This is the first in a series of scenes from the emergency room, told by an alumnus with a long, distinguished career in emergency medicine.
“I have this guy who was working under his monster truck. He hurt his neck.”
The day was late and long; I knew the voice on the other end of the phone. This was a physician in a small facility, calling for help for his patient.
“The truck slipped off the stands and landed on him. He can’t move from his shoulders down. I have his CT scans done. I think he’s dislocated at C5. Will you take him?”
When you work in a well-resourced verified Level 2 trauma center, your job is to say “yes” and ask questions later.
Flipping the phone up from my face, I signaled the nurse to call the helicopter to get going to the sending facility.
“Of course. Send him down.”
Another call to the neurosurgeon on call and we were ready to receive this young man. He was quickly assessed and cleared by the trauma team. Surgery is open, trays and traction are in place. Soon, he is in the operating room, the fracture/dislocation/jumped facets are reduced, stabilized and fixed.
All pretty much in a day’s work. A well oiled team, working together, does what is supposed to be done. The patient walks out a few days later, minimally weak in one limb. No big deal. All in a day’s work.
Except that I had a couple of observers. Ugandan medical students Charles and Lydia are visiting for a week, rotating in our emergency department, as part of DMU’s global health program. They do a real emergency physician schedule, 24/7/365, no holidays, no birthdays, no weekends. One goal is to show how systems work.
It is a common misconception that our extraordinary results in trauma care come from whiz-bang technology and lightning-fast emergency physicians, hair gelled, with nurses at their side, perfectly made up, coiffed to the nines. And orders are all followed by “Stat!” (Aside: “Stat” comes from the Latin statim, or “immediately,” not the Latin stat, or “he stands,” even though, in practice, it seems the opposite meanings rule.)
In reality, the best results are from systems that have their people train and work together continuously. Mistakes are made in practice so as to not occur in real life. “In case of emergency” is no time to break the glass and read the manual. This smoothly functioning orchestra appears effortless and fluid to the untrained eye.
Our visitors have trained eyes. “How do they all know what to do?” queries Lydia, seeing radiology swing the Bluetooth machine into position. (Love it – an ADD-enabled EM physician’s friend. Press the button, five seconds later, the image is on the touch screen.) Lab is drawing blood, nary a “Stat” in the air. Anesthesia is running a Malipatti score. An ICU nurse is gathering injury data.
“This isn’t their first rodeo.” The blank looks tell me this idiom probably didn’t translate. “They’ve done this 100 times before. They barely need me to tell them where to start. My job is to guide, to conduct the orchestra.”
The neurosurgeon arrives. The patient has been cleared from a general trauma perspective. The operating room is ready and willing. With a quick introduction to a gracious neurosurgeon, our Ugandan students are accepted to observe in the operating room. (In general, a surgeon will be much more gracious if his/her patient has been well cared for and systems are responsive, ready to go. Channeling Dr. Paul Trimmer, “Don’t give me what I ask for, give me what I want!” works pretty well.)
In the OR, our students got to see tools, purposely designed to do one task well, used with skill and precision. The jumped facet is reduced with traction and manipulation. The fracture is stabilized. Skin closed, the patient is moved to post-anesthesia recovery. And he can feel and move all four limbs again.
Full healing will take time. That’s the way of the body. But this patient will benefit from a system designed to help him and keep him from a path he will never know he could have walked or, more correctly, been wheeled down. Not knowing the pit avoided is a blessing, as this knowledge can paralyze just as surely, albeit by a different mechanism.
Lydia and Charles got to observe what might be characterized as a miracle in some settings. From another perspective, though, it is a combination of excellent systems, good people and a body prone to healing.
This was the desired lesson to be carried back with our observers. Yes, the technology is razzle-dazzle. But it is the people, working and training together to make a system that functions to produce results for patients like this that make the miracles happen.
And this is a lesson that can be taken down the street and across the ocean. It does not take a lot of money to create a good system. It takes training, dedication and leadership. That’s what we hope to be forming. Even more surely, failure to create systems that work cost plenty; the payment is in money, disability and lives lost too soon.
Miracles or systems? Maybe it depends…
“Every system is precisely designed to achieve exactly the results it gets.” – attributed to Don Berwick, M.D., former head, Centers for Medicare and Medicaid
This story is intended to be HIPAA compliant.