by David Page
TV cameras and associated technology: For laparoscopic surgery; one or two screens and multiple cables and hoses.
The OR Personnel
What's the maximum number of people who might be involved in a trauma case? For a level I trauma center, the number of personnel is considerable, and within the ranks seen in the OR are many young doctors and medical students. In smaller community hospitals, the team to be described may shrink considerably.
Most or all of the following medical personnel will participate in the care of the trauma victim in the OR:
Trauma surgeon: The leader, a general surgeon whose life is devoted to the care of the injured.
Surgical residents: One or more; often do the procedure under the supervision of the trauma surgeon; may be at any level of training. The big secret: these unsung heroes do all the grunt work, are in the ER when the trauma victim comes in, and save the lives that are nearly shattered at the scene; they have never been given credit by the public who so desperately and unwittingly rely on them.
Third and fourth year medical students: One or more observe, scrubbed and crowded about the OR table or in the way somewhere else. They see life from the "other side" often for the first time on the trauma service.
Anesthesiologists: One or more monitor vital signs, give anesthesia, support volume with blood and IV fluid; may leave the room periodically to let the anesthesia resident sweat the case.
Anesthesia residents: They are actually doing a lot of things under the supervision of the anesthesiologist; they try to give an alternate explanation to the surgeon for the patient's blood pressure dropping when the surgeon knows it's because of the hole in the bloody spleen in his hand.
Circulating nurse: One or two RNs. Gets supplies; coordinates the room internally and with the front desk regarding the progress of the case, anticipated ending time, when the next case starts, etc.; gets "stuff" for the annoyed surgeon; keeps the equipment in the room functioning properly; gets more "stuff" for the anesthesiologist; answers the resident's beeper, calls central supply for the one instrument the surgeon doesn't have but needs now.
Scrub tech: Stands within elbow distance of the surgeon and, unlike in American football, is not permitted to wear protective equipment. Hands instruments to the surgeon, including sutures, in a swift cadence.
OR assistants: Sometimes called orderlies. They help move patients onto the OR table before the case starts and off of the table at the conclusion of surgery; clean rooms (mop floors, stuff laundry, move the table, etc.) between cases and keep supplies available; go to preadmission for elective patients and return the gurneys to the surgical floors; know a lot about sophisticated OR equipment and how to keep it running.
Front desk personnel: Nurses or secretaries. They coordinate elective and emergency cases as well as all of the calls coming into the OR, some of which must be passed on to specific rooms. When the place heats up, there is no more stressful place in the world—for air traffic controllers, a plane might get into difficulty if something isn't done immediately; in the OR, trauma patients are wheeled down from the ER who are already in the act of dying', while this is going on, five other surgeons can't understand why they've been delayed; oh, and a patient in radiology having his coronaries reamed out just "crashed"—which means the chest boys will soon dance on the front desk person's head and will drown out the rest of the noise.
How Cases Are Listed: The "Bumping" Scenario
Most of the multiple trauma cases come in at night. Booze, drugs and barrel-bottom human behavior kick in when the sun sets. It is then that the world turns more slowly and groans on its axis.
It is at night when the blood flows.
Last night, as I prepared my notes to write this section, I discovered yet another human had died in our trauma room of savagely inflicted stab wounds to the chest. Lest you believe this to be purely theoretical, I remind you there is a head injury sustained somewhere in the U.S. every seven seconds, a stab wound inflicted every fifteen minutes, a woman raped every six minutes. Operating room time is needed for the "knife and gun club," as doctors call them, as they unpredictably slash and maim each other. Within hours, a schedule of elective surgery booked for the next day must be completed. Someone has to make time. Also, other nontraumatic emergencies, such as perforated ulcers, burst appendixes, fractured hips, dog bites, etc., must be squeezed into the schedule, night and day.
Where do the trauma crunches go?
At least one operating room is kept open for dire emergencies. When the trauma surgeon calls from the ER and says, "We're coming down with a gunshot to the chest, in shock... oh, we may need bypass," he doesn't ask for the next available room. That's a different kettle of physical insult. The next available room is for a lesser type of distress, the perforated intestine cases that can stand a little "buffing up," a few hours of IV fluids and antibiotics.
Big trauma goes to the operating room immediately.
Stat.
Sometimes, the victim isn't in extremis. There's nothing to wait for because in this circumstance, surgery is part of the process of resuscitation. If the hole in the heart isn't patched, it doesn't matter how much IV fluid you administer to the patient. On the other hand, a stab wound to the belly, like the busted intestine, may need stabilization and fluid resuscitation, then an operation.
And sometimes a room just isn't available.
That's when bumping comes into play.
Often the surgeon who books an emergency doesn't know exactly what the problem is with his patient. Alas, the diagnostic rub! Although the surgeon knows something bad is going on in, say, the patient's belly, he never knows for certain the nature of the problem. Honesty is imperative to make bumping work.
Bumping refers to the selecting of one case over another to go directly to surgery because of the perceived acuteness of the emergency. The second case, although also urgent, is considered to be less so. That patient is taken to the next available operating room, and everyone gets the care that's needed.
It's another wonderful source of conflict for a story.
Doctors milk the system for their own advantage. Often, bumping becomes an issue because everyone wants to get home. If the patient is stable, the wait for OR time is usually no more than an hour or two—a little time for a stable patient, an eternity for an impatient surgeon.
There's a final chapter in the bumping story.
The OR personnel—the anesthesiologists and nurses—talk to the surgeons involved about their patients and set up the order in which the cases will be done. If the surgeon who must wait disagrees, she must discuss it with the surgeon listed to go first. Listen to the conversation: The pediatric surgeon asks the neurosurgeon if it were his (the neurosurgeon's) child with the perforated appendix, would he want the pediatric surgeon to be bumped? The neurosurgeon counters with a demand that the pediatric surgeon tell him what he would want the neurosurgeon to do if this were his (the pediatric surgeon's) mother with the clot in her brain.
You take it from there.
Easy Cases
Most trauma victims never go to the operating room. Only 15 percent need surgical treatment. For example, the drunk kid who bumps his head in a car crash and has a negative CT scan will be observed in the ICU and eventually discharged when stable. He may need a chest tube to treat a pneumothorax (collapsed lung, more on this in part two), or his fractured fibula may require a cast before he goes to the ICU or special neurology unit for observation. But no major operation is needed.
Single organ trauma is the buzzword for uncomplicated cases. A broken thigh bone represents a major injury with lots of rehabilitation in the wings. For the orthopedic surgeon, it's a matter of placing a rod into the bone (marrow cavity) to stabilize the fracture and encourage early ambulation.
A smashed spleen may be preserved by follow-up serial abdominal CT scans to make certain there is no further bleeding. Or the trauma surgeon may find blood in the abdomen when he performs an abdominal "tap" in the ER, which le
ads to exploratory surgery. There the issue becomes saving the ruptured spleen (less complicated than saving the whales) for its immune function. If terribly lacerated, the trauma surgeon may be obligated to remove the spleen.
But single organ trauma can also be horrible.
Take the case of a lacerated liver. Although most liver lacerations are small and the bleeding stops spontaneously, some livers are shattered and massive blood loss may spell eventual death, even though only one organ is damaged. So it depends which one. Woe to the poor soul with a major isolated head injury who slips into the persistent vegetative state.
Complicated Cases
Multiple organ system failure is the end point in trauma care gone wrong. The vital organs that ultimately fail—heart, lungs and kidneys, as well as the immune system, brain and intestines—may not be the organs injured. Thus, multisystem trauma refers to badly hurt people with some combination of broken bones, chest injury, brain trauma, ruptured abdominal organs and shock on admission to the ER trauma room. Not all systems on this list must be injured for the victim to be in serious difficulty.
Let's see what happens with a complicated case in the operating room. Two or three teams of surgeons swell the OR ranks and everyone is screaming "priority." Who actually operates first? If you've got an OR scene in your story, you need to know who gets to fix his or her system first.
Here's a guide:
• Any serious bleeding must be handled first. If the surgeon is in a small hospital, she will do most of this work alone (with an assistant). In a level I center, the specialist in whose anatomic territory the bleeding occurs will stop the hemorrhage, unless the trauma surgeon decides to handle it (remember the turf battle issue?).
• Any acute head injury with brain compression from a blood clot or a depressed skull fracture must be handled next.
• Any chest injury that wasn't handled in the trauma room must now be fixed, and the thoracic or trauma surgeon will work simultaneously with the neurosurgeon on the multiple injury victim.
• The abdominal part, if not approached earlier for exsanguinating hemorrhage, is next.
• Lastly, the orthopedic surgeon does what's needed for extremity damage—except when there's a vascular injury and the orthopedic surgeon operates first to fix broken bones (stabilize with rods, pins or screws) or reduce and stabilize dislocated limbs before the vascular surgeon attempts to suture delicate disrupted blood vessels.
• Somewhere in the course of the trauma victim's multiple, simultaneous operations, the plastic surgeon may become involved, as might an ENT surgeon, for maxillofacial smashes. The urologist works with the abdominal surgeon if the kidneys, bladder or other parts of the victim's plumbing are disrupted.
Multiple trauma is a team endeavor.
Major trauma occurs most often because someone took a calculated risk and lost. Enter the trauma team, the dedicated group of specialized doctors, nurses and other technicians—the "expensive care" team. A hospital with high-tech facilities and a dedicated staff of surgeons, nurses, OR personnel, ICU staff and regular floor nurses greet and care for the trauma victim.
When Things Go Wrong in the OR
Not all surgery ends happily.
Not all victims of trauma treated at a dedicated facility get better. Some don't make it out of the hospital alive. Not all injuries are treated successfully. Disabilities often linger long after all efforts have been exhausted to return the victim to a state of sound health.
Sometimes excreta strikes the flabellum.
Your stalwart surgeon hero may feel the nibbling pangs of fear when up from the depths of the opened abdomen, blood appears in huge clots and dribbles over the drapes. "Oh my God!" he cries, before catching himself. "Quick! Suction . .." The controlled atmosphere of the OR abruptly disappears, replaced by panic and uncertainty.
Experienced surgeons get rattled?
It happens.
A sudden, unexplained fall in blood pressure, a cardiac arrest, a heart rhythm change, an unexplained rise in airway pressures suggesting a blocked windpipe, massive bleeding from the depths of a body cavity— all of these cause rapid acceleration of emotions among members of the operating team. Not all surgeons react with emotion. Most move through their planned emergency drill, step by calculated step. But the atmosphere is never the same again in that OR on that day.
At times, frustration creeps up on the surgeon. It's more of an insidious unraveling of the doctor's expectations. He can't locate the bullet in the belly. He can't actually find the blood vessel in the torn lung that's hemorrhaging. He can't get adequate exposure behind the liver where fresh blood keeps puddling.
OR Atmosphere
You've just had a taste of a panic scene—something that doesn't occur very often in the OR. At times, things heat up for other reasons. Surgeon and anesthesiologist may disagree about what constitutes adequate abdominal or chest wall muscle relaxation (permitting easy access to organs), how much fluid to give, which antibiotics to administer, where the patient should go after surgery (ICU versus the floor) and on and on.
Maybe the front desk calls into the room to see how much longer the surgeon thinks he'll be before closing. "Why are you asking?" fumes the surgeon. Is he late for the trauma clinic? Did his boss refuse to consider a raise? Is his wife out shopping as they speak? Did his favorite stock drop twenty-six points? Or was it because the resident doing the case is a klutz and the surgeon gets chest pain watching? It's anyone's guess why the surgeon loses his temper.
Often in the easier cases, music plays and everyone in the room begins to talk once the tough part of the operation is over. The scrub tech asks the circulating nurse for a recipe for chicken francais or the name of her boyfriend's brother who fixes mufflers. The surgeon hits on the intern who asked if she could try to close the skin. Use your imagination. Most of the time it's just solid professionals doing their jobs.
Worked into these various levels of communication is the ever-present question-asking ("pimping," as the residents call it). Anything in the surgical field or facts related to the case is fair game if a medical student is scrubbed. These obtuse questions are asked in the name of education.
Many exchanges, both with instruments and verbally, occur during a case. In the OR there's a doe's-eyelash distance between harassment in all forms and accepted behavior. Sometimes it's just harassment. In this case of on-the-job education, excreta obeys the laws of gravity. It flows from the trauma surgeon downhill to the intern. It's a wonder they're not all on antibiotics.
PACU: The Recovery Area
The severity of the injury determines where the trauma patient goes after surgery. Most post-op injured go to the post-anesthesia care unit (PACU) to recover from the effects of anesthetic drugs, the shock state caused by the trauma and the impact of major surgery. Monitors are used to watch heart and lung function (EKG, blood pressure, pulse, respiratory rate) as well as record urine production and keep track of bandages and drain output. When extubated (breathing tube removed from the windpipe), awake and stable, the patient is taken to the surgical floor.
Sometimes the trauma victim will go directly to the ICU from the operating room. In the more severely injured, there is no need to stop in PACU as the ICU serves the same purpose and the patient cannot be extubated anyway. Intense monitoring and care is begun in the surgical ICU beginning in the immediate postoperative period.
The Intensive Care Unit
Special medical services and personnel are available to ICU patients. Also available on the surgical floors, these services and treatments are given priority in the intensive care unit.
Special medical services available in the ICU include:
• The intensivist—a doctor specially trained in critical care medicine
• Specially trained ICU nurses
• Multiple high-tech machines to support ventilation, blood pressure, kidney function, nutrition, etc.
• Residents (in teaching hospitals) who work around the clock at the bed
side, making minute-to-minute adjustments in sophisticated treatments
• Doctors and nurses with special training
There are also special critical care units in the hospital that function like the main ICU in providing specialized care. These include cardiac surgery ICU, coronary care unit, pediatric ICU and dialysis unit.
The Surgical Floor
Depending on the body system most injured, the trauma victim may be transferred from the PACU or ICU to a regular surgical floor. Some go to a specialty floor. For example, the hospital may have a neurological care floor to manage all head trauma, stroke victims and postneurosurgi-cal patients. The orthopedic floor handles all of the bone and joint cases. If one of these is the predominantly traumatized system, the patient then goes to that floor.
Other trauma patients recover from their injuries on a floor designated as a specific unit for certain surgeons. Most are cared for on a general surgical floor, which manages a variety of cases. This includes elective operations.
Trauma patients go through a series of steps in their recovery. As each phase of recovery is completed, a number of possible complications is treated or the likelihood of getting a particular complication passes. Eventually, the patient "turns the corner." What does this mean?
Here is a list of general phases of recovery that every trauma victim passes through on her path to renewed health.
The acute injury phase: Stress hormones make the body retain fluid to fight shock and to use energy efficiently; much IV support is needed. The patient is ill in this phase for days.
The turning point: When the body decides the threat to survival is over, the patient feels better and begins to get rid of excess body fluid via increased urine production, temperature returns to normal, appetite improves, walks become longer, stairs seem less treacherous.
The anabolic phase: A natural buildup or anabolic replacement of lost body protein associated with major gains in strength, resumption of activities of daily living, and a return of interest in hobbies and work; even sex drive returns now (assuming it didn't reestablish itself moments after leaving the operating room).
