all trauma is not the same

Monday, June 3, 2013

One of the sad truths of medicine is that those who care for trauma victims are excited about their job and the ability to diagnose, treat and potentially heal those who are injured. Of course, it requires trauma victims for those skills to be honed. All traumas are not the same. The approach to blunt or penetrating trauma may require different mindsets, offering intellectual and physical challenges to the specialists involved. The stabbing of the Pittsburgh Steeler, Mike Adams, and the car wreck of retired NBA player, Mookie Blaylock, both would have triggered referral to trauma centers and while the initial approach to resuscitation would be the same, the treatment paths diverge quickly.

The initial resuscitation requires the stabilization of the ABCs. Is the (A) airway intact; are they awake and able to breathe on their own, or is there injury to the face, mouth or neck that would require intubation to put a breathing tube into the trachea. Do the lungs work; is the (B) breathing mechanism intact, so that oxygen can get into the blood stream. Is blood pressure maintained so that blood carrying oxygen can be (C) circulated to the organs of the body.

Injuries are prioritized but normalizing the ABCs are job one. Penetrating wounds to the abdomen caused by a gunshot wound, almost always require an emergent operation to look for damage to internal organs. Stab wounds, like those sustained by Mr. Adams, most frequently damage the liver, small intestine or colon, but as long as the ABCs are stable, there is opportunity to go a little slower and perhaps avoid the OR. While surgeons by nature like to operate, their skills also allow them to decide when it’s appropriate to watchfully wait and re-examine the patient over time.

The decision to wait is perhaps harder than the pone to go forward with an exploratory operation. Watching a patient for a day or two and then having to go to the operating room when the patient develops an infection or starts to bleed can be difficult to explain in retrospect. It is easier to explain a negative exploratory operation was performed and nothing untoward was found. The skill of not operating is as special as the technical skills of cutting into a patient.

Mr. Blaylock presented in a different manner. His injuries, sustained when the car he was driving crossed the center line and hit another vehicle, killing that driver. Reports were that he had a bloodied head and was placed on life support, likely meant that the initial ABCs were unstable, or as likely, his head injury made it difficult for the doctors to evaluate his condition because of his inability to cooperate. In the ideal situation, patients will lie still and do as they are asked, but with a head injury, the patient may be combative and potentially worsen an undiagnosed injury like a broken neck or back. In these situations, the patient is sedated, paralyzed, intubated and placed on a ventilator (taking care of A and B) and allowing the search for injured parts to occur.

Care for the blunt trauma victim is often overseen by the trauma surgeon, who gets to orchestrate when other doctors get involved, but often to their dismay, they do not get to operate. In the stable patient with the ABCs under control, physical exam, supplemented by the ability to peer inside the body with CT scans, has decreased the number of exploratory surgeries that are done. It’s often the orthopedic or neurosurgeons that get to have the fun of operating on body parts, while the trauma surgeon gets the responsibility of looking after the patient as a whole.

More than ever, medicine has combined high touch and high tech to allow surgeons to watch. It’s an approach that would make terrible television. Imagine ER or House with nurses at the bedside, tending to their patients quietly and speaking with family in calm tones. Or the physicians spending time examining the patient and deciding to do nothing, except to wait for 4 hours and do it over again. Rushing to the OR is often the right thing to do, but as trauma, the disease, becomes more understood and technology gets more sophisticated, some victims are spending more time in the ER and ICU than under the knife.

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