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Trauma unit: to help cure the crises
Trauma unit: to help cure the crises
George T. Anasf, MD
There appears to be an increased demand for health care, arising from the increased population and from increased social pressure and change. The provision of medical care and the receipt of medical care have become issues of great social significance. There is no question that improving the distribution and availability of medical care in our society is of paramount importance and will continue to attract the attention of both public and private sector, in years to come. George T. Anast, MD, i s secretary o f the American Academy of Orthopedic Surgeons' National Subcommittee on Emergency Room Care and also a member of the Academy's National Committee on Injuries. H e i s senior attending orthopedic surgeon at Ravenswood Hospital Medical Center and attending orthopedic surgeon for Cook County Hospital. Dr. Anast chairs the postgraduate course for emergency room nurses, Chicago Committee on Trauma, American College of Surgeons. This paper was adapted from Dr. Anast's portion of the 1971 A O R N National Congress program "Time waits for no man-trauma."
44
We are told over and over again about the various shortages of medical care and medical personnel and the inequities of the distribution of medical services. I strongly believe that most shortages which have been described are relative rather than absolute shortages, and the problem is really one of more maldistribution rather than real unavailability. I do believe, as do others, that the over-utilization of existing outpatient care facilities may well serve to create artificial shortages by diverting resources in short supply to areas where they are not truly needed. Further problems, of which we are all aware, are the general decline of dedication, inclination, and self-sacrifice on the part of some physicians and nurses. The pressure of times and the result of organization and bigness has, in many cases, made the profession more of a job than a calling. I emphaThe vast majority-and size the vast majority--of nurses and
AORN Journal
doctors remain willing to extend themselves in the name of humanity. But they would, by and large, prefer to do this as they had done in the past out of the sense of dedication rather than merely in receipt of some altered pay scale or some additional time off. In discussing the availability and distribution of medical care, the experts seldom point out that there are really three basic kinds of patients. Group one patients need skilled medical or surgical care for life endangering or potentially disabling injury or illness. Patients in group two have a bonafide illness or injury which is self limiting and which will get well by itself, but there is pain and suffering and their possible period of disability will be substantially shortened or improved by skilled medical care. In group three are the people who think they need medical care and have imaginary or psychosomatic illnesses. Regretfully, group three possibly constitutes a very substantial proportion of all people seeking medical care at any given moment. When you examine the situation in detail, it is obvious that the services of a physician are only required, really, in the group-one type patient and, to a moderate extent, in group two. The vast majority of those in group two could be adequately cared for by other health professionalists; that is, health professionals other than physicians, under the supervision of a physician. Many of the patients in group two require only a few sutures, the application of a pressure dressing, a bit of Furacin, a tetanus shot, an or-
August 1971
nade or some other simple medication; and such simple diagnostic procedures as laboratory studies or x-rays which are ordered by filling out the appropriate form. This type of outpatient care, combined with screening and routine triage, is well within the province of the properly-trained nurse working under the supervision of a physician. Unfortunately, no data presently exists as to what extent the efficiency of the emergency room doctor muld be increased by this technic, but I would hazard a guess that a 200% to 300% improvement in his personal efficiency would certainly result. The third group of patients require, by and large, only psychological support or symptomatic care for their complaints. They also, however, have to be obviously screened so that they are absolutely sure no potentially serious illness or injury is being overlooked or masked by their psychological problems. Insofar as the statistics are concerned, the instances of illnesses and injuries in group one - the serious ones - can be largely calculated. The statistics for the occurrence of heart disease, cancer, stroke, gall bladder trouble, hernias, discs, fractures, femur, broken arms, are all well in hand. Barring some radical change in the environment, the occurrence of such condition can be predicted with substantial accuracy in almost any given population. Being able to predict the total number of such serious cases which are likely to occur, the proper amount of health care and the proper resources can be mobilized and ample
45
measures taken to accomplish their proper and complete treatment. It would appear possibly that with better preventive measures in early diagnosis and early treatment, some of the conditions in group one might actually decrease as the years go by. By this, I refer to the increased automotive safety, more adequate construction of automobiles to reduce injuries at the time of accident, and public training programs to make people more aware of these possible potential hazards in every day life. Group two comprises the bulk of illness and injury. That is, people with the minor problems, infectious diseases, upper respiratory diseases, minor injuries continue to comprise the bulk of the medical care and this might actually increase the overcrowding and some alterations of human ecology. To a large extent the total occurrence of such conditions may not be as predictable as are others in group one. Group three - the psychosomatic problems - will unquestionably increase as crowding and social pressures continue to challenge people’s competency to live and function in the environment we have today. There is no question in my mind, and in the minds of others who have considered the problem, that the bulk of patients in group two and group three can be cared for by the specially-trained nurse, with enormous benefit to the profession and to humanity as a whole. It is interesting that the American Medical Association has taken the official position which would elevate the nurse to the position of physician’s assistant and permit various changes in the State Nursing Act and
46
education so the nurse can actively participate in the medical care of the patient as opposed to her traditional duties solely as a nurse. The various nurses and professional organizations are likewise beginning to be aware of such possibilities and are actively seeking aid in their realization. It is no secret today that for years and years nurses have functioned in this capacity without adequate compensation; and on most occasions, with no thanks whatsoever except from the patient. For one reason or another, until four years ago, the postgraduate education of nurses by physicians was largely overlooked as a possible solution. It would not appear that the opportunity for further education of nurses will proliferate rapidly under the sponsorship of far-sighted medical organizations and teaching institutions; and I hardly need to emphasize to you the importance of such training. I cannot stress to you enough the necessity of nurses absolutely insisting upon such training. More and more you are being called upon to meet the problems of society. There is no reason why the medical establishment should not help you by providing the required training. In addition to the emergency room, I consider the operating room to be a branch of the emergency room-and it many times has become this because of the ultimate resort of the injured patient. When your hospital cannot provide the physician coverage required, you are expected, in the absence of the physician, to solve problems until a physician can be summoned or in many cases cajoled into coming in.
AORN Journal
I know in many cases, in many smaller hospitals, the OR nurses double as ER nurses. There is no reason why you cannot be trained to do this; and there is no reason why you cannot do it well. There is further no reason why, as your responsibility and experience increases, you should not receive pay commensurate with your responsibilities and function. I am sure you feel, as I do, that compensation is not a primary consideration in this matter, but I feel the idea of expbiting any segment of our profession to the benefit of any other segment or to the benefit of society is totally out of date and it simply cannot be tolerated! There is further substantial evidence that the leadership-both in the nursing and the medical professionshas at times failed to recognize the true nature of the situation and has failed at times to recognize the true needs and wants of the members. For that matter, I suspect at times that the official organizations representing both physicians and nurses have failed to protect not only the needs of their members, but in many cases their rights as well.
I feel it imperative that the individual members of the medical profession continuously point out to their leadership the true nature of the situation as they see it in the United States and insist that appropriate steps be taken by the leadership to solve specific problems. Physicians and nurses have traditionally occupied themselves with the practice of their profession and caring for the sick and injured. It is a demanding and time-consuming effort. Regretfully, the demand for the bedside leaves little time for the ad-
August 1971
ministrative tasks and this has lead, unfortunately, to the differentiation within our ranks between service and administrative categories of professional personnel. Like it or not, the administrative group is the group who must make the decision.
I truthfully feel the nursing office would be a great deal more cognizant of your difficulties and more quick to act on your behalf if they were occasionally asked to take charge of the operating room on the evening shift and set up for an emergency laparotomy once in a while. The American College of Surgeons, with its local Committees on Trauma, will continue to provide postgraduate courses for nurses and continue to support the concept of advanced schools for nurses. I believe that the College of Surgeons may soon take a stand with respect to recognizing the importance of nurses as equal members of the health care team. One of the ways you can try to improve the quality of the emergency room care or emergency care in the hospital is by the formation of the so-called trauma unit. It has been said by reliable people and people whom I know and respect, that except in very rare instances, if a patient gets to a decent hospital alive, there isn’t any reason why he shouldn’t stay that way.
I want to point out that obviously there are some things which are irreversible, but generally speaking, if the injured individual can be gotten to the hospital alive, there is a chance he can be saved. We have recently seen the formation of units which are for intensive
47
care of the acutely injured. Such installations are found chiefly in the large teaching hospitals such Cook County in Chicago o r city hospitals such as Receiving in Detroit, where a very large volume of trauma is encountered. It now appears that such units can be of substantial value, for a number of reasons, in the smaller community hospitals. It is impossible for any so-called inservice training to provide adequate training for all institutions’ nursing personnel with regard to the care of injured patients. It would seem sensible, therefore, to provide such training in large measure for a few nurses until they truly become experts and then bring the injured patient into the presence of these nurses for their care. I believe it is morally and perhaps legally required that hospitals consider their obligation to place the patient in the area where the maximum resources of the hospital can be brought to bear and solve this particular problem. Now, the way that this can be done is to form a trauma unit, something I like to call an inpatient emergency room. Within the emergency room proper or the emergency department, which I think is a better term, is a constant flood of patients, the vast majority of whom are not seriously ill or injured. As someone pointed out, if only the out-patient department would stay open after 5 pm and those nurses didn’t go h o m e , the emergency wouldn’t be quite so busy. We are all familiar with the fact that the presence of one seriously ill or injured person within the emergency department creates an impos-
48
sible situation insofar as further prompt delivery of treatment is concerned. Whereas, you, as nurses, realize what is an emergency and what needs treatment first. The patient who t h i n k he has an emergency has one, at least as far as he is concerned, even if i t is only a sore throat. Human nature being what it is, he feels himself entitled to as much tender loving care as the man with a gunshot wound in the chest. It is therefore possible, through the use of an inpatient emergency room or trauma unit, to divert the seriously ill and injured patients who obviously could be admitted to the hospital, out of the emergency department and into the hospital setting where definitive treatment can be done and further treatment can be done. It makes little sense to provide interim treatment and make an endless number of phone calls or unnecessary laboratory tests or get caught up in the “trivia trap” in the emergency room when i t is obvious the patient has an admissible condition and obvious he is going to have to be operated on. It is obvious that he should be somewhere being cared for rather than having a person from the admitting office trying to get data to fill out necessary forms. Therefore, the trauma unit provides the definitive care of the patient’s problem on an inpatient basis and provides nurses who can solely dedicate themselves to the treatment of the seriously injured without having t o expend aspirin for people from house service who have backaches and were referred down to the emergency mom by the nursing office. Now, within the trauma unit there are forms of hospital administration
AORN Journal
formalities which can be dispensed with. For example, when the patient has arrived in the emergency room and it has been determined by the emergency room personnel that he has a compound fracture, this will obviously require admission for surgery. When the emergency room has received his name and address he goes immediately to the trauma unit. Once there, he is officially admitted, whether a doctor says he is admitted or not. Upon arrival there, he is managed and treated as an inpatient, the preliminary information as regard to his name and age has already been taken and transferred with him and all paperwork becomes inpatient record. You don’t have this endless problem of separating inpatient and outpatient records and trying to crowd two hours of treatment in that tiny area of the emergency room form. Having been admitted, the necessary x-rays can be obtained and all the information finaled into the patient’s chart with a great number of unnecessary bookkeeping steps and paperwork rejected and removed.
You might ask why this bypass and why you would use an area like this to bypass the intensive care portion of the hospital. This is true; although it is recognized that there are two varieties to follow in any intensive care: surgical and medical. I feel it is better to keep the surgical problems in the surgical intensive care unit and keep the traditional intensive care area for the medical problems which, by and large, may be the most overlooked problems in the hospital. Now, within a trauma unit, your
use of your nurses should be as effec-
August 197 1
tive as you can make it. In our own particular unit, our ratio is four patients to each nurse. This is somewhat unbalanced; it would be better off if it were two patients to each nurse. However, to some extent this depends upon the volume and activity. The ideal situation would be a two-to-one basis. For an eight-bed unit you need about nine nurses to staff it on a two-per-shift basis with the traditional two off and one on vacation. In the trauma unit, as we have it, we have mixed the sexes, we have an open ward with curtains and men, women, and children are all mixed together. They all see a sense of involvement, they all feel the sense of warmth toward one another and a lot of good and lasting friendships are made. Also in the trauma section, although the patient is on an inpatient basis, he is not necessarily kept there all day. He is kept there only so long as he needs the services which we provide. He may be charged by the hour under certain circumstances since he is receiving rather costly care. We don’t feel he should be charged for a day of it if he only uses eight hours of it. Therefore, he is charged on an hourly basis under certain conditions. If his problem is a minor one or if a bed is left over and he is going to stay in the trauma unit because there is no other bed to transfer him to, once his immediate problem is over, he goes over to a standard bed charge and doesn’t get extra charges. The trauma unit also provides a convenient place where the postoperative patient can go after the recovery room is closed; and it is often a convenient place for the treatment of shock for any cause.
n 49
George T. Anasf, MD
There appears to be an increased demand for health care, arising from the increased population and from increased social pressure and change. The provision of medical care and the receipt of medical care have become issues of great social significance. There is no question that improving the distribution and availability of medical care in our society is of paramount importance and will continue to attract the attention of both public and private sector, in years to come. George T. Anast, MD, i s secretary o f the American Academy of Orthopedic Surgeons' National Subcommittee on Emergency Room Care and also a member of the Academy's National Committee on Injuries. H e i s senior attending orthopedic surgeon at Ravenswood Hospital Medical Center and attending orthopedic surgeon for Cook County Hospital. Dr. Anast chairs the postgraduate course for emergency room nurses, Chicago Committee on Trauma, American College of Surgeons. This paper was adapted from Dr. Anast's portion of the 1971 A O R N National Congress program "Time waits for no man-trauma."
44
We are told over and over again about the various shortages of medical care and medical personnel and the inequities of the distribution of medical services. I strongly believe that most shortages which have been described are relative rather than absolute shortages, and the problem is really one of more maldistribution rather than real unavailability. I do believe, as do others, that the over-utilization of existing outpatient care facilities may well serve to create artificial shortages by diverting resources in short supply to areas where they are not truly needed. Further problems, of which we are all aware, are the general decline of dedication, inclination, and self-sacrifice on the part of some physicians and nurses. The pressure of times and the result of organization and bigness has, in many cases, made the profession more of a job than a calling. I emphaThe vast majority-and size the vast majority--of nurses and
AORN Journal
doctors remain willing to extend themselves in the name of humanity. But they would, by and large, prefer to do this as they had done in the past out of the sense of dedication rather than merely in receipt of some altered pay scale or some additional time off. In discussing the availability and distribution of medical care, the experts seldom point out that there are really three basic kinds of patients. Group one patients need skilled medical or surgical care for life endangering or potentially disabling injury or illness. Patients in group two have a bonafide illness or injury which is self limiting and which will get well by itself, but there is pain and suffering and their possible period of disability will be substantially shortened or improved by skilled medical care. In group three are the people who think they need medical care and have imaginary or psychosomatic illnesses. Regretfully, group three possibly constitutes a very substantial proportion of all people seeking medical care at any given moment. When you examine the situation in detail, it is obvious that the services of a physician are only required, really, in the group-one type patient and, to a moderate extent, in group two. The vast majority of those in group two could be adequately cared for by other health professionalists; that is, health professionals other than physicians, under the supervision of a physician. Many of the patients in group two require only a few sutures, the application of a pressure dressing, a bit of Furacin, a tetanus shot, an or-
August 1971
nade or some other simple medication; and such simple diagnostic procedures as laboratory studies or x-rays which are ordered by filling out the appropriate form. This type of outpatient care, combined with screening and routine triage, is well within the province of the properly-trained nurse working under the supervision of a physician. Unfortunately, no data presently exists as to what extent the efficiency of the emergency room doctor muld be increased by this technic, but I would hazard a guess that a 200% to 300% improvement in his personal efficiency would certainly result. The third group of patients require, by and large, only psychological support or symptomatic care for their complaints. They also, however, have to be obviously screened so that they are absolutely sure no potentially serious illness or injury is being overlooked or masked by their psychological problems. Insofar as the statistics are concerned, the instances of illnesses and injuries in group one - the serious ones - can be largely calculated. The statistics for the occurrence of heart disease, cancer, stroke, gall bladder trouble, hernias, discs, fractures, femur, broken arms, are all well in hand. Barring some radical change in the environment, the occurrence of such condition can be predicted with substantial accuracy in almost any given population. Being able to predict the total number of such serious cases which are likely to occur, the proper amount of health care and the proper resources can be mobilized and ample
45
measures taken to accomplish their proper and complete treatment. It would appear possibly that with better preventive measures in early diagnosis and early treatment, some of the conditions in group one might actually decrease as the years go by. By this, I refer to the increased automotive safety, more adequate construction of automobiles to reduce injuries at the time of accident, and public training programs to make people more aware of these possible potential hazards in every day life. Group two comprises the bulk of illness and injury. That is, people with the minor problems, infectious diseases, upper respiratory diseases, minor injuries continue to comprise the bulk of the medical care and this might actually increase the overcrowding and some alterations of human ecology. To a large extent the total occurrence of such conditions may not be as predictable as are others in group one. Group three - the psychosomatic problems - will unquestionably increase as crowding and social pressures continue to challenge people’s competency to live and function in the environment we have today. There is no question in my mind, and in the minds of others who have considered the problem, that the bulk of patients in group two and group three can be cared for by the specially-trained nurse, with enormous benefit to the profession and to humanity as a whole. It is interesting that the American Medical Association has taken the official position which would elevate the nurse to the position of physician’s assistant and permit various changes in the State Nursing Act and
46
education so the nurse can actively participate in the medical care of the patient as opposed to her traditional duties solely as a nurse. The various nurses and professional organizations are likewise beginning to be aware of such possibilities and are actively seeking aid in their realization. It is no secret today that for years and years nurses have functioned in this capacity without adequate compensation; and on most occasions, with no thanks whatsoever except from the patient. For one reason or another, until four years ago, the postgraduate education of nurses by physicians was largely overlooked as a possible solution. It would not appear that the opportunity for further education of nurses will proliferate rapidly under the sponsorship of far-sighted medical organizations and teaching institutions; and I hardly need to emphasize to you the importance of such training. I cannot stress to you enough the necessity of nurses absolutely insisting upon such training. More and more you are being called upon to meet the problems of society. There is no reason why the medical establishment should not help you by providing the required training. In addition to the emergency room, I consider the operating room to be a branch of the emergency room-and it many times has become this because of the ultimate resort of the injured patient. When your hospital cannot provide the physician coverage required, you are expected, in the absence of the physician, to solve problems until a physician can be summoned or in many cases cajoled into coming in.
AORN Journal
I know in many cases, in many smaller hospitals, the OR nurses double as ER nurses. There is no reason why you cannot be trained to do this; and there is no reason why you cannot do it well. There is further no reason why, as your responsibility and experience increases, you should not receive pay commensurate with your responsibilities and function. I am sure you feel, as I do, that compensation is not a primary consideration in this matter, but I feel the idea of expbiting any segment of our profession to the benefit of any other segment or to the benefit of society is totally out of date and it simply cannot be tolerated! There is further substantial evidence that the leadership-both in the nursing and the medical professionshas at times failed to recognize the true nature of the situation and has failed at times to recognize the true needs and wants of the members. For that matter, I suspect at times that the official organizations representing both physicians and nurses have failed to protect not only the needs of their members, but in many cases their rights as well.
I feel it imperative that the individual members of the medical profession continuously point out to their leadership the true nature of the situation as they see it in the United States and insist that appropriate steps be taken by the leadership to solve specific problems. Physicians and nurses have traditionally occupied themselves with the practice of their profession and caring for the sick and injured. It is a demanding and time-consuming effort. Regretfully, the demand for the bedside leaves little time for the ad-
August 1971
ministrative tasks and this has lead, unfortunately, to the differentiation within our ranks between service and administrative categories of professional personnel. Like it or not, the administrative group is the group who must make the decision.
I truthfully feel the nursing office would be a great deal more cognizant of your difficulties and more quick to act on your behalf if they were occasionally asked to take charge of the operating room on the evening shift and set up for an emergency laparotomy once in a while. The American College of Surgeons, with its local Committees on Trauma, will continue to provide postgraduate courses for nurses and continue to support the concept of advanced schools for nurses. I believe that the College of Surgeons may soon take a stand with respect to recognizing the importance of nurses as equal members of the health care team. One of the ways you can try to improve the quality of the emergency room care or emergency care in the hospital is by the formation of the so-called trauma unit. It has been said by reliable people and people whom I know and respect, that except in very rare instances, if a patient gets to a decent hospital alive, there isn’t any reason why he shouldn’t stay that way.
I want to point out that obviously there are some things which are irreversible, but generally speaking, if the injured individual can be gotten to the hospital alive, there is a chance he can be saved. We have recently seen the formation of units which are for intensive
47
care of the acutely injured. Such installations are found chiefly in the large teaching hospitals such Cook County in Chicago o r city hospitals such as Receiving in Detroit, where a very large volume of trauma is encountered. It now appears that such units can be of substantial value, for a number of reasons, in the smaller community hospitals. It is impossible for any so-called inservice training to provide adequate training for all institutions’ nursing personnel with regard to the care of injured patients. It would seem sensible, therefore, to provide such training in large measure for a few nurses until they truly become experts and then bring the injured patient into the presence of these nurses for their care. I believe it is morally and perhaps legally required that hospitals consider their obligation to place the patient in the area where the maximum resources of the hospital can be brought to bear and solve this particular problem. Now, the way that this can be done is to form a trauma unit, something I like to call an inpatient emergency room. Within the emergency room proper or the emergency department, which I think is a better term, is a constant flood of patients, the vast majority of whom are not seriously ill or injured. As someone pointed out, if only the out-patient department would stay open after 5 pm and those nurses didn’t go h o m e , the emergency wouldn’t be quite so busy. We are all familiar with the fact that the presence of one seriously ill or injured person within the emergency department creates an impos-
48
sible situation insofar as further prompt delivery of treatment is concerned. Whereas, you, as nurses, realize what is an emergency and what needs treatment first. The patient who t h i n k he has an emergency has one, at least as far as he is concerned, even if i t is only a sore throat. Human nature being what it is, he feels himself entitled to as much tender loving care as the man with a gunshot wound in the chest. It is therefore possible, through the use of an inpatient emergency room or trauma unit, to divert the seriously ill and injured patients who obviously could be admitted to the hospital, out of the emergency department and into the hospital setting where definitive treatment can be done and further treatment can be done. It makes little sense to provide interim treatment and make an endless number of phone calls or unnecessary laboratory tests or get caught up in the “trivia trap” in the emergency room when i t is obvious the patient has an admissible condition and obvious he is going to have to be operated on. It is obvious that he should be somewhere being cared for rather than having a person from the admitting office trying to get data to fill out necessary forms. Therefore, the trauma unit provides the definitive care of the patient’s problem on an inpatient basis and provides nurses who can solely dedicate themselves to the treatment of the seriously injured without having t o expend aspirin for people from house service who have backaches and were referred down to the emergency mom by the nursing office. Now, within the trauma unit there are forms of hospital administration
AORN Journal
formalities which can be dispensed with. For example, when the patient has arrived in the emergency room and it has been determined by the emergency room personnel that he has a compound fracture, this will obviously require admission for surgery. When the emergency room has received his name and address he goes immediately to the trauma unit. Once there, he is officially admitted, whether a doctor says he is admitted or not. Upon arrival there, he is managed and treated as an inpatient, the preliminary information as regard to his name and age has already been taken and transferred with him and all paperwork becomes inpatient record. You don’t have this endless problem of separating inpatient and outpatient records and trying to crowd two hours of treatment in that tiny area of the emergency room form. Having been admitted, the necessary x-rays can be obtained and all the information finaled into the patient’s chart with a great number of unnecessary bookkeeping steps and paperwork rejected and removed.
You might ask why this bypass and why you would use an area like this to bypass the intensive care portion of the hospital. This is true; although it is recognized that there are two varieties to follow in any intensive care: surgical and medical. I feel it is better to keep the surgical problems in the surgical intensive care unit and keep the traditional intensive care area for the medical problems which, by and large, may be the most overlooked problems in the hospital. Now, within a trauma unit, your
use of your nurses should be as effec-
August 197 1
tive as you can make it. In our own particular unit, our ratio is four patients to each nurse. This is somewhat unbalanced; it would be better off if it were two patients to each nurse. However, to some extent this depends upon the volume and activity. The ideal situation would be a two-to-one basis. For an eight-bed unit you need about nine nurses to staff it on a two-per-shift basis with the traditional two off and one on vacation. In the trauma unit, as we have it, we have mixed the sexes, we have an open ward with curtains and men, women, and children are all mixed together. They all see a sense of involvement, they all feel the sense of warmth toward one another and a lot of good and lasting friendships are made. Also in the trauma section, although the patient is on an inpatient basis, he is not necessarily kept there all day. He is kept there only so long as he needs the services which we provide. He may be charged by the hour under certain circumstances since he is receiving rather costly care. We don’t feel he should be charged for a day of it if he only uses eight hours of it. Therefore, he is charged on an hourly basis under certain conditions. If his problem is a minor one or if a bed is left over and he is going to stay in the trauma unit because there is no other bed to transfer him to, once his immediate problem is over, he goes over to a standard bed charge and doesn’t get extra charges. The trauma unit also provides a convenient place where the postoperative patient can go after the recovery room is closed; and it is often a convenient place for the treatment of shock for any cause.
n 49