Windy December
Helani walked into the resuscitation room, or the R room, as it is known here. When this trauma center was designed a few decades ago, they had decided a 5m x 5m square is adequate for the purpose of resuscitation. It had not changed much since then thanks to the resistance of the nursing staff; with much trying by enthusiastic doctors, its wall cupboards were now labeled to indicate what was in there; there was a trolley like the ones you see at supermarkets, which served as the crash cart. The room was air conditioned. It had 3 doors, one of which was permanently blocked by cupboards. One door opened to the triage area; staff used the other entrance, which opened to the general treatment bays. The anaesthetists and the emergency physicians chose to stay inside the R room while the rest of the staff members arrived only at the triage bell that indicated the arrival of a category 1 or 2 patient.
There were 3 comfortable chairs next to a table fixed to the wall. The X ray viewers were posted on to the same wall, making it easier for the doctors sitting there to appreciate the X rays. There was a scanning machine next to this table, and two telephones. Several on call rosters were hanging from the wall.
This is going to be her work place for the coming months.
She did not have much time for introductions as the first patient for the day was wheeled in: a woman in her late thirties who had jumped from the first floor in a suicide attempt.
The staff gathered around the patient. It was not difficult to see that they lacked much training in their approach; one or two people actually did anything while the others just observed. The family was chased out of the room: we will call you if necessary!
The woman was unresponsive; her breathing was slow and shallow. Helani connected the monitoring equipment while the anaesthetist, Dev, examined the chest. Air entry and saturation was alright; the heart rate was 84/minute with a blood pressure of 140/90 mmHg. The only response was extension; pupils were size 5 and nonreactive. The patient had an irregular deep laceration over right forehead with some bleeding. Exposure showed a massive swelling of the right femur, indicating a fracture there.
The patient was intubated; IV access was obtained and a saline was commenced. A splint was applied to the right leg. Bedside blood sugar was 187 mg/dl. A blood sample was sent for cross matching as it was obvious she needed emergency surgery. Considering the fact that she was most likely showing Cushing's response, 150ml of 3% saline was infused.Thereafter, the patient was taken for radiological studies.
The resuscitation room was a little calm for a few minutes. Radiology department offered inward CXR but nothing else; for other X rays the patient had to be taken to the X ray room which was near-by; a doctor would come for FAST scans. Fortunately, the CT room was not too far.
The patient had an SDH measuring 1.5cm at the widest point, with a mid line shift of around 7mm; the brain stem was already tight with loss of gray-white demarcation there. The neurosurgical doctor was summoned. They did not have a free theater to take her immediately, so they arranged transfer to an ICU, which again, was going to take some time. The right femur had a spiral fracture and the orthopaedic team advised to apply traction to it. Capnographic monitoring was in place but the trolley the patient was in did not have any facility to raise the head end. Her MAP remained high, due to Cushings reflex.
"Have you explained to the family?" Helani asked.
"I told her husband that the CT shows bleeding." answered Minari, who accompanied the patient for CT.
"Can I call them in?" Helani asked, as she was new here.
"Please don't, doctor, the relatives are not allowed in here!" the nurse replied.
So, Helani stepped outside, where two women were waiting with tear-filled eyes. They rushed to her even without being called.
"I'm the sister of hers" one woman identified herself.
The conditions were all unsatisfactory for breaking bad news: it was the corridor at the entrance leading to treatment areas; there was no privacy at all, with many people including staff, patients and visitors watching; there were no chairs to offer the family and for a second, Helani wondered what she could do in case any of the women fainted right there after hearing the news. But there was no turning back now so she decided to do the best she could. With a calm voice, she explained to them what had happened, what they intended to do, how long it is going to take and the grim prognosis despite the treatment. She knew that she should invite any questions, but stopped for a moment. The sister said the patient had just started treatment for depression and that she had several small children. She had a strong family history of depression as well. Helani just listened. The other woman, who was an elderly relative, asked if there is any drug which needs to be bought from outside. Helani explained this was not needed at the moment.
The discussion had to be ended due to the arrival of the next patient: a woman in her forties who was brought in because she had 'fallen'.
One glance at the patient showed that she was unconscious and not breathing. Helani started chest compressions but as the trolley was too high, she could not exert enough force. Dev quickly took over. The two nurses came with a cannula and started looking for veins. Helani found an ambu bag. The monitor was finally connected and it showed asystole. Dev seemed to be new or excited, as he did not follow 30:2 ratio and even the hand placement appeared to be more to left than on the central sternum but this was not the time to discuss this. Adrenaline was given and a saline was started. Helani noted the time. The teenage son who had brought the patient in had been sent outside. Helani handed over the ventilation to a nurse, and went to talk to him- patient did not have any obvious injury and the history needed to be explored.
The patient had diabetes and hypertension. She slipped and fell while going to kitchen; then she was helped to a sofa, but she did not talk. Breathing was laboured. So he called the neighbours and brought her to hospital. Helani briefly explained that it could be a heart attack, the patient was in cardiac arrest and the staff are trying their best but her life is uncertain at the moment.
The patient was resuscitated for 45 minutes. The rhythm converted to a VF and Helani asked for the defibrillator. By this time, Minari was giving compressions, and Helani was providing ventilation. Dev struggled with the defibrillator- he could not get ECG signal from the machine. He, and the nurses did not know how to select the lead so Helani had to attend to it. Obviously, the machine was not used frequently in this setting, which has led to the unfamiliarity. After the third shock, the rhythm converted to a PEA and following an adrenaline bolus a pulse returned. The patient was intubated. However, she went back to asystole and could not be recovered from it.
Dev started documenting the events- there was no scribe here and everything had to be recorded retrospectively. The son now returned with the adult neighbours who wanted to know details regarding release of the body. Helani explained that an inquiry into death and possibly a post-mortem is needed in this situation. A note will be sent from here to the hospital police post, and the family should go there and discuss the proceedings. It was unlikely that they would be able to get the body until the following day. However, the situation would have been different if the patient was a Muslim. Muslims would contact their politicians and administrators and try to get the body released somehow. Helani had enough experience on this.
The main issue that came to light with this patient was the disadvantage of separating the medical emergency treatment unit from the trauma unit. The medical ETU was situated about 200m away. The field triage by the family and the vehicle drivers is 'slipped and fallen therefore trauma unit'. Same applies to hospital security officers and gate keepers, and even the triage nurses. Like this patient, many patients with medical conditions such as acute coronary events, arrythmias and metabolic imbalances are brought to the trauma unit because 'fallen' is the immediate problem the family has identified. The isolated trauma unit staff is often not trained to handle medical emergencies and the unit itself is unequipped to handle medical cases. Transferring these patients back to the medical ETU is not that easy either. If the patient has the smallest wound as a result of the fall, the medical ETU staff tend to resist acceptance of the patient. If a patient is unconscious following a fall, the trauma unit priorities include sending for CT scan etc. and it may take a long time to identify the metabolic derangement or the ECG changes, which would have been the priorities at the medical ETU, or, at a place that accepts both types of patients.
The third patient arrived before Helani could ponder on these thoughts for too long. He was an elderly man, with a neck cut. His shirt was soaked with blood. Despite the frightening appearance, the patient appeared calm. He spoke. It was again a suicidal attempt but fortunately, the cut was superficial. The vital signs were stable and the bleeding had already stopped. IV access was obtained and the ENT team were summoned in. The patient was questioned to identify any drug ingestions or other injuries. AMPLE history was taken. He was sent to general treatment side.
And Helani decided to run to the cafeteria for a snack. She was already drained.
There were 3 comfortable chairs next to a table fixed to the wall. The X ray viewers were posted on to the same wall, making it easier for the doctors sitting there to appreciate the X rays. There was a scanning machine next to this table, and two telephones. Several on call rosters were hanging from the wall.
This is going to be her work place for the coming months.
She did not have much time for introductions as the first patient for the day was wheeled in: a woman in her late thirties who had jumped from the first floor in a suicide attempt.
The staff gathered around the patient. It was not difficult to see that they lacked much training in their approach; one or two people actually did anything while the others just observed. The family was chased out of the room: we will call you if necessary!
The woman was unresponsive; her breathing was slow and shallow. Helani connected the monitoring equipment while the anaesthetist, Dev, examined the chest. Air entry and saturation was alright; the heart rate was 84/minute with a blood pressure of 140/90 mmHg. The only response was extension; pupils were size 5 and nonreactive. The patient had an irregular deep laceration over right forehead with some bleeding. Exposure showed a massive swelling of the right femur, indicating a fracture there.
The patient was intubated; IV access was obtained and a saline was commenced. A splint was applied to the right leg. Bedside blood sugar was 187 mg/dl. A blood sample was sent for cross matching as it was obvious she needed emergency surgery. Considering the fact that she was most likely showing Cushing's response, 150ml of 3% saline was infused.Thereafter, the patient was taken for radiological studies.
The resuscitation room was a little calm for a few minutes. Radiology department offered inward CXR but nothing else; for other X rays the patient had to be taken to the X ray room which was near-by; a doctor would come for FAST scans. Fortunately, the CT room was not too far.
The patient had an SDH measuring 1.5cm at the widest point, with a mid line shift of around 7mm; the brain stem was already tight with loss of gray-white demarcation there. The neurosurgical doctor was summoned. They did not have a free theater to take her immediately, so they arranged transfer to an ICU, which again, was going to take some time. The right femur had a spiral fracture and the orthopaedic team advised to apply traction to it. Capnographic monitoring was in place but the trolley the patient was in did not have any facility to raise the head end. Her MAP remained high, due to Cushings reflex.
"Have you explained to the family?" Helani asked.
"I told her husband that the CT shows bleeding." answered Minari, who accompanied the patient for CT.
"Can I call them in?" Helani asked, as she was new here.
"Please don't, doctor, the relatives are not allowed in here!" the nurse replied.
So, Helani stepped outside, where two women were waiting with tear-filled eyes. They rushed to her even without being called.
"I'm the sister of hers" one woman identified herself.
The conditions were all unsatisfactory for breaking bad news: it was the corridor at the entrance leading to treatment areas; there was no privacy at all, with many people including staff, patients and visitors watching; there were no chairs to offer the family and for a second, Helani wondered what she could do in case any of the women fainted right there after hearing the news. But there was no turning back now so she decided to do the best she could. With a calm voice, she explained to them what had happened, what they intended to do, how long it is going to take and the grim prognosis despite the treatment. She knew that she should invite any questions, but stopped for a moment. The sister said the patient had just started treatment for depression and that she had several small children. She had a strong family history of depression as well. Helani just listened. The other woman, who was an elderly relative, asked if there is any drug which needs to be bought from outside. Helani explained this was not needed at the moment.
The discussion had to be ended due to the arrival of the next patient: a woman in her forties who was brought in because she had 'fallen'.
One glance at the patient showed that she was unconscious and not breathing. Helani started chest compressions but as the trolley was too high, she could not exert enough force. Dev quickly took over. The two nurses came with a cannula and started looking for veins. Helani found an ambu bag. The monitor was finally connected and it showed asystole. Dev seemed to be new or excited, as he did not follow 30:2 ratio and even the hand placement appeared to be more to left than on the central sternum but this was not the time to discuss this. Adrenaline was given and a saline was started. Helani noted the time. The teenage son who had brought the patient in had been sent outside. Helani handed over the ventilation to a nurse, and went to talk to him- patient did not have any obvious injury and the history needed to be explored.
The patient had diabetes and hypertension. She slipped and fell while going to kitchen; then she was helped to a sofa, but she did not talk. Breathing was laboured. So he called the neighbours and brought her to hospital. Helani briefly explained that it could be a heart attack, the patient was in cardiac arrest and the staff are trying their best but her life is uncertain at the moment.
The patient was resuscitated for 45 minutes. The rhythm converted to a VF and Helani asked for the defibrillator. By this time, Minari was giving compressions, and Helani was providing ventilation. Dev struggled with the defibrillator- he could not get ECG signal from the machine. He, and the nurses did not know how to select the lead so Helani had to attend to it. Obviously, the machine was not used frequently in this setting, which has led to the unfamiliarity. After the third shock, the rhythm converted to a PEA and following an adrenaline bolus a pulse returned. The patient was intubated. However, she went back to asystole and could not be recovered from it.
Dev started documenting the events- there was no scribe here and everything had to be recorded retrospectively. The son now returned with the adult neighbours who wanted to know details regarding release of the body. Helani explained that an inquiry into death and possibly a post-mortem is needed in this situation. A note will be sent from here to the hospital police post, and the family should go there and discuss the proceedings. It was unlikely that they would be able to get the body until the following day. However, the situation would have been different if the patient was a Muslim. Muslims would contact their politicians and administrators and try to get the body released somehow. Helani had enough experience on this.
The main issue that came to light with this patient was the disadvantage of separating the medical emergency treatment unit from the trauma unit. The medical ETU was situated about 200m away. The field triage by the family and the vehicle drivers is 'slipped and fallen therefore trauma unit'. Same applies to hospital security officers and gate keepers, and even the triage nurses. Like this patient, many patients with medical conditions such as acute coronary events, arrythmias and metabolic imbalances are brought to the trauma unit because 'fallen' is the immediate problem the family has identified. The isolated trauma unit staff is often not trained to handle medical emergencies and the unit itself is unequipped to handle medical cases. Transferring these patients back to the medical ETU is not that easy either. If the patient has the smallest wound as a result of the fall, the medical ETU staff tend to resist acceptance of the patient. If a patient is unconscious following a fall, the trauma unit priorities include sending for CT scan etc. and it may take a long time to identify the metabolic derangement or the ECG changes, which would have been the priorities at the medical ETU, or, at a place that accepts both types of patients.
The third patient arrived before Helani could ponder on these thoughts for too long. He was an elderly man, with a neck cut. His shirt was soaked with blood. Despite the frightening appearance, the patient appeared calm. He spoke. It was again a suicidal attempt but fortunately, the cut was superficial. The vital signs were stable and the bleeding had already stopped. IV access was obtained and the ENT team were summoned in. The patient was questioned to identify any drug ingestions or other injuries. AMPLE history was taken. He was sent to general treatment side.
And Helani decided to run to the cafeteria for a snack. She was already drained.
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