At the Battle of Waterloo, Wellington noticed a French doctor in the midst of combat, attending casualties and moving them quickly by horse and cart from the battlefield to the rear. Upon discovering that it was Dominique-Jean Larrey—chief surgeon to Napoléon Bonaparte—the British general ordered his men not to fire in the doctor’s direction and, according to legend, lifted his hat in salute.
In medicine, the importance of speed has long been recognized. Larrey, present on the battlefields of the late eighteenth century, had witnessed heavy-artillery units wheeling and then retreating rapidly from the advancing enemy while casualties were left behind unattended. Only after hostilities ceased were the wounded collected and transported to field hospitals, introducing significant delays before definitive surgery could begin. And in an age of more powerful firearms and artillery, surgery often meant the amputation of more than one shattered limb.
For those soldiers whose treatment was delayed longer than twenty-four hours, Larrey noted that death was far more likely. His solution was to embed agile horse-drawn carriages with frontline troops so that the injured could be quickly carried from the field of battle during combat. Coupled with a rudimentary system of triage in which the casualties were prioritized according to the severity of their injuries, this innovation transformed battlefield care. Men whose traumatic injuries would have previously proven fatal were able to survive largely because of the speed with which they were attended. The system was first implemented in the closing decade of the eighteenth century, and its virtues were instantly recognized. Larrey’s “flying ambulances” were soon adopted throughout the armies of France.
Of course ambulances wouldn’t actually take to the air until well into the twentieth century. The first helicopter evacuations of casualties took place in World War II, and by the time the Korean War arrived, the sight of casualties being ferried through the sky to mobile army surgical hospitals—better known as MASH units—had become iconic. Helicopter evacuation of battlefield casualties continued to play a key role during the Vietnam War, dramatically improving the survival rates of severely injured soldiers. As a consequence, during the 1960s, civilian hospitals in the United States started to adopt these military solutions and began to use air transport to respond to trauma scenes—road accidents, shootings, stabbings, and the like.
A new goal had arrived. For the best chance of survival in the face of traumatic injury, it was understood that treatment should begin as soon as possible. The concept of the “golden hour” was introduced: the idea that after injury no more than sixty minutes should elapse before a patient received definitive care. The message was clear: Delays in the treatment of victims of trauma were no longer acceptable. By the closing decades of the twentieth century, the process that Larrey had started during the Napoleonic Wars had led to a revolution in civilian trauma care.
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IN JULY 1998, AFTER MY BRIEF stint as a student intern in Washington, my colleagues and I stood on the steps of the medical school wearing capes, mortarboards, and smiles that were impossible to wipe from our faces. It was over; we had graduated. We threw our hats high into the air and the official photographer clicked away.
As newly qualified doctors, we moved into the Middlesex Hospital eight weeks later, twenty-four fresh-faced juniors, wide-eyed and terrified. We had studied for more than five years, endlessly learning and reciting the vocabulary and grammar that underpinned the art of medicine. We had learned the language well enough; there was no other way to pass the final exams. But starting work was a challenge on a different scale. It was like going to live forever in a country whose mother tongue you had only just started to speak.
In the first few days, we received instruction on everything from how to wash your hands to the correct way to complete a death certificate. They crammed the pockets of our long white coats with handbooks and then shoved us out onto the wards. For all of our training, we were, at the beginning at least, worse than useless. We were guided not only by our senior medical colleagues but by nurses, ward clerks, and hospital porters—all of whom, at that stage, knew far more about our job than we did.
Most evenings those of us who weren’t on call retired across the road to the Cambridge Arms. There were better pubs, but to the exhausted house officer, this one had the virtue of being closest. We would drink too much, share the stories of the day, and laugh at one another’s most recent misfortunes and breathtaking displays of ignorance.
We quickly discovered that most of the job wasn’t about life and death. Too much of it revolved around filling in forms and organizing the list of patients. As the team’s most junior doctor, your job was to keep a faithful inventory of the patients in your care and their medical complaints, guiding your senior team around from bed space to bed space so that they could bring their experience and knowledge to bear.
Still, there were rare, terrifying occasions when you were temporarily alone—usually in the middle of the night, standing at the bedside of a blue and breathless patient. Knowing immediately that they were sick and that you didn’t have the skills to stop them from crashing, you picked up the phone and called for help. After the phone went down you had a few hundred seconds of responsibility: a brief opportunity to make a difference—or at least to hold the line and prevent things from getting worse—before the cavalry arrived. This was how all of the emergencies were supposed to work. You were little more than a sentinel: responsible for summoning a much more capable team to confront something beyond your abilities. Complex, rapidly evolving disease that threatens the life of a patient demands a swift and definitive response. The world of medicine has come to understand that trauma is precisely that: a complex, fast-moving disease.
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AS A STUDENT, I LEARNED THAT trauma derives from the Greek word for “wound.” In the world of medicine, it refers to injuries sustained as a result of violence or accident. That pair, violence and accident, are as ancient as the species itself. To the noninitiate, the mechanism by which they compromise the function of the human body looks as though it should be easy to grasp.
Trauma is, after all, not the result of a bacterium invisible to the naked eye or a virus that subverts biology at the molecular level. It is not like heart disease, in which unseen plaques of cholesterol lurk in the fat-laden vessels of the coronary circulation, nor is it like cancer, in which some arcane malfunction in the script of our DNA leads to the unstoppable division of a cell and its eventual invasion of our vital organs.
When you’re first introduced to the specialty of trauma, it is a relief to encounter a disease entity in which the link between cause and effect appears absurdly clear. In your imagination, it is little more than the transfer of energy to a mechanism and the disruption of its vital structures or the rupturing of its fuel lines. Only, like everything else in medicine, under the magnifying glass, it turns out to be brutally complex.
Still, your first foray into the specialty of trauma is deceptively straightforward. “Keep the oxygen going in and out; keep the blood going round and round” remains the mantra. The familiar Boy Scout, ABC priority list is the first step: Fix the Airway first, then Breathing, and last, Circulation.
There are subtle modifications. While clearing and opening the airway, you have to pay attention to the spinal column. The bones of the spine—the vertebrae stacked carefully on top of one another—form a hard but flexible hollow tube that protects the bundles of nerve fibers running in the soft tissue of the spinal cord. If this bony armor has been damaged, then the cord will be vulnerable to injury, and waggling the neck around is likely to damage those nerve fibers and sever their connections, leaving the patient paralyzed in all four limbs. For the traumatically injured, protection and immobilization of the spinal column high in the neck are deemed as essential as the letter A in the list of ABC priorities.
Then, after having dealt with injuries threatening the Breathing or the Circulation, you’re taught that in trauma the alphabet goes a little further than C. There is a D and E to look after too. D stands for Disability and is a way of making you remember to look for signs of injury to the spinal cord by making sure that the power in the muscles and the sensation in the body’s extremities remain intact. The E is for Exposure, and is an aide-mémoire to make sure that you have looked from head to toe for hidden injuries. Casualties lying on stretchers have been known to bleed to death from small, penetrating wounds or scalp lacerations hidden from frontal view. This is why trauma teams unceremoniously shear clothing from victims and then roll them naked onto their side.
Confronted with the worst traumatic injuries, it’s easy to get distracted and miss easily treatable but potentially fatal injuries. The ABCDE approach is a tightly honed protocol, designed to offer a systematic approach to trauma that stops casualties from dying of precisely such oversight. Properly adhered to and executed, this system, dubbed the Advanced Trauma Life Support protocol, will get you through the worst five minutes of even the most horrific trauma case.
At least that’s the idea.
—
IN THOSE FIRST FEW MONTHS, we became marginally more competent and much less scared of just about everything. We got used to being exhausted, because the worst weeks still ran to over a hundred hours. We lived and worked in the same building. Our dorm rooms lined a corridor on the fourth floor. Though we tried to make them feel like home, with scattered posters and plants, they were little more than a place to sleep.
Weekends, we’d make a break for freedom. On a Friday afternoon, if you weren’t due on call, you got yourself out of the hospital as fast as you could. Those who remained, holding the pagers and covering the emergencies, looked on with envy as colleagues fled the building.
On Friday, April 30, 1999, it was my turn to be on call with the surgical team. It was the start of a bank-holiday weekend, which served only to accelerate the usual exodus. I stood at the rear entrance of the Accident and Emergency department dressed in hospital greens, watching the ambulances come and go.
The A&E was windowless and always looked the same. Open twenty-four hours a day, every day of the year, it was constantly illuminated by flickering fluorescent tubes and the glow of the X-ray boxes. Inside, the whirling hands of the clock on the wall somehow didn’t give you a proper sense of the passage of time. We gathered in the quieter moments at the rear entrance to the hospital, with its less than spectacular view of the car-park asphalt and the subtle aroma of ambulance diesel, to catch sight of the fading light or breaking dawn.
It was a fine and unusually warm evening. By half past six, all but the most essential staff were gone. The department was quiet, and the casualty waiting room nearly empty. People drawn out by the good weather were packed into pubs and bars throughout the city and well on their way to being drunk. The injuries—the usual catalog of assaults, road accidents, and ankles turned on cobblestones—generally followed later, after people were kicked out onto the streets. I turned back into the department.
On the wall next to the nurses’ station was the red phone, an old Bakelite thing with a dial. It took only incoming calls and rang with the old-fashioned trilling of a real bell. It was there so that the ambulance service could call ahead and tell us if they were bringing something bad in, giving us time to assemble and prepare in the big resuscitation bays at the back.
Just before a quarter to seven, the red phone rang. Alex, the nurse in charge, listened intently, scribbled some details, and put the handset down. Usually a pithy case summary about the imminent arrival of a single patient would follow: a heart attack, a massive drug overdose, or perhaps a stabbing. The department was set up to tackle these blue-light emergencies without breaking its stride. A small team would peel off into the crash rooms and get on with the resuscitation while the ingrown toenails, superglue accidents, coughs, and colds continued to stream in through the front door.
But this call was different. Alex raised her voice to make herself heard. There had been a bomb, she told us, in a nearby pub in Soho. There were many casualties. A major incident had been declared so that we could prepare to receive casualties. That was all the information we were given.
We all stopped for a moment, trying to digest the news. Then the sound came, with heart-stopping strangeness, of every pager in the hospital bursting into song simultaneously. A machine-gun succession of monotone chimes was followed by the crackling of the pagers’ tiny loudspeakers. “Major incident declared,” came the slow and deliberate voice of the switchboard announcer, and then again: “Major incident declared.”
The trauma team assembled in the crash rooms: a surgical registrar, a senior house officer, and me; our consultants were already on their way back to the hospital. The red phone rang again. There were many people injured and some trapped. The ambulance service was asking for a mobile team of doctors and nurses to go out to the scene.
The surgical registrar didn’t want to lose surgeons who would likely be needed to run the resuscitation bays or assist in operating rooms. I, on the other hand, could be spared.
The mobile team was comprised of three doctors and three nurses. The accident and emergency nursing staff, familiar with the major-incident drill, manhandled us through the preparations. I was pushed into an equipment room that I had never before noticed. I found myself pulling on a fluorescent suit and donning a hard hat. A trauma pack, full of equipment and drugs, was shoved into my hands. And then I was being ushered out into the ambulance parking bays. Before anything more could be said, a pair of ambulances screamed into the parking lot and flung their rear doors open. The six of us climbed inside.
I sat clutching my trauma pack next to an A&E registrar and opposite Christine, one of the nurses. The rest of the team was in the other ambulance. Christine leaned in and raised her voice above the noise of the sirens: “This is a major incident,” she said. “You are wearing your personal protection equipment. In your jacket pockets and pack are the following items . . .” She started reeling off the list.
I just stared at her. She was looking me right in the eye and talking to me—nearly shouting, in fact, to get above the din of the engines and sirens—but it felt as though she were addressing someone else. She paused, waiting for me to carry out my checks. I pulled the pockets open. It was all there, just as she’d said it would be. How could she know what was in my pockets? And then I realized that she, unlike me, was trained for this event. She, at least, knew what she was doing.
The ambulance went up and down through its gears, hurtling toward the scene with us in the back. The journey couldn’t have taken more than five minutes. When it drew to a halt, I didn’t really know where we had arrived. Then the rear doors opened.
It took more than a few moments to orientate ourselves. We were at the junction of Old Compton Street and Dean Street, part of London’s theater district. The streets there usually thronged with tourists and clubbers. But as the doors opened, it was unrecognizable. Glass carpeted the street, ambulances crowded all of the access roads; the place was awash with casualties.
When we arrived, the scene was barely under control. The bomb had gone off less than thirty minutes earlier. The pub was still smoking; the fire brigade had just finished hosing bits of it down. A registrar from the Helicopter Emergency Medical Service (HEMS) had arrived ahead of us and had taken charge of the medical decision making. He, along with the ambulance officers, had separated the walking wounded from those most severely injured.
When we arrived, we were pointed at a litter of bodies in the middle of Old Compton Street being attended by paramedics and firemen. They were the most severely injured people I had ever seen. They remain so to this day. There were perhaps a dozen people on the ground in front of us. They were exposed; most of their clothing had been incinerated in the flash fire that followed the detonation. Their bodies had suffered burns; some of their limbs had fractured or been amputated by the blast.
In the worst situations, the trick is not to think too hard. It’s best to stay focused on the one task at a time and to make that task as simple as possible. For fast-moving situations, there are protocols that can be unpacked and delivered almost reflexively. While these achieve many things, one of their most important functions is to stop you—struggling in the midst of events that words could never adequately describe—from grinding to a halt.
The alphabet of survival comes to the rescue, the Advanced Trauma Life Support. Those simple ABCs get you moving and stop you from thinking. You don’t much care about where the system came from or how it was designed. You are just grateful that it exists, and you wonder how anyone could be expected to cope without it.
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BACK IN 1976, DR. JAMES K. STYNER was flying his family from Los Angeles to his home town of Lincoln, Nebraska, after attending a wedding. The family had traveled some considerable distance: east across Southern California and Arizona, landing briefly in New Mexico to refuel.
They took off and continued their journey home, eventually turning north over Texas and up through Oklahoma and Kansas. As they crossed over into the airspace of their home state, Nebraska, they ran into thin, low-lying clouds. The day was coming to an end, and, not being rated to fly on instruments alone, Styner chose to stay below the cloud base. By the time they reached Lincoln, the sun had already set, but they were almost home. Then—flying low with the skies nearly dark—Dr. Styner became suddenly disoriented. He steered his plane low across a pond and realized too late that he was below the treetops.
There was a deafening roar as the aircraft hit the trees and plowed into and then across the ground, ripping through the underbrush, disintegrating as it went. In those brief seconds, James Styner waited for his life to end. The wings were torn off almost immediately and the remaining fuselage slid for over two hundred feet, spinning so that it finally faced backward. The plane somehow came to rest upright, its fuel tanks ruptured and spilled, a huge hole gouged in its right-hand side.
James opened his eyes, amazed that he had survived the impact. The lower ribs on the left side of his chest were fractured, and his forehead and face, which had smashed into the dashboard, were deeply cut. Charlene, his wife, was nowhere to be seen.
The world fell silent around him. Dazed, he pulled himself out of the aircraft. Once outside, his head cleared a little, and his priority became the children still trapped in the wreckage.
Chris, ten years old and the eldest of the four, was least injured—his arm was broken, and his hand was bleeding, but he was still awake, alert, and oriented. Kim, sitting on his lap with the same belt around her waist, was unconscious, her head having collided with a fire extinguisher. She was three years old. The other children, Rick and Randy, were in even worse shape. Eight-year-old Rick’s head was deeply lacerated, and he too was unconscious. Randy’s leg was partly impaled on the jagged fuselage and trapped beneath the plane.
Dr. Styner got Kim and Rick out first. He knew that Randy was pinned and injured but feared that the aircraft might yet burst into flames. If that happened none of them would survive and so, as hard as it was, he had to stage and prioritize the rescue of his own children. He carried Rick and Kim a safe distance from the wreckage and set them down on the ground. Then he returned to the plane and dug into the ground around Randy’s trapped leg, excavating and freeing it from its impalement. He expected it to bleed profusely, but mercifully it didn’t. Chris, with his broken arm, managed to find his own way out.
They gathered some clothes from the scattered luggage and piled them like blankets over the younger children. It was winter in Nebraska, and that night temperatures fell below freezing. They waited in the near darkness—illuminated only by the light of the moon—for help that never came. Finally, realizing that they were on their own, James went out in search of his wife, Charlene. He ventured out twice without success, returning to the children each time. On the third occasion, he found her. She had been thrown more than three hundred feet from the plane and had suffered a catastrophic head injury. Charlene was dead. With temperatures still dropping outside, James now had to focus his attention on his children.
Worried about the injuries they had suffered, Dr. Styner decided to go in search of help. From the crash site, they could see a road in the distance. He was aware of pain in the ribs overlying his spleen and wondered if it too might be injured and bleeding or in danger of rupture. If that were true, then the long march in search of help would only make things worse. But with no idea when, or indeed if, rescuers would arrive, he decided that he should take the risk and go anyway.
James talked frankly with his ten-year-old son, Chris. He told the boy that he was concerned about the state of his own spleen but more worried about the children’s injuries. He explained his plans to go get help and said that if he didn’t return, Chris shouldn’t go looking for him but instead stay with his brothers and sister. His voice was calm and remarkably free of emotion. James said good-bye and then shortly after two A.M., he set out for the road.
After what seemed an eternity, he finally reached the road and flagged down a car. His face was caked with blood, and initially the occupants were hesitant to leave their vehicle. But he managed to explain his situation, and together they returned to the crash site. They gathered up the children, and James said a final good-bye to his wife. Then, somehow, the five of them crammed into the back of the car and drove a few miles south to Hebron hospital.
Hebron was a small community hospital, and when they arrived in the early hours of the morning, the door to its Emergency Room was locked. A lone night nurse stood at the door and asked them to wait for the doctors to arrive. Somehow they forced their way in, but things didn’t improve much when the hospital’s medical team finally arrived. Their approach lacked structure and seemed to ignore key injuries. It became obvious to James that they were unprepared for the nature and extent of the family’s traumatic injuries. Sliding off his trolley, he stopped the local doctors from treating his children and took over their care. He had come too far for things to fail here.
Next he contacted colleagues in Lincoln and organized transport by air back to his own hospital. They landed at Lincoln Airport and traveled by road to Lincoln General Hospital’s Emergency Room, arriving at eight A.M.—more than fourteen hours after their crash. There James Styner could finally resign the role of doctor to a team of his friends and colleagues and once more become a patient and parent.
Dr. Styner was incensed by how long it had taken to get his children the trauma care they needed. He didn’t blame the physicians and nurses at Hebron, but he felt that he’d been able to deliver better care as a trauma victim at the scene of the accident than he’d received at the local hospital. If that was the case, the system was broken, and things would have to change.
In the years that followed the accident, James K. Styner invested all of his efforts in designing a straightforward protocol for the management of cases of trauma; one that could, if necessary, be delivered by even the smallest of hospitals. He based it on existing models for the delivery of cardiac resuscitation, adopting that powerful ABC approach and extending it. Just four years after his plane crash, Dr. James K. Styner’s Advanced Trauma Life Support (ATLS) course was adopted by the American College of Surgeons. He trained people to deliver lifesaving trauma care whatever their situation, and then he trained them to train others. Courses sprang up all over the United States and then all over the world. In the years that followed, ATLS went viral. To date, more than a million people have learned to follow it. In a 2006 lecture, Styner told the remarkable story of its origins and finished by joking that it had spread around the world and would soon be taught on the Moon and Mars. He wasn’t far wrong.
—
ON THE CHAOTIC SOHO STREET, I checked the first of the casualties I reached. He was lying on the ground, his clothes in tatters, his skin scorched. There were nails embedded in the skin of his chest and abdomen, but his hands were warm and he could still talk to me clearly. I pushed an intravenous drip into a vein on his arm. I tried to stick a dressing over the top of it but it wouldn’t hold; the layers of burned skin just sloughed off underneath. I’d never seen anything like it. Grabbing a crepe bandage from my pack, I wound it around the line and tied it in place. And then, having done the little I could, I realized I had to leave him with the paramedics and move on to someone else. I turned to discover a much more seriously injured man with Christine already at his side.
There was bleeding; at least that’s what I remember most of all. One of his legs was missing and his face and chest were burned. Bits of shrapnel protruded from his remaining limbs. He was awake but only just. I started at the top, at A, checking his mouth for injury or obstruction. Then on to B: I got my stethoscope out and went through the motions of placing its bell on his chest. But above the chaos of the scene neither the gentle rush of air nor the drum of his beating heart was audible. I put my cheek close to his mouth and turned my head to look at his chest, watching for its rhythmic rise and fall and the rush of warm air against my face. At this point one of the firemen pointed out the amputated leg, worried perhaps that I was ignoring the obvious injury.
He was right, of course. When it comes to trauma the alphabet arguably should start at C for Circulation. Major hemorrhage has to be dealt with first. The adult heart circulates around five liters of blood a minute, more if you’ve just been injured and there’s a lot of adrenaline around driving it harder and faster. For a man of average height and build, the whole circulation holds perhaps only five liters and so a significant bleed will kill in minutes—at least as fast as an obstructed airway or injured chest. I looked at the leg. There was plenty of blood on the floor, and it appeared to be oozing steadily. I felt down for the femoral artery in the front of his right thigh. The pulse there was still good and reasonably strong. I grabbed one of the firemen and pulled his hand down onto the spot where I could feel the pulse, asking him to push down hard over the artery with his thumb, hoping that this would close it off and slow the rate of blood loss. Then I carried on with my survey, working again from head to toe.
I sited a line into his arm, too, and started some fluids. He was sick and getting sicker. There in the middle of the street, there was nothing else I could offer, nothing else I knew how to do. Just at the point at which the protocol I was following ended and I might have started to flounder, one of the HEMS paramedics walking by put a hand on my shoulder and said: “Does he need to stay or go?”
“He needs to go,” I said.
—
IT IS TEMPTING TO THINK of that moment as the end of the story for trauma: the point at which the ambulance doors shut and the victim is sped along to the nearest hospital. In truth, rapid access to treatment and the ATLS protocol have transformed the survival rate of seriously injured casualties. But the fight doesn’t finish there.
For Dominique-Jean Larrey on the battlefields of the Napoleonic Wars, trauma surgery relied largely upon getting casualties into a field hospital as fast as possible and then stitching wounds and performing amputations promptly to arrest bleeding. There were no anesthetics or antibiotics, and survival depended upon addressing the primary injury before it became truly life threatening.
Today, for the patients who arrive in our trauma units, we can do a lot more: We fill them with blood, splint limbs, throw stitches in the ruptured vessels we can see, scoop out bleeding spleens, repair punctured viscera, and pack lacerated livers. All this we do while holding their physiology stable with drugs and life-support machines.
Innovation in the pursuit of survival has taken us further still. We use beautifully nuanced physics to image, in fascinating detail, what remains hidden. We can thread long tubes into vessels, snaking them up from distant points of entry. We deploy devices that block or stent torrentially bleeding arteries and veins that can’t be reached safely or quickly with a knife.
Once the patient has been taken from the scene of the accident and resuscitated, opened up, and the hemorrhage stopped, the fight continues. It’s not enough to understand the mechanisms of bleeding vessels, crushed viscera, and fractured limbs. The bleeding taps having been turned off, limbs and organs having been saved, patients can still continue to decline.
In the most severely injured patients, kidneys can shut down, hearts can malfunction, and lungs can fail. It is this secondary wave of illness that follows in the wake of major injury that takes trauma out of the realm of the simple, physical disruption of a mechanism and turns it into a complex and formidable disease.
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WHY DO YOU BLEED TO DEATH? That’s the sort of seemingly innocuous question they dish out at finals. But it’s like someone asking you how a wheel works. You think about it for about ten seconds, and then realize two things: You don’t know and you never knew. If there’s no blood running in your veins, you die. Yes, but death, or at least cardiac arrest, happens long before the system is empty of blood. So the question becomes what causes the cardiac arrest. That innocent question rests on determining what is behind the force and energy of every heartbeat. And then you know you’re in trouble.
Nerves running from the brain send impulses to the heart, moderating its pace and force of contraction, and at times of stress, adrenaline circulates in the bloodstream, driving it harder and faster. But in the face of injury and massive blood loss, it’s not the malfunction of this system that causes the heart to falter and stop. It is the mechanism of the heart itself. The heart has specialized muscle fibers that match the force of their contraction to the amount of blood entering it. If more blood returns to the heart just before the start of a heartbeat, the muscle contracts harder and so pushes out a larger volume. It’s a way of making sure that the heart ejects the same volume of blood as enters it. If it were unable to match its ins and outs in this way, it would rapidly balloon and fail.
But when less blood returns to the heart, it beats with less force. And if the circulation is suddenly losing volume because of a hemorrhage, the heart empties further and its contractions become weaker. If bleeding continues unchecked, the heart eventually arrests.
In the first moments of treating a trauma victim, you’re trying to prevent exactly that. It’s why it’s so important to stop the bleeding and maintain an adequate circulating volume in the blood vessels. Once the first phase of resuscitation is complete, after you’ve followed James K. Styner’s all-important ATLS alphabet to the letter, much of your effort continues to be dedicated to the same task, stopping hidden bleeding with surgery and restoring volume with blood and fluids.
But even without resuscitation, the body starts to protect itself using the same strategy. In the face of massive hemorrhage, injured blood vessels spasm and shut themselves off to prevent further loss. Elsewhere, vessels in the extremities constrict, forcing blood back toward the central, vital organs, temporarily depriving less important tissues but returning more blood to the heart. This reflexive recoil of peripheral capillaries near the surface of the skin is partly what accounts for the pale appearance of trauma victims. But the body’s response to trauma goes beyond the heart and its system of blood vessels.
Hormones pour into the bloodstream, mobilizing fuel stores from fat and raising the body’s sugar levels. The protein in muscle, too, begins to be broken down and its constituent components recycled to assist in the defense, like a country putting its economy onto a war footing.
But the most complex and problematic aspect of the human body’s response to major trauma is that of the immune system. At the site of injury, white blood cells patrolling in the bloodstream and the cells lining injured vessels and tissues release messenger molecules. These summon a host of other immune cells that take part in removing dead and damaged material and prepare the way for healing. In moderate injury, it is a beautifully orchestrated process that sweeps away cells that are no longer viable and replaces them with new ones, all the while making sure that enough energy is made available to cope with the increased metabolic demand of this restoration.
These mechanisms evolved over millions of years. They are what allowed our ancestors to hunt and to defend their families—to be predator and prey—and then limp off into the bushes and return rebuilt. For minor and moderate injury—deep lacerations and wounds that don’t involve vital organs or uncontrolled blood loss—the body’s response has been carefully honed over Darwinian timescales to work in our favor, assisting our survival and ensuring that our genes continue.
But for severe injuries of the type that would have killed a person quickly in the days before modern medical intervention, no appropriate survival process has evolved. Instead the immune response to trauma oscillates wildly, causing more harm than good. The immune response is effectively like firing up a nuclear power station. You want to encourage the reaction to kick off, go critical, and generate heat, but you have to moderate it well enough to avoid meltdown. Underactivation would leave the victim prone to infection. Overactivation would lead to the malfunction of our organ systems, the biological equivalent of meltdown.
There is no evolutionary precedent for the limits of survival we are now probing. By the time we’re supporting multiple organ systems on an intensive-care unit in the wake of major trauma, we’ve left evolution far behind. Out at those extremes, we depend not on our physiology but upon state-of-the-art systems of life support and the speed with which they can be brought to bear. The idea that, in the event of major accident, a team might literally drop out of the sky, scoop you up from the road, and propel you within minutes to a hospital is a construct of modern medicine that has existed only in recent decades. The edge of life, in that respect, has never been more heavily invested in. Expectations of survival in the face of horrific physical injury and physiological insult have never been so high. All of this means that today, when faced with even the most extreme trauma, we are less willing to accept defeat.
—
WHEN THE BOMB SITE WAS CLEAR of all the major casualties, we moved up to Soho Square to check over the walking wounded. We walked along Dean Street. The cafés and bars were entirely vacant, their tables covered with half-eaten meals and hurriedly left drinks. Afterward, we returned to the hospital, and I worked through the night.
The pub that had been bombed was called the Admiral Duncan. It was a bar popular with gay men. The bomber, a twenty-three-year-old paranoid schizophrenic and former member of the ultra-right British National Party, had planted and detonated two previous devices in the preceding fortnight—one in Brick Lane and one in Brixton. The bomb in Soho was the first one to inflict fatalities.
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ON FRIDAY, APRIL 30, 1999, ANDREA DYKES and her husband, Julian, traveled to London. John Light, who had been the best man at their wedding, was with them. Andrea was newly pregnant, and they were in a celebratory mood; John was to be godfather. They were on their way to the theater to watch the musical Mamma Mia! but decided to stop for a drink at the Admiral Duncan. They were joined by John’s friend and former partner, Nick Moore.
The bomb detonated at 6:37 P.M. More than a hundred people were injured. The blast killed Andrea and Nick instantly. John died the following day. The nine other casualties admitted to intensive care all ran difficult and prolonged courses, but all of them survived.
On June 30, 2000, David Copeland was found guilty of the murder of Nick Moore, Andrea Dykes, and John Light. In 2007 the High Court ruled that he must serve at least fifty years in prison.