Medics Make Traumatic Decisions : But for Life Flight and Hospital Staff There Are Rewards

Dr. Dave Guss had a plan of action well in mind before the Life Flight helicopter touched down at the grisly, chaotic scene where two police officers and a civilian lay critically injured. The idea was to check all three gunshot victims immediately and decide how best to apply his trauma skills in the limited time available.

The first victim had no vital signs despite frantic CPR administrations by fellow officers for almost 15 minutes. After a quick check, Guss turned away. “I think we’re going to have to call this one off; there’s nothing I can do for this guy, I’m sorry,” he said evenly, moving immediately to the second officer as sobbing broke out among police.

Guss, laboring rapidly but methodically along with flight nurse Mike Epperson and numerous paramedics, was able to stabilize the other victims for transport to Mercy Hospital, where trauma surgeons waited. Those two are recovering.

Such is the pace of a trauma doctor in San Diego, where the highs and lows--”the big hits and big losses,” in the words of surgeon A. Brent Eastman--come in rapid-fire succession.

“We like the pace, we like the pressure that requires fast decisions,” Dr. Steven Shackford, surgeon in charge of the trauma unit at UCSD Medical Center, said. “We may not thrive on it but we certainly don’t mind it.”

Eastman stood on the south apron of the helicopter pad at Scripps Memorial Hospital squinting at the glimmering Life Flight chopper about to touch down with a woman critically injured in a head-on traffic accident.

“It really gives you a feeling of M.A.S.H. seeing this,” said Eastman, head of the Scripps trauma unit.

Trauma nurse Brenda Masnack said, “It sure gets your adrenalin pumping.”

Eastman had sprinted down the rear stairwell from the hospital’s fifth floor after getting the call to activate the trauma team, the first of five calls that day. “I never wait for the elevator,” he said.

For the people who make the county’s 9-month-old trauma system work, there is a thrill--a surge of goose bumps up the spine--when confronted with critically injured patients.

“People can only be so badly hurt,” Eastman said. “My philosophy is that there is no situation you can’t handle; the only question is what do you need to handle it well?”

Says UCSD’s Shackford: “Why are we trauma surgeons? You can have instant gratification when you put your finger on a bleeding heart and watch the blood pressure come up, to see the immediate response. And you see the sweat on the forehead of the anesthesiologist, on the person handling the blood, and the tension level begins to go down, and everyone on the team is saying, ‘Let’s go, let’s move.’ ”

The team concept is crucial to the success of the trauma system. The doctors, the nurses, the respiratory therapist, the X-ray technicians, all have designated places to stand and prearranged duties to carry out without delay as soon as a victim is moved onto the table.

“Everything is pretty well orchestrated during the first four or five minutes,” Scripps doctor Rick Pfeiffer said. “After that, there’s a little more ad-lib.”

“Without your team members, without knowing their anticipation, you’d be up a creek,” said Jan Kociencki, a Scripps trauma nurse.

Scott Riek, burn service coordinator at UCSD Medical Center, had paged the trauma team, lined up the various vials and labels for the first tests and stood impatiently along with Shackford and other members for the arrival of a Ramona man burned when a carburetor exploded in his face.

“You’re prepared and psyched up for it,” Riek said. But the intensity is not unabated. Two nurses kidded a third about her new shoes and Shackford needled Dr. Jim Bennett about his new haircut. “It’s early Attila the Hun,” Shackford said.

Yet as soon as Life Flight’s Guss delivered the victim to the trauma room, Shackford was all seriousness. “C’mon, let’s move it,” he urged his team, slamming his fist into his hand three times. To the victim, he apologized for the various tests and probings: “You’re going to be uncomfortable, but hang in there--you’re doing real good, babe.” The victim, in pain but conscious, invited everyone out to his ranch for a barbecue “as soon as all this is over.”

The esprit de corps among those involved with trauma carries over beyond the job. UCSD’s James Dunford, one of the first doctors involved with Life Flight five years ago, counts among his best friends a helicopter pilot and mechanic. Even hospital volunteers associated with the team share the adrenalin surge.

“This is exciting to be around,” Ezra Duong-Van, a UCSD premedical student, said of his work every Sunday in the Life Flight communications center. “I want to be a flight doctor. I want to fly.”

Most of the Life Flight doctors and nurses like to fly. “They all like the idea that every time the motor blades turn on the chopper, they’re turning for a good purpose,” pilot Dave Patrick said.

“I’ve always had a career goal to fly,” said Mike Epperson, a flight nurse. Epperson spent three years as an Air Force nurse, tending to overseas evacuations of military dependents on hospital planes.

“But the situations with helicopters are much more of a challenge, to show your skills in the field. It’s a lot more like combat.” Epperson drives to San Diego from his San Clemente home--65 miles north--for the opportunity to work as a flight nurse.

Epperson said one doctor described trauma treatment in the field as “being thrown into a dark closet with a couple of patients and some dust and seeing if we can start an IV (intravenous solution).”

“Most satisfaction in medicine comes from doing something positive for someone and, percentage-wise, you are offered more satisfaction, more excitement, being on a helicopter than in most other fields,” Guss said.

“There’s nothing magical about the work,” Dunford said. “You try not to get too sophisticated out in the field, just work the ABCs (clearing airways, insuring breathing, protecting circulation). Nothing fancy, but important so that everything else subsequently will go right.

“It’s a supercharged environment, lots of thrills, often incomplete or inaccurate information; the helicopter is the penultimate in emergency rooms.”

The doctor must remain in control at all times, Dunford said. “You want to be the person taking charge when all hell is breaking loose, to be the person in the leadership position, especially when it comes to multiple victims.”

At times, Dunford explained, you cannot hear a person’s blood pressure because firefighters are still cutting away the side of a smashed automobile with their “jaws of life” pliers. At night, Life Flight personnel must often improvise lighting from fire trucks or from the sheriff’s helicopter or simply use flashlights.

At the scene of the police shootings March 31, Guss said that he needed to know immediately how long CPR (cardiopulminary resuscitation) had been administered to the dying officer in order to know how to respond.

“There is dead and there is dead,” Guss said. “If there are no vital signs but CPR has just been started and injuries are due to trauma, I’m inclined, even if success probably is minimal, to proceed in an aggressive manner.

“But in this case there wasn’t any hope.”

Guss said he could have allowed CPR to continue, taken the officer to the hospital and pronounced him dead there. “I considered doing that as a social service, if you will, for the other police. There were a lot of officers around and I knew it would be very difficult to pronounce the death at the scene because the emotion level was running very high.

“But I didn’t know at the time whether we had enough resources (transport) to cope with the injured. So I had to do . . . what is extraodinarily difficult and heart-rending. As doctors, you get better at what you do medically but you never get better at telling someone another person has just died.”

Guss said despite the brief span of time he had, “it was still a very uncomfortable 10 seconds leaving the dead officer before going on to the next patients.”

The trauma workers have disciplined themselves not to react to terribly disfiguring injuries until after crises have past.

“You have to work without thinking of the fact that this person on the table may be bleeding to death,” Shackford said. “You disassociate yourself from the emotion, you don’t wring your hands.”

Added Dunford: “You just figure out what you should be doing and not go around saying, ‘Oh my God, Oh my God.’ ”

Epperson concurred: “You just could not do your work in the field if you took time to think about the gore every time you saw a person smeared all over the road.”

But the reactions do come. Guss attended the dead officer’s funeral as a sign of sympathy from Life Flight, which has close contacts with police and other safety officers.

Every trauma worker interviewed for this story said the sight of critically-injured children brings special pain, largely because children are almost always true victims, having been passengers in a car or recipients of severe child abuse. Or, as in the San Ysidro McDonald’s massacre, simply in the wrong place at the wrong time.

“No question, it gets to you,” Eastman said. “To be playing tennis on a Saturday and less than an hour later trying to explain to the parents of a 17-year-old that you couldn’t save their son who hanged himself.”

Epperson still recalls an accident on Interstate 15 where a lumber truck, its driver drunk, overturned onto a car driven by a mother and two children. Epperson had to reach over the crushed body of the 9-year-old to work feverishly on the mother, who trauma surgeons managed to save. The two children died.

“What bothered me most, and still does, is that the family was just doing its normal thing and how quickly your own kids could be snatched away.” Epperson has two children the same age as the I--15 victims.

Shackford said, “Does it bother me especially to see kids? You bet. Women too, although someone will call me a chauvinist. I don’t like it when kids are tugging at a father and asking ‘Where is Mommy, Daddy? Where is Mommy?’ ”

Kociencki of Scripps praised the group encounters that the trauma team periodically holds to deal with the stress.

Epperson said that while he has never broken down and cried, he has “vented” to other nurses and thought a lot about situations while driving to and from his San Clemente home.

Yet there is great satisfaction with the many people who are saved under the trauma system.

“I think of the little girl I now see in the cafeteria (as an outpatient) who had a critical head injury after being tossed off a horse,” Dunford said. “It’s such a delight now because she was really touch and go. You’re thrilled to make a difference with those people.”

Life Flight pilot Dave Patrick retains a friendship with a 9-year-old girl, one of three survivors in a 60-mile-an-hour head-on collision in the Imperial Valley that killed three other people. “She has become our real sweetheart,” Patrick said.

Shackford, who first immersed himself in emergency medicine as a Navy doctor, still corresponds with a college student who, as a child, was run over by a truck and brought to Shackford.

“His parents have had dinner with my family, I exchange letters, he is now running for student body president at his college. It gives great pleasure to see a guy who can return to be a functioning member of society and not just a custodial case.”

For Scripps, the patient the trauma team remembers most is Oscar Jiminez, an illegal alien from a rural mountain town in Guatemala who was badly beaten and left for dead in a North County agricultural field. Jiminez, 20, was admitted as a John Doe and remained unidentified for more than a month despite phone calls and letters by Marilyn Alf and Terry Bondurant of the trauma social services department. Only after Jiminez was able to talk did his story of immigration to the United States become known.

When Jiminez left Scripps almost four months after being admitted--and well on his way to recovery--the entire staff threw a party and many cried.

The field of trauma medicine is still new but its practitioners already have strong feelings on prevention. They have seen enough accidents to know drunk driving and use of drugs cause a disproportionate number of accidents and that the failure to wear seat belts adds tragically to the severity of injuries.

“I never wore a seat belt before I started working in trauma and now I always do,” Kociencki said. “I guess that seeing other people in dangerous situations makes you more aware of the dangers for yourself.”

“I wish I could share with everyone some of my experiences regarding alcohol-related injuries and those resulting from not wearing belts,” Dunford said.

“I’ve never heard a drunk say he or she was sorry for causing deaths. I remember a guy who caused a head-on collision on (state highway) 94 leaving the husband in the other car dead and his wife critical.

“When I asked him his name in examining him for injuries, he said he didn’t want to say anything until he saw a lawyer.”