Most trauma units operate under intense pressure, but the staff of Atlantic City’s hospital deals with challenges unique to a high-crime area.
As the only Level II trauma center in South Jersey, AtlantiCare Regional Medical Center’s City Campus is the first stop for victims of violence in Atlantic City and Pleasantville.
Often crime investigations begin on the hospital floor, with some victims coming straight to the emergency room from crimes scenes without alerting police.
“When you do response to trauma, you’re just responding to the patients, not the circumstances that brought them to the hospital,” said trauma surgeon Ayoola Ali, who has worked at the hospital more than five years. “We are not there to judge them. We’re there to treat them.”
Regardless of how the victim arrives, hospital protocol always involves the police, but those tending to the victim don’t diverge from normal treatment.
And, always, there is the human factor.
When Ali began working emergency rooms 15 years ago, he didn’t think much about these victims beyond the initial sadness of the moment. A native of Nigeria, he entered medicine to help people — that was his focus. A residency in New York City primed him for the emotional stress of working in an ER.
But now, as the father of a 17-year-old son, the losses stay with him. Privacy laws prevent him from speaking about individual cases, but he recalls the recent death of one 13-year-old victim.
“It really did hit me, which was something I wouldn’t have given any more thought than an hour in my earlier years,” he said.
The frustration is evident: “It’s not like this person had cancer that they had no control over — it’s just stupid, risky behavior that’s causing this life to be snuffed out.”
Triage in a war zone
Joshua Cross walked into the Trauma Unit at about 1 a.m. April 18, 2012, with a gunshot wound to his left arm. An hour earlier, Pleasantville police had responded to a shots-fired call, with no victim located.
But Cross wouldn’t answer questions about when or where he was shot.
“The issue with that is, by the victim not being there, we have to now backtrack to figure out what happened, which makes it more difficult,” said Pleasantville Police Chief Jose Ruiz.
Such cases make the jobs of both hospital staff and police more difficult, since both need to piece together the circumstances of the injury using unreliable information.
For Atlantic City police, at least, a new system of audio sensors called ShotSpotter can pinpoint suspected gunfire, giving them a starting point for their investigations.
Cross survived his wounds, only to wind up hospitalized again two months later, shot multiple times. While the wounds — including a shot to the chest — were not fatal, this time he was unable to arrive at the hospital on his own. Now, Cross is implicated in a third shooting; he is one of four men charged with the killing of Sedrick Lindo at Atlantic City's Carver Hall apartments on July 29, 2012.
Ali agrees it’s not uncommon for victims to forgo the ambulance and walk straight into his ER. There is a chain of custody, however, once police are notified, Ali explained.
A victim could still be a target — or even a potential perpetrator. Access to the trauma bay is restricted to essential staff, with family members prohibited from entering
“We really don’t get the true story most of the time, so you don’t want any revenge shooting or stabbing in the trauma bay,” he said.
Medical staff can never be sure if a visitor is really a family member or someone who intends further harm. Similarly, cell phone use is prohibited while patients are being treated in order to limit the dissemination of information.
Ruiz said police need to exercise caution when dealing with victims.
“You have to be able to interview them as a victim,” he said. “As you’re progressing with the interview, you have to know when to stop, especially if that person is going to eventually turn out to be a suspect.”
In such emergency situations, Ali said, a four- to five-person security detail typically mans the ER doors to ensure only authorized personnel enter. And the increased security continues even after a patient is stabilized and taken to either a private room or the intensive care unit for observation. Often, an Atlantic City police officer is assigned to guard the patient.
“(Police) give us names of who can specifically see them and security makes sure only these people have access to these patients,” Ali said.
The golden hour
Medical staff never know when the next trauma will come in, so AtlantiCare’s trauma bays are always ready.
Saline bags hang from IV poles waiting for the next patient. Extra oxygen tanks are filled and at the ready. A refrigerator fully stocked with blood is a few steps away.
“‘Trauma zero’ means the patient is already on the bed — sometimes they’ve walked in,” Ali said. “ ‘Trauma 20 minutes’ means the patient is on his way. We have anywhere from zero to 20 minutes to prepare.”
Once the trauma code is called, the team abandons what they are doing and dashes — “as safely as you can because you don’t want to be part of the trauma yourself,” Ali said with a chuckle — to the trauma bay to determine what treatment is needed. Often, EMTs from the field have given the ER staff an idea of what to expect.
Ali said penetrating wounds make up just 9 percent of the hospital’s 2,000 admissions each year. In 2012, stabbings accounted for 5.1 percent and shootings accounted for 3.9 percent of all patients.
Most gunshot injuries tend to be in the torso, because the average shooter on the street is less concerned with aim and more concerned with shooting and escaping, he said.
“That reminds me of when you look at rap videos, guns are held sideways, which shows that you are not sighting the gun,” Ali said.
“It’s hit or miss: anywhere on the body could be hit,” he added. “The trunk presents a larger target, so most of our injuries go to that part of the body.”
But all penetrating injuries — whether it’s a bullet, a knife or the steering column of a car — are generally treated the same.
“The body does not really discriminate as to what’s trying to kill it,” Ali said. “When you’re shot in the chest or stabbed in the chest, the organ that is injured is what matters.”
The first step is a primary survey to determine what the immediate life-threatening conditions are. A more detailed examination will follow that, where staff asks the patient about their medical history, their last meal and any drug use that could impact treatment.
On the last point, Ali said, patients are not always honest. But once he explains the possible consequences of that dishonesty, many relent.
“You tell them whatever that you’re on may interact with the drugs and, eventually, they do tell you,” he said.
Of course, that’s assuming the patient is conscious. If not, Ali said, the team relies on feedback from the first responders and imaging scans to determine internal injuries.
If a victim comes into the ER with no vital signs, the likelihood of being revived is minimal. But Ali said the team will still try aggressively to save the life.
“Even without a pulse, if we have an (electrocardiogram) rhythm showing the heart’s still beating, we’ll do more aggressive things: open up their chest and try to control the aorta,” he said.
Ali said one of the top priorities for any trauma team is to control bleeding, since blood loss is the No. 1 cause of death from traumatic injuries.
“We have the concept of the ‘golden hour’ in trauma,” he said. “You have this one hour after your injury to do everything we can to stabilize you and save your life.”
Everything the team does within that first hour has a serious impact on the patient’s survival and recovery, Ali said. There is a risk of infection after the victim is stabilized, he said, but antibiotics help mitigate that.
If Ali’s team has been successful, families will see his measured smile as he enters the consulting room. If not, their eyes will follow him as he closes the door, walks solemnly to the chair and sits down.
The emergency-room veteran asks any agitated family member to sit down. He likes to speak to families on their level.
After making sure he’s speaking to the correct family — “there’s nothing as bad as delivering bad news to the wrong family,” he said, chuckling absently — Ali outlines the events of the previous hours clearly and concisely.
The patient died, he said. Ali has never “lost” a patient. “Didn’t make it” isn’t in his vocabulary. Ali asks if the family would like him to call in an imam or a pastor. Then he leaves the family to grieve.
Ali isn’t content to try to save lives from traumatic injuries. Ideally, he said, he wouldn’t have to treat gunshot or stab wounds. He would prefer not to have to walk across the consulting room to deliver bad news.
AtlantiCare, which is a member of the newly formed Coalition for a Safe Community that’s working to address violence this summer, started its own outreach program in October.
The hospital brings high school-age students, led by Ali and other ER staff, into its trauma unit as part of “Prevention in 3D”. The goal is to make young people more aware of their actions and, hopefully, prevent them from ever needing his skills.
“We bring them through the normal experience of a trauma patient to show them this is not fun,” he said.
Each program is tailored to the needs and risk factors of the respective classrooms. Most are told of health effects of drinking and drug use. For some, it’s texting while driving. For others, it’s street violence.
“Initially, (the students) come in with this sense of invincibility,” he said. “They leave with a sense of their own mortality.”
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