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“A Textbook of Trauma”

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Dr. Sheldon Teperman in one of Jacobi's trauma bays. Shortly after this picture was taken, he had to rush off to attend to a patient mauled by a pit bull.   

Rounding the floor, Teperman is reminded of the Little Chester shoe-store massacre in 1995, when a man opened fire, killing five and injuring three. Jacobi treated the victims, but this disaster is an order of magnitude worse: a “shit storm,” he says, “a textbook of trauma in one day.” And not just because of the number of casualties, though fifteen at once is huge even at a Level 1 center. Jacobi admits 1,900 trauma cases a year. About 21 percent—a very large portion—are “penetrating” traumas, mostly gunshots and stabbings. The rest are “blunt”: car accidents and falls as well as more deliberate blows. The bus victims have both kinds, and Teperman is further troubled by the strange addition of wounds caused by shearing. They never tried that combination with pigs.

Teperman uses the word sick the way laymen would say “dying.” One woman is severely hypotensive, with bleeding from midface injuries and trauma to the chest. But she isn’t—yet—as “sick” as some, and the source of her problem is not clear.

So he turns his attention to a man whose blood pressure is dropping precipitously. He has rib fractures, many blunt injuries, and some sort of brain trauma. He is running out of time. A sonography exam finds bleeding in his abdomen—but where exactly? The scan doesn’t name the organ.

Teperman sends the patient to an operating room; several are now up and running. There, Peter Kim, an attending surgeon, opens him up. The bleeding is coming from the spleen. That’s luck; you can live without a spleen. Kim contacts Teperman. Given the need to keep operating rooms available for more critical patients, should he wait? No, Teperman says: “Whack it.” Kim throws down the clamps, cuts out the organ, sews the surrounding vessels.

“Once the clamps are on, the game is won,” Teperman says. “He’s dying, dying, dying, and then he’s saved.”

Saved for the moment; his broken ribs and brain injuries remain to be dealt with. But others need more immediate attention.

“People are constantly trying to die on me,” Teperman says. “It’s very annoying.”

A victim whose arms were sheared off by the stanchion, the tissue and bone “pulled, torn, and gouged up,” is sent to the OR. The wounds are cleansed and the amputations “revised”—cut back to healthy tissue so they can be prepared for closure and the acceptance of prostheses later.

Meanwhile, another man, with multiple fractures, is in very bad shape. A CAT scan shows that he is bleeding from the pelvis. Doctors fit him with a T-Pod, a corsetlike binder commonly used in battlefield incidents involving improvised explosive devices. By stabilizing the area, the T-Pod can often stop the bleeding, but this time it doesn’t. Once again the question is, where exactly is the blood coming from?

In the interventional radiology suite, radiologist Conway Yee tries digital X-ray fluoroscopy to pinpoint the source. He inserts a micro-catheter through the femoral artery, threads it carefully into the pelvis, then injects a dye and studies the screen. If blood is leaking from vessels, the dye will make it visible. He looks everywhere, but there’s nothing. He asks Teperman what he should do; Teperman says to try again, fast. “And even if you don’t see anything this time, take out the big feeding vessels.” Neither the patient nor Jacobi can afford any more bleeding.

Yee performs a second run, injects the dye—and there it is. A ruptured vessel, leaking black on the screen. Tiny surgical tools inside the catheter allow him to disable it without damaging larger vessels. Next he inserts a “gel foam” that instantaneously seals the cut ends. Another injection of dye shows no further bleeding. The man is saved; his vital signs become “rock stable.”

Despite the TV-ready clichés—shock paddles, blood spouts, adrenaline injected into hearts—the emergency floor is strangely calm. Four hours in, more than 100 staff are working feverishly if quietly on the fifteen patients. (Another five, including the driver, were taken to St. Barnabas Hospital, several miles farther west.) Trauma centers don’t get much glory; no one peruses a best-doctor list to decide where to get shot or run over. But Teperman feels confident enough of his team’s response to think, for a moment, that the situation is under control.

It’s true that the patients are unusually quiet. Removing the dressing on an open fracture, a procedure that would ordinarily produce a scream, produces nothing. Some of course are not even conscious, but even those who are seem astonishingly stoic. Or are they simply too shocked to understand what’s going on? Having been told that the most severely injured patients are Cantonese, Teperman takes a Cantonese-speaking resident to each bedside and has him say, “You’re in a hospital, you’ve been in an accident, you’re going to be fine.” Mostly, they do not respond.


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