bizarre injuries.
The trauma surgeon expects to operate in all body cavities. All tissues are potential areas of injury. Nothing's a given.
The Operating Room
The operating room (Figure 6) is a familiar place to most readers. Movies and television productions portray realistic, well-researched hospital scenes. Your readers know intuitively that there's a lot going on in that clean, well-lighted place. When you write about the operating room, it's the drama that counts, not a detailed description of the hardware. Sprinkle a few details onto your reader's visual screen. She'll f
ill in the rest.
You may choose a splash of authenticity from any of the following items on this OR list.
Anesthesia machine: Bulky and on wheels with a screen that displays the patient's blood pressure, pulse, temperature, oxygen saturation; dials that control the "inhalation" gases to keep the patient asleep; plastic tubes going to the patient; other hoses connected to a wall oxygen source; large corrugated hose from machine to patient; suction apparatus.
Anesthesia cart: On wheels, with drawers containing everything from vials of drugs, syringes, plastic tubing, instruments and gauze pads
Cure of (he Truuma Patient in the Operating Room / 49
to anesthesia journals, the most recent stock market report, and a copy of your last novel.
OR table: Narrow with thin plastic mattress, restraining belt, foot pedals to adjust height and tilt, small pillow.
Back table (or two): Stainless steel tables draped with sterile sheets, laden with all of the instruments to be used during surgery; manned by the scrub tech, the person who hands the surgeon instruments and whatever else is needed.
Suction apparatus: Usually one for the surgeon and one for anesthesia; consists of tubes coming out of the ceiling or walls, going to huge disposable plastic containers that seal for the disposal of body fluid.
Cautery machine: The electrocautery has several settings for cutting or cauterizing tissue; the current varies and different levels of intensity may be used from a setting of twenty to what the residents call "stun" at fifty or more.
Laser machine: Used much less often than the cautery, the laser is an excellent source of energy for delicate surgery such as fixing a detached retina; not much use in trauma.
Small prep table: Covered with a sterile towel, holds two or three stainless steel cups or bowls to hold antiseptic solution; scrub tech puts a sponge stick (a clamp to hold sponges when the surgeon cleans the skin) on the prep table from his bundle of instruments.