How does a trauma team respond when their red phone rings?
“The ambulance service ring us on our red phone to say we’ve got a trauma coming in,” Dr Gary Cumberbatch explains. He is the clinical director for emergency services at Poole Hospital NHS Foundation Trust. His trauma team receive around 60 calls a year.
“We have specific criteria to make a trauma call,” he tells us. “If you’re unconscious from a head injury, that will trigger it. If you’re breathing very fast or very slowly following an accident, that will trigger it. If your blood pressure is low, suggesting you’ve got internal bleeding, or if you’ve got back or neck pain and you’re paralysed, that will trigger it.” Dr Cumberbatch’s team are reserved for the most serious trauma emergencies.
Most trauma patients go to a Major Trauma Centre. The closest to Poole is at Southampton General Hospital. But if they can’t get there within 45 minutes, or they don’t have 45 minutes to spare, Dr Cumberbatch’s team step in.
The accident and emergency (A&E) consultant takes the lead. “If they’re not in this department they get a phone call immediately and are expected to arrive within 30 minutes,” Dr Cumberbatch says. There are doctors to perform procedures, nurses to assist, a radiographer to take X-rays and perform a CT scan, and a scribe to make notes. “We automatically call the anaesthetist out from the intensive care unit, as well as the surgeon,” he continues. “Someone to put them [the patient] to sleep and someone to do an operation to stop them bleeding.” Each team member has a pager so they don’t miss the call.
When the patient arrives, the first priority is their airway. Easy to remember, Dr Cumberbatch tells us, because it begins with an ‘A’. “If you don’t open someone’s airway so they can breathe through it, you only have three minutes before they die. That takes priority.”
The team use suction to remove any blood or vomit in the windpipe, making a clear passage to the lungs. From then on they need to keep the neck still. “We assume they’ve all got an injury to the spine,” Dr Cumberbatch says.
The next step is breathing. “You may clear the airway only to find that they’re not even breathing, or they are breathing but very shallowly. So we’ll breathe for them using something called an Ambu bag.” This is usually performed by the anaesthetist, who pumps oxygen into the lungs through a facemask. If this doesn’t help, the next step is life support: a tube goes in through the voice box and a machine takes over the work of the lungs. “To do that we have to give them drugs to make sure that they’re deeply unconscious and all their muscles are paralysed,” Dr Cumberbatch explains.
Then they can move on to ‘C’ for circulation. “That means, are they bleeding?” says Dr Cumberbatch. “If they come in and they’re hosing blood from their leg, then you should press on that even before seeing to the airway. A lot of this experience has come from the military.
“If it’s not an obvious wound but their pulse rate is high and their blood pressure is low, we’ve got to find where they’re bleeding from internally,” Dr Cumberbatch explains.
“You can bleed in five places,” he continues. The patient might be bleeding onto the floor from wounds on their back. Alternatively, the wound could be in the patient’s chest or their abdomen. Or it could be that they have broken their pelvis. The fifth possibility, explains Dr Cumberbatch, is a broken thigh bone.
The team need to stop the bleeding to get the patient ready for step ‘D’, which stands for disability. “You’re not allowed to move from one letter of the alphabet to the next until the first one’s sorted,” Dr Cumberbatch explains. “We can put a probe on their abdomen to see if there’s any blood internally. We use a probe on their chest to see if there’s a collapsed lung or any blood. Otherwise most patients go through the CT scanner. We stabilise them and then we take them there.”
The scanner reveals any internal injuries to the brain or internal organs. But not everyone can go straight away. “If they’re bleeding heavily, they’re not getting a scan.” Instead, the surgeons take them to the operation theatre and open them up, find where the bleeding is and stop it. The patient can only go to the scanner when they are in a stable condition.
Only then can the team move on to ‘E’. “That ABCD approach is what we call the primary survey,” Dr Cumberbatch explains. “Your assessment is purely to work out threat to life immediately. Fortunately, most patients don’t have that, so we move to the secondary survey, where we look for other injuries. That’ll be broken arms and legs, missing teeth, internal injuries that aren’t causing bleeding, like a perforation of the bowel.”
The letter ‘E’ stands for ‘exposing’. [We have to] “Make sure they don’t get too cold,” Dr Cumberbatch warns. “We work methodically down from the top. It’s as important to save lives as it is to pick up other injuries.” The trauma team work extremely quickly, aiming to get their patients stabilised and scanned within 20 minutes.
The work can be intensely stressful, especially when the patient is a child. “You can’t afford to be distracted by emotion,” Dr Cumberbatch tells us. “You have to give the child the best chance.”
The above describes major trauma but the team at Poole also manage minor injuries. “One of the things I particularly like to treat is crushed fingers. You come in, your nail is hanging off, there’s blood. I can numb your finger in 30 seconds flat. Within five minutes your finger is pain free. We take the nail off, repair the nail bed injury, put the nail back on delicately. Wow, looks like a finger again.”
The job has obvious challenges, but as Dr Cumberbatch says, “the sweet comes with the bitter”. And sometimes the little things provide the biggest rewards.
Interview conducted and article written by Laura Mears, originally published in issue 106 of How It Works.
Many thanks to Dr Gary Cumberbatch and the Poole Hospital NHS Foundation Trust for their time and assistance.
Opening image by Sasint
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