A tangle of people surround the bleeding man on the table, a bullet lodged in his left leg.
The crowd is disorganized, a whirl of people in different colored scrubs working amid palpable tension and beeping machines, all played out in front of a background of stark white walls.
Overhead, a clock ticks.
To those who know the trauma center, there is order in the chaos.
The center at the University of Arkansas for Medical Sciences is the only adult Level 1 trauma center in the state. It is one of 256 Level 1 trauma centers in the United States, and the next-nearest ones to Little Rock are in Memphis, Shreveport, Oklahoma City, Springfield, Mo., or Jackson, Miss.
That means that for the majority of the 3 million people who live in Arkansas, UAMS is the closest care for their worst injuries. Hospital officials say more than 2,600 trauma patients pass through the hospital's double doors in a year.
The leading cause of death for people ages 1-44 in the United States is traumatic injury. The federal Centers for Disease Control and Prevention's 2015 data show that about 214,000 people die from injury each year, a rate of about one every three minutes.
But studies have shown that Level 1 trauma centers, which pull together the skills and technology to treat the worst kinds of traumatic injuries, have significantly cut the chances that a trauma victim will die. One study, by the Bloomberg School of Public Health at Johns Hopkins University, put the decrease at as high as 25 percent.
That makes the ordered chaos in the UAMS center critically important to the state and its people.
And more than that, it is fascinating, demanding and exhilarating, and sometimes heartbreaking.
NOT LIKE THE MOVIES
One night in late October, trauma nurses received a call about a person with a Level 1 gunshot wound who was about 10 minutes away. Sometimes they don't get that much notice. A lot of calls give only a two- or three-minute warning, leaving little time for the staff to prepare.
Once a call comes in, a dozen pagers ring across the hospital, summoning doctors, surgeons, nurses and technicians to the trauma room. An on-call chaplain makes his way to the trauma center, too, ready to talk with family members or patients if needed.
About 62 percent of all Level l trauma intakes at the hospital are transported directly from the trauma scene, according to data from UAMS. Around 35 percent are transported in from another hospital, and 3 percent arrive via a personal car or other means.
Occasionally, getting a patient to the trauma room plays out like it does in the movies, said Ashley Ruiz, a trauma room nurse. She remembers one nighttime helicopter arrival last year in which she had to run to the cold, windy helipad as the chopper blades sliced the air above her head and rush a bleeding man to the trauma center.
Ruiz said she looked back at the helicopter and noticed something red splattered along its side, like painted flames on a race car.
"It was blood," she said.
Once the gunshot victim -- the man with the leg wound -- is wheeled into a treatment room, the care team gathers. An organization chart hanging overhead indicates each person's position. The moment the patient enters the trauma center, everyone takes his or her place.
Ruiz oversees the bedlam, documenting every step the staff takes to save the man's life. Slightly removed from the flurry, Ruiz can see the man staring at the ceiling, occasionally glancing at the doctors around him.
No one asks where they should stand or what they should do. The room is quiet, barring the beeping of a heart monitor and occasional groans from the man on the table.
Since the shooting is a criminal case, a second huddle of people -- police officers and investigators -- waits for the patient to speak.
Dr. Ron Robertson, a surgeon and the UAMS trauma medical director, said the relationship between detectives and medical personnel is not like it is in the movies -- there is no turf war or feud.
"They understand our duty is to the patient," Robertson said. "And we understand what they need."
In the trauma room, Robertson speaks quietly, his voice rarely rising above a whisper. His soft tone, he said, is echoed by the nurses, lab technicians and even the patient.
"I grew up in the heyday of Little Rock's knife and gun club," Robertson said, referring to his residency during Little Rock's turbulent gang wars in the 1990s. "We were getting so many violent crimes that were so significantly injured, you could get spun up very easily. I found when I got spun up, everybody else in the room got spun up. If I could keep my demeanor calm, it tended to keep the room calm."
With the trauma team working steadily, the gunshot victim, from time to time, squirms beneath the surgeon's tools or groans when someone moves his bleeding leg, his olive skin stark against the white-and-red bandages. For the majority of his time in the trauma center, though, he is quiet.
The ticking clock overhead tracks the man's stay in the trauma center. It allows the documenting nurse to keep track of what nurses have done when -- when an IV was started, when the patient was given oxygen -- and reminds the staff when nurses need to begin other treatments.
Each of the three trauma bays is equipped to handle anything. It has ultrasounds, X-rays, clamps to close off gushing arteries and even emergency surgery equipment. But Ruiz said the goal is to get the patient stable enough to move to the intensive care unit, to the radiology center, or to a surgery room, if necessary.
The job of the trauma center is not inherently to heal a patient, Ruiz said, but to stabilize him to the point that he can live to heal.
"You'll notice, trauma patients don't stay here long," she said.
For penetrating trauma -- a gunshot wound, stab wound or other severe injury -- the average stay in the trauma room is 10-12 minutes, according to data from the trauma center.
"We're very proud of that," Robertson said.
QUICKLY IN, QUICKLY OUT
The clock stops just after 11 minutes for the gunshot wound victim in late October. He was stable enough to go to a nearby room, and nurses wheeled him down the hall.
When the surgeons and nurses walks away, all that is left in the trauma room are a few pieces of bloodied gauze and gloves on the floor.
All are quickly cleaned up as the staff readies for the next patient.
After two years, Ruiz said, she has become accustomed to the relentless tide of need that rushes through the trauma center doors, but that doesn't mean it doesn't affect her.
The stereotype of the hardened emergency room nurse, who has seen everything and is affected by nothing, isn't true, she said. Sometimes a night in the trauma center leaves her angry and drained, needing to be alone. Other times she recounts her day to her boyfriend or her mother, needing someone to hear her frustrations and worries.
"It's a calling, not a job," said Terry Collins, UAMS' trauma program director. "I believe very strongly the people that do this for a living -- and sustain it -- are called to do that work. I don't think it's a choice."
Collins, a 30-year veteran of UAMS, knew she wanted to be a nurse when she played founder of the American Red Cross Clara Barton in a third-grade play. It made an impression on her because "Clara got to wear a cape." Though she left the cape behind, she stuck with the profession, she said.
Collins can tell when young nurses have a passion for the trauma center, she said. Those who don't won't stay long.
"You can't sustain it if you don't have the passion," Collins said. "It's too overwhelming. It's more than a job."
What makes the job wearing is the degree of injury that trauma patients suffer. It's the aftermath of violence that passes through the hospital's double doors every day and the families who are affected by it.
"It can be very emotional," Robertson said. "If you don't really love it, I think it can consume you very quickly."
Even when Robertson was a resident in the early 1990s, Collins said she knew he would stay in the trauma center.
"You really can tell if they're meant to be in the trauma room," she said. "The job is hard, but how many people get to say they saved a life today?"
Even those who really love the work must have a way to release the tension, Collins said. For her, it's reading. For Robertson, it's fixing old cars like the 1975 Corvette sitting in his garage.
Ruiz said she likes to close her blinds, bake a tray of brownies and watch TV.
Though she was the documenting nurse for the leg-wound victim, Ruiz's position on the trauma room map shifts almost daily. Some days she's checking vital signs, placing IVs or assisting the surgeon.
She loves the nonstop nature of her job. She loves that she gets to do something new every day. But sometimes the parts of her job she loves most are the most taxing.
After hours of moving from task to task and need to need, Ruiz said, she sometimes needs to sit on the couch with her two dogs, Kiki and Reese, turn on Netflix and just be alone.
"Sometimes you just feel like a sponge for everybody else's emotions, and you don't get to have your own," she said. "I get so many other feelings from everybody else at work, sometimes I just need to be alone with my own thoughts. You have to learn to remove yourself and let yourself recoup so you can go back and do it again."
It's hard to describe loving a job that is so often grueling, Ruiz said.
"You can really make a difference," she said. "You develop a different kind of bond in the ER. It's like 'I'm hurting, and I'm trusting you immediately to fix this.' You get to know people almost immediately because they're so vulnerable."
Ruiz, who is finishing her master's degree in pediatric emergency care at UAMS while she works her hospital shifts, said she knows this is where she wants to be. Hectic and stressful the job may be, but it's what she wants.
"This job is definitely not glamorous," Ruiz said, "but it's worth it."
CHANGING ROLES
Thirty years ago, Collins might have been the nurse to place the October gunshot victim's IV or to talk with his family after he left the trauma center, but over the years her job and Robertson's job have changed.
They've both taken on more administrative roles, supporting the younger nurses, residents and surgeons as much as they can and coordinating big-picture plans for the trauma center.
Part of that new responsibility, Robertson said, is being an advocate for the trauma center.
Despite the fact that trauma is the leading killer of a lot of people, Robertson said, there is no American Heart Association or American Cancer Association for trauma victims -- no advocacy group for the leading cause of death in the nation.
"We are those advocates," Robertson said.
"We're both champions for trauma care," Collins said.
That role means supporting patients as much as they can, teaching people how to how to respond to traumatic injuries and, importantly, supporting the trauma room staff.
Collins and Robertson volunteer to teach residents to apply tourniquets and to stop major bleeding, a part of their work that they say is crucial to keeping a patient alive long enough to receive medical care.
They've taught police officers and firefighters some of the same life-saving techniques, saying that first responders can mean the difference between life and death.
"We want to take this knowledge, what we've learned, and help the community, too," Collins said. "Our work doesn't just have to be in here."
A BRIEF RESPITE
When the clock finally stops in the trauma room, Ruiz said, the patient moves on.
Not long after the gunshot victim left the trauma center in October and the room was cleared of the aftermath, Ruiz sat down behind the charge nurse's desk and sighed. She had charts to fill out, work to finish and patients in hospital rooms to check on.
Less than 15 minutes later another call came over the radio.
"They whisk this patient off to the [operating room], and it feels like it's been so long, but you look up and it's only been 10 minutes," Ruiz said. "And you can't process [what you're seeing] here, because when one leaves, you have another coming."
A Section on 12/31/2018