12:25am Sunday 20 August 2017

When seconds count, trauma team is ready

by Toni Baker

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Amanda Barnes and her boyfriend had spent the evening with two friends they had fixed up. Within sight of his farm in rural Warrenton, Ga., Amanda, wearing his cowboy hat and essentially dancing in the passenger seat of his truck, turned around to grab her purse and cellphone.

The 24-year-old woke up to pitch black, pain and her boyfriend calling her name.

He had swerved to miss a deer and the oversized pickup apparently spun, cutting a swath through a nearby patch of trees, before coming to rest on its side.

At some point, Amanda was thrown out the window; the jagged trees punctured her like spears; the truck may have rolled over her. She could feel the dampness of blood, but her sweatshirt and fleece jacket and, no doubt, the dark, kept her from realizing the full extent of her injuries.

Amanda was essentially cut from her breast bone to her pubic area, her pelvis was crushed and broken. The force of something pushed a portion of her intestines down into her leg, between the fat and muscle.

Amanda was really cold. She could move her arms, but thought her back was broken. The punctured lung kept her normally resounding voice at a whisper. When Trina and Russell Barnes got the early-morning call, Amanda’s father, a longtime firefighter, knew it was bad. Trina, a little groggy from a sleeping pill, was trying to brush her teeth when her large, but characteristically tender husband said they had to go.

Their vivacious, precious daughter, who Trina homeschooled along with brother Russell II, was airlifted to the Level One Trauma Center at Georgia Health Sciences Medical Center in Augusta.

There, four teams of surgeons, led by Dr. Linda R. Atteberry, a former Army surgeon with wartime experience, operated throughout the early morning hours and into Sunday afternoon to rescue Amanda’s future.

Anyone, anytime

“The clock starts ticking the second this happens and any delay can result in the loss of life,” says Dr. Colville Ferdinand, Chief of the Medical College of Georgia Section of Trauma and Surgical Critical Care at Georgia Health Sciences University

Recognition of dramatic reductions in death and disability that result from timely trauma treatment – known as the golden hour – grew primarily out of the Korean and Vietnam War experience and spurred stateside development of trauma centers and systems beginning in the 1970s.  The National Academy of Sciences’ landmark white paper, Accidental Death and Disability: The Neglected Disease of Modern Society, published in the late 60s pressed the urgent need for a comprehensive emergency medical services network that included a national 911 network, training for first-responders, ambulance communication and statewide emergency medical services training.

A Clear Picture
“A lot of people like us have never had anything traumatic happen before. You don’t know what questions to ask. You don’t know how to feel,” says Trina Barnes.Like many trauma patients, her daughter Amanda was young and previously healthy until an early-morning wreck threatened her life.The two, who call each other best friends, had long shared the blessing of a large, mostly healthy family so their endless conversations had not focused on hospital care. But their instantaneous immersion into trauma left both with a deep commitment to making care even better for the next patients and families.They reinvigorated a monthly trauma support group, an informal gathering of mostly family members, and helped develop educational materials to help them digest the impact of a subdural hematoma or ruptured spleen.As her thesis project, Emma Vought, now a graduate of the Georgia Health Sciences University Medical Illustration Program, created line drawings of the anatomy to help family members better understand what happened to their loved one, says Jennifer Edmunds, Nurse Educator for the Shock Trauma Intensive Care Unit. “As things change for the patient, physicians and nurses can write on the silhouettes and explain it to the families.” Edmunds says. Typically a family spokesperson emerges who, in turn, uses the drawings to update the extended family. Often, the drawings are displayed on a white board in each patient room. Three-dimensional electronic images also are being developed.The support group lets family members blow off steam and benefit from the experiences of Amanda and Trina. “We were thrust into it, which is trauma,” Trina says. They talk about – not just hospitals and care – but the collateral damage that occurs when, for example, a breadwinner is injured. They talk about finding some sense of control at a time when everything seems beyond it.“Every single person I worked with at (GHS) from the cleaning lady to Dr. Atteberry, made it their mission to make my life better and make sure I was okay and I am fine,” Amanda says.Adds Trina, “We want to give back some of what was given to her.”

A man with global insight on this emerging priority rolled into Augusta in 1973.  Dr. Arlie R. Mansberger Jr., now 90, had helped organize the first shock unit at the University of Maryland in 1969, a traveling team that dropped whatever it was doing whenever a new or existing patient’s blood volumes dropped dangerously low. Shock often accompanies trauma and is a primary reason time is of necessity: irreversible shock causes platelets to coalesce and organs to shut down. The small unit was the genesis of the R Adams Cowley Shock Trauma Center, one of the nation’s first, with Mansberger as its first Director of Clinical Care. With heavy support from the state legislature, the center developed a network that blanketed the small state and included nine helicopters that aided traffic control but had as its priority the rapid transport of trauma patients.

When Mansberger arrived as Chair of the MCG Department of Surgery, he found a tertiary hospital that lacked even an emergency room. Undaunted, he recruited Dr. Dan Ward, emergency medicine physician, to help start an emergency room and Dr. Richard C. Treat as the first Trauma Chief. Over time, an after-hours clinic called Immediate Care was repurposed as the hospital’s first emergency room, which included one large trauma resuscitation room. A small recovery area in the operating suite became the first Shock Trauma Intensive Care Unit. And in 1982, GHS Medical Center became Georgia’s first designated Level 1 Trauma Center.

“The cause of medicine has always been advanced by pioneers who have blazed paths before us, and we have to give full credit to them,” says Ferdinand. An experienced Mansberger and visionary Treat essentially took the hospital from no role to providing the highest level of trauma care while Dr. Michael Hawkins, the second Trauma Chief, built from there, says Ferdinand, who now has the ball.

Organized chaos

“Trauma is essentially the care of injured patients and that can be the gamut of things from gunshot wounds to stabbings to animal bites to drowning to motor vehicle accidents and falls,” Ferdinand says.  Unlike larger urban areas with higher rates of penetrating trauma – the so-called knife and gun club – about 18 percent of patients at GHS Trauma Center have a penetrating trauma while the majority suffer from blunt trauma, particularly automobile accidents.  The center, which covers primarily a 13-county region that blends urban and rural living and includes one of the Southeast’s largest public recreation lakes as well as the Savannah River, also gets a few snakebites and watersports injuries each year.

The common denominator is the consistency of care that begins with first-responders extricating patients like Amanda from often dark and sometimes dangerous circumstances to get them to definitive care within that “golden hour.” The hospital’s Emergency Communications Center stays in tight contact with this front line to ease rapid transport of patients whose physiologic condition or even cause of injury indicate they would benefit from the Trauma Center. Internally, a home-grown algorithm determines whether it’s a level one or two trauma and the makeup of the team that will be waiting in the trauma resuscitation room in the hospital’s Emergency Department.

Every team member and instrument has a place in the trauma resuscitation room, where often-extensive injuries are rapidly assessed by the team, led by the trauma surgeon. In the case of a level 1 trauma, the team also includes an emergency medicine physician, a senior-level surgery and emergency medicine resident along with two of their more junior peers, an emergency department nurse, respiratory therapist, radiology technologist, operating room nurse and an anesthesiologist. For the youngest patients, a similar team comprised of pediatric providers assembles in the pediatric Emergency Department, led by the pediatric surgeon on trauma call. An operating room and the Blood Bank always stand ready.

“It looks very chaotic but it’s controlled chaos,” says Trauma Program Director Regina Medeiros.  “Everybody has a function, everybody has a role and they know what that is,” she says. No doubt trauma is a team sport where a single patient might also need a range of other subspecialists such as orthopedic surgeons, neurosurgeons and cardiothoracic surgeons.

Serving as a Trauma Center is a huge commitment by the hospital, the university, faculty and staff, from housekeepers to surgeons, who each play a part in caring for patients, Ferdinand says.

But there are huge rewards in battling the loss of life and limb to a disease that targets society’s potential, team members say. In fact, trauma is the number-one cause of death in people age 1-44 and the number-three overall cause of death, according to the Centers for Disease Control and Prevention.

“When you leave your house in the morning driving to work anything can happen. We’ve got to cross train tracks here in Augusta sometimes, you know, something can happen. Your kids could be in the playground playing and something happens,” Ferdinand says.

Trauma centers give people the best chance of surviving that “something” and getting back to their lives.

Shot through the heart

There’s little doubt the Trauma Center gave Julian Williams that chance.

It was a Friday night – 11-11-11 – and the 17-year-old was playing video games at a friend’s house. One thing led to another and a young man he didn’t know, pulled out a 22-caliber pistol. Julian’s memory is sketchy, but he recalls telling the young man to get the “raggedy” gun out of his face. In what has been called an accident, Julian got shot in the chest.

His friend’s mother had just gotten home, so they piled Julian into her car and were speeding to GHS Medical Center when they saw an ambulance parked at a convenience store. The paramedics quickly started working on Markeith Williams’ only child.

Markeith got full custody of Julian when he was 2 and several years later made the decision to relocate from Baltimore to Augusta. While they have family in both cities, Markeith thought Augusta would provide better opportunities for them both.

When he learned Julian had been shot, Markeith thought that maybe both their lives were over.

As the trauma team was moving Julian from the transportation stretcher to the bed in the trauma room, his heart stopped. Ferdinand and Dr. Brandy Cross, a 2007 MCG graduate who is now a fifth-year surgery resident, were leading the trauma team that night.

While still in the emergency room, they made a quick incision on his left side so they could manually massage his heart; the heartbeat restored, they immediately took Julian to the operating room so they could find and ideally repair the full extent of his injuries.  In what’s described as a clamshell incision, they extended the cut across his body to get a better view of his heart.

They found a bullet had passed through the upper and lower chamber. They repaired the holes, then discovered the small-caliber bullet resting in the durable sac around his heart. A cardiothoracic surgeon confirmed that no other heart repairs were needed.

Ever ready

The immediate availability of surgeons and surgery to intervene in critical scenarios like Amanda’s and Julian’s has been and continues to be the hallmark of trauma care. Also like these two, many of their patients are young and healthy until trauma puts their future in limbo.

Now a faculty member and one of the first graduates of GHS’s Surgical Critical Care Fellowship, Dr. Steven B. Holsten Jr. was still a GHS surgery resident when he decided he wanted to help turn such tragedy into triumph.

“It’s exciting, which is probably what everybody says, but there is a lot of variety, a lot of thinking on your feet because no two situations are exactly the same.” But the real clincher for him came in helping a young car accident victim negotiate a particularly rough recovery and, one year later, running into her at the grocery store with her two children.

“I can’t tell you how awesome I felt.” He and wife Amy’s own busy blended household of five children, from age 21 to 3-year-old twins, made him hesitant to pursue such a life-consuming specialty, but ultimately the desire to help other families sealed his destiny and put a smile on his face.

In fact, trauma is now a family topic as he and his wife, a psychologist at Augusta State University, are working to reduce recidivism for some patients. He’s not talking about wearing seat belts and not drinking and driving – at least at that moment – but about how living with injuries that could have killed may leave patients with posttraumatic stress disorder and, perhaps, an increased risk, of being hurt again.

They want to know whether a prior history of mental health issues or poor family support or either numb or hyperactive reactions to the first injury, are risk factors for more trauma. “Those are all things we know are predictors of having psychological problems afterward,” Holsten said. They also know that they will see some patients in the trauma resuscitation room more than once.

The day before, he treated a patient who had been stabbed in the liver and still had buckshot in his flank from a previous injury. “We take X-rays and see old bullets,” he says. Still, don’t be looking for judgment; that’s not Holsten’s job. “My job is to fix them and hope they are going to have some good Thanksgivings and Christmases and be the best person they can be,” although he won’t deny that occasional dark humor helps him and his colleagues cope with the tragedies that bring people to them.

Ferdinand shares his sentiment. “My job is to take care of you; whatever good or bad you were doing at the time of injury, you will be taken care of in the same manner.”

Trauma vision

While certainly not dispassionate, the ability to push past the moment seems a necessary trait for trauma surgeons who must focus on treatment rather than the horror that a 17-year-old is dying in front of them. Trauma is what they choose, what they love and what they know.

“When a cardiologist looks at an EKG for example, he can read more into it, what is likely to happen, what the real possibilities are,” say Hawkins. Decades of trauma experience have made Hawkins more attuned at looking, for example, at a football player who just took a hard hit in a game and knowing whether his soreness and elevated pulse signal hidden injuries. “We learn that, we practice that, we try to teach that,” Hawkins says.

This insight has led to at least one seemingly unnatural realization: sometimes rushing to the operating room isn’t the best answer. It wasn’t a lesson of choice, rather it was gleaned from overburdened trauma centers where sometimes patients must wait.

Their pediatric colleagues had been sharing the message that sometimes waiting and watching is better. For example, the risk of removing the spleen, which filters old red cells, stores new ones and contributes to the immune response, is more significant in a child than an adult. And, like busy adult centers, pediatric surgeons have learned that sometimes with an experienced eye and proper support, the spleen or even the very vascular liver will heal by itself.

Hawkins notes the evolving, evidence-based approaches are no different than the fact that 30 years ago a healthy 20-something-year-old spent a week in the hospital after gallbladder surgery and didn’t eat for three days. Most often today, she would go home that day with recommendations of what foods to avoid.

The key is using experience to figure out what’s best. “Moderation is hard; extremes are easier to practice,” but balance provides better, safer care, he says. “There is always a risk and most of the time there is a benefit. We try to do what is best for this patient, at this time, under these circumstances.”

On the other hand: “When we get someone who needs to go the operating room, we go.”

The evolution also means that trauma surgeons don’t do as much trauma surgery, says Ferdinand. Like many of his colleagues, Ferdinand essentially always knew he wanted to be a surgeon and he loves to operate. Growing up in the Caribbean Island of Saint Vincent, with his school teacher mom and engineer dad, biology and science were at his fingertips. Leaving his beloved and beautiful homeland “was the price of ambition,” bringing him to the states to study surgery and trauma/critical care at MCP Hahnemann University in Philadelphia after completing medical school at St. George’s University School of Medicine in Grenada, West Indies. Now 42, he’s emphatic he’d make the same choice again.

Despite such commitment from those “in the business,” their beloved subspecialty hasn’t looked so great to future surgeons as the number of surgeries dwindled. “A surgeon was happy to do trauma because he was utilizing his surgical skills and following his passion,” Ferdinand says.

Trauma in the U.S.:
  • Is the number one cause of death in people age 1-44, killing 47 percent of all people in this age group
  • Costs $400 billion annually, including health care costs and lost productivity
  • Accounts for 30 percent of all life years lost
  • Accounts for 42 million emergency room visits and 2 million hospital admissions.

*Source, Centers for Disease Control and Prevention

The solution became about balance as well, with trauma surgeons not only more involved today in ongoing critical care, but helping their general surgery colleagues by performing late-night surgeries to stop a gastrointestinal bleed or drain an abscess. “A well-trained trauma surgeon is up anyway,” Ferdinand says. That means trauma surgeons stay busy, hospitals cover their on-call schedules and general surgeons have more flexibility in managing their schedules.  It also means MCG’s Section of Trauma and Surgical Critical Care is growing from three to seven surgeons.

Back to life

Amanda and Julian don’t remember the moment of injury that nearly took their life. They have far more clarity about the months each spent in the hospital, in rehabilitation and the people it took to help get them there. Amanda’s best friend and mother, Trina; her stalwart dad, the “baby” brother she helped raise. Julian’s dad, who returned to his job as a mechanic at Kimberly Clark within a week, but slept by his son’s side every night for the two months Julian was hospitalized.

“I am just glad to be here,” says Julian. Like his father, Julian enjoys working with his hands. He was on track to study mechanical engineering back in Baltimore at Morgan State University when he was injured. Less than a year out and still recovering his attention span, Julian started this August at Augusta Technical College studying air conditioning technology but with an eye on a future in automotive repair.

Amanda’s first questions when she woke up were whether she could still have babies and walk. While the answers were more about hope than promise, she quickly got to work on the walking. While her pelvis likely will never be 100 percent, she pronounces herself  “fine. When I get tired, I walk a little funny and you should see me run, that’s hysterical.” As far as babies, she and fiancée David Wilkey will be making those plans after their wedding this spring. Amanda met David, a man she describes as the best guy ever, after her accident. Whether through the traditional route or adoption, she plans to have many children with the man she loves.

See more photos from this story in the Fall 2012 edition of Georgia Medicine.


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