‘Fighting the Noble Fight’ Trauma Doctors Make Split-Second Decisions to Save LivesApr 12, 2022 05:02PM ● By Liv Osby
A framed photo of a little girl pedaling a bicycle occupies a special place on Dr. Robert Gates’ desk.
When she was just 1½, she was so seriously injured in a wreck it wasn’t certain she’d recover fully.
But several years later, her parents sent the picture to let Gates know how well she was doing. It serves as a reminder of why he does the work he does.
“The children we save. That’s what keeps me going,” said Gates, a pediatric surgeon and Director of Pediatric Trauma at Prisma Health.
Doctors who work in trauma care have countless stories of patients like that little girl who beat the odds to survive. But there are others who tragically don’t make it in spite of all the tools modern medicine has.
Gates remembers the innocent 5-year-old boy who died after a bullet came through a wall in his home.
‘Harder with children’
“A death in any situation is horrific,” he said. “But it’s harder with children … a child who has so much to live for.”
Dr. Ashley Hink, a general, trauma, and critical care surgeon at the Medical University of South Carolina, recalls the teacher who suffered such extensive injuries in a wreck that she wasn’t expected to live.
“She had open fractures in all her extremities. She had chest trauma. A head injury. We would have expected her to potentially die,” said Hink, who is also assistant professor of surgery.
“But I came in (one) morning and she was sitting there eating with her husband beside her. I thought to myself, ‘Wow. This is amazing.’”
One of the patients who stands out for Dr. Hugh Willcox of Lexington Medical Center is the 20-something who hit a wire while riding a four-wheeler.
“It ruptured his stomach. He had a laceration of the kidney. And one of our providers took him to ER and closed the hole in his stomach, and the bleeding was controlled,” said Willcox, a surgeon who is Director of Trauma Medical Care and Medical Director of Acute Care Services.
“He was in the hospital three or four days and he did great.”
Trauma care is a branch of medicine that treats patients with potentially life-threatening conditions from falls and workplace injuries to motor vehicle accidents and gunshot wounds, according to the American College of Surgeons.
Trauma surgeons work with a team that includes other surgeons, physician assistants, nurse practitioners, and surgical residents to provide continuity of care.
Their 12-hour days start early – before 7 a.m. – when they meet with the overnight care team coming off their 12-hour shift, develop and update care plans for existing patients, and then conduct rounds to check on their progress.
A variety of surgeries
They tackle a variety of surgeries during the day – emergency appendectomies, ruptured spleens, bowel obstructions.
Inevitably, the trauma cases start arriving.
There’s the child who broke his legs after falling off a trampoline and the teen with multiple organ injuries from crashing his ATV into a tree, said Gates, who is also professor of surgery and pediatrics.
Sadly, gunshot wounds are on the rise by about 20 percent, he said. And while most were related to safety issues in the past, more are gang-related today, he said.
“Some of them are the perpetrators,” he said, “and some are a child behind a wall caught in the crossfire.”
Among their patients are “super saves,” says Gates, like the child who was in and out of surgery for weeks after being run over by a lawn mower. But a year and a half later, he said, “she was running around like nothing happened.”
Hink recalls the young man shot so many times it was hard to know where to start treating him.
“He had bullet holes in all his extremities, multiple in the chest, the abdomen and pelvis. A bullet had gone through his lung, through his intestines, his stomach, his liver, his spleen,” she said. “It was bad.”
But in the OR, Hink and her team went to work to put him back together, removing his spleen and stopping the bleeding.
“I was worried he was not going to make it, but he’s what we might call a great save,” she said. “And I loved getting to know him afterward.”
There’s typically little notice when a trauma comes in, says Hink. But the team jumps into action and follows protocols to identify any life-threatening injuries in a matter of seconds.
If the patient isn’t breathing, does he need to be intubated? If the blood pressure is low, do fluids need to be started? If there’s no heartbeat, can he be resuscitated?
Then, tests are ordered and decisions made about whether other specialists – orthopedic surgeons, neurosurgeons – need to be called in, Hink said.
“Unfortunately, we sometimes have multiple patients at once – there’s been a crash or a house fire or a mass shooting event,” she said. “Then we have to … identify who’s sickest and mobilize additional resources if we need them.”
Violence intervention program
Moved by victims of violence she’s seen, Hink last summer launched a violence intervention program at MUSC aimed at patients 12 to 30 years old who’ve experienced gunshot wounds, domestic abuse, and sexual assault, among other injuries.
“So many of the people I was helping were interfacing with the medical system,” she said, “but the violence they were experiencing was rarely recognized.”
The program aims to provide help to reduce the risk for future violent injury, and to help people recover fully, Hink said, noting many suffer PTSD after these injuries.
“I love being able to care for them from the minute they hit our trauma bay, through the care and back to their lives,” she said. “Lives that are frequently altered.”
Prisma and MUSC are Level 1 trauma centers that see the most serious cases. And while Lexington Medical is a Level 3 trauma center, it has one of the busiest ERs in the state, Willcox said.
Children with traumatic injuries are typically stabilized and transported to a nearby hospital with a pediatric trauma unit, he said, while there’s also a local Level 1 trauma center for the most severe adult cases.
But the hospital still sees its share of serious cases, including head and spine injuries from accidents, ruptured aneurysms, and gunshot wounds, he said.
The saves are memorable. But the doctors also have poignant memories of the patients who don’t make it.
For Gates, that’s often the children who battle a variety of debilitating physical ailments during their short lives.
“We struggle to get (them) to lead a semi-normal life,” he said, “and yet they succumb to illness.”
As he’s working to save a child, Gates is focused on the task. It’s the next day when it hits him.
“You get so busy you have to be able to compartmentalize it … and go on to the next disaster,” he said. “It’s the next day when … you suddenly realize, that’s a 5-year-old, and that shouldn’t have happened.”
Bad outcomes are no doubt the toughest part of the job, said Willcox. But sometimes they’re inevitable.
“You always hold on to the victories. You know that you’re fighting the noble fight,” he said. “But despite all our best intentions, things don’t always turn out the way we want them to.”
Hink says it can be easy to get down after someone dies.
“Sometimes we have to remind ourselves, especially with really bad traumatic head injuries, that there’s only so much we can do,” she said. “I have to stop and remind myself of all the people we help.”
All three say the system is designed to review these cases and learn from them. But sometimes there’s nothing that could have been done differently.
Coping with loss
Meanwhile, they must cope with the loss.
Gates says team members often console one another.
“We watch each other and continue to encourage each other,” he said. “Those of us who have good supportive family systems do better.”
His faith helps him too.
“Every day, God gives me the opportunity to do this,” he said, “and it’s a privilege to be his hand.”
Willcox says everyone handles it differently. He decompresses with his wife and three boys by taking family trips and boating on Lake Murray.
“Some have hobbies they turn to to take their mind off the stress,” he said. “A lot of folks have a strong support system at home. I do.”
He adds that there’s been a focus on physician mental health in recent years that’s led to growing resources for providers who may need help to get over a difficult case.
The good news, Gates says, is that most children get better despite their injuries and go on to lead normal lives.
And happily, he said, patients and their parents often stay in contact through Christmas cards, letters and photos, expressing gratitude for the care they received.
One patient who had multiple stitches after a bad wreck when she was small sent a picture of herself and her boyfriend at the prom 15 years later with a note saying, “Look Dr. Gates. No scars.”
“Parents need to know how much that means to us,” he said. “It makes a big difference.”
Hink says it’s therapeutic to hear from patients with devastating injuries who are walking and talking again.
“It fills my cup to know people are doing well after we take care of them at such a critical time,” she said.
Trauma care requires years of training – four years of medical school and five years of surgery residency plus a trauma critical care surgery fellowship. It can be demanding and chaotic. And it can be heart-wrenching comforting families who’ve lost a loved one.
So why choose that specialty?
Gates was a youth pastor and high school chemistry teacher before he went to medical school. He’d planned on going into family practice but eventually switched when he fell in love with pediatric surgery.
“I love taking care of acute problems and being able to cure with a knife, or heal with steel, as they say,” he said.
But the best part for him, he says, is taking care of children, even as some of them reminded him of his own.
Willcox got interested in trauma in medical school. In 2009, he joined a general surgery practice while working as an Advance Trauma Life Support trainer but jumped at the chance to do trauma again when the opportunity came up at Lexington Medical.
“At a busy center like that, you have to be ready for the next one to come in,” he said, “to make sure that coverage of acute care and surgery is as seamless as possible.”
Hink was in high school when she became interested in medicine and pursued a public health track. Surgery wasn’t on the radar at all.
But after seeing victims of serious injuries and violence – in part from working as a crisis volunteer – she fell in love with trauma and changed course.
“On any given day, you can be dealing with … a car crash, a fall or violence. It’s a wide breadth of practice,” she said. “And I feel so privileged to take care of every walk of life.”
There are days when it can be frustrating, dealing with preventable injuries, with the lack of insurance, and other disadvantages people endure, she said.
But having that insight into people’s lives instills empathy and understanding about what puts them at risk to begin with, she said.
“It’s important … to understand their backgrounds and lives,” she said. “It makes us better (doctors) for our patients.”