Trauma-rama

I only have 8 nights left on trauma nights, before I start my month of trauma days. I am being traumatized early on and then won't see it again all year. I'm actually quite sad about leaving trauma nights. Yes, it is exhausting when Ohioans decide to celebrate America's independence by stabbing each other all night long, and the lack of a helmet law in Ohio is troubling at best, lethal at worst and mostly, keeping vampire hours is weird. I report to work between 6 and 6:30 PM, we sign out for about 45 minutes (usually screwed by the seemingly scheduled "sign-out trauma alert") and work until 6 AM when we sign out until about 7AM. Mondays we have Morbidity and Mortality conference from 7-8 AM and Thursdays we have Trauma conference from 6:45-8:30ish AM (expect a future post on the value of M&M conferences). So basically, I am a transient in my house. I have one day off a week, Tuesday nights, which, when you're on nights, kinda screws with your rhythm. You end up trying to stay up all night with nothing to do, just so you don't revert to normal human hours, but usually fail and end up sleeping through the night. At this point, I anticipate unpacking sometime around the end of my second year, maybe third year.

But it's seriously awesome. A large part of it is the incredible people I work with. I love my chief resident (kinda like the VP of the service) who is a PGY4 (post-graduate year 4, meaning he graduated med school 4 years ago and has 1 year to go). He wants me to be involved, he sends me to the OR whenever appropriate and is exceedingly patient when I am very hesitantly dissecting appendices laparoscopically, offering very subtle advice such as, "you might want to actually grab that [piece of inconsequential schmutz that's obstructing our view of the appendix] and just kind of pull it down and out of the way". It is very kind because I'm sure everyone in the OR is thinking "Please stop letting the intern do cases, we all want to get out of here sometime today" (luckily what I lack in speed of dissection I try to make up for in being otherwise helpful, such as moving the stretcher out of OR and just being generally nice). He is also super-smart, doesn't mind my auto-default to diagnosis of malingering or my tendency to double-check stupid orders with him, like "um, can this patient with a fever have tylenol?"

I also have the exquisite pleasure of having some of the most hilarious, bad-ass women trauma physician assistants on with me at nights. Jamie, Leanna, Pattie, and Megan are some seriously funny ladies who know how to handle just about anything that comes their way, and it all does. Their phone is the one that is always ringing and they all seem to know exactly what is going on with every patient on our list. It's pretty amazing, I am in awe and have much to learn from them. Rounding out the team is a third-year ER resident who is awesome, she is super-smart, happy to teach, and coined the term "Gummicolith" which is the obstructive structure that the trauma night team will all eventually have jam in their appendices and cause acute appendicitis due to our excessive consumption of gummy candy eaten between the hours of 3-7am. They also have incredible senses of humor, are incredibly warm and actually more fun to be around than most people, so it makes coming to work kinda like hanging out with friends.

We are a level 1 trauma center, which, from my understanding, means something different in every state, but boils down to the ability of the hospital to handle catastrophes. For us that means that we have a dedicated trauma team, an in-house trauma surgeon, a CT scanner that we have access to as soon as we deem it necessary, ORs and OR staff to do cases at any time of day and a helipad to helicopter patients in. I did my surgery clerkship at a level 1 trauma center in Brooklyn, so I am not unfamiliar with the "running of a trauma", but I have to say, we do it a little better here in Ohio, probably because the volume is pretty ridiculous. Usually it goes like this: we get a page to our trauma pagers (yes, I carry multiple pagers and phones, it's awesome being able to be found so easily) alerting us to a trauma that's coming in, the category of trauma, the ETA and hopefully a little something about the mechanism. Category 1 means badness: penetrating trauma, arresting patient, unstable vital signs, etc. It also means the attending will be present at the arrival of the patient. A category 2 is still not a smiling rainbow of a patient, but they are usually pretty stable, just banged up, a usual example is a little old man or lady on a blood thinner that fell/hit their head/restrained driver, etc. When it's around 5 minutes to the ETA we all gather in the trauma bay put on lead aprons (so we can take X-rays while doing secondary survey, without having everyone step out of the room), gowns, gloves, masks. We have our gear ready: trauma shears to cut off clothing instantly and stethoscopes. The members of the team include our surgical team, the trauma nurse who somehow manages to ascertain and filter all the important info that is being shouted out and records it on the trauma flow sheet. We have respiratory therapy there in case the person comes in intubated or will need to be, x-ray techs to do our immediate chest and pelvic x-rays (if needed), lab techs to draw trauma labs and a kind of circulating nurse to help with everything else. So, everyone knows their job and there is a kind of organized chaos that probably looks like a cluster from the outside, but is actually quite controlled.

Being a resident at a level 1 trauma center requires you to be certified in Advanced Trauma Life Support (ATLS), which is like CPR on crack. You need to know how to stabilize just about any patient with minimal resources. I believe my final practical exam was a patient ejected from a car, who was 32 weeks pregnant with a pelvic fracture, tension pneumothorax, open femur fracture and hypotension. It's really easy to sit in a lecture hall and read the algorithms of ABCDEs of trauma (Airway, Breathing, Circulation, Disability/Deficits and Exposure)and think, "no problem, I can totally do this", but when you are standing there in a simulation, your mind goes in a million directions and your begin to triage your own thoughts or it goes completely blank. Needless to say, I was terrified of starting out as the intern on the trauma night team, in the summer (which is the season for trauma) at a level 1 trauma center that sees incredible volume.

Starting my surgical training on the trauma/emergency general surgery service was absolutely terrifying, but just about greatest lesson ever. I don't think I have ever been so petrified in my life as when I was told to "take the head of the bed" for the first time. "Taking the head of the bed" means running the trauma. You are the one that declares the airway clear (or not), assesses breathing, circulation and basically are the commander of the room. Yes, lots of other people are around and checking these things as well, but your assessment is considered accurate unless proven otherwise. Yes, it's easy to assess airway when the patient comes in talking and can answer your questions, but what about the deaf mute that comes in from a car accident? (that took lots of creativity and many drawings and pointing to "yes" and "no" on a paper). Can you really hear clear breath sounds over the commotion of the trauma bay? What if you think you do, but the chest x-ray shows a tension pneumothorax? No intern wants to be a 007 (licensed to kill), especially not in the first week. The thing I have noticed most in these past few weeks is how easy it was to armchair quarterback as a medical student, when you had no real responsibility. I remember sitting in M&Ms or listening to plans on rounds and thinking, "I would have done that better, I would have thought of that sooner, etc". And yes, presented with a whole picture it's easy to see what's what. When you're in it and information is trickling in, the picture becomes less Mondrian (all clear lines and boundaries) and a lot more Seurat (lots of tiny dots of color that only make a clear picture when you stand far away from it). I'm finding that the hard lessons we learn in our surgical training really applies to a much larger demographic, if not everyone. On trauma, the whole story is usually unknown and the injuries are very rarely clear cut. Sometimes you just have to take what information you have, be guided by the best intentions and do what you think is right at that time given that information. Knowing this, I think we need to allow others to do that without judgement outside the trauma bay. We all armchair quarterback other people's lives and decisions, not necessarily from a mean place, but judgement is a natural reaction. I think if we are just a little more gentle with each other, knowing that sometimes a person makes the decisions they do with limited information and the best intentions, will allow us all to be more gentle with ourselves and I think we will find ourselves carrying lighter loads on our shoulders and having less regret in the long run.