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Date: 13.02.2018

Controlled Chaos (2003)

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Reginald Alexander, here consulting with surgical residents, says work in the trauma unit is a total team effort.

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.

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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.

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.

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.

There are a half-dozen people treating the patient, looking at information, and consulting with one another as data is pored over. 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.

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. 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.

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. Level 1 is the highest designation for trauma units, and such facilities provide the highest level of care, said Dr.

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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. Key elements of a level-1 center include 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. 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.

Since this Monday was relatively quiet, Alouidor was able to spend some time with HCN and discuss the many nuances of work in trauma. 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.

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. 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. Airway, breathing, and circulation are the first things checked, he said, adding that disabilities, mental status, and injuries are also assessed.

Is this patient stable? Is this a patient we will do a workup on? And with every step in the process, the team is involved.

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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. Mazen Al-Mansour, a surgical resident at Baystate who spends good deal of his time handling trauma work. 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.

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.