Trauma Call

I had trauma call for my Surgery rotation last night. It was traumatic, all right. Not in the gruesome sense of the word, images of human flesh cleaved open by a car, or fecal matter spraying the walls of the OR or anything like that. Let's just get that out of the way.

It was intellectually traumatic.
Trauma situations require fast thinking, reflexive actions. They don't spare any moment for deep, ponderous considerations, my usual sort of cognition. I read through a few thick handbooks the night before, nodding off and on around 10-11pm in a meager attempt to prepare myself for the Trauma call.

We had a Trauma Simulation lab at my medical school in the afternoon, complete with ED physician teachers going through the routine of the Primary Survey: ABCDE -- airway, breathing, circulation, disability, exposure/environment... the stuff we've heard "since grade school." There were some fancy manikins (not mannequins) at the SimTiki lab with different critical conditions resulting from a car crash. Also present: ten medical students with varying degrees of ED experience (ranging from super-star ED ward clerks with trauma experience to ... me.)

One by one, we were pulled out of the lab to get an assessment with the surgery clerkship coordinator on our TEAM (Trauma Evaluation and Management) skills. I was the first one and we were only five minutes into the first training scenario.

... I totally let my simulated patient die in front of me.
It was tragic. There were some technical difficulties as the manikin needed to be restarted three or four times. In the interim, before the monitors were setup, the surgeon told me -- "continue with your primary survey."

It went something like this:

"Uhm... I hear breath sounds, but they sound weird. I don't know how to describe them. Rubbing? Clicking? It's ... not right. Where's my pulse ox and BP data?"
"The manikin is still being launched. What else are you going to do?"
"Uhm... I don't know. I can't figure out what those sounds mean. I'm going to continue with Circulation."
then Disability.
then Exposure.

Doh. I clumsily attempted to do some assessments, but I failed to provide any definitive treatment. When the manikin's eyelids closed, the pulse ox data disappeared off the screen and the BP dropped down to the 20s, the overhead voice said in a sardonic tone: "Blood pressure in the 20s is incompatible with life." My failure to diagnose a massive hemothorax with decreased breath sounds, as well as my complete inability to assess the patient properly, led to his eventual demise.

Luckily for me, it was just a fake patient.
The shame of the experience, especially with the surgery clerkship coordinator telling me that I needed to read and review everything really hit home. It's one thing to recognize the correct answers; it's another thing entirely to recall it under stress by yourself with a patient changing status before your eyes.

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I spent my Trauma call reading through the TEAM handout and dreading the moment when a trauma call came in.

On the plus side (which is the whole point of the training sim) I learned the Primary Survey by heart! I'll spell out the basics just for fun.

A: Airway (head and neck)
-establish airway, put on c-spine
-foreign objects?
-if GCS <8, intubate
B: Breathing and vent (neck and chest)
-100% O2 for everyone, nasal prongs
-bag-valve mask if need be or ventilate
-if lung sounds are reduced, needle thoracostomy!
C: Circulation and control of hemorrhage (chest and abdomen)
-BP and EKG
-hemostasis with direct pressure, inflatable sleeves, etc
-place two large bore IVs, drop in 2L of LRs for hypotension
-type and cross for further blood loss
D: Disability (head and rectum)
-neuro exam: PERRLA, rectal tone, GCS (E+V+M<=15)
E: Exposure/Environment
-Strip clothing
-Logroll patient, examine back
-Warm patient (blankets, bair-hugger, fluids, lights)

SAMPLE history
S/sx
Allergies
Medications
Past history/Pregnancy
Last meal
Events

Labs/Studies
ABG
EKG
CBC, Chem7
Type and Cross
PT/PTT
UA, UDS
FAST/DPL
XR/CT/MRI