I'm ready to tackle triage and hospital emergency rooms. I will cover this information sequentially to help you best understand the process.
1. After a motor vehicle accident (MVA), 911 is called and first responders arrive on the scene. Always wait for EMTs to arrive instead of driving someone to the hospital if possible. There are several reasons for this, but the most important one is that not every hospital is equipped to deal with every emergency. EMT will assess the situation and determine what level of care the patient needs. They will also call ahead to the hospital to report their assessment of the situation so that doctors and nurses can be ready to care for a critically ill patient as soon as they hit the doors. Nurses will prep surgical suites for trauma patients and doctors will collaborate with interdisciplinary colleagues to prepare.
2. On the scene, EMTs follow the ABCDE assessment and treatment method to prioritize care.
a. Assess and stabilize the patient's airway. Temporary oropharyngeal airways can be placed by EMT on scene. These are plastic tubes which basically hold the mouth open.
b. Breathing is closely associated with airway. EMTs listen to patient’s lungs and watch breathing patterns. If a patient is not breathing or breathing raggedly, they will attach a ambu bag to the oropharyngeal airway in order to manually force air into the lungs.
c. Circulation: EMTs check their pulse and blood pressure. Patients without a pulse will obviously need CPR, and while this is dramatic it is an overused trope. Patients with low blood pressure may need fluids or medications which increase the blood pressure. EMTs will insert IVs in order to give normal saline (basically water with salt) and epinephrine (increases the blood pressure). Important note which just really bugs me: IVs DO NOT HAVE NEEDLES permanently in your skin. We use a needle to insert IVs and then remove the needle, leaving behind only a flexible, soft tube. They should not hurt and it is safe to move your arm around with an IV in it. EMTs will either insert 1-2 IVs, but when they get the hospital, us nurses LOAD those suckers up! We like to give lots of meds fast, so four IVs is pretty typical.
d. Disability looks at a patient's mental status. Are they alert? Can they talk? Do they grimace when you pinch their nailbed or rub their chest? What do their pupils look like? Level of consciousness is a good indicator of blood flow to the brain. Stabilize the neck of a patient with suspected brain injury and activate code stroke for a patient with possible bleeding in the brain. If they are having a stroke due to bleeding, this is a traumatic brain injury. As I’ve already said, stay away from it actually coming to fruition, but it can be mentioned by the medical professionals as a risk of MVAs.
e. Expose the patient by removing clothing to look for signs of external injuries. Stop bleeding with pressure or tourniquets or surgicel (super useful dressing that stops bleeding).
3. Arrival at the hospital: Ok, so your MC has been picked up by EMT. They are breathing, have IVs in place, are getting some fluid, bleeding is under control, and the EMT has applied a neck brace to stabilize the patient's neck because they suspect a spinal cord injury. MC arrives at the hospital with at least one doctor, maybe a couple residents, a respiratory therapist, and at least two to three nurses ready to receive them. Depending on how critical the patient is they are either taken to an ER room or OR room. Either way, the process is pretty much the same and follows the ABCDE method!
a. First, airway doctors will almost always intubate a patient once they arrive at the hospital. If a patient is not already unconscious, they will sedate and paralyze the patient and then place a plastic tube into the mouth and down the trachea. Patient's must be intubated prior to surgery, so this is gonna happen at some point for most critically ill patients.
b. Breathing: The breathing tube is then connected to a machine called a ventilator which breathes for the patient.
c. Circulation: While the doctor and one nurse worry about intubating the patient, another nurse is attaching the patient to monitors to continuously assess their heart rate, blood pressure, and oxygen saturation. They will most certainly place more IVs and may give more fluid and may start a continuous infusion of medication (levophed) to increase blood pressure. The nurse will also draw blood from the patient’s IVs in order to test it for chemical imbalances. At this point, the doctor will also determine if the patient needs blood emergently or not. Emergency blood is given differently than normal and I will discuss it in depth next.
d. Disability Finally we are ready to talk about imaging of the brain and spine. CT usually takes about twenty minutes to complete and is performed by a special technician while a nurse monitor's the patient's condition. However, if the patient is actively dying, we skip CT and go straight to the surgery suite. We won’t know the extent of injury to the spinal cord until after surgery, but some things are more important than that. For example, is your patient actively bleeding? Have low blood pressure? Imaging is less important if a bleed of the brain is not suspected.
4. Let’s sidestep moment to talk about giving blood. This is super common for traumatic injuries, but how blood is given is determined by how urgently the patient needs blood.
a. Typically, we have to wait to give blood until we test them for their blood type, cross check it with blood in our blood bank, and then wait for blood bank to send us the blood. Then the blood is given slowly over the course of an hour and the patient is closely monitored for signs of blood transfusion reactions.
b. If a patient is uncontrollably bleeding, resulting in low blood pressure, we will almost always will activate the massive blood transfusion protocol. Blood banks then immediately sends us 4 bags of O negative blood, 1 bag fresh frozen plasma, and 1 bag platelets. All this is given in under six minutes (one minute per bag) using a special machine with a lot of horsepower.
c. Giving blood using either method can be done during surgery and does not delay the patient getting treatment.
5. Surgery Ok, you've got intubation, IVs, vital sign monitors, fluids, blood pressure medications, blood labs pending, imaging maybe, you've given blood, and the patient is in the surgery suite ready for the doctor. Now what? Basically, the surgeon explores the problem and fixes it as they go. They can use ultrasound (which looks at soft tissue inside the body) or xray in the surgery room to assess the problem as they go. A surgeon might relieve pressure on the spinal cord, remove debris or shrapnel from the wound, or stabilize the vertebrae with screws or rods. They will also address any other wounds the patient might have by stabilizing fractured long bones, stitching up skin tears, and cauterizing bleeding wounds.
6. ICU is next. Following surgery patients with SCI typically go straight to the ICU. ICU nurses have already been made aware the patient is coming and they are waiting receive for the patient. Most importantly, they have called the family to tell where to wait for their loved one (typically in the ICU’s waiting room). Some really good, nice surgeons will go to talk with family while the nurse is getting the patient situated in the ICU to tell them how surgery went. If they don’t nurses will invite family members into the ICU room once the patient is situated and answer any preliminary questions while they wait to see the doctor. During this entire process, patients are not awake. They still have the breathing tube in place and are medically sedated. Families should be warned that this may look shocking before entering the room. Families should also be told that their loved ones will not respond to them, but that does not mean they can’t hear them. Good nurses may encourage families to talk to unconscious family members. Nurses, under the direction of doctors, continue to manage patients in much the same way as described above and may take patients to get more extensive imaging (including CT and MRI) over the course of the next few hours to days.
7. Recovery Patients wake up slowly as we gradually decrease sedation over the course of several days. The first thing you will feel when waking up is a nurse rubbing on your chest with a bruising force and shouting in your ear all those classic questions: "Mr. Green! Can you tell me what your name is?", "You were in a motor vehicle accident and are now in the hospital! Where are you right now?", "Can you tell me what year it is?" and, of course, don't forget, "Who’s the president of the United States?"
Ok, that’s all I have the energy to answer about hospitals for today. ICU, as I’ve said, is my nursing specialty, so I feel like I could go on forever about this. For the sake of brevity, I’ll stop here. If you want to know anything more, just ask!