"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.

Nurse of the Future, 2025

SEPTEMBER 2025

It's time to say goodbye to her 'virtual' nursing cap. Dr. Jade Marciano is ready to hang up her stethoscope, finally. After all, she had been working as a nurse for 42 years now. After completing her Doctorate of Nursing Practice degree 10 years ago, she had moved on to the executive leadership position in the hospital.

“Hi, Tita Jade. I will miss your daily stops.” Her niece Charlene gave her a quick buzz on the cheek before she ran over to the ambulance ramp to meet the EMS trauma notification. Charlene is the senior nurse practitioner on duty.

Nurse practitioners had finally been integrated into the fabric of ED care. It had taken years of resistance from the medical community, but after the exorbitant malpractice insurance costs had driven down enrollment in medical schools, the emergency attending physicians had begrudgingly accepted the NPs to practice alongside the EM residents.

Dr. Jade chuckled at the thought of one clueless senatorial what’s-her-name candidate who had tried to belittle the nurses in her native country by implying that the student nurses could get by with limited education. Her concept of “room nurses” had angered the Filipino nurses, and she eventually lost the election in 2013. In her wildest imagination, she probably did not even think that nurses would even rise in stature even more.

The 2010 Institute of Medicine’s landmark report had been quite a revelation in its success. The hospital had achieved an unprecedented 100% BSN-prepared nursing staff, belying the prediction of a nursing shortage by 2020. A remarkable 35% of the ED RNs has Masters’ degree, and had been utilized as Senior Staff Nurses 5th level, with expanded responsibilities as patient care navigators and evidence-based practice advocates. The ED administration had wisely adjusted their staff by providing more Patient Care Techs and other ancillary staff to offset the higher salaries of these advanced practice RNs.

Dr. Jade is a prime example of the IOM’s vision. She was trailblazer in her profession, having collaborated with the physicians to introduce new care initiatives. She agreed that the public’s and medical community’s perception of nurses had greatly been turned around when faced with more educated nurses.

“Trauma Team, Resus 51”, a melodic announcement interrupted Dr. Jade’s thoughts. A patient from a multi-vehicular accident had just been wheeled by EMS, with a mechanical compressor performing CPR on the bloodied patient. There was no time for an intubation in the field.

In the age of microchips, only the most privacy-concerned patient would have an unknown medical history. The triage nurse bar-scanned the patient’s wrist and soon the patient’s recent medical history was displayed on a medical I-Pad Patient Screen under the cardiac monitor. The patient was an open book, a reality (and a necessity) in Big Brother's world.

Mr. C was a 35 year-old man with an AICD from a cocaine-induced cardiomyopathy. The EM-NP quickly deactivated the AICD. A glove EKG remained on the patient’s torso, a far cry from the bulb-suction EKG electrodes of Dr. Jade’s student years.

The ED attending wrapped a DBAC (Deep Bleeder Acoustic Coagulation) cuff on the patient’s upper arm to seal an arterial bleed. The trauma surgeon then activated the ultrasound zap to coagulate the severed vessel. The nurse had started her Trauma Bleed cocktail- Tranexamic acid (antifibrinolytic), Kefpush (an IV push antibiotic) , and Tetanus toxoid.

The EM-NP also had started an intraosseus line and gave a Blood Substitute polyheme on the accident scene; a necessary intervention in a depleted Blood Bank supply. There was no need for cross-matching; no chance for a transfusion reaction.

The ED attending stopped the compressor to check for the pulse. The patient pulse was steady and bounding, Sinus tachycardia was reflected on a sleek touch screen. The patient was still unconscious and was having labored breathing.

“BP 90/62, HR-120, O2 sat 92% on 100% non-rebreather.”, the nurse announced just loud enough to be heard by the Trauma Team, as well as to record the vitals on the lapel mike that was attached to her Dragoneer Head set. The hands-free device allows her to tape her assessments while she assists with patient care. As soon as she would have the time, she would review then accept the recordings on her own hospital-issued mobile phone to be written into the permanent electronic chart. Most of the nurses preferred the mike than typing into their mobile device.

NP Charlene assisted the Trauma resident in intubation and administered the dosage-controlled bar-coded RSI meds via the brachial line, and soon the resident inserted a Glidescope for easy tracheal intubation.

“ETT to vent, Tidal volume 500, F1O2 100%, AC rate 0f 16”. The trauma nurse continued to intone into her mike, as the respiratory therapist connected the endotracheal tube to the new compact-sized three-pound portable ventilator.

The trauma nurse had sent the blood tubes on the Chute to Lab, but gave the smaller sample tube to the Patient Care Tech for bedside testing.

The Patient Care Tech keyed in the results of point-of-care hematocrit, lactate and basic metabolic panel and transmitted the results on the Patient Screen. The ED attending reviewed the trended results, and nodded with satisfaction on the improved hematocrit level.

The Trauma attending brought out his newest gadget to show off, a hand-held body ultrasound scanner to check on a possible aortic dissection or any vaso-aneurysm. There was none, and suppressing a disappointed sigh, he called for the x-ray technician to come into the room.

The technician turned on the switch and the portable multi-purpose x-ray/MRI scanner lowered down from the ceiling. A series of clicks and lights emanated from the machine, creating a surreal glow around the patient.

A lacerated liver was displayed on the Patient Screen. Snapping to attention, a gaggle of trauma residents started to disconnect the patient from the cardiac monitor.

Even with the sophisticated and ultra-modern technology, the doctors still did not know how to calmly prepare the patient for transport, without unhooking the wrong tubes and tangling the IV lines. In their haste, they just wasted precious time. The nurses quickly took over, and finally declared the patient ready to go.

It all happened in twenty minutes, and off to the OR did the patient go. The RFID tracker recorded the patient’s move.

An audible decrease in the decibel and excitement level in the ED coincided with the patient’s transfer. And soon, the ED was back to its usual non-trauma frenetic pace.

Dr. Jade surveyed the newly-renovated ED, and decided that she will again propose more beds to be added. The patient daily census still remained in the 500s because of more hospital closings. The medical scene would remain a challenge.

Back at her corner Penthouse office, Dr. Jade enjoyed a 180-view of Brooklyn and Manhattan. It is a good feeling to have gone through it all. She had emerged triumphant.

From a simple nursing student in the Philippines in the late 70’s, where the students used to help sterilize the glass syringes and needles,, make their own cotton balls, reuse most supplies, and carry the metal patient charts for the doctors with their superior airs.

When she moved to the United States in the early 1980’s, she was thrust into a chronic care hospital. With 40 patients under her care, she was introduced to functional nursing. Most times, she gave out meds with only a 2x2 index card with transcribed hand-written medication orders.

In the 1990’s, she entered the world of emergency nursing and she was hooked. It was a world in transition. The nurses had to prove themselves against some medical doctors who could not believe that nurses should have a voice.

The 2000s was a year for innovations, and medical breakthroughs. Electronic charting decreased medical errors. And nursing was poised to take bigger roles in hospital leadership. In 2012, she started her Simulation journey. Now, all her nurses prepare for real-life nursing with mandatory intensive simulation experience in the state-of-the-art Sim Lab..

Now, in 2025, the transformed nursing workforce had fulfilled its promise to take a much-deserved equal acknowledgement from the public. Somehow, the world had embraced the new and expanded roles of the nurse. An empowered nurse.

Yes, it’s time to retire and hit the beaches with Max, her doctor-husband, 12 years her junior.

Pediatric Trauma: Pedro and his Mets Baseball Cap ("When the Boy's Heart Stopped")

In honor of Emergency Nurses Day (Oct. 17), here's a reminder of the many rewards that keep us sane, as well as make us grateful for the chance to make a difference.

Author's note: This is an updated version of the article I renamed "When the Boy's Heart Stopped" with an 8th place finish at a US writing competition. 11/5/11



August 1997...

"This is EMS. You're getting a 9-year old boy in traumatic arrest after a direct blow to the chest with a baseball. He's intubated; we'll be there in 2 minutes. " My hands shook when I replaced the EMS notification phone.

After years of dealing with gunshot wounds and stab wounds in our Level 1 Trauma Center , I was not easily fazed, but taking care of pediatric patients scared me. I worked at the Adult Emergency Room but hospital policy dictated that pediatric traumas come to the Adult side for the initial rescue interventions. Many of the ED staff have young children at home, and cases involving kids always evoked strong responses among the parents in our group. I could almost imagine some of the parents in my staff calling on the phone for their family.

The baseball stunned our patient's heart, and it was being squeezed to life by the frantic efforts of the paramedics who initiated cardiopulmonary resuscitation at the field. Commotio cordis describes a sudden cardiac arrest from a blow to the chest. The baseball had caused a disruption on the heart rhythm at a critical point during the cycle of a heartbeat resulting in ventricular fibrillation. The quivering heart did not produce a heartbeat. There's a 65% mortality rate. A nightmare coming to our doorsteps.

The ER staff's collective groan when I told them about the notification reflected all our anxieties. The sight of the trauma surgeons and the pediatric doctors and nurses rushing to our side was met with some relief. We expected them to lead the rescue efforts.

The ambulance doors whooshed open, and the Trauma Team who was called in advance stood in attention. I was standing at the Trauma entrance and saw a paramedic perched on top of the guerney doing CPR on the patient, while another paramedic was giving breaths to the patient via an ambubag. Several pairs of hands reached up to hold on to the EMS guerney. I could smell the sweat of fear around me. Everybody took a deep breath.

The Trauma team swung into action. At that moment, everyone was focused on the small kid; he was ours and we would exhaust all efforts to bring him to life. Without question, this kid demanded our full attention.

"Check the pulse!". The ED attending physician barked. CPR was held as one doctor felt for the carotid pulse. The cardiac monitor confirmed the negative reply. External defibrillation failed. We knew that prognosis was bleak.

The decision was made to open the chest for the internal cardiac massage. Within minutes, the chest lay open and the surgeon started to massage the young boy's heart. Anxious eyes watched for any sign of response. A short burst of applause broke out when the heart started to beat on its own.

"We are not done here yet so hold the applause" was the curt reply from the Trauma Chief. The patient needed to go to the OR stat.

A commotion at the door caught my attention. The mother had arrived. I grabbed one of the residents to talk to the mother. She let out a piercing wail before she collapsed to the floor.

In a plaintive voice, she sobbed, "Please help my son, please." I heard sniffling behind me and saw the other nurses wiping tears. The mother was trembling, her cries of agony filled the Emergency Room. We assured her that the Trauma Team was doing their best. Empty words. Vague promises.

"His name is Pedro. He loves the Mets." The mother said softly, as she showed me the picture of her boy. He was in full Mets uniform , complete with the baseball cap. Pedro's face beamed in delight as he struck a pose for the camera.

Not knowing what to say, I replied, "Me too." It was a stupid remark, I thought, but it brought a tentative smile to the mother's face. Perhaps she thought that a little humor meant that her son was not that sick.

The mother wanted to see her son, but the Trauma Team had gathered around the patient's bed. The surgeon was issuing orders to his residents while the nurses were busy preparing the patient to the mad dash to the OR.

Being a mother myself, I shared the fear that gripped Pedro's mother. Knowing that her son was extremely critical, I wanted to give the mother a chance to see her son. In my mind, I wanted her to say goodbye.

I cleared the pathway so that the mother can finally kiss her son's blood-caked face. The surgeon did not want to wait and impatiently glared at me. I raised my eyebrows at him in defiance and said, "Just one moment."

For some of the team members, I could sense their annoyance at the interruption but I pulled the mother to the head of the bed and motioned for her to kiss her son. At that point, a sterile drape covered the hole on Pedro's chest, but the mother reacted to the intubation tube on her son's mouth with an anguished cry before she finally leaned over to kiss her son on the cheek. She closed her eyes and muttered a short prayer.

I gently pulled the mother away as the trauma team rushed the patient to the operating room. The Trauma Coordinator offered to accompany the mother to the OR Waiting Room. I ran after them to give the mother the Mets cap that Pedro had left behind.

The case had shaken the ED staff. As we cleaned up the trauma room in preparation for the next patient, we spoke in hushed tones about little Pedro. I worried about the boy's family as they struggle to keep their hopes alive. Pedro's distraught father had arrived a few minutes after. He was being held up by his friends as they all rushed to the OR waiting area.

We got word that the boy survived the operation but was placed on sedation. There was the unspoken fear that the boy will emerge brain-damaged when he is weaned from the medications.

The emotions that had churned in me that day left me feeling drained. As I walked towards the hospital parking lot, I met the boy's mother in the lobby. She kept her face composed but I could feel that she would be unleashing her emotions pretty soon. As soon as she saw me, she asked where the hospital chapel was. Alarmed, I asked about her son's condition. She informed me that her son was still being sedated.

I accompanied the young mother to the chapel. She appeared to be Catholic but I am not so I turned around to leave. My steps were halted when the mother burst into heart-wrenching sobs, so I stayed behind and patted her back in consolation. After sometime, she stopped crying and knelt down on the pew. I remained seated as I uttered my own prayers to God. Our different religions did not matter, but we both prayed to our Supreme Being for the little boy in the Mets cap.

When I went home that night , I enveloped my seven-year old son in a tight embrace. I thanked God for my precious son, then added an extra prayer for the boy named Pedro. The next day, I learned that all my fellow nurses did the same thing with their own children.

Several days later, the Trauma Coordinator informed us that Pedro was transferred to a children's specialty hospital in Long Island.

Three weeks later, the Trauma Coordinator surprised the ER with a most welcome sight.

A mother was guiding a young boy with a shy, tentative smile towards the group of ED personnel in the Nursing Station. Pedro stood in front of us, in full Mets uniform, his blood-stained Mets baseball cap clutched in his tiny hands. His mother explained that Pedro refused to part with his baseball cap. Pedro pulled his shirt up to proudly show the scar on the left side of his chest.

All the patients around us looked bewildered at the sight of nurses with tears in our eyes as we grinned and high-fived with Pedro. I said a silent prayer of thanks.

Life, Death, and Renewal

A sense of foreboding gripped me as I entered the department. The aides were pushing a morgue stretcher away, leaving sharp intakes of breath and a muffled cry. Three nurses huddled around the triage desk, one nurse was visibly upset.

Outside the trauma room stood two burly policemen. The aftermath of a trauma resuscitation greeted me: the blood-splattered floor was strewn with discarded clothes, a used stylet, wadded gauze, and the blue overwraps from the instrument trays.

The night nurse looked shell-shocked. On Bed A, an unconscious male patient lay in a tangle of wires and tubes. The ventilator hummed and the monitors bleeped. Endotracheal tube to the ventilator, sinus rhythm on the monitor, an arterial line, two large-bore IV lines, a urinary catheter, right chest tube, right leg splint, dried blood on bandaged head, and his left hand cuffed to the side rails.

"Here's our 20 year-old trauma patient... this..." the night nurse bit her lip to stifle an expletive. "This person just murdered his girlfriend, her two children and her grandma. Shot them point-blank. He jumped four stories off the roof after he was chased by the police. All this because she tried to leave him after a night of beatings. That was the youngest child we just sent to the morgue. " Her voice broke and we both shuddered.

We stood at the bedside and shared each other's anger. The thought of the carnage this man left behind made me recoil in disgust. I felt a need to cry; bile rose up in my throat. Even in repose, this man's face looked so evil, almost satanic. Despite all the repulsion I felt, I had no choice; I had to take care of this patient. My training and my ethical responsibility will ensure that I give this patient the best of care, no matter what.

No matter what… it was the mantra that I kept repeating to myself that day. I had never had a problem with being non-judgmental, but that day, the case touched me. Like everyone, my heart bled for the innocent ones who lost their lives.

The night nurse struggled to finish the report. She was rambling, obviously wanting to simply put the ugliness behind her. I could only pat her back. "He's pending the CAT scan results. His pupils are fixed and dilated; he's unresponsive to any stimuli, no corneal reflexes, and he's posturing." This patient is as good as dead, I thought. The machines keep him alive.

As if on cue, the physician strode over. "He's got a huge subarachnoid bleed. No surgery for him. We're starting brain death protocol on him... and surprise! The cops just found his organ donor card."

Somehow, my anger simmered away. I clutched at one straw of sanity... in one rational moment, this man has willed his organs so that in his death, others could live. The organ donor card tells me that at one point in his life, this man cared enough. A little too late. Why couldn't he be as generous in life?

Then I reminded myself that in his death, he would be lending a gift to someone else. Would his gift of life a renewal for his soul? I doubt it will be, but a gift is a gift, and somewhere, somebody else will live.