Ten p.m. at Ryder Trauma Center in Miami: A gunshot victim in his late twenties has just been cut open from sternum to groin, exposing glistening organs that quiver and pulse. The attending physician, Fahim Habib, and two surgeons in training—a fellow and a resident—are using powerful retractors to pry apart the giant incision. Then four, five, even six hands at a time reach in and begin probing for the source of the bleeding. Soon the man’s gut is piled on top of his body like a mound of spaghetti. Working side by side, the fellow and the resident begin gently unraveling the intestine, inspecting it for damage a foot at a time. “Clear!” they call out again and again. Thirty-one feet later, they get to the large intestine, and finally, the bladder. A small incision is made in the organ. Instantly it begins disgorging blood. Habib plunges a finger deep inside it and feels around. The gushing, he determines, is coming from the neck of the bladder. A plan is hatched to stanch the bleeding, and three hours later, the operation ends successfully. Habib’s work, however, has just begun. Before the night is over, he will go on to treat another gunshot victim as well as four people battered in car crashes.
Founded in 1992, Ryder is one of the country’s oldest and busiest critical care facilities; about 4,000 people come through its doors each year. But Ryder physicians do far more than local emergency trauma care. They train all Army forward surgical teams for deployment in Iraq and Afghanistan. They are developing better methods of triage and making improvements in surgical techniques. The center has even been a prime mover—through its extensive exposure to auto injuries—in enhancing automobile safety and expediting treatment of crash victims. It is also a pioneer in the development of trauma telemedicine, the pairing of robots and advanced telecommunications technology to extend the expertise of its specialists around the globe. Small wonder the institution is viewed as a trendsetter and a paragon of care in the field.
Located at the University of Miami/Jackson Memorial Medical Center, Ryder is one of only three freestanding facilities in the United States designed from the ground up as a trauma center, making it a model of streamlined efficiency. Housed within the structure is everything needed to do the job: resuscitation bays, operating rooms, CT scanners, an intensive care unit, a burn unit, and a rehabilitation department. On the building’s roof is a helipad (40 percent of its patients come by air). Ryder owes much of its success to the fact that Florida was among the first states to have a coordinated 911 system and was at the forefront of setting up regionalized networks for transporting patients quickly to hospitals with the equipment and expertise to treat their injuries. Florida invested heavily in both Ryder and in a community-based system of care—and it paid rich dividends. Trauma is the leading killer of people aged 1 to 44, and Florida’s system has reduced preventable deaths from serious injury by half. Many other states have not made the same commitment (see page 65). In large swaths of the country, trauma care is quite literally in need of emergency resuscitation.
A man with an arrow in his head, a baby with a crushed skull, a teen with a knife plunged so deep in his belly only the handle is visible. A relentless onslaught of catastrophic injuries comes through Ryder, making it an ideal training ground for doctors preparing for both civilian medicine and the battlefield. In addition to having one of the largest fellowship programs in the country, Ryder is responsible for instructing military surgical teams made up of doctors, nurse-anesthetists, nurses, and technicians—20 people in each unit—before deployment overseas. Many team members have seen little in the way of severe injury beforehand, and it is the job of Lieutenant Colonel Donald Robinson to bring them up to speed in just two weeks. To that end, he relies heavily on a $200,000 mannequin that looks and behaves remarkably like a real patient. It breathes, urinates, oozes blood, and even cries out in pain. A microphone is embedded in its head, and Robinson himself provides some of the sound effects. “I groan, swear, and scream out things like ‘Get away from me!’?” he says. During training, the teams practice resuscitating the high-tech dummy, which can be programmed to mimic any number of dire casualties—for example, it may go into cardiac arrest or need a limb amputated. Thanks to these mock trials, Robinson says, the teams can rapidly progress to the core part of their training: assisting in the treatment of real patients.
Just as important as its teaching mission, Ryder invests huge resources in finding better methods of caring for trauma patients. A big concern, for example, is triage. As many as 40 percent of injured people flown in or rushed by ambulance to Ryder are discharged the same day they arrive. That’s a clear indicator they never needed to be there in the first place. Conversely, others appear unscathed after an accident—and may even decline treatment, only to deteriorate rapidly 20 minutes later from an unsuspected internal injury.
