Friday, June 12, 2009
This was my second rotation at the Inova Fairfax Emergency Department. My prior study at Inova consisted of about 12 case observations, ranging from care for patients with significant hypertension, respiratory difficulty, wound care, substance abuse, cancer-related medical disability, syncope, and psychogenic issues; as well as procedures such as male patient personal care, cleaning medical equipment, electrocardiograms, ultrasound, and computerized axial tomography (CAT). My preceptor gave me high marks, but apologized that the round was “not very exciting.”
For my second study, I arrived at 6:40 AM, and was assigned to ER triage. The initial observed cases included leg joint swelling, abdominal pain (suspected early pregnancy), severed finger (construction accident), severe hypertension (BP 294/179) with acute abdomen, and a cancer patient with tachycardia (P 200). At about 9:00, we were notified of incoming code yellow and code blue vehicular trauma patients, transported by ambulance and air, respectively.
My preceptor assigned me to stand in a doorway between the two large ER patient care bays. Patient 1, the code yellow, arrived first, and was transferred to an ER bed in bay 1. S/he was alert, responsive and in severe pain. ER staff performed a rapid trauma assessment and identified probable pelvic fractures and lower abdominal injuries. The patient received x-rays in the bay, and was to advance to CAT scan. Cervical spine immobilization and backboard techniques were used throughout patient care.
Patient 2, code blue, arrived and was transferred to a ER bed in bay 2. Patient 2 received a Glasgow Coma Scale rating of 4 at the accident scene and 3 in the ER. (GCS scores range from 3 to 15, with 3 being most severe.) Prior to arrival, the patient was intubated by EMT personnel. The unresponsive patient was catheterized, given intravenous fluids and medications. Rapid trauma assessment indicated no obvious trauma beyond ecchymosis (bruising) and swelling about the left eye, and slowly reactive pupils. I helped transport the patient to CAT scan. I considerately asked a few questions. A medical resident, previously an EMT-paramedic, instructed me to ‘follow [and observe] this patient all day.’ Imaging showed approximately 2 cm midline deviation of the cerebrum. This indicated cerebral hemorrhaging and swelling. The patient and trauma team returned to the ER bay and further medications were administered. The patient received various assessments, including deep foot stimulation, for which s/he was unresponsive. The patient showed seizure activity in the arms. Subsequently, we took the patient to the Trauma Intensive Care Unit (TICU). The patient was evaluated by a neurosurgeon. An intracranial pressure (ICP) monitor was inserted by drilling a hole in the patient’s skull above the right ventricle and inserting a fiber optic measurement device. Patient position was managed, from Trendellenberg (feet elevated) to reverse Trendellenberg to observe ICP. ICP ranged as high as 85; normal is less than 15 mm Hg. Medications, including mannitol (an osmotic diuretic to reduce intraocular and intracranial pressures), were administered. The patient appeared to be roused, moving all four limbs, and a doctor worked to evoke a patient response by loudly calling the patient’s name, asking the patient to show two fingers, slapping the patient’s chest and squeezing the patient’s hand and arm. The patient did not respond to the stimulation.
ICP remained high. Medical staff inserted main line IV routes for high-volume administration of medications in the patient’s chest and arm(s). I maintained traction on the patient's right arm, to help manage swelling caused by the new line. Doctors indicated that surgery was required. We took the patient for a further CAT scan in order to image the current positioning of the brain. The patient was taken to an operating room (OR). Because I was not wearing surgical garb, I remained in an outer hallway. The patient was prepped for surgery, head shaved and orientation lines marked on the patient’s head (with lines indicating a left-superior cranial incision arc, from the top of the head to above the left ear). My preceptor returned from the OR and saw that I was outfitted in surgical garb — hat, mask, shirt, pants and booties. I put on gloves in the OR. There were approximately 12 medical personal in the OR, including the neurosurgeon and resident. I stood out of the way, about six to twelve feet from the patient, observing medical procedure and asking infrequent questions. The surgeon cut a rounded triangular skin and tissue flap (approx. 10x15 cm.) from the patient’s left superior cranium, and lifted this flap back to expose the skull (cauterizing vessels/tissues in the process). The surgeon drilled approximately six burr holes on the perimeter of the exposed skull area. (This procedure is termed craniotomy.) When the surgeon(s) subsequently pierced the dura mater beneath the skull, cerebrospinal fluid and blood gushed from the opening(s). The burr holes were connected by the surgical drilling/cutting instrument and the patient’s skull segment removed. (This procedure is termed craniectomy.) Incisions were made into the dura mater. Upon broad opening of the dura mater, the brain herniated about 2-3 centimeters from the plane of the skull. This was dramatic. It looked like patient’s brain leapt from its container. Several medical staff commented: “Did you see that? ... That’s not good.”
Surgeons reattached the patient’s skin and tissue flap and conducted various closing and wound care activities. I accompanied the patient back to TICU. The patient’s ICP was reduced, but s/he remained in critical condition. At 3:30 pm, I excused myself, returned my surgical garb, met with my initial preceptor (in ER triage), obtained signoff, and returned home.