by Eric Flint
Trauma—1 Team, 1 Goal
In the OTL, definitive treatment of trauma is a well-established surgical specialty. Most practitioners are true general surgeons, capable of both handling surgery in any major body cavity, including at least basic brain surgery, and of providing the intensive care needed in the vital hours, days, and weeks following that surgery. Most major trauma centers maintained at least one surgical team available on short notice—usually within minutes. The head of a team is an Attending Surgeon [i] or a Trauma Fellow [ii] , and such a surgeon was expected to be "in-house" and available 24 hours a day, seven days a week, 52 weeks a year. Along with the surgeon leading the team, major centers generally keep multiple residents, fellows, and specialists of all types on staff, all available on short notice around the clock. Additionally, specialized equipment such as CT scanners, ultrasound scanners and “Cell Savers” (equipment to salvage blood that has been lost inside the body) are found in these major centers.
Ideally, critically injured patients barely stop in the ED on the way to the Operating Room (OR) or specialized care unit (e.g. the burn center), but this often isn't done. Frequently, the surgery suite is in use or a needed subspecialist is not immediately available. Initial resuscitation has to take place, in such cases, in the ED's trauma bay. Such first treatments might include putting tubes or probes in all natural and often several unnatural openings of the body, or even surgically opening the chest or abdomen in an effort to control severe bleeding. These trauma bays are stocked with the appropriate sizes of equipment most often needed—for example, some facilities specialized in pediatric trauma have a larger selection of the smaller instruments needed to handle children. The first mobile Computed Tomography (CT) scanners were appearing in 2000, allowing the machine to be brought to the patient, saving time and reducing problems moving the patient.
Hot and cold running residents are not always available.
Smaller trauma centers depend on surgeons who are on call but do not stay in the hospital. Those facilities utilize experienced physicians, usually certified in one of the general medical specialties (either Emergency Medicine or Family Medicine in the US, often Anesthesia in other areas of the world) to lead the center's trauma team as part of their duties in the ED.
Depending on how badly a patient is injured, and what other specialty physicians are available at the facility, these centers may or may not transfer major trauma cases to larger facilities. Most of these facilities have fixed CT scanners in the ED, so that the patient does not have to leave the department to be scanned. Both critical trauma and medical patients could be treated in these centers' emergency departments, which usually include at least one room with a cart with specialized pediatric equipment.
Rural and small town hospitals may not have a surgeon around all the time.
The smallest facilities may not have a surgeon on call on a regular basis, and will have to transport any major (and even some relatively minor) trauma patients to a larger facility for further care on an urgent basis. Recommendations for many smaller facilities included consideration for direct transfer, often by helicopter ambulance, for seriously injured patients, bypassing the smallest facilities and taking the patients directly to a large trauma center.
See One, Do One, Teach One
While learning the care of severe trauma is a years-, even life-long, process, there are courses available to introduce physicians, nurses and paramedics who are not trauma specialists to the systematic care of trauma patients. These include:
Advanced Trauma Life Support (ATLS)
Trauma Nurse Core Curriculum (TNCC)
Anesthesia Trauma and Critical Care (ATACC)
Basic Trauma Life Support (BTLS)
International Trauma Life Support (ITLS)
The US Department of Defense Combat Casualty Care Course (C4)
The C4 program includes ATLS for physicians (and physician extenders like Nurse Practitioners (NPs) and Physicians’ Assistants (PAs) and TNCC for nurses. Please note that while NPs generally have collaborative but independent practices with physicians, they are still considered as physician extenders by the American College of Surgeons as far as the ATLS certification is concerned. [iii]
Any family medicine physician who wants to work in the ED or even to practice in a rural area will most likely have taken ATLS [iv] . Similarly, the TNCC course is recommended for any nurse wanting to work in an ED or a trauma ICU. Any physician, dentist or nurse with more than three years of (US) active duty military experience [v] will probably have taken the C4 course during that time. These courses, of themselves, do not qualify a physician or nurse to perform major surgeries, but instead gives them a good basis for starting treatment, and the knowledge to provide immediate life-saving care involving critical airway and chest injuries. I expect that Drs. Adams and Shipley will have taken ATLS in the years just before the Ring of Fire (RoF), Drs. Sims and McDonnell may have taken ATLS in the late 1970s or early 1980s, and that at least Mary Pat Flanagan may have been exposed to TNCC before the RoF. I have not found any evidence in canon that this was the case, but based on my experience in the ED during the 1990s, I believe it is likely.
Major surgeries associated with trauma care range from the short procedures best described as “damage control,” to hours-long reconstructive procedures. Aseptic (without infection) conditions are the norm in surgery and later care OTL. Frequently, further surgeries and treatments work together to help the patient heal fully or to address areas that could not be safely dealt with until the patient was more stable. These may range from an assortment of powerful antibiotics to high-technology instruments that monitor a patient's condition. Life support can include everything from a ventilating machine that can breathe for a seriously injured patient to a specialized bed that helps prevent bedsores. Skin, bone, muscle and even digits can be re-implanted, transplanted, or grafted to repair or replace missing parts. Powerful anesthetic and analgesic drugs are available to allow the most seriously injured patients rest while intravenous or tube feedings prevent dehydration and malnutrition, provide routes to administer medications and allow healing to continue. This is the general pattern for trauma care in the US and Canada, and, with a few modifications, true in the rest of the developed world.
What can be done immediately after the Ring of Fire?
The complex and comprehensive care taken for granted in the developed world is not available in most of the world in OTL. This state of affairs will most likely be true in the NTL at least through the late 1640s or even the mid 1650s, due to the need to develop both the physical plants and the medical infrastructure out of the ruins left by the “Fifteen Years War.”
In OTL, outside of the U.S., Canada, Europe and other developed countries, complex and comprehensive care is usually limited to a few large hospitals in major metropolitan areas. People with major injuries in other areas of those countries, or even in metropolitan areas after a disaster, will receive care that is much more limited. As we shall see, "limited care" does not mean bad care, or even a bad result.
Canon shows that work on the Leahy Medical Center was the major construction project started in 1631 after the RoF, as Mike Stearns and company realized that the lack of an operational medical facility was a potentially disabling problem for the community. Leahy Medical Center (LMC) is in canon as operational by late 1632, when overtures were made to the medical faculty in Jena for a cooperative education effort. This leads in turn to the program now turning out advanced midwives, Bachelors of Science in Nursing (BSN) [vi] and Doctors of Osteopathic Medicine (DO) by sometime in 1634. Some of the equipment for Leahy's operations and the Jena joint effort will be transferred from the physicians’ offices, some from the veterinarian’s offices, some from the nursing home, but many more instruments and devices will be made down-time, out of sheer necessity.
Trauma care in the NTL, before the establishment of the Leahy Medical Center, will be similar to that seen during the recent earthquake in Haiti or the floods
in Pakistan—simple, even rough, and much more concerned with saving a life than saving a limb. Even after the establishment of LMC, only those patients fortunate enough to end up at LMC will benefit until other facilities open up.
The experience of Drs. Ellis, McDonnell and Sims during the middle years of the twentieth century will help the only fully trained surgeon, Dr. James Nichols, bring other physicians to the point of being able to handle all the surgery that is practical between the RoF and at least 1637. It should be recognized that all three of the older physicians will die by 1637, according to the Grid, which does put a premium on their remaining life spans.
By 1637, there will be New Model medical schools at Jena and Padua, as well as the New Model hospitals—at minimum in:
Grantville
Magdeburg
Bamberg
Essen
Jena
and probably in Padua and Venice, but in time, there will be others. These hospitals and medical schools will not only teach a fusion of up-time and down-time information, but will also start new medical research to further extend medical knowledge. It is in canon that by November 1634, the new hospital at Jena is capable of handling major trauma and burns. [vii]
An important point here: Dr. Nichols was trained during an era when a general surgeon was expected to be able to operate safely in any area of the body, at least enough to provide life-saving care in almost all conditions. The three older doctors, while not surgeons, were trained in an era when rural general practitioners were expected to handle basic surgeries and orthopedics as needed. I will explore many of these operations later in this series.
The initial limitations of surgical techniques will revolve around the lack of trained personnel, lack of instruments, lack of medications, (safe and titratable analgesics, muscle relaxants, and sedative agents) and lack of equipment (especially anesthesia equipment), but most importantly, the lack of a safe, clean place to operate. The older doctors probably remember the efforts of Josep Trueta i Raspall, MD—a Catalonian orthopedic surgeon who took the lessons from WWI and developed them into a consistent framework involving careful debridement, limited closure and long-term dressings with plaster cast immobilization of horrendous wounds during the Spanish Civil War. There is a fair chance that the older physicians had experience with these techniques during their training and practice in the late 1930s, 40s and 50s. There is also a good chance that Dr. Nichols will have learned some of those techniques while he was in surgical residency, since it is guaranteed that his older professors had experience with those techniques during WWII. Beulah McDonald should also be familiar with them, as these techniques were part of nursing training at the time and she would have used them in Korea.
These techniques are still used today by surgical teams from the International Committee of the Red Cross/Red Crescent and Doctors Without Borders who work in areas affected by major disasters. I have included links to PDFs available from the International Commission of the Red Cross/Red Crescent Societies covering much of this information.
Despite the Trueta method, the lack of vascular repair will increase the number of amputations markedly [viii] with up to half of the patients needing ligation of a major artery requiring eventual amputation. This is five to ten times the rate seen in OTL, especially as the art of trauma surgery has evolved with the current war on terror. We had recognized, after Operation Desert Shield/Desert Storm (1990-91), that limiting IV fluids and using tourniquets to stop severe bleeding was actually very effective at saving lives. However, direct pressure on the wound remained the quickest and safest method of bleeding control. Mary Pat Flanagan and David Dorrman would have been aware of these details, even if Dr. Nichols was not.
We already know that up-timers with varying degrees of training have overcome many of the obstacles to surgical training, since Dr. Nichols’ daughter, Sharon, who was trained as an EMT with a BS in Biology (Magna Cum Laude, WVU 1999?) before the RoF, was able to master the techniques abdominal surgery well enough to save “Filthy” Sanchez after he was gut shot in 1634 [ix] . Tom Stone was able to make it back from Padua to provide the open cone anesthesia, and provide Sharon with some light relief. Canon also mentions several industrial accidents, as well as combat injuries, that result in amputations [x] , paralysis [xi] , severe burns [xii] and other disabilities, where the patients probably would not have survived without the efforts of the up-time medical team. Beulah and Mary Pat saved the life of the young printer Veit when they first got to Jena, by inserting a chest tube to relieve a collapsed lung and tension pneumothorax. [xiii] As life-saving as this action was, it almost sank any chance to work with the Jena medical faculty, because of the embarrassment of the up-time, female nurses saving a patient that the down-time male doctors would have had to watch die.
Dr. Trueta’s work, on the other hand, was more involved with salvaging horribly damaged limbs, and to this end, he developed a network of fixed, mobile and railroad hospitals during the Spanish Civil War of the late 1930s. His philosophy of debridement, loose closure, and sterile dressing followed by a long period of supportive plaster casting was responsible for a marked reduction in the infection and amputation rates for horrendously injured limbs. He was able to show, in an era before effective antibiotics, that it is often more important not to disturb the healing wound with dressing changes than it is to observe the healing wound for signs of infection. This technique was well-documented in the surgical textbooks written during and after WWII, and so should be available to Dr. Nichols even if he didn’t learn about it during residency and the older doctors do not have direct experience with it. [xiv] This was something that was being gradually rediscovered in the 1990s, as more problems were being noted with infections resistant to standard antibiotics. I will discuss this more in Part 2.
Basics save Lives.
The basics of trauma care are surprisingly easy to teach: every US soldier and Marine has received this “buddy aid” teaching for years, culminating in the combat life saver course that was developed in the 1990s. The important steps are remembered with the mnemonic “ABBCDEE”: open the Airway [with cervical spine (neck) control], start the Breathing, stop the Bleeding, start the Circulation, evaluate for neurologic Damage, Expose the wound and Evacuate the patient. An experienced medic should be able to identify all of the immediate life threatening problems in a field situation in less than two minutes, given decent light. More importantly, this same experienced medic should be able to determine in less than one minute if the patient is treatable within the capabilities of the situation, or if the patient will die despite the medic’s best efforts, a technique called "triage," from the French word for "sorting." It is important to note that children can be taught the basics of CPR and first aid, and babysitters often take a more advanced first aid training class, as do many lay people. Thus, there will be a fair number of people with that knowledge to spread.
Not every victim can be saved.
Based on my experience both doing and teaching triage, this is one place where the down-timers training as medics, nurses and physicians will have a definite advantage over their up-time counter parts, since most of the up-timers will have a desire to help no matter what the circumstances. That being said, just the use of paramedical personnel trained in the up-time methods will improve combat and field medicine. It is in canon that several groups of soldiers and sailors have taken the new EMT program, in addition to up-time trained EMTs who were first deployed by the NUS/USE government. These troops would have been trained not only in trauma stabilization but also in a broad base of core knowledge in the areas of medicine, pediatrics, obstetrics, sanitation and communications. Just having personnel on the battlefield who know the life-saving skills of stopping the bleeding, ensuring ventilation, splinting fractures and reducing infection will be a qualitative force multiplier. By reducing the troop losses from various infections, and by increasing the morale levels of the troops (since they know that one of their buddies is there to take care of the
m if they are wounded, and that they will not be left to die, alone, and in agony), [xv] the units will remain more cohesive and more effective. Canon shows that a number of the up-time EMTs died due to combat or disease by December 1635.
For the want of a horseshoe nail
Of the 3500 folks transported to 1631 by the Ring of Fire, fewer than 100 had substantial and systematic medical training and education. A number of others had training as emergency first responders (police officers, firefighters, some of the mine employees) or in basic first aid (teachers, childcare workers). Active, up-time physicians included:
James Nichols, MD (born 1947, Surgeon, probable residency graduation 1979 to 1981 due to his time in the service)
Susanna Shipley, DO (born 1963, Family Medicine, probable residency graduation 1992)
Jeff Adams, MD (born 1962, Family Medicine probable residency graduation 1991).
As a baseline for comparison, despite being older than either Dr. Shipley or Dr. Adams, I would have been in medical school only a couple of years ahead of these two, because I spent four years in the Army as a medic between college and medical school.
Three older physicians: