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Tue, 17 Dec 2002 14:36:54 -0800 (PST)

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Not to cast blame or pass any type of judgement, but I was curious about a couple of things.  Why did you intentionally withold intravenous fluid after IV insertion and also why did you decide not to decompress the right side of the chest?  I can understand how a trauma patient with numerous injuries can tax one's mental compacity and if you have certain reasons pertaining to the above situations I would like to know (from a learning standpoint).
Sven
 San namir <sody@gotomy.com> wrote:wgh

This case sure leaves a hell of a bad taste Both prehospital and trauma room , let me hear what you guys think:

Woman driver slams into an iron gate behind which a guard is minding his own business. He is 24 years old an only son. 
The guy goes flying 15 feet and falls to the ground
at the scene, gash of the forehead, spontaneous breathing.
Conscious Glasgow 15, has neck fixed in a Phil collar and put on a wooden backboard. 
Loaded onto the ambulance, pulls out towards trauma center, during loading left ankle external rotation , seemed like it was fractured. Oxygen 100% with rebreathing mask, manual pressure to bleed
IV fixed in left antecubital , no fluids administered intentionally.
Head injury seems only skin, guy very combatant but then starts to answer our questions. Mumbles that abdomen hurts. 
Head firmly stabilized on both sides to board. chest - no breath sounds to right chest, heart sounds heard vagely, good entrance to left, no sign of tension pneumothorax. 
Chest tube intentionally withheld. 
Abdomen completely soft, no hematoma, no specific tenderness, no rebound no fullness. Trousers opened but not completely removed. 
Hooked up to LIFEPACK 12 shows sinus rhythm, rate 112 oxygen saturation 84-89% maximum at one point 90%
Automatic blood pressure cuff attached to right arm , consistently shows blood pressure 120/75 continues measuring this every 5 minutes all the way to the hospital with roughly same result.
REspirations 40 per minute
Can't manage to palpate pulses! Tried the femorals-nothing , over and over again , can't understand it. Radial pulse not palpable either
I was sure nothing more than my own low proficiency! He's sweating, heaving and puffing but still responding verbally with significant irritablity. Radio in with details of victim to the ER where we arrive 35 minutes from departure . Last time he uttered a word. 

He is examined, Blood pressure 60 systolic . An ultrasound performed on the trauma bed showing blood in the abdomen, a missed pelvic fracture found before anything else. A shout is heard prepare the Operating room. X rays are performed of chest and pelvis. Someone pours in fluids IV. Antibiotics are begun , I run back with the X rays : normal chest , bad fracture of right pelvis. Soemeone has inserted needles to the right upper chest.
The orthopedic surgeoun is taping a heel to the ankle, the pelvis is tied with a sheet, catheter is inserted (after careful penile antiseptic of course). I the jerk still haven't passed on to anybody that I couldn't feel any pulses all along. He is then "rushed" to the operating room 30 minutes from arrival. 
I understand he had a ruptured aorta, ruptured spleen ruptured and badly bleeding liver. Declared deceased on the operating table.100 minutes after the time of injury. 

Queries: 
Do you think he could have been saved if managed differently?
Have you seen such a compromise of oxygenation because of liver damage alone probably causing limitation of right diaphragm (incidentaly no radiological evidence of lung contusion)?
Has anyone else experienced such misleading information from these automatic electronic blood pressure recorders?
Wouldn't the hospital staff relate differently had they noticed no pulses were registeded to the lower limbs early on in the game?
Should every trauma room have seniors 24 hours a day in the ER so that things run as they should?

Let's all try and learn from this sad and devastating case. 

Sody Naimer
Goosh Katif Emergency Ambulance Team 
Israel 79779
Fax. 972-8-6846329
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<P><FONT face="Times New Roman">Not to cast blame or pass any type of judgement, but I was curious about a couple of things.&nbsp; Why did you intentionally withold&nbsp;intravenous fluid after IV insertion and also why did you decide&nbsp;not to&nbsp;decompress the right side of the chest?&nbsp; I can understand how a trauma patient with numerous injuries can tax one's mental compacity and if you have certain reasons pertaining to the above situations I would like to know (from a learning standpoint).</FONT>
<P><FONT face="Times New Roman">Sven</FONT>
<P>&nbsp;<B><I>San namir &lt;sody@gotomy.com&gt;</I></B> wrote:
<BLOCKQUOTE style="PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LEFT: #1010ff 2px solid">wgh<BR><BR>This case sure leaves a hell of a bad taste Both prehospital and trauma room , let me hear what you guys think:<BR><BR><BR>Woman driver slams into an iron gate behind which a guard is minding his own business. He is 24 years old an only son. <BR>The guy goes flying 15 feet and falls to the ground<BR>at the scene, gash of the forehead, spontaneous breathing.<BR>Conscious Glasgow 15, has neck fixed in a Phil collar and put on a wooden backboard. <BR>Loaded onto the ambulance, pulls out towards trauma center, during loading left ankle external rotation , seemed like it was fractured. Oxygen 100% with rebreathing mask, manual pressure to bleed<BR>IV fixed in left antecubital , no fluids administered intentionally.<BR>Head injury seems only skin, guy very combatant but then starts to answer our questions. Mumbles that abdomen hurts. <BR>Head firmly stabilized on both sides to board. chest - no breath sounds to right chest, heart sounds heard vagely, good entrance to left, no sign of tension pneumothorax. <BR>Chest tube intentionally withheld. <BR>Abdomen completely soft, no hematoma, no specific tenderness, no rebound no fullness. Trousers opened but not completely removed. <BR>Hooked up to LIFEPACK 12 shows sinus rhythm, rate 112 oxygen saturation 84-89% maximum at one point 90%<BR>Automatic blood pressure cuff attached to right arm , consistently shows blood pressure 120/75 continues measuring this every 5 minutes all the way to the hospital with roughly same result.<BR>REspirations 40 per minute<BR>Can't manage to palpate pulses! Tried the femorals-nothing , over and over again , can't understand it. Radial pulse not palpable either<BR>I was sure nothing more than my own low proficiency! He's sweating, heaving and puffing but still responding verbally with significant irritablity. Radio in with details of victim to the ER where we arrive 35 minutes from departure . Last time he uttered a word. <BR><BR>He is examined, Blood pressure 60 systolic . An ultrasound performed on the trauma bed showing blood in the abdomen, a missed pelvic fracture found before anything else. A shout is heard prepare the Operating room. X rays are performed of chest and pelvis. Someone pours in fluids IV. Antibiotics are begun , I run back with the X rays : normal chest , bad fracture of right pelvis. Soemeone has inserted needles to the right upper chest.<BR>The orthopedic surgeoun is taping a heel to the ankle, the pelvis is tied with a sheet, catheter is inserted (after careful penile antiseptic of course). I the jerk still haven't passed on to anybody that I couldn't feel any pulses all along. He is then "rushed" to the operating room 30 minutes from arrival. <BR>I understand he had a ruptured aorta, ruptured spleen ruptured and badly bleeding liver. Declared deceased on the operating table.100 minutes after the time of injury. <BR><BR>Queries: <BR>Do you think he could have been saved if managed differently?<BR>Have you seen such a compromise of oxygenation because of liver damage alone probably causing limitation of right diaphragm (incidentaly no radiological evidence of lung contusion)?<BR>Has anyone else experienced such misleading information from these automatic electronic blood pressure recorders?<BR>Wouldn't the hospital staff relate differently had they noticed no pulses were registeded to the lower limbs early on in the game?<BR>Should every trauma room have seniors 24 hours a day in the ER so that things run as they should?<BR><BR>Let's all try and learn from this sad and devastating case. <BR><BR><BR><BR><BR><BR>Sody Naimer<BR>Goosh Katif Emergency Ambulance Team <BR>Israel 79779<BR>Fax. 972-8-6846329<BR>���� ��� ��� ����<BR><BR>------------------------------------------------------------<BR>Interested in YoYo's?<BR>Click-&gt; http://TheYo.com<BR><BR><BR>---------------------------------------------------------------------<BR>Express yourself with a super cool email address from BigMailBox.com.<BR>Hundreds of choices. It's free!<BR>http://www.bigmailbox.com<BR>---------------------------------------------------------------------<BR>�����b���C</BLOCKQUOTE><p><br><hr size=1>Do you Yahoo!?<br>
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