University of Vermont

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ER Answers

Emergency room

Helen White, a 23-year-old skateboarder grits her teeth and lets out a deep groan. Her knuckles look like hamburger meat. She has black flakes of blood on her lower lip and around her nose, a curving laceration across her forehead and two glistening holes in her knee.

A white-and-orange cervical collar holds White’s head still, but her eyes move back and forth as two EMTs in green jumpsuits wheel her into a room on the main floor of the Emergency Department of Fletcher Allen Health Care.

Kalev Freeman leans over the stretcher to look White in the eye. “I’m Doctor Freeman. You’re going to be OK,” he says very gently, as a team of nurses and technicians pull up trays of supplies. “We’ll get you feeling better here.”

Freeman turns to one of the nurses, Sheena Fisher, who is adjusting an IV line. “Let’s do a hundred of fentanyl,” he tells her and then turns back to his patient. “We’re getting you some medicine to help with your pain.”

The EMTs report that White collided with a streetlight and fell, face-first, over a small concrete wall in downtown Winooski. No helmet. (“Helen White” is not this patient’s real name and some details of her case have been changed to protect her privacy.) “Where are you hurting, my friend?” Freeman asks.

“My head hurts so bad,” White tells him, groaning again, and her eyes drift up to a monitor overhead, beeping out a record of her breaths and beating heart. “I’m looking to see what needs stitches,” he says, peering closely at his patient’s forehead. But Freeman is more concerned about what he can’t see, about what might be happening inside White’s skull.

“Are you able to sit still for a few pictures?” he asks. “We’re going to take some pictures of your head and then we’ll get you stitched up.” White grunts and gets whisked down the hall for a CAT scan.

Just outside the exam room, Chelsea Manning ’12 has been waiting quietly. She’s holding a tube for collecting blood. Freeman steps out to talk with her. “We are going to draw blood from her for the study,” Freeman tells Manning. “We’ll enroll her. I think she’s going to get admitted. Head bleeding? Could be. I’m guessing she broke some of the bones in her face. She’s pretty crunched.”

Trauma, almost by definition, is disorderly and unpredictable. A blinding rush of headlights. A leg blown off at the finish line of the Boston Marathon. A sudden rending of our gossamer plans by an intrusive, searing snap. “This is why we haven’t figured out the answers to many trauma questions, because it is so challenging to study; you can’t plan for it,” Freeman says. “These are people in the worst of circumstances, in the middle of the night, and we have to work fast: it’s very hard to get this data. It’s simply a feasibility challenge. An emergency room is a very difficult environment to do robust scientific research.”

Freeman has crafted a way to meet this challenge through the aid of a team of bright, pre-med inclined UVM undergraduates eager for the opportunity to experience both medical research and the realities of the ER. His research on trauma — particularly traumatic brain injury and blood clotting — depends on the 24-hours-a-day, 7-days-a-week efforts of undergraduate students (and a few recent graduates, like Manning) enrolled in two courses he founded: Surgery 200 and 201. Since 2008, he’s had hundreds of students — in four-hour shifts as the required lab for the courses — working alongside him and other doctors in the emergency room, screening and enrolling patients for clinical studies. “They’ll be here at 3 a.m. on a holiday weekend,” he says.

One could be forgiven for imagining Kalev Freeman saying, “I’m only a real doctor; I don’t play one on TV.” His blue eyes, athletic chin, and Gen-X tattoos, barely visible beneath a short-sleeved shirt, might make the cut in Hollywood. And after hearing his slightly goofy, guffawing laugh, one could see how he considered a different career as a bluegrass fiddler. But spend more time with the man and it becomes clear that here is someone with remarkable drive and sense of mission.

When Freeman arrived in Vermont in 2007, he approached Dr. Steve Leffler, who heads UVM’s Division of Emergency Medicine and is now the chief medical officer for Fletcher Allen. “I knew that there was a very strong clinical program in emergency medicine but almost no research arm,” Freeman recalls. “My first love is science, and I told Steve I thought I could set-up a trauma research program with a shoestring budget.” Leffler wanted to know how. Modeled on a program at the University of Pennsylvania, Freeman told him, “My plan is to build an infrastructure using undergrad students as a team.”

Unlike most medical schools and Level 1 trauma centers, UVM and Fletcher Allen are surrounded by undergraduate students, with many pre-med and science majors eager to get experience in the hospital. Several UVM dorms literally look out on ambulances arriving at the emergency department. “We have this unique pair of institutions in Vermont where we have undergrads right around us. Let’s tap in to this motivated young workforce and have them help us,” Freeman told Leffler, who helped him get started. So far, the students have gathered data for some two dozen studies, both for Freeman and for other researchers across the medical school.

Every 23 seconds someone in the United States sustains a traumatic brain injury, the CDC reports — about 1.7 million people each year, resulting in 52,000 deaths. Many of these deaths come hours, days, or weeks after the initial trauma and are often triggered by failure of other body systems outside the brain. “There is a fundamental knowledge gap in our understanding of the long-term impact of acute brain injury on systemic endothelial (the inner lining of blood vessels) function,” Freeman writes. In other words, when a car crash victim with a head injury dies of a heart attack a week later, it may be because “the cardiac tissue was damaged by brain trauma. All the blood vessels are affected by the stress of a brain injury,” Freeman says.

And similarly for uncontrolled bleeding, one of the major causes of mortality in trauma. Of U.S. soldiers injured by combat, most of them — 88.9 percent according to the U.S. Army Institute of Surgical Research — die on the battlefield. But of those combat injuries that were “potentially survivable,” Freeman says, more than 90 percent of soldiers who die simply bleed to death. For some reason, many severely wounded people can’t form blood clots — and Freeman would like to know why.

“You’d think we could just give these patients blood transfusions. No one should ever die from bleeding, because we can give them blood!” Freeman says. “But they just can’t make a blood clot.” There are several theories about why this happens: massive infusions of red blood cells and plasma change the biochemistry of the blood’s natural clotting mechanisms. Saline infusions dilute blood proteins. Dropping body temperature and build-up of acid may contribute. Genes matter. Freeman would like to show how dysfunction of the endothelium is also a culprit.

“We’ve already figured out most of the possible surgical procedures for trauma, but sometimes you stitch up all the holes and they’re still bleeding out and there’s not much you can do about it,” he says. “What is there after mechanical surgery?” Freeman asks. His answer: “Better biochemistry.”

“If we can understand what is going on with blood vessels after trauma,” Freeman says, “then we can target therapies to help protect them and thereby benefit blood clotting capabilities and prevent brain swelling.”

That’s why, just before midnight, Chelsea Manning is still waiting outside of Helen White’s examination room. The patient has returned from her CAT scan, and Manning is hoping that a technician will soon return her vial, filled with White’s blood. If White gets admitted to the hospital overnight, she’ll qualify for one of the trauma studies Freeman is helping to lead, with a team of other researchers and universities, on the biochemistry of blood clotting. Manning’s job as one of Freeman’s student “chiefs,” — having completed his two surgery courses and now working for him before applying to medical school — is to take the blood from the technician and go to a tiny lab just off the trauma bay in the ER. There, she’ll prepare it for study, to see how fast and firm it clots.

For Ashley Deeb ’14 joining Freeman’s course became a way of joining a community. She had been volunteering on her own in the hospital — “I was just restocking supplies, which was fine — I was helping out — but I really didn’t talk to anyone,” she recalls. Then she heard about Freeman’s class. Two semesters later, she’s talked to dozens of patients, nurses and doctors, enrolled volunteers to be part of studies, and helped to orient new students in Surgery 200.

“If you watch ‘Grey’s Anatomy,’ you think all these crazy cases come in all the time,” Chelsea Manning says, with a rueful laugh. “But doing this work gives you a realistic impression of what actually goes on in the ER.” In other words, there’s a fairly large dollop of tedium and tension. But this grounding is exactly what both Deeb and Manning came to find. And for both of them, like many of the students who work with Freeman in the hospital or his lab, it confirms that, “we really want to go into medicine,” Manning says.

While Chelsea Manning waits, Kalev Freeman and a medical student sit in the blue gloom of an image viewing room, looking at glowing scans of Helen White’s head and spine. “The big risk for her is bleeding. She’s gotten facial trauma, so I’m looking to see if she’s got any blood inside the skull,” he says, as he scours the ghostly gray images for telltale bright-white patches behind the eye sockets or between bone and brain. “You can see she broke her nose here,” he says pointing to an unhappy-looking angle in the picture. “But I don’t see any threatening bleed in the skull,” he says. “That’s good.”

As the clock on the emergency room wall approaches 1 a.m., things are, indeed, looking good for Helen White. Her injuries hurt, but they’re not too serious and her head seems fine. Some stitches, wound scrubbing, pain medications — and she’ll be heading home.  “We got the first blood sample, which we can use in the comparison group,” Freeman says to Manning. But because the patient is being discharged, she can’t be in the main trauma study. And in that, Helen White, lacerated, sutured and sore, could count herself fortunate.

“I work in the lab all week,” Kalev Freeman says. “Then I go work a shift in the ER and see someone on Friday night, someone in a car accident, with the same injury that we’re modeling and studying. That brings it home. It reminds me why we’re doing the research.”