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.


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!

john said...

If im in the situation of the owner of this blog. I dont know how to post this kind of topic. he has a nice idea.

Anonymous said...






Anonymous said...

(法新社倫敦四日電) 英國情色大亨芮孟的成人公司昨天說色情,芮孟a片下載日前部落格去世,享壽八十二歲;成人網站這位身價上億的房地產開情色電影發商,曾經a片在倫敦推出av女優色情一場脫色情衣舞情色表演。






Anonymous said...

(法新社a倫敦二B十WE四日電) 「情色二零零七」情趣產品大產自二十三日起在倫敦的肯辛頓奧林匹亞展覽館舉行,倫敦人擺脫對性的保守態度踴躍參觀,許多穿皮衣與塑膠緊身衣的好色之色情徒擠進這項世界規模最大的成人生活展,估計三天展期可成人網站吸引八萬多好奇民眾參觀情色電影




Anonymous said...


Anonymous said...

艾葳酒店經紀公司提供專業的酒店經紀, 酒店上班小姐,八大行業,酒店兼職,傳播妹,或者想要打工兼差打工,兼差,八大行業,酒店兼職,想去酒店上班, 日式酒店,便服店,制服酒店,ktv酒店,禮服店,整天穿得水水漂漂的,還是想去制服店日領上班小姐,水水們如果想要擁有打工工作、晚上兼差工作兼差打工假日兼職兼職工作酒店兼差兼差打工兼差日領工作晚上兼差工作酒店工作酒店上班酒店打工兼職兼差兼差工作酒店上班等,想了解酒店相關工作特種行業內容,想兼職工作日領假日兼職兼差打工、或晚班兼職想擁有鋼琴酒吧又有保障的工作嗎???又可以現領請找專業又有保障的艾葳酒店經紀公司!

一般的酒店經紀只會在水水們第一次上班和領薪水時出現而已,對水水們的上班安全一點保障都沒有!艾葳酒店經紀公司的水水們上班時全程媽咪作陪,不需擔心!只提供最優質的酒店上班,酒店上班,酒店打工環境、上班條件給水水們。心動嗎!? 趕快來填寫你的酒店上班履歷表

等相關服務 幫您快速的實現您的夢想~!!

madelaine said...

New comprehensive, evidence based guidelines on the management of open fractures should lead to reorganization of service delivery and a more comprehensive approach to these potentially catastrophic injuries.

generic viagra online

Alex said...

Thanks a lot for sharing this site. I would like to read few more articles from you.


generic viagra for men

Anna said...

There is so much horror in a trauma center I guess. Winstrol

Roger Smith said...

What an amazing story very well written. Complete and safe approach should be developed for catastrophic injuries. Thanks for the information and hope you keep posting such great articles.

Mens Health

Clark said...

I would like to work in a trauma department as you, your history is interesting, i love when someone posting topics about trauma,anesthesia.... i hope that you can do the best work that you have ever done. For this, you can use Generic Viagra

jimmychooshoes said...

Manolo Blahnik Red Pointed-Toe Pump
Manolo Blahnik Satin Jeweled d'Orsay Pump
Manolo Blahnik Something Apricot Satin Pump
Manolo Blahnik Something Black Satin Pump
Alexander Wang Mirte Laced Zip Flat Boot Black
alexander mcqueen shoes

برامج said...

this is scaring me god help those people
فيس بوك

healthy-lifestyle-tips said...

Generic viagra is the anti-impotence drugs,which is very effective for treating erectile dysfunction.


Steve said...

Great Story...........
Generic Acomplia

niub520 said...

Hi, great article. The way you explained it is really awesome and makes every one to read till the end. keep posting..dugi's wow guide free

Steve said...

Hello, this is certainly cool stuff, what a fine attempt. I liked your way of narration...simply beautiful. I'm sure you must have invested a lot of time in investigating the details which are so astonishing and never heard before. Generic Cipro

dubaiexperies said...

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
Dog Life Jacket

rose said...

If i am in the situation of the owner of this blog. I don't know how to post this kind of topic. he has a nice idea.

rose said...

What an amazing story very well written. Complete and safe approach should be developed for catastrophic injuries. Thanks for the information and hope you keep posting such great articles.
Austin Real Estate

Josh said...

It is a very good article, I am so happy to get so many good points in this article and its an inspiration and I prefer to read the quality content. Thanks
Capsiplex Reviews

Josh said...

A very good and informative article indeed . It helps me a lot to enhance my knowledge, I really like the way the writer presented his views.
Meratol Reviews

man 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.
Austin Custom Home Builder

Neil said...

I have never ever come across such a wonderful piece of information. Today I am proud to say that I have finally gain knowledge on this topic and here on I shall also spread the same preaching ahead so that the world become a better place to live in.
Provillus Reviews

emma said...

Hi guys, I want to say thanks for this useful information, I shared it on my wall to be honnest cause I LIKE it(:

Acheter Levitra

Anonymous said...

Please keep on posting as this was a quality is rare to find these days. I'm always looking for articles online, I can help. looking forward to another great blog. Good luck to the author! All the best!

John Legacy said...

Thanks for sharing, much appreciated and useful post, congrat and keep on track!
Cialis Online

sophie said...

Oh, that drunk guy on a bike! What happened to him, then, after being with you and under your care? Did his condition improved at all? :-)
phentermine 37.5 without prescription

julie said...

I appreciate write-up. It absolutely was valuable know-how. I will keep a check out onto your posts for the purpose of newest posts. Regards.

e cig reviews

savsuns said...

Explore your options for healthy aging. Find research and information on the health benefits of resveratrol, the miracle polyphenol found in red wine and its miraculous antiaging benefits. Resveratrol research suggests it has antiaging, anti-inflammatory, anti-cancer, anti-oxidant, and cardiovascular benefits.Buy synthroid online

savsuns said...

Shopping from buy lasix online it about 6 month still want to say that service is excellent cheap prices very fast delivery and good quality generics.

dubaiexperies said...

I admit, I have not been on this webpage in a long time... however it was another joy to see It is such an important topic and ignored by so many, even professionals. I thank you to help making people more aware of possible issues. Great stuff as usual
Abilene Roofing Contractors

Roman said...

that is very cool post, thanks


Naveen said...

Details are very true and factual, I do really learned something new upon reading this interesting post. Good job! and Thanks!

SEO Services Company
Guaranteed SEO Services

Jason Smith said...

This is great information found here... Keep posting such an amazing blog post. Thanks for the share.


logoonlinepros said...

This blog is an exact representation of skills. I appreciate the blogger for posting the most excellent thought.

Cheap Logo Design

Farrah said...

We are impressed by your clear description of your topic. Thanks for the information. Keep on writing.

3d ultrasounds

Juliette Morgan said...

Thanks for a good case story, very well told. Will read more here, thanks for sharing.

diamante dog collars

JohnHawk1989 said...

Hello very nice one post this is good....!

JohnHawk1989 said...

Wow very nice post..............
Generic Viagra

dubaiexperies said...

I can't see anything." Keeping the cervical spine secure makes the procedure more difficult.

Juliette said...

Too mch action for me, do you like a good movie in your spare time? This one I recommend for you, tongue in cheek!

'Fracture' Movie Review

Anonymous said...

These kind of post are always inspiring and I prefer to read quality content so I happy to find many good point here in the post, writing is simply great, thank you for the post.Shawna

Anonymous said...

Took me time to read all the comments, but I really love the article. It proved to be very helpful to me and I am sure to all the commenters here! It’s always nice when you can not only be informed, but also engaged! I’m sure you had joy writing this article.Shanklin

Farrah Khan said...

i have read your blog and find that your articles are amazing, i have added this into my bookmark. Thanks a lot. ~^- organic supplements -^~

saim said...

I have read your post thoroughly and got mind blowing information.... Please send me mail if your are going to improve something advance..

natural supplements

Augusta Tina said...

This is one of the highly informatics and attractive blogs that has not only educated also informed me in a very effective manner. There are very few blog like this one I have read. Corporate Logo Design

Bob said...

Hey excellent weblog, just searching around some blogs, appears a pretty terrific platform you will be making use of.
health insurance california

Mike said...

I am trying to repair my online reputation..Especially in blogs. Working with http://reprx.com/ ..they are pretty decent..but I am not sure if I will able to sustain my rank in long run..

Bob_Alfredo said...

Amazing post, I like it. It was quite interesting nice work. I appreciate the information you provided is excellent post. Thank you for sharing you do.

Internet Marketing Agency

SteveBrad said...

Good post. I study something tougher on totally different blogs everyday. It should at all times be stimulating to learn content material from other writers and follow a bit something from their store

Adim said...

That is really very good article. I am glad to know. Thanks for sharing !

Retailers Logo

justin albert said...

Recently i ran into your website and so are already reading along. I think I’d leave my first comment. I don’t understand what to share with the exception that I’ve enjoyed reading. Nice blog. For certain i will keep visiting your blog really often

Custom Facebook fan page

DENICE said...
This comment has been removed by the author.
Frank said...

I'm so glad I found this post because I've been looking for some information.
Extenze Pills

Anonymous said...

This was an amazing site that I had never seen it before. Thanks a lot for the information because Buy Paxil 10mg Online had liked it very much!

Anonymous said...

Thanks for sharing this such a valuable and useful information. You must have researched a lot on this topic.Template Design | PSD To HTML

colaveri d said...

This is a great blog. Thanks for sharing all the information!
maqbool mirza | mirza maqbool

colaveri d said...

The post is written in a very good manner and it entails many useful information for me. I am happy to find your distinguished way of writing the post. Now you make it easy for me to understand and implement the concept.
pakistani matrimony | pakistani matrimonial | pakistani matrimonial sites | pakistani dating

colaveri d said...

It is a very informative and useful post thanks it is good material to read this post increases my knowledge..
urdu newspaper | english newspaper | news from pakistan

colaveri d said...

This site is excellent and so is how the subject matter was explained. I also like some of the comments too. Waiting for the next post.
Pakistani wedding stage | pakistani wedding planner | event management companies in pakistan

somnus11258 said...

That is really cool. Thanks for finding it. Some really good ideas there, this is going to be a real time sink. I am a china tour lover,You can learn more: Guilin tour packages  | Travel to Lhasa | Lhasa Travel Guide

dubaiexperies said...

I have been deciding on institutional move and this has helped me with one aspect.
personal statement for dental school

Mia Smith said...

Good post….thanks for sharing... Very useful for me i will bookmark this for my future needed. Thanks for a great source Amazon Promo Codes
American Eagle Promo Code
AutoZone Coupons
Barnes & Noble Coupon Code
Barneys Warehouse Coupons
bebe Coupon Codes
Bed Bath and Beyond Coupon
Best Buy Coupons
Bluefly Coupon Codes
Groupon Promo Codes
Haggar Coupons
JcPenney Coupons
Kohls Coupons
Light In The Box Coupons
Macy's Coupon
Next Day Flyers Coupon Codes
Overstock Promo Codes
Sears Coupons
SmartBargains Coupons
Target Promo Codes
Walmart Coupon Codes
Woot Coupon Codes

Learn Chinese language on hanbridgemandarin said...

Hanbridge has adopted a structured and interactive educational approach to enable you to learn Mandarin effectively and reach your targeted proficiency level. Clear pronunciation, the proper use of tones, real-life topics, and bilingual instruction all combine to ensure you will be able to communicate effectively.

More Chinese learning tags : best way to learn Chinese online | Chinese Teaching Online | Study Chinese


this story is based on the advantages of leakier. this is very interesting story about the drining this is very interesting story i very attractive from this story thanks for sharing it..........

Onlinepillsshop net said...

Nice post. Thanks for sharing this post.
buy generic vardenafil 20mg

safegenericrx said...

Nice blog thanks for sharing this informative blog with us.
Buy etizolam online USA

tim adam said...

nice information,
buy cheap viagra generic 100mg