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Emergency Department: Teamwork in trauma care

This is the fourth in a five-part series examining emergency trauma care at Duke and in the community.

At 9:20 p.m. Friday evening, Alumni Weekend is getting into full swing on main campus and the bands and deejays are warming up for a long night. But less than half a mile away, in the Emergency Department of Duke Hospital, it's business as usual as physicians and nurses prepare for the arrival of a gunshot victim.

The emergency call came in from a Durham County ambulance a few minutes ago. A young man has been shot many times, and medics are now pulling him out of the woods. Expected time of arrival: 10 minutes from now. As James Freeborough, the shift's head-or "charge"-clinical nurse, hangs up the transmitter receiver, the emergency team begins to move into action.

After relocating a stable patient from one of the two rooms set aside to handle trauma cases, the entire staff gathers and dons extensive protective and sanitary gear.

The group includes an orthopedic surgeon, an x-ray technician, several nurses, three respiratory specialists, orderlies, a medical student, a nurse to record the activities and a social worker. In all, seven people are dressed in full surgical garb and others simply wear protective latex gloves.

From time to time, police and rescue workers peek in. In cases like this, the trauma chief is brought down to direct the care. "We pull in the specialties we need depending upon what it is," says Julie Johnston, a clinical social worker in the ED.

The trauma room is quite warm-they keep it at 98 degrees Fahrenheit for the patients' well-being. The 10-minute estimated time of arrival elapses into about 15 as the ambulance gives one final siren salute and pulls into the Emergency Department.

Meanwhile, outside this hotbed of activity, the other Emergency Department staff goes about caring for the other ED patients. Nurse Diane Sharpe notes, "While everyone is in there, everyone out here tries to keep up." For the past week, the hospital has been full, so patients that normally would have moved up into other hospital departments are biding their time in the ED, adds Nurse Manager Kathleen Finch.

The ED includes four primary areas-acute, non-acute, urgent care and pediatrics. The gunshot victim goes directly into the urgent care section of the ED, whereas most children that come into the ED are admitted into the pediatric care area.

The pediatric hallway, while still maintaining the structure and design of the ED, has an atmosphere meant to soothe young patients. "Where's Waldo" paintings and colorful mobiles hang from the walls and ceilings; there are also books, toys and Winnie-the-Pooh stickers along with coloring book drawings by previous patients hanging on the walls.

For example, around 8:30 p.m. Friday evening, a young boy was about to undergo a CT scan after falling on his head. While the boy's father comforted him, and the nurse gave the young patient the necessary IV, a child-care specialist played with a colorful Slinky in front of him.

The ED at Duke Hospital is one of five of the highest-level trauma centers in the state. There are significantly more level-two trauma centers, including Durham Regional Hospital, now a subsidiary of the Health System.

Back at the main operating room, Johnston flips a switch to make sure the automatic doors to the ED remain open for the arriving patient. She will try to determine which family members to contact and who may be allowed in to see the patient. "You never know who's coming behind them," she says.

Johnston adds that especially in cases of shootings, the perpetrator may still be at-large and interested in paying a call to the patient.

When the patient arrives in the emergency room, he is half-conscious, clearly bleeding and wounded in several places. The trauma team moves in to insert IVs and monitors and begins cutting off the remaining clothing he has on him.

"Oh God, I'm going to die," the patient says; however, he is quiet for the remainder of the time due to the variety of drugs that the emergency team has given him. Amidst the many people in the room assisting the patient, the atmosphere remains calm. Freeborough explains after caring for the patient that there is standard protocol for dealing with gunshot victims and all other types of patient care.

"We haven't had someone come in with 14, 16 holes in awhile," says Freeborough. "That was common five or six years ago.... But it seems to be picking up again."

Police have determined that gang activity is likely involved in this case.

Since the ED staff is afraid that a bullet has pierced his lung, they intubate him, ensuring that his lung will not collapse, Freeborough explains.

Also, in an attempt to locate the bullets, they take a series of x-rays using a mobile x-ray machine. The caretakers also perform an ultrasound to determine if his heart is bleeding into his internal cavity.

Approximately 40 minutes after arriving in the ED, the patient is transported up to surgery using a back elevator. There, he is to undergo an exploratory laparotomy of his belly in which surgeons will suture any internal cuts.

Hospital environmental services personnel are then called in to clean the trauma room, and police come on the scene to find out more information. By 11:00 p.m., the room is spotless.

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