They come from quiet rural towns and turbulent city streets. They're injured by hurtling cars, heavy machinery, flying bullets. One man, thrown from a van on a Mississippi highway, moans and squirms on his bed till morphine kicks in. Another, whose leg and pelvis have been flattened by a forklift, manages a joke; he tells a nurse he's allergic to pain. Just behind him, a trembling man, his face streaked with sweat, wipes at caked blood near his temple; assailants have beaten him with chairs, sticks, and fists.
On the roof, a helicopter lands and two nurses rush to meet it. They load a patient onto an elevator, then whisk him down a hallway. One nurse shouts, "Make a hole, make a hole! Thirty-seven-year-old male with a gunshot wound to the back of the head, eyes dilated, blood pressure dropping . . . ." The corridor clears, the nurses wheel their charge into the shock trauma unit, and caregivers converge in a life-saving effort that's played out thousands of times a year at the Elvis Presley Memorial Trauma Center at The Regional Medical Center.
One of the top five such centers in the nation based on numbers of patients treated -- more than 15,000 in 2005 alone -- The Med's trauma center takes in patients from a five-state area who are crushed, broken, stabbed, shot, or otherwise injured badly enough to qualify as level 1 (most severe) or level 2 trauma cases.
"We're just one of a few in the country with a trauma center that's separate from the emergency room," says Dr Martin Croce, medical director of the center since 2000. "It used to be that some of our cases would be sent elsewhere, but not now. We're the only game in town."
It's a costly game, too, representing more than a fourth of The Med's $300 million total budget, with anesthesiologists, neurosurgeons, orthopedic and general surgeons on board round the clock, and costing about $216,000 a day to run. The Med, the only state-designated "safety net" hospital in the Memphis area, is required to take patients regardless of their ability to pay. As such, it faces TennCare disenrollments and a growing number of uninsured or self-pay patients, a number that already stands at 30 percent. Although president and CEO Dr. Bruce Steinhauer expects to feel the fiscal pinch through 2007, he says, "I think by 2008 we'll have other approaches to funding the health-care system in Tennessee that will help us a lot."
Helicopters often deliver the most critically injured patients to The Med's rooftop landing pad.
Meanwhile, people will still be shattered in car wrecks, thrown from motorcycles, injured by power tools. They'll still get shot, stabbed, or beaten senseless. And they'll be rushed by ambulance or helicopter to The Med's trauma center. "Trauma is a field that will always be important," says Steinhauer. "Even if every car had eight airbags, we'd offset safety features with higher speeds. We find new ways of hurting ourselves." "They stitched me right up. " Dr. Martin Croce, medical director, has confidence in his trauma team, who include physicians, nurses, therapists, technicians, and other vital personnel. "Every case is different," he says. "We all have to think quickly."
It's around 6 p.m. on a warm spring evening, and all 14 beds in The Med's critical-care assessment room are taken. Extras have even been set up in the shock trauma area across the hall, normally used to treat or resuscitate the most critical patients. In one bed lies Samuel A. Smith, who's preparing to eat a diabetic's meal of turkey, broccoli, corn, and fruit. "Be sure you put 'U.S. Air Force retired' after my name," he says. A former cook at the old Four Flames restaurant -- "if you looked back in the kitchen you'd see me; I was that tall fellow with the white hat on" -- Smith blacked out the night before and hit his head on a glass table. When he came to, he saw blood, lots of it. "A friend was with me and he didn't know what to do. I said, man, call 911. The ambulance brought me straight here and they rushed me into triage," says Smith. "I'd cut an artery near my ear and they stitched me right up, did a quick outstanding job. I've been watching them here and there's no bickering, no arguing, they've got it altogether."
In another room, behind a curtain, a 65-year-old woman lies with fractured vertebrae. She was returning from Tunica and was injured in a chain reaction involving several vehicles. Her daughter, Sherry Sanford, has traveled 500 miles to sit by her side. Unlike Smith, Sanford's impressions so far about the trauma center haven't been so positive. "It's very loud," she says, "and I'm not pleased with some employees' attitudes. I questioned a nurse about my mother's pain medicine and she snapped, 'Look, lady, we've got a lot of people laid out here.' Meanwhile my mother is hurting," says Sanford, who says she's a nurse herself.
Certainly, on any given day, in a facility that's often full to bursting, voices may rise and tempers flare. But on this busy evening, employees appear to go about their jobs with a calm competence despite the number of patients in their charge. Nurse Tommy Willette's blue eyes twinkle as he says, "I call it chaos as usual. A lot of people might not think so, but it's organized." He has just ministered to a man whose upper right leg and pelvis were trapped between a support post and a forklift. "Any injury to the pelvis concerns us because there are so many blood vessels in that area, not to mention the internal organs and the male genitalia," says Willette. "But he's neurologically intact and has good circulation."
Another patient lying nearby was flipped from his vehicle and brought to the trauma center in "acute distress," says Willette. "He kept repeating questions and that concerned ambulance drivers because it can signal a brain injury. He's got blood on the brain, some bruising, a concussion, but all in all I think he'll be okay."
Meanwhile, the man beaten by sticks and chairs is being treated by a nurse who identifies herself as Deborah. Asked how often she sees victims of assault, she says, "A lot. It's a violent city." "A black hole for black people"?
No doubt about it: Memphis teems with violence. But that's not what brings most patients to the trauma center. Just ask Dr. Martin Croce, who strides into the assessment room and eyes the nurses' station, with its clutter of paperwork and personal mementos.
"No Easter candy?" he demands. "I can't believe you people don't have any leftover Easter candy!" Then he perches on a stool and takes in the scene with a sweep of his dark eyes.
He's passionate, with strong opinions (some might call him bullheaded) and perhaps he feels most strongly about a perception many Memphians have of The Med, that it's "a black hole for black people," as he has heard it described earlier in the day. "They think it's the old John Gaston [a hospital for poor blacks] in a newer building. That really pisses me off. It is so far from the truth."
Take that misconception a step further -- that the trauma center is filled 24/7 with thugs who've shot each other and innocent bystanders, in conflicts over drugs, women, or stolen chicken legs -- and Croce shakes his head.
"Less than 25 percent of the traumas that come here are from gunshots, stab wounds, or other kinds of assaults," he declares. "True, most of those victims wind up here sooner or later. That's because we're an urban hospital and we're going to get those kinds of trauma. But the most common cause of injury we see is from car crashes. And that affects people across the socioeconomic strata. We have the wealthy, we have the homeless, black and white. And I like to think we treat them all the same."
While he's on call, Croce visits the trauma intensive-care unit, where some 20 percent of patients are sent after their initial assessment and treatment. He teases the nurses, speaks with some residents, and stops to visit the victim of a car collision. "He's had a significant pulmonary injury," says Croce, after a 10-minute talk with the patient's wife. "He's a lot better today but he's not out of the woods."
Next, he heads to the operating room to see a man with a bullet wound in his leg. He'd been shot some time ago and had been seen -- "more like initially ignored," says Croce -- at another local hospital. The wound still festers. In the O.R., Croce scrubs, suits up, and briefly observes other surgeons at work on the man's calf, which is slit open to the ankle. One doctor mentions the presence of dead tissue. "Shit," Croce mutters. Looking both sad and disgusted, he seizes an instrument. Soon he removes a glistening piece of atrophied muscle and lays it on a tray.
Once the surgery is over, he explains that the bullet was probably lodged in the man's tibia. "We left it there," he says. "Only TV doctors take out bullets. We'll remove them if they're easy to get to or if they go through the colon or intestine, where there's an increased chance of infection."
And the patient's leg? "He should keep it. He won't be able to take his foot off the gas but he can get a brace that should help with that. He can feel his foot and he'll still walk." "When can you put the bone back in my head?"
Just as violence brings in assault victims, intersecting interstates (commonly known as malfunction junctions) push up the number of vehicular injuries seen at The Med, many of which involve head traumas. "That's something we deal with on a daily basis," says Dr. Shelly Timmons, the center's chief of neurosurgery, whose department deals with more head injuries than any other trauma center in the nation.
Occasionally major pileups, sometimes involving 18-wheelers, send multiple victims to The Med, but more often the accidents occur one or two at a time. "And those can be horrible," says Timmons. "We see severe brain injuries, and damage to the spinal column that leaves patients paraplegic or quadriplegic. These people naturally have seriously problems; all sorts of things are affected." Treating such victims is enough to make trauma caregivers more conscious of their own driving habits. As one nurse puts it, "I used to speed, no doubt about it. But you see a few of these cases, the really bad ones, and getting home five minutes sooner doesn't seem so important."
If any other good comes from such tragedies, it's funding for research that could help the next victim. "We're one of only eight neurotrauma centers in the nation in a clinical trial network through the National Institutes of Health," says Timmons. "The goal is to advance our understanding of what can be done at all levels -- in the field, on the floor, in ICU, in rehab, after patients go home -- to improve their chances of recovery." Now in its third year, the NIH study will be published later this summer "to show what we've learned," Timmons adds.
Certain surgical interventions set the neurotrauma unit apart from others. It's among the top two centers in the U.S. that perform decompressive surgery when medicine can't control brain swelling. The procedure involves removing a piece of bone and opening a membrane over the brain, which allows the brain to swell outward rather than inward, then stitching up the scalp. "We've been more aggressive about this procedure in an era when people are throwing up their hands and saying, 'There's nothing we can do to help this 10-year-old child.' But there is," says Timmons. "People tend to think that while it might increase survival it can cause the patient to be vegetative. But that's not our experience. They do very well." She adds that individuals who have been in a coma in ICU for days will eventually walk into her office saying, "When can you put the bone back in my head?"
While 20-year-old Stevie Mooney didn't need the decompressive surgery, his brain is still healing as he lies in trauma ICU. His parents, Barry and Sherrie Mooney, who live in a small town southeast of Jackson, Tennessee, say their son was airlifted to The Med nearly two weeks ago after he was hurled from an all-terrain vehicle (ATV) and hit his head on a rock. He wasn't wearing a helmet. A probe in Stevie's brain constantly measures the air pressure.
"He's doing a lot better than they expected," says Sherrie. "He's still a little confused and we have to remind him of things. He hurt his spine and neck, so he can't use his right arm or leg real good. But he couldn't move them at all at first; we've been working with him."
"You can't give up," adds Barry.
As for whether he'll ride that ATV again, Sherrie says, "I doubt it. I would tell families that if the kids are gonna ride those things, they need to wear helmets." "You have to be present in the moment."
During their stay at the trauma center, one of Stevie Mooney's parents sleeps in their son's room each night, the other in the critical-care waiting area. It's a well-lit room, with 36 reclining chairs, and it becomes a second home to family members whose loved ones might be hospitalized indefinitely.
Among these is Becky Connelly, of Selmer, Tennessee, whose 83-year-old brother has been in the trauma ICU for more than two weeks. "He was trying to live in the old home place, having it painted and fixed up," says Connelly, "and a painter had just set up a ladder by the doorstep. It was a windy day and a gust blew the ladder on my brother and it knocked him to the ground. Broke his pelvis and caused other injuries." Tears fill her eyes as she continues her story. "He has a tube in his throat so he can't talk, but today he wrote me a note that said, 'My baby sister is here,' and he signed his name." Connelly's brother will likely be in traction for some time, so at night she stays with a relative who lives in Memphis and comes to the critical-care waiting room every day. "They've been wonderful here," she says. "Very compassionate."
Her praise is echoed by a Germantown resident who preferred not to give her name; her husband has been in trauma ICU since a car accident in February and his wife spends most days in the waiting room. "I can't say enough about how kind everyone is and how clean they keep the place," she says. "They provide us a place to shower, make coffee, and make sure we're being taken care of. And on Mondays and Fridays, we have a devotional with the chaplain."
Leading those devotionals is Reverend Walter Spears, The Med's pastoral care manager who oversees eight chaplains. At 39, he looks 10 years younger, but Spears brings to his job maturity, patience, and empathy. Sitting in a small conference room where chaplains first take family members after a trauma, Spears smiles and says, "I know about this room from personal experience." In 1998, his father-in-law was hauling a motor home when "it just blew up." He was flown to The Med and survived the accident, but Spears can relate to the agony of waiting for news and possibly hearing the worst.
"You have to be present in the moment with each person," he says, "and sometimes there's little we can do but sit still and listen." Beyond that, he's learned that every patient and family member brings his own baggage to a trauma scene. The hardest cases, he says, are those involving children from broken homes. "You've got a 16-year-old in an accident and a major decision must be made about his care. The parents can't agree and they've brought their painful history with them. Family strife -- it's tough."
During the twice-weekly devotional times with critical-care family members, Spears leads a service and lets them talk or pray if they like. Sometimes several relatives and friends will stay the first night after a trauma, especially if they come from out of town. "We try to narrow it down to two people from each family after the first couple of nights," says Spears. Or, for $30 a night, they can stay on the ICU floor of nearby Nora's Home, a private foundation that provides housing for relatives of patients.
To prepare himself for some of the worst cases, Spears often goes up to the helicopter landing pad and waits for the next incoming trauma. "The patient's not conscious, but I get as much information as I can from the staff, and being there, seeing that person brought in, helps me prepare for what's to come." "We've tried to cut that 'golden hour' to 20 minutes."
It's a Tuesday afternoon and Dr. Martin Croce knows he'll be on call in the trauma center that night. "You never know what to expect," he says. "In that way, trauma is a very inefficient business, like firefighting. Nothing may happen or all hell may break loose."
After 17 years, he's witnessed some devastating sights. Brain injuries, especially to children, hurt him the most. "Maybe because I have two boys. You want 'em?" he adds with a smile.
Even so, trauma never fails to challenge this 49-year-old University of Tennessee Medical School graduate and faculty member. "Every case is different," he says. "You have to think quickly and accumulate as much information as you can, then go with it." And though he praises the trauma team -- which involves a host of players from anesthesiologists to orderlies, X-ray technicians to lab personnel -- he's quick to add, "This is not a democracy. I tell the residents, we don't vote on things here." While one staffer describes the trauma team in action as a ballet, Croce laughs and says, "Sometimes it's more like a rugby scrummage. To do this you must have a certain amount of confidence not just in yourself, but in all the people you work with."
In trauma, caregivers refer to "the golden hour," a period during which appropriate treatment is crucial to give patients the best chance of survival. "Depending on the injuries," says Croce, "we've tried to cut that golden hour to 20 minutes."
Sometimes no amount of time can help a patient -- like the 37-year-old gunshot victim who was flown to The Med from a small town 50 miles away. He was working in his store, when a man came in demanding money. After the store owner turned to get cash from the safe, the assailant shot him in the back of the head. He literally blew the man's brains out. "The guy hardly had a chance," says Croce.
But happier outcomes -- some might call them miraculous -- make the tragedies a bit easier to bear. "Nothing short of a miracle."
Flo Larson will never forget that November night in 1998, when her 23-year-old daughter Frances-West Cook was driving in the pouring rain on an isolated Mississippi road. "Adults hardly use that road because they know if you had a flat tire or something, you'd be stuck out there alone," says Larson. "But kids think they're invincible."
As it turned out -- Larson calls it the first miracle of that whole experience -- a husband and wife were heading home on that road when they spotted a smashed-up vehicle in a cotton field and called the sheriff. When a deputy contacted Larson, asking what kind of car her daughter drove, Larson says, "I knew it was bad if they couldn't even tell that. That car was so crinkled it looked like tissue paper."
Frances-West, who wasn't wearing a seatbelt, had lost control of her car in the torrential rain. When EMTs arrived, she wasn't breathing and had no pulse. She was rushed to the emergency room in Clarksdale, where a doctor broke the news to her mother: "It looks bad, Flo. I don't think she'll make it."
Larson had never heard of The Med or the services it offered North Mississippians, but within minutes, her only child was being flown there. A chaplain met Larson on arrival: "That little lady took my hand and stayed right with me through the night." The grateful mother watched the trauma team surrounding Frances-West, whose multiple injuries included a crushed left arm, a broken femur, a lacerated liver, and a collapsed lung. "They worked on both sides of her body at one time because they didn't want to put her to sleep for too long," says Larson. Surgeons repaired her arm with a metal plate containing 25 screws; they slid a rod into her femur.
By far the young woman's most serious injury was a brain-stem contusion, which plunged her into a deep coma. On a 1 to 15 coma scale used by neurosurgeons, her brain registered 3. Larson recalls being told that most patients who register 4 or below die within a short time. In 1998, Frances West-Cook suffered multiple injuries from a car crash and was flown to The Med's trauma center. Her experience there prompted her mother, Flo Larson, to help change legislation and raise money for the fiscally strapped hospital.
During the next few weeks, the agonized parent recalls many kindnesses shown to Frances-West by trauma center caregivers. Perhaps the most poignant occurred two days before Christmas. Larson had just come back into the room to find that a nurse had bathed her daughter, rubbed her with baby powder, and washed and combed her hair. Weeping, she was able to choke out the words, "You washed her hair!" The nurse replied, "I have a daughter too."
Eventually, Frances-West was transferred to another hospital and Larson spent most every waking minute with her. "People probably thought, 'This woman is either crazy or in denial,'" she says. "But I stayed right with her."
In March, something happened that Dr. Shelly Timmons called "nothing short of a miracle." Frances-West began to emerge from her four-month coma. A few weeks later, Larson kept a promise she'd made on Christmas Eve to herself, her daughter, and The Med's caregivers. "I pushed her in the wheelchair to the trauma center entryway, pulled her up and got her to her feet, and with her leaning on me, I said, 'Come on, baby, we're gonna walk through those doors.'"
Over the last eight years, Frances-West has had 16 surgeries. Recurring balance and speech problems haven't stopped her from marrying and having a 3-year-old child. During that time, her mother has been an outspoken advocate for The Med and its life-saving services. While Jackson, Mississippi, has a trauma center, it's located too far away for those who live in the northern part of the state, near Memphis. Thus for years, The Med has been spending millions on North Mississippi trauma patients, with minimal reimbursement. Thanks to impassioned lobbying by Larson, The Med is now the only out-of-state hospital that can apply for trauma funds from the Mississippi legislature. Last year it received about $7 million.
Larson also pushed to create and sell special Mississippi car tags; $24 of the annual cost benefits The Med.
"There's no way I can fully explain how I feel about that place and the staff," she says. "I love them for being there for people who don't even know what it does. I often say that at 12:42 a.m. my daughter didn't need the Elvis Presley Trauma Center. At 12:48 she couldn't live without it."
The Trauma Center: At a Glance
-- Opened in 1983, under the leadership of medical director Dr. Tim Fabian.
-- Sees patients within a 150-to 200-mile radius of Memphis, which covers parts of five states: Tennessee, Mississippi, Arkansas, Missouri, and Kentucky.
-- Is one of the top five busiest centers in the nation, along with those in Baltimore, Dallas, Los Angeles, and Miami.
-- Sees more head trauma patients than any other trauma center in the U.S.
-- Tennessee also has trauma centers in Nashville, Chattanooga, and Knoxville.
-- Number of trauma center employees at The Med : 253
-- Shock trauma patients (level 1, with most severe injuries) seen in 2005: 4,016 Five most common "injury mechanisms": Patients treated
Vehicle collisions 1,416*
Gunshot wounds 576
Stabs (penetrating) 194
* Includes 257 motorcycle and ATV collisions
-- Patients seen last year in the trauma center's critical-care assessment (level 2): 11,508
-- Patients sent last year to trauma center's intensive-care unit: 821