Ready for anything
The Level I trauma centers at Shands at UF and Shands Jacksonville are always prepared to treat the most severe injuries, thanks to multidisciplinary teams of employees that keep the centers going around the clock.
By Laura Mize
The paramedics found Lori Morton unconscious in the grass near the road, not far from the pickup truck she had been driving just a few minutes earlier.
She and the truck had flown through the air across the road after the vehicle sped into the median in a single-car accident. Something had caused Lori to swerve toward the shoulder, then overcorrect sharply into the median. She was thrown from the truck, which landed driver’s side down.
ShandsCair, the medical flight team for UF&Shands, the University of Florida Academic Health Center, airlifted Lori to the trauma center at Shands at UF, where a multidisciplinary team of health care providers began their well-rehearsed trauma care routine in an effort to save her life.
It’s a routine the team executes about 1,200 times a year, whenever the hospital receives a trauma alert — although no two enactments of it are exactly the same.
Lawrence Lottenberg, M.D., an associate professor of surgery and anesthesiology and the original medical director of the Shands at UF trauma center, says the variety inherent in trauma care keeps him excited about his job.
“The passion that keeps me dedicated to my job is that no patient presents with the same set of injuries as another,” he says. “To find out what the injuries are, how to stop the bleeding and repair the injuries so that these patients can return to their work, return to their families, is second to none.”
Although each patient has different needs, the goals in every case remain constant: keep the patient from dying, minimize long-term damage and stabilize him or her for transfer to an operating room or intensive care unit.
A race against the clock
Shands at UF and Shands Jacksonville receive patients with some of the most horrific injuries in Florida, ones too extreme for effective treatment in an emergency room or even in a less equipped trauma center. That’s because of their Level I rankings, the highest achievable. In fact, Shands Jacksonville is home to TraumaOne, the first Level I trauma center in Florida — which opened in 1983 — and has set the bar for trauma care across the state. Florida is now home to seven other Level I centers, including the one at Shands at UF. The rank means these centers are equipped to provide the best available treatment to adult and pediatric patients suffering the very worst injuries. The Shands at UF trauma center also includes a burn center, one of just three in Florida.
“We want to stop the bleeding,” says Donna York, trauma program manager at Shands at UF, “and we want to discover all of the things, the main things, that are injured and move on to the next thing.”
The idea is that patients should be in an operating room or intensive care unit for thorough treatment within one hour of the time the injury occurred, a principle known as the “golden hour” of trauma. Miss the mark too much and a patient’s chances of survival decrease significantly, many health care providers believe.
“Research has shown that the faster you can treat a trauma patient, the better they will do,” says Lynne Sheffer, B.S.N., R.N., a nurse manager at Shands Jacksonville’s TraumaOne.
This is what led TraumaOne to explore ways to further reduce the amount of time it takes to get patients to the hospital. The state’s first trauma program now has three medical transport helicopters instead of two. In addition, TraumaOne has adopted a new philosophy on where to station its helicopters in order to best serve the community.
“The goal is simple: get people the treatment they need to survive an accident or emergency as quickly as we can,” said Wayne Marshall, director of trauma and flight services for Shands Jacksonville. “Having three helicopters out in the community ready to serve on a moment’s notice allows us to do just that.”
Adhering to the golden hour time limit also requires an efficient, life-or-death rush that not every health care provider is cut out to deliver.
“I feel like there’s a special type of person that is able to work in the trauma setting,” says Ashley Babinski, a nurse who works in Shands at UF’s emergency department and trauma bay area. “You just have to have the calm personality. One minute it could be so slow and then, all of a sudden, you have three patients rolling in and they’re all critical. Then you have to triage and do what you can with what resources you have and treat whomever’s sickest first. It’s exciting. I love it.”
The rush in the trauma bays, operating rooms and radiology area, where trauma patients undergo computerized tomography, or CT, scans shortly after arrival, requires the collaboration of a diverse collection of health care providers ready to act whenever the hospital receives word a trauma patient is en route. Trauma surgeons serve alongside pediatric surgeons, anesthesiologists, plastic and reconstructive surgeons, radiologists, respiratory therapists, pharmacists, orthopedic surgeons, obstetricians, oral surgeons, neurosurgeons, emergency medicine physicians, nurses, nurse practitioners, physician assistants and other providers to address patients’ life-threatening wounds before it’s too late.
Justin Morton arrived at Shands at UF around 10 a.m. on Dec. 2, 2011, about two hours after his wife Lori’s accident. He had been in Jacksonville for business but rushed to Gainesville after receiving a phone call from Shands.
“When I got there, they had performed immediate emergency surgery,” Justin says.
Doctors had removed Lori’s spleen and stitched up her liver, both of which were badly damaged.
Lori also had suffered brain shearing, the breaking of some of the neurological connections within the brain, when she crashed and her brain slammed against her skull. Based on a commonly used “coma scale” assessment, Lori’s brain injury was categorized as severe, the worst possible rating. Doctors inserted a monitor into her skull to observe pressure inside, and put a tube into one of her brain cavities to drain excess fluid.
Plastic and reconstructive surgeons stitched up cuts she had sustained in the crash, and doctors also found she had two breaks in her jaw and one in a vertebra. Meanwhile, Justin spent agonizing hours waiting to see his wife.
“It was probably three or four o’clock when I saw her,” he says. “I asked the question, ‘Is she, like, going to be alive?’ and they said, ‘We’re not sure.’”
While Shands Jacksonville has been leading the way in trauma in the state for 30 years, the trauma center at Shands at UF officially became a Level I trauma center in 2005. Before that, the hospital only had an emergency department, not a designated trauma center. To attain Level I status, a hospital must submit documents showing how it will comply with Florida Department of Health requirements that pertain to almost every conceivable aspect of a trauma center: equipment and its placement, staffing, continuing education for health care providers, trauma-related research, community education and more.
Equipment and personnel requirements extend to operating rooms and other areas where patients receive care after leaving the trauma bays. An attending trauma surgeon is in house at all times, and a pediatric surgeon must be on site within 30 minutes of receiving notice of a trauma alert involving a child. The same is true for many other specialists who sometimes work on traumas. Nurses and technicians are on staff in the trauma bays and emergency department around the clock.
Such standards help to ensure that when a patient like Lori Morton arrives, the equipment and people needed to save her life are available. With patients’ lives on the line, the Department of Health is very serious about ensuring not even the tiniest details slip through the cracks.
Abiding by state standards is just one part of keeping a trauma center ready for patients. In addition to the myriad of health care providers ready to respond at a moment’s notice, dozens of other people work behind the scenes to make sure patients get the best care.
When a patient is rolled into one of Shands at UF’s four trauma bays, for example, nurses and doctors reach into open-front bins lining the walls in each bay to find the supplies they need to save his or her life: needles and tubing to start IVs, surgical thread (called suture) to stitch up large wounds and a warmed blanket to fight off plummeting body temperatures caused by shock, to name a few. There’s no wiggle room here for an out-of-stock item.
It takes a detailed inventory and automated ordering system, run on computers throughout the hospital, to keep each trauma bay supplied for daily operation and to ensure Shands at UF always is prepared for a mass casualty situation. Enter Raymond Williams, a 30-year Shands employee with a dedication to his work that stems in part from his personal connection to the hospital. Williams was born at Shands at UF, as were all of his six children and nine of his grandchildren. He started at Shands as a linen tech and now takes great pride in his job as assistant manager of supply logistics for the Central Distribution Center.
“My passion, it is for our patients,” he says. “I tell you, I take this seriously when a patient is up on the floor. I look at those patients as if they were my family, and I like to make sure that they have everything that they need.”
The center orders and stocks disposable medical supplies for clinical units at Shands at UF. Williams oversees the center’s arm that tends to the cancer hospital, which includes the trauma bays. In a 24-hour period, three of his employees are assigned to replenish the trauma bays and ensure each has enough supplies to service numerous patients. At least one person trained in stocking the trauma center is always working.
Williams and his team also prepare trauma carts full of extra goods, which they roll up to the trauma bays in mass casualty situations. As a last layer of caution, the team stockpiles enough materials to get the trauma center through an extended period of time should the hospital’s supplier fail to make daily deliveries.
Another department called sterile processing works continuously to clean instruments, such as scalpels, saws and trays that come in from all areas of the hospital. Emergency department and trauma bay supplies get top priority and are sterilized immediately when they arrive, then sent straight back.
The red phone
Though trauma care has come a long way in the past several decades, patients still face two major immediate threats to survival, says Fred Moore, M.D., chief of acute care surgery at UF and Shands at UF’s trauma medical director.
“If you look at what has evolved, the real way that people die is they either have a bad head injury or they bleed to death,” he says. “The bleeding to death, we sort of hit the wall, in that we can get people to the trauma center, but we have only so much time in which to do life-saving interventions and we need to get the people to live long enough for us to do that.”
To help overcome that hurdle, trauma care providers at Shands at UF depend on two lines of support. One is a mini refrigerator stocked by the hospital’s blood bank with six packs of red blood cells and six packs of plasma.
The second is the red phone that sits atop the refrigerator, which providers use to order a massive transfusion protocol.
“Then we will continuously feed that patient additional units,” says Belinda Manukian, manager of the blood bank. “We do waves of six packs of red blood cells, six plasma, continuously, until they say ‘OK, we got the patient stable.’”
Moore cited other resources used to prevent patients from bleeding to death, including a dedicated operating room also supported by the blood bank and the adjacent radiology suite. There, radiologists can stop internal bleeding through a procedure called an angioembolization, which involves injecting special material into a blood vessel to block bleeding.
Although they may never see the patients they serve, workers in the blood bank, sterile processing and the Central Distribution Center play crucial roles in helping trauma patients beat their injuries and return to a life that’s as normal as possible.
When Justin Morton finally did see Lori, she was unconscious, but alive.
“The outlook was still pretty much, ‘Even if she does wake up, she probably won’t regain any independence or inherent functionality,’” he says.
Justin never lost hope. He was there while Lori spent six weeks in Shands at UF and slowly began to emerge from unconsciousness and respond to her surroundings. Lori and Justin went to live at an inpatient rehabilitation facility in Atlanta in mid-January 2012. With many hours of intensive therapy, she started to become herself again. After several more months of care at an outpatient facility, the couple returned to their home in Ocala in May.
Lori’s recovery continues. She hasn’t yet returned to driving and some basic movements, such as running, remain difficult. Speaking is a particularly tough chore.
“It’s really hard for me to get out the words that I want to say,” Lori confesses, “which is weird, considering I talked all the time before the accident. I’m a teacher, so it’s hard for me to be able to tell a student what I want them to learn without fudging up my words.”
But Lori is intent on teaching again. For now, she volunteers three days a week for a local high school math teacher, biding her time until August, when she hopes to be back in a classroom of her own.