1.07.2008

a trauma story

Since I got such positive feedback, I'll post one more story.

I work at a couple/few different places - which is nice because my ER shifts are quite different depending on the location of the ED (obviously). One of 'em is a trauma center. The trauma center is way cool...and has top of the line everything. The trauma resuscitation bay is like 20 feet from both the CT scanner, and the OR. The anesthesia and surgery call rooms are actually *in* the trauma center. We even have a teeny-tiny police department (2-way glass and everything) in the entry-way to the trauma center.

So, I was at work recently, at my trauma center ED. Things were steady. Our traumas so far consisted of a drunk dude who was riding his bike, crashed into the curb, fell off of the bike, and lost consciousness. Granted, there are quite a few things possibly wrong with 'drunk dude', but more than likely, he's just drunk. But, he fits 'trauma criteria' so he was brought to us. There was a kid who jumped off a roof, obvious deformed leg...but otherwise okay.

Then we received the EMS call:
"This is rescue 25 to base with a trauma run."

This is base. Go ahead with your run.

"We have an approximately 30 yo male who jumped from a 2nd story window to escape an apartment fire. He has 2nd and 3rd degree burns over his anterior chest, neck, and his right forearm. He has an obvious deformity of his left femur, and multiple abrasions to his face. He's alert, but appears intoxicated, and is combative. We have PD on scene helping us secure him for transport. His vital signs are 150/84, heartrate 120, respiratory rate is 22, and his O2 saturation is 98%. We're attempting to establish IV access, we have him on O2, full spinal immobilization, and would like to have an order for morphine. You are our closest trauma center with an ETA, after we get him loaded, of 7 minutes. Over."

We rally the troops, and congregate in Trauma bay number 4. Upon arrival, EMS notifies us that this guy was 'set on fire' by a girl. Apparently this girl is the girlfriend of a rival gang member...and 'word on the street' is that she decided to get revenge on this guy for killing someone in her boyfriends gang. Because of this, there were already members of both gangs 'interested' in our patient's condition....and our parking lot was starting to look a lot like Crenshaw Blvd on Sunday night.

As firefighters approach us in Trauma 4...we see a young adult male, laying on the paramedic gurney with a c-spine collar on a long spinal backboard. His face is covered in blood and glass. His chest wall has 3rd degree burns over the entire anterior surface. His left femur is obviously fractured; as is his left tib/fib. They have no IV access. Patient is on O2 via facemask. He's yelling loudly, and wiggles on the backboard. We transfer him to our gurney. And the nice thing about trauma centers, especially where there are residents, is that there's enough people around to do everything.

My mind is yelling "oh sh*t. This guy looks horrible!!" The residents are eager to *do something*. It is times like these I really appreciate the simplicity of the mnemonic ABC.

As the attending (gulp)...I start giving instruction.

"Okay, lets get him on the monitors, pulse ox, and let's get some sterile gauze soaked in saline." That sends a few people scurrying away. Someone assess his airway and listen for breath sounds. Let's set up for intubation, and obtain central venous access...via...via..."

(hmmm....can't do subclavian because of the burn...or IJ for that matter. He has an obvious left lower extremity long bone fracture...so maybe that's not the best place to stick him).

"via right femoral vein. Someone call the burn center and let them know this guy is here."

The crowd around the bed is now half it's original size...with everyone doing their various tasks and all. Now, we have some room to work.

A - airway first. "let's intubate this guy" I tell the junior resident. There's some resistance from the nurse, "but he doesn't need to be intubated." I try to quickly explain to her (while the resident proceeds with the intubation) that this guy has major trauma, major burns, and was in an enclosed space, likely intoxicated, with fire...and smoke...and CO...and CN. His airway is closing...and every moment we contemplate will just make the edema in the airway even more difficult to overcome. The resident struggles, "I can't see anything." Keeping the cervical spine secure makes the procedure more difficult. The monitor goes from a high-pitched 'blip-blip-blip' to a decrescendo 'bloop-bloop-blooouuuppp' as his oxygen levels drop. Okay, that's enough. Let's bag him up.

I'm too 'insecure' to let him try again. We bag mask the patient, restore the oxygen saturation to an acceptable level (and the nice high pitched blipping)...and I try. Wow. All I see is pink mucosa - there are no landmarks!! I do the BURP maneuver and a small opening reveals the cords. I use a bougie and successfully intubate this guy with a 6.5 ETT (tiny little tube)!! We listen to breath sounds, and the left is decreased. We pull the tube back a bit. Still decreased. Then I ask the resident, "did he have equal bilateral breath sounds before intubation?"

He isn't sure. Maybe the left was less audible. We order a chest xray.

As we secure the ETT the patient, who intially improved his oxygen saturation, started to desaturate, and his blood pressure was about 115/70 with a heart rate of 130. Let's bolus him warm saline thru the Level 1. And let's get some o-positive blood here (we like to use 0-positive for the fellas).

Moving on to B - breathing: I instruct the resident to dart his chest. Things got a bit better after that. Then, he placed a chest tube. 500mls of red blood squirted out of the left chest...but his breathing improved. Let's autotransfuse that blood right back in.

And now to C - his blood pressure was stable at the moment. His arms/hands had good circulation. Palpation of the left elbow elicits a painful response. His right forearm has a medium sized 2nd degree burn on the radial surface - it is not circumferential, and his distal pulses are good. His right leg is fine, and our femoral line is working wonderfully. His left leg is mangled. There is decreased pulse to the foot, which is cool and cyanotic.

At this point we order initial labs and studies. Xray...basically everything. Order CT of...basically everything. Call ortho for the leg. Trauma panel of labs. And dress his burns with the sterile saline soaks. We keep him sedated. And order a tetanus and antibiotics while we're thinking of it. Then we go back and do a secondary survey.

We look into his eyes. In the left eye there's a piece of glass obviously penetrating the globe. The right eye is reactive and appears normal. Typanic membranes reveal no hemotympanum. There was no evidence of midface injury. However there are multiple deepish lacerations to the forehead and scalp. The PA is eager to repair these.

The neck has 1-2nd degree burn over the anterior surface, but it's not circumferential, and is not deep enough to expose any underlying structures. The chest tube is in place, and the breath sounds are present bilaterally, but greater on the right. There is a 3rd degree burn over the majority of the anterior chest wall.

Abdominal exam is difficult to execute....so we'll just scan him.

Pelvis is stable. Left hip is questionable. And his back and rectal/genitalia are unremarkable.

We continue IV hydration per Parkland Formula, and call ophthalmology for the eye injury.

Xrays reveal a femur fracture, tib/fib fracture. There's a distal humeral shaft fracture on the left. CXR shows what we interpret as a likely pulmonary contusion on the left. Chest CT angio, cervical spine, and abdominal CTs were unremarkable (except the pulmonary contusion and some rib fractures). CT pelvis revealed a small, but significant pelvic fracture, with acetabular involvement. Labs revealed an alcohol level of 420 (legal limit is 80). Utox positive for cocaine, marijuana, and meth. And head CT revealed a left parietal skull fracture (with no underlying brain involvement apparent), and glass fragments in the left eye with globe rupture.

Ortho took over the management of the broken bones, and decreased distal blood flow to the left leg. The leg was splinted, and vascular surgery was consulted. Because the patient had extensive chest trauma, I believe trauma consulted CT surgery. And, of course you can't ignore the burns. We are not a burn center...but we have the capacity to care for burn patients (yeah, go figure).

At our institution, it's the trauma service that stays with the patient thru his scans, and see to it that the appropriate consults are obtained after initial stabilization is achieved. So, at this point...we're actually done. My residents stay and play with the trauma service...but I have other residents to supervise (only one junior and one senior responds to the trauma calls, the other 4 continue their work in the ED).
***

Later I found out that the guy, unfortunately didn't have insurance...and the ortho procedure he required involved a series of operations, close follow-up, and specialized equipment. And because orthopods don't work (much) for free...especially when the patient is a high risk patient (high risk meaning not likely to be compliant, and more likely to sue, as determined by his lifestyle...and according to them, it's the poor, uninsured, disenfranchised, non-contributor to society that's likely to try and take something that doesn't belong to them...and is therefore more likely to sue). So, no orthopod in the City would do his surgery...and he will require the use of a cane/walker for the rest of his life (or, I guess, until someone thinks it's worth it to fix him).
And he lost the sight in that left eye.

As for us...
...well, it was interesting leaving our shift that night. Navigating the parking lot in the middle of gang warfare is quite stressful - especially when, no matter the outcome...someone's going to be pissed off.

70 comments:

ERP said...

Wow - no orthopod will do the surgery? Usually these messes are handled by residents at large subsidised, teaching hospitals (like just about every hospital in NYC, the Bronx, and Brooklyn). He suffered from "Poor Choice of Acquaintances Syndrome "

Allen said...

What an awesome story... so well written and tons of action. A great read, thank you for sharing! I'm looking forward to seeing the same stuff over at Jacobi!

Kate said...

*drooling* over your OR in the trauma center. That seems like a great idea to me as a lot of times it is easy to lose track of people once they leave the department for some nebulous OR on a different floor. Great case.

Question: so if you work in mult hospitals are you part of a large group or do you contract out with several places as locum tenens?

ER doctor said...

yep, having everything you need right there in the trauma center...is great!! the scanner, the surgeon, anesthesia, the OR!!

i contract with a couple different groups...working part-time at each location.

Petri said...

That's just an amazing story. If I had been a medical student shadowing that night I wouldn't have been able to sleep afterwards.

I hope no one subsequently got hurt in the parking lot, though it would be a convenient place to get shot, if you have to get shot.

That guy was extremely fortunate he didn't die, hope he learned from the experience.

Kelly said...

Great Story!

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