(++++) CARE NO ONE WANTS, ANYONE MAY NEED

All Bleeding Stops: Life and Death in the Trauma Unit. By Stephen M. Cohn, M.D. Mayo Clinic Press. $26.99.

     All the basics dictated by modern medical care – informed consent, a carefully assembled history, lists of medications and supplements taken, existing and prior medical conditions, extent of insurance coverage and clearance, family involvement, power of attorney for healthcare decisions – go out the window when someone suffers massive, life-threatening trauma. When that happens, it falls to surgeons such as Stephen M. Cohn to deal with the emergency without many of the appurtenances of contemporary medical expectations and requirements. It is, quite literally, a do-or-die situation.

     This has been Cohn’s life for four decades, both in military service and in civilian trauma centers – and it is the life he explains and explores in All Bleeding Stops. It is essentially a surgical life centered on extremes: emergency-room doctors manage emergencies of all sorts, but trauma surgeons take on the cases when injuries are very severe, when operations must be done quickly, when intensive-care patients are desperately ill and need special care, and when surgeries being done by other doctors suddenly result in life-threatening complications such as massive uncontrolled bleeding.

     To say this is exceptionally difficult medicine is an understatement. “We are on call (and responding to general surgical emergencies and trauma cases) and may remain at the hospital, working for twenty-four to thirty-six hours,” writes Cohn. “We often work without sleep but are required to function at the highest level.” Many doctors who practice in hospitals face grueling schedules, but just about every case handled by a trauma surgeon involves a patient on the verge of death – which produces a stress level that doctors such as Cohn must find ways to master, in part by not dwelling on the cases that do not go well, in which the patient does die. Evaluations of failure are constant and rigorous and “can be brutal on both the resident and the staff,” but are necessary to find weaknesses in the trauma-treatment system and to try to save future patients’ lives: “Surgeons must dispassionately learn from judgment errors” and not “be paralyzed by the fear of making another error.”

     All Bleeding Stops includes its share of deaths – inevitably – as well as its share of success stories. It takes readers on a harrowing journey through what is really a team effort – no surgeon operates alone – and through a wide variety of forms of trauma. “Most of the trauma cases seen at some 450 trauma centers in the United States are blunt injuries sustained in falls, vehicle crashes, or workplace mishaps,” Cohn explains, but when it comes to knowing what the specific injuries of a specific patient are, “the answer is, we have no idea.” Again and again, Cohn gives examples of real-world cases that had to be very quickly and coolly diagnosed and managed to keep patients alive.

     Also again and again, Cohn explains the exasperations of trauma work, which in part involves persuading people to do things that prevent them from landing at trauma centers in the first place: “The tidal wave of trauma cases can be frustrating to the trauma care team” because while some forms of injury prevention are now widely accepted and employed – such as the use of seat belts and helmets – “we have failed in reducing other common causes of injury such as drunk driving and gun violence.”

     It is in his vexation with some of those continuing sources of traumatic injury that Cohn can be most forceful and, at the same time, least effective in the prescriptive elements of his book. It is completely understandable that he is angry about drunk driving and gun violence, and he has far more everyday experience with both than most people (thankfully) will ever have. He also has plenty of statistics to back up his concerns: “The worst mechanism of injury in the civilian world is being struck by a vehicle as a pedestrian. …Fifteen percent of pedestrians struck by a car will die, and the death rate is over 30 percent for older people.” And he is aware of the unrealistic notion of solving problems by throwing money at them: “One of the problems with injury prevention programs is they often require financial support from grants, so when the grant is completed and the money’s gone, the program is over. Other programs depend on local taxes.” Despite all this, his understandable level of upset involving matters such as gun violence bubbles over without really adding any new ideas to a matter of very significant societal as well as medical importance.

     Other highly personal elements of All Bleeding Stops are much more effective, such as Cohn’s own instance of being bitten by a black widow spider: “their bites, from personal experience, hurt like the devil.” And Cohn’s discussions of forms of treatment of which most people are unaware is also exceptional, as when he explains the use of maggots (fly larvae) “to treat complicated chronic wounds…for which operative debridement would be treacherous, like when dead tissue is overlying an important ligament or nerve.” His insights into the way trauma surgeons expand their knowledge base are fascinating as well: “The ME [medical examiner] provides us with not only the cause of death but also the number of trauma deaths that never make it to the hospital, which is about 50 percent of all trauma-related deaths.”

     Taken as a whole, Cohn’s book proffers tremendous insight into trauma surgery – and emergency medicine as a whole – in ways both expected and unexpected. One of his most remarkable comments has to do with celebrities: “While the rich and famous pay for top treatment and spare no expense, they often get worse rather than better hospital care. One of the problems is that other physicians (typically specialists), who may or may not be competent, show up and try to direct care. …Every physician becomes an expert in your condition if you are a VIP. …So those that actually know what they are doing can be largely ignored.” What no reader of All Bleeding Stops will be able to ignore is the depth of knowledge Cohn has amassed over his decades of practice, and the depth of commitment to patients that he has clearly shown again and again when he has dealt with people in extremis and, often against the odds of survival, preserved their lives.