Ask the doc: What happens in the trauma center?

Mar 30, 2017

Welcome to the trauma center!

If you crashed, you have likely arrived here on a long, hard backboard, sporting a rigid neck brace, often an IV, and are secured like cargo attached to the top rack of your SUV.  Great! You are alive to enjoy what follows next.

Zillan Dan McBrearty recently wrote about his crash and subsequent visit to the trauma center. Here's the view from the doctor's perspective and an explanation of what to expect. Now go out there and try to avoid visiting the trauma center yourself.

In the United States, there is a well developed network of trauma centers dedicated to caring for you and your injuries. Trauma centers are verified by either the American College of Surgeons or by their state. The top tier of centers is designated as a Level I regional resource trauma center; lower levels (II or III) indicate differences in research program presence, resources, or capabilities. Regardless of level, trauma care is remarkably similar in its early phase (think Emergency Department).

Make no mistake, being verified as a Level I center is a big deal and leverages a vast amount of resources towards saving injured patients, helping them recover, and performing related research. Some healthcare systems have both Level II and Level I centers within their network. This is an increasingly common practice according to Patrick Kim, MD, FACS the Trauma Medical Director at the PENN-Presbyterian Trauma center in Philadelphia, a city that boasts five adult and two pediatric Level I centers and one Level II adult center. We get a lot of business in the city of brotherly love, and sport well tuned trauma centers as a result.

Once you arrive in the ED, you will have a very good view of the ceiling and little else since you will be secured to the stretcher and the backboard. As fascinating as the trauma center is to view, please stay on your back until we have fully assessed you and your injuries. Our first priority is to determine whether you have an immediately life-threatening injury.

It does seem that everything important was learned in kindergarten with the ABCs and trauma in no different — it is where we start. And while we do this, you will lose all of your clothes, generally by having them cut off so that we can find external signs of injury (good clues to internal ones), and do so without needing to move your limbs or bend you at the waist of neck to get things off. Imagine how bad that would be if you have a broken arm or leg, or a fractured neck. Yes, we will try to preserve your dignity and your expensive gear — especially your colors if you have them — but not at the expense of missing an injury or creating one to preserve clothing. Many of us ride, so we get it, but life is precious and we aim to maintain it above all else.

Assessment by alphabet

We will ask you to speak to us to see if your “A”irway is intact; if so, great. If not, we will put in a breathing tube. Sorry, you will not be able to speak once that happens, but we will give you lots of really good meds so that you are comfortable.

“B”reathing is next to determine if gas moves equally through both of your lungs. If it does not, you might get a tube through the side of your chest that goes between your lung and your ribs to evacuate gas or blood that should not be there.

“C”irculation is next and we will check your heart rate, blood pressure and pulses. If your pressure is really low you will likely get both intravenous fluid and blood products to bring it back up – even before we know what injury or injuries have caused it. If your blood pressure is low, you don't send oxygen to your heart and brain very well; we work hard to fix that!

“D” is for disability, so we ask you to move your arms, legs and hands and feet for us as an indicator of major injury to your brain or spinal cord.

Finally, “E” is for exposure, where we remove all of your clothing to look for injuries and then log roll you side to side to check your back. We will look in your armpits, in your groin, at your perineum, and between your butt cheeks. Yes, you will also be the recipient of a rectal examination to look for blood, but also to ensure that your spinal cord properly allows you to control the muscles there (we will ask you to squeeze). Don't take it personally and don't think you are getting “special” treatment. We do this for everyone so that we do it the same every time and make it less likely to miss something. We need to know what is likely wrong to best treat you. Once this is done, we will cover you with an unflattering gown and a warm blanket or two.

None of this happens in isolation. While all of this is happening, someone is putting on a tourniquet to draw blood after placing an IV catheter (usually one in each arm). Someone else is talking to you from above your head telling you what is happening; all of us will have on a hat, mask, lead apron and a gown – not comforting for you since we are a visual society, but it does protect us from blood and body fluid exposure as well as x-rays that we will need to take. You will have someone else putting you on a variety of monitors that will track your heart rate and rhythm, a blood pressure cuff that will automatically inflate every few minutes, and a fingertip monitor to track your oxygen saturation.

Dan in the ED
Dan's visit to the trauma center was just like what the doctor described. Photo by Dan McBrearty.
Speaking of that, you will have some supplemental oxygen given to you from thin prongs that stick up your nose a little bit, or by a face mask. The gas through the face mask is noisy and we will have a hard time hearing what you say, but we really want to understand what you are telling us about pain, breathing, what you can or cannot feel, and the like. Statements that you do not have insurance, are angry at the guy who cut you off, will be late for work, and any questions about your gorgeous new ride that is now mangled — well, not so much at that specific moment; tell us later once we understand what injuries you have and best how to treat them.

Besides a chest X-ray, we routinely obtain an ultrasound of your belly and your chest, including your heart. We are looking for fluid or gas that is where it should not be. The ultrasound gel may be a bit cold, and the probe may have a good bit of pressure so that we can see what we need. Bear with it. It does not take long.

If you are likely to be seriously injured we will CT scan your brain, neck, chest, abdomen and pelvis (also known as a “pan” scan since it scans everything). CT scans are really fast. We generally give you some intravenous contrast agent that goes where your blood goes so it helps us identify injuries and how well blood is getting to specific organs. Some centers also have their patients drink a small amount of oral contrast that provides a road map to your GI track in addition to the IV contrast. Be aware that the IV contrast goes in pretty quickly and may make you feel really warm and like you need to empty your bladder; if that happens, don’t be embarrassed – we see this. If you have injuries to your arms or legs, expect X-rays of those, too. You may even get a CT scan of them to look at the individual bony pieces.

Depending on what injuries you have, you may be operated upon as an emergency right from the ED. You may also be seen by a number of specialists and be examined multiple times. Orthopedic surgeons and interventional radiologists are very commonly involved in trauma care, but virtually any specialty may be required – and we have them all on tap. Some of these consultants may also need to operate upon you to fix what is injured. In addition to the physicians, you will have the major caretakers of injured patients — the bedside nurse — with you virtually constantly. A social worker, a case manager, an intake clerk all may be involved early on in your care. Others, such as a respiratory therapist, may also be involved from the start if we need to put you on a ventilator (breathing machine), you need nebulized medications, or a lot of oxygen as part of your care. Of course all of this started with the Emergency Medical Services crew who brought you in for care. They, along with the police, are often unsung heroes in trauma care.

What you can do beforehand to help

You may receive a host of different medications during your ED stay including pain meds, antibiotics, and a tetanus booster. Please tell us if you have allergies to any medication, food (especially shellfish, as IV contrast has iodine in it, just like shellfish), or latex. If you do, then put it in a card in your wallet, wear a medical alert tag, and put it in your smart phone — preferably all three. If you are unconscious when you come in or have a brain injury, you will not be able to tell us, and we need to know! By the way, please have an emergency contact listed somewhere like your wallet or phone (ICE contact — In Case of Emergency).

While we try to keep it quiet, the trauma bay of the ED is often a noisy place, and can be a bit scary too. The trauma team, machines, alarms, and the patient next door all make for a less than quiet environment. Not everyone needs the entire trauma team, but know that we are there for you if you do. And while we strive to make you feel special, we really treat you just as well as everybody else who comes through the doors.