Chapter 10 - Alpha, Bravo, Charlie

"Trauma is a chronic disease." - Anonymous

Alpha, Bravo, Charlie

“Trauma, level one. Repeat. Trauma. Level one. STAT.”

The implications of this overhead page vary depending on the setting. At a busy urban medical center, a level one trauma code might mean a gunshot to the chest or a knife to the neck. In more rural settings, it could imply high-speed interstate trauma or a farm injury.

“Level One Trauma” activates several teams at once, including Emergency Medicine, Trauma Surgery, and numerous nurses, respiratory therapists, and phlebotomists. The “A,B,C’s” of trauma must be practiced: Airway, Breathing, Circulation. Lifesaving procedures and decisions are accomplished at terrific speed.

Orthopedic Surgeons typically don’t come down for every Level One trauma, as our “A,B,C’s” are more like “Ancef,¹ Bone, Cut,” or “A Bone Coming-out-of-the-skin-is-bad.” Still, when we hear a level one code called, we’re supposed to remain on high alert, and if not otherwise occupied (a rare scenario for an in-house orthopedic resident) we’re expected to assist.

The convention in major trauma centers is to assign each trauma patient a pseudonym in cycling alphabetical order, often using the NATO phonetic alphabet. The first patient would be Trauma Alpha. The next would be Bravo, then Charlie. The use of military terminology seems especially appropriate given that many trauma protocols and techniques were developed in military field hospitals.

However, in hospitals where real “hot trauma” cases like those are uncommon, Code Trauma might be activated for more mundane cases, such as a slip and fall, or a or pedestrian struck… by a parked car.

I’ve seen lots of different things called a level one trauma, both the extreme and the extremely benign. Between medical school (seven), residency (eleven), and fellowship (five), I worked in twenty-three different hospitals.

That’s a lot of ID photos.

Each of those hospitals differed slightly in their setting, and consequently in the type and frequency of trauma admitted.

In the hospitals where we did our main orthopedic trauma rotations, “Level One” was basically background noise. I wouldn’t even flinch unless I specifically got paged. 

At others, a Trauma Code was a desperate call to action, an all-hands-on-deck. “Level One” meant “We’ve got something serious here, please send reinforcements.”

At a hospital we'll call CTH (Cold Trauma Hospital), we weren’t supposed to hear those words at all.²

My CTH rotation followed Fracture, and the two couldn’t have been more dissimilar. The Fracture team is at home base, they’re the main squad. The CTH team, geographically isolated, consisted of one intern and one senior resident. That’s it.

It’s not that we needed more. If anything, that was almost too many.

CTH had the potential for a very busy service, but the perfect storm of a bureaucratic nightmare, chronic understaffing, and a general culture of laziness meant we could hardly get anything done.

“Everyone is against you,” the resident before me advised before I started my rotation.  “Everything you try to do will be sabotaged.” Reports traveled of holes being poked in the sterile sheets to intentionally contaminate them and delay cases. Cases that got delayed were as good as cancelled. Any operative case that even threatened to come close to lasting beyond 1pm would be at extremely high cancellation risk.

We covered call for CTH’s ED, though the name was hardly apt. “Call” was so slow that the intern was on “home call” the entire time. It was more or less ceremonial, though. During the entire two months, I received a grand total of three calls.

One of those, however, was a patient we’ll call Trauma Alpha.

Trauma Alpha had multiple myeloma, a diffuse form of bone cancer that makes patients susceptible to fracture. As he was leaving a CTH building from an oncology appointment at around 4:30 PM, he fell in the parking lot. He couldn’t stand up and felt severe pain in his thigh. He was rushed to the nearest ED, which in this case was about 500 feet away.

I had just spent most of my day waiting around and seeing a few patients in a sluggish clinic. Some of them had been waiting to see me for about 7 months, which was just about as long as I had been a doctor.

“Hurry up and wait,” often an appropriate motto, came to mind.

Clinic was slow, long, and not very interesting. I was finally in my car, crawling along through traffic in my 7-mile, 60-minute commute home.

Suddenly, a high-pitched beeping interrupted me. It was my pager, alerting me of a Level One Trauma. I disregarded it initially. Clearly that page was intended for someone else. A mistake. Or perhaps a prank? There’s no level one trauma at CTH. Ever.

I kept driving.

 Then the music stopped; I had an incoming call. Private number.

“Hello?” I answered.

“Yeah, hi, I’m calling from the CTH ED. You’re on ortho call, right?

“Yep. What’s going on?”

“Can you get here quick? We have a guy with a femur fracture.”

“Femur… as in, mid-shaft? Not a hip fracture?”

“Mid-shaft.”

“Femur... of the leg? And you’re calling from CTH?”

“I’ll see you soon.”

____

“It’s never as bad as the ED says it is,” a co-resident once observed. “The only exception is when it’s a lot worse.”

I met Trauma Bravo at the end of my intern year, on a rotation in a smaller academic hospital that got some occasional hot trauma, but usually not particularly complex cases. Let’s call it Warm Trauma Hospital (WTH).

Bravo was a 50-year old man who did construction and was working on a local bridge sometime around 2:30 AM, when he was unfortunately struck and run over by a 20-ton dump truck.

“Trauma, level one. Repeat. Code Trauma. Level one. STAT.”

I ignored it. Probably a chest or neck injury, nothing Orthopedic for me. I had just caught up on my work and thought I might catch some sleep, when my pager and phone went off simultaneously.

“Orthopedics,” I replied.

“We need you down here now. There’s a guy who has an open femur fracture.”

“I’ll be right there.”

My pager sounded off three more times in the five minutes it took to get down to the ED—all of them for Trauma Bravo. Overhead announcements blared. I entered the stairwell and noticed general surgery residents also hurrying down. More reinforcements, all ready for battle.

As I hustled down the stairs, I checked the call schedule to see which attending was on, and then made sure I had his phone number. There was no senior resident at WTH, it was just me separating the ED from the boss.

I pulled it up on my cell, which amazingly had service in the WTH ED, and kept it ready just in case the situation required more backup.

I walked into the trauma bay, and after one glance at Trauma Bravo, I hit “dial.”

_____

Trauma Charlie came in during my first week of nights, at the start of a local carnival in the neighborhood around Hot Trauma Hospital (HTH). It’s a huge annual party. Not coincidentally, it’s also—without fail—the busiest call night of the year.

The ED was a war zone. I would end up seeing 18 gunshot wounds that night, and when I shared that number at the next morning’s conference, I was told that was “about average” for such a night. But among all the other consults I saw that night the only one I remember is Trauma Charlie.

My shift began at 6:00 PM. The ED paged me about Charlie at 6:01.

I returned the page as soon as we finished sign-out a few minutes later. The phone rang over and over until finally, someone picked up.

“ER.”

“Hi, it’s Ortho. I was paged?”

“Hang on, DID SOMEBODY PAGE ORTH-” Hold music

I waited a full minute until Derrick, an EM resident picked up.

“Hey is this ortho?”

“Yeah, what’s going on?”

“We got a guy here with a finger amp. Trauma bay. Thanks.” Dial tone

That’s terse even for them. Guess the war has begun.

And so I went down to the trauma bay to find the patient with the finger amputation.

Busy as the ED was, the main trauma bay was empty. “Where’s the finger guy?” I asked a few techs and nurses, only to be met with confusion. Finger guy? Nobody knew who I was talking about.

I finally found Derrick as he raced from the trauma bay to Pod B. Sweating, hair a mess, he carried a two-liter bag of normal saline in one hand and a spinal needle in the other.

“Oh, hey Ortho,” he said, out of breath. “Your guy’s not here anymore.”

“Where did he go?” I asked, “For X-rays?” X-rays would have been appropriate for a finger amputation, to see if there was any bony involvement and to aid in planning for reconstruction.

“What? No. He’s in the SICU. You can see him there, I guess.” He then ran off toward Pod A.

Surgical ICU? For a finger amputation? I looked back into the trauma bay. There was a fair amount of blood in there. That was my second indication that perhaps there was a bit more going on with Trauma Charlie than was let on.

_____

Trauma Alpha writhed in the CTH hospital bed, clearly in pain despite having received a healthy dose of morphine. His left thigh was swollen; a big “X” drawn on the dorsum of his foot indicated the location of the intact dorsalis pedis pulse.

I showed him his x-rays.

“Your femur has been damaged by the myeloma,” I told him. “It was weakened and it broke during your fall. Luckily, we can fix it.”

Even more luckily, I kept to myself, tomorrow is the only day of the week orthopedics operates here, so we can fix this expeditiously.

Femur fractures used to carry mortality rates upwards of 60% prior to the wide adoption of internal fixation (plates/screws or internal rods to stabilize the fracture and allow rapid mobilization). Patients with femur fractures who don’t undergo rapid internal fixation are at risk of deep vein thrombosis (blood clots), pulmonary emboli, pneumonia, and a host of other complications. Cancer increases all of those risks.

 I told him we’d make every effort to fix this fracture the next day and have him up and walking soon thereafter.

I got him on some longer-acting pain medications, and looked around for a traction setup to ease his muscle spasm and control the pain. The ED didn’t have one. The floors didn’t have one. The OR didn’t have one. There wasn’t a single traction apparatus to be found anywhere in the entire hospital.

After half an hour of searching, I ended up finding one traction boot and a lot of tape. I rigged together a pathetic traction setup, with tape rolled into ropes, using the edge of his bed as the pulley, and three-liter bags of normal saline as the weights. It would have to do to hold him over for the night. It wasn’t much, but it helped.

I spoke with the senior resident and the attending. We already had an elective case scheduled for the following day: a total knee replacement in a patient who had been waiting years for it. If we cancelled his case, he’d be put back onto a waiting list and have to take the next available spot, which could be months away. There was no way we were cancelling him. At the same time, we remained acutely aware of the possibility that we would not be allowed to do two cases in the same day, lest the second surgery bleed into the afternoon. 

A Friday afternoon case. At Cold Trauma Hospital.

How dare we.

We made the decision to keep both cases on—the knee replacement first, followed by the fracture. I called the OR to put Trauma Alpha’s fracture case onto the schedule.

“You already have a case tomorrow,” I was informed.

“Yes, I know. This is a femur fracture. It can’t wait. It will be quick.”

“I’m sure. How quick?”

“Half an hour to an hour max.”

“We’ll have to discuss this with Anesthesia.”

Hurry up and wait.

_______

Trauma Bravo lay on the table fully exposed, as trauma patients are meant to be. I could see why they thought he had an open femur fracture. If only it were that simple. 

The dump truck brutalized Bravo’s midsection. Tire tracks tore through the superficial flesh of his lower abdominal wall and upper thigh; entire sections of skin and fascia were shorn off. His jarringly visible pelvis was grossly unstable. The general surgery team had packed his abdominal wounds to slow the bleeding, and the ED already had him intubated and on pressors to improve his critical hypotension. Wide-bore IV’s poured blood and crystalloid into Bravo’s quickly emptying circulatory system. I grabbed a sheet and applied a binder to stabilize his crushed pelvic ring.

“He’s going to the OR right now,” the attending told me. “This pelvis fracture is unstable. We need you to put on an external fixator to stabilize it while we do a laparotomy. Meet us up there.”

“Sure,” I replied, as if we apply hundreds of pelvic external fixators per year.³ 

“My attending is on his way in right now,” I added to nobody in particular, if only to assuage myself.

______

By the time I got to Charlie’s room in the SICU, it became clear that I was late to the party. A dozen doctors and medical students crowded around his bed. Hushed whispers flitted about between the outer rings of observers. I couldn’t see a thing.

“I heard it was a machete,” one student whispered.

“I saw the gash; it even cut his tongue,” another offered.

“Yeah, I heard that, he was talking when they brought him in,” the first one replied. “Is that just the craziest thing in the world, or-”

“Hey, excuse me,” I said, “Sorry to interrupt. But I’m with ortho. I was called to see this patient. What’s going on?”

“Machete to the face,” the first student explained as she gestured her hand over the front of her face vertically. 

“Like, all the way through.” a second student added. “Stem to stern. Doesn’t look good.”

“Gruesome,” I offered. “But what’s wrong with him… orthopedically?”

“Oh, hey Ortho.” a SICU resident said from behind me, as the crowd continued to build. “I think his right fifth finger also got cut off.”

“Small finger?” I corrected.⁴

“It is now.”

______

As Trauma Alpha waited patiently in his traction boot, we performed the total knee replacement efficiently, which is no small feat at CTH. The time was already 11:30 AM when we finished, though, since we couldn’t begin the case until after 9:00 (Anesthesia wasn’t ready). We were reassured multiple times that Trauma Alpha’s surgery could go on as scheduled, right until the moment it was cancelled.

Dr. Gabriel was livid, and carried on arguing and advocating with every staff member he could find. Nobody would budge. The case wasn’t going.

“So, from a practical standpoint,” I said to my chief resident, “he probably isn’t going for surgery anytime in the next few days, right?”

“Correct,” she replied.

“He needs to be in traction that entire time.”

“He does.”

“He’s currently in skin traction,” I observed, “and that’s only recommended for a maximum of 24 hours. I’ll need to switch him to skeletal traction, won’t I?”

“You absolutely will,” she said. “Good luck. You’ll probably be the first person in Cold Trauma Hospital to apply skeletal traction in half a century.”

I needed a lot of equipment to set up traction, but the one thing I desperately needed was a long, thin metal pin to drive through Trauma Alpha’s tibia and attach to the traction setup. Everything else, I could MacGyver. That pin had to be sterile. Thankfully, the OR had exactly one of them available.

I explained to Trauma Alpha what had happened. He understood and thanked us for trying. So it goes, I remembered a particularly jaded attending once pontificating, The better someone’s personality, the more likely it is something will go wrong. Murphy’s Law: medical edition.

The rolled-tape pulley would be inadequate though, it kept tearing and sticking. I needed rope, and maybe some carabiners and a real pulley. I went to the only place I knew I could get what I needed. Back home. I grabbed rope, carabiners, and a skateboard wheel, and brought them back to CTH. I placed his skeletal traction pin at the bedside—numbing the skin with lidocaine and drilling the pin through his tibia as he watched—and manufactured a passable traction setup.

Every morning I came in to round on him, I expected to see that he was in respiratory distress, or had pneumonia, or had died. Amazingly, Trauma Alpha made it six whole days in the improvised traction assembly without getting a DVT, PE, or pneumonia.

He maintained a positive outlook and greeted me cheerfully every morning on rounds. The next available OR day we had, which was six days later, we removed the traction pin and fixed his femur. He was discharged from the hospital four days later, healthy, walking unassisted, the sole exception (to my knowledge) of Murphy’s Medical Law.

_______

Bravo was brought straight to the OR, where I met the General Surgery team after taking a brief detour to look up the technique for placement of a pelvic external fixator. Anesthesia looked particularly concerned.

“This guy won’t last two more hours,” they said. “He’s going to die on the table if he’s not out of here ASAP.”

“Well then we better get started,” said my attending, as he wheeled the portable x-ray scanner into the room.

We applied the pelvic ex-fix as the General Surgeons explored Bravo’s mangled torso. Periodically, the cardiac monitor would temporarily beep incessantly; at other times it stopped beeping entirely. Anesthesia’s grave warnings increased in frequency. 

“We need to get him out of here now,” they finally said. “Pack the wounds, the case is ending. He needs to be in an ICU.”

He never made it that far.

_____

Trauma Charlie’s right small finger had been amputated at the PIP joint. It seemed, judging by my experience having watched hundreds of episodes of Law & Order: Criminal Intent, like a defensive wound suffered when he tried unsuccessfully to deflect the arc of the machete that was headed for his face.

I wasn’t given much space to do my exam. Representatives from Neurosurgery, Plastic Surgery, and ENT constantly jockeyed for position near the patient’s head, wondering what to do about the brain matter herniating through Charlie’s facial wound. 

“This is a mortal injury,” the Neurosurgery resident declared. “There’s no sense in any of this.” He gestured to the life-saving equipment in the ICU.

“The family wants Everything Done⁵,” said the ICU attending. “Soon enough they’ll change their minds, but until then, we respect their wishes.”

Of course it made sense the family would say that. Charlie was somehow conversing before he arrived at the hospital. Probably not higher-order brain function, but some lights must’ve still been on in the attic. Charlie sure looked young. Initial estimate was 35 years, but we later found out he was only 28. Rumor had it the person who attacked him was a friend, high on synthetic drugs.

I held Charlie’s right hand and examined it. He was a big man. Huge. He barely fit in the extra-large ICU bed. Rippling muscles bulged beneath his young skin. 

The machete had ripped right through his middle phalanx. It was a clean laceration. It was gruesome. Nothing compared to his face, but gruesome nevertheless.

The bleeding had mostly stopped. I could have easily placed a bulky dressing on his finger and left it at that. He would be dead by morning, or a few days later at the very longest. Had I been further behind on consults at that point, and not particularly interested in Hand surgery, I would’ve been tempted to do so.

Instead, I ran down to the ED and grabbed a bucketful of equipment, which I brought back up to the SICU. I boxed out four medical students and created a small operating space. OR in the ER was one thing, but this was OR in the SICU, a new adventure. Space was at a premium and not a single person in the room wanted to see what I was doing. They were all mesmerized by the gore of his face.

I injected local anesthetic and revised the amputation to a clean PIP disarticulation with a V-to-Y flap. Afterward, prior to applying the dressing, I admired my work. With the distraction of Charlie’s face, nobody else in the room was going to.

It was good practice, and if nothing else, his family might appreciate a clean, sutured stump to a grisly amputation wound. The procedure bordered on mortuary cosmetology, but it felt like the right thing to do.

“Good night, Charlie.”

1.  Cefazolin, or Ancef, is the antibiotic of choice for most orthopedic surgery.

2. The phrase “Hot Trauma” is used to describe acute, life- or limb-threatening injuries. Naturally, “Cold trauma” is the opposite.

3. I applied a total of three in my five years of residency, and that’s a pretty good amount.

4. It’s conventional among hand surgeons to refer to the fingers by their proper names. Thumb, Index, Middle/Long, Ring, Small. Enumeration (first, second finger etc) causes lots of confusion. Is the index finger the second finger? In truth it’s not – it’s actually the first, since the thumb is not a finger. Which means that “fifth” fingers are only found on patients with six digits. Hence the naming.

5.  “Everything Done” is a phrase that stems from the way many doctors talk about end-of-life care with patients and their families. While it is entirely reasonable in a young patient and/or one with a potentially reversible condition to “Do Everything” possible to prevent death than to initiate comfort care, the phrase Everything Done evolved from conversations regarding patients who were already as good as dead if not for the fact that they were hooked up to machines creating artificial vital signs.