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Imagine this scenario. Your longterm cardiac cripple patient – the one you successfully rescuscitated from a VF arrest some 8 years ago and who has eked out an existence due to an implantable defibrillator – has finally succumbed to a chronic illness and is deceased.
You’ve managed to wade through the completion of the death certificate – but 3 hours later are telephoned by the Funeral Director who tells me that the patient is to be cremated.
Here’s the question – does the ICD need to be removed? If so, does it need to be deactivated first? And can you do this as a “Medical Macgyver” with just a multitool and a strong arm?
Needless to say it is a Saturday and the cardiology clinic is closed until Monday. The nearest tertiary hospital is 600km away…
Would you cut the wires?
Dates Confirmed for Masterclass in Rural Practice
Friday 15th & Saturday 16th November 2013 on Kangaroo Island
sapmea is holding a Masterclass in Rural Practice on Kangaroo Island, with a focus on teamwork, hospital based equipment, checklists, protocols and a higher level of management of psychiatric, medical, airway, trauma and obstetric difficulties.
There will be a Trauma Surgeon, Obstetrician, Psychiatrist, Paramedics and the fabulous MedSTAR team as well as key rural GP’s on tap to discuss and work through issues.
Please email Erin Gray email@example.com with your registration of interest.
Hope to see some of you there…
New content (mostly ‘Hypothetical Cases’ and ‘RDN Podcasts’ with various people) will be added here to allow automatic RSS feed via posts. More Cases and Podcasts are collated under the respective menu tabs as individual pages.
Here’s a list of Cases & Podcasts to date – more content should be automatically added here in future…
03/05/13 – Dr Penny Wilson – GP Obstetrician – @NomadicGP
30/04/13 – Dr Gerry Considine – Rural GP Registrar @RuralFlyingDoc
It is a quiet Sunday morning and you are thankful that most of your community is either in Church, still hungover from the night before or otherwise enjoying an illness-free day off…
…until the local ambulance rings to advise that they are 15 minutes out with a young woman who has been kicked by her horse and suffered a head injury.
There is ‘lots of blood and she is unconscious’. They request that the Duty Doctor be present at the hospital on their arrival. You arrive at the hospital with about 7 minutes to spare. Your team is the usual day shift complement of two RNs, plus a carer.
Q1: How will you use this time to prepare?ANSWER – preparation of self, team, environment…then patient On the phone advise the nursing team that you are leaving immediately and will be with them shortly. On the meanwhile they need to contact the oncall theatre team and any available extra staff. They need to prepare personal protective equipment (gown/glove/goggles) for what is essentially a trauma call. They should ensure the resus bed is clear, adequate space and lighting, and have available oxygen-suction-airway adjuncts-warmed fluids etc. They should draw up intubation agents I would encourage them to use the RSI kit dump and bring both standard resus trolley and difficult airway trolley’s to the resus bay. On drive in, mentally prepare for management of head injury sing standard C_ABC approach. Unless peri-arrest, take 45 secs to get a structured ISBAR handover from the paramedics, then perform own assessment as a team. – cervical collar : may make intubation attempts difficult, may need MILS – airway threatened through loss of protective airway reflexes; will need RSI. I’d opt for ketamine/roc. Run through plans A_B_C_D in head and be prepared to articulate this shared mental model to the team – breathing; will need to optimise to avoid hypoxia and hypercarbia. Consider vent settings and post-intubation sedation. Exclude HTX, pTX, flail. – circulation: “find the bleeding, stop the bleeding” IV access will be needed. Avoid hypotension in TBI. Identify any obvious sources (scalp, long bones, abdo, pelvis and Rx accordingly). Two good IVs, plus possible minimum volume extension sets for infusions, via sideport – diasability: initial GCS on scene and subsequent changes. Look for evidence of base of skull fracture, maxillary injuries and pupil inequality – exposure : log roll, glucose etc Use this shared mental model on arrival to manage the patient
On arrival the patient is a previously well 19 yo whom you recognise. She has a Guedel oropharyngeal airway in situ, RR is 18 and noisy, SpO2 on NRB is 97%. Pulse is 90, BP is 130. Her eyes remain closed even to painful stimuli, she makes incomprehensible noises and withdraws from pain. She has matted blood on her left scalp and on palpation you suspect a depressed skull fracture. Pupils are equal but sluggish.
Q2: What next?
ANSWER : At present A,B.C are covered – but D is a concern. Obtain IV access and have IV fluids running. She clearly is “big sick” and her needs outstrip the available capabilities of your hospital. Having the retrieval service on speakerphone is helpful – again an ISBAR handover to explain the situation, and share decision-making. An ideal retrieval service will coordinate patient disposition, meaning you dont have to waste time rnging around neurosurgicl units but can focus on the task in hand.
Priorities therefore will be around anticipated clinical course – airway needs to be secured without causing any of hypoxia, hypercarbia or hypotension. ketamine is an ideal induction agent in head injury (despite previous concerns of raised ICP). Suxamethonium is a short acting paralysing agent – potential advantages of wearing off if CICO, but this is falsely reassuring. Once decision made to secure the airway, then this course of action is what needs to occur – many would now use rocuronium (also diminishes risk of incr O2 consumption through fasiculation).
Team brief – RSI kit dump – challenge response check list
Standard pre-oxygenation 4 minutes, have high flow nasal cannulae for apnoeic diffusion oxygenation during intubation attempt
Ketamine 1-2 mg/kg induction with rocuronium 1.2mg/kg for paralysis
MILS & Cricoid – convert to ELM if view hard
Plan A – direct laryngoscopy with a bougie, pre-loaded Kiwi grip or the new ‘D grip”
Plan B- consider VL
Plan C – place a SGA iLMA and intubate through that
Plan D – surgical airway
Once intubated, maintain normocarbia and normotension. Regular neuro obs – DO NOT TAPE THE EYES as will obscure pupillary changes. Continue to package for transfer – NGT, IDC, A line etc
20 minutes later you notice that her left pupil is dilated to 6mm and unresponsive to light. The retrieval team are about 3 hrs away. You are still trying to get through switchboard to get neurosurgical advice from the nearest tertiary centre.
Q3: What is going on and what can you do about it?
ANSWER : she has an extra-axial haematoma causing pupillary inequality. She needs a hole in the head. Mannitol or HTS will buy you some time, whilst you consider your options.
Will you do this? Or wait for transfer?
WATCH THIS VIDEO FROM NEUROSURGEON AND HEMS DOCTOR, MARK WILSON
CLICK THE ‘COMMENT’ BUTTON AT THE TOP OF THIS POST TO LEAVE YOUR THOUGHTS…
It is 2am when the hospital calls. There has been a normal vaginal delivery attended by the experienced local midwife in the Hospital birthing suite – but during controlled cord traction the cord has separated from the placenta which is retained.
Your obstetric colleague is also on the way in but has asked for your assistance should a manual removal of placenta in theatre be needed.
The drive in takes six minutes. What extra information would you require and what would be your approach to this patient?
Answers invited – the prize for best answer(s) will be an invitation to a future RuralDoctorsNet podcast…
CLICK THE ‘COMMENT’ BUTTON AT TOP OF POST TO LEAVE A COMMENT
A 23 yo man presents with pain in his right shoulder after slipping on the wet floor of the men’s room in the local pub. He is right handed. He appears mildly intoxicated and admits to 3 beers and a plate of moussaka 45 minutes ago. Clinically you suspect a right shoulder dislocation.
Part A – three questions :
- what methods are available to you to fix this man’s problem?
- is imaging required? Justify your answer.
- what sequelae may he suffer?
Two weeks later the same young man is back, this time complaining of pain in the left wrist after a fall on an outstretched arm at the local Footy club. His left wrist appears sore over distal radius with some marked swelling & deformity but is neurovascularly intact. He admits to three beers and a party pizza shared with his footy mates some 45 minutes ago.
Part B – three more questions
- what options do you have to prove or disprove the presence of a fracture?
- what are your options to fix his problem if there is an underlying Colle’s fracture ?
- is he unlucky?
Answers invited – click the LEAVE A COMMENT button at top of this post to reply.
The prize for best answer(s) will be an invitation to a future RuralDoctorsNet podcast…
ANSWERS ARE IN !
Congratulations to Dr Bernadette Morris from NSW for supplying answers to Case #1.
He needs his shoulder relocated. Check out the numerous options at shoulderdislocation.net. My favourites include the Zagorski & Cunningham methods.
Whilst plain films are preferred (ideally the AP and lateral/scapular Y views)) this may be difficult for the solo operator or in remote areas. Of course this does not preclude the need for a thorough history and clinical examination prior, especially to avoid causing harm (eg: mistaking a humeral fracture for a dislocation). A non traction/counter-traction method is ideally suited for primum non nocere.
Most shoulder dislocations will be anterior or antero-inferior (subcoracoid & subglenoid respectively). There is an excellent recent review of posterior dislocation at the Blunt Dissection
In terms of associated injuries, don’t forget to check for fractures (30%) including Hill-Sachs, Bankart lesion and SLAP. Ligamentous injury may include glenohumeral ligament and rotator cuff damage. Nerve damage may involve isolated axillary nerve damage or brachial plexus injuries. Vascular injury is also possible and should be excluded.
First time dislocators should have follow-up X-ray, mandatory if neurovascular deficit, suspected fracture fragment or difficulty relocating the joint. Recurrent dislocators may elect to avoid this. Evidence for sling vs full immobilisation is equivocal; most will mobilise the joint as soon as tolerate pain.
Check out shoulderdislocation.net for more FOAMed goodness on this topic.
Classic ‘dinner fork’ deformity (dorsally displaced and angulated) suggests a Colles’ fracture. X-ray can be useful and is relatively straight-forward to perform and interpret.
X-ray does need to be repeated post-reduction – which can take time to develop films and require re-do of carefully applied plaster. Ultrasound can be useful both to diagnose fractures and to confirm adequate reduction – and has advantage of being a quick bedside test. There is a short four minute video on this from Academic Emergency Medicine
In terms of treatment, he is unfasted and so you may prefer to use a regional technique such as either a Bier’s block, axillary block or a haematoma block.
Needless to say sedation in the unfasted patient is not without risk and I would prefer to either wait until adequate gastric emptying or to secure his airway with a formal RSI, GA-ETT-IPPV for the duration of the procedure. Axillary nerve block is possible with ultrasound – but requires some practice!
For the isolated practitioner, haematoma block may be preferred. Tempting though this is, be aware that a Cochrane review suggested poorer pain relief and adequacy of reduction of haematoma vs intravenous regional anaesthetic techniques, data also supported by BestBETS
Is he unlucky? Perhaps. However you may wish to counsel him on alcohol use and associated trauma!
The issue is whether such incidents be classified as accidents or not. It was over 10 years ago that the BMJ ‘banned accidents’ – suggesting that we abandon terminology such as ‘motor vehicle accidents’ in favour of ‘motor vehicle collisions’ or ‘crashes’. If we are serious about trauma, then there is porbably more bang for buck in trauma prevention – it may not be as glamorous as working in ED or the prehospital environment – but perhaps money is better spent on prevention than cure. I was inspired a few years ago hearing Dr Karim Brohi of trauma.org talking on “being the fence at the top of the cliff rather than the ambulance at the bottom!”
Stay tuned for next case…
These hypothetical FOAMed cases illustrate various concepts useful to the experienced Rural Doctor.
A new case will be added every fortnight starting May 2013.
Comments on cases as they evolve are welcomed.