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Visiting a Level I Trauma Centre in the USA
indirect patient activities such as EMS tion, Continuous Quality Improvement programmes and public education.
Visiting a Level I Trauma Centre in the USA F?Lau
A visit to a Level I Trauma Centre (Trauma Centre) in October I996 is described. A group of seven emergency nurses from Hong Kong visited a major trauma facility in Minnesota USA, the Ramsey Medical Center, and took part in a Trauma Nursing Core Course (TNCC). The writer was one of the group and would like to thank everyone there who offered the group a warm reception and invaluable instruction.
INTRODUCTION
Manuscript accepted I5 September I997
The hospital is one of the major medical centres in Minnesota, designed to care for severely injured and/or burned patients. The hospital was built in 1965 and opened a new Emergency Centre (Level 1 Trauma Centre) on 1 July 1995, with approximately 56 000 patient visits per year and trauma team activation (TTA) about twice a day. The admission rate is 18% and health care f?om resuscitation through to rehabilitation is provided. Apart from the advanced emergency centre and intensive care units (ICUs) for different specialities (for example, Burn Centre, Surgical ICU), there is a Rehabilitation Centre to help clients regain the skills and confidence to return to the community after their recovery from trauma. As a leader in the Emergency Medical Service (EMS) arena, the hospital also sees community education as important. For example, young people are invited to participate in patient treatment scenarios so that they can see the sad consequences of domestic violence and hostility The trauma care system is very well organized, from care at the scene of the trauma, institutional care (resuscitation through to rehabilitation), follow-up treatment and various
Accident and EmergencyNursing (I 997
19&199 0 Harcourt Brace and Company Ltd 1997
Ping-Fat
Lau TNCC, BSN, RN, Nursing Oficei; Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
PRE-HOSPITAL
educa(CQI)
CARE
The Emergency Medicine faculty serves as medical directors for more than 35 ambulance services. The hospital provides various courses ranging from First Responder courses to Advanced Trauma Life Support (ATLS), and training for firefighters and paramedics. Physicians in the trauma centre may give medical advice directly to paramedics at the scene, via telecommunication, so the trauma centre provides indirect but active on-scene care. The Level 1 Trauma Center has 9 cubicles designed for delivering critical care. Two of them are designated ‘Trauma Rooms’ and contain sophisticated life-support equipment (for example, Level 1 fluid warmer, physiological multi-monitor) and are designed so that carers may easily reach anything they want. A Stryker bed is placed in the centre of the room and Bag-Valve-Mask (BVM) devices and neck collars are hooked on the wall at the head end of the bed. There is a power column to the left of the patient’s head, on which equipment is mounted, such as a high-rise multi-monitor, defibrillator, oxygen and suction sources and extra AC sockets etc. Under the bench on both lateral side walls are trolleys for different functions, such as medication trolley, IV therapy trolley and airway care trolley. Other equipment, such as linens, gastric lavage kit, chest tube insertion pack, urinary drainage set, Diagnostic Peritoneal Lavage (DPL) accessories are stored on the open shelves of another large trolley. Resuscitation devices for children and infants (for example, infant ambu-bag, very small size oral airway, endotracheal tubes and intravenous catheters) are boxed according to different sizes and stored on the open shelves of a large trolley so that they are immediately accessible. Equipment that may be needed less urgently, such as the ultrasound machine and ventilator are stored nearby in the room. The other critical care cubicles contain less equipment, but still enough to care for patients in critical conditions and to perform resuscitation.
RESUSCITATION REHABILITATION
THROUGH
TO
Upon notification from paramedics at the scene, the hospital pages the trauma team members to get ready in the Emergency Room (ER) so that care can be offered immediately the patient
Level
arrives. The Trauma Nurse Clinician (TNC), who is specially trained, coordinates and takes part in the resuscitation. After initial stabilization in ER, further investigations are performed (for example, X-rays) and then the physicians will decide whether to send the patient to theatre or to the appropriate ICU for further management. One operating theatre is reserved for trauma patients who require immediate surgical intervention, and has been specially equipped to this end. Pre-sterilized instrument packs and other life support equipment are ready so that the theatre can be used immediately. A fully-equipped laboratory is located next door to the theatre. The hospital contains several ICUs and the Burns Centre, which provide speciality care to patients with different pathologies. All the health care units use similar models of monitors and equipment, so that care is continuous as patients are handed over from one unit to the next. As part of the trauma care system, the hospital adopted a multi-disciplinary approach in their rehabilitation services for trauma patients. In addition to nurses and doctors, other health care professionals such as physiotherapists, occupational therapists, social workers and psychologists are involved in rehabilitation. Again, the TNC is responsible for coordinating the various rehabilitation activities, thus providing continuity of care. The multi-disciplinary team meets to discuss appropriate rehabilitation programmes for individual patients. During the visit, group members spent time with paramedics in various disciplines outside the hospital. I spent one day at the fire station in St Paul, seeing the various fire fighting and life-support equipment and turning out with the paramedics to the emergency calls (91 Is), which that day varied &om back pain to a fall from a height. Apart from learning about the care at the scene, I learned about the life of the community and the cultural differences and similarities between us. Another day was spent with a facility called ‘Life Link III’, a joint venture between two
I Trauma
Centre
I99
Minnesota hospitals for the transportation of critically-ill or injured patients by helicopter, aeroplane or ambulance vehicle. The aeroplanes have specially-built advanced-life-support interiors to provide the maximum space and equipment for the patients, including those who need ventilators, intra-aortic balloon pump support or haemodynamic monitoring. Each aircraft has a flight phone and an air-to-ground communication system for talking directly to the control physician. This was my first flight in a helicopter, and in addition to being a challenging environment for caring for patients, it was also a good vehicle for sightseeing! The Trauma Nursing Core Course (TNCC) took place over 2 days at the Capitol Professional Building near the hospital. After outlining the course content, the instructors demonstrated trauma nursing skills and increased the group’s understanding of the responses of various body systems in the event of trauma. One of the major clinical skills in TNCC is the Trauma Nursing Process (TNP), a systematic approach integrating elements of classical nursing process and trauma nursing. It is a way of examining trauma victims in order to identify any life-threatening conditions and sustained and/or suspected injuries. Trauma life support measures can then be taken immediately. The 2-week schedule was tight, to accommodate the clinical activities and the course work, and everyone in the Hong Kong group passed the TNCC examination. However, one day was set aside for sight seeing, particularly the spectacular tree colours in the autumn sunshine, and this relieved the tension built up during such an intensive learning period. During the clinical activities everyone was friendly and enthusiastic, encouraging us to investigate the structure of the unit and explaining operational issues and introducing various items of equipment. The TNCC course instructors were excellent, both in their explanations and their demonstrations. Our knowledge and skills in trauma nursing were greatly enriched, as was our personal development.
Visiting a Level I Trauma Centre in the USA F?Lau
A visit to a Level I Trauma Centre (Trauma Centre) in October I996 is described. A group of seven emergency nurses from Hong Kong visited a major trauma facility in Minnesota USA, the Ramsey Medical Center, and took part in a Trauma Nursing Core Course (TNCC). The writer was one of the group and would like to thank everyone there who offered the group a warm reception and invaluable instruction.
INTRODUCTION
Manuscript accepted I5 September I997
The hospital is one of the major medical centres in Minnesota, designed to care for severely injured and/or burned patients. The hospital was built in 1965 and opened a new Emergency Centre (Level 1 Trauma Centre) on 1 July 1995, with approximately 56 000 patient visits per year and trauma team activation (TTA) about twice a day. The admission rate is 18% and health care f?om resuscitation through to rehabilitation is provided. Apart from the advanced emergency centre and intensive care units (ICUs) for different specialities (for example, Burn Centre, Surgical ICU), there is a Rehabilitation Centre to help clients regain the skills and confidence to return to the community after their recovery from trauma. As a leader in the Emergency Medical Service (EMS) arena, the hospital also sees community education as important. For example, young people are invited to participate in patient treatment scenarios so that they can see the sad consequences of domestic violence and hostility The trauma care system is very well organized, from care at the scene of the trauma, institutional care (resuscitation through to rehabilitation), follow-up treatment and various
Accident and EmergencyNursing (I 997
19&199 0 Harcourt Brace and Company Ltd 1997
Ping-Fat
Lau TNCC, BSN, RN, Nursing Oficei; Accident and Emergency Department, Pamela Youde Nethersole Eastern Hospital, 3 Lok Man Road, Chai Wan, Hong Kong
PRE-HOSPITAL
educa(CQI)
CARE
The Emergency Medicine faculty serves as medical directors for more than 35 ambulance services. The hospital provides various courses ranging from First Responder courses to Advanced Trauma Life Support (ATLS), and training for firefighters and paramedics. Physicians in the trauma centre may give medical advice directly to paramedics at the scene, via telecommunication, so the trauma centre provides indirect but active on-scene care. The Level 1 Trauma Center has 9 cubicles designed for delivering critical care. Two of them are designated ‘Trauma Rooms’ and contain sophisticated life-support equipment (for example, Level 1 fluid warmer, physiological multi-monitor) and are designed so that carers may easily reach anything they want. A Stryker bed is placed in the centre of the room and Bag-Valve-Mask (BVM) devices and neck collars are hooked on the wall at the head end of the bed. There is a power column to the left of the patient’s head, on which equipment is mounted, such as a high-rise multi-monitor, defibrillator, oxygen and suction sources and extra AC sockets etc. Under the bench on both lateral side walls are trolleys for different functions, such as medication trolley, IV therapy trolley and airway care trolley. Other equipment, such as linens, gastric lavage kit, chest tube insertion pack, urinary drainage set, Diagnostic Peritoneal Lavage (DPL) accessories are stored on the open shelves of another large trolley. Resuscitation devices for children and infants (for example, infant ambu-bag, very small size oral airway, endotracheal tubes and intravenous catheters) are boxed according to different sizes and stored on the open shelves of a large trolley so that they are immediately accessible. Equipment that may be needed less urgently, such as the ultrasound machine and ventilator are stored nearby in the room. The other critical care cubicles contain less equipment, but still enough to care for patients in critical conditions and to perform resuscitation.
RESUSCITATION REHABILITATION
THROUGH
TO
Upon notification from paramedics at the scene, the hospital pages the trauma team members to get ready in the Emergency Room (ER) so that care can be offered immediately the patient
Level
arrives. The Trauma Nurse Clinician (TNC), who is specially trained, coordinates and takes part in the resuscitation. After initial stabilization in ER, further investigations are performed (for example, X-rays) and then the physicians will decide whether to send the patient to theatre or to the appropriate ICU for further management. One operating theatre is reserved for trauma patients who require immediate surgical intervention, and has been specially equipped to this end. Pre-sterilized instrument packs and other life support equipment are ready so that the theatre can be used immediately. A fully-equipped laboratory is located next door to the theatre. The hospital contains several ICUs and the Burns Centre, which provide speciality care to patients with different pathologies. All the health care units use similar models of monitors and equipment, so that care is continuous as patients are handed over from one unit to the next. As part of the trauma care system, the hospital adopted a multi-disciplinary approach in their rehabilitation services for trauma patients. In addition to nurses and doctors, other health care professionals such as physiotherapists, occupational therapists, social workers and psychologists are involved in rehabilitation. Again, the TNC is responsible for coordinating the various rehabilitation activities, thus providing continuity of care. The multi-disciplinary team meets to discuss appropriate rehabilitation programmes for individual patients. During the visit, group members spent time with paramedics in various disciplines outside the hospital. I spent one day at the fire station in St Paul, seeing the various fire fighting and life-support equipment and turning out with the paramedics to the emergency calls (91 Is), which that day varied &om back pain to a fall from a height. Apart from learning about the care at the scene, I learned about the life of the community and the cultural differences and similarities between us. Another day was spent with a facility called ‘Life Link III’, a joint venture between two
I Trauma
Centre
I99
Minnesota hospitals for the transportation of critically-ill or injured patients by helicopter, aeroplane or ambulance vehicle. The aeroplanes have specially-built advanced-life-support interiors to provide the maximum space and equipment for the patients, including those who need ventilators, intra-aortic balloon pump support or haemodynamic monitoring. Each aircraft has a flight phone and an air-to-ground communication system for talking directly to the control physician. This was my first flight in a helicopter, and in addition to being a challenging environment for caring for patients, it was also a good vehicle for sightseeing! The Trauma Nursing Core Course (TNCC) took place over 2 days at the Capitol Professional Building near the hospital. After outlining the course content, the instructors demonstrated trauma nursing skills and increased the group’s understanding of the responses of various body systems in the event of trauma. One of the major clinical skills in TNCC is the Trauma Nursing Process (TNP), a systematic approach integrating elements of classical nursing process and trauma nursing. It is a way of examining trauma victims in order to identify any life-threatening conditions and sustained and/or suspected injuries. Trauma life support measures can then be taken immediately. The 2-week schedule was tight, to accommodate the clinical activities and the course work, and everyone in the Hong Kong group passed the TNCC examination. However, one day was set aside for sight seeing, particularly the spectacular tree colours in the autumn sunshine, and this relieved the tension built up during such an intensive learning period. During the clinical activities everyone was friendly and enthusiastic, encouraging us to investigate the structure of the unit and explaining operational issues and introducing various items of equipment. The TNCC course instructors were excellent, both in their explanations and their demonstrations. Our knowledge and skills in trauma nursing were greatly enriched, as was our personal development.