Trauma 1 versus Trauma 2?

Question

The "other" day, we had an annoncement in the E.D. that a Trauma Level 2 (bad, but not serious) was comming in. The case: bilatal fracture (both ankles broken). When she came in (by helicopter from a 50 ml away remote area), she was unconscious... and upgraded to Level 1 (imminent).

Now the EMT-P and Nurse in initial charge were taking good care with ordering the administration of epinephnrine, fluid bolus' and what have you not. As soon as the (brand new) physician came into the room, everything went down hill from there.

The M.D. assigned to the case is practically the commander in chief. He was so inexperienced, that he was concerned with an arterial line, instead of starting to bag (ventilate with oxygen) when she went into resperatory failure. Predictably, she went into cardiac arrest, and I dont need to tell how senseless CPR is on a trauma cardiac arrest...

in any case, we were fondling around with this lady, whose feet were barely dangling on her tendons

Answer 1

Go ahead and vent. It helps. Surely you have some informal network in your department for such as this. Lord knows, I can't seem to get away from nurses venting to me!

Perhaps a better plan might have gotten you a "save," at least for the time being. Or maybe not. Keep in mind that all the people who come through and go to surgery don't subsequently go home. And if we're to assume that the woman wasn't initially unconscious, then it's likely she had a big IC bleed.

In terms of the doctor going into a panic, I'd suggest you put your thoughts on paper, and be succinct. Then take it as backup and speak with the department director. Talk to the system problems; don't make it a personal attack. And don't expect much to happen initially. I wouldn't fire the guy, but I'd certainly want to look on it as a "development project" and something to keep an eye on.

I've always relied on the nurses for the extraction if they find my cranium positioned intra-rectally, and I've encouraged them to do the same with other doctors. Generally, they've been happy to comply. Keep in mind, though, that there are ways to do so with some diplomacy when needed (for me, diplomacy isn't: "hey, dumbass, how about the airway? works for me), and this guy was probably scared in part because he was young and new, and I wouldn't be surprised to find you're in a teaching hospital and he is a resident.

Answer 2

I think the initial plan was correct - once she presented to the ER unresponsive, she automatically goes to level 1.  

I can understand your frustration with how it went down.  I would hope that the Dr would be open to suggestions from the team.  I'm assuming, since this pt came by air, that you are a trauma center, so I would hope that when a trauma comes in, you have a team there to work on the patient - not just one doctor and one nurse.  Was there anyone who could step up and say, "Dr, should I go ahead an intubate the patient and start ventilating, or should we just BVM for now?"

I have worked with physicians who have a "God complex" and won't take suggestions from others, or worse yet, will flat out shoot down any other suggestions, just to assert their power.  It's extremely unfortunate when this happens.

Don't beat yourself up over this.  It sounds like you did nothing wrong.  I hope you have a process within your facility to review this situation and look for ways to improve care based on this experience.

Good luck!