There’s a calm that comes before the storm.
*beep beep beep beep*
The trauma pager goes off and I feel it to my very core. A shot of norepinephrine through the system – a sympathetic response to the stress of what is to come.
The message reads “Level A trauma, ETA 20 min”.
“Crap, I never got to eat,” my chief resident mutters. If this trauma is anything like the last few days, we’ll be spending the next several hours in the OR, and food will be the last thing on our minds.
I nod sympathetically, suddenly very thankful for the tamale that I shoveled down a few minutes earlier. We stop by our call room and she inhales the salad she brought from home, and we’re moving again.
When we walk into the ED, all eyes are on us. People pay attention when the trauma surgeons enter – something must be about to go down.
From this point, each trauma goes about the same.
We meet up with the ED attending and residents outside of the room – the patient hasn’t arrived yet. Making small talk, we don our trauma gear: cheap blue gowns, hair nets, gloves, and protective masks that cover our mouth, nose, and eyes (you never know where blood will be going in a trauma).
In the moments before the patient arrives, an eerie calm settles over the room filled with doctors, residents, nurses, respiratory therapists, and med students like me. We’re standing in a circle around the empty hospital bed, preparing ourselves – knowing that literally anything could be coming through the doors.
It could be a meth addict who fell of a ladder. A hiker who slipped off a waterfall. An unrestrained MVC with the driver thrown 100 ft from the vehicle after going over a 150 ft cliff. A GSW to the chest, abdomen, or head. A man who fell out of a tree trying to rescue a cat. A kid who was stabbed in a road rage incident.
From in the hallway someone announces “make way” and we watch as the EMTs roll the patient into the room.
The thunder starts to roll.
The EMTs are giving report, and before the patient is even fully transferred to the hospital bed the nurses are searching for IV access. Vitals are being taken, both by hand and machine. The junior resident starts the primary assessment, calling out the ABCs (airway, breathing, circulation) and head to toe inventory of injuries. My senior resident is standing at the foot of the bed, taking it all into account, making the decision of when to escalate. We’ve called for the “black blood” and packed RBCs and FFP are running.
As they work, I’m writing it all down. As a medical student my job, second only to not getting in the way (the golden rule for any trauma situation) is to take notes on everything happening. All the damage called out, questions asked to the patient, details about the incident – we’re going to need it all for our note, which must be completed before we can take the patient to the OR. That’s also my job.
The first few trauma’s I’m massively overwhelmed, but after a couple of times I learn to tune out the unimportant voices, and I begin to recognize the voices of my team amongst the crowd. By the end, I’m grabbing staplers, gaze, c-collars – anything my senior resident calls out for.
It’s time for a chest x-ray: the eye of the hurricane.
It’s our first step to analyzing the internal damage to the patient, and requires us all to take a few steps back (outside the room to be exact) and regroup.
During these moments our ACS team gathers together. Our chief tells us the imaging she wants to have done, and the junior goes to put in the orders. She turns to the attending and they decide if the patient is stable enough to go to CT, or if we need to go straight to the OR.
The x-ray is captured, and we walk back into the room to take a look at the result on the machine.
The eye has passed, and the winds howl once more.
From there, we’re either placing chest tubes or rolling the patient – time to see the damage on the other side and discover spinal tenderness and decreased rectal tone. This is where I end up with blood on my gloves and gown, rolling trauma victims is not a clean business.
We’re off to CT, and the whole trauma team accompanies the patient. My junior resident logs into the computer in the control room and I start writing the note, we only have about ten minutes until we know if we’re going straight from here to the operating room.
We watch with bated breath as the scans appear on the screens. None of us are radiologists, but years of looking at similar images has made our attending adept enough to see when something is wrong.
Some of the results are obvious enough for even me to see – a massively bleeding spleen, free fluid around the bladder, air under the diaphragm. Sometimes it’s subtle. Sometimes there’s nothing at all.
Sometimes they’re gone before we even get to the scanner, and we’ll never know why.
The dichotomy continues. We’re breathing a sigh of relief or we’re already on our way to the operating room. I’ve already finished the H&P, written a progress note and an updated H&P. If we’re heading up, it’s all about damage control. We plan the operation to get the most dire things finished before they become to unstable and we have to pack them – we’ll close after a few days of cooling off in the ICU.
On occasion we get to finish it all, surprised as we close the skin that our patient is still rock solid.
If we’re lucky, we haven’t gotten more trauma’s while we’ve been operating. When we’re not, the senior has run out to meet the next level A, with the attending not far behind and sometimes I am the only one of the surgical team in the room with the open patient for a few minutes until the back up attending arrives.
When we’re finished, it’s back to rounds. No chance to take a break or sitting down. We have lists of patients to manage, and we must be efficient.
For only one thing is certain in this business – another storm is coming.