Two trauma scenarios

[Bjorn, Pret]

Don't know the specifics of your trauma system; but in Maine, case #2
would be referred for review by the trauma center.  The nature and level
of review is at the joint discretion of the hospitals involved, but
we've done on-site debriefings in far less alarming cases.

See what your system allows for, and reiterate your concerns to the
trauma center and trauma system administrator, or his/her local
approximation.  If you truly have a system, it has a performance
improvement function.  Find out who's in charge, and bird-dog it.
Trusting your version of events, there's clearly plenty to be learned at
all levels.

Best of luck.

Pret Bjorn, RN
Bangor, ME USA.

-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org] On Behalf Of Jenny Moncur
Sent: Thursday, May 01, 2008 8:11 PM
To: ccm-l at ccm-l.org; trauma-list at trauma.org
Subject: Two trauma scenarios


These two cases occurred on my shift the other day (I am a dispatcher at
the
moment so was co-ordinating ambulance and retrieval responses). They
represent the highs and lows of being a part of a health care system. 

 

Motor bike rider - lost control of his bike at a rural location just in
front of an ambulance returning from an interhospital transport with
three
intensive care paramedics on board. They jumped out, pt was decerebrate
with
obvious closed head injury. Intubated, sedated, paralysed within 10
minutes.
A helicopter was just passing overhead and was directed to land nearby.
Pt
transferred to chopper within 10 more minutes. Landed at major trauma
centre
15 mins later. Patient in trauma centre well within an hour from
incident
and now doing very nicely. Expected to make full recovery from closed
head
injury. I am not sure exactly what type of injury, but required
neurosurgical management. 

 

Motor car driver - lost control of her car and was partially ejected
with
car rolling. Ambulance crews on scene within ten mins - just outside
large
rural town. Rapid extrication and transferred to local hospital - scene
time
under 20 mins. I tried to organise heli evacuation but unable to get
rotary
or fixed wing due to weather conditions. Intensive care ambulance crew
in
area directed to hospital to aid rapid road transfer to major trauma
centre.
Hospital refused to allow patient to be moved - they had to x-ray
patient!!

Three and a half hours later a surgeon calls me to say he has a 'time
crtical' patient who needs a helicopter to fly to trauma centre. Still
unable to provide air support (weather) so send IC paramedic crew to
hospital to effect rapid road transfer. Apparently surgeon not notified
by
hospital until just before he had called me.

 

Shortly after that I get a call from the paramedic at hospital to say
that
this 28 yr old woman has bilat small heamopneumo thoraces, avulsed left
kidney, lacerated liver, torn spleen, suspected mesenteric artery
injury. 

She is having large amounts of IV fluids and blood, but does not have
chest
tubes, urinary catheter, nasogastric tube or ETT. She spent the best
part of
three hours in x-ray and cat scan. No operative management and going
downhill rapidly. 

I place a call to the trauma registrar at major trauma centre to see if
he
can speed things up. He is shocked to find out that patient still in
clutches of local hospital and her conditon. Several phone calls between
local hospital and trauma registrar trying to speed up transfer. 

Time elapsed now over four hours from initial injury.

Paramedic calls me 30 mins later to say he has demanded an anaesthetist
come
in to intubate this patient as her resp status and conscious state
worsening. As he has a two hour road trip to major trauma centre this is
a
resonable request. 

Patient finally escaped from local hospital 7 (seven) hours after intial
injury. Intubated, ventilated, one chest tube placed, lots of fluid and
blood products given but still very hypotensive and tachycardic.

Able to get a chopper in the air at that stage - arrived at trauma
centre 40
mins later.

Straight to theatre - over ten hours of operative management.

Left nephrectomy, aortic repair where renal artery torn; splenectomy,
hemicolectomy for mesenteric injury, liver packed - not sure what else.
Pt
doing very badly - developing ARDS, DIC, the whole works.

 

These two cases demonstrate to me the highs and lows of our trauma
system. 

The first patient could not have received quicker treatment unless he
dropped his bike in the car park of the Alfred Hospital. 

The second had the misfortune to be taken to a hospital with a junior
doctor
in ED who did not understand the state Trauma System, and no FACEM.
Surgeon
not involved until way too late. The whole thing so frustrating and a
young
patient who has been seriously compromised by delay in receiving
definitive
surgical care. 

 

There are big rumblings going on at a medical level at the local
hospital,
so maybe something will improve. 

My ambos are limited to taking any patient there if we cannot get air
support, as the next largest hospital with a FACEM is over 40 mins away.
I
finished my shift feeling very sad and frustrated.

 

Jenny Moncur

IC Paramedic currently in OpCen. 

Oz

 

 

 

 

 

 

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