On the front line of emergency

"It’s a tragedy that plays out on a lot of different levels" - Professor George Braitberg, Director Emergency Medicine, Royal Melbourne Hospital

The Royal Melbourne Hospital’s Director of Emergency Medicine, Professor George Braitberg, is in his usual element, in a medical bay full of tubes and wires and boxes of surgical gloves, bright lights and overhead X-ray machines, and all manner of devices that go bing.

But he’s not talking about any of that, the cutting edge of trauma technology. Having battled the medical aftermath of road trauma for almost three decades, he’s talking about people: the road victims that his team treats 800 or more times a year, and the impact of that trauma on the patients, their families and, yes, his staff.

This is a surprise of sorts, because when you spend time in the trauma bays, there is a conspicuous and deliberate lack of emotion. Sights and situations that would haunt non-medical folk are dealt with calmly and efficiently by teams of experts, who then move seamlessly to the next bay and deal with whatever new set of graphic injuries they find.

But of course, under the professional veneer they are human, with human emotions and empathy. And all have their pressure points. The doctor, for example, trying to save the life of a child who is the same age as his or her own, and maybe even physically resembles their child. That can rattle even the most experienced and rational professional.

George acknowledges this challenge of the job. “It’s not so much every trauma that we see, but if I was to ask my staff – medical, nursing, social workers – to think of a trauma that sticks in your mind over the last 12 months, they’ll each have a number that they’ll refer to, so some aspects of a trauma do actually leave an emotional stamp on us, and on a regular basis.”

That blink-of-an-eye moment

“It’s a human business and it’s a tragedy that plays out on a lot of different levels. At the end of it you have a person who, before the accident, had their life, their aspirations, often had a life that was well planned out for them and then in the blink-of-an-eye kind of moment things will change.

“Not everyone recovers 100 per cent from a trauma. In fact, the more significant the trauma, the less likely you are to get a full recovery, so then you’ve got to think about what’s the disability of that person? Is it affecting their spinal cord, is it affecting their brain? If they were a footballer, are they going to play football again? Because the effect of that trauma is individualised to that person. What is important for one person might not be as important for another, and we have to learn that along the way of the person’s recovery and rehabilitation.”

Of course, when the ambulance or air ambulance arrives and a trolley is first wheeled into Emergency, such concerns are secondary for the medical team that gathers. At the Royal Melbourne, and the city’s other major adult trauma hospital, The Alfred, there is a constant factor acknowledged by all senior medical personnel: pre-patient preparation is everything.

“I guess the first thing is hearing about it (an incoming trauma) and getting prepared and making sure we’ve got the right number of people in the room, knowing what job they’re supposed to be doing and focused on that particular part of their role,” George explains. ‘We really do need to get the right number of people. Every so often you get a lot of people who want to look in or get in the way, so everyone who is in that room has to have a specific role to play. Once we’ve set it up, we have a team leader who is like the conductor of an orchestra. He or she will oversee everything and make sure it’s working.

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“Once we are in that moment, it almost isn’t challenging any more. It’s almost like the heat goes down, people get on with the job they’ve been trained to do, and we go through the problem list as it’s presented to us. What the nature of the injury is, are the vital signs OK, do we need to protect the patient’s airway, do we need to put this tube in, what sort of lines do we need? All of those questions just sort of come fairly naturally. The next thing is what sort of imaging do we need, and getting the patient off to CT to see what the internal injuries are.

“That part goes really quickly in our minds and it should behave the way we expect it to behave.”

At this point in the proceedings, emergency medicine is an intellectual problem-solving game; a list of challenges and the known ways of solving them. But as that part of the trauma treatment comes to an end, George says another major challenge for his team is just beginning, one that requires a difficult emotional and intellectual shift.

“What we sort of lose sight of, I think, at that point anyway, is the emotional context of the patient’s presentation,” he says. “So this might, for example, be a person who has gone into the back of a truck at 100 kilometres per hour and has multiple injuries from head down to foot and they’re going to have a lot of pain as a consequence of that and maybe some disability, but that’s not our focus at that point in time. Our focus is to fix the fixable and get the thinking process going about what we need to do next for the patient.

Meanwhile, in the relatives’ room

“But we often then have the relatives in the relatives’ room who are knowing that their loved one, partner, father, daughter, whatever has been in a very serious car accident and their emotional state is all about what’s happened, what’s the outcome going to be? They’re in that emotional space and we’re working in this very cognitive, intellectual space and at some point that has to meet.

“So our role at that point is to give the information about the clinical nature of the injury, but take into context where they are emotionally, what they can take in, what they can understand, knowing they want to come and see their family member as soon as possible and making sure that the person is prepared for that visit and that the people who are going to see the patient are prepared for what they are going to see. What tubes are going to be in, he’s sedated, he’s not going to look the way you last saw him, etcetera, etcetera.

“And then afterwards, we often have our own emotional moment as well, particularly if it’s been a particularly nasty injury. So when you’re in the mood or in the zone, that’s not an issue, but we often do have to have a debriefing afterwards to make sure the staff have come to terms with the emotional output or outcome of the injury.”

‘It’s all about preventability’

George says he wishes Victorian drivers were more aware of road trauma causes beyond alcohol and the need for seatbelts. “It’s all about preventability, if you weigh up the lifetime effect of making a poor choice versus not making that choice,” he says. “I think there is an emerging problem both in terms of recreational drugs and prescription drugs. A lot of trauma is not just people driving their cars into walls and other vehicles, but elderly people crossing the road or drug-affected people crossing the road and crossing in front of a car. I think we know about recreational drugs, but we probably need to think a little bit more about pharmaceutical drugs that make you sleepy. They’re not good to be taking before you get into your car.

“I also really believe we have to be very careful about the way we use mobile phones in vehicles. Texting and driving is the equivalent of being .05 so if we’re so prescriptive about not having alcohol, we need to be as prescriptive about texting, and we don’t seem to have penetrated people’s minds with the texting-mobile phone story, as much as we have put the alcohol-driving story into people’s minds.

“It’s about those preventable things, those silly choices or decisions people make. I got away with it yesterday so I can do it today. But it’s an all-or-none phenomenon. You don’t improve your chances by getting away with it on Tuesday and think you’ll get away with it on Wednesday. You’ve got the same chance of having a disaster every single day you do that sort of thing. For us as people working in emergency who deal with trauma, seeing people’s lives change as a result of silly decisions or choices is something that is hard to watch.”

"People are good at repeating mistakes"

Not to mention the frustration of watching those same mistakes made over and over again. “People are good at repeating mistakes,” George acknowledges. “As I said, it’s about penetrating into consciousness. Alcohol and drink driving, we’re all brought up on the problems with that and it’s an easy thing to test for.

“I think the police and others have been very strong about the messaging about mobile phones but the policing of it is harder. You can’t have a roadside station and check vehicles because you’ll get off your phone as soon as you’re called to the side, so they’re behaviours that we have to rely on people to exhibit themselves, to do the right thing, to make the right choice.”

Spend time in George’s day-to-day world, in the trauma bays, and the message quickly becomes extremely clear. The problem is, many Victorians will only learn the hard way. As our interview winds up, the sound of the air ambulance rotors can be heard approaching the Royal Melbourne Hospital helipad, a few floors above. Professor George Braitberg heads back to work.

Written by Nick Place, Photos by Meredith O'Shea
October 01, 2016