LJIDOL SEASON 8 PROMPT 5

INCONCEIVABLE
TRAUMA TRIAGE DOING GRAPHIC TRIAGE THINGS

Traveling on I-65 at seventy miles an hour Danny felt safe since he’d installed his extra headlight with a brighter beam on his motorcycle. He hadn’t counted on a seventeen year old Max driving and texting in his Daddy’s Suburban. Max swerved over into the other lane without a glance in his mirror.

Danny didn’t have a chance; he and his Harley hit the embankment sideways spun in the air, and ricocheted off the thirty foot Privacy walls that keep the traffic noise down for the residents. The Harley cracked under the pressure of hitting the wall at 70 mph tearing Danny’s right leg off in the middle of his thigh. A car stopped immediately behind the accident and a man used his tie as a tourniquet while his wife called 911.

Luckily the next exit had a fire station so the EMTs were there within minutes and used hemostats (clamps) on the large vessels and undid the tourniquet. They found his leg and packed it in ice before LifeFlight landed on the interstate having had traffic stopped by the police.

Meanwhile, in triage. it was one of those nights, mainly because we had a lazy, incompetent resident. Rotations had just changed (SIGH) and I had two nurses in training that followed my every move, one scribbled down my every word (which is good) and the other said she could remember everything (which is not so good.)

I notified the resident we had a catastrophic injury in flight. He shrugged; he was arrogant, did as little as possible and thought he knew everything.

I slipped out and made calls to the Vascular Attending I knew was still in house and I called the Neurology Attending who was in house due to a VIP patient. Finally I woke the on-call resident for Orthopedic Surgery.

I heard the blades shredding the air outside the triage unit, the thump of a landing so I ran and drafted Paula to help and re-entered triage. Moments later the automatic door burst open and Danny’s gurney was pushed through. The paramedic rapidly med-spoke the vital data. They’d left the helmet on and placed a soft collar around his neck. He strapped to a back board.

“How am I supposed to start a central line with that thing on,” the resident actually whined at me.

“We’ll start a line in his arm to draw labs and to start IV fluids, while the portable scans are run over the rest of him.”

“I’m just supposed to stand here?”

“Unless YOU want to do it. There is his leg.”

He huffed, “What's to be gained by wasting my time on something with a staggering chance of reattachment. Clean up the stump, that's a nurse's job. Well, get to it. I’m going to the lounge. Call me when the labs and scans are back.”

I bent to hear Danny ask me if he were going to live.

"Of course."

"And my leg? The doctor said..."

"That was a learning doctor, he doesn't know. I'm going to put you to sleep and some of the best surgeons in the world are going to be taking care of you. Now go to sleep and dream peacefully." I'd have liked to strangled the resident.

***********

(GRAPHIC ALERT, SKIP NEXT 2 PARAGRAPHS IF SQUEAMISH)

Keep in mind he hadn’t bothered to look at the young man’s leg, either part.
The patient's skin was torn and raw. The femur(long bone) protruded about six inches, it was a clean break no loose shards. The hemostats were holding. We covered the bone with a with an icy wet sterile dressing. There was some oozing of serosanguineous fluid from around the muscle mostly capillary blood. This was continuously flushed with sterile water until all debris was cleared.

I checked the severed limb. There were torn muscles and skin. A deep hole in the center, a light shined inside showed the break matched his leg bone with no shards. The worst part was the long tendon that runs from the hip across the knee to the inner ankle. When severed it curled and rolled up and down. That was part of Ortho's job -- re-attaching that tendon. The flesh was still red and viable.

***********

“Alright, Ladies, these are extra-long tweezers. Carrie, you are going to pluck every piece of foreign material out of his stump and Gina, we are going to ice wrap his leg over here on this gurney and you will do the same. Paula will supervise, her word is law. Be extremely careful what you pluck or you may damage nerves or vessels or tissue. Let Paula do inside the femur tunnel"

Both were horrified. “You can’t imagine that his leg can be put back together, it's impossible?"

"That's incredible.”

“The patient is awake watch what you say and yes, it’s a clean break the tissue looks good. I think he has a good chance,” I hissed softly. "And in triage you'll learn anything is possible.

“BUT...but...how can you think...”

“To work, hurry; pay close attention to what you grab with each pinch of those tweezers. Use the magnifier if needed.”

The labs and scans returned -- no head trauma. The helmet had saved him there, but a cervical disk in the neck was putting pressure on the spinal cord causing it to swell. Still we left the helmet to be removed in surgery. No internal injuries miraculously showed up. A dislocated shoulder on the damaged side and wrist fracture were all the broken bones.

The resident ordered a huge dose of a steroid IV push for the spinal swelling and 2 units of PRBCs (blood). He finally deigned to examine the torn shattered leg. He pronounced it unsalvageable and gave orders to remove the hemostats and place a tourniquet. He began DE-gowning, he was done.

I was grateful we had sedated the patient for the resident certainly hadn’t bothered to check.

“With that neck injury he’s probably going to be a quad anyway,” he nonchalantly predicted as he pulled off his gloves--he had never touched the patient.

I never, well usually never, refuse a doctor’s order, but remember that temper I told you about last season, pure fury.

"NO! I REFUSE! You only gave his leg a cursory look and didn't bother to check the severed limb. You are supposed to help people to start the healing process in triage. But you've decided to play God with his life not bothering to consult Vascular or Neuro or Ortho doctors. You never examined the severed leg; you never put YOUR hands on the patient. You are the laziest resident I have ever had the misfortune to work with. You care nothing about the patient, whether he lives, how this will affect his life, his family. YOU'RE A SELFISH JERK. You didn't even check to see if the patient was awake when you made your pronouncement. Oh. AND you are an incompetent ass, and a danger to patients.” In for a penny and all that.

He actually turned purple. I thought he was going to have a stroke, and he opened his mouth but before he could say anything the Vascular and Neuro Attending walked in, gowned up and went to examine the patient.

The resident puffed up and twice began to speak and both times an Attending held up a finger to silence him. I handed the neck scan to the Neuro doctor. I'm afraid they overheard me. My voice was raised a tiny bit. Well maybe more than tiny.

The Vascular Attending (who is the one who reconnects all those blood vessels) smiled at my girls, “You did a fine job cleansing out all the debris. He used the tweezers to stir the bowl, “No gravel, makes our job easier, severed leg looks good. I believe we can put Mr. K.’s leg back where it belongs and after rehab he’ll be better than before with the titanium rods Ortho will bond to his femur.”

“Why bother when he’s gonna end up a quad?” this from the idiot resident to Attending doctors. He should have known. I almost...almost felt sorry for what I knew would happen later.

“The spinal cord isn’t severed or even punctured. We’ll remove the cervical disk and do a little fusing and I think once his swelling recedes, he’ll be good as new.” To me, “Can you spare a couple of Care Partners to take him down to surgical suite six they are waiting? Don’t forget the leg. And thanks for the calls."

The resident glared at me, "You called Attending without an order from me?"

“You,” the Neuro Attending pointed to the resident, “with me.”

Thank heaven the remainder of the night was GSWs (gunshot wounds) and knifings. The resident did not address me all night; he relayed orders through my two girls as if I weren't there. It would have been funny if his attitude weren’t so terrifying for future patients.

As the shift neared the end, he informed me he would have my job since I blatantly refused a direct order from a doctor. That is a big no no.

“Go for it, Big Boy,” I infuriated the scrawny runt and I didn't care.

Day shift arrived and report had been given. With trepidation I saw the Trauma Attending as he stormed toward me hand filled with papers He looked like thunder. Thrust them into my hands, “Read.”

I couldn't prevent the frustrated sigh that escaped. The Vascular and Neuro and Ortho Attendings had written him up didn’t surprise me; but my two nurses, Paula and both Care Partners all wrote the night up about the resident and put them under the Trauma Attendings door.

“Well? Are they true?" A nod. " Then where the hell is yours? Sit and write it now. Why didn't you call me?”

“You know I don’t like writing people up. And I already had three surgeons what would be gained by getting you out of bed?”

“The ass is going to go to David (my boss). Probably is in his office right now about you. Write. Barbra, do you want him back here tonight? He would have destroyed that boy's life and his family would believe it was the accident; no one but you nurses would have known the truth. He's a liability to the patients and the hospital. WRITE.”

I did as he asked but wasn’t happy about it. David rarely came in before nine so he could stay over into the next shift. So I didn't have to deal with it today.

Nothing was ever said by my boss. However, a week later I was summoned to a committee meeting, sat and recapitulated the entire night to two men in suits and six Attendings. Then I was summarily dismissed. "Thank you. You may go." Never heard even through the grapevine what happened to him; but he did not return to Trauma and I never saw him anywhere in the hospital.

A year or so later Danny walked into Trauma one night with boxes of pizza to thank us for saving his life. I told him the surgeons did that. But he just smiled at me and thanked us all again.

You get hardened to what comes through those double doors so I sometime think nothing of a traumatic amputation as graphic when it is to the general population. Please, if you think something's too graphic let me know so I can place warnings.

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