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Trauma Team Works Outside the ER

When Dr. James C. Jones saw the trauma alert, he knew his expertise was needed for an important medical situation. He didn't know at the time, however, that he'd soon be contemplating amputation involving a 15-year-old boy 10 miles away from Southeast Alabama Medical Center.

Less than 20 minutes later, Jones, an emergency physician and the medical director of SAMC's emergency department, was on his way to Ashford with an anesthesiologist, a vascular surgeon and an orthopedic surgeon, the boy's future hinging on their decisions and actions.

When they arrived on scene at Summerford Pallet, they were greeted by a horrific sight. Brian Jacobs Jr. had fallen into an auger machine while helping his stepfather at work, and his legs were stuck in the machine, which is used to grind mulch. When local emergency responders first arrived, they feared amputation was the only way to remove Jacobs from the auger. That's when they called in the SAMC trauma team.

"They were asking for a team to come and possibly amputate an extremity or both extremities to free the patient," Jones said. "We put together a team of emergency staff to evaluate and assist in working to get the patient out. We were there if they needed us." Luckily for Jacobs, it didn't come to that.

Dothan Fire Chief Larry Williams led a team of paramedics and firefighters that developed a plan to remove the boy from the machine without the need to amputate. They consulted the trauma team and decided to go ahead with the process. The decision, however, wasn't an easy one to make. "There were some medical decisions that had to be made regarding the best way to extricate the patient," Jones said. "We had some opinions about the timeline of how long would it take versus another way. We had to weigh the risk of doing it one way with the benefit of getting him out, factoring in the timeline."

The longer Jacobs stayed in the machine, the harder it would become for him to survive. Ultimately, however, the team went to work and managed to save not only his life, but his legs as well. "It was a successful venture. We were able to extricate the patient using a process of supporting the patient while he was trapped in the machine," Jones said. "Our fire medics got in and got multiple IVs started, then when our trauma team arrived, we were able to begin giving the patient universal donor blood to support him. We worked to prevent shock there on the scene, which allowed us the time necessary to actually deconstruct the auger apparatus he was trapped in, and we were able to basically hoist him up and unwrap his legs." From there, the team took care of Jacobs' multiple fractures, and he was airlifted to SAMC, where he only stayed for a little more than a week before being discharged in good condition.

Instances like that one, which happened June 8, are rare. Most trauma patients are treated in the emergency rooms of hospitals. "From time to time, we get calls requesting physicians at the scene," Jones said. "It's rare. There are times when we have physicians at the scene assisting, but it is rare that a physician has to perform a procedure in the field. In fact, probably 99 percent of the time, EMTs and paramedics handle the patient prior to getting to the hospital." When those situations do arrive, however, emergency physicians need to be ready to respond at a moment's notice.

"One other time, probably two years ago, I got a call at 2 in the morning about a patient trapped in a vehicle, and a Dothan policeman picked me up at my home and drove me to the scene," Jones said. "In that case, we were able to extricate the patient without amputating the extremity, too. We've been able to meet every pre-hospital challenge we've been dealt."

Trauma teams consist of an emergency physician, an anesthesiologist and any specialty surgeons that may be required for the situation. According to Jones, any surgeon on call carries a trauma alert beeper, while an anesthesiologist is picked at the beginning of each day.

Even though they aren't often faced, outside environments pose unique and ever-changing problems for the teams that assemble. "Pre-hospital medicine is very different from hospital medicine," Jones said. "It may be dark outside, it may be raining or the patient could be upside down in a vehicle in a ditch. The whole process of caring for patients in non-traditional hospital settings is an art in and of itself." That art takes quite a while to master. "We spend a number of months training in the field for this," Jones said. "No two situations are exactly alike. Scene assessment is part of it. When you go into a pre-hospital environment, scene safety is an issue and making sure you don't get injured in the same fashion the patient was injured."

Despite the pressures of dealing with trauma patients, the last thing trauma team members want to do is panic. Most trauma patients are treated in the emergency room, an enclosed environment that is often filled with other victims. "If it's early morning and there's not a lot going on, it's no big deal," said Charlie Tew, associate director of nursing services at Flowers Hospital. "At busy times, it is a little more urgent. The charge nurse or nurse manager will evaluate where we need to put this trauma patient. They'll make space to get that patient, make sure everything in that room is ready to go. We want to always look, assess and be ready to go."

Doctors and nurses have to overcome the crowded nature without panicking. "It's a busy place, but the words 'hectic' and 'frantic' are never good adjectives to describe the ER, because they denote chaos and disorder," Tew said. "Just because you have two trauma alerts at the same time and an ER full of people, getting flustered is not productive. You want to look at it, take care of it and move on." According to Jones, the team's success is owed to that composure and teamwork. They may not be miracle workers, but to victims like Jacobs, the trauma team doctors, surgeons and nurses are lifesavers.


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