Crozet Annals of Medicine: “I’ve Got to Go!”

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Look sharp, be sharp. That’s what I was taught in medical school. It is generally true, I thought, as I put on my freshly laundered, medium-starched, pristine white lab coat. I snugged up my red power tie over my striped shirt and buttoned up my lab coat. I was ready for whatever the day threw at me.

Whenever you feel that you are ready for whatever the day throws at you, be careful.

My first patient of the day was a muddy mess. Found fifty feet from a crashed and flipped pickup truck, he had no recollection of how he arrived in our trauma bay. He kept insisting he was in a convenience store and had been dropped off there by his buddy. The helicopter crew that brought him in just shrugged. No other body or buddy had been found on the scene.

It was a bit of mystery what had befallen him for there was not a mark on him. We presumed he had been ejected from the vehicle. He was covered in mud but had no cuts, abrasions or limb deformities.

He was polite and well-mannered but perseverated anxiously over finding his buddy to drive him home.

Whenever a trauma patient arrives by helicopter we assemble a large team to do the initial evaluation. Multiple nurses, techs, residents, respiratory therapists, pharmacists, X-ray techs, medical students and paramedic students were milling about the trauma bay waiting to see what direction this case was going to go.

This is when we decide if the patient is “sick” or not (see last month’s column). Generally patients ejected from motor vehicles have a high likelihood of severe injuries, so we were keeping an open mind and what we call a “high index of suspicion.”

The team swarmed the patient, swiftly cutting off all his clothes with the ferociously effective trauma shears that ER nurses carry. These shears are capable of cutting through pennies, a common parlor trick in the ER during down times. Simultaneously, other team members were taking vital signs, inserting IVs, applying oxygen, ultra-sounding the abdomen for signs of bleeding, and performing primary and secondary surveys for any occult injuries.

As the evaluation progressed the patient became more and more agitated. This is common in head injuries.

“I’ve got to go!” he kept insisting as he struggled to get out of the bed.

I was at the head of the bed and was able to calm him down multiple times by distracting him with banal and unexpected questions.

“What kind of truck do you drive? What color is it?”

The questions distracted him and forced him to focus his attention momentarily away from what was happening around him.

Eventually, though, his head injury overcame his normal inhibitions and he exploded, shrieking and grabbing at me and trying to leap from the table. In the struggle my pristine white coat was splattered with red clay mud. Oh dang, that was not going to come out! I was a little nonplussed. So much for looking sharp.

The team was experienced, though, and expected the move. Many hands grabbed the patient and quite gently restrained him onto the bed to protect him from further injuring himself. We administered increasing doses of sedatives and the team patiently held their positions while waiting for the sedatives to take effect. Despite the wild thrashing violence of the patient the team was calm and conversed quietly amongst themselves. Pros.

Suddenly a second explosion occurred and the source of some of the patient’s agitation became evident as a cascading fountain of urine poured forth, spraying several unfortunate teammates before a urinal was procured and contained the mess. Amazingly, no one broke their hold.

“Oh! I got peed on!” the nurse next to me wailed. “Again!” she added.

“You are pretty muddy, too,” I observed.

“How was work today, honey? Anything interesting happen? Why are you so dirty? Is that pee I smell?” I mock asked her.

“I know, right?” she gamely replied and gave me a grin. “No, just the usual, you know, got peed on again.”

“I am so sorry that happened to you.” I added.

She smiled sincerely and said to me, “No big deal, I had boys. This is not the first time this has happened to me.” And with that she put it behind her and continued to care for the patient.

Sometimes you don’t have to look sharp to be sharp.

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