State of shock
When the red telephone at Dunedin Hospital Emergency Department rings, those working know to brace themselves.
It is the phone that rings to alert staff of an incoming trauma patient.
If they are lucky, they might have half an hour to prepare. If it is something nearby, it might be just minutes.
Clinical director Rich Stephenson has been working in emergency departments for more than a decade.
Dr Stephenson sees people involved in crashes come through the doors every day. Several each week are serious.
Dealing with people in the immediate aftermath of a crash brings with it a set of mental challenges as well as physical.
"They’re people that will always be very traumatised ... and in a state of shock, they’ve often been trapped in a vehicle for an extended period of time and needed rescuing and then flying from a helicopter," he says.
"Then, suddenly, they end up on a trolley with bright lights shining in their eyes while a bunch of people they’ve never met do painful things to them. They’re in an incredibly vulnerable position and they’re often quite emotionally affected by it."
He struggles with children the most. He, like many of the staff, has young kids.
"Severely injured children are rare, thank God, but we still see them, still deal with them. Often, when I think back to stuff that I remember particularly, then it’s often children."
He recalls one incident where a child had died at the scene, and staff were dealing with her injured mother.
"Even though the medical side of that was fairly straightforward, we’re dealing with that immediate, terrible emotional reaction that mother’s going through."
Then there are the cases where he has to treat those responsible for causing a crash — for example, someone who is clearly drunk, crossed the centre line and hit another car.
"I’ve personally looked after people who I know have killed somebody. I might also be looking after a relative of the person who’s died."
As difficult as it is, staff have to filter it out and stay professional.
"I know that staff really struggle with that. It might be that you have to physically keep the people separate, making sure different family members don’t meet.
"At the end of the day I think we’re all pretty good at being objective about it, but it does gnaw at you a bit."
The most traumatic injuries he deals with, particularly brain injuries, tend to be the result of crashes.
"I think we all find those really difficult to deal with, because we know the outcome from brain injuries is often so debilitating, we know these people will never go on to live normal lives again.
"We might well see these people two, three years down the line again coming in with their family members who are now their carers ... and they’re wheelchair-bound or bed-bound or needing 24-hour care."
Even seemingly minor injuries, such as a fractured ankle, could mean that person will never walk normally again.
While in the emergency department, the patient will be given initial treatment and assessed for injuries. Staff also work with police, and the majority of people involved in a crash will have their blood-alcohol level taken.
Then, depending on injuries, specialists in areas such as orthopaedics and cardiothoracic surgery will be brought in.
If people have very specific injuries, they may also require a secondary transfer to Christchurch or Auckland.
Kate Stephens is somewhat unusual at Dunedin Hospital, in the sense that she can be working with a crash patient from the scene, in intensive care, and through to anaesthetising them in an operating room.
It means she has a very good understanding of the realities of crash injuries.
Intensive care is not so much about fixing injuries. Rather, it is about keeping that person alive while their body starts to fix itself before they progress to surgery.
There is usually at least one trauma patient in Dunedin’s intensive care unit at any given time, and often they are crash victims, Dr Stephens says.
Staff are very aware of the psychological impacts of trauma, some patients getting post-traumatic stress disorder from being in intensive care.
"We’re always reminding people that it’s easy to forget there’s a person there, under all those lines and tubes."
Part of her job is jumping in a helicopter and heading to crash scenes or smaller hospitals and medical centres to retrieve patients.
She tends to get called to scenes where there are multiple casualties, or a specific treatment is needed. In one case, she was called to a crash site when paramedics thought an amputation may have needed to be performed at the scene.
Dr Stephens used to work in a similar role in her native Wales, where she was called out to crash scenes more often. She still recalls the harrowing details — including one incident where she had to use a patient’s thumb to unlock their cellphone so she could find contact details for their next of kin.
In the rush of immediate treatment, medical staff are usually able to compartmentalise. It is afterwards that the full impact of a trauma case can hit, she says.
"One important thing to remember is that it’s OK for it to affect you. The day it stops affecting you is the day you’re burnt out and you need to take a break from it.
"I try to lead by example and say ‘that was really tough’ and talk through it with people, rather than trying to build a wall and pretend it doesn’t affect me."
Because people can be brought to the intensive care unit from all over the lower South Island, sometimes family members have to travel long distances to see their loved one.
Dr Stephens has become used to delivering bad news over the phone.
"With road trauma, it’s the suddenness, the unexpected nature of it, that I think makes it really hard for people.
"What you’ve got to tell them is going to hit them like a tonne of bricks."
She believes driving should be considered a privilege, not a right.
She likens it to her work as an anaesthetist; if she did her work drunk, or if she did not follow safety procedures, she would no longer be allowed to do it.
She works with the Right Track programme, which aims to show recidivist dangerous drivers the impacts of their actions and prevent further offending.
From that, she has realised many people have no idea of the potential consequences of bad driving.
"Some of them ... are prepared to accept a certain risk of death, but they don’t think about the risk of permanent disability and the risk of the loss of dignity, the dependence on other people."
Ange Price and Sammie Graham see people at their sickest.
The two are senior cardiorespiratory physiotherapists at Dunedin Hospital’s intensive care unit.
It is a bit of a mouthful, but essentially their role is two-pronged — they ensure the patient’s lungs are kept clear while they are on a ventilator, and they also work with the patient to start getting them mobile.
They work with crash victims every day, and this year in particular they have had a lot come through the ICU doors.
When patients arrive, their injuries are mapped out. Not everything gets fixed at the same time. Some fractures will be attended to immediately, while others may not be dealt with until days or weeks down the track.
The injuries patients have will determine the kinds of movement they can work on, from how high they can be seated to whether they can stand.
Some patients with head injuries may be kept unconscious for a week or so, to protect their brain and to allow for swelling to go down.
"Different injuries will have different seating needs, then hopefully get them a plan so they’re sitting out in the chair for periods of time during the day," Ms Graham says.
"But also trying to make whatever rehab goals we have for them, to do with what they enjoy doing."
They are there for the early milestones. The first time somebody might squeeze a hand, the first time they smile, or talk, or sit on the edge of the bed.
They try to involve family members, so they can see the progress.
"I personally tend to focus on what we’re doing during that session, because it’s difficult to predict how we may progress. I try to keep it as present as possible," Ms Graham says.
But the flipside to that, Ms Price points out, is when people are not progressing.
For instance, sometimes people will react reflexively to something, and their family will think they are progressing because they have moved.
"What do you say in that situation? That’s probably the harder aspect, how to explain those sort of things," she says.
Some people will be in and out in a couple of days, while others might be with them for weeks or months.
Some patients may need a tracheostomy, if they have a head injury and for some reason cannot be weaned off a ventilator.
That involves creating an opening in the neck to place a tube into a person’s windpipe, allowing air to enter the lungs.
In some ways that can be a good thing, Ms Graham says, because it makes communication a bit easier — the patient can mouth words.
Once a person leaves intensive care for another ward, or for rehabilitation, they often do not know what happens to them.
Occasionally, they do pop in, and are often unrecognisable.
"Sometimes with older people, you sort of think they might survive, sometimes their resilience surprises you and they do fantastically well," Ms Price says.
"You’ll remember the ones that do really, really well, and you remember the ones that maybe haven’t done so well."
Ms Graham says working with trauma patients makes her extremely aware of her own mortality.
"The rehab from it and everything else takes a really long time."
The long haul
The brain controls everything from how you breathe to whether you can recognise your loved ones.
When your brain suffers a traumatic injury, even the most basic actions have to be learnt all over again.
For many of the crash victims who end up in Dunedin’s Wakari Hospital, that is their reality.
Wakari has one of just three traumatic brain injury rehabilitation services in New Zealand.
Brain injury rehabilitation consultant Toni Auchinvole sees about 40 patients with severe brain trauma come through Wakari each year. Of those, 20-30 would have been injured in crashes.
A brain injury is a life-changing event, and one that affects not only the patients but their family, friends, and colleagues, she says.
Staff work in teams with the patient and their families to establish goals, usually in one- to two-week blocks.
Some people have limited consciousness when they arrive, and initial work could be helping to maintain their bodily functions.
But generally the work is about giving the person as much independence as possible.
"Even if that’s facilitated by simply being able to learn to feed themselves again, being able to learn to wash themselves again, to perhaps being able to walk again."
Patients tend to stay for a few months, working towards learning how they will be able to adapt to being back in the community.
The mental trauma can be significant.
"There’s a lot of adjustment, especially if they don’t remember what has happened to them," Dr Auchinvole says.
"People’s personalities can be very different, which can be challenging for families."
There are psychologists on hand to support families and patients adjust to their new reality.
People have an extraordinary ability to make gains, she says.
But she has also seen people who have not progressed as much. Parents who are no longer able to parent their children as they once did. Children who were the apple of their parents’ eyes, no longer able to be that person.
It is that reality Dr Auchinvole wants people to be mindful of as they hop in their cars this summer.
"All the individuals in that crash, those people’s lives have changed forever from that moment.
"That is not something you tend to just get up and brush off and walk away from a few weeks later."
In fact, it can take years of "hard slog" to get back to some level of function that is unlikely to be close to your previous life.
"When you’re young there is so much potential, and to have that cut off ..."
