Things are usually fairly quiet till 4 or 5pm; before that, you can get a couple of little old ladies falling down stairs, or old men falling over their canes (that’s actually what the trauma pager said). Depending on whether the neurosurgeons have a white cloud or a black cloud on call, they could get one or two operative subdural hematomas out of that list.

5pm, just when you’re wishing for dinner, is when the action starts. 39 year old female, MVC (motor vehicle crash). She was drunk, and everyone in the trauma bay wonders how she got that way at 5pm, and wouldn’t it be nice if we had the time to do that too (actually, I’m surprised how many of the staff voice this thought; you’d think we’d have learned by observation the dangers of drinking). She has a small post-traumatic subarachnoid hemorrhage, which is somehow much less lethal than the ruptured-aneurysm variety, so she gets a night in the ICU for observation. Next!

56 year old male, pedestrian vs. car. Depending on his luck, this could mean a variety of injuries. Tonight, a tib-fib fracture, a radius/ulna fracture, some facial lacs. He gets to spend the night, or maybe a couple nights, till ortho has time to fix his fractures. This time of year, they operate practically non-stop, and if you don’t have an open fracture, it may take a day or two to get to the top of the OR schedule.

91 year old female, MVC vs retaining wall. (Who let her drive? Amazing how many concerned family members show up once the damage is done.) Of course she’s taking coumadin; we’ll be lucky if she isn’t taking plavix too (notorious blood thinners; coumadin can be reversed, plavix can’t). Lucky for her, no intracranial hemorrhage, just an ankle fracture, with the incision of her knee replacement above it torn open, and a few nonsignificant vertebral fractures. Collar x12 weeks, OR in a few days with ortho. She can go to a floor, but it has to be a monitored floor, because of her atrial fibrillation, and we can’t tell whether she had some kind of cardiac event that caused her to black out or lose control of the car. That’s why cardiac enzymes are part of the laundry list of labs sent from the trauma bay.

Then, three in a rush: by helicopter, unhelmeted driver MCC (motorcycle crash), obtunded, open fractures; unhelmeted passenger MCC, intubated, closed fractures, distended abdomen; by ground, 89 year old man with a head bleed, from a nursing home via an outlying hospital. It’s the luck of the draw which one of them hits the door first. The old man has intracerebral contusions on the CT from the outside hospital, which we dutifully repeat: his mental status is deteriorating, he’ll be intubated by morning, and there’s nothing neurosurgery can do to help. Call the trauma ICU for a bed.

The motorcycle driver isn’t that obtunded once he arrives; drunk would be a more accurate term. Drunk enough to be quite cheerful, and not to understand what’s happened. He makes plenty of noise, though, when ortho shows up to reduce his fractures and splint them before taking him up to the OR.

His girlfriend is another story. She seems to have a head injury bad enough to have gotten intubated already, which makes the rest of the exam a little more difficult, since she can’t tell us what hurts. Neurosurgery is in the background, grumbling about her having gotten vecuronium for the intubation, and a couple hits of fentanyl for sedation/pain control on the helicopter ride over (because that obscures their exam, and besides the vital signs, there’s little more important about a trauma patient than getting a good neuro exam). Once they’ve finished giving the story, the chopper nurses can be heard muttering about the dangers of transporting a flailing patient in a confined space.

What few members of the trauma team haven’t split off with the other recent arrivals hurry through the protocol: pupils are equal, still reactive;  no blood in her ears, so it doesn’t look like a basilar skull fracture; lung sounds a bit diminished on one side, but it’s hard to tell in the commotion of the trauma bay; can’t be sure, so we’ll wait to put a chest tube till we see the chest xray (the xray technicians have a great knack for pushing themselves into the middle of the commotion and standing still until we notice and make way for them). Abdomen is distended, good peripheral pulses, maybe a bit weak – can we get a manual blood pressure please? – veins hard to stick, somebody put a femoral introducer in, give us some labs, hook up the rapid infuser; where’s the FAST? Someone pulls up the little ultrasound cart, designed to take a quick look at four spaces where there should be no free fluid; if you see a black line around the heart, or between the liver and kidney, or around the bladder, or between the spleen and kidney, you have hemopericardium or hemoperitoneum, and in an unstable patient, should go straight to the OR. She isn’t exactly unstable, her pressure’s staying at 100 with several liters of saline running, so we decide to take her to CT for a look at her head. CT shows various intraparenchymal contusions with tight ventricles from the swelling – neurosurgery states their desire to place a ventriculostomy as soon as she’s still in one place long enough – but the abdominal CT is the chief’s jackpot for the night: a shattered spleen, in four different pieces, with the dye from the iv contrast frankly extravasating around it. Call the OR, we have a trauma ex lap. Neurosurgery requests to be paged once she’s intubated, so they can do the ventric while we open the belly. . . Brief stop in the ER to arrange lines in order, dress a few gaping wounds, and let the OR open their instrument trays, and another piece of the team is off upstairs with her.

The pager is still going off. 58 year old male, fall, intoxicated, altered level of consciousness. 19 year old male, ATV accident, chest pain, shortness of breath. 87 year old female, fall at nursing home. 26 year old male, gunshot wound to the thigh. 28 year old male, gunshot wound to the chest. 20 year old male, stab wound to the abdomen. You never know what they really are. The 58 year old might arrive with such poor consciousness that he’s already been intubated. The ATV rider might have a pneumothorax, or nothing more than a bruised chest. The 87 year old female might have nothing wrong with her, or she might have a subdural, a C2 fracture, and a splenic laceration. The gunshot to the chest might arrive in traumatic arrest, or it might have grazed his side. It’s like a very bad Christmas nightmare – you never know what’s inside the package. And it isn’t even midnight yet; the real drunks will start showing up later.