Inside Palmetto Health Richland Trauma Center (with video)

05/03/2014 7:44 PM

05/05/2014 11:30 AM

As unlucky as the man on the EMT stretcher is, considering he has a compound fracture of his left femur and unknown internal injuries, he also is fortunate the head-on collision that caused his injuries occurred in Kershaw County, close to one of the state’s premier trauma centers.

The Palmetto Health Richland Trauma Center is the only Level 1 center in the Midlands equipped and staffed to handle the most severe injuries. Last year, the American College of Surgeons verified Palmetto Health as a Level 1 trauma center, a recognition given to only 116 facilities in the country, including MUSC in Charleston.

“Trauma is a really resource-intensive effort,” said Dr. Stephen Ridley, a trauma physician at Richland. “That’s the reason there are trauma centers. A hospital like (KershawHealth in) Camden or even Baptist downtown can’t pull this many people for trauma. They don’t have the staff.”

Palmetto Health ensures that enough physicians, nurses and support personnel with intensive trauma training are on duty at all times. Many work their regular shifts in the adjoining emergency department, located in the heart of the first floor of the hospital campus off Harden Street. Some work upstairs in intensive care units. All are ready to hustle to the trauma rooms whenever their beepers indicate a case is on the way.

The State spent several months with the trauma center’s crews as they hustled to save the lives of people who arrive in the back of the hospital via ambulance and enter through the double doors on EMT stretchers.

Various players form smooth team

As soon as the Kershaw patient is transferred to the trauma bed, three doctors and three nurses swarm around him. Eight others – doctors, nurses, pharmacists, respiratory therapists — take their places at stations nearby, ready to provide help.

Ridley, the attending physician, stands at the edge of the table. Each player anticipates what to do, and the basic steps are taken without so much as a nod from Ridley. For the processes that are specific to this case, Ridley gives instructions.

A nurse connects patches for the device that measures heart activity. Another attaches the device on the patient’s finger that measures pulse and oxygen rate. One resident does a quick ultrasound of the broken femur. A nurse prepares a bag of blood for transfusion. A nurse installs an intravenous connection. Another nurse takes blood samples from the patient and labels them. A pharmacist prepares antibiotics to be inserted in the intravenous tube when necessary.

The patient’s readings are called out to a nurse who keeps all of the records.

An 8-1-1 beep indicates a trauma. A 9-1-1 means the case is absolutely life-or-death. The Kershaw County wreck victim is an 8-1-1, but his case makes it clear that level also often is life-threatening. The internal bleeding, which wasn’t obvious on the scene of the accident, could indicate a major organ is at risk. A few minutes into their work, the trauma team knows the patient is bleeding internally but isn’t sure where the problem is.

Ridley says they need to get his blood pressure up and stabilized before they can wheel him to the CT scan room. In less than 30 minutes, the patient is stable enough to be moved. “Nice job,” trauma surgeon Dr. Jeremy Reeves says to everybody on the team as the patient is wheeled out.

Some of the doctors and nurses tag along with the patient. The rest take a deep breath, gather their thoughts and return to their jobs treating less critical patients.

The same car wreck patient returns to the trauma unit from CT. Because of broken ribs and the internal bleeding, doctors need to insert a tube in the man’s chest to re-expand the lungs.

Before they put the patient under anesthesia, Reeves asks a patient advocate to bring in a member of the man’s family to speak with him briefly. Four family members come into the trauma room, but only one speaks with the patient. Because of the powerful pain medications, conversation is difficult. The family members hold up well while in the room but collapse in a sobbing heap as soon as they leave.

Only seven people are around the table as a surgeon cuts into the man and inserts a chest tube. The patient is stable enough that only the basic trauma team is necessary. About 20 minutes later, the patient is wheeled out, en route to the fifth-floor ICU about two hours after his original arrival. The aim is for patients to be in and out in less than 30 minutes, but this was a rare case.

Several members of the trauma staff remain with him on the trip upstairs. “We never leave him,” Reeves says. “Even when he goes up to ICU, he’s trauma’s patient.”

You don’t want to be trauma’s patient unless you have a traumatic injury. Then you really want to be trauma’s patient.

Center brims with high-tech and heat

The trauma center is two rooms that are mirror images, with a small space in the middle where personnel not immediately involved in hands-on care stand behind windows. X-ray machines hang down from the ceiling, and the patient stretchers are surrounded by the high-tech medical devices necessary to keep a patient alive.

The top of a chest-high set of rolling drawers serves as the desk, where a nurse keeps up with the paperwork during the event. While the rooms look spacious when empty, they are cramped when a patient stretcher is set up and a dozen or more medical personnel gather around performing their specific chores.

The first thing many newcomers notice is that the trauma rooms are much warmer than the rest of the emergency department. It’s like a sauna for the workers, but the thermostat is set for the patients’ benefit. They often are wearing little or no clothing while on the trauma stretcher. They need a warm environment.

“It’s not unusual to be completely wet, scrubs covered in sweat, by the time you’re done,” Reeves says.

Most of the trauma staff work 12-hour shifts, but the physicians are on call for 24- to 36-hour shifts and sometimes stay longer. The physicians have on-call rooms where they can catch a nap. The team members joke about how often trauma patients arrive right on shift change – around 7 a.m. and 7 p.m.

On cue, the team gets a call at 6:50 p.m. that an EMT with a trauma case coming from a rural county is about 10 minutes away. Staff members hurry to the trauma room, throw on scrubs, prepare equipment and wait and wait. The EMT has underestimated the time of his trip.

About 7:05 p.m., the day charge nurse pulls off her temporary scrubs when the night charge nurse says she’s ready to take over. The day respiratory therapist hangs on for another 10 minutes before turning over his post. Finally, the patient arrives about 7:30.

As soon as the patient rolls into the room, the EMT begins a rapid-fire condition rundown. Within seconds he has blurted out details of her obvious injuries, pulse, blood pressure, medications. The woman has a huge gash on what appears to be a broken arm. Her knee is badly swollen. She’s on morphine for pain but is coherent enough to help with her care. The EMT ends with “Any other questions?”

By that time, the patient already is transferred from the EMS stretcher to the trauma stretcher, and the staff starts examining her and asking her questions. They use handheld ultrasound devices to check her arm and leg, sew up the gash on the arm, bandage other nasty scrapes. She’s wheeled out to the CT area by 7:50 p.m. and then up to the ICU unit.

Quality recognition

from peers

Palmetto Health has done Level 1 trauma work for a long time, but the verification from the American College of Surgeons last year was special.

“This is what we’ve been working on since I started,” says Dr. Raymond Bynoe, medical director of the trauma center since 1996. “It’s like winning the World Series. We’ve been working at it, trying to get there. We’ve gotten a stamp of approval that says the facility has put the resources in to allow us to do the job we want to do.”

The job is never easy, and never boring. Friday and Saturday nights often turn into the bullets-and-blades shifts as young people fueled by alcohol, drugs and testosterone turn to violence.

This Friday night, a man is wheeled in around 11:50 p.m. with a massive wound on the side of his head. The patient appears to have a fracture of the skull above the eye, along with big cuts and swelling around the eye. His shirt is covered in blood.

Though in bad shape, the man is conscious. The doctor leans down close to the patient’s face and asks, “When’s the last time you ate something?” About 4 o’clock.

“When’s the last time you drank something?” Right up until the time he was hit, not surprisingly.

Then the crew has to remove the plastic ambulance slider used to move him to the trauma stretcher. Most of the team members go to the left side of the patient. With a 1-2-3 call from the doctor, everybody pulls up on the man’s side. He is a big man, difficult to move, but they get him up and two other team members pull the yellow sled out from under him.

As the team members get back to stabilizing the patient and determining his injuries, the EMT takes an electronic tablet to the charge nurse to have her sign that he has handed off the patient.

A few minutes later, the patient suddenly realizes his pants have been cut off. He tries to sit up. “Where’s my pants? I had money. Where’s my pants?”

“I’ve got everything from your pockets, and we’ll put it in the safe,” says patient advocate Judy Nielsen, who had deftly slipped into the crowd to snag his clothes just as they were cut off.

Nielsen is 79 and leans on a cane as she walks around the room, but her experience makes up for her lack of quickness. After doing this for nearly 40 years, she knows where to be.

As the patient is wheeled off for a CT scan of his skull at 12:08 a.m., Nielsen puts the contents of his pockets in a Ziploc bag to be put in safe-keeping until he’s in better shape. Nielsen also asks the patient if there’s any friend or relative she can call for him, he says no.

The trauma team usually learns the patients’ first names. It makes it easier to ask them questions. But they don’t ask for last names, and the patient is known by a number on all forms.

The numbers start with an “M” or an “F” for the gender, two digits to mark the year and another four digits that indicate how many patients have been given a trauma number that year. In 2013, the trauma center admitted 2,301 patients - 1,538 males and 763 females.

Like most emergency services, trauma isn’t a money-maker for the hospital. Palmetto Health lost $2.8 million on trauma center services in 2013.

Sometimes, the patients arrive with police escorts. This Friday night, the officers patiently wait outside the trauma room while the team treats a young man whose leg was shattered by a gunshot. The officers place paper bags over his hands and bind them with rubber bands on his wrists, an indication he might not be an innocent victim and gunshot residue evidence could be on his hands.

Weekend nights often bring gun and knife wounds from clashes among young people, but only 10 percent of the trauma center admissions in 2013 were for those types of wounds. More commonly, trauma patients suffer injuries in vehicle or motorcycle accidents (37 percent) or falls (28 percent).

Filling important roles, with style

Keith Sullivan saunters through the emergency department in wearing a flight suit, chewing on the butt of an unlit cigar. Sullivan works for Air Methods, which hires the pilots and owns the helicopters that bring emergency patients to hospitals in the state. He works out of the Irmo area, and many of his trips end at Palmetto Health.

Pilots need at least 1,500 hours of helicopter flight experience, so most come from the ranks of the military, including Sullivan. They have to land in open fields or on roads to pick up injured patients in rural areas, then they have to land on the helipads at hospitals.

But much of the pilots’ 24-hour shift (the crew members do 12-hour shifts) is spent anticipating a call. “When we’re at the airport, all we do is wait,” says Sullivan.

Pilots wait again after delivering patients, as the nurse and medic on the flight crew debrief the trauma surgeons on the injuries. A few minutes later, they all fly off into the night sky.

Teamwork is built on practicing skills

It takes a rare mix of intelligence and skill with a tolerance of, if not a craving for, adrenaline to work in the trauma center. It also takes years of work. First you need experience in the emergency department in your respective field, then months of watching and learning with a mentor in the trauma center. The entire team practices different scenarios in the simulation lab.

“We try to make sure that the individuals who have been here the longest find somebody they can nurture and take through that whole process,” Bynoe says. “You keep rechanneling that. I kind of compare it to baseball. You always have got to have good drafts and get good people in the minor leagues that come through that want to do this.”

He likes the phrase “the 100 hands of trauma” to indicate how many different staff members touch a patient from the time of the injury until the patient goes home.

But Bynoe thinks his job starts even earlier, trying to prevent trauma cases. He talks to youth groups through a program called Project READY, which stands for Realistic Education About Dying Young. He shows photos of the injuries caused by reckless driving or gunshots or knives. He even asks former trauma patients to talk with youngsters about avoiding the poor decisions that landed them in the hospital.

Trauma is the No. 1 killer of people under the age of 45 in the U.S., more deadly than cancer or heart disease at that age group.

“It’s a never-ending battle,” Bynoe says of his education effort. “I don’t think that I can ever say that we’ve been able to stop trauma completely, but we’ll try.”

The patient arrives on a sunny October morning completely unresponsive from injuries in a car accident. He has no pulse when taken from the ambulance to the trauma center, but trauma workers don’t give up easily on someone’s life.

They take turns pumping his chest in standard CPR, some standing on stools or leaning on the operating table to get better angles for their work. The pump-pump-pump-then-wait pattern exhausts each staffer after a couple of minutes, and the role is handed off to next on the team.

At one point, a weak pulse returns. There are no cheers of celebration, but the warm air in the room suddenly fills with a sense of hope. Then the pulse is gone again. After 20 minutes with no pulse, the CPR effort is stopped. The attending surgeon looks up at the clock and declares the time of death, 11:45 a.m.

One of the doctors spends several minutes dictating every detail of the team’s effort into a phone. There’s more paperwork to fill out. The body is still on the trauma stretcher, covered in sheets. The surgeons had cut into his chest at one point, desperate to get the heart beating. Now there are bloody footprints on the floor. The cleaning crew comes in to wipe up the blood, pick up the discarded gloves and begin re-sanitizing the room.

Two of the members of the team come back in to move the body bag to a gurney to take it to the morgue. They cover the body with a special black drape, held up a couple of feet on a stand so it doesn’t touch the body.

The non-trauma staff watches the black-shrouded stretcher roll past and knows this will be a tough day for their friends in trauma.

Some things don’t get easier with experience

Nurse manager Diane Savage has worked in emergency and trauma for 28 years. Every time they lose a patient, it hurts, deeply.

“We’ll try to focus the rest of the shift,” Savage says. “It’s hard. You’ve got to keep your wits about you. Then when we drive home, that’s when the floodgates will open. I just turn off the radio and cry all the way home.”

Certainly that doesn’t happen often?

“At least once a week,” she says.

On tough days, she keeps reminding herself of all the people whose lives are saved in the trauma center. Usually, it’s a team effort, and the doctors make the potentially life-saving calls. But Savage can remember those rare cases where something she did with her specific skill set was especially important in saving someone’s life. “That makes it all worth it,” she says.

Everyone on the trauma staff shares that mixed bag of emotions.

“It’s an emotional roller coaster some days,” Bynoe says. “You’re working on people and you think you’ve got ’em back, and everybody’s ‘Yeah!’ And something occurs (and the patient doesn’t make it), and in your mind you’re thinking what else could we have done, how could we have changed it.”

For Bynoe, the toughest cases involve telling parents a child has died.

“The emotions changed when I started having kids,” he says. “It’s the worst thing to say that their child has died or their child won’t walk again. There’s no getting around, when you walk out, they look in your eyes and they know what the story is.”

The trauma team has a staff psychiatrist, and they do formal and informal group therapy. But sometimes, the best therapy is getting back to work.

Trauma means not knowing what to expect

The elderly patient arrives from Orangeburg Regional Medical Center, but some of his records haven’t arrived with him. The EMT knows the man has a history of strokes. The patient is conscious but is disoriented and he can’t provide information to the physicians. His family suspects he suffered a head injury from a fall.

After quickly examining the patient while waiting for records, the trauma team decides to go ahead and do a CT scan. The team led by Dr. Roberts Smith looks at his heart and lungs and checks the abdomen for bleeding, all in about five minutes.

They can’t yet determine what happened to make the man disoriented, but he’s stable now. He’s taken up to the fifth-floor ICU. In the realm of the trauma center, that was about as undramatic as they come. He probably should have gone to the emergency room instead. But in some ways, he was a classic trauma case.

Bynoe performs some general surgery, as sort of his wind-down exercise in a break from trauma work. “In general surgery, I know what’s wrong with them, and I know what we need to do,” Bynoe says. “Trauma is when we don’t know what’s wrong, and we’re trying to figure out what to do.”

Making those determinations on the fly with a life on the line is what trauma is all about. It’s what drives everyone on the team.

“This is not a job,” Bynoe says. “When people talk about their job, they use that long, depressive ‘ jaaaab.’ I feel like it’s more of a calling for me.”

Story by Joey Holleman | Photographs by Gerry Melendez

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