Monday, July 26, 2010

“Tree fall”

25 July
What happens when you mix alcohol with tree cutting? - Nothing good, especially when the tree falls on you in the process. Charles and I are on call this weekend, covering the ICU, the ED, the two main wards and Pediatrics and the nursery. We do have a intern on call, and a clinical officer staffing the ED. After fairly uneventful rounds this morning, I was called at 3:30 PM by our surgery team to see a patient with them in the ED who was drunk and had volunteered to help some guys cut down a tree. In the process of pulling the tree over, he failed to get out of the way and it landed on his left shoulder and neck.
The patient was lying in the ED on his back with a cervical collar loosely wrapped around his neck to stabilize the spine but with every inspiration, you could hear a very guttural sound emanating from his airway. Clearly his upper airway was being compromised. With gentle traction stabilization of his head and neck, I opened the collar to inspect his neck. There was swelling of the neck laterally on both sides. We replaced the collar and tried to position him better to clear his secretions but he continued to struggle. We had our anesthesia nurse in house so we called her, anticipating this could be a challenging intubation. With heavy sedation and paralytic drugs, we were able to intubate him under traction without disturbing his neck. The rest of his trauma survey was clear so we focused on maintaining his airway.
So now Charles and I rotated bagging him for the next hour as we prepped the ICU for his arrived and got his X-rays done. The X-rays showed a clear C4-C5 subluxation of about 4-5 mm, a small anterior avulsion fracture and a shattered scapula on the left side. His lung was slightly bruised at the apex but otherwise he was remarkably spared more significant injury. Trouble is, his airway is going to be swollen for days, so we’ll need to keep him intubated for days as a result. Once in the ICU, I hooked him up to the ventilator, wrote orders to keep him snowed overnight and started him on steroids for the swelling in his airway. Now it’s time for the waiting game to see how he does.
26 July – We had a completely full house by Sunday PM. The ICU was the only place with an open bed, which I thought I was going to fill at 5 PM on Sunday when a 74 year old man was brought in with signs of a massive stroke. However, he herniated his brain into his brainstem within about 60 minutes of arrival an died in Casualty with Charles and I watching him through his final decline. He arrived with fixed and dilated pupils so we knew he had little chance of any brain function even before we started to treat him.
Our young man with the C-spine injury went off to surgery today. I hope to have him extubated in 2-3 days and he should do very well. He is amazingly fortunate, considering what his outcome could have been.

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