by Marc Dauphin
When wounded people come in, they are dying. They are dying of, basically, one or both of two things:
a) not enough oxygen coming into the lungs;
b) not enough oxygen getting to the cells because of loss of blood and therefore not enough blood left to do the job of transporting that oxygen.
So we try to correct both those things at once. There is precedence in the order we perform these procedures and that is the way it is taught in the civilian world. But because military trauma teams are so proficient at resuscitation (because they only do trauma, and only war trauma at that), they do it all at once. But if two things need to be corrected at the same time, we respect the priority.
In the civilian world, we resusc in the sequence A-B-C-D, and the Trauma Team Leader (TTL) will not go to the next stage before the one preceding it is stabilized:
A is for airway
That is, make sure your airway is not obstructed. If so, de-obstruct it and, if need be, put in a plastic tube to keep it open (intubation — very difficult skill to acquire with consistency). Anaesthesiologists are the specialists of intubation as they have to do it all day long in the OR — but that’s the point: “in the OR,” where everything is under control. In the ER, nothing’s under control, and guys (and ladies) who do it every day in the ER are sometimes better at tricky intubations. Having the airway as a No. 1 priority makes sense: no oxygen, no-can-deliver it. You die.
B is for breathing
Once A is under control, go to B. Okay, so your airway is patent and guaranteed through intubation, or through the patient’s being conscious enough to maintain an airway. Now, are the lungs doing their job? To find that out, you listen for the air entry. If there is air in the chest outside the lungs, or blood squashing the lungs, they can’t inflate, you won’t hear anything, and, thus, you know there is no oxygen available for the RBCs. So you have to suck that air or that blood out of the chest. You do this by placing tubes into the chest. As in making a hole between the ribs and poking a tube or tubes into the chest cavity, and connecting those tubes to a suction device. Easy, right? Just make sure that, when you make your hole (since you’re doing it blindly) you’re IN the chest cavity, and not in the liver or the spleen, or even worse, into the heart. (Honey, I had a baaaaaad day at the office …) Besides listening, another way of monitoring the oxygenation of the patient is through a small device which looks like a snap-on tool, and which you place on the end of a finger. It’ll tell you how much oxygen the blood is carrying. But to do that, you have to have sufficient circulation to have a pulsation in the end of the finger. This device is therefore useless in the case of uncorrected shock — which happens often in trauma, especially war trauma.
C is for circulation
Do you have enough blood pressure (BP) to keep up the flow of RBCs? Do you have enough RBCs to do a proper job? In the first case, if not, you need to get the BP up again. Why is it down, anyway? In trauma, it’s usually because of loss of volume in the body’s circulation. If there is not enough blood volume in the circulation, the pump can’t keep the pressure up in the pipes. So you give volume: IV fluids, and RBCs. In civvy street, they give a lot of IV fluid. In the military, we have realized that this thins out the blood too much and sustains bleeding. Besides, IV fluids do not transport oxygen. So we give a little bit of IV fluids and go right to blood products. Thus, RBCs.
Once you’ve got A, B, and C under control, you go to:
D is for disability
That is, brain function. If your brain isn’t doing its job right, or is in danger of dying, it’s no use saving all the other cells in the body. Therefore, we act on D if it threatens to mess up the brain permanently. And here are two cases where it can.
Case 1 is an open brain injury that can cause bleeding to death, or bleeding inside the skull. The brain does not like blood outside the blood vessels. Plus, if there’s enough of this extraneous blood, it will do what happens in Case 2, below. If so, Mr. Neurosurgeon has to go in and remove the blood and control the bleeding.
Case 2 is sometimes an open, but usually a closed, brain injury in which the brain is squashed against the skull. Some physiology: the skull is a closed, rigid box with only one hole out, at its base. Squash the brain and it has nowhere else to go except out that hole, sort of like toothpaste being forced through the opening of the tube. If this happens, you have a baaaaad day at the office, i.e., your patient dies. So, we have to reduce that pressure inside the skull. This we try to do through medications, hyperventilation, and positioning the patient. If that doesn’t work, we have to go in and release the pressure. If it’s a blood clot that’s causing the increase in pressure, remove said clot, control bleeding, and voilà: instant fix. If the brain is swelling because it didn’t like what happened to it, and its collective cells are swelling up individually, then you have to go in and take away part of the skull (i.e., one of the sides of the box) to give the brain room to swell up. After a few days, the brain swelling goes back down, and you can put the piece of skull back in. This is a technique that is gaining favour in the civilian world, and is used extensively in the military. It is called craniectomy — the taking away of a part of the skull and replacing it sometime later (not craniotomy, which also involves taking out a piece of the skull, but includes putting the piece back in later in the same operation).
So that’s what we do in the resusc bays (aside from the brain surgery), controlling the airway, the breathing, and the blood volume, and figuring out what’s more important and needs to be corrected in every individual case. And to do all this, you have only a few minutes. This means that when everything is happening all at once, you don’t have time to think. You must react, and quickly. The trauma bay is not a place for thinkers and intellectuals. Which suits me just fine. In the military, we do so much of this that, after a while, the teams barely have to talk to know what’s going on. NO YELLING. NO PANIC. Hardly any talking. And what is said is said very calmly, even though everything may be falling apart.
Except we don’t exactly follow the ABC thing. We do it all at once. A patient will come in and, at a glance, you know if that patient is in trouble, and usually you can tell what that trouble is. So the whole team gets to work at once. Expert teams in civilian trauma centres also do it that way.
Here are some of the tasks, broken down between the individual team members.
Team member one
Number one puts in an IV, while at the same time taking some blood samples to run a basic blood screen, and to group and cross-match — that is, figure out what kind of blood group you’re in, and figure out, in that group, what blood products are compatible with you (if you’re given blood that isn’t compatible, you may die). If we need to give blood to the patient before the lab can help out with grouping and matching, we give universal donor. For a woman, this is O negative. For a man, O positive or negative. This first IV will also serve to give medication for intubation, or to attempt control of the brain swelling.
Team member two
Number two “puts the patient on the monitor” — that is, applies those little sticky things (electrodes) that give you an ECG tracing; puts on the BP cuff that inflates automatically (and not on the same arm that the other team member is putting up an IV on — you don’t want to stop the blood or fluids from going in while the stupid thing is inflating, cutting off your blood flow); and applies the Oxygen saturation (O2 sats) probe — the little gadget I told you about that goes on your finger — go below 92 to 90 percent O2 sats and you’re in trouble. At the same time, this team member gives the casualty some extra oxygen through a nose piece — you know, those green prongs that go in your nostrils — or through a transparent face mask.
Team member three
Another member of the team (usually the nurse) is ripping the clothes off and attending to “special needs” — that is, if we’re going to intubate the patient, we need to give him drugs. Just remember that if the patient gets so much as a drop of fluid down their windpipe that they can coug
h and choke. Imagine getting a plastic tube down there … So we have to paralyze them so they don’t “reject” the tube (we don’t use that term). Imagine being completely paralyzed, someone shoving (well, we try to be more delicate) a tube in there, and a machine doing your breathing for you: you really, really need to take a breath, but none comes — then, when you don’t feel like taking one, someone gives you one anyway … So we give you drugs to make you forget and/or knock you out. Problem is, in trauma, these drugs may also lower your blood pressure. You may be fighting off a drop in your blood pressure by being stressed out. We give you drugs to relax, and you do just that, taking away the only thing (stress) that was keeping your BP from falling through the floor. Baaaaad. So, each case being different, the intubator will ask for different drugs. The team member attending to special needs has to be ready to give whatever drug is needed as soon as it is requested. Better have prepared your stuff beforehand. (Sorry, I haven’t got that one, but I can ask the head nurse for the keys to the narcotics box, and … oh my God, she’s on her coffee break!) Also, to intubate, you need to have a laryngoscope with a working light so the intubator can look down and see the vocal cords (without a light, it’s a bad time to realize how dark it is down there …). What if there’s bleeding or gastric contents (a.k.a., “puke”) in there, that is keeping you from seeing what you’re doing, and you need to suction the stuff out? It’s your job, as that member of the team, to hand the suction over and place it in the intubator’s hands, because the intubator is not going to look up; he’ll only stick his hand out to you and say, “Suction.” After that, you have to have the right-sized tube ready (yes, there are different sizes), and to make sure the cuff on the end is working (yup, it does happen that there are defects). This cuff will help hold the tube in place, while minimizing pressure and scraping on the inside of the trachea, and also helps keep gastric contents (a.k.a., well, you know what I’m talking about) out. Also, you must have a syringe full of air attached to the end of the small connector on the side of the tube. This air will inflate the cuff once the tube is in. You have to be able to put the tube, with attached full syringe, into the intubator’s hand in just the right way so that he doesn’t have to look up, nor will he get entangled in the syringe and the connector. It all looks so easy when a team is trained and used to working together, but it takes a lot of practice to become proficient. Then, once the intubator is “in,” you have to unplug the bag from the mask that you were using, and connect the bag to the tube, without shoving the tube in further. If you do shove it in further, it’ll go in the right mainstem bronchus, and you’ll be ventilating only the right lung. (“Honey, I’ve had …”) Well, you get it. Then, you have to securely take the tube from the intubator’s hand still without shoving it in (or even worse, pulling it out! — Honey, …), then tape it in place while giving breaths with the bag, then set the ventilator settings that the Trauma Team Leader (TTL) will give you. Yes, you have to be proficient in how a ventilator works. There are no respiratory therapists to take care of that, at the Role 3. The nurses (and sometimes even the medics) have to be able to do it. And there are a lot of settings on a modern ventilator.
Still team member three ...
Another special need: if you need or anticipate needing a lot of volume or blood products, you’ll want to have access to a big old vein, one that can handle all that stuff you’re going to pour in. Those little veins in the crook of our elbows aren’t big enough. They can handle some volume, but usually, in severe trauma, you’re going to need a biiiiig vein, one the size of one of your fingers. Those veins are located deep within the body and are not visible from the outside. They are called “central” veins. You have to know your anatomy to put a special type of IV catheter into one of those veins. Those catheters come in a special plastic case (disposable) called “a kit” with a lot of stuff in it because putting in a central line involves some tricky manipulations and you need specialized instruments. You have to be able to open a central line kit with a sterile technique (i.e., without getting germs all over it), and swab down (“prep”) the area your operator is going to use to get access to the big old vein. And if your operator contaminates the kit or hits an artery instead of a vein while poking around in there, you better have another kit on hand. Or if your patient is in big doo-doo, you might have two operators poking around at different veins at the same time, in the hope that one of them will get in first. In Kandahar, in peak periods, we could go through thirty to fifty of those kits a day. You need good logistics to run a Role 3.
Still team member three ...
What about chest tubes? You have to prepare the chest tube kit for your operator. Sometimes two tubes, sometimes three or even four in bad cases. That means surgical kits, iodine, local anaesthetic (yes, we’ll put a chest tube in while you’re conscious). And, you have to prepare those devices that use water to control the intensity of suction, and to keep it constant; think of what your vacuum cleaner does when you catch a large object on the opening — wouldn’t want to rip the lung out (Honey, I’ve had …). These also come prepackaged, but you have to fill the different chambers with the right level of water. And, once everything is in place, you have to keep up with telling your TTL how much blood is coming out in how much time. This will have an impact on the treatment the surgeon will choose.
Team member four
Yes, there is a team member four. It’s the note-taker. War trauma charts are a set of prepared sheets on which you just have to tick the (seemingly millions of) right boxes. This is so all charts are universal, and contain the same info in the same places. In addition to facilitating communications between caretakers and between MTFs, it also ensures that when the JTTR (Joint Theatre Trauma Registry — sometimes called “Jitter” — another acronym; don’t you just loooove the army?) nurse puts all that info in the computer and sends it to Washington, D.C., the info comes in the same form from everywhere; from Iraq, Germany, Texas, or Ottawa. There (in D.C.) the numbers are crunched by the JTTS (“S” for system — a system for quality assurance to make sure the care given everywhere is of the best and keeps improving), trends are spotted, and info flows back to us in the form of CPGs (Clinical Practice Guidelines) that reflect how fast the science of war trauma care is moving. This means that if you follow the CPGs, you are practising medicine that has evolved in the last few months. The JTTS is one of the reasons the military are years in advance of the civilians in the care of war trauma. All the information flows to the same place, trends are immediately spotted, and corrections applied within weeks. Canada joined the JTTS and that’s how we provide the most up-to-date medical information to our military physicians. The JTTR forms start to gather info as soon as the soldier is injured.
So the note-taker stands on the edge of the trauma bay and records everything on a JTTR form. The note-taker has to know what he or she is seeing, because team members don’t always say what they are doing.
Okay, one last thing: in the military, we don’t resusc in the sequence A B C D. We do it C A B C D. The first C being for “catastrophic bleeding.” That is, we stop the obvious catastrophic bleeding via tourniquets that we (the military) were, until recently, the only ones to use. Or we crack a chest right then and there. You see, the survival rate of cardiac arrest in closed trauma is 0. Yup, that’s right, 0. Nada, nil, zéro, niente, nichts. So, if we get an arrest, the only hope we have is that it’s an “open” trauma — a hole in the heart or one of the big vessels into or out from it. If that’s the case, we cut the chest open from left to right, open it up like a clam (and we call it “the clamshell”), clamp the large vessels shut, and look for a hole to repair, while at the same time massaging the heart or getting it back to pumping again. It is spectacular. And it sometimes works (twice during my roto — and twice it didn’t — still, 50 percent isn’t bad compared to 0).
Another thing with catastrophic bleeding is that, if we can’t get to it to stop it immediately (if it’s internal), we have such a good quantity o
f blood products that, many times, we can get it in faster than you can lose it. Talk about feeling powerful! And we can infuse these blood products very quickly through a pressure pump we call a “Level One Infuser.” I don’t know where the name comes from. One thing is sure, when you start using it, you’re married to it. First you need a catheter in a large central vein. Then, the nurse who starts to man the Level One inserts a pack of RBCs in the chamber on side one, connects it to the tubing, closes the chamber, and presses the “go” button. Then she opens the second door, and does the same with fresh frozen plasma (FFP). By the time she’s finished installing the second bag, the one in the first chamber has run through, and she gets to do it all over again. You have to have very severe bleeding in order to outperform a Level One. And usually, if you’re bleeding that much, you just don’t make it back to us alive in the first place.
Something I didn’t mention. Temperature. When you go into shock, your temperature goes down. Even if you’re left out under a 60°C sun (that’s when it’s 50°C in the shade). I remember the first time I received a soldier in obvious shock. It was crazy hot outside. I put my (gloved) hand on his forehead and was stunned that his skin was cold. Not cool — cold. Shock will take your temperature down, and will hamper our efforts to resusc you properly. That’s why we use those aluminum-foil blankets on all traumas. And in the TBs, we will use wraparound devices that blow hot air on you, called Bear Huggers. And the Level One machine mentioned in the previous paragraph also warms up the blood products we give you.
I’ve just finished intubating a casualty in Captain Parent’s trauma bay. Corporal Dionne is doing the bagging while Captain Rémi Pelletier is getting “married” (see Appendix C) to the Level One Infuser. I don’t know who took this picture, but it was with Captain Pelletier’s camera.