Biomedical subjects
O J Dominguez
Publications and source records attributed to O J Dominguez.
What's so unusual?
You're probably asking yourself, "What's so different about this case?" The patient was on the side of the road, explained what she was doing there, denied any injuries and refused treatment and transport. Sounds like a routine call--what's the big deal? But this case did not end after the patient signed a treatment refusal form and was asked by law enforcement to get back in her car and drive on. The EMS providers returned to their station, only to get called back 30 minutes later to the same spot they had just responded to, again for a "woman down." Upon this arrival, they found the same car on the side of the road, and a parked semi tractor trailer in a traffic [figure: see text] lane approximately 25 yards ahead of the vehicle. There was no damage to either vehicle, and providers noticed a familiar dog inside the woman's car. A police officer informed the providers that the woman, the driver of the vehicle, had jumped in front of the semi, as described by the truck's driver, and was hit at a very high rate of speed. The victim was deceased on the scene. Upon assessing the scene, providers confirmed that the victim was the same woman they'd responded to earlier. Several days after the incident, more information about the patient's medical history was released. She had been released on the morning of the accident from a mental health institution, where she'd been diagnosed as a manic depressive. Manic depression is a condition characterized by mood swings. For example, a patient might rapidly go from a state of euphoria to experiencing debilitating depression. Although this patient appeared fine on the exterior, she had been diagnosed with a severe psychological disorder. She presented as being alert, oriented and non-threatening moments before taking actions that led to her death. This case posed a significant challenge for the EMS providers because there was no clinical evidence that there was anything wrong with the patient. Moreover, the patient denied any past medical history. It was a lesson to all involved with this case: There is no such thing as a routine call.
The injured coach.
The patient in this case was diagnosed as having an epidural hematoma (shown in x-ray at right). This results from hemorrhage between the dura mater and the skull. The hemorrhage may result from a traumatic insult to the side of the head, which can fracture the temporal bone and lacerate the middle meningeal artery. Since the hemorrhage is arterial in nature, the patient may deteriorate quickly. These patients may present with what is referred to as a "lucid interval." The patient typically has a significant blow to the head that results in a short period of unconsciousness. They then regain consciousness at a time that frequently coincides with the arrival of EMS. Once conscious, they are in a period known as the lucid interval. They will still have a headache, but may otherwise be acting normally and show no other physical findings on examination. Many such patients refuse treatment and transport. [table: see text] Inside the skull, however, the problem will grow. Broken arterial vessels are bleeding, causing an expanding hematoma. The patient typically will soon complain of a severe headache along with other associated complaints, such as nausea/vomiting, then will lose consciousness again and/or have a seizure. Initial physical findings may include contralateral weakness and a decreased Glasgow Coma score. As the hematoma expands, cerebral herniation may occur, compressing the third cranial nerve, which presents as a "blown pupil." EMS providers should have a high suspicion of injuries that affect the side of the head and the base of the skull. It is important to not only assess such injuries, but also the mechanism of injury, and to know the complications or later presentation that can arise from such injuries. Given that this patient was alert, oriented, not obviously intoxicated, and accompanied by his wife, the providers in this case would have had no choice but to abide by a refusal of treatment and transport. However, that could lead to serious complications, such as ongoing minor neurological deficits, later on. If this is the case, contacting medical control should be the priority.
Wipeout.
When prehospital providers transported this patient to the trauma center, they felt a bit awkward, to say the least. The patient appeared to be intoxicated, and had fallen from approximately three feet. Nevertheless, upon EMS' arrival, the patient was responding only to painful stimuli and was not moving his lower extremities. This prompted EMS to activate the trauma system and treat the patient accordingly: He was immobilized on a long backboard. During transport, however, the patient became responsive to verbal stimuli and began moving his lower extremities. When he was transferred to the ED staff, he appeared to be doing fine neurologically, except for the intoxication. The EMS crew felt a bit embarrassed for the activation of trauma services. Three hours later, however, the ED physician called the providers at their station to inform them that the patient had an unstable cervical spine fracture (see x-ray above), and their care was definitely appropriate.
Prehospital rounds. Beyond SVT.
This patient had a complex presentation, with many potential causes for his shock status. He was obviously in shock, with many signs of poor perfusion. He presented with very rapid heart and respiratory rates, and poor skin perfusion and oxygenation. The clinical presentation of the patient prompted the EMS crew to consider electrical cardioversion in hopes of addressing the unstable tachycardic rate. However, the crew opted to consider the patient's past medical history--i.e., the diarrhea, vomiting and lack of fluid intake--and instead treat the patient for hypovolemia. The picture had not improved by arrival at the ED, and had not been corrected with a fluid bolus.
A mouthful of trouble.
The prehospital providers in this case performed a thorough and detailed assessment. They searched for and found a puncture wound in the posterior buccal region, and learned the patients was also hypoglycemic, with a history of diabetes, and insulin-dependent. It was not clear how the patient arrived at a hypoglycemic state, or if he had suffered a seizure. After the family arrived at the hospital and went to the patient's home, they determined the circumstances that caused this unusual presentation: The patient was the victim of a home-invasion robbery and had been shot in the mouth with a small-caliber weapon. The home invasion had taken place approximately 12 hours prior to the victim being found. The victim had been knocked unconscious by the force of the shot, although the bullet did not break any bones. He had not eaten prior to the shooting. Upon arrival at the ED, a small exit wound was noted behind the patient's left ear--hair and dried blood had obscured it from the prehospital providers. However, the providers did alert the ED physician to the buccal puncture wound, which enabled the physician to consider the possibility that the mouth wound was the result of a gunshot. Gunshot wounds are unpredictable in their damage patterns and effects on their victims. They might lead a patient to become hemodynamically unstable, but that was not the case here. Hemodynamic stability should not preclude the consideration of traumatic insult throughout your assessment. The initial presentation of this patient may have tempted EMS to pursue the suspicions stated by the neighbor at the scene (seizure), but a detailed assessment provided the information necessary to treat the man appropriately.
Abdominal aortic aneurysm.
Explore the source record for details and available documents.
Prehospital rounds. Pulmonary embolism.
Explore the source record for details and available documents.
Basilar skull fracture.
Explore the source record for details and available documents.
Prehospital rounds. "Masking the signs".
Explore the source record for details and available documents.
Prehospital rounds. Irregular narrow complex tachycardia.
Explore the source record for details and available documents.
A transpositional skin flap for release of volar contractures of a finger at the MP joint.
We describe a finger flap which, in properly selected patients, and with careful planning of the incision design, has been useful for covering small defects over the volar aspects of the MP joint. The donor site can be closed without skin grafting.