The Trauma after the Trauma

ScrappyED, BSN, RN

He was able to answer our questions for the first few minutes and it looked like it was going to be a "routine" trauma where we stop the arterial bleed, set the fracture then scan the pt from head to toe to make sure there are no hidden internal traumas. About 5 minutes into our routine the guy's heart stopped and we attempted resuscitation for over half an hour. We tried everything in our power including cracking open his chest and doing cardiac defibrillation and cardiac massage (where the attending MD actually puts his hand into the pt's chest and manually "pumps" the heart). When the MD eventually "called it" the nursing student I had been precepting all weekend lost it and ran away crying.

It is a sad process after such a lengthy code to clean up the trauma bay. There is debris everywhere, most of it covered in blood and sometimes other bodily fluids. There are bloody footprints where the 20+ members of the trauma team weave around the pt and each other in the frantic dance of pitting life against death. There are usually various bloody, metallic instruments lying around from cracking the chest, clamping off arteries, inserting the breathing tube and various other life-saving procedures-looking like some medieval torture chamber toolbox has been upended and abandoned . Pieces of paper and plastic that once enclosed precious sterile instrumentation, blood products and medicines litter the counter-tops, the floors, the code cart, the stretcher surfaces and the respiratory arrest airway boxes. Blood-soaked clothing torn in the wreck or cut off by us lay in a few piles on the floor. Since this patient will be a case for the Medical Examiner there are several plastic tubes of varying sizes protruding from the patient that we are not allowed to remove. The breathing tube spills bubbles from the gasses that begin to form immediately postmortem giving the illusion that something of this patient's life is still possible to retrieve. Like so many other times after a pt death I catch myself looking closely at the body for signs of spontaneous respirations-something my brain knows that by man's understanding just isn't going to happen-wondering if I may yet witness a miracle.

Everyone not considered directly responsible for the patient's care starts to file out, some quietly talking to one another, some silently shaking their heads, some already laughing about something silly that happened during the mad rush in the way only people who routinely face these kinds of things can do. Now the feeling in the room has changed. The pace slows, your internal focus relaxes and can broaden again to more than the immediate moment and the immediate task at hand. Each team member, in their own way, processes the events of the past 45 minutes or so. Some wonder if they could have done something differently, performed a skill better or faster, called for an intervention sooner. Some put it behind them and move on mentally as fast as they do so physically. Some are angry, some sad, some businesslike in their tasks after the death.

The small crew that is left begin cleaning the bay and bundling up the pt, cleaning the face off as well as possible so that if the family wants to see him they aren't any further traumatized than necessary. One of the Residents that is left begins to quietly sew up the chest as we work around him. Another Resident sits at the trauma desk for this bay, trying to reduce that 45 minutes of chaos into the impartial medical charting required by law. She looks up occasionally and asks for the time that something happened, the size of a tube or the name of someone who intervened in one way or another. One of the other nurses sits in another corner and finishes the detailed charting that we are required to do-referencing the frantic notes chicken-scratched during the code. . About half-way through our vigil word comes that family has arrived. It is the moment we all dread. From a receipt in his wallet we knew that approximately an hour ago this man had just finished a trip to the grocery store. Now we have to go inform his family that their husband, their father, their son isn't going to make it back home from this trip. That receipt, found after the patient had passed away while logging his belongings, got to me more than anything else. I suppose it became a symbol that this man was not just another day at work but a fellow human and was a blaring siren screaming how fragile life really is. You almost don't want to find things like this that humanize your patient because it makes the job harder once they become more real. But then you are glad, in a way, that you do discover that your emotions still function and that you haven't become totally disconnected from what most of our non-ER friends think and feel about human life.

The resident, my charge nurse, our patient representative, the chaplain and myself walk into the small room where four scared people have gathered to wait on word of their loved one. The chaplain is the last person to enter the room. What I notice first are their eyes, already showing signs of being a little overwhelmed by the situation and the number of us coming to talk with them, begin to widen in dismay at the sight of the chaplain in his familiar black shirt and white collar. Two of them, our patient's older children, put their hands to their mouths. The woman who is our patient's wife, says "It's bad isn't it?" and the resident in a calm, quiet and compassionate voice begins to tell them the story. He does a wonderful job, where others have bungled it badly, and we give the family time to absorb the first impact from the blow of his words. Eventually, we lead them to the patient, skin already starting to mottle in places but also still bleeding from the facial laceration. This was disturbing-I had not seen this happen as badly before and, of course, the family did not understand at all. Like I had done earlier they sought for other signs of life, saying over and over that this wasn't real and couldn't have happened. One by one they leave to begin "taking care of the details" as those in the business of death like to call it. They will have to decide on where the patient's body will spend his last days above ground, what clothes he will be buried in, what kind of casket he will have. They will have to endure calls from the local police department about the wreck, the county forensic office about the autopsy, friends and family calling to give their condolences. Things that moments earlier had never even entered their minds. As is my duty, I hand them a small card with the name and number of the Medical Director of the forensic center as they are leaving, feeling like this just wasn't enough to hand a family as they leave the hospital without their father and husband. The charge nurse comes up to me and tells me I did a great job during the code and while meeting the family. I thank her and then the tears begin to well up. I push them and the thoughts of what just happened to a back corner of my mind and walk back to the scene to continue my part of the job.

Thankfully, the trauma bays spend the majority of their time empty and are many times a haven for those of us who may need to get away from the rest of the craziness in the main ER. It is different right after we have lost a patient-especially one that came in awake and was relatively young and died so unexpectedly. The bays seem not just empty then but desolate. They truly remind you of the proverbial "war-zone"for a short time until all traces of the tragedy are bleached, mopped and taken off in the trash. Then within minutes, in a somewhat surreal fashion, everything looks normal again and you can almost believe it was just a dream.

As I got home last night and crawled into bed beside my husband I hugged him extra hard and thanked God that we had at least one more night together. I had already peeked in on the kids to make sure they too were still on this side of life. I can almost feel my skin toughen just a little as I wake up today to face the new day. I have survived the trauma after the trauma and will go back for more.

Kellie G., RN

The Trauma after the Trauma

About ScrappyED, BSN, RN

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