"Oh, No! Trauma Again?"

EMS notification
The red phone rings above the din of the mid-day controlled chaos of the emergency department.

Gloria, the charge nurse sighs and picks up the phone. The resuscitation room nurses and Dr. Cooper, ED attending, approach the nursing station with expressions on their faces something akin to dread. The weariness of the back-to-back cardiac arrests and trauma cases in the past three hours is still visible on their faces. “Oh, no! Trauma again?" is the collective response from the ED staff.

Gloria writes furiously on the log book, her script almost illegible in her haste. “Stab wound to the chest, patient hypotensive 90/50, tachycardic 118, alert and responsive, paramedic, 3 minutes ETA”. The word “Trauma” is like a magic wand that transforms the frenetic atmosphere in the ED to an even more hyped-up vibe. With a quick consultation with the ED attending, Gloria activated the Trauma Team. The phone operator repeats her every word “Trauma Level One, Adult, stab wound to the chest, Resus 1”.

Team in action
The ED team galvanizes into action. Three minutes before all hell breaks loose again. The EMS notification gives them time to prepare. Sometimes, patients walk in from a trauma incident. Other times, victims of gang-related incidents are dropped off by their friends at the ambulance area. Usually, the friends scamper away when the police authorities come around to investigate.

The team leader, Dr. Cooper, calls for a brief to reinforce the roles and responsibilities of his team. There is a diagram on the wall and painted squares on the floor to remind the team. Gloria pulls one of the triage nurses to act as the scribe nurse. The team members all suit up with gowns, gloves, and goggles. The airway physician checks his airway equipment and pulls the glide scope from the other room. The nurses prepare the chest tube set-up and the rapid infuser. The survey physician is the intern who is visibly shaking since this is his first month on the job.

Other ED staff and visitors try to come into the trauma room, only to be rebuffed by Gloria. The diminutive charge nurse is intimidating as she takes her place outside the trauma room; she will not allow any other non-essential personnel in the room. Somehow, a trauma case attracts rubber-neckers and it is Gloria’s duty to do crowd control, until the nurse manager comes to take over.

The patient comes. Gloria could not help but think “It’s show time”. The EMS paramedic directs her report to the team leader, not losing her beat as her partner motions for the transfer of the patient to the trauma stretcher. The other team members work in silence as they half-listened to the report while they undress the patient and hook him to the cardiac monitor.

The paramedic intones “This is a 20-year-old male who was involved in a battle between two gangs. He was stabbed in his right chest. The knife is with the police now. He was carrying on at the scene cursing a streak, then he became hypotensive and tachycardic so we just rushed him in here.”

The ED attending glances quickly at Gloria when the paramedic mentions the gang. Gloria instinctively scans the crowd gathered outside the room. She mouths “gang activity” to the nurse manager. Marlene is an experienced ER nurse who had seen her share of gang-related traumas in her previous hospital. She immediately summons a security officer who then moves all the on-lookers away from the door. Security will need to contact NYPD to apprise them of the situation of the potential for gang retribution and to secure all entrances to the emergency department and the hospital.

The team leader asks the survey physician to report his primary assessment. “Airway is intact but there is decreased breath sound on the right. I will put a chest tube”. The secondary nurse readily hands over the 38-french chest tube and insertion kit. The chest tube drains three hundred mls of blood. The patient is still alert and awake but no longer belligerent. He finally realizes that he is in big trouble and he silently endures the poking from the survey physician after he received an intravenous pain medication.

Like clockwork, the nurses effortlessly insert 16-gauge IVs antecubital bilaterally. The primary nurse, Rick, hands the labeled blood tubes to Gloria who then hands them off to the patient care tech to run over to the Blood Bank. Dr. Cooper activates the massive transfusion protocol. The nurses prepare the new rapid transfuser. Gloria retrieves two units of O-negative blood from the room refrigerator.

Crowd Control
However, the responding surgeons come in droves and crowd control becomes a losing battle. Marlene tries to question everyone who responds to the trauma activation. All this talk about crowd control has to be directed to the surgeons and the consultants who bring three members of their team inside the crowded room. Everyone thinks they’re indispensable.

Initially, the ED team communicated quietly with each other. The arrival of the surgeons shatters the peace, but only for a few minutes. The team leader takes control and says in a firm but controlled voice, “Everybody shut up. The only person to talk is me and the chief surgeon and the nurses or whoever I ask to speak”.

The scribe nurse Aysha calls out the vital signs. The blood pressure responds to the blood transfusion with the blood pressure slightly higher. “BP- 100/52, heart rate- 100”. She keeps track of the vital signs and guides the survey physician as he does the secondary assessment.

The chief surgical resident discusses the patient's disposition with the ED attending. He then says to his junior resident, “Call the OR now.”

Case closed
Dr. Singh calls out, “Team, thank you. Our in-situ simulation is over. Please stay for a few minutes for a quick debriefing. Great job, everybody. ” He covers the simulation manikin and turns off the laptop with the programmed scenario.