Crushed organs, shattered limbs — a look at how NUH trauma centre's frontliners save lives and the miracles that happen

SINGAPORE — After a suicidal young man leapt from a height of around 10 storeys, he was found with multiple fractures, pelvic injuries, severe muscle damage and was rapidly losing blood.

Yet, against the odds, he lived — thanks to the extraordinary efforts of a trauma care team.

From arresting the bleeding in his abdominal cavity to surgically removing a massive blood clot, many healthcare workers with various specialised medical skills came together to coordinate a series of life-saving interventions.

Dr Jonathan Lim, a consultant with the department of anaesthesia at National University Hospital (NUH), recounted this unforgettable case from four to five years ago, describing the patient’s survival as “a miracle”.

Dr Lim is an anaesthesiologist by training who also specialises in intensive care.

“He survived and he went out of the intensive care unit (ICU),” Dr Lim said, adding that the patient was also referred to receive psycho-social care as part of his recovery.

“I looked at the medical notes (when he arrived) and thought this was impossible, but he was still alive. He was still conscious, but his body was broken.”

Recalling the exceptional lengths that the team went to in saving the young man's life, he said: “It was a miracle he survived the first injury and all the subsequent complications, which would have been lethal.”

SEVERE TRAUMA CASES SEEN AT NUH

This particular case above is one of the 1,300 severe and critical trauma cases that NUH handles on average a year.

Of these, some 140 are industrial accidents and 70 involve children and teenagers.

For Dr Lim and his colleagues with the trauma care team, such harrowing scenes are part of their everyday work — salvaging crushed organs and shattered limbs, bringing patients back from the brink of death.

A multi-disciplinary and holistic team effort is essential when managing severe trauma and multiple injuries.

This is because such cases require complex and quick-thinking decisions from various medical professionals.

Extra support in the form of rehabilitative and psycho-social care is also important.

This is because these patients may have temporary or permanent disabilities that leave them in shock and will have a significant impact on their everyday life, as well as their emotional and mental health.

On July 4, NUH took a step forward in providing holistic trauma care for adults and children with severe or life-threatening injuries with the launch of the National University Centre for Trauma.

At an emergency department, patients are treated for a broad range of conditions such as breathing difficulties, fainting, heart attack or stroke.

At a trauma centre, patients have more critical or life-threatening conditions usually because they were seriously injured from a traffic accident, a fire, a fall from height or were stabbed, for example.

With its enhanced direction, the centre at NUH will strengthen outreach efforts to improve safety awareness and injury prevention by prioritising children, older adults and migrant workers.

It has identified these groups to be particularly susceptible to trauma incidents due to vulnerabilities unique to them.

For example, children are prone to accidents, older adults are at higher risk of falls and aged-related injuries, and the physical demands of migrant workers’ jobs increase their risk of being hurt in accidents.

Data presented in the Workplace Safety and Health Report 2023 showed that sectors such as construction, manufacturing, transportation and storage contributed to 60 per cent of fatal and major injuries last year.

In recent months, the centre has hosted talks and workshops on injury prevention for these groups:

• It recently conducted sessions for seniors on how to prevent falls, since falls accounted for 85 per cent of trauma cases involving older patients seen at the hospital's emergency department
• In July, the team spoke on injury prevention to around 800 students at Fairfield Methodist Primary School, telling students what to watch for when using escalators without getting their feet stuck, for instance
• In June, its personnel imparted vital first-aid techniques to migrant workers who took part in an outreach event

As for patients at the centre who suffer from severe physical trauma, Dr Lim said that many cases are typically due to fall from height and road traffic accidents.

“Based on the case load that we see in ICU, most of them are motorcyclists and quite a number of them were drunk,” he added.

The National University Health System (NUHS), which covers public health institutions in the western region of Singapore, collectively attended to a total of 406 road traffic accident cases in 2022 and 461 in 2023.

THE ‘GOLDEN HOUR’ BETWEEN LIFE AND DEATH

When managing critical trauma cases, time is of the essence.

The first one to two hours after a traumatic injury or event has occurred is known as the “golden hour”.

During this time, resuscitating and stabilising the patient are the top priorities.

Dr Lim said of the main principle they go by: “In the immediate aftermath of the trauma, we do not go in for a definitive, long surgery to correct every single thing that's gone wrong.

“In that acute first one to two hours of trauma, we need to go in to arrest the haemorrhages (the bleeding) and save certain organ systems.

“Say, for example, there's an acute brain injury, we’ll need to relieve pressure in the brain.

“If there are certain bleeding disorders that developed during the trauma, we have to correct that through transmission of various blood products,” he added.

Since minutes may mean a difference between life and death for trauma patients, the National University Centre for Trauma has also introduced what it calls “code trauma”.

In essence, it is a code of action for how various parties should respond and what the workflow should be when a patient arrives with severe or life-threatening injuries.

It aims to streamline the duration from the moment the patient arrives at the emergency department to when the patient gets into the operating theatre.

So when this code is activated, the action begins even before a patient arrives, based on information provided by its paramedics and the Singapore Civil Defence Force.

A team of medical professionals is mobilised — including emergency physicians, nurses, trauma surgeons, anaesthesiologists and intensive-care physicians — to accelerate decision-making and prepare the resources needed such as advanced imaging and a hybrid operating room.

The code ensures that everything is ready for immediate action, from rapid blood transfusions to intensive care support.  

BONE INJURIES, PELVIC FRACTURES CAN BE FATAL

Bone injuries can be life-threatening.

For orthopaedic surgeons such as Dr Nazrul Nashi, the tough work lies in managing not only the broken bones, but also the severe complications that may accompany these injuries.

A pelvic fracture or injury is an example of a potentially fatal injury.

Dr Nazrul is a consultant with the division of orthopaedic trauma surgery at NUH’s department of orthopaedic surgery.

He said: “In such injuries, there's a potential loss of blood and can compromise circulation. If we do not intervene early, there's a risk of death,”

Another critical concern arises with open fractures, where broken bones penetrate through soft tissue and skin.

“There's a higher risk of infection and a risk of the patient losing their limb as well,” Dr Nazrul explained.

In severe trauma cases involving crushed limbs and broken bones, orthopaedic surgeons usually perform “damage control surgery” after the patient is stabilised, he said.

“During the golden hour of trauma, to stabilise the patient first, we work together with the emergency physicians and intensivist (a physician who specialises in treating patients under intensive care).

“If the patient is not stable enough for prolonged surgery, we perform what is termed ‘damage control surgery’.

“This usually involves the use of external fixators, which are pins inserted into the bones to stabilise them, in order to reduce bleeding and discomfort,” Dr Nazrul added.

Once the patient’s condition stabilises, he or she is either moved to ICU, a high dependency or general ward. Only then do the surgeons plan for more definitive surgical interventions.

EVERY SECOND COUNTS

In the fast-paced environment of trauma care, the role of nurses is indispensable.

Ms Caroline Lim, a nurse manager at the department of operating theatre, has to be able to think on her toes and keep a cool head when critical patients arrive.

As a nurse manager, one of her key responsibilities is preparing the operating theatre the moment a trauma patient is on the way — and “this can be in a matter of a few minutes within receiving an activation”, she said.

Ms Lim and the nursing team swiftly coordinate with the medical team to understand the procedures that will be required.

In a matter of minutes, the team must also gather everything required for the surgery, organising the necessary equipment and instruments.

This communication and fast turnaround are crucial, because every second counts when dealing with life-threatening injuries.

When a trauma case requires a multi-disciplinary approach, such as the involvement of a few surgeons from different departments, Ms Lim steps in to coordinate and assigns specific roles to the nursing staff members, ensuring that everyone works together seamlessly.

WHEN PATIENTS' FAMILIES FEEL HELPLESS 

After the fast-paced life-saving work is done and the patient stabilises, physiotherapy comes in next as an essential part of multi-disciplinary trauma care.

As early as a day after admission, physiotherapists such as Ms Kwan Peijun may begin their work in this area.

Ms Kwan is a senior principal physiotherapist with the department of rehabilitation at NUH.

Contrary to the common misconception that physiotherapists’ roles are limited to sports injuries, Ms Kwan has attended to patients with severe trauma injuries, who are still in ICU and hooked up to life-sustaining tubes and machines.

“In ICU, we do respiratory care for patients who could be having lung contusions.”

Through specific techniques, they help to clear secretions and optimise lung function.

Ms Kwan said of the shift in the field of rehabilitation: “In the past, we used to come in at the tail-end of a patient’s recovery. But now, we start earlier and caregivers tend to see the benefits of intervening early.

“There are also fewer complications from prolonged bed rest.”

Ms Kwan’s work also includes empowering patients’ family to care for their loved ones, at a time when they may feel that the situation seems dire and helpless.

This may be guiding a caregiver or a family member to perform passive range-of-motion exercises such as bending and straightening a patient’s knee, or bending and straightening the patient’s fingers to maintain joint flexibility.

“I think that it gives them some autonomy and control of the situation, where they feel that they can still do something for their loved ones,” she said.

As the patient’s condition improves, physiotherapists continue to work to get the patient up and moving.

The goal is to help the patient regain normal function and mobility, such as sitting on a chair, standing, walking and eventually getting back to the community, Ms Kwan added.

WHEN A PATIENT DIES

Despite pouring all of their efforts into saving a life and working tirelessly for hours on end, sometimes not every trauma case has a happy ending.

Facing death, like saving lives, is also part of what the team experiences.

Reflecting on his time working in ICU, Dr Lim said: “We don’t always win. We know what we want for the patients, we always hope for a good outcome but it doesn’t always happen.”

These moments can be difficult for the trauma team, whether they are the younger or more experienced members.

He also said that the weight of losing a patient can “wither down resolve and morale”.

“I tell my juniors, friends and colleagues that we're not God, but we're just instruments of God. Each of us is blessed here with a certain vocation. We bring our niche to the table.

"Every time we see a trauma patient, we do our best, put our heads and minds together, put our skills together, but sometimes it's not good enough.”

The emotional toll does not end with the loss itself. Delivering the bad news to the grieving family is another heartrending task.

“Sometimes it's a double whammy for the team and staff involved,” Dr Lim added. Yet, even in these moments, the team carries on, knowing that the next patient they see will need them. 

WHY THEY ARE THERE AT 3AM WHEN DUTY CALLS

When asked what keeps them going at work, the team members said that they are unified by a common purpose. “We are all in this profession to make a difference,” Dr Nazrul said.

“We see value in helping our patients, to ensure that they have a successful surgery and recovery, to see them return to their normal function and their loved ones — those are the key things that drive us.

“It’s why we go back at 2am, 3am to treat the patients because providing the best care, especially in the critical first hours after an injury or trauma, can give a better outcome. Knowing that is what drives us.”

For Ms Kwan, seeing her patients on the right track to recovery is always heartening. 

“I always tell my patients that I would like to be a giver of hope to them and their families, helping them get them back to what they want to do eventually.”

Simple moments, such as seeing an ICU patient moving around in the wheelchair, keep her motivated.

Recalling a traffic accident case that left a child with multiple fractures, Ms Kwan was deeply moved when, during a physiotherapy session, the child sat up and finally gave her mother a hug for the first time in weeks since the accident.

“I have kids and that resonated with me. The mum said ‘thank you’ to me — just two words but they spoke volumes of her gratitude. Like Dr Nazrul said, this is what keeps us going,” she said.

“Of course, we have our down days, but we will always get back up because we know there are people out there who continue to need our services, skills and expertise.”

ADVICE TO ELDERS, ROAD USERS ON STAYING SAFE

Having encountered all types of trauma cases, the team emphasised that many of the cases are preventable through vigilance, responsible behaviour and proactive measures.

Ms Lim the nurse manager stressed the importance of being vigilant and aware of one’s surroundings because accidents can happen even in familiar settings.

“Even at home, you may be so familiar with where your sofa, dining table is, but you can just trip over a chair, fall and have a head injury. So I think vigilance is so important.”

Dr Nazrul agreed, adding that prevention measures for falls are important, especially for older adults.

Simple ways to reduce the risk of injuries at home include making sure that the floors are free of clutter, cables, loose towels or mats that could cause someone to trip or slip, and ensuring that there is sufficient lighting for trips to the bathroom at night.

“In the home environment, family members have a key role in preventing such injuries. For the elders, we have to be cognisant about their eyesight and balance problems and making sure that there's no clutter at home,” he said.

Seniors who sustain simple falls that can have life-changing repercussions.

Dr Nazrul said of the older patients seen at the trauma centre: “These are frail patients and they often present with hip fractures, which are among the most common fragility fractures."

This is because of the underlying health problem of osteoporosis, a disease that causes the bones to become weaker and easily broken.

“Our centre tracks these older patients as well, ensuring early intervention for those who are fit for surgery so as to provide them with the best outcome,” he added.

For motorists, Dr Lim emphasised that reckless driving and drink-driving are “not worth it”, and cautioned against the impulse to gamble with safety while on the road.

“The road is a very dangerous space. Recklessness during driving — somebody pays for it, if not yourself.

“A moment of recklessness can result in months of rehabilitation, so it's really not worth it,” he said.

“That little bit of effort, or that 10 seconds to slow down your pace could make a big difference. You don't have to spend the next 10 years with an injury.”