Working Level I Trauma
It could be the snap of a bitterly cold January morning, or the flames from a horrifying Christmas morning fire. It could be the screams and shock of another school shooting that surprises a sleepy, rural community in anywhere USA. But suddenly, the glare and shriek of ambulance sirens awaken a community as they speed towards assistance, carrying two teenage boys whose only hope for survival might lie within the resources that are anxiously waiting for their arrival.
They’re in luck. The car versus truck motor vehicle accident (MVA) from which they were carefully extricated was within a few minutes from a Level I Trauma facility. Paul (name changed for privacy), totally unresponsive, was by far the worse of the two, but he was intubated at the scene. His brother was lucid but tremulous, unable to answer questions. Both required full assessment by a trauma service.
Trauma services are comprised of many specialties, dependent upon what level of Trauma rating the hospital has obtained. Trauma centers are identified in two fashions, by designation, or by verification. The different levels (I, II, III, IV, or V) refer to not only the kind of resources available in a hospital, but also the number of trauma patients seen per year. The standards are defined nationally and are unique to both Adult and Pediatric facilities.1
A Trauma Center designation is done at the state or municipal level and lasts three years. These designations are evaluated and performed by the American College of Surgeons and meet regional needs as well as regulatory authority. They may vary from state to state, but Performance Improvement is included as well as a commitment to improving overall trauma care and outcomes.
The team waiting for Paul and his brother’s arrival was topnotch. Of the 190 Level I Trauma Centers across the nation, they arrived at one of the best. (It is not a coincidence that within the Nation’s Top Hospitals, several premiere institutions are Level I Trauma Providers). Although Paul had significant facial lacerations and suspected rib fractures, it was his head injury that required the most immediate attention.3,6
Closed head injuries from MVA’s can be frighteningly devastating, depending upon the amount of damage. Being at a Level I Trauma center meant that both Neurology and Neurosurgery were readily available should Paul need intervention for elevated intracranial pressure or bleeding. Additionally, Plastic surgeons would be available for repair of his facial wounds once surgery was determined to be appropriate. Oral and maxillofacial surgeons could be consulted if needed. As Paul was being assessed and examined, around the clock care (by both Trauma Nurses and experts in Critical Care) was being provided, so prevention of future complications could be avoided at every opportunity.
But what of Paul’s younger brother? Had he (amazingly) walked away from a motor vehicle crash that might have killed him?
Yes, he did! But, overcome with guilt, he peppered the nurse with questions as he waited for Paul to open his eyes. What, he wanted to know, was the difference between a “regular” Emergency Room RN and a Trauma Nurse? Good question, the team answered, but no, it wasn’t as simple as attending a seminar. It was a lot of training. A Trauma Nurse must be prepared for whatever could come through the door, which might include burns, hypothermic drowning victims, gunshot wounds, MVA’s, falls, industrial accidents, acts of terrorism, natural disasters, even suspected cases of emotional or physical abuse.2
Emergency Room nurses typically work with patients who arrive in stable condition and are prioritized based on condition, although that is a generalization that often doesn’t occur. Anyone who has spent five minutes working in an ER knows it only takes that length of time for a stable, coherent patient to walk in and collapse into full cardiopulmonary arrest. But in general, the ER nurse cares for patients who arrive with an “illness or sickness” and the Trauma Nurse will work closely with the “Trauma Center to care for patients who are brought in by ambulance” from MVA’s and/or have more serious injuries requiring advanced interdisciplinary assessment and support.
Trauma Nurses, while having increased responsibility for dealing with severely ill patients entering the Emergency Room, also have an immense amount of respect for their field of expertise. In fact, by the year 2024, Trauma Nursing as a specialty is expected to grow as much as 16%, a larger increase than many specialty areas in nursing. The requirements for this specialty are steep. Not only does the Trauma Nurse come from a variety of backgrounds, from vocational nurse to Nurse Practitioner, but they must also be current in ACLS, BLS, and depending upon the institution, possibly PALS.10
There is a great deal of overlap between Emergency care and Trauma Nurse certification, consequently many institutions require emergency medical training (internship) of their Trauma Nurses. Trauma Nurses, once certified, may work in a variety of areas within the institution, including the ICU, the OR, Step-down Units, with the Trauma Team, or rounding on patients throughout. The actual Trauma Nursing Core Course (TNCC) is a two-day certification program. It provides hands-on didactic classroom learning, with a certification that is valid for four years. There is an equivalent course (ENPC) for Pediatrics: The Emergency Nursing Pediatric Course. Pediatric certification is also valid for four years.
But, before the Emergency Room nurses could explain to Paul’s brother that there was an additional National certification for Trauma Nurses, Paul began to deteriorate, and all conversation ceased…
The interdisciplinary team rushed to Paul’s bedside. His limbs had begun a spastic shaking as his BP began to spike and then plummet erratically. He had no nuchal rigidity, but an ICP sensor was indicated for monitoring. The neurologist and neurosurgeon consulted on the risks/benefits of surgery if bleeding should occur. They decided to wait and keep the patient on multiple infusions. Diffuse axonal injury was suspected. The family was updated and reassured. Paul was young, and he was in the best of hands.
So, what about the other Trauma Certification, his brother wanted to know? (He seemed intent on keeping anxiety at bay by learning as much as he could about the hospital environment, to the nurses’ wry amusement). Could any nurse decide to take the exam? Well, yes, they could if they had at least 1,000 hours of practice with trauma patients (direct and indirect patient care) and an active unrestricted RN license, as well as 20-30 hours of trauma-specific coursework. A BSN would not be required to sit for the exam. This Certification was called the Trauma Certified Registered Nurse (TCRN) and once achieved, is also valid for four years.
Going forward, the nurses stayed on their toes with this complex case, because Paul’s brother and family not only continued to ask as many questions as possible, they also kept a bedside notebook and media page (which they updated every day Paul remained in the hospital!). The nurses never knew when their trauma facts might be displayed on social media, or if their knowledge of brain recovery might be tested and subsequently stored as family memorabilia!
As luck would have it, although Paul was eventually diagnosed with Grade III Diffuse Axonal Injury (DAI) to his brain, he finally made it home and is continuing therapy for gait and muscle strengthening, exactly 13 months after his initial injury. As neuro nurses would realize, Grade III is the most severe form of DAI, and functional recovery is not always possible.4 Because Paul was treated at a Level I Trauma Center, where his brain injury could immediately be assessed, diagnosed, and stabilized by an interdisciplinary team of experts committed to continually improving Trauma outcomes, he is home, working towards recovery.
That’s life in the fast lane. The stress is relentless, the rewards limitless.
Should you give it a try?
“Extended Anatomical Grading in Diffuse Axonal Injury Using MRI: Hemorrhagic Lesions in the Substantia Nigra and Mesenthalic Tegmentum Indicate Poor Long-Term Outcome”, Sami, A, Niklas, M., (…), and Per Enblad, Journal of Neurotrauma, available ncbi.nlm.nih.gov.
“How is an Emergency room nurse and a Trauma nurse different?” (Emergency Nurse Association/ENA). bestnursingmasters.com.
“National Inventory of Hospital Trauma Centers”, JAMA Network, Original contribution March 26th, 2003, jamanetwork.com.
Trauma Levels Explained: “designation versus verification”. (American Trauma Society/ATS). amtraum.org
“U.S. News Announces 2018-19 Best Hospitals”, August 14th, 2018, usnews.com.
“What is a Trauma Nurse?”, Information on Certification, TCRN, ENPC, TCRN, registered nursing.org.