Chapter 2_Saving Lives The Golden Hour-pp 30-41

Chapter 2_Saving Lives The Golden Hour-pp 30-41 - 'tWO'...

Info iconThis preview shows pages 1–12. Sign up to view the full content.

View Full Document Right Arrow Icon
Background image of page 1

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 2
Background image of page 3

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 4
Background image of page 5

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 6
Background image of page 7

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 8
Background image of page 9

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 10
Background image of page 11

Info iconThis preview has intentionally blurred sections. Sign up to view the full version.

View Full DocumentRight Arrow Icon
Background image of page 12
This is the end of the preview. Sign up to access the rest of the document.

Unformatted text preview: 'tWO' Saving Lives: The Golden Hour Emergency room doctors and nurses speak of the “golden hour.” If the victim’s airways are open and he or she isn’t hemorrhaging from a major artery, then the body’s vital systems continue to func— tion relatively well for about sixty minutes following major trauma. After that, those systems left unaided tend to decline toward death or permanent damage to major organs. Treatment of severe trau- matic brain injury almost always involves surgery, and the patient wheeled into the operating room within or close to that golden hour stands a much better chance of surviving the stress of an operation. If surgery isn’t performed within four hours, a victim of a serious closed head injury usually is beyond saving. One San Diego study followed eighty—two brain-trauma patients with sub— dural hematomas—blood clots under the brain’s tough outer layer. The mortality rate was 30 percent for those operated on within four hours of injury, 90 percent for those who waited longer. In severe head trauma, it’s not just the sudden mechanical dam- age that kills and disables. Much of the destruction results from what neuroscientists call secondary insults. Many of these delayed injuries result from the brain’s reaction to the initial impact. Take the most immediately life—threatening secondary insult, lack of oxygen. Although accounting for only one—fiftieth of the body’s weight, the brain demands one—fifth of its oxygen. Without oxy— gen, brain cells begin to die within six minutes. A fall or motor— cycle accident may block a victim’s airway or cause bleeding severe enough to interrupt the flow of oxygen to the brain. Or hema- tomas pressing on sections of the brain can cut off the supply to those areas. Such clots are the major cause of what neuroscientists call “talk-and—die syndrome,” in which a patient is conscious and oriented enough to speak after a head injury yet doesn’t survive. Like any bruised or lacerated tissue, the battered brain swells. But unlike an injured muscle, the swollen brain can expand only so far. When it reaches the bony casing of the skull, the internal pressure builds, squeezing blood vessels and cutting off the flow of oxygen and nutrients. Half of all brain-injury deaths in patients who teach the hospital alive result from this uncontrolled pressure. Even when the seriously injured brain gets enough oxygen, its chemical balance goes haywire. For reasons that medical science has yet to fathom, the injured brain becomes more acidic; until its pH, or acid—base balance, is brought under control, the whole brain, not just the injured part, operates abnormally. Because the brain regulates all physical functions essential to life, the victim may die or suffer permanent physical damage if the problem is not corrected quickly. Ensuring such swift treatment is the job of, among others, Life Flight pilot Al Vaiani. He spends most of his workdays in John Sealy Hospital’s trauma area—the part of the emergency room set aside for victims of life—threatening injuries. The physicians, nurses, and emergency medical technicians (EMTS) who work in the crash Saving Lives I I unit focus their skill and energy on two things: saving lives and preventing further damage during the crucial first few hours after injury. When a victim of accident or Violence rolls through those doors, the trauma team puts on what basketball players would call a full court press. From his small office,Vaiani supervises the care of the Life Flight helicopter, a specially equipped Messerschmidt BK—117 that he flies for the University of Texas Medical Branch. He also waits for codes to appear on his beeper’s digital display: 1111 means “Stand by”; 1188, “Come on ahead.” Around the country, major medical centers retain services like Life Flight as the front line in their battle to save the lives of trauma victims. Trips from accident scene to emergency room that might take hours in an ambulance can be accomplished in minutes by air. Medical evacuation helicopters are nimble enough to land on railroad tracks. They fly loaded with essential drugs and equipment and staffed by emergency medical technicians (often registered nurses) trained in trauma care, so life—saving measures that once had to wait for the hospital can be performed at the scene and in flight. Police, sheriff ’s deputies, state troopers, and fire departments’ emergency medical service teams call on Life Flight to transport the victims of potentially fatal catastrophes ranging from heart attacks to knifings. But the most common are motor vehicle accidents, which are also the most frequent cause of severe head trauma: in the United States, 44 percent of traumatic brain injuries and 57 percent of head—injury deaths result from car, truck, van, and motorcycle wrecks. In about 70 percent of fatal vehicle crashes, brain trauma is the cause of death; in more than two-thirds of the automobile accidents in which people are hurt, someone suffers a head injury. The next most common culprit in brain trauma is violence, including gunshot wounds, accounting for 30 percent of Saving Lives 0 a cases. Serious falls, like my own plunge just before I turned two, are third, causing 10 percent of traumatic brain injury among the population in general and a larger proportion among young chil— dren and the elderly. Head injury alone is sufficient reason for transport by Life Flight. That’s because the speed with which a victim receives help often means the difference between life and death or between recovery and lifelong disability. Sixty percent of the people who die from brain trauma do so before reaching the hospital, and many of those expire because they just don’t get there fast enough. Because speed is so essential in trauma care, Al Vaiani’s heli— copter sits on a concrete pad just outside the John Sealy Hospital crash unit. Normally, he and the Life Flight team of two registered nurses, both trained in trauma care, lift off three and a half to five minutes after the 1188 code appears on his beeper. The nurses ride in the rear of the aircraft, which is fitted with two removable rigid backboards and hookups for the monitors and equipment that will help keep the victim or victims alive on the trip back. On the seat to Vaiani’s right, a rack holds detailed maps to help him locate the scene of the injury. If the victim is lucky, the accident hap- pens somewhere in the fifty miles between Galveston and Houston. Both cities have major medical centers staffed with neurosurgeons and equipped with the latest diagnostic technologies. And both have Life Flight helicopters. Vaiani can reach Friendswood, halfway to Houston, in twelve minutes. Once he’s airborne,Vaiani radios ahead to the police or troopers on the ground. He gets an update on the circumstances of the trauma, the number of victims, their conditions, and the character— istics of the site. If the victim crashed a car on the interstate,Vaiani asks for reassurance that traffic has been blocked off; if the victim drove it into a marsh,Vaiani needs to know the nearest dry place to land. He checks the location of any spilled fuel or downed power Saving Live: a o lines. If the head injury resulted from domestic violence or a drive- by shooting, Vaiani makes sure that police have secured the scene so he won’t come under fire as he sets the craft down. With the crew keeping an eye out for obstacles and for other air— craft, Vaiani lands on a hard surface 100 to 150 feet from the site. The nurses jump out, carrying a backboard piled with the equip- ment and medications that they think they’ll need. Among these are an intravenous solution of mannitol, a diuretic drug that helps control brain swelling; a ten—inch cube that monitors blood pres— sure, heart rate, oxygen saturation, and carbon dioxide levels; both nasal and oral breathing tubes; and an ambu-bag, an oxygen unit fitted with a bag-valve mask. Toting this potentially life—saving burden, the nurses walk briskly to the trauma scene. Sometimes the victim is still pinned in the wreckage. In that case, one of the trauma staff climbs in with him or her and gets to work while the Jaws of Life are cutting away at the metal. The first step is to make sure that the victim is getting the oxy- gen the brain needs. That means seeing to it that the patient has an open airway and is breathing well enough on his or her own. “Oxygen is the one drug that you never withhold,” explains trauma nurse Barbara Bowers, the program coordinator for Life Flight at the University of Texas Medical Branch. “If the patient is awake and alert, we give him the breather mask. If he’s unconscious or real groggy, we intubate him.” Intubation is the process of inserting a flexible plastic breathing tube to open the victim’s airway and prevent the tongue and mu— cous from blocking it. If the head injuries don’t involve the face, nurses use nasal tubes; if the area around the nose is damaged, they use a mouth tube. In either case, they avoid tilting the victim’s head back; if the patient has a crushed vertebra high in the neck, that could damage the spinal cord. Anyone suffering head trauma from Saving Live: .34- a vehicle accident or a fall is likely to have other serious injuries as well. Once the patient is breathing, the trauma team immobilizes the head with a cervical collar and a head brace secured by one tape across the forehead and one across the chin. Then they treat any life—threatening bleeding or shock. Stabilizing the victim well enough for transport takes no more than fifteen or twenty minutes. While they’re working flat—out to get the patient to the hospital alive, the nurses try to assess the ex— tent of the brain injury. They use a test called the Glasgow Coma Scale (see the accompanying table). The possible score ranges from three to fifteen points. A score of eight or fewer points indicates a serious brain injury; a reading of thirteen to fifteen generally points to relatively mild damage and a good chance of full recovery. But an alert accident victim can slip into unconsciousness, an initially comatose patient can begin to come around, and the alcohol in— toxication common in both motor vehicle wrecks and falls can make a head injury seem more severe than it is. For these reasons, the nurses often perform the Glasgow twice—once on the scene and again en route—to detect changes for better or worse. On the flight back to the hospital, the Life Flight staff moni— tors vital signs and gives the victim whatever help he or she needs to get to the emergency room with the best chance of survival and recovery. That often means starting intravenous mannitol and sometimes other drugs to reduce pressure inside the skull. It always means administering pure oxygen and monitoring the carbon di— oxide level; keeping the amount of carbon dioxide below normal helps reduce brain swelling. When the Life Flight helicopter touches down outside the trauma center, the crew unloads “hot”——with the helicopter’s ro— tors still whirling—if they think the two and a half minutes re— quired to shut them down will make a difference. The trauma staff rushes to stabilize the victim well enough to make it through Saving Live: a o . i. E: ii j g Glasgow Coma Scale Examiner's Assigned [CSI Patient’s [CSPODSC SCOI‘C Eye opening Spontaneous Opens eyes on own Commands Opens eyes when loudly asked to do so Pain Opens eyes upon pressure Pain Does not open eyes Best motor response Commands Follows simple commands Pain Pulls examiner’s hand away upon pressure Pain Pulls part of body away upon pressure Pain Flexes body inappropriately to pain (decorticate posturing) Pain Body becomes rigid in an extended position upon pres- sure (decerebrate posturing) Has no motor response to pressure Verbal response Carries on a lucid conversation and tells examiner where he or she is, who he or she is, and the month and year Speech Seems confused or disoriented Speech Says words that examiner can understand but makes no sense Speech Makes sounds that examiner cannot understand Speech Makes no sound evaluation and surgery. With a helicopter evacuation patient, this generally takes no more than a few minutes; much of what the hos— pital trauma unit would do initially has already been done at the scene and in transit. Until a few years ago, head injury victims went straight from the trauma unit to the operating room. Nowadays, they have a CT scan first. Invented in 1973, computerized tomography combines X rays with computer imaging to produce three-dimensional representa— tions of the brain, visually slicing it into cross sections to pinpoint the operable lesions and hematomas caused by the head injury. A CT scan acts like radar, showing the brain surgeon where to cut. “If you operate without a CT scan, you might get into trouble,” explains Greeley, Colorado, neurosurgeon Pam Harmann. “It’s not the case, like you see in the movies, that external signs like a blown pupil on one side or paralysis on the other can tell you where the patient might have an operable lesion.” Sometimes the evaluation stafic also uses magnetic resonance imaging, or MRI, which can pick up small lesions that CT scans may miss. “If there’s an identifiable lesion, we’ll operate on any— one who has any sign of life,” Dr. Harmann says. An even more recent noninvasive imaging technique, positron emission tomogra— phy (PET), identifies irregularities in the brain’s chemical balance and metabolism. Even if no lesions or hematomas show up on scans, the brain may be seriously damaged. Life—threatening swelling can result from diffuse axonal injuries—the little bleedings that commonly occur when the head speeds up and then stops suddenly, as in vehicle accidents and falls. All too often, patients with traumatic brain injuries but normal CT scans end up dead, vegetative, or severely disabled. To prevent this, neurosurgeons frequently place a fiber-optic intracranial pressure monitor in one of the brain’s fluid Saving Lives u o spaces, or ventricles, and a ventriculostomy to drain off excess fluid into a bag. Surgery for severe head injury is an ordeal demanding hours of precise work on tiny structures within the restrictive confines of the skull. On March 31, 1981, when a bullet intended for Ronald Reagan hit his press secretary, James Brady, in the forehead, neuro- surgeons needed six and a half hours to remove the trail of metal and bone fragments and the slug itself, which had lodged near his right ear. Brady made a relatively good recovery. Although he re— mains partially paralyzed, he can walk with a cane, and he retains his sense of humor and his interest in writing. But there was no way that his doctors could have known that. Like the Life Flight emer— gency rescue team, the emergency room team and neurosurgeons focused on saving his life and minimizing the secondary damage. After the initial operation, the head—injured patient often needs more surgeries as the long, delicate, acute—care stage begins. Main— taining oxygen intake and controlling swelling continue to be key to survival and recovery, so the acute—care team hooks the patient to a respirator and administers diuretics to minimize fluid buildup. If this fails to control intracranial pressure, they may use barbitu- rates to put him or her into an artificial coma or give Pavulon (a long-acting muscle relaxant) combined with morphine as a seda— tive for inducing paralysis. Researchers aren’t sure why these drugs sometimes work, but they suspect that slowing the body’s func- tions reduces blood flow to the brain. The most recent treatment that shows promise in reducing swelling consists of lowering the brain’s temperature by two degrees Fahrenheit. Damage to the brain stem—the part of the brain that controls breathing, heart rate, blood pressure, and body temperature— means that the patient needs assistance with all these vital functions. Damage throughout the brain can disrupt the body’s immune re— sponse, so fighting infection, from both penetrating wounds and Saving Live: 0 n surgery, is a major challenge. Traumatic brain injury patients often suffer epileptic seizures and a host of other medical complications that can demand months of acute care. After my childhood injury, I spent five weeks in the hospital. James Brady was in the hospital for eight months, Russell Moody, off and on for three years. Often it is only after acute care is well under way that the medi- cal team gets an inkling of the victim’s chances for recovery. Some patients who early on look as though they’ll do well slip into a coma and never regain consciousness. Others who are unresponsive sud- denly and unexpectedly begin to improve. “You try not to get real hopeful with head injuries, because a lot of times, the results are pretty dismal,” explains Dr. Harmann. “But when you do see some- one respond to a verbal command the first time, everyone’s elated.” EMTS, neurosurgeons, and emergency room doctors and nurses deal daily with head injury victims who look as though they will never regain what most of us agree is minimal human function— the ability to perceive and relate to what’s going on around them, to feel love and pleasure, to communicate with others. In the cases of botched suicide attempts and octogenarians who have suffered serious falls, the temptation to be less aggressive in the battle for the patients’ survival can be great. But absent written advance di— rectives to the contrary, the team goes all out to save these lives. A quarter of the victims of severe traumatic brain injury suf— fer lasting disabilities. In a 1984 report by the National Institute of Neurological Disorders and Stroke, only half of the survivors of serious head traumas had recovered well enough in three months’ time to conduct the basic tasks of everyday life, such as feeding and bathing themselves, and to communicate with others. Of course, this doesn’t suggest that they were back at their previous jobs or that they were entirely free of confusion, memory lapses, or emo— tional and sexual problems. Of the remainder, 35 percent experi— enced moderate disability: they were confined to a wheelchair, for Saving Live: a o example, or their speech was halting and slurred. Another 10 per- cent were severely disabled—conscious but completely dependent, with a serious loss in mental capacity. And 5 percent were in the ghostly limbo known as the persistent vegetative state. Researchers are working on tests to predict a head injury patient’s prognosis at various stages of treatment, but at this point all the available tests miss a substantial number who suddenly decline or improve. Of three patients rushed to the same hospital with appar- ently similar serious brain trauma, one may die of initial or second— ary damage, another may be discharged conscious but severely dis— abled, and a third may recover well enough to live independently and hold a job. For the sake of that third patient, we don’t want the trauma and acute-care professionals to give up—and even for the sake of that second patient. We can’t judge what quality of life that survivor might find acceptable, and we can’t know whether, given proper support and rehabilitation, he or she might continue to improve. Most of the medical professionals who have worked with trau— matic brain injuries have had all too many experiences like the one that Barbara Bowers had one night when she was flying with Life Flight. A group of teenagers in a pickup truck had been speeding along a narrow road through the beach resorts fifteen miles east of Galveston on the Bolivar Peninsula. None of them was wearing a seat belt. The driver lost control. In the horrific crash that followed, the kids were thrown out of the truck and onto the nearby fields and hedges. Bowers found one boy unconscious, inserted a nasal breathing tube, and got him back to the emergency room alive. A few weeks later, while Bowers was sitting in her office, a col- league stuck her head in the door and announced that some people were there to see her. “It was the grandparents with this kid in a wheelchair,” Bowers says. “All he could do was sit there and moan Saving Lives . 40 . and cry. But the grandparents were so grateful that he was still alive. They came by because they wanted to thank me for saving him.” Although Bowers, who calls herself “a real quality—of—life per— son,” found that experience upsetting, it didn’t alter her determi— nation to do everything she could to save the life of every injury victim that she was called upon to help. That was her mission. And, after all, she couldn’t know what progress that kid might make in the coming weeks and months. A lot could depend on whether he had the insurance or other resources necessary to buy him the most appropriate, advanced rehabilitation. Three decades ago, 90 percent of the victims of severe traumatic brain injury died. Now, thanks to the speed and sophistication of ‘ the treatment delivered from the accident scene through the acute— care phase, at least half live. As we shall see, responding to the needs of these survivors is a tremendous challenge that requires the concerted efforts of a great many people. Saving Live: 04]- ...
View Full Document

Page1 / 12

Chapter 2_Saving Lives The Golden Hour-pp 30-41 - 'tWO'...

This preview shows document pages 1 - 12. Sign up to view the full document.

View Full Document Right Arrow Icon
Ask a homework question - tutors are online