Brookdale Emergency MedicineTrauma Orientation

Welcome to the trauma experience at Brookdale’s Emergency Medicine Department! The goal of this orientation is to help you become better familiar with trauma here at Brookdale prior to your rotation with us.  In this orientation, you will find: ·         General Information·         Major Trauma (resuscitation beds, trauma bay)·         Notifications, Arrivals, Triage, Activations·         Personnel·         Physician Roles, Spatial Designations·         Physician and Nursing Supplies·         Massive Transfusion Protocol, Blood Fridge, Emergent Blood·         Sim Sessions, Mock Code·         Website, Procedure Videos, Other Resources

Not included in this orientation document: Physician Roles in Trauma (separate attachment), Trauma Team Positioning (separate attachment), website (see URL at bottom of this document) General Information         Brookdale University Hospital and Medical Center is a NYS Level 1 Trauma Center (American College of Surgery Level 2) servicing a number of neighborhoods in eastern Brooklyn.  We have a variety of subspecialties readily available including neurosurgery, orthopedics/hand surgery, oral and maxillofacial surgery (OMFS)/dental, ear-nose-throat (ENT), ophthalmology, vascular, and interventional radiology.  We are also a receiving transfer center for some of our neighboring non-trauma center hospitals.         Emergency Medicine House Staff (residents) have shift changes at 7am and 7pm. EM residents are expected to arrive 15 minutes prior to a shift in area A to go over resident checklist and the resuscitation areas.  The trauma surgery service residents have 24-hour call and have shift change at 8am.

Major Trauma (resuscitation rooms)         Patients who have sustained or have suspected significant traumatic injuries are treated in the Major Trauma area of our emergency department (our trauma bay) which contains several beds including two monitored beds (Trauma-1, Trauma-2) capable of handling trauma resuscitations.  Major resuscitative interventions that can be performed in the trauma bay include (but not limited to) ED thoracotomy, chest thoracostomy, central venous and intraosseous access, pelvic binding, traction splinting, extremity tourniquet application,

extremity dislocation reduction, emergency blood transfusion, coagulation reversal, and rapid volume resuscitation.

Additional areas capable of handling major trauma resuscitations include Crash, B-2, and Area D if open.  Once stabilized, patients who require additional care are often transitioned out of Major Trauma into other areas including Area D and Trauma-Step-Down.

Notifications, Arrivals, Triage, ActivationsActivation Criteria

Patients with traumatic injuries arrive to our emergency department via field ambulances, walk-in, or inter-hospital transfers.  Pre-hospital providers who suspect major injuries often call ahead with pre-arrival notifications.

Initial assessment of ALL trauma patients (including pre-arrival notification report) is always a determination of whether the patient’s presentation meets criteria for a Level 1 or Level 2 Trauma Activation.  The activation criteria are posted throughout the trauma bay and are included here for reference. Any provider, including nurses, physician assistants, residents, and attendings who recognizes a patient meets criteria for activation should call the Brookdale stat line by using any hospital phone and dialing “13”, then indicate to the operate what level trauma to activate, providing your last name and title.  The operator will then make a hospital announcement overhead and notify appropriate personnel via page.

All Level 1 and 2 patients are treated initially in the trauma bay and can be transitioned to other areas once stabilized.

Activation Personnel

A variety of team members will respond to Level 1 and 2 activations respectively. Team members who respond (depending on what level of activation) include the emergency medicine residents and attending assigned to Area A, ED trauma nurses, patient care technicians (PCTs), the on-call trauma surgery team, trauma surgery attending, orthopedics, neurosurgery, radiology technicians for portable images, respiratory technicians, and anesthesia.

Physician Roles, Spatial Designations In trauma situations, chaos is inevitable if there is no organization. It is imperative for everyone involved to have specific roles and duties to carry out. As the emergency medicine attending/senior resident in the trauma bay, assigning roles either before shift or before the trauma arrives should be done for every person in area A.

Physicians in a trauma resuscitation have specified roles, which include an airway physician, primary survey physician(s), and trauma team leader.  The duties and responsibilities of each physician team member are detailed in a separate attachment.  Please review each attachment sheet and familiarize yourself with the roles prior to your shift.  We will also have a introduction video of each of these roles on our website (please see website details below).

Physicians who are a part of a trauma resuscitation work together with other members of a team that include nurses, PCTs, other technicians.  Team members with assigned roles will have designated positions to stand around the patient (some refer to this area as “the box”) and perform their duties.  It is IMPORTANT for the team members to stay in their designated positions and complete their tasks unless either instructed to move elsewhere or to perform other duties by the trauma team leader.  

It is also CRITICAL for individuals who do not have assigned roles in the trauma resuscitation to not actively participate around the patient (in “the box”) unless specifically instructed to by the trauma team leader.  With too many individuals around a patient, those who do have roles may not be able to carry out their duties without adequate space.  Those outside “the box” who are asked to perform a task (i.e. to help undress a patient, to help logroll a patient; ortho team who need to place an emergent splint, radiology technicians who need to perform imaging) should complete their tasks as quickly as possible and then move away from “the box”.

Physician and Nursing SuppliesTrauma Airway Cart and Airway Boxes

Prior to your first shift, please identify the location of and familiarize yourself with the various nursing/physician supplies and equipment that may be used in a trauma.  Located in the trauma bay is a Resident Supplies Checklist binder that must be filled out every shift.  Any missing item must be communicated to the trauma nurse or charge nurse in order to expedite the replacement of the item.  

Trauma Airway Cart (see pictured) - is located between beds Trauma-1 and Trauma-2.  Additional airway boxes (see pictured) are also available in the trauma bay.  Physicians who anticipate assuming the role of Airway Physician during a trauma must ensure both the cart and boxes are fully stocked prior to each shift.  

Ultrasound - we currently have two ultrasound machines, a Zonaire (see pictured) and a Sonosite (backup).  The Zonaire is typically located between beds Trauma-1 and Trauma-2.

Level-1 Transfuser - we have two Level-1 Transfuser (see pictured) devices located in the trauma bay.  Videos on how to set-up and use these transfusers can be found on our website (see below, end of document)

Other Equipment/Supplies - Glidescope (with blades, stylets), chest tube (with trays/kits/pleuravacs), thoracotomy tray, cardiac resuscitation carts (behind Trauma-1 adjacent to airway cart), IO gun/needles, central venous catheters (triple lumen, cordis).  

Zonaire Ultrasound Level-1 Transfuser

Massive Transfusion Protocol, Blood Fridge, Emergent Blood

Blood FridgePatients with signs of shock, active hemorrhage, or

instability secondary to trauma may require emergent blood transfusion and possibly undergo massive transfusion protocol (MTP).  In order to activate MTP, a physician must call the blood bank at “5509” and notify their personnel.  Two units of uncrossed packed red blood cells (PRBCs) are readily available at all times in the blood fridge (pictured) located in the trauma bay for immediate use; additional blood products for MTP must be picked up from the blood bank.  To pick up these additional products, the Emergency Transfusion Request Form (pictured) must be filled out and provided to the blood bank.  These forms are available in the trauma bay in the shelves above the provider computer desks (pictured).

If the patient requires emergency blood transfusion but does not require MTP, the same form can be used and blood bank is to be called but you would not use the blood in the fridge.

Emergency Blood Transfusion Request Form

   Shelf Location of the Request Form

Sim Sessions, Mock Codes

We will occasionally hold sim/pseudo-sim sessions for rotating residents, medical students, and in-house Brookdale residents to go over special trauma cases and to improve procedure competency.  Dates, times, and locations for future sessions to be announced periodically on our website (see below end of document).  

Periodically we may run mock codes on shift within the trauma bay to assess the effectiveness of team response and identify any deficiencies that may need to be corrected. Dates and times of these mock codes will not be announced ahead of time.

Website, Procedure Videos, Other Resources

Please visit our website below.  Included on the website will be this same orientation packet, other documents including Physician Roles in Trauma and Trauma Team Positioning, procedure videos, additional resources/reading material, planned sim session dates, joint surgery-emergency medicine trauma conference dates.

https://brookdaleemresidency.com/trauma/