Controlled Chaos In the Trauma Bay, Work Is Carefully Choreographed

It is 4:56 p.m., and Dr. Reginald Alouidor is looking at his pager.

It is alerting him to the fact that an elderly woman is being transported from Cooley Dickinson Hospital in Northampton to the trauma unit at Baystate Medical Center. She had fallen in her home, suffering injuries to her face, as well as a broken wrist, but there are fears that she has also sustained brain injuries. “She was stable, but there was blood in her brain and the potential for deterioration,” Alouidor would explain later.

In the parlance of the trauma unit, this is what is known as a ‘category-2,’ or ‘cat-2,’ emergency, an incident less severe in nature than a ‘cat 1,’ which could be a serious motor-vehicle accident; a gunshot wound, or GSW, as one is called; a stabbing; or perhaps a paralyzing injury to an athlete.

But with either category, the message on the pager sets in motion a highly choreographed response that is part and parcel to life in the only level-1 trauma unit in Western Mass. When the patient arrives from CDH, the so-called ‘trauma team’ is ready and waiting to administer care that will continue long after the individual is taken from the trauma bay.

On this particular Monday, HCN was a guest in the bay and surrounding emergency department to talk with team members about their work, its challenges, and rewards, and also record what would be considered a typical night in the trauma unit, although all those involved say there is no such thing.

Each day is different, said Alouidor, the attending trauma physician on this night, and unpredictability is the only constant.

Soon after the aforementioned patient, who suffered what’s known as a ‘mechanical fall’ arrives, the bay becomes awash in motion, with the various players — Alouidor, residents, a nurse, and others — attending to specific duties while trying to maintain order in what would be considered close quarters. There are a half-dozen people treating the patient, looking at information, and consulting with one another as data is pored over. In other instances, including most cat-1 cases, there may be two or three times that many people in the room (including security personnel and family members), necessitating what Alouidor calls “crowd control.”

“Having 10, 15, or even 20 people in the room is not unusual, and there’s a sign on the wall that identifies who is supposed to be there,” he explained. “It shows the room, it shows where the bed is, and it shows the position of each member of the team. As trauma-attending, when I have a very ill patient, I don’t just walk around the bed; I know where I’m supposed to stand — I have a position at the foot of the bed. My airway resident has a position at the head of the bed, the ED-attending has a position at the head of the bed, the trauma nurse and the trauma scrub nurse all have their positions marked out, they know where they’re supposed to be.

“So when we talk about choreography, or ballet, when we walk in the room, everyone knows their role,” he continued, “and everyone knows where they’re supposed to be.”

Life in the trauma unit is demanding, said those we spoke with, work that requires a broad mix of abilities, from the surgical skills needed to save lives to the soft skills one must possess to properly inform, comfort, and console patients’ family members.

“It’s a golden rule — the family needs to know what’s going on,” said Alouidor. “Even during resuscitation, family members have a right to be present, and someone from the team will detach from the team and stay at the side of that person so that they know what’s going on. If we admit a 4-year-old, the best medication I can provide to calm that child is his mother or father to hold his hand.”

Both tragedy and triumph, if it can be called that, can be found in the trauma unit.

“We make a lot of great saves here,” said trauma nurse Concetta ‘Chetty’ Jez, an evening supervisor in the emergency department and 38-year nursing veteran, who would emphasize that word ‘we’ with every comment she made about the trauma unit. “We don’t save everyone, but when you walk away, you’re thinking, ‘we really did it.’”

For this issue, HCN talked at length with Alouidor and other members of the trauma team that night to gain a perspective on the choreography that goes on in the trauma unit, and how the ‘controlled chaos,’ as some described it, represents teamwork personified.

Step by Step

Alouidor, who was born in Zaire but is a citizen of Haiti and grew up in that country, told the Healthcare News that he’s always been drawn to emergency-room medicine and especially trauma care.

And in Haiti, where he did his first four years of surgical residency work, this care took on a different tone and tenor than what he would experience here later in his career, and provided different kinds of learning experiences.

“I come from a third-world country where our trauma systems are not as well as organized as here in the U.S.,” he explained. “Back home, we see things that you may have seen in the states 50 or 60 years ago, because at work, employees are not protected, and as a result, their hands get mangled in machines. Also, the streets are not properly lighted and the cars are not properly inspected, and as a result, you have a vehicle traveling with 20 people that was meant for 10, and when this vehicle tips over, everyone is injured.

“It’s a country where basic emergency services and transportation are not well-organized,” he continued. “So someone who has a car crash in a town 100 miles away from the capital is not stabilized and is brought to us by means other than an ambulance, and without having been properly screened or triaged. These are the patients that we had to take care of, so as a medical student, I was always very involved in the care of these patients and recall in my third and fourth year of medical school taking extra time to spend with residents in surgery so I could get more exposure to trauma.”

Alouidor would do a second surgical residency in New York City, and eventually came to Baystate in the summer of 2006. There, he spends roughly one-third of his time in what is the only level-1 trauma unit in the four western counties of Massachusetts — there is one at UMass Medical Center in Worcester and six in Boston — and one of three that serve Connecticut.

Level 1 is the highest designation for trauma units, and such facilities provide the highest level of care, said Dr. Ronald Gross, chief of Trauma and Emergency Surgery Services at Baystate Medical Center, noting that there are three in Massachusetts and as many as five in other states.

“If you take the overall spectrum of trauma, 100{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of all injured patients, level-1 centers will care for about 15{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5} of the trauma patients,” he explained. “All of the rest can be very well-cared for at community hospitals that are level 2 or less. The most severely injured patients should go to a level-1 center, and the statistics show that, if they do, you decrease their mortality by 25{06cf2b9696b159f874511d23dbc893eb1ac83014175ed30550cfff22781411e5}. In fact, the numbers show that if you don’t take your patients to a level-1 trauma center and they go somewhere else first, mortality is four times that of those who go to a trauma center first.”

An emergency department is part and parcel of what is needed to have a level-1 trauma center, he continued, adding that trauma surgeons work hand-in-glove with emergency medicine physicians who staff the ER.

Key elements of a level-1 center include 24-hour in-house coverage by general surgeons and prompt availability of care in varying specialties, such as orthopedic surgery, neurosurgery, plastic surgery, anesthesiology, emergency medicine, radiology, internal medicine, oral and maxillofacial surgery, and critical care, said Gross. In addition, a level-1 center has a program of research, is a leader in trauma education and injury prevention, and is a referral resource for communities in nearby regions.

The long, severe winter of 2010-11 has added to what would be considered a typical workload in the trauma unit — again, if there is such a thing, said Gross. He noted that there have been more weather-related motor-vehicle accidents, by his estimation, a higher number of serious slip-and-fall incidents, and considerably more cases of people falling off roofs, an obvious result of the heavy snowfalls and homeowners’ attempts — almost always ill-advised — to reduce the threat of collapse. Meanwhile, Alouidor said this winter has seen a high volume of what he called ‘interpersonal violence’ — “there’s been a lot of penetrating injuries, a lot of gunshot wounds and stabbings” — a statistical anomaly he could not explain.

A recent serious head injury, a true cat 1, provides an insightful look at the full breadth of the work performed by trauma-team members after the pager goes off — and well after the patient leaves the bay.

“He had a very severe brain injury, and at the time of admission, we were all concerned about the potential outcome,” Alouidor recalled. “This patient put in a week in our ICU in which he received what we categorize as maximum medical therapy.”

Elaborating, he said that surgical teams moved quickly to decompress the brain, a procedure gaining more acceptance after recent success with soldiers in Iraq and Afghanistan.

“A large fragment of bone is removed, and thus the brain has room to swell,” he explained. “When there’s a brain injury, the brain’s main response is to swell, and with the swelling, the pressure in the brain increases, and that’s what leads to complications. There are multiple medications we can use to decrease the swelling and decrease the pressure and stabilize the patient, but this patient did not respond to any form of medical therapy, so at that point we had to decompress his brain.

“Despite this, his brain pressures were not properly controlled,” he continued. “After several days, he eventually died. We spent those days with the family, hand-in-hand with his wife, his children, his parents; it was a very long process, and a case that shows how we’re not just taking care of the patient, but taking care of the family.”

On the Clock

When asked what he enjoys (if that’s an appropriate word) about trauma work, Alouidor said he takes a great deal of satisfaction from making a profound and often immediate impact on someone who is probably having the worst day of his or her life, but there is much more to it than that.

“I like what I do for a variety of reasons,” he explained. “It’s not only the relatively quick results, but also the fact that I really like taking care of my patients; I’m very busy and very involved in their care, and that’s rewarding.

“There’s a wide range of results in trauma,” he continued, adding that not all of them come quickly, and some are obviously tragic in nature. “It’s not only the person who comes in in extremus that you can turn around very quickly by properly resuscitating them in the emergency room, bringing them to surgery, and doing the right operation at the right time, and watching this patient turn the corner within hours and come back to life; that’s the best-case scenario, but they’re not all like that.”

On the Monday he spoke with HCN, Alouidor’s day began at 7 a.m., and the shift would continue until 7 the next morning. That might seem like a long shift to most, but he’s used to it — so much so that his body’s ‘clock’ is impacted when he’s not working. Indeed, he finds that, when he’s on vacation, by the time he’s a few days into a trip, or about when he’d normally be taking a turn in the trauma unit, he finds himself staying up all night.

Since this Monday was relatively quiet, Alouidor was able to spend some time with HCN and discuss the many nuances of work in trauma. He said he arrives each day expecting “anything and everything,” and quite often gets both.

There is often no rhyme or reason to the level of the activity in the trauma unit, although there are some circumstances that will obviously contribute to volume, he explained, noting that the frequency of motor-vehicle accidents increases with bad weather and poor road conditions, and, in general, more bad things happen when people are outdoors, such as the summertime.

And there is, he maintains, scientific evidence of — and common-sense explanations behind — surges in activity during hot weather and full moons.

“The heat does things to people,” he said with a smile. “There is actually data in the literature that demonstrates that, when it’s a warm summer night or when the moon is out, trauma departments are more busy, and this is something we have known for years. When it’s warm, people are outside, and when they’re outside, things tend to happen — accidents, people fall off the balcony — and some bad things, like fights. And when you have a full moon, there is light until very late, and since people are out later, there’s more potential for them to get into trouble.”

And while this Monday was uncharacteristically calm — until mid-evening, at least — there are occasions, and many of them, he noted, when the patient volume on the first day of the work week will prompt someone to say, ‘are you sure today is Monday?’

Penetrating wounds, especially those related to interpersonal violence, have been occurring with great frequency this winter and, in general, over the past several years, said Alouidor, who noted that, had there been a shooting on the night of HCN’s visit, he probably would not have been at liberty to talk about it due to health care privacy regulations. So he used a hypothetical situation to discuss these cat-1 cases and all the ways the trauma unit responds, starting with what his pager would be telling him when it went off.

Teaming with Anticipation

“It would be alerting us to a ‘category 1, GSW,’” he explained. “There would be an age to follow, a location of the wound or wounds — chest, body, head — and there be be vital signs, blood pressure, heart rate, mental status, and EMS can tell us if the patient is critical, meaning minimum vital signs, or stable.

“And stable is a relative term — young, healthy people can tolerate a lot before they crash, but when they do crash, they’re in trouble,” he explained, adding that ‘critical’ is a relative term as well, and one that refers to potentially life-threatening injuries and an individual who needs to be stabilized.

With the information from EMS in hand, the trauma team begins to mobilize, said Alouidor, noting that the information on his pager is also now in the hands of other departments and individuals whose services will likely be required. This list includes the ICU, the operating room, radiology, the blood bank, lab, and also pastoral care.

“We care for these patients, but also their families,” he said. “If someone arrives here and has their 25-year-old wife or 50-year-old mother or 17-year-old son with them, someone needs to sit down with these people and talk them through what’s going on. We’ll provide the necessary medical information, but they also need support; we want to make sure there’s someone there for the family if they need someone to talk to.”

By the time the patient arrives, the team members are ready, he continued, adding that, by this, he means they are gowned, masked, and fully prepared to perform the rapid assessment that is needed in such cases. Airway, breathing, and circulation are the first things checked, he said, adding that disabilities, mental status, and injuries are also assessed.

“I’m not distracted by the fact that someone has a hole in their chest and a hole in their abdomen and they’re screaming bloody murder,” he told HCN. “What’s important to me is to see if the person is stable first, and then, in a very systematic fashion, we go over things. People look at us very cynically and say, ‘this guy’s been shot in the abdomen; why are you looking at the airway first?’ That’s because the first thing that’s going to kill this person is not the fact that they’ve been shot in the liver or in the blood vessels in the stomach. What’s going to kill them first is that they’re not breathing. What’s going to kill them afterward is the fact that they don’t have circulating blood.

“Then, we go on to assess the injuries and do what’s called a secondary survey,” he continued. “Then we make our decisions. Is this patient stable? Is he critical? Is this a patient we will do a workup on? This might be a gunshot wound we assess in ED and determine it’s not a penetrating injury. Then we can say, ‘it’s your lucky day; you got shot, and the bullet only grazed you,’ or ‘it didn’t go through any significant structures.’”

If the patient is critical and needs surgery, he or she is in the operating room within minutes, Alouidor went on, adding that other types of trauma, be they injuries from a car accident, fire, or fall from a roof, are assessed and treated in the same fashion.

And with every step in the process, the team is involved.

“I don’t work alone — I work with a team,” he stressed. “I could not provide the care I provide alone. And one of the reasons why modern trauma centers are so successful is not just because they have good doctors, nurses, X-ray technicians, or anesthesiologists. They are successful because they have good systems, and these systems are put in over months and years, and it is these systems that lead to good outcomes.”

Children make up a small percentage of the caseload in trauma, said Alouidor, adding that they bring some additional challenges to the fore.

Communication is one of them, he explained, adding that very young children can’t articulate what’s happened or where it hurts. “Parents can provide a story,” he explained, “but sometimes, that story is, ‘I was in the other room, I walked in, I saw him lying on the floor,’ so we don’t really know what happened in those circumstances. And to me, that’s one of the more challenging aspects of caring for kids.”

“Some people say it’s difficult to treat children because when you look at them you see your own children,” he continued. “And while that’s true, when I look at my patients, whether it’s the 20-year-old, the 45-year-old, or the 85-year-old, I tend to see someone I know. I think about my niece, who is 20 years old, I think about my brother, who’s 45, and I think about my parents. You tend to find yourself in any patient you’re seeing.

“It is more difficult to accept a child who has significant injuries, especially when you know the outcome will not be good, as opposed to someone who’s older,” he continued. “That’s not to say that you don’t care as much [with the older individual], but it’s easier to understand and cope with someone who’s 88 and coming to the end of their life than it is with a child who’s 4 who has a devastating injury and will live with those complications for the rest of his life.”

Work in Progress

‘The Q word.’

That’s the usually unspoken term for ‘quiet’ in the trauma unit — and in most hospital settings, for that matter.

Those who are superstitious won’t say it out loud, said Dr. Mazen Al-Mansour, a surgical resident at Baystate who spends good deal of his time handling trauma work. That’s because doing so will, in their minds, inevitably change the course of an otherwise calm evening in the bay.

Al-Mansour is a fourth-year resident in the Department of Surgery, which means he’s nearing the end of this long, grueling stretch of his training. He told HCN he would like to become a general surgeon, but enjoys many aspects of trauma work, especially the pace and unpredictability of the work.

When asked if organized, or controlled, chaos would be a good way to describe what goes on, he said only those who don’t work in the unit would use that term, even if it is fairly accurate.

“Everyone knows exactly what’s going on and what’s going to happen next, when there are multiple traumas at the same time or when we get extremely sick patients,” he explained. “It can be a little chaotic, but that’s the nature of traumas.”

Echoing Alouidor, Al-Mansour said work in the trauma unit requires a mix of skills, from the ability to assess and treat a penetrating wound to the compassion needed to address the wants and needs of family members.

“We work closely with extensively trained trauma surgeons who have the experience of dealing with life-threatening injuries in different areas of the body and different kinds of trauma, such as penetrating trauma or blunt trauma such as a motor-vehicle accident or people who are struck by vehicles,” he said. “We get to work closely with these people — we get to be the first-assist when it comes to the operation, and we get to watch these people talking to families, and we get to be involved with the families as well.

“There are different levels of people who get involved, and different levels of experience,” he continued, “and a lot of mentorship and observation on the part of younger people to pick up on the skills and the knowledge of how to handle the trauma patients and their families.”

Jez, whose job it is to coordinate nurse activity in the emergency department, including the trauma unit, said trauma nurses are specially trained for their work, which is demanding physically and also emotionally, but in many ways rewarding.

“It’s one of the greatest places to work in, and the nurses, while they can feel stressed — it’s a very, very busy place — will say that they truly make a difference,” she said, adding that the nurses play a critical and yet often overlooked role in the ED and the trauma bay.

“When these patients come in to the trauma unit, there’s this huge hurry — everyone’s in this big rush, everyone’s all excited, and the adrenaline’s flowing,” she explained. “And the nurse is in the middle of it. It’s the nurse and the patient, it’s the nurse who brings in the family, it’s the nurse who does all the meds, it’s the nurse that’s doing all the re-evaluation, it’s the nurse who’s there when you’ve lost the patient, and it’s the nurse who makes the patient look presentable so the family can come in and see him.

“They do it because it they love it,” she said of the nurses and their work. “They cry a lot down there — that goes with this territory — and they find order in the chaos.”

The Bottom Line

Alouidor stressed repeatedly that ‘quiet’ — he’s not at all afraid to use the ‘Q’ word — doesn’t translate into not busy.

Indeed, trauma physicians have patients to continually evaluate and myriad other types of work to handle when beds 9 and 10 in the trauma unit are empty or emergencies have passed. And they know that, at any minute, even if the moon isn’t out or it’s warm outside, the pace of the evening can change dramatically — and often does.

That’s why there are systems and procedures and signs on the walls in the bay telling people where to stand. The only job description for the people who work in this unit is to be ready — before the pager alerts them to an arriving patient, and long after the controlled chaos begins.