Trauma call

For the past month I've been on trauma nights. In our residency we do two months of nights, my first month was in the beginning of residency as I've talked about, and I'm doing my second month now. Before I was a med student, before  I was a resident if someone told me "trauma nights" I would think it was the coolest thing in the world. In fact that happened recently, we had a bunch of friends over one Sunday, and as I got ready to go to work on Sunday evening everyone was saying how awesome it must be to be on trauma. I tried to explain how depressing it is, but stopped before I said anything stupid. Grey's anatomy, House, Scrubs - they've all made life as a doctor and surgeon out to be something it isn't. In those shows, the terrible traumas come in, but in the end everything works out. Shit isn't real. But it hits in you in trauma nights how real things are.

A little background on trauma. The ED handles the vast majority of simple trauma without activating the trauma pager. IE you have a car accident, you hurt your hand, no other injuries - that won't be a trauma. But, if its a bad accident, essentially any thought that surgery needs to be involved then the trauma pager is activated. You gotta remember, if someone unstable after a trauma, they are tanking in the field, an ED doctor can't do all that much other than acutely stabilize the patient. You need a surgeon, and its best to have the surgery team at the bedside waiting for you so as soon as you get in we're ready to roll. So when that trauma pager goes off, we haul ass down the trauma bay and get ready. We always expect the worst. We are notified whether its a level 1 or 2 trauma. Level 2 are generally stable, still a significant enough impact to activate a trauma but generally not someone who you expect to die any second (but you never know). A level 1 is serious, you have no idea what you're going to get but its generally bad. For level 1 traumas we expect to immediately intubate (breathing tube), line them up with central lines, chest tube/thoracotomy trays ready. You just never know. Its better to have a trauma surgeon and the team available then not. One of the memorable traumas: (identifying details obviously changed)

Its 7PM, Tuesday night. I'm running around the hospital, answering pages, doing post op checks. I was hoping for a quiet night, the thing with trauma nights is that if their are no traumas, by midnight you can be done with all your work and get some good rest as long as no floor patients are crapping out.  So anyways I'm on the floor when the trauma pager goes off. The sound of that pager always gets my HR going, scares the hell out of me. Its a level 2, so me and my med student head down the trauma bay right away. All I'm thinking of is the work that I have to do, and hoping this trauma isn't too bad.

I get my lead on (we always take xrays in the trauma bay and as the intern, I stay with the patient during the xray), throw on some gloves and wait to hear whats coming in. The ED nurse tells us its a pedestrian hit by car. This is one of the most common traumas we get. Me, my chief resident and the ED attending are just hanging out in the trauma bay waiting, joking around. Finally about 10 minutes later the ED doors bang open and paramedics are rolling the trauma in. They yell "22 year old female, jogging, struck by car ~20 mph". We transfer her to the trauma bed and get to work. We are a well oiled machine, consisting of the chief resident, junior resident, and myself (the intern). The junior resident starts with the ABC (if you remember from CPR, just make sure their breathing and airway is intact), while I help the nurses get the BP cuff/EKG leads on for our first set of vitals. While the junior completes the head to toe assessment I start cutting off all the patients clothes. Trust me - you never want to be a trauma, no privacy, no dignity. We cut everything off.

Her vitals were stable, she was alert and oriented with no obvious life threatening injury so we all slow down a bit. We do a FAST abdominal ultrasound exam, which tells us if their is a large amount of free fluid in the abdomen which would imply an urgent trip to the operating room. Its negative. Because she lost consciousness in the field, we decide to get a CT of the head and cspine just to be safe. We roll her over to CT, grab a seat and wait for the scans. This is what we see:

She had a huge epidural hematoma (brain bleed). As med students we see these pictures a hundred times, and I had seen a couple of subtle ones on traumas before. This one wasn't subtle (Obviously that picture is not her, its from google, but it was that big). She had midline shift and everything, yet her neuro exam was perfect. We call neurosurg right away, they come down, evaluate her, and recommend sending her to the neurosurgery ICU and watch her closely.

Why did this trauma stick out in my head? Well after the CT, but before she went to the neurosurg ICU she had a bunch of lacerations that needs to be sutured in the trauma bay, nothing unusual and the task usually falls to the intern. We also had some time where I had to stay with her while the transfer to the ICU was being sorted out; the team didn't want to leave her alone unmonitored. So we start talking, and it kinda hit me how completely normal she was. Its this 22 year old girl from Europe who came to LA to work in fashion. She was just out for a jog and thinking about her weekend plans.

Working in this field, seeing all the trauma's roll in one after another you lose a sense of the human connection. The traumas, the patients are just work. We don't even assign them real names, they have trauma code words (oftentimes traumas who come in don't have ID and we can't ask them their name, so by default all traumas get assigned a code word). You lose empathy, start to identify the patients by their disease process. We don't say "how is mr jones doing", we say "how's the old guy who had the splenectomy doing".

But talking to that girl I saw how scared she was, she kept on thanking us but she as clearly in shock at what was happening. We never stay with out patients long enough to talk to them about anything but the acute medical/surgical problems; the social workers/nurses/therapists/case managers are the ones who figure the "other stuff" out. She had emergent surgery that night to evacuate the hematoma, she was going to have a serious scar and probably a long recovery.

But the main point here I think is that I understand why we don't try and connect with our patients. It would destroy you. We get so many drunk people who come in after doing something stupid - hell not too many years ago that could have easily been me or my friends. We never empathize with them, we call em drunken idiots and try to get em out of the ED as soon as possible. For all the terrible motor vehicle traumas we see and don't think about, man we all drive to work. That could be our family, our friends, us. We never think like that; its just a job. And it has to be like that because like any other thing in life sometimes things don't go well, bad things happen that are out of your control. And sometimes bad things happen because you or someone on your team screwed up. And if you treat this like more than a job, if you stop and actually put yourself in the patients shoes or if you try to treat everyone like you would treat your mom or dad I really think you will lose your mind. If you thought about the consequences your actions had on peoples lives, I don't think I could bear it.

And that sobering thought, the idea that I treat work like work I think has really defined my intern year. I know lots of people think that we become doctors for women, power, and money - but really thats not what drove me and most people I know to do medicine. I worked in tons of menial jobs in high school and college, and what made me want to do medicine was the idea that I could get paid, my career would be doing something intellectually stimulating, interesting, and I'd be helping people. I like to think I'm a genuinely nice guy who cares about others. I've always been that way. I remember as a medical student spending hours with patients, talking to them. I really empathized, and I couldn't understand why residents and attendings were so callous, so rushed (their will actually be another post about a patient from my third year of medical student that really changed me). I remember thinking I'd never be like that...

And then I think of how am I know. I'm just 8 months into my residency, and already I'm losing that emotional touch. I just want to get through the day. When the trauma pager goes off, my mindset isn't f**k someone may be badly injured, its f**k I hope its not too bad so MY day isn't ruined by this. It sucks, and its just not surgery its all specialties. We all try and dump patients on other services. No-one wants to sit down and figure out the social situation, the background, we want to just get on with our day. We have the same mentality with the hospital that virtually everyone has with their  daily job. The  only difference is instead of have that attitude towards meetings, the bottom line, clients, customers etc that is completely acceptable in any other profession we have that attitude towards sick human beings who are coming to us for help.

Every once in a while something reminds me of how I used to be, how much I used to empathize. And please don't get me wrong, myself and most people in our field are genuinely good people. We do want whats best for our patient. Thats the underlying sentiment, thats what drives us. But this damn system, you are so overworked, so tired, so stressed that sometimes you lose sight of the big picture. I work in an era where work hours are significantly improved from where they used to be, but its still nothing like 99% of the population will ever experience. I easily hit 40 hours by Wed afternoon. I go the entire year averaging about 80 hours a week of work. I get one day off a week, and its sometimes in the middle of the week. We don't get many holidays, and tend to be on call for most of them anyways. But the point of this post isn't to complain, because honestly I still think I'm blessed to be in the position I'm in and wouldn't trade it for anything. But this system changes you, and not for the better. I know I'm still that person that cares, that I would do anything for my patient. I just need to remind myself of that sometimes...