Trauma Room

I’ve been bringing quite a number of patients to the trauma room lately. You get hurt in a routine motor vehicle accident, you end up in a regular room in the ED or probably even more likely, a bed in the hallway until they can clear your c-spine, get you off the backboard and send you home with a script for a muscle relaxer. You get hurt in a big crash, you will likely get the trauma room. There, you will get all your clothes cut off and likely get fingers or tubes in all of your orifices, including orifices you didn’t know you had.

The rules for who gets the trauma room are constantly changing. They seem to go from permissive to restrictive and back depending on who knows what. There was a time when the biggest complaint paramedics had was “I asked for the trauma room and they didn’t give it to me.” Now I can’t tell you the number of times I have brought in a patient non lights and sirens, wheeled him down the hall, past the open trauma room door where I have seen a fully gowned trauma team, awaiting a patient and I have wondered what they were waiting for, what was coming in? a shooting to the head? a horrific MVA? a high fall with loss of consciousness and multiple fractures? Only to discover they were awaiting my patient — a woman who had fallen down five stairs and had a headache or a man in a rollover who was ambulatory on scene with no complaint other than a laceration on his arm.

All I ask for is consistency. Depending on the day don’t put one patient in the trauma room and his identical brother from an identical accident with an identical complaint in the waiting room after tearing off his c-collar in triage.

Most of my trips lately to the trauma room have fallen into two categories. A) I didn’t call for the trauma room, but they decided the patient belonged in the trauma room(usually due to mechanism, in some cases self-reported — human radar gun patient says the other car was going fifty-sixty miles an hour when it struck his car) and B) Calls where I asked for the trauma room on mechanism only with the patient not showing much in the way of injury.

* There were times in the past (depending on the pendulum) where mechanism really didn’t matter, you had to be banged up to get in the trauma room. Nowadays mechanism alone buys you the trauma room most every time.

In each of these categories, I would see disappointment in the trauma team members’ eyes as they saw that the trauma really wasn’t very interesting — they had been paged for this? — much like we sometimes can think we got called for this? when we show up on the site of a supposed bad car wreck to find really no injuries at all.

I feel like the director of a boring movie, the author of a boring book, a boring college professor. I want to say either “I didn’t call for the trauma room” or “Hey, I’m just following your protocol.”

Then the other day we get called to a motor vehicle accident. I know the location and I say to my partners “this is going to be a real wreck.”

We arrive to find a car into a tree with no skid marks. The tree is embedded in the engine. The man sits in the front seat of the car, in which the air bag has deployed. He looks dazed. When I ask how he is, he says, “Anyone else hurt?”

“I think just you,” I say.

“Anyone else hurt?” he says again.

“I think only you.”

“Anyone else hurt?” he says.

The steering wheel is crumbled. Then I look down at his legs. I see jagged bone ends. His right foot is upside down next to his considerably shortened right leg, hanging by a thin margin of skin and muscle.

“Are you in any pain?” I ask

“Anyone else hurt?” he says.

We rapidly extricate him. He also has bruising on his chest and abdomen. I have to use four trauma dressings just to wrap his legs which in addition to the open fractures have deep lacerations to the subcutaneous layer. His heart rate is in the 120’s and I am worried he may soon go into shock.

“Anyone else hurt?” he asks.

Not to mention the question of a brain injury.

I give my report in the trauma room. I feel bad to say so but I feel almost like a celebrity chef unveiling a master dish when I finally unveil the man’s grotesquely deformed limb. “Open tib-fib fracture,” I say with a flourish.

Their heads nod, their eyes alive with interest.

12 Comments

  • Ian says:

    and they (trauma team) train so hard to keep their interest up…well written and keep up the good work.

  • Rogue Medic says:

    There is no good reason to activate the trauma team for mechanism only.It is probably not the trauma team that has been making these decisions, but someone with more political pull in the hospital. They may want to boost their trauma stats, improve the percentage of good outcomes, or the ED may be panicking at every minor trauma when some doctors are on.I only give them what they need to know when I tell them what I am bringing in. If they want to know more, they sometimes get the response that “I am not trained in the estimation of vehicular speeds from examination of the vehicles,” or “I am not a mechanic, so I am not interested in the damage to the exterior of the vehicle.” I will tell them of any intrusion into the passenger compartment, vital signs, and other patient assessment information. If they want me to make a patient a trauma alert, when the patient is essentially asymptomatic, I do start my report to the trauma team with “There is absolutely no reason for this patient to be a trauma alert.” Why should the trauma team be misled into believing that EMS cannot assess patients?Maybe they can address the people who do not understand trauma in their facility. Unfortunately, the trauma people are often not favorites in the hospital, since they tend to be very direct – not a good political skill.

  • PC says:

    Thanks for the comments. The different trauma room standards over the years, I think very much have do with numbers. Like you, I often just describe the accident and let them decide. For awhile I stopped asking all together, but then I realized the mere act of prefacing my radio patch with “I am requesting the trauma room” compelled them to pay attention. Once I described a stabbing, and the nurse was upset because I didn’t sound urgent so she had tuned out what I was saying and missed key parts and thus the trauma room wasn’t activated. I will also ask for the trauma room if I think the patient needs it, but it is not obvious by mechanism or injury.

  • Anonymous says:

    I think sending some patients to the trauma room based on mechanism is reasonable. Some mechanisms can result in no injury anywhere to grievous injury.And yeah, I’ve noticed that the pitch on the voice of the receiving charge nurse raises about half an octave when my reports include the words trauma alert or trauma protocol.

  • Rogue Medic says:

    I have no problem taking a nice slow ride to the trauma center with a patient who has a significant mechanism, but no evidence of serious injury. I do not believe in racing across town and paging the trauma team just because of mechanism.If there is something that I missed, they will be in the right place.Mechanism is supposed to raise your suspicion about possible injuries to look for. Mechanism is not supposed to make your decision for you.

  • PC says:

    Mechanism alone is in fact written into our state regulations (not just protocols) when addressing destination hospitals for trauma patients. Apparent high speed impact or rollover or fall from over 20 feet among other criteria, you must go to a level I of II trauma center. If you are over 20 minutes away, you must call medical control to determine destination.Individuals hospitals use mechanism alone for trauma room activations. Apparent high speed impact, rollover, etc, will activate the trauma room. (although I have seen sometimes they have skirted this when they have other more serious traumas going on).Maybe it shouldn’t be that way, but that’s how it has become around here.

  • Gertrude says:

    When I was working in the trauma center we triaged Alpha (full team) or bravo (abbreviated team) based on mechanism. Now we are in the age of not mechanism but acutal complaint and assessment findings. I like this way better. I have found that I send less to the trauma center and more to the facility in my city that is capable ( mostly) of handling non-life threatening trauma. I think this is better for our patients. The true trauma patients get the care that they need and the trauma bay isn’t filled with patients that could have gone to a closer or other facility. I know that look your talking about though. They get cranky when you bring in a patient they don’t find “exciting enough”.

  • Rogue Medic says:

    I guess I am fortunate, then. While I will transport them to a trauma center, there is not disruption of traffic to increase the risk on the way. The criteria are only for consideration of trauma alert, and not automatic here.There will probably be some revisions to the mechanism criteria, death of occupant in the same vehicle, separation of motorcyclist from the motorcycle, age over 55, and roll over are some that have plenty of research to suggest removing them.

  • Gary says:

    Rogue Medic is absolutely right on this. Mechanism is an incredibly poor predictor of injury severity. The patient that PC described in his post needed to go to the trauma room based on his injuries, not the damage to his car. If I think the patient needs to go into the trauma room, I’ll say so. In fact, I’ll even call ahead on the radio to make a reservation. Since we don’t have to notify on every transport [Side note: it’s really stupid to have to call on every patient, but that’s a different rant] if I do call in, it usually gets the nurses attention. If I call in and the triage nurse wants to re-triage, I’ll point to the trauma room doors. That generally works. Just as in ACLS we say treat the patient, not the monitor, in trauma we should treat the patient, not the body damage.

  • Anonymous says:

    We currently bring patients in under a “level two” trauma based mostly on mechanism. Now while this area may be rather subjective I would hope hospitals would grant us this call sine we are on the scene. For example, the 17 year old female who is the passenger of a mustang that requires extrication to remove other patients, complaints only of head pain but when you have the resources do allow it became a “level two” trauma. Or, the 35 year old high risk pregnant female who had no serious complaints but the mech on her car and medical status gave her “level two” status. Word on the street in Pa is the next state revision of protocals is going to move away from mechanism, but until then…The real question to me comes when we have these “soft” trauma cases and have your choice of trauma centers to transport to in under 20min, you do it. But do those patients become “trauma patients” when transport to a trauma center would be an hour plus via ground or calling for the bird? csmith

  • Rogue Medic says:

    “The real question to me comes when we have these “soft” trauma cases and have your choice of trauma centers to transport to in under 20min, you do it. But do those patients become “trauma patients” when transport to a trauma center would be an hour plus via ground or calling for the bird?”What does 20 minutes have to do with anything? Stable patients do not wait 20 minutes and, if they are not in the trauma center, suddenly deteriorate.The patients you describe have more than just mechanism as criteria. What about the roll over patient, ejected from the vehicle, but with no signs of any injury?Or the patient in a vehicle, with not a mark on the vehicle occupants, the outside of the vehicle has a lot of deformity, but there is no intrusion into the passenger compartment?Pennsylvania is working on decreasing the abuse of helicopters by people who will not drive half an hour to the trauma center.They also need to work on those who feel that their ambulances are to precious to transport by ground more than 20, or 30 minutes, to a trauma center. To protect their precious ambulances they call for a helicopter to transport people who will walk out of the trauma center before the helicopter crew is available for another call.Or they just think helicopters are cool and have absolutely no understanding of risk management.What does any of this have to do with appropriate patient care? Very little. If you discourage good assessments and encourage flying anything that might be “bad,” you end up with a bunch of medics who are only competent at sitting on scene and getting a couple of lines while waiting for a helicopter. Appropriate treatment will only happen accidentally.

  • Marin says:

    my add used to work at a military hospital, that’s more like 24 hour trauma room. brutal stuff… youclash.com

Leave a Reply

Your email address will not be published. Required fields are marked *