The ED: The Race Against Time

By ACM Regional
15 January 2017

AFTER emergency services have assisted at the scene, road trauma victims will arrive at emergency departments throughout the state.

From the smallest EDs, to some of the best in the world, these are the people tasked with saving your life...

"It’s a real team effort"

IT’S OFTEN a race against the clock to save people, according to Horsham’s Wimmera Base Hospital emergency department registrar Sarah Oldfield.

“We will get a call from the paramedics telling us that there has been road trauma and they are on their way, and we then get our teams ready,” she said.

If the road trauma involves multiple vehicles or passengers, doctors must work quickly to assess everyone.

“We call radiology in because we are likely going to need images of these people,” Dr Oldfield said.

“We might need to call the surgeons in - we call in whatever team is necessary.

“We have to get quick access to the services. We might need the anesthetists if patients are having airways problems, or the surgeons if there is penetrating trauma or someone needs an operation.

“It’s a real team effort to look after these people.”

The first few minutes or hours are hectic for the emergency department.

But even after the patients have moved on, the memories of what occurred stick in the minds of doctors and hospital staff.

No matter how experienced they are, it never becomes easy to see the effects of road trauma.

“It’s brutal,” Dr Oldfield said.

“Some days you will be fine and it won’t touch you and then something will happen and it all changes.

“When someone first comes in, you are generally not too bad because you are concentrating on what you are doing, but then afterwards, once they are stable or they have left, it hits you.”

Emergency department acting nurse unit manager Verity Drysdale said staff often sat down and debriefed after viewing serious trauma.

“Sometimes seeing that can trigger a memory from a previous incident,” she said.

“But we sit down, have a coffee and talk about it - that’s how we survive.”

The emergency teams can stabilise people, but often victims of road trauma need serious help.

Dr Oldfield said patients were sometimes transferred to Melbourne.

“This happens particularly when there is mass trauma, because they need more specialised services,’’ she said.

“We sit down... and talk about it - that’s how we survive.”

THINK of The Alfred trauma centre as a Formula One pitstop, veteran trauma centre director Mark Fitzgerald says.

The patient arrives in the bay and the fuel – their blood – is checked. Doctors then check the tyres – the limbs and body - for other injuries. The patient then goes into ICU or an operating theatre. The process is so ordered and fast, Dr Fitzgerald likens it to an assembly line.

Dr Fitzgerald and the trauma team can usually determine in a matter of minutes if a person will survive or not.

Doctors work with a minimum of three trauma nurses, one anesthetist, two surgeons and one or two emergency doctors. Sometimes neurosurgeons, cardiologists or orthopaedic surgeons will be on scene.

Sixty per cent of road trauma accidents are high speed. Patients commonly have head injuries, chest injuries, abdominal injuries and fractured bones.

Paramedics might have given them an anaesthetic or put in a tube. Often the victims might have rib fractures and might have their spine splinted.

Sometimes doctors will have to puncture the chest to drain it.

“Time is critical. The longer it takes for care to be given, the more likely the patient is to die.

“The major fractures are spinal fractures and pelvis fractures – they are in the mid-line of everything important. Patients can bleed a lot from a pelvic fracture.”

The resuscitation bay at the centre is an open-ended operating theatre.

If doctors have to open someone’s chest they can do it in the bay, saving time and reducing the number of times a patient has to be moved.

“A lot of things we do are risk reduction – to check for injuries that could kill someone that aren’t always immediately obvious,” Dr Fitzgerald said.

Within a minute of arrival doctors can X-ray the patient’s chest or pelvis. They can immediately run ultrasounds around the chest or abdomen to see if there is any damage to the heart.

Doctors can even continue resuscitating patients while running a CT scan.

“Last financial year we saw 1300 severely injured people with life-threatening injuries. We are among the top 10 trauma centres in the world,” Dr Fitzgerald said.

On average, four severely injured people with life-threatening injuries are treated at the trauma centre a day. Doctors rank the patient’s survival rate on a scale of 1 to 5. The scoring system is precise - not observer-based or subjective.

“The score links to the likelihood of death. If you add the injuries together you can build a particular score,” Dr Fitzgerald said.

“Time is critical.”

Chances of survival are always changing.

Injuries that would have killed a person 15 years now often have a high survival rate.

“The system is so sophisticated. If you ruptured your heart 15 years ago you basically died – now chances of survival are 26 per cent,” Dr Fitzgerald said.

Increased life expectancy and an ageing population have produced challenges for doctors. Dr Fitzgerald has seen a significant increase in the number of people aged 70 or over presenting with serious road trauma injuries.

Pre-existing medical conditions such as diabetes, the fact that many elderly people are on blood-thinning medication, and pre-existing heart conditions affects their ability to survive severe trauma.

“People are living with conditions that years ago would’ve killed them and sometimes the trauma is compounded. If someone is on blood-thinning medication and has a severe head injury they can haemorrhage into the brain – that will kill you,” Dr Fitzgerald said.

Technology has heralded the greatest change in medicine for the past few decades, Dr Fitzgerald said. Starting out in 1982 at Ballarat Base Hospital, Dr Fitzgerald led casualty wards and set up the St John of God emergency department in Ballarat before he was seconded to The Alfred in 1993.

“Each year I saw people surviving things that I didn’t expect them to survive the year before. Particularly back when I was at Ballarat Base Hospital, I did everything that I possibly could have and they might have died - now you wouldn’t expect someone to die from those type of injuries,” Dr Fitzgerald said.

“It’s better to be late than dead on time.”

BALLARAT emergency department director Andrew Crellin has seen it all. He used to work in some of Melbourne’s busiest hospitals and these days, as head of a regional emergency department in a growing area, his day is flat out.

Ballarat Base Hospital averages more than 160 patients a day. Dr Crellin deals with all types of issues, but road trauma remains one of the worst types.

“Increasingly we are seeing patients with a variety of trauma. In some cases, they are too sick to be flown to The Alfred. If the weather is not safe for flying, the worst cases will go straight to Ballarat,” he said.

“We are set up to deal with the worst."

“We see everything, including major neuro trauma – that includes trauma that is life-threatening and life-altering.”

A trauma team at Ballarat Base Hospital is similar to one at The Alfred and includes surgeons, doctors and trauma nurses. Doctors test patients for a number of things and attempt to stabilise them and treat them immediately.

While stabilisation before transfer is important, medical professionals at Ballarat also perform essential, time-critical treatment – including inserting chest tubes, pain relief, fluid increase and surgery.

Young people remain most affected by road trauma, but doctors are increasingly seeing trauma across all age groups.

“We see a broad spectrum of drivers in road trauma. Speed, alcohol, drugs, inattention of the road, being too tired – they all play a part,” Dr Crellin said.

“The biggest changer of lives is the head trauma – neurological trauma. Major trauma is a result of a major incident. Most of it is because something very wrong has happened.”

“Seven days a week, 24 hours a day - be vigilant when driving.”
Next time…

The consequences: What happens when you are to blame?

Credits:
WORDS | Erin McFadden & Olivia Shying.
PHOTOS | Fairfax photographers and file images.
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