Trauma Bay

Kandahar, Afghanistan

The city of Cusco in Peru was the center of Incan culture many centuries ago.  I spent a month there during medical school and was amused to find out that in Quechua, the Incan language, Cusco means umbilicus: Cusco was the navel of the Incan world, its figurative epicenter.

The trauma bay is our umbilicus.   Although we provide outpatient medical care for thousands, our raison d'etre is the trauma bay and our ability to quickly resuscitate trauma victims and get them to the operating room or ICU in an expeditious fashion.

                                                    The Wait

Many subplots play out in each trauma bay, every day.  It might as well be called the drama bay.  First there is the wait:  we learn about incoming trauma victims through cryptic "9-lines" -- terse messages with slivers of information about what is heading your way in usually 30 minutes or less.  We joke about how inaccurate they often are.  We may assemble dozens of people who anxiously wait for a truckload of people actively "trying to die," and then a handful of patients who barely rate medical attention get wheeled in.  Or, we may get virtually no notice and a victim gets dropped off without a pulse, or exsanguinating before your eyes.  So the wait has a true angle of suspense - what really is coming our way?

Once the patients get situated into the bay there is the frenzy.  First the patient must get "trauma naked."  He is descended upon by at least two people with trauma shears, getting the patient completely naked so that an accurate primary survey can be conducted.  While this is happening each person on the team is rushing to do his or her bit part - starting an iv, securing the airway, getting a blood pressure.  If it wasn't so serious it would be cartoon-worthy, like when a cartoon cat and dog get in a fight and all you see is a dust ball with cat or dog paws coming out of that ball.

When the blood begins to pool on the floor a new phase of care is reached: this person is really sick and could die.  Although every trauma victim deserves this kind of respect, it does get kicked into a higher gear if there is a lot of blood, some bowels hanging out, or other body parts mangled into unnatural positions.  I just left the trauma bay not 2 hours ago during a mass casualty in which a patient was given a surgical airway in the field - his neck was cut below the Adam's apple and a breathing tube was inserted into the airway.  But it wasn't really in his airway - it had been put in the wrong tissue plane and instead of air going into the lungs, blood was coming out of the tube.  The collective pucker factor in that bay that I was in grew and grew.  His oxygen saturations dropped even after that tube was removed and another was put into the same position.  The decision was made: we had to re-attempt to get the tube in from above, from the mouth.  This is can be difficult in a non-challenging situation, like when one is taken to the OR for an appendectomy.  But if you are trying to see the vocal cords in the oral cavity of a patient who now has several tablespoons of blood in his throat, well, that is what one calls a shit sandwich.  Fortunately for this patient, an airway was secured from above.

While the now-unconscious patient had an anesthesiologist placing a tube into his bloody orifice, he had one physician on his right side cutting into his thorax to place a chest tube, another one sliding a needle about two inches long below his left collar bone in order to place a straw-sized iv there, and a third poking another needle into his groin for even better access.  He already had a nurse or two attempting iv's on his arms.  Hieronymous Bosch could not have painted a more gruesome visage, but it was all being done with the intention of saving his life.  We save many lives in the trauma bay, and it's not always pretty.

Funny things happen in the trauma bay sometimes.  This morning before the mass casualty, one of my colleagues was able to pluck a bullet out of back of a lucky Afghani.  The pristine bullet had settled near his his shoulder blade.  What a souvenir for him, if he is allowed to keep it.

In the old Role-3 I remember a word painted on the ceiling over where a trauma victim would have been lying supine:  Breathe.  As if he had a choice, but I understood.  Help us help you.

The red line is painted on the floor outside the trauma bays.  One is not supposed to cross that line unless she is actively involved in the resuscitation or trauma bay activities.  It is commonly violated by well wishers hoping to lend a hand.  The problem with that is that it spoils the choreography.  Even if you are just trying to yank a boot off, it's not your place.  Honor the red line.