by Robert Lanz, LCSW
When the overhead pager announces a trauma code everyone gets immediately focused, responding to some internal list of mental preparations and physical tasks to perform in anticipation of the arrival of the patient. That includes the social worker too, of course.
The social worker, like the rest of the trauma team, has to prep for anything that comes through the door. Will this be a frantic mom in the ambulance with the soon-to-be-dead child? Will the paramedics be carrying a healthy baby with the soon-to-be-dead mom on a stretcher? Under such circumstance, the healthy baby and/or the living mom will be taken aside by the social worker so the trauma team can work on the patient. What a place to start an intervention – so far behind the curve it will seem like there is no catching up. Catching up to what: finding someone with some good news? Finding a functional family member who can take over some of the social work tasks? And on top of all that, having a trauma family doesn’t mean I get to forget all the other cases I’m attached to in the ER – it just means I get spread a little thinner.
More cops with questions. More phone calls to answer. More requests from the charge nurse about family coming. More lab values to be aware of. More interventions to discuss with the families. More radiological information to assimilate for when more family members and friends show up.
And when the family and friends and co-workers do show up there is a reversal in the information flow: is the patient on any medications or have any ongoing medical problems we should know about? Is the patient addicted to drugs or alcohol? More information to break down into its simplest elements and feed into the trauma team.
All information out of the trauma bay is filtered to family members by the social worker. Everything relevant from the family to the trauma team is filtered back the same way.
The night the “nicest guy I never met” showed up presented as a mystery, as they often do. An unconscious young white male, who could have been any garage-band grunge-rocker or a community college kid, had been hit by a car while riding his bike on a busy street. The car that hit him didn’t stop and the nice guy was knocked unconscious immediately. Upon arrival he appeared to be a more highly-functional type than the majority of our trauma patients: no smell of alcohol; no marks to imply injections; well-groomed, clean clothes. But, no identification.
Part of the social worker’s task-list is to identify a patient, notify the family and secure the patient’s valuables. Unless ruled-out, it is assumed he may be the victim of a violent crime, so the clothes and other personal property may become evidence and need to be treated as such. Gloved-up, I routinely plunge into pockets, shoes, pant cuffs, backpacks and cell phones, car keys and wallets or anything can give me a clue as to what happened and who this person is “attached” to.
Over the years in pursuit of patient identification I’ve found lots of drugs, money, fake ID’s, bullets, porn, sex toys, coke spoons, crack pipes, and once a small lizard living in a homeless guys sock. I really didn’t expect to find anything strange in this young guy’s stuff. Wrong. He had seventeen crisp one-hundred bills in the front pocket of his Levis.
Jeez. According to the police, he was on a funky old three-speed bike. No one around recognized him as an ER regular. No wallet, but maybe it had been blown-out of his pants and onto the street, but nobody had found it yet. That’s not uncommon. Sometimes patients that come from board and care facilities have their name inked on their shirt collar or on their underwear band. Not this guy. No gaudy cubic zirconium in his earlobe. No gold chains around his neck. No tattoos or obvious scars. Just all that cash. I’ve had several drug dealers brought to the ER with more money than this guy had, but it was never in the form of crisp new bills straight from the bank. Drug money is more often a bunch of crumpled small bills, and the holder has ink and jewelry that advertises: “I sell dope. Step right up.” Not this guy.
Somewhere, someone knew this guy, and they would be looking for him. I was right about that, and found out when my secretary called from the front: “There’s a group of people out here. I think it’s the trauma guy’s family.”
I greeted them and walked them into the “quiet room” and got them seated. Their anxiety was so obvious it could be cut with a knife. I asked for a physical description and it fit the trauma patient. I wished it didn’t. These seemingly nice people had no clue how bad-off their loved-one was nor how bad-off the night would most likely turn out. I started my slow slog into the bad news zone and watched as my practiced words sucked the color from their faces and the hope from their hearts. It sucked it from my heart, too.
That news wasn’t good. The neurosurgeon wasn’t hopeful as he explained that massive intra-cranial bleeding was not going to be fixed surgically. Too much blood. Too much swelling. John would go to the ICU, hooked up to machines and IV‘s pumping medications. Desperation interventions, but hope for the best.
I went back to the quiet room, now the “desperation room” and did my best to ready them for the worst. This morning everything was great. Tonight, everything went wrong. In a few moments the neurosurgeon came in – he was one of my favorite trauma team members.
“John’s been hit hard and has bad fractures on both his legs.” The family gasped as if that was the worst of the news. I cringed but kept my game-face on. “Orthopedics is tending to those injuries. He also has a collapsed lung and a badly lacerated liver and they were talking about removing his spleen. The trauma surgeons are tending to those injuries.”
The family gasped again and swooned, then leaned forward toward the neurosurgeon. “John’s also had a major head injury. From the scan of his brain, it does not look hopeful, I’m afraid.”
Desperate for something — anything positive — the family pressed on: “But he’s going to live, isn’t he?”
“I’ve never seen anyone in my practice with this severity of injuries survive. But we’re not giving up.”
After the neurosurgeon exited, the family started to understand how grave the situation was for John. It probably didn’t help much when I handed all John’s money to his father, who immediately start crying. Everyone in the whole room looked at those hundreds. Dad turned to one of the female friends, who I was about to find out had been more than just a friend. Dad held the stack of bills in his hands and stared at them. He said to the pretty young woman: “John went to the bank today to get this money so he could buy an engagement ring. He was going to propose to you tonight.”
The best and worst moments of life at the same instant. Tears of joy merged with tears of sorrow.
Upstairs in the operating room, John died. When the story got back to the ER staff, we had something in common with the family, we all died a little, too.