by Marc Dauphin
One little thing about trauma teams. They are small (five members — the TTL plus the four team members described above) and they have to have absolute trust in each other. That’s why we always try to have the same people working together. Since this is not always possible, we try to standardize the way the trauma teams work so that anyone can replace anyone else on a trauma team, and fit right in. Before our roto, there were not enough personnel in the hospital to have dedicated trauma teams, so we would take a nurse from the ICU, a medic from the OPD, and a GP from there, and assemble our trauma teams with whoever happened to be around. More than once, before I deployed, I had some junior medics tell me that, on other rotos, they were TTL! Well, the CF corrected that. On our roto, we had enough people to institute permanent trauma teams, and enough people to ensure that we could have MDs or PAs in every trauma bay. Those permanent teams would be on continual standby. Every thirty days or so, I would rotate them before they burnt out. It was a matter of great prestige to be nominated to a permanent trauma team. There were some energetic discussions preceding the establishment of the first trauma teams, including a bit of a pushback, but once they were up and running nobody could dispute their usefulness. Colonel Savard helped me a lot with the discussions and the pushback, and she always did it discreetly.
Now, the TTL is absolute God in his bay. (What’s the difference between God and an ER physician? — God knows he’s not an ER physician.) You can question a decision but he or she has the last word.
Trauma bays
Their floor surface areas are delineated by duct tape. (Duct tape holds the whole planet together — if there weren’t any duct tape, pieces of the earth would fly away into space. This is a quote, but I couldn’t name you the source.) RED duct tape. Nobody (except the Triage Officer [TO] and the Chief of Surgery — more on that later) can come into the TB uninvited. Now the TTL does all the thinking (a.k.a., reacting) and generally leaves the actions (intubating, putting in chest tubes, accessing central veins) to invited operators. Sometimes surgeons, sometimes unemployed TTLs, sometimes anaesthesiologists, sometimes radiologists; and when all hell breaks loose, the chief of surgery or the TO. Once that invited operator has done the job, he or she steps out of the TB.
Same thing while we’re waiting for the casualties: once you’ve entered your TB, you stay in it. No wandering around and clogging up the corridor. If you have to go wee-wee, think about it before you enter your TB.
Now, the TO’s job is to understand what is happening in every trauma bay, and to prioritize treatments accordingly when the resources are limited. No problem with blood, which is usually plentiful. Or with ultrasound machines either, although there are only two mobile ones. But there is only one CT. And there are only so many operating rooms (ORs). So the TO has to guide treatment beyond the TBs. This I (yes, in addition to being the hospital OC, I was also the TO) usually do in concert with the Chief of Surgery, because he knows what needs to happen after the TB. Think about how complicated one resusc is. Now imagine ten of them at once. So the TO and the CoS walk a lot. In fact, the TO used to be called “the walker.” And since this TO was not the tallest guy in the place (at five-foot-ten), he decided to wear red. A red surgical top, and a red baseball cap, so he can be seen from all points of the trauma room compass. You’re in trouble? Call after the TO. TO is an extremely stressful but also an extremely exhilarating job. Think about it: you have the particulars (constantly changing) of a half dozen major traumas in your head, and you must decide within seconds who gets what, and who goes where. Those TTLs (not to mention the patients) are counting on you. Best job I’ve ever done — did I mention I was an adrenalin freak?
Facing top: Lending a hand in a trauma bay early on in the roto. I seem to remember it was an intubated child transferred to us, and that during the transfer the tube had gone in too far, a common occurrence in children. All those years of critical care experience with children proved handy and helped to make up for thirty years’ worth of lost nights, weekends, Christmases, and parties. The team stands by for a few seconds, as nobody is going anywhere until the airway is secure, the first priority if there is no catastrophic bleeding.
Facing bottom: In the civilian world, I dreamed of working with a team like this. As the trauma team leader, USN Commander Sean Neimann supervises the patient’s care; USN Lieutenant Commander Sonya Waters, orthopaedist, evaluates the casualty’s lower-extremity injuries; USN Lieutenant Commander Denis Primakov, radiologist, performs the FAST ultrasound; and RCAF Captain Philippe Parent prepares to insert a chest tube into an apparently conscious patient, as he seems to be talking to him, likely explaining the procedure. Our interpreter’s face has been blanked out for his own protection.
When the patients arrive from the chopper, the TO stands by the back door, and with the list of MISTs in his head (or written on the back of his hand — you can’t misplace your hand), he assigns patients to the teams as they come in. In the books, triaging is a very complicated thing. In reality, it’s done in the blink of an eye. The longer you dawdle, the longer you deny a patient the care he needs. You can evaluate a patient in two seconds: Colour? Conscious? Skin temperature? Obvious bleeding source? Breathing? Tourniquets? Active bleeding? Pulse? Now, more and more, the manuals are saying just that: don’t waste time on triage. Assess quickly and decide. And stay out of the way of your stretcher-bearers.
Once reception and triaging are done at the back door, and all casualties are in their TB, the TO walks back and forth between the board and the TBs and discusses with the board keeper, the TTLs, and the CoS. The central board monitors the evolving status of each casualty. This board, which is maintained by the most experienced nurse (and not only because he’s the tallest guy around …), is our situation board, to which everyone refers.
A word about the interpreters. These guys are nurses or pharmacists or teachers. They interpret at great risk to themselves because the Taliban want to kill whoever helps us. When interpreting for a Taliban, they will hide their faces. They are always there to help. They will perform the last rites for a countryman. They are the anonymous faces about whom we cannot talk. Thanks for everything, guys.
Now, before we know it, everything is settled. Patients are in the OR, or the ICU, or with Allah, or in the CT. We’re cleaning up and restocking the TBs, and ready to go again. Day and night.
Okay, now, some last notions and I can tell you the stories. These notions are more specialized, so, if you want to, you can skip them.
Shock
When you lose a lot of blood, your body automatically shuts down the flow to less important organs in order to send what little blood there is to the brain, kidneys, heart, and lungs (some will include the liver in this list). The cells of the other, left-out organs receive less oxygen, and fight to stay alive. They do so by generating energy in an oxygen-less way called anaerobic metabolism. They can do this for a short while. A very short while. This generates tremendous amounts of toxins, which are released in the circulation. These toxins are acidic (mostly lactic acid). Therefore, a good way to figure out how bad things are is to measure the acid level in the body. This we do on all our traumas, immediately on arrival. Remember your high school chemistry? The pH is an indication of the acidity of a fluid. The lower it is, the more acidic your fluid is. Seven is neutral. Human blood is 7.40, or between 7.35 and 7.45. Anything outside that range is abnormal. When you hit 7.20 you’re in trouble. Anything below 7 is virtually un-survivable: it is an indication of cell death on a large scale. The human body cannot work at low pH levels. Chemical reactions are skewed. Blood pressure drops. Circulation stops. Blood doesn’t clot. So the quicker we can stop cell death by giving oxygen to all our organs, the better the survival rate. In the TBs, we are fighting death itself. If the cells are left too long without oxygen after secreting these acids, they die. And dead cells give out even more toxins, which in turn complicate our shock state even more. You can see this as getting worse and worse at a faster and faster speed. We ca
ll this circling the drain. The closer you are to going down irretrievably, the faster you spin.
If you are reading this in a hundred years (you never know …), you are probably so advanced that we seem quite primitive. Please don’t laugh at our ignorance. That’s all we know today. So enjoy your reading like I enjoy reading a medical textbook from the First World War.
Blood
When we collect blood from a donor, it is good for a few days. After that, it begins to go bad. To make it last longer, someone figured out that if you separate blood into its different components, these keep longer. A lot longer. So that’s how we get our blood over there in Afghanistan. In components.
RBCs. Red blood cells typed by group and Rh factor. You know what RBCs are used for.
FFPs. Fresh frozen plasma. It contains the fluid in which RBCs circulate, plus proteins. Lots of different kinds of proteins, that do lots of different things in the body. The most important of these are the coagulation factors. Coagulation factors are, as you have guessed, extremely important in trauma because they stop you from bleeding to death. But they degrade quickly. With time, even though the plasma is stored frozen, its proteins lose some of their effectiveness.
Platelets. These little pieces of cells are responsible for clot initiation. If you don’t have any, you don’t clot. (By the way, we are now discovering lots of other uses for platelets that we had never suspected — interesting!)
So when we resusc somebody, we give 1 for 1 for 1 of these three elements. But in massive blood loss, that is not enough. The clotting factors in the FFP have deteriorated too much, or don’t work so well once that pH is down. So we give Factor VII (as in “seven”). There are also a bunch of other types of clotting factors, in addition to the platelets (classically, there have been said to be thirteen, or XIII), and the one that is most sorely missing in resusc has been found to be VII (as of 2009, that is — by now, in 2012, all this is in question). So we can give Factor VII, which in civvy street in Canada is not given for hemorrhaging caused by trauma. We had to have special permission from our Surgeon General to give it under those circumstances. It costs a bundle, too. Lots and lots of tax dollars for each dose. So it’s given out only on permission from the Chief of Surgery or the Chief of the ICU. They’re the most knowledgeable on the subject.
Our lifeline: the daily blood products shipment. U.S. Army Captain Vidhika Persaud supervises her boxes as a mother lion would her cubs.
Then, there is cryoprecipitate. It contains Factor VIII, Factor XIII, fibrinogen, and a couple of other things.
When we’re really in trouble, and blood products can’t hold back the bleeding, we give fresh human blood, which contains everything. That’s when we activate the WBB, or walking blood bank. When we do this, we send out over the PA on base that we need such-and-such a blood type immediately. People will come in from all over the place to give blood. Typically, because we don’t have all the fancy screening instruments available to the Red Cross back home, we take blood only from pre-screened donors, that is, Canadian and American service people. They have all been screened as donors before the mission and once cleared they will do what it takes to help save a brother-in-arms. I have seen people standing in line for hours in the middle of the night to give blood. That fresh whole blood has all the necessary coagulation stuff, but it keeps a few hours at best. The WBB is a very labour-intensive proposition and you must be careful not to waste any.
Tourniquets
They are a wonderful tool to keep somebody alive. But they have to be properly put on. If not tight enough, you simply cut off the blood flow OUT of the limb, while leaving the blood still flowing IN. So you increase the pressure inside the arteries and capillaries, and speed up the bleeding. (Honey, I had a bad day…) Okay, so let’s say you put it on properly onto a shattered limb that is spewing blood like a fountain. You stop the bleeding. You saved a life. Wait a minute: you ain’t done yet. What happens to the cells downstream from the tourniquet? They don’t get any oxygen. First, they try to fight back with anaerobic metabolism. That releases toxins. But these toxins can’t go anywhere because they are stuck behind the tourniquet. Then, if you leave the tourniquet on, for long enough, the cells die. That releases even more toxins into the bloodstream, but these toxins are stuck behind the dam-like tourniquet. Now you make it to the Role 3 and we resusc you, and then you go to the OR. There, the surgeon releases the tourniquet, and … all hell breaks loose. All these toxins are released into your general circulation at once. Your BP drops faster than a sack of rocks in a well. This we call “acid dump,” or “crushed-limb syndrome.” The term was coined in the early eighties after the major earthquake in Mexico City in which many people were found alive in the rubble, but with their limbs trapped under tons of concrete. The rescuers put up IVs and hydrated the patients, who, apart from that old crushed limb, were doing fine. Then they lifted the piece of concrete and the people died. Why ? Well, now we know. Sort of.
Damage-control surgery
You’ve heard about craniectomy, where we take out a piece of skull, and sew the skin back over the brain. Well, we basically do the same thing with other surgeries. We have discovered that time spent in the OR is bad for you. Bad in the sense that your temperature drops, and your body is subjected to such stressors that it worsens your condition. So we keep surgery to a minimum. We just stop the bleeding, then, once that is controlled, we stop operating. We don’t even close you up. We just pack the open wounds with dressings, and we scoot you over to the ICU, where we “fix the numbers.” That means getting your platelet level to normal, your RBCs to normal, your coagulation to normal (measured through a test called INR, for International Normalized Ratio), your temperature to normal, your kidney output to normal, your pH to normal, your cardiac output to normal, your oxygenation to normal with the lowest possible numbers on the ventilator. Then there are your sodium, your potassium, your calcium, your magnesium, your creatinine, your myoglobin, et cetera, et cetera. ICU is now an extremely complicated science, but one that has yielded the most interesting advances in medicine in the last twenty years. I know: thirty years ago I used to be able to manage ICU cases. In fact, I was in charge of an ICU myself. Not anymore. ICU specialists are the most respected specialists today. They know a lot of stuff. And have the humility to realize how little they know. You gotta love those guys and girls. I sure do.
Now, a patient who doesn’t have a normal INR, normal platelet levels, normal O2 sats, a normal pH, and normal RBCs is going to start oozing blood through all his capillaries into his wounds. This we call “medical bleeding” because no amount of surgery is going to be able to fix that. Only the ICU can. To successfully fix that surgically, you’d need a blowtorch to scorch all those capillaries dry and shut. Not exactly what we want. Only the ICU guys can fix medical bleeding.
A surgical team composed of Dutch, American, Canadian, and Australian personnel rushes to start an operation. Another young life is at stake.
Two orthopaedists attempt to save a leg. The one sitting down is Major (now Lieutenant-Colonel) Max Talbot, a Canadian. The other is Dr. DeWit, a Dutch surgeon.
So, after twelve hours (generally — this is when things go well), you’re ready to take the patient back to the OR and finish what you had started. Then, once the surgery is done, if you’re stabilized, you can fly him out on the next flight. If you’re extubated (i.e., off the ventilator), you go with a normal AE (Air Evac) crew. If you’re still intubated, because your status is too precarious, then you go out with a CCAT Team (Critical Care AE Team) composed of an ICU doc, an ICU nurse, and a respiratory therapist to manage the ventilator. Just remember that aircraft cabin pressure is maintained at about five thousand to eight thousand feet ASL (above sea level) in order to minimize stress on the aircraft (think about it as an overinflated tin can looking for a way to explode when the surrounding air pressure drops as the altitude increases — and there are mountains on the way to Kabul).
But, the concentration of oxygen
available for the lungs drops dramatically at that altitude. That’s why it’s not always safe for grandma to take that trip to Paris or to Halifax.
This is how we figure it:
PA O2 = [(AtmP – PA H2O) × FiO2] – (Pa CO2 × 1.25)
Sounds complicated, doesn’t it? It boils down to this: the oxygen pressure available to your alveoli (those little sacks in your lung where you exchange oxygen for carbon dioxide), at sea level, is about 100 mm of mercury. But if you climb up to 8,000 feet ASL, it becomes about 50 percent of that. Remember the importance of having oxygen reach your cells to keep them from dying? Now, suddenly, in the plane, you’re making available to your patient only 50 percent of what he needs. You better be sure he’s going to make it to the other end. That is a small part of the art of AE. The Role 3 Flight Surgeon (yes, that’s also me — did I tell you I had a busy time over there?) has to vet every patient before putting him on an AE flight. Then the patient is re-vetted by the JPMRC (Joint Patient Movement Request Center) Flight Surgeon, located somewhere in the Middle East. JPMRC coordinates all AEs out of Asia and Africa, but most importantly Iraq and Afghanistan. When you think that, in six months, we had about two thousand patients AE’d out of KAF alone, JPMRC must be a busy place (now reread that last sentence without knowing what those acronyms stand for …). Of these two thousand or so patients out, only one went bad on the plane: a surgical graft on one of his arteries blew open on the way (remember the lower air pressure on the plane?) and they had to turn back somewhere over Saudi Arabia. Since in the plane it’s dark, and there is vibration, noise, et cetera, they couldn’t figure out which of his legs was bleeding (we had repaired both) so they put a tourniquet on both to keep him alive. He ended up losing both legs. But alive. C’est comme ça.