A Night in Trauma
24 Hours Inside the ER at Scripps Hospital
The La Jolla Light, February 28, 2002
by Lance Vargas
Dr. Fred Simon Is tbe exact type of surgeon needed in a trauma ward. He Is confident but not cocky, forceful but not overbearing and intelligent but not arrogant. He exudes an aura of perfection but often communicates It In the results of his work rather than personal pride. He rarely uses "I," and instead says "we," to mean tbe entire trauma staff.
"We are, without question, one of the highest-quality, cost-efficient trauma centers in the country. I can state that without reservation," said Simon, the clinical director of trauma at Scripps. "A lot of effort and time as well as a multitude of personalities are dedicated to making that so. It bas been a total team effort."
Simon's picture-perfect analysis of an incoming trauma patient is absolutely necessary in the environment of the trauma ward where the term "preventable death" lingers behind every decision and action. His skills are methodical and his expertise in the field is so blatant that he doesn't need to show it off, because it's readily apparent to anyone who spends time with him.
The La Jolla Light recently had the opportunity to follow Simon on a typical Saturday night in the hospital's trauma ward. This is what was observed.
Simon's first order of business for the evening is the removal of a drainage tube from the chest of a 66-year-old female patient recently involved in an auto accident. The tube's purpose is to drain air and blood from a chest injury.
The patient is good-natured and even humorous despite the presence of the tube, her serious injuries and placement in what's called a "halo," a device attached to her head to stabilize a neck fractUre. The halo is uncomfortable and cumbersome, but is a vital and necessary piece of equipment for spinal injuries.
Just before he starts the procedure, Simon gives a set of instructions to the woman that explain exactly what he is going to do and how she is supposed to react. With a bedside manner that is equal parts comforting and clinical, he explains to the patient when she is to breathe in, how long to hold her breath and when to breath out. Then he begins.
Though only a small portion of the tube is originally visible, the full length of it is exposed as Simon removes it. It's well over 10 inches long and smeared with blood. The patient seems to be in only a marginal amount of discomfort throughout the procedure and remains in good spirits the entire time.
Aller the drainage tube is removed, Simon takes time to address the smaller details of his patient's stay, asking, "D0 you want the TV on?" and "How well is the staff taking care of you" before assuring her she'll be home soon. In reference to her windowed room on the corner of Scripps' 4th floor, Dr. Simon asks the patient. "Did you know you have the VIP suite here at Scripps?"
To which she replies, "My room at home would be a lot better." Her wish is eventually granted as she is discharged a week later.
The general operating room at Scripps is busy. The entire staff is working and Dr. Simon is considering whether he should divert any trauma cases that may occur to other hospitals in the San Diego system. After discussing the situation with the hospital's anesthesiologist. it is decided that the load of patients in the OR will likely decrease and there is no need to go on bypass.
Dr. Simon decides he will call Dr. Imad Dandan, a surgeon who will handle any trauma patients that may come in while Simon is performing an emergency appendectomy. Dandan has just finished working a 36 hour shill (including on-site sleep time) at the hospital and will be back tomorrow at 7 a.m.
"Such is life as a trauma surgeon," states Simon.
In reference to his ability to perform deIicate surgicaI procedures and make life-altering decisions for long periods of time, Simon said, "It's a function of conditioning the mind and directing an intellectual process. It is an issue of visceral body needs recognizing the importance of the issues at hand and dealing with someone's life versus your own needs. It keys in on focusing on the betterment of the patient because of the intensity of the situation and knowing the outcome will effect someone for the rest of their life. The focus is on that patient and those issues. (A surgeon) needs to perform at the highest level and overcome any issues that exist personally. Everyone on the trauma team functions this way."
The appendectomy patient is in the operating room awaiting his surgery. He is a large, bearded and bald younger man who resembles a professional wrestler. He has been living with a burst appendix for a day and has a decent demeanor despite his condition. Dr. Dandan has been called to cover any incoming trauma patients that may occur while Simon is performing the procedure on the patient.
After the arrival of Dandan and a short prepping procedure, surgery begins on the appendectomy patient. As Simon and a small group of doctors and nurses gather around the patient, a smell similar to burning flesh permeates the operating room and the incision is made. The smell is from the bovie, an electric conducted cutting knife that has replaced the traditional scaIpel. It coagulates the blood vessels as well as cuts tissue.
The doctors and nurses are calm throughout the operation and a boom box pIays classic rock music in the background. As Dr. Mike Martin, the anesthesiologist, is monitoring the patient's vitals, he explains that the man is placed on a respirator due to the muscle-relaxing drug he has been administered. The diaphragm, which controls the inhaling and exhaling of lungs, is paralyzed due to the muscle relaxers, justifying the need for the respirator. The muscle relaxer is administered to prevent unconscious reactions by the patient to the surgery. Everything is cause and effect, and nothing has been left out. If complications arise. Dr. Manin is ready to instantly administer another drug that will quickly counter the muscle relaxer and allow normal breathing to reoccur.
Shortly after the incision is made, the first parts of the appendix are begin to be removed. They are pink, soft and fleshy.
A short time after the appendectomy begins, a trauma patient arrives and Dandan is called away while Simon, Manin and the nurses continue the operation.
The trauma patient is a young Canadian man who was sitting in the backseat of an automobile rear-ended by a drunk driver.
In the trauma room, the patient's vital signs and responsiveness are analyzed through a series of standard procedures. His clothes are cut off of his body and feathers from his down jacket spill out onto the floor of the trauma room. There is blood all over his face. Quickly, X-rays are taken of the patient from a machine above him and are back in just a few moments.
Though films and television shows emergency rooms as places where there are many doctors and nurses all moving about and screaming at each other, it's nothing like that in reality. The staff at Scripps are unbelievably calm in their beginning analysis of this trauma patient, and everything is very structured and methodical. There is no panic and certainly no cliches like "hurry up, we're losing him!" are uttered. Rather than pandemonium, the mood at Scripps is much more like a presentation or ritual than an out-of-control emergency. Even though that's essentially what it is.
Mere minutes after his arrival at the hospital, the unconscious patient is wheeled into another room to undergo a CT (computerized topography) scan.
CT scan is where the most crucial analysis begins. It essentially scans the entire body and feeds the results to a computer in cross-section images that closely resemble slabs. The term "topography" is an accurate one because the images that are drawn from the patient's body resemble a landscape or map. Tissue and bone are like land areas and bodies of water.
Dandan and the CT technician, John Swanson, analyze the results and methodically search for areas that look abnormal. Often, they stop to examine a small blotch of matter that is either marked for further examination or dismissed as a natural occurrence. Areas marked for this particular patient are his jaw, spine and skull, where there are signs of fractures and subdural hematoma or bleeding of the brain.
When asked if the patient's condition is critical, Dr. Dandan says, "That's the understatement of the century."After an hour in CT scan, the car accident victim is transported to Intensive Care Unit where he will be closely monitored by the ICU statT for the rest of the night.
The patient will remain in the hospital for weeks, suffering a brain contusion, a cervical spine fracture, a thoracic spine fracture and a mandible fracture. He will be on assisted ventilation for days before improving remarkably and breathing on his own.
Dr. Simon enters the trauma ward after having finished the appendectomy. Apparently, it was the hardest appendectomy he ever performed due to the location and shape of the patient's appendix. Nevertheless, Simon finished the procedure without complication. The appendicitis patient will remain in the hospital on antibiotics before fully recovering and returning to work
in two weeks.
Simon feeds his self-professed sugar and salt habit by patronizing the ER's vending machine. Ruffles are his particular choice for this night, but he confesses a love of donuts as well.
Another trauma patient arrives at the hospital. He is wheeled on a gurney into the trauma room where the details of his accident are explained to Dr. Simon. The patient is an I8-year-old man who fell from a tree he was climbing and injured his arm and head. He was found disoriented by paramedics who then brought him to trauma due to the possibility of a head injury and the distance of his fall.
Seconds after the man enters the trauma room, Simon is examining him. The patient is conscious and responsive. To determine the patient's state of coherence, Simon asks him, "Who was the intern with the blue dress that had fun with President Clinton?" The patient immediately answers, "Monica
In the trauma room, it is clear that Simon is the captain. His call-and-response type of patient care is quick, precise and exact. The doctors and nurses who surround him are excellently trained in their duties and perform them without instruction. Like an Indianapolis 500 pit-crew, they have the
patient x-rayed and analyzed in under six minutes.
With the tree-faller in CT scan, Simon is informed that his parents, a pair of pediatricians, have arrived and are in the waiting room. He immediately meets them and in his standard caring-but-clinical manner, he informs a nervous mom and accepting dad of their son's condition - which does not
appear to be serious at this point.
"He's lucky." Doctor Simon says in reference to the boy's 25-foot fall from the tree.
While Dr. Simon assures the parents that their son's condition is not serious, he noticeably excludes any absolutes. Never actually committing to the fact that the kid is going to be fine, but doing his best to communicate to them that everything appears fine.
"All cases are individuals so we must persist with hope," said Simon. In discussions with families, we continue to give them hope until we are absolutely sure that the outcome is a non-resolved permanent disability." Fortunately, no lingering effects of this patient's fall will exist. He is eventually discharged with no post-injury complications.
After following Dr. Simon for a short portion of an average night, it is easy to see how thankless his and the trauma staff's jobs can be. While their position garners a tremendous amount of respect from society, it is usually behind closed doors where they receive their thanks, praise and accolades. A deep sense of accomplishment and a profound understanding of humanity are obvious rewards, but mostly, only the people who are directly affected by physically traumatic health problems truly grasp the pivotal and thorough job performed at Scripps and other San Diego trauma units on a nightly basis.
"Our job is not one often publicly acknowledged glamorous positions, but that is ot the reason why we chose the profession. It is certainly well-recognized in the medical community when patients and families understand the expertise we provide," said Simon. "Recognition happens at a much more personallevel than any public recognition and is exceptionally satisfying."
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