Crozet Annals of Medicine: Holiday Spirits

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Working in the ER during the holidays has its advantages. All the hospital administrators are at home, so the place runs efficiently. No elective surgeries are scheduled so there are plenty of hospital beds available and admitted patients go right upstairs. There are usually goodies in the staff lounge. Of course there are some downsides, too. The goodies may be fruitcake. You may be asked to climb up on a wobbly gurney and perform a 300lb deadlift in front of 20 spectators.

The radio call was all too familiar. A middle-aged female was entrapped in a car after a high speed crash. She had multiple deformities of her arms and legs. She had alcohol on her breath. It was eight o’clock in the morning.

The car had rolled over multiple times. Neither the driver nor the passenger was wearing seatbelts. The driver had been ejected from the car during the wreck and would not be coming to the ER. Ejection from a car during a crash is usually fatal (75 percent mortality).

The chain of survival was hard at work for this woman this morning. Multiple passersby called 911 on cell phones. First responders were quickly on scene and called for more resources. A heavy rescue vehicle was dispatched with specialized tools designed specifically to dismantle automobiles. The helicopter was standing by while the rescue crew prized the car apart, power saws ripping metal, hydraulics inexorably prying the flattened roof off. The chain of survival was stretched so tight it was practically humming and my part was coming up.

After a prolonged extrication, the flight crew stabilized the patient as best they could and delivered her to us. She was strapped to a long board with her neck immobilized in a hard plastic collar and her head taped to the board. She had many obvious injuries but what was most striking to me was that her right leg was flexed at the hip and inwardly rotated. Her knee cap had a small abrasion on it.

We put the patient to sleep, intubated her and turned to her many injuries. Her deformed bones were returned to anatomic alignment and splinted. Next we addressed her right hip. The injury pattern was so classic we call it a doorway diagnosis. Just glancing in from the doorway of the room an experienced practitioner could tell from the position of the hip that the patient had not been wearing a seat belt and had smashed her kneecap into the dashboard, driving her hip into a posterior (backward, toward the buttock) dislocation. These are time sensitive injuries as the blood flow to the hip is usually compromised until the hip is relocated and so I assigned an Emergency Medicine resident to relocate her hip. Reducing a hip is usually a matter of awkward brute force. This resident is a very mannered southern gentleman, with an elegant carriage and a genteel accent and approach to his duties. He is also well read and was anxious to try a novel reduction technique he had recently read about in an Emergency Medicine journal. He slipped his knee behind the patient’s knee and elevated his own knee into the classic Captain Morgan’s salute. This is the so-called Captain Morgan maneuver and is supposed to be quite successful but this hip was really stuck and did not budge.

I directed the resident to climb up on the narrow gurney and stand over the patient with his feet on either side of the patient’s hips. We usually assign spotters to catch the residents if they fall, but this resident declined any backup. I showed him how to clasp his arms together behind the patient’s flexed knee and using the strength of his legs deadlift the patient’s leg skyward. Two assistants held the patient’s pelvis firmly onto the gurney.

The EM resident, weighing in at 160 lbs, huffed and puffed and strained till his face was red and swelling. Nothing happened. I refined his posture and grip and he tried again. Still nothing. The trauma team looked on expectantly. The nurses paused in their duties to watch this contest. The biggest surgical resident in the room moved closer to the bed, clearly anxious to have a try. He looked like he weighed well over 200 lbs. I asked the EM resident if he wanted some help from this bigger fellow. As I expected, I got a brusque refusal from the slightly winded resident who was now even more determined to succeed. This determination led to some resourceful thinking. My resident directed the nurses to give a large dose of IV anesthetic, enough to completely relax all of the already anesthetized patient’s muscles. Once this dose took effect, the resident resumed his labors and with a mighty heave the hip audibly clunked forward, back into position.

We passed the patient off to the trauma team for definitive care (she would recover completely) and debriefed amongst ourselves. Among the many lessons we discussed, the single biggest take home message from this case was that almost none of these injuries would have occurred if the patients had been wearing seatbelts. It seems obvious but is worth reemphasizing. Always buckle your seatbelt!

Also, while Captain Morgan may inspire a novel orthopedic maneuver, it is never otherwise appropriate at 8 o’clock in the morning.