you did what???

[Roy Danks]

Wow.  Crazy.  
 
Here's my "you did what?" case of the month.
 
I took over the trauma service (floor, for a week) this week and had transferred from the SICU a very young man with a colostomy, s/p perineal laceration (fall).  Here's the kicker: he was taken to the OR and underwent an ex lap (for a positive FAST) and had his perineal lac explored and repaired.  NO rectal injury...NONE...no colon or other bowel injury.  Small liver lac.  Very clear in the op report.  And, the surgeon notes, essentially, "we were in the abd, so we elected to make a diverting colostomy"....huh?!?!  Why?  
 
So, tomorrow, Saturday, my day off and my day to deer hunt, I'm taking him to the OR to reverse this less than 1 week old colostomy.
 
I don't know...I just don't know....scratch, scratch (my head, puzzled)
 
R



> Date: Thu, 22 Nov 2007 19:31:32 -0700> From: PatrickOffner at Centura.Org> To: trauma-list at trauma.org> Subject: Trauma case> > I have a case I would like some opinion on. The patient is a 19 yo who> fell while snowboarding and hit his head and left torso. He had about 15> seconds of unconsciousness. His main complaint was left posterior chest> wall pain. Evaluation at an outlying facility revealed a left 1st rib> fracture, left pulmonary contusion, occult left pneumothorax and a grade> IV splenic laceration without extravasation of pseudoaneurysm. He was> hemodynamically stable with a normal hematocrit. For some reason,> troponin was drawn and revealed mild elevation. He was transferred to us> for further management. We put him in our ICU for observation and> nonoperative management of his splenic injury. We felt that he likely> had a myocardial contusion as well. Subsequent EKG show 2mm ST segment> elevation in the anterior leads. Somehow, the pulmonary/critical care> service became involved (haven't figured out how yet)--but order serial> troponins, serial EKG's and an ECHO. I saw this the next day and made> fun of them to the nurses--asking how they got involved anyway.> Unfortunately, the echo shows normal cardiac function--BUT an apparent> thrombus in the inferior IVC just below its junction with the atrium.> Well this starts the ball rolling---CTA, MRA, cavagram, IVC filter> placement and full anticoagulation. The IVC gram showed a clear thrombus> adherent to the IVC just above the confluence of the hepatic> veins--measuring about 1.5 x 2 cm. All of this was accomplished over a> 24 hour period when I was off. When I got back, I was worried that this> was VOMIT. I would not have even gotten the echo to begin with. But the> IVC gram seemed pretty clear cut when reviewed with the interventional> radiologist. Fortunately, the kid has done well. NO splenic> complications despite anticoagulation--although I used a conservative> PTT target of 50-60. Repeat duplex ultrasound shows persistent thrombus> that is smaller--now about 1 cm. My plan is to continue his> anticoagulation for the present and repeat the duplex in 3 or 4 days. If> the thrombus has completely resolved, I want to stop his anticoagulation> altogether. Would anyone continue it for 3-6 months empirically? Would> anyone just stop it now? > > > Patrick J. Offner MD MPH> Chief, Surgical Critical Care> St Anthony Central Hospital> > > *****************************************************************************> This communication is for the use of the intended recipient only. It may > contain information that is privileged and confidential. If you are not the > intended recipient of this communication, any disclosure, copying, further > distribution or use thereof is prohibited. If you have received this > communication in error, please advise me by return e-mail or by telephone and > delete/destroy it.> *****************************************************************************> --> trauma-list : TRAUMA.ORG> To change your settings or unsubscribe visit:> http://www.trauma.org/index.php?/community/
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