He learned later that he had incurred some of his injuries after the collision by hurtling into objects inside his own car. He broke his right hand, probably against the gearshift on the floor. And he lost four teeth, perhaps after he pitched forward into the rearview mirror, although a dentist told him later that he may have destroyed the teeth by involuntarily clenching his jaw at the moment of impact. He doesn't know how he fractured several bones in his pelvic area. But it's likely that the impact of the other car on the driver-side door inflicted the worst injuries, to his chest. He had a dozen broken bones on his left side. Both of his lungs collapsed. Rescue personnel had to cut through the roof to reach him, and to shear off the steering column to pull him out.

Roth manages a bookstore, called New Jersey Books, in Newark. And in those few seconds of painful consciousness - unable to catch his breath - his mind recreated desolate scenes from books he had read. He was in a dark cave described by the philosopher Plato. He was alone in an existentialist novel where life is a void and "nothing exists except you and your thoughts." That's all he remembers until he got to the hospital.

Most Americans forget or ignore the danger trauma poses for them. At a comfortable distance from the pain, they watch shows like ER and Chicago Hope. The TV patients are often mere extras, often faceless. "The perception is that trauma always happens to someone else," says David Livingston, MD, director of the New Jersey Trauma Center at UMDNJ-University Hospital. "Americans think that the patient is some inner-city gang member who gets shot. It's not your daughter on prom night." It's certainly not you, not in your car on a short trip, perhaps to visit a relative.

In real life, though, the patients are people like Allen Roth, the amiable man who sells books and lives with his wife in West Orange. An articulate man who likes reading nonfiction about Asia, and hopes someday to write a book whose hero will be a foreign correspondent. A devoted son who was on his way to visit his mom a half hour away in Hawthorne that day when the crash knocked him out and deleted the memory of the worst moment of his life.

It's time that all of us woke up and paid heed to the peril of violent injury. More than 6 million Americans a year are rushed to hospitals with wounds that often make them look like battleground casualties. More than 100,000 die annually - one death every six minutes, more of us every year than all the Americans killed during the nine years of the Vietnam war. The numbers mean that trauma is the leading cause of death for people between the ages of 1 and 44. Shootings aren't the major problem. Like Roth, many of the patients are battered in car crashes. He arrived at University Hospital at about 11 am, barely conscious of the half dozen people on the trauma team who went to work to try to save his life. "They were poking me and asking, 'Do you feel that? Do you feel that?' - to make sure I wasn't paralyzed." Luckily for Roth, he wasn't. Equally fortunate, he had arrived at a "Level I" trauma center where the initial assessment of his condition went far beyond the prodding Roth could feel.

The Level I designation means the center carries certification - reviewed every three years - from the state of New Jersey to handle the most serious trauma patients, around the clock. There are two other Level I trauma centers in New Jersey, at Robert Wood Johnson University Hospital in New Brunswick and at The Cooper Health System in Camden. All do original research and offer teaching to medical professionals on how to treat patients and save more lives. In addition, New Jersey has six Level II centers, also well equipped to handle trauma patients, but with less emphasis on research and teaching.

The centers are much more than glorified ERs, Livingston says. At each, "there is care waiting for trauma patients instead of patients waiting for care." A surgeon specializing in trauma is on duty 24 hours a day, along with other specialists - pain management, neurosurgery and rehabilitation experts, for example - who join the team when needed. "We don't do just one thing at a time," Livingston says. "Multiple things happen in parallel. It's the medical equivalent of an auto-race pit crew."

Many of the doctors running today's trauma centers remember an earlier, horse-and-buggy era in the treatment of injuries. Jeffrey Hammond, MD, chief, trauma/surgical critical care at UMDNJ-Robert Wood Johnson Medical School, was a medical student in 1972 when he took time off to go to Washington and work as a congressional aide in rallying federal support for emergency medical services. "Fifty percent of the ambulance services in those days were run by funeral homes," he recalls. "And the standard ambulance was a hearse," one of the few vehicles designed to carry people lying down.

A couple of crucial studies in California in the early 1980s made many physicians think it was time to retire the hearse and strive to get more patients back on their feet. "The researchers looked at people who were dying of injuries," Livingston says. "They reviewed autopsy records after patients had been lost to injuries, and they realized that a lot of these people shouldn't have died." The researchers concluded that doctors could reduce the chronic disabilities and loss of life by establishing hospital facilities that would be as tightly focused on trauma as other units that specialized in heart transplants or brain surgery.

The research proved that treatment should begin at the scene of the accident. Replacing the hearse, new "mobile intensive-care units" were boxier, bigger and more practical transport vehicles in which trained medical personnel could begin saving people even before they got to the hospital. And the new approach to trauma continued after the life was saved, as patients routinely moved on into rehabilitation. "We're here not only to patch people up," Livingston says. "We're here to get them back to previous employment, to being productive again."

A: The team found out immediately that Roth's nose, mouth and throat - his airways - were open and clear. C: There were no apparent circulatory problems. A nurse monitoring his blood pressure reported that it remained fairly normal, with no evidence of internal bleeding. Readouts from an electrocardiogram showed his heart was strong and steady.

That left B, a major problem with his breathing. Despite all his other injuries, Roth himself suffered the greatest pain in his lungs. "It felt like the time when I was a kid and used a bamboo pole to vault over a clothesline and landed on my back," he says. "It knocked my breath away." Now, more than breathing comfort was at stake. His lung problem was jeopardizing the normal flow of oxygen to every cell in his body. The team could see that he was gasping for air. They got further information from a small cuff they attached to the end of one of his fingers. The device, called a pulse oxymeter, lit up regularly, making the finger tip appear to glow red like E.T.'s finger when the cinematic alien performed a healing. "It works by measuring the redness of the blood," Livingston says. "The redder it is, the more it's saturated with oxygen." In Roth's case, the color under the bright light was tending slightly toward purple. That meant his body was starved for oxygen.

The device confirmed the physical exam. Air was getting to the top of the lungs. But it wasn't filling them. The team knew with some certainty that fluid, and air leaking through small holes in the lungs, were infiltrating the space in the chest cavity outside of the lungs, and compressing them like a belt tightening around two delicate balloons. Without a quick intervention to relieve the pressure, Roth was in danger of suffocating.

The team injected a local anesthetic into the side of his chest under his left armpit and cut a small hole between two ribs. They inserted a tube about the size of a magic marker into the chest cavity - not into the lungs themselves - and turned on a pump to withdraw the fluid and air. The lungs began to expand to normal size.

His immediate crisis averted, Roth was moved about 100 feet in the trauma center to a CT (computer tomographic) scanner. That's a ring shaped X-ray machine that delivers cross-sectional pictures of the body to reveal fractures, organ injuries and areas where fluid has built up. The pictures began appearing in seconds as the team watched, twice as fast as CT-scanning five years ago. In just a couple of minutes, the team knew that Roth had no serious head injury. And that the broken bones in his pelvis, which could have put his life at risk by causing internal bleeding, were not a threat.

The certainty of the CT scan was good medicine in itself. The all-clear pictures meant that Roth would avoid exploratory surgery to make sure he wasn't bleeding. Surgery would have carried its own risks. His lungs weakened, he probably would have required a ventilator - a device to assist his breathing - to get him through the operation. And that could have prolonged the danger. "Sometimes patients have more difficulty breathing on their own when the ventilator is removed," Livingston says.

The new and more accurate generation of CT scans means that more trauma patients these days can go home earlier after an accident, without taking up hospital beds where they were traditionally held for observation. Research by Livingston and others at four Level I trauma centers tracked more than 2,000 patients with abdominal injuries. Their study found that it was safe to send patients home if their CT scans revealed no organ injury or excess abdominal fluid. That's good news for them and their families - a night not spent in a hospital bed - but also for people with more serious injuries. "If you take three or four patients off the trauma floor who don't necessarily need to be there and send them home, then nurses, doctors and other health care personnel can concentrate on patients who really require attention," Livingston says. As other hospitals put more trust in the scans and reduce admissions for observation, the U.S. stands to save more than $5 billion a year in unnecessary hospital bills.

In Allen Roth's case, the bed and the observation were essential, and carried him safely to the next step of rehabilitation. He began physical therapy just six days after the trauma team brought him through his crisis. He got out of the hospital in two weeks, and spent three more at a rehabilitation center. Today, he's back at work. He reports only a few residual effects - some shortness of breath, occasional stray pain and difficulty sleeping, although his memory of the crash itself has not returned. But he will never forget what he learned about the fragility of life.

"My brother came to visit and brought his son Brian when I was in rehabilitation," Roth says. "I took one look at my nephew and burst out crying because it occurred to me at the time that I might never have seen him again. If I had died in the car, I wondered if I would have even known that I was making an exit."

His story isn't nearly as dramatic as the portrayal of life and death in the novels he sells, Roth says. The ending is just this: The trauma team blocked the exit. "They saved my life, pure and simple," he says.

Fall 1998 Table of Contents

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