Life and death in the emergency room.

• Author: Glastris, Paul
• Position: Includes article on Dr. John West - Part 1

LIFE AND DEATH IN THE EMERGENCY ROOM

Ayoung black man, shot in a housing project on Chicago's West Side, lies moaning on a table in the trauma unit of Cook County Hospital. The bullet cut a ragged path through his right thigh, shearing the femoral artery. Like water from a half-open tap, blood runs from the wound until a surgical resident, Dr. Lipov, leans heavily on the entry wound with a handful of gauze. The victim isn't enjoying the procedure--"Ma leg, man, you got to lay off ma leg,' he pleads. But Lipov, well into his twenty-first consecutive hour on duty, is in no mood for complaints. At some point in his evening's adventure, the victim has fouled his trousers. The stench fills the air. Lipov considers what antibiotics he'll administer since the exit wound on the back of the thigh is awash in excrement.

At 4:30 in the morning on a Saturday in August, Cook County's trauma unit is no place for the faint-hearted. The bars have just closed, so it is a peak hour for gunshot wounds. The trauma team has treated about a dozen other seriously injured patients tonight; some of their blood still stains the floor. Though the staff is tired, this latest patient's condition is sufficiently urgent to give them a surge of adrenalin. They crowd around him, inspecting, probing, taking notes, voicing opinions. Then they draw blood, start I.V.s, clean what needs cleaning and determine that without prompt surgery, the man will lose his leg.

Though he probably doesn't know it, the patient is fortunate to have been brought to Cook County. The Dickensian grimness of this tax-supported institution--old gray walls, exposed pipes, crowds of poor people in the halls--doesn't inspire confidence. But ask a Chicago paramedic where he would want to be taken if he suffered a gunshot wound, and he'll probably say Cook County. Emergency medical personnel all over the country know of Cook County's excellent record. And the reasons for the hospital's success are simple.

Trauma is the umbrella term given to all forms of injury. The primary treatment for serious trauma is surgery. For this reason, the Cook County unit is set up to do immediate, often complicated operations. It has its own operating room and surgical specialists of every stripe available in the hospital ready to pitch in at any time. Wheel a seriously injured patient into most conventional operating rooms, and you usually get a Chinese fire drill: nurses dashing around looking for the right type blood and special equipment, interns trying to locate surgeons over the phone or rousting them from bed, bottlenecks in getting X-rays, CAT-scans, and lab work done. Such delays kill a surprising number of trauma patients who succumb to shock or a hemorrhage. Trauma surgeons speak of the "golden hour' immediately after the occurrence of an injury, when the statistical chances of saving a patient by sewing up his wounds are greatest. Wait much longer than an hour, and no matter how brilliant the surgery, the effects of shock will frequently kill the patient hours or perhaps days later.

The second reason for the success of the Cook County trauma unit is experience. The surgeons and staff handle thousands of gun and knife wounds each year--a volume which allows them to hone their skills and teaches them to attend to the subtle signs in a patient's condition which indicate hidden injuries.

Lethal delays

Unfortunately, Cook County is an island of competence within Chicago's emergency medical system. To begin with, numerous seriously injured patients don't end up at Cook County or the other area trauma centers. That's because paramedics aren't given rules--"field triage protocols,' as they're known in the trade--to determine what kinds of injuries go to which hospitals. Instead, local ordinances direct the paramedics to proceed to the nearest emergency room, unless the physician advising them on the radio--their "on-line medical director'--tells them otherwise. Since paramedics often can't or don't call their directors, and since these physicians, for various reasons, often won't direct the ambulances to a trauma center, too many patients die in emergency rooms that aren't prepared to handle them. In one notorious case last November, Ben Wilson, a 17-year-old high school basketball star, was shot twice in the abdomen on Chicago's South Side. Fire department paramedics brought him to St. Bernard's Hospital, which does not have a trauma unit, where he waited almost two hours before being taken to the operating room. He died shortly thereafter. Had St. Bernard's doctors transferred Wilson to a trauma center, or better yet, had he been taken to one directly, some physicians in Chicago believe he would have lived.

Nor was Ben Wilson an isolated case. Nurses, physicians and paramedics say delays like this kill patients in Chicago hospitals regularly. Studies conducted by Cook County Hospital show that patients with serious head injuries who were first taken to the nearest hospital and then transferred to Cook County were twice as likely to die as patients taken directly to Cook County.

Another problem is that not all trauma centers are as proficient as the one at Cook County. The...