A Night in Emergency
Torin Constable is doing what any 11-year-old boy might do on a warm, summer day – climbing the old maple tree in his front yard.
On his way down, his foot lodges between the trunk and a branch. When he yanks it free, he loses his balance and falls hard to the ground, striking the back of his head on a rock.
He is unconscious, and blood trickles from his ears.
He needs help, and he needs it fast.
“When someone is critically injured, minutes matter,” says Robert Muelleman, MD, emergency medicine specialist and medical director of the Emergency Department at The Nebraska Medical Center. “In emergency medicine, we call it ‘the golden hour’ – the time in which severely traumatized patients need to be stabilized if they are to have a chance.”
The Nebraska Medical Center’s Emergency Department (ED) brings together an extraordinary range of capabilities and technology including highly-trained emergency physicians and nurses, the latest imaging and therapeutic technologies and on-call specialists in nearly every field – all available 24 hours a day, seven days a week.
The new, 33-bed ED, located in the hospital’s Hixson-Lied Center, is the largest emergency department in the Midwest and one of two designated trauma centers in Omaha, treating 44,000 patients a year – an average of 120 patients each day. As a designated trauma center, the ED has all the components necessary for lifesaving care, including physicians, surgeons and anesthesiologists as well as vital diagnostic equipment such as CT scans.
“The ability of an experienced medical staff to respond quickly and decisively with the latest medical technology can make the difference between life and death,” says Richard Walker, MD, emergency physician and clinical director of the ED at The Nebraska Medical Center.
The medical center’s on-call trauma team is activated an average of 10 times a week. “The presence of these individuals is important in a trauma situation,” says Suzanne Watson, RN, BSN, clinical manager for the ED. “Each provides a critical service to the patient and allows us to get many things accomplished in a very short period of time. The patient’s outcome has a lot to do with the care they receive from the emergency staff.”
The ED has a variety of sub specialists on call, says Kathy Warren, RN, BSN, trauma nurse coordinator. “We have orthopedic surgeons who specialize in hands, backs, necks or knees; and we have neurosurgeons who can be available within minutes of a trauma call.”
Activation of the trauma team begins with a report from on-scene paramedics to the ED doctor on call. If the doctor determines that the trauma team is needed, the team is paged. Within five minutes, as many as 20 healthcare professionals assemble in the trauma bay.
The Nebraska Medical Center’s team includes 15 emergency-trained and board-certified physicians. As many as a dozen nurses, trauma-trained and certified, staff the ED during its busiest times, in addition to seven technicians, a phlebotomist and a pharmacist, respiratory therapists, radiation technologists and environmental service clerks. The trauma medical director for the state, Joseph Stothert, MD, also critical-care and trauma trained, is on staff and on call at The Nebraska Medical Center.
It is immediately clear to paramedics that Torin Constable has been critically injured. They request LifeNet helicopter to respond and take him to The Nebraska Medical Center ED trauma center.
Trauma team members are in place when Torin arrives. Acting according to Advanced Trauma Life Support (ATLS) protocols, the team performs the airway, breathing, circulation and disability (ABCD) primary assessment. The attending physician’s assessments are charted by the recording nurse.
Quickly and methodically, the team moves to a secondary assessment, a “look, listen and feel” inspection of Torin’s head, neck, chest, abdomen, pelvis and back. If needed, a “fast test” ultrasound machine can be rolled bedside to provide a more accurate diagnosis of any abdominal injuries.
Within approximately 15 minutes of arriving at the trauma bay, Torin is wheeled to the CT scan room to assess the extent of his brain injury.
Trauma cases are defined as those involving life-threatening injuries. Paramedics and emergency medical technicians (EMTs) identify the criteria before referring to a trauma center: unstable vital signs, loss of consciousness, and abdominal or chest pain. Common non-trauma cases include undefined illnesses, pain, shortness of breath, appendicitis, ulcers, asthma or allergic reactions.
Providing order in a hectic environment, the ED at The Nebraska Medical Center is designed to place patients in treatment rooms specifically equipped according to the severity of their injury or illness. There are rooms for non-critical cases, exam room specialty beds, 13 critical-care private rooms, an eight-bed clinical decision unit for short-stay patients, and a separate four-bed trauma suite. For patients with severe brain injuries, two radiology rooms equipped with high-technology CAT scans are a few steps from the trauma suites.
“Our philosophy is that we will see anyone for any thing at any time,” says Dr. Muelleman. “A great deal of planning went into the ED’s design to provide the most efficient, technologically-advanced and work-friendly space, and to allow for optimal care of our patients.”
Having immediate access to the most advanced technology allows medical staff to diagnose more quickly and intervene with lifesaving treatments.
The Nebraska Medical Center’s stroke team, a specialized team of healthcare experts trained to provide critical treatment to stroke patients, uses a well-defined, systematic approach. Studies indicate patients treated within three hours of an acute stroke using specialized treatments and medications experience the most positive outcomes. The medical center is home to the only nationally-certified stroke center in the region.
Care has also been elevated for heart attack victims. To halt the effects of an acute heart attack, the 24-hour Cath Lab team can be activated and ready to respond within 30 minutes. “Ten years ago, we would monitor them and then send them to cardiac rehab,” Dr. Walker says. “Now our goal is to administer a clot-busting drug within 30 minutes of arriving at the ED, followed by emergency angioplasty. The new protocols are responsible for saving lives and greatly minimizing the damage incurred to the heart.”
Ultrasound has become a valuable tool for diagnosing trauma injuries, pregnancy issues and aortic aneurysms, he says. Other technologies improving ED efficiency include an electronic tracking board that helps prioritize patient care, alerting staff when lab results are ready and flashing red when a critical result comes through; electronic documentation of patient records to improve continuity; and low-frequency cellular phones so ED staff may communicate without the use of the overhead intercom system.
“This is the most state-of-the-art facility in the region,” Dr. Walker says. “Our goal is to provide the best experience and care to every patient.”
Torin’s head injury is diagnosed with the aid of The Nebraska Medical Center’s new rapid-image CT scanner, which is capable of capturing the image of an internal organ in one second or a complete body trauma scan in 10 seconds.
The 11-year-old is experiencing bleeding and severe swelling in the brain. A neurosurgeon sees Torin within minutes of the brain scan. The boy’s parents, Howard and Missy Constable, are briefed on his condition. Friends and family members join them in the waiting room.
Torin is transferred to the pediatric intensive care unit (PICU) and placed on an intracranial pressure monitor (ICP) to monitor the pressure in his skull and his brain tissue oxygenation.
Warren, the trauma nurse coordinator, says the ICP monitor has dramatically improved the outcomes for these patients. “Ten years ago, we didn’t have monitors to track blood pressure and brain tissue oxygenation.?We now know that it’s important to keep blood pressure as high as possible in order to increase blood supply to the brain, which is exactly the opposite of what we used to do.”
The decision is made to take Torin to surgery to stop the bleeding and relieve pressure from the swelling. Tears well up in his mother’s eyes as she steals a glimpse of him for the first time since he was carried from her front yard. She whispers encouragement as Torin squeezes her hand.
In the ED, no two days are ever the same. “We are staffed to handle whatever situation comes our way,” Dr. Walker says. “During our busiest nights, it can be quite demanding with multiple patients coming in at a time. You never know what kind of situation you are going to walk into.”
The Nebraska Medical Center is home to the first and only emergency medicine residency program in the state. The goal is to increase the number of emergency-trained, board-certified physicians practicing in rural communities across Nebraska. “This is another indication of our commitment to quality medicine,” Dr. Muelleman says. “Our emergency physicians are involved in advancing the field of emergency medicine not only through their clinical work, but also through teaching and research.”
Technology, knowledge and experience are combining to make a significant difference. “Thanks to our state-of-the-art ED, we can respond and help patients in the most critically dire situations,” Dr. Walker says, “some of whom in the past may have had no hope.”
Afraid to leave their son for more than a heartbeat, Missy and Howard settle into the PICU waiting area for what will be a long vigil
“The first 72 hours were touch and go,” Howard recalls. “Torin’s condition would change from one hour to the next. His doctors were continually tweaking his medications and breathing pattern to find the best scenario for that particular hour. It was a very difficult and emotional time.”
By Day 17, Torin begins to show signs of improvement. He is responding to massages, and he squeezes his parents’ hands when asked. “In terms of emotional impact, seeing Torin begin to respond and knowing there was hope ranked right up there with seeing my children being born,” Howard says.
After three weeks, Torin is ready to leave the hospital and begin rehabilitation.
“The doctors at The Nebraska Medical Center were godsends for us,” says Missy. “They did everything in their power to save Torin’s life. The ICU nurses were also a big part of it. They were there every day and made sure he was comfortable. They always kept us informed of what was happening. We could tell they were truly concerned about Torin and about us.”
Today, Torin continues to receive occupational, speech and physical therapy. He is back in school, but only for half-days. He must relearn many things that were second nature to him before the accident, but is continuing to progress, his mother says.
“I don’t think it will be too long before he’s on the baseball field again,” she says.
Enjoying a warm summer day like 11-year-old boys do, but keeping a safe distance from that old maple tree.