my barbaric yawp

It kills me that I can’t tell you more about the patients I see come through the trauma bay–like the patient who was literally rescued from an assault by her seeing eye dog, or the patient found down for God knows how long, abdomen filling with feculent material.  But, at least, on Trauma, I think that my role is interesting enough for a story or two.

As I had mentioned, Casey and I (the medical students) are in charge of the primary and secondary survey during a trauma.  It might not seem like a big deal–I mean, we’re not the ones securing an airway or IV access, splinting bones, or making major medical decisions–but it’s crucial, so much so that my voice should be able to be heard above everyone else’s, and there is a person in the Bay whose job it is to record everything I say.  Pretty cool, huh?

The primary survey is also called the ABCs (really, ABCDE): Airway; Breath and ventilation; Circulation; Disability; Exposure.  So, an unidentified pedestrian struck by a motor vehicle is brought into the bay by Emergency Medical Services.  I ask, “Sir, can you tell me your name?”  If he says anything at all, I yell, “AIRWAY INTACT.”  Then I move on to evaluate his breath sounds, all of his pulses and possible locations of blood loss, and his Glasgow Coma Scale (his conscious state)–shouting my findings every step of the way–and finally perform a quick scan of his body including a rectal exam (“DIMINISHED RECTAL TONE, NO BLOOD PER RECTUM.”)  Hopefully, this is done in under a minute or two.

Then I move on to the secondary, which is basically a more thorough head-to-toe examination, as much of a complete physical exam as possible.  Some (I’m sure not all) of the big hitters to look for in our pedestrian described above, for example: facial instability; unequal/unreactive pupils (alert! alert! brain/neural damage!!!); any cuts or lacerations; scary bruising (especially around the eyes or behind the ears); rib fractures; unusual masses; unstable pelvis; limb deformity; motor or sensory losses.  As one of the fellows told me yesterday, “It’s one of the few times in medicine when the physical exam is probably one of the most immediately important components of patient care.”–this is terrifying because, honestly, as medical students (or maybe I’m just speaking for myself), we kind of suck at the physical exam.  There are so many subtleties, you just need to perform a ton to be able to differentiate what’s normal from what’s not and what’s truly emergent.  Well, okay, the five-inch laceration sliced across the patient’s forehead, the right lower leg that lay in the most unfortunate position–those abnormalities I can identify.  But, in the heat of the moment, I had to check his pupils three times before I felt comfortable screaming, “5mm PUPILS BILATERALLY, LEFT PUPIL UNREACTIVE TO LIGHT” and still I was a long way from confident with my finding.  The secondary survey should take about five minutes.

Something that’s a little funny: sometimes my classmates on their Emergency rotation will follow the trauma in to observe the action.  Of course, there’s so much going on, you never notice the extra bodies in the room.  But after the fact, I pink up a little thinking about my friends watching me “perform” in front of them (particularly when it’s such a rusty show!).  I spoke with one of my classmates later about it:

Me: So, how’d I sound?

Him: In command.

Boom!  Fake it until you make it.

(For the record though, soooo glad none of classmates were around to witness my most recent primary and secondary.  We were struggling with a somewhat uncooperative morbidly obese patient and, as we tried to make sure he didn’t fall off the bed with every new position, I’m afraid I was not terribly eloquent with my words–it’s difficult to describe wounds you can’t see :/)