Case Study #5: Motor Vehicle Collision (MVC)
Time: 03h30 (5 hours post MVC)
Place: Operating Room: Charge nurse’s desk
“Dr. Labinski! On-call again, I see.”
“Yes, Ruth, and I see you are in charge again. I have a patient downstairs with a lacerated spleen. Aaron Knoll. I have classified him as a 1A. Needs to be done soon. Is that possible?”
“Yeah, we should be finished with the C-section in OR 4,” says Ruth. “I’ll ask Lydia to set up a major abdominal set for you. Is there anything special you need?”
“No, that should be good. Let Dr. Lai, the anesthetist, know that he may need the rapid infuser and should have four units up, as I expect a lot of bleeding,” instructs Dr. Labinski. “And make sure there are a lot of suction containers available. Is there an assist around to help me out? I’m concerned that this could go sideways quickly.”
“Dr. Bondie is available. She’s watching the C-section right now.”
“Excellent. Which OR?”
“We’ll set up OR 7 for you. It’ll be ready in about 30 minutes.”
Time: 04h00 (5.5 hours post MVC)
Ruth looks up to see Dr. Bondie and Lydia bringing a patient through the doors.
“Is this Aaron Knoll?” asks Ruth.
“Yes, it is. I have checked the pre-op checklist and checked him against his consent. His mother identified him as well,” confirms Lydia. “So, right patient.”
“Ok, you’re already set up. Bassam is scrubbed in and ready. I’ll follow you down and help you position.”
“Thanks, Ruth,” says the doctor.
Positioning their masks correctly, both Dr. Bondie and Lydia enter OR 7 to see that Bassam has most of the back table set up and is standing in his sterile gown at the far end of the back table. Dr. Lai is relaxing on his stool by the anaesthetic machine.
“Hey, guys, this is Aaron Knoll. He’s still a bit unconscious, most likely from a concussion post-MVC. Let’s get him positioned and draped.”
Ruth, Dr. Lai, and Lydia slide Aaron from the stretcher onto the OR table. Dr. Bondie checks the patient’s identity again and assists with positioning him at a 45 degree tilt to the right, with his left arm stretched over his head and supported by the arm board attachment from the OR table.
Dr. Bondie steps back. “That looks good, but before we go ahead and prep and drape, let’s check with Dr. Labinski.”
Dr. Lai nods. “Sure. I’m going to go ahead and start putting him to sleep and getting myself ready here. Should be about 15 minutes at the most.”
A few minutes later, Dr. Bondie and Dr. Labinski re-enter the OR and assist with prepping and draping the patient.
Dr Lai looks over top of the drape separating him from the operative field. “I’m ready and the patient is fully under.”
“Thanks. Ok, everyone let’s just pause before we begin and double check we have everything, and we all know what’s going to happen.”
Ruth and Lydia gather a bit closer but stay a meter away from the surgical field. Bassam, who is scrubbed, and Dr. Bondie lean in close. Dr. Lai adjusts his stool so his head is above the separation drape.
“Ok, let’s confirm a couple of things. This is Aaron Knoll, right?” Everyone nods. Ruth and Lydia confirm that his identity is correct.
“Great. Aaron was in an MVC about six hours ago. Appears he fell asleep at the wheel. Pretty messed up crash, which required fire rescue to cut the car into pieces. His girlfriend is still in Emergency; not sure what is happening there. Aaron received a significant laceration to his head and a concussion. The spleen laceration was confirmed on CT. Most likely from the trauma of the seat belt. The bleeding looked a bit loculated, but I expect it is tamponaded due to the swelling of the spleen and the parietal membrane.”
Bassam nods. “I have extra lap sponges and three extra sterile suctions with bottles hooked up.”
“Thanks. I hope we won’t need all of that, but I expect we may. Looking at the CT scan, I had hoped to repair minimally invasively, but there is so much blood and swelling that I’m unsure how big the tear may be. My plan is to go in slowly and once I get to the parietal membrane, expose it as much as possible. I’ll let Dr. Bondie and Bassam know when I’m going to cut in deeper. It will be a smaller incision. Then we will stick the suction in to see if we can relieve some of the pressure and help visualize the area better. Once that’s done, we’ll fully open him up, find any bleeders, tie those off, and then if we can sew the spleen up or do a partial splenectomy, that is preferable to fully removing it. I can’t decide which until I see what is what in there.”
Ruth speaks up. “Four units of PRCs in the fridge and Dr. Blake has told me he’s going to stick around in case Dr. Lai needs any help managing the rapid infuser. PACU is aware that he may be unstable and I have arranged for ICU nurse coverage if necessary.”
“I have extra vascular clamps, retractors, and silk on the back table. I’m all counted in and ready.”
“Ok, if there are no more questions, let’s get started,” states Dr. Bondie. “Lydia, would you turn on the Michael Bublé mixed tape, please?”