Annals of Medicine: Trauma Surge Capacity

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May is the best month in the ER. The contagious diseases of winter are mostly gone, lessening the chances that I will get some horrible flu or stomach bug. The senior residents are as clinically strong as they will ever be as residents and require little supervision from me. I do have to put up with their “senioritis” though. They are good and they know it. They push back and challenge my attempts to minimally supervise them. At the same time they are realizing that in a month they, and not I, will have the ultimate responsibility for their patients’ outcomes and so they are now paying very close attention to the details of my patient management. I am enjoying our friendly sparring all the more knowing in a month they will all be going to new places, geographically and professionally.

May brings its own diseases as well. Asthma visits are soaring thanks to Charlottesville’s incredible yellow- green spring pollen blanket. It would help some if the patients could stop smoking. May is also the beginning of motorcycle crash season. This is largely a disease of males although we do see the occasional female injured, usually as a passenger. It would help some if the patients could stop drinking. Trauma of all types begins to spike in May as more people engage in outdoor activities, climb ladders, operate machinery, and participate in recreational sports. I like treating trauma and asthma. Unlike the flu and stomach bugs, I can’t catch them.

The trauma experience and organization in Charlottesville mirrors the national trends in trauma care that resulted in so many good outcomes in the Boston Marathon bombings. Remarkably, every one of the bombing victims who wasn’t killed instantly will survive. That’s 264 people, many critically injured, descending on the emergency medicine system simultaneously. How did Boston do this, and could Charlottesville?

As horrific as the bombing was, it was mitigated a great deal by several factors, some planned, some fortuitous, and some simply heroic.

The first factor was heroic, the number of spectators who, despite the initial panic of two explosions and the gruesome carnage all around them, immediately began first aid for the victims. Tourniquets fashioned from sweaty T-shirts undoubtedly saved many lives. Given Charlottesville’s record of volunteerism, I suspect the response here would be similar. As a side note, tourniquets had fallen out of favor for first-aid many years ago in the EMS community due to concerns about impairing circulation and killing limb tissue, but the endless wars in Iraq and Afghanistan have taught us the value of immediate tourniquets as primary damage control in trauma and we are back to using them.

The next factor was both planned and fortuitous, the nearby medical tent. The tent was set up at the finish line and staffed to care for many patients, both runners and spectators. This was good planning. That the tent happened to be so close to the victims was fortuitous. Here in Charlottesville we do something very similar for almost all mass gatherings. The organization is called Special Events Medical Management (SEMM) and they provide support for Foxfield, UVA football games and graduation, concerts at the John Paul Jones center and even JMU football games. For the most recent Foxfield races, SEMM deployed on-site five ER doctors and 50 paramedics in a well-equipped medical tent. So Charlottesville is well prepared to medically support mass gatherings.

The next factor in Boston was both fortuitous and heroic. The bombing occurred ten minutes before the 3 p.m change of shift at all the hospitals in the city, so twice the nursing staff was present in the ERs and ORs, both the oncoming and off-going shifts, and of course nearly all the nurses stayed to work. I am certain my nursing colleagues here in Charlottesville would do the same. ER nurses!

The next factor was just plain fortuitous. The bombing occurred on Patriots Day, a state holiday in Massachusetts and the operating rooms were running at relatively low capacity with fewer elective cases and so had a larger surge capacity. This was critical because several dozen of the victims needed immediate surgery and many more needed urgent surgery.

The last factor cannot really be duplicated here in Charlottesville. The Boston ambulances were well coordinated to distribute the patients equally to seven trauma centers citywide so the numbers of surge patients were more manageable for any one hospital. Charlottesville only has one trauma center. But we have several plans we drill on to increase our surge capacity, should we ever need to. Here’s hoping we never do.