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Guess the Management

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DriftingBore

Labs would be useful, and to check he wasn't drinking.

Yes. However, alcohol is going to come quite far down our list, we've got other problems to deal with first, and if done for legal reasons needs a police surgeon (FME) to do it IIRC.

Reply 21

Renal

DriftingBore

I thought a GCS (Glasgow Coma Scale, right?) of 14 indicated a minor problem. What are the individual E/V/M ratings? Sorry if I'm being and idiot.

GCS

14 indicates a minor problem at the moment - does that mean everything's okay? This chap has a verbal score of 4 - he's confused or disoriented - in someone who's had a car crash is this a good thing?

Reply 22

Philosoraptor

It depends what kind of scans you're gonna want - Xray is available 24/7 in a separate room and also in resus.

(At least in UCH)

Reply 23

Renal

We'll have XR in resus for the purposes of this.

Right, the punter is here;

The ambulance crew run in with the punter on a stretcher, you see that his neck is collared and blocked and that he's immobilised on a backboard.

You lean forward for a closer look as the team drag him onto the trolly, he looks to be in a bit of a state, but at least he's quiet.

At this moment the A&E domestic pops his head through the door - 'Doctor, he's bleeding loads from his right leg - all over the floor. You've got to stop that bleeding stat!'

What's next?

Reply 24

martin101

Im guessing the ambulance crew would notice serious blood loss and let you know? That said I wouldnt take that for granted and upon admission Id want a damn good external exam (RTAs generally dont just damage one bit) and be prepared for an transfusion. Get an ABG for ****s and giggles, pump the guy with some morphine for the pain (Im guessing it hurts). His neuo symptoms and the low BP would seem to fit with shock symptoms but arent in the critical zone, so I think an XR would be rather handy to fit in about now(in addition to the leg XR id want a CXR)

Reply 25

Elles

Stop distracting me, I will deal with your leg later - but first I will save your life!
Airways (+C spine), Breathing, & Circulation...

*walks up to patient with ATLS montage hands irregardless of collar & becomes thrown by the fact there is a whole team of people there, so she may not have to do everything separately & sequentially!* :eek:

Reply 26

jc123

As a first aider I would raise the leg and bandage. And replace the bandage after the blood comes through 2 layers of bandage.

Reply 27

martin101

pressure, transfuse 1 unit O neg. How bad is the wound? does it require surgery to fix it up?

Reply 28

Renal

Martin, JC, you've got good ideas but you've skipped ahead a bit.

Well done Elles, but you're the Team Leader - are you going to do ABCs?

Nurses do ABCs??

OK, I haven't done A&E, so this is a bit of guesswork, but hopefully slightly more accurate than previous attempts (which it should be, given I have more clinical experience even if not A&E specific).

Get someone else to stop the bleeding while you whack up some oxygen, sort ABCs, do a primary survey, and do the usual venflon + bloods job? We'll give him some fluids too; just crystalloids to start with, but might well need an urgent cross-match.

Try to reassess GCS. Try and get any kind of history if he's coherent.

In between all the mayhem, try to do some examinations (neuro, cardio, resp, abdo in something like that order). We're going to need an ECG if the ambulance haven't already done one. Ditto some morphine.

Have a look at the leg (or get orthopod-on-call if they're there yet), decide about need for exploration, x-ray etc. If it's an open fracture he's going to need IV antibiotics.

Basically, we need to find out what's going on with the leg but also why his GCS is low and his obs are kooky - suggests some kind of head injury and can't rule out a degree of CV compromise. Given how very senior and important I am, various of these jobs can be done by nurses (obs, ECG, ABC) or my minions (venflons, examinations, etc). Multidisciplinary team love in action!

Then kick the SHO's arse for eating my haribo.

Reply 31

DriftingBore

That was great Renal, you should teach. Maybe you would need a little more patience... :wink:

Reply 32

Renal

jc123

Nurses do ABCs??

What do A and B stand for? Who do we have in the team who specialises in playing with them? The nurses will probably get on with attaching the patient to all the machines that go beep without being told but it's always nice to ask, they'll tell us a bit about C in a minute.

Oh, and our patient's mother has just walked into the department, what are we going to do with her?

Reply 33

Helenia

Renal

Is the anaesthetist there already? :eek:

I'd like someone to take mum to the relatives room, or at least out of resus.

Unless he has signs indicative of a tension pneumo, I'd like the standard trauma series of X-rays (C-spine, Chest, pelvis, plus the injured bits?) when someone's got a minute, too :smile:

Reply 34

Elles

Renal

Well done Elles, but you're the Team Leader - are you going to do ABCs?

'Fraid not, at the mo I'm the Opthalmology Doctor toddling back to their own part of the hospital to practice for their forthcoming exams! :p:

But I suspect the Team Leader wouldn't personally (see, this is where our completely artificial OSCE situation falls down & I betray my lack of any exciting Majors shift experience) - they would delegate & make use of the keen bean team in here who have lots of ideas & enthusiasm but need some systematic protocols applied & specific jobs allocated to them. :wink:

(Re. relatives in Resus there was an interesting article a while back about how it can be appropriate/beneficial in some situations apparently. Might dig that out if Opthalmology gets any more boring...)

Reply 35

martin101

stop her going beserk and getting in our way. Get a nurse (or security if its more approprite) to get her a coffee etc (and while theyre at it get me more red bull too), if shes in a fit state a history would be useful - I dont suspect anything other than blood group and DH to come up and be of much use, but you never know, thats why you do them!

Reply 36

jc123

You speak to the mother and tell her whats happened and when he's stable she can see him.
Airway and breathing not sure who wud do them if not the nurse or you :s-smilie:

Reply 37

Renal

Helenia

Yay! Luff you!

Are we happy with that or do we want to go on a bit further with this scenario?

If yes;

As the A&E sister wanders off with mum for a coffee and a natter (this is really important - ethically, legally and medically), you turn back to the patient.

The gasman has said hello to your patient for you, not getting much response she stuck an OP airway in. Not sure if the patient noticed...
She's also stuck him on some oxygen and is listening to his chest. So that's A & B sorted.

Looking at the monitors you see the following obs;
P 140
BP 90/30
SpO2 92%

Oops.

The gasman looks up and anounces that the left chest is a bit dull to percussion compared to the right and that she can't hear much breath sounds on the right.

Bugger.

The general surgeon looks up expectantly. What now?