When things go well in a trauma, it's like a ballet. People move effortlessly around each other, needs are anticipated and things are done exactly when they're supposed to be, nobody gets in anyone else's way and the patient gets great care. When things don't go well, it's a mess. Maybe the surgical resident is scared shitless and is trying to compensate by yelling, or maybe he's just stupid. Maybe one of the nurses is in the ozone, letting IV fluids run out, bumping into others or trying to do what someone else is already doing. Maybe the patient is thrashing around, cursing, fighting, trying to get up and leave and precious time gets wasted tying him down to the bed. When those things happen, it becomes a fight to get things done. It's a cascade of effects: IV's are missed, x-rays have to be retaken, procedures take twice as long or twice as many times as they are supposed to, there's no admission bed available or the Cat scanner is down or the OR's not ready. Anything and everything. And you've just got to work through it as best as you can, because the person on the cart, the guest-of-honor, doesn't care about the excuses.

Things are going well this time. between EMS and police, MDs and RNs, other staff and the patient himself, there 20 people more or less involved: looking, feeling, touching, listening, reacting, anticipating.

"Who shot you, K?"

"I don' know, man!" Damn! This hurts like a mother!

"C'mon, K! What happened?"

"Shit, me and this other dude was walkin' down the street, just mindin' our own bidness, when this dude came up and shot me for no reason!"

"Who was it?"

"I don't know, man! Somebody I never saw before. Thought I was somebody else, pro'ly"

Ah, if it were only that easy. Some nights it seems that the only people getting shot or stabbed are those who are simply minding their own "bidness". In KM's case, however, the police mentioned that his business involved trying to steal someone else's car. KM's not looking so good, though.He's had two liters of fluid in from his IV and his pressure is better, but his breathing is barely acceptable. He has all the symptoms of a collapsed lung with blood where the lung ought to be, and the bullet hole to prove it. There's not much to decide - he's bought a chest tube.

"Give him 5 milligrams of morphine, please. Let's get set up."

The thoracotomy tray is open. It has all the equipment needed to cut a hole in K's chest and insert a tube the size of an index finger. The tube is connected to a container that collects whatever blood comes out and keeps the lung expanded. I've already connected the container to suction and placed all the connecting tubing where it needs to be. The senior surgical resident guides his junior. Numbing medication is injected into the skin along the right side, about six inches under the armpit. Using a scalpel, an incision is made and then the opening is widened by stretching the tissue and muscle. Guiding the hemostats over the rib, pressure is applied until the tube pops through the lining of the lung, the pleura. This is painful for K, much more so than the actual shooting. As the resident enters the lung space the is a rush of air outward. The chest tube is hooked up to suction and sutured in place. Almost immediately, blood flows through the chest tube into the collection bag, nearly half a pint.

The results are promising. K's blood pressure is better, his pulse drops slightly (a good sign) and his breathing is a little easier. He's a long way from well, though. One of the laws of trauma care is that you can never trust the path of a knife or bullet. Things may look straightforward, but a bullet can break up and the pieces head off in different directions, hitting the heart or the bowel or liver, for example.

Blood has been ordered, X-ray is here with a portable machine to check his chest. We are already starting to filter his blood from the chest tube and give it back to him in his IV. Vital signs are checked constantly and his pressure is improving. His oxygen level is good. He is still responsive. Once it is determined that he has no other injuries, it's time for staff to start filtering out. With things stabilized, Sharon goes back outside, EMS has restocked the rig and are ready for the next call, Surgical Intensive Care (SICU) has been notified that they're getting an admission, the surgical senior has instructed his junior on what to do next. It's a matter of crossing the t's and getting him upstairs to the SICU. He'll be watched through the night to make sure the bleeding has stopped and the lung stays expanded.

KM will do well. No major arteries were hit, his lung will re-expand and he will go home in a week or two. This was a good trauma because the outcome was good. Sometimes the traumas rate a "good" because it was interesting, even if the outcome was bad. Mostly a good trauma is one that doesn't happen to me.

So this is what it's like. Nestled in between the noise, confusion and blood is a routine and a protocol that varies only in the details. KM was a good composite patient. Another one might have just as easily fought and bit and spit and threatened to kill us all. Another may have been dead on arrival, or shortly after, or made it to the OR before dying. It's time to clean up and get ready for the next one, because there is always a next one.
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