"Trauma In-bound, auto vs ped, one patient. Alice, make sure he's hooked up to our monitor and get me vitals as soon as you can. Jay, you're scribing. Dr. Taylor, you're on physical, Dana, you're assisting Dr. Taylor." shouts Dr. Chen, the third year resident in charge of the trauma team today.
*Everyone confirms their role.*
The pride and an aura of control radiate from him in this pinnacle moment. In a few short months, he and his fellow third year residents are about to complete their training and be sent into the world to be on their own. This guy's a strong leader, and I have little doubt that he'll do well with this patient.
Today is an easy one for me: I get to babysit the Emergency Medicine residents over in Trauma. Luckily for me, it's the second half of the year, and my third years know more than enough to make it through and keep track of the first and second years. My job is to make sure the third years are doing the right thing and to educate the residents when a teachable moment comes up. In other words...baby sitting...but that's just fine by me.
The trauma team is getting organized. There is loud chatter and a clatter of things moving around. The patient's ETA is about 1 minute. Everyone's getting into position and gowned up. No one knows what to expect.
*I walk up to Dr. Chen from behind and place my hand on his shoulder.*
'Who's on airway?' I ask quietly into his right ear from behind.
'Ummm...' he pauses.
'Well, I think you better find someone.' I say to him. He immediately starts looking around.
*I start look around as well and see a victim. A first year intern.*
'What about Dr. Jensen over there?' I suggest to Dr. Chen. He looks over where I'm pointing and see's the Intern washing his hands halfway down the hall.
'Dr. Jensen! I need you.' he says loudly while gesturing for the first year resident to come to the trauma bay.
*The Intern looks confused as he approaches.*
'Dr. Jensen we have a trauma coming in and I need you on airway.' Dr. Chen commands the young intern.
'You got it.' Dr. Jensen says with forced enthusiasm as he starts to gown up and get into position.
The intern looks a little terrified. I think this is only his first or second day in the ER. Although he is an Emergency medicine resident, his year up to this point has been spent rotating through other areas of the hospital. Now he's being thrown into the fire. I almost feel bad for him. Unfortunately for him, I'm a big fan of the Intern experience.
*I hear a commotion out in the hall. The patient is here. The commotion grows louder. I see a gurney and a paramedic walking along side, one hand on the patient's chest doing one handed compressions.*
This isn't a good start.
*The EMS crew arrives at the trauma bay and brings their gurney along side the trauma table. The paramedic doing compressions starts giving report as everyone works to move the patient over.*
'Alright people we have a 16 year old male, auto vs ped hit at approximately 50 miles per hour. He was found unconscious on our arrival. GCS 2-3-2. He's got bilateral battle's signs, and an open fracture of the left femur, and left chest instability.' The paramedic pauses as they move the patient over. He hands off compressions to one of the trauma techs and stands back to finish his report.
'Last vitals were 68/40 hr 134, respirations 12 and irregular. He lost pulse as we were pulling in, before I could tube him. Monitor showed V.fib, I got one shock off before we came inside. No drugs, and 2 large bore IVs with saline running wide.' he finishes.
*The team begins doing their assigned tasks*
'Name? History?' Dr. Chen asks.
'Kevin Laforte, no history or anything that we know of. The mother rode in with us. This whole thing happened out in front of their house. I guess some drunk was speeding down the street and hit him from behind while he was walking down the side of the road. The driver left the area too...the coward....anyway the mom's out in ambulance reception.'
'Thanks.' Dr. Chen refocuses his attention on the resuscitation at hand.
'I have bilateral battle's signs and fluid leakage from the right ear.' Dr. Taylor reports as she is examining the patient.
'Can we stop CPR for a rhythm check please.' Dr. Chen commands.
*Everyone stops for a moment*
'Okay V. fib. charge to 200, continue CPR' he commands.
'Left pupil is blown, both are non-reactive to light.' Dr. Taylor states.
*Dr. Jensen is preparing to intubate while a tech is actively bagging the patient.*
*The Defibrillator beeps. It's charged.*
'Alright everyone stop and stand clear for a shock' Dr. Chen commands.
*He nods to Alice, the nurse working the defibrillator.*
'Clear.' she says before hitting the shock button.
*The patient's body jerks with the shock.*
'Continue CPR' Dr. Chen states. 'Lets work on getting that airway secure.' he says staring at Dr. Jensen, who is struggling to get the intubation.
'Negative JVD or tracheal deviation....I have a deformity ribs 7-9 on the left!' Dr. Taylor shouts over the noise.
*The room grows incredibly loud with chatter. Emotions are running high. People have to shout louder and louder to hear each other over the growing roar of commotion.*
'I have upper abdominal rigidity! Pelvis is stable!' Dr. Taylor shouts.
*I step forward*
"EVERYONE!" I shout to get their attention. The rooms quiets a bit.
"I need you all to calm down and keep the volume reasonable. You're all doing the right things, so take a deep breath and keep doing what you're doing." I say in hopes of calming everyone down. It works to a degree.
'I have an open fracture of the left femur and some instability in the right. Can I get a bulky dressing, please?' Dr. Taylor asks her assistant.
*From behind me comes Dr. Gegoravic, a tiny female fourth year trauma surgery resident. She must have been behind me the whole time, waiting for the perfect opportunity to jump in.*
*Dr. Gregorvic grabs the ultrasound machine and starts doing a FAST exam on the patient. She takes the probe and checks the predetermined areas.*
'Can I get 1 milligram of epi onboard please?' Dr. Chen asks. Dana, a nurse, acknowledges and preps the drug for administration.
*I step forward again*
'Where's that airway?' I ask loudly for Dr. Jensen to hear me.
'I'm working on it.' he says, struggling with the laryngoscope trying to visualize the vocal cords.
'Let's go Dr. Jensen. Every second that ticks by is a second he's not getting oxygen.' I say.
'I hhhave positive Morrison's' Dr. Gegoravic says in her thick Eastern European accent as she ultrasounds the liver.
*I take a peak at the ultrasound screen.*
This poor kid has a massive amount of blood around his liver.
*Dr. Gegoravic continues the exam. She checks the heart, no blood around the heart. She checks the spleen....*
'Christ. All I see is blood.' she says out loud.
'Dr. Jensen, how long are you going to take on this attempt? Bag him..and try again.' I say a little angrily.
'I got it!' he says triumphantly. as he slides the tube in.
*A tech connects the bag valve mask to the tube and starts ventilating. Dr. Jensen starts to listen. Curious, I walk over as well to double check.*
*I place my stethoscope on the patients left lung. I can't hear anything. I check the stomach. I hear nothing, which is good. Then I check the right lung.*
'It's good. Keep ventilating.' I hear Dr. Jensen say.
*I hear good lung sounds on the right. No sounds on the left, but good sounds on the right....this isn't a good tube.*
'Which patient are you talking about Dr. Jensen?' I ask. He looks at me confused.
'Because this patient has a right endobronchial intubation.' I say in a bit of a smart alleck-y way.
*He looks at me in disbelief...and listens again.*
'Crap.' I hear him mutter as he listens to the left lung. 'Okay lets remove it' he says disappointedly.
'No no. You don't have to remove it. how do you fix this?' I ask.
*He looks at me like a deer in the headlights*
'Come on man, the medical students could answer this.' I say to him. Still nothing in reply.
'Withdraw the tube just a little bit' I say. His eyes light up and he begins to do so.
A small retraction of the tube and he now has good lung sounds bilaterally.
'There you go.' I say as I take a stand back.
'Okay everyone stop CPR.' Dr. Chen commands. He checks the monitor. A sinus tachycardia appears on the monitor.
'Is there a pulse?' he asks.
'No.' Dr. Jensen replies as he feels for a carotid pulse.
'Alright resume CPR' Dr Chen says.
*I take a step back out of the way and continue to watch. Dr. Gegoravic comes along side me, her assessment complete.*
'I'm going to have to do a thoracotomy, but this boy has no chance. His liver is torn, his spleen has exploded, he has unknown brain injury. It's not good.' She confides in me before she starts to set up to open the boy's chest.
*I leave the trauma bay and make my way out to ambulance reception. A see a woman sitting in a chair against the wall, trying her hardest to hold back tears. This must be the patient's mother. I ask the nurse running ambulance triage if the woman was indeed the patient's mother. She tells me it is. Now I know.*
*I walk back to the trauma bay. It's a bloody mess. Dr. Gegoravic is wrist deep into the side of the patient's chest, doing a manual heart massage. The patient's skin filleted open partially across his chest. I walk up to Dr. Chen and get his attention.*
'The mother of the patient is out in the hallway over there. Before you call this, it's usually good to tell her that things aren't looking good...that way she can start preparing herself for the bad news.' I say to him softly.
*He nods back at me*
'What's the survival rate of a multi-system trauma patient who has an open thoracotomy?' I ask Dr. Chen to see if he remembers.
'Less than 1 percent' He says sadly, realizing that this kid has virtually no chance.
*I take a few steps back. The resuscitation continues. At the 20 minute mark, Dr. Chen makes his way out to talk to the patient's mother. When he returns he see's that no new progress has been made. After a few more minutes he's had enough.*
'Okay everyone stop.' He says as he checks the monitor. PEA.
'Someone check a pulse' he states.
A reply of 'no pulse' is returned.
'Alright...uh...I think we've done enough here. Anyone have any further suggestions or objections to calling it right now?' he asks.
Everyone remains silent.
'Okay then. Time of death 17:53' he says in a defeated voice.
*Everyone starts cleaning up and turning off all the equipment. I turn around and head back out of the trauma bay and grab a drink from my water bottle. Dr. Chen approaches me.
'Now here's the part I hate the most. Baring bad news.' he says giving a nervous chuckle.
'You did good.' I tell him, 'unfortunately it just wasn't in the cards for him.' I say.
'When I went out into the hallway to update his mom....she...she uh...begged me to save him...she told me that he was her only son and that he was the only one she was ever able to have....' he sighs heavily. 'She's not going to like this....'.
*I place my hand on his shoulder*
'It'll be alright' I say reassuringly.
'Over the past 2 and a half years I've been here, I've had to tell a lot of families that their loved ones have died....and oddly enough...it hasn't gotten any easier.' he tell me.
'And it never will.' I interject. 'Even after six years, I have to hold back my own tears when I give bad news.' I say to him in reply.
*He walks away, dragging Dr. Jensen, the poor intern on his second day in the ER, off with him. The social worker is close on their tail*
*I take a seat at the nurses station and start doing some work. 15 minutes passes and I hear the sound I hate the most, the sound of a mother who's lost her child. I look up and see that Dr. Chen has brought the patient mother to see the body of the son she tragically lost.*
No, it's never gets easier....and the day that is does, is the day I need to re-evaluate my own humanity.