Wednesday, November 30, 2005
OUR PRECARIOUS LIFE
It was 1.45pm yesterday. I was taking a respite after settling a number of cases, in and outpatients. Shidah, the staff-nurse called for me albeit in a casual way and I assumed it was a non-urgent case. Thus I approached the patient who was lying on the bed and asked the male attendent for any info about her. In a relaxed manner he said, "alaa, perempuan ni, dia orang jumpa pengsan tepi jalan.." I took a quick glance at her and immediately I percieved that she was gasping and her breathing was markedly erratic. "My goodness! She's gasping!" Grabbing the torch-lite, I checked for her pupillary response: Right side fixed and dilated (full-moon) and the left side was 4 mm and sluggish. "Call for code-blue!" I shouted. Calling for code blue means that staffs(code blue team) who are trained to handle emergency/ resuscitation from other floors and departments are to come straight away/stat to the A and E.
In an instant everyone started moving frantically. I demanded the ambu-bag and ordered that the patient be masked and bagged (oxygen 10 litres/min). As the patient was still breathing on her own although erratically, I ordered the nurse to synchronize the bagging with the patient's breathing or the effort will be futile. I managed to set an I/V line in her right arm and started running a pint of Hartman's. At the same time, another I/V line was installed in the other arm for drug infusions.
A swift examination revealed a hematoma and laceration on the occipital region. There were also two small hematomas on the forehead.
The patient was still unconscious. I took over the bagging and demanded the nurses to prepare equipments for intubation and check the ECG leads. The ECG rythm was tachycardic but still in sinus rythm. Her blood-pressure was 90/60. There was blood coming from her mouth.
"Call the surgeon and anaesthetist stat!" I ordered . Meantime, we prepared the patient for an urgent brain-scan and group-cross-matched 4 pints of whole blood. In between resuscitation, I managed to retrieve history regarding the patient. Apparently, patient was brought in by a passer-by who found her sprawled, unconscious on a back alley, surrounded by onlookers. The good samaritan carried the lady into her car and drove her straight to the A and E.
Each time when we face such a case in the A and E, with unknown cause of unconsciousness relating to head injury, we have to consider the possibility of cervical spine fracture. Thus stabilization of the neck is crucial. In this case we used a cervical collar. Another important diagnosis to be looked into is fracture of the base of skull which if not properly handled will worsen the condition especially during forced intubation.
The patient was transfered to the ICU, intubated and on ventilator. The brain-scan showed fracture of the occipital bone extending to base of skull. There was a huge subdural hematoma causing a midline shift. Her BP crashed and she was supported with adrenaline and dopamine infusions. She continually bled from her mouth and the endotracheal tube and continuous suction had to be done. Blood was transfused.
This is a sad story of someone whom just 24 hrs ago was living her life unassumingly. As her husband had died a year ago of leukemia, she had to make ends meet to support her 2 children (8 and 9 yrs old) and an elderly mother. To top it all, she was diagnosed with SLE.
On that fated afternoon, she had just withdrew money from the ATM machine and was walking towards her car in the small alley when a theif on motorbike snatched her bag. Whilst struggling she lost balance and fell, hitting the hard cemented pavement. She never regained consciousness.
I took her photo in sadness. She is fighting for her life which the visiting Neurosurgeon postulated only 40% chance of survival rate even if surgery is attempted in view of the massive hemorrhage. I can't bear watching her two small kids cry over her. It's truly heart-wrenching.
Maybe this can be a lesson for us to be extra, extra careful. Avoid lonely alleys. Withdraw money from ATMs with friends and not alone. It's probably better not to struggle with a snatcher and avoid head-injuries. After all what's a few hundred ringgits compared to dear life. And to all snatch-thieves out there: stealing is one thing but to take another person's life? Is it worth it?