June week case: Day 2: Unexpected turn of events (Term 8 Week 4)
Excellent comments on Twitter! Remember to use #gasclass so that everyone can follow the comments. Please continue to read on as the case develops. First a little summary and a few points to ponder.
So yesterday’s case started with a tricky situation: A two car accident occurred on corner streets of your hospital. EMS apparently 10-min away. The main consideration was: Should you go check it out or stay in hospital and prepare for patients arrival?
Here are a few points I was thinking of:
Summon help: Ensure that the local EMS activation number has definitely been dialled. It could be that this has not happened and someone just saw there is a hospital nearby and ran in, expecting or anticipating that the hospital will activate the prehospital providers. Also consider summoning more hospital resources early. Hopefully even a small hospital has some sort of escalation plan.
Remember, you have an established duty of care to these hospital patient and cannot leave them without sufficient medical care. It might be that you are the only clinician in the hospital and then you definitely can’t leave.
Don’t underestimate the pre-hospital environment. It is unsafe, unpredictable and not kind to novices. Personal protective equipment is essential. Hospital medics in scrubs and trainers are definitely not ideal.Also, take into account, the “jump bag” or transfer kit is not alway fit for purpose in the prehospital environment (what the heck are you going to do with an arterial line transducer on scene…?)
Having said all of that, there are some potentially essential life saving things that can be done in the first few minutes following an incident while EMS is still on route. We know this from the impact bystander CPR has on prehospital (non-traumatic) cardiac arrest cases.
Equally, in trauma cases, secondary brain injury from, for example hypoxia due to an occluded airway can have a dramatic impact on longterm neurological outcome of head injury patients. There are patients who die from potentially reversible causes before the ambulance crews arrive. Simple interventions could make the difference between leading a full live and being severely impaired or worse, death. Some of these simple interventions include: Opening an airway or putting direct pressure on a bleeding wound. You don’t need any equipment for this and could literally save someones life…
I’m not 100% sure there is a right answer to this. Like most things in medicine you have to way up the risks and benefits and try and make the best decision with the information, skills, team and equipment you have.
OKAY, DONT STOP READING NOW, the good stuff is still coming! Lets continue with the case:
So, luckily as you are trying to find the code to the combination lock on the (locked) door to the high-viz jackets and transfer bag, you can hear the sirens of an ambulance (with the prehospital professionals) turning the corner and arriving on scene. (Ambulance control had several calls on the incident and managed to mobilise an ambulance crew nearby.)
Within minutes the EMS crew brings three patients to the ER. Due to the proximity of the accident to the hospital, not too many interventions were done before the patients arrive with you. One patient is the driver of a large German car and he has only minor injuries and declines any medical care. The other two patients are husband and wife from the smaller car that had the side impact to the driver’s side.
The rest of the case will focus on the driver of the smaller car. Lets call him Adam 55.
Brief handover from ambulance crew to your trauma team (i.e you as anaesthetic airway support and whoever is there):
- 55y/o called Adam
- 10-min ago two car RTC
- Side impact on driver’s side. Was wearing a seatbelt. No clear history of loss of consciousness. Not mobilised on scene. Extricated via side door on an extrication board
- Injuries found: Neck pain; Tender ribs, good bilateral air entry. Open wound and possible fracture to right elbow. No suspected abdo, pelvis or other long bone injuries.
- Prehospital treatment received: Reassurance, spinal immobilisation with cervical collar, head blocks and on a hard board.
- GCS 15/15, moving all four limbs. Pupils equal and reactive. Vitals stable last 10-minutes.
The team do a thorough systematic evaluation (CAcBCDE) and confirm the above findings. eFAST negative. Portable pain chest X-ray and pelvis X-rays are normal. Observations within normal range. As an anaesthetist at this point you decide that your services are no longer required in the ER and this has been far to much excitement for a Saturday afternoon and you retreat to the coffee room – topping up on caffeine in anticipation of this patient potentially needing some sort of surgery for his elbow injury later.
In the mean time your Emergency Room colleague sends the patient to the X-ray Department at the back of the hospital for his elbow X-ray. No trauma CT done. To get a weekend CT in this hospital the CT radiographer needs to come in from home.
20-minutes later an out-of-breath hospital porter tracks you down in the coffee room and says: “Doc, the ER doc needs you to urgently go to the X-ray Department! That patient is now ‘not quite right’. That man is making no sense, doesn’t want to lie flat, looks like a ‘dear staring into headlamps’. The ER doc is dealing with the other lady patient and can’t go. Come!!”
You follow the porter to the rather remote X-ray department to find the radiographer physically trying to keep the patient on the bed. He is combative, and slurring his speech.
- What’s going on? What could have led to the change?
- Think of a differential diagnosis and how you would exclude or confirm it.
- What’s your course of action?
- What are the potential obstacles / challenges you might face to achieve this?
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More to follow later…