Case Study #5: Motor Vehicle Collision (MVC)
Time: 07h00 (8.5 hours post-MVC)
Place: Post Anaesthesia Care Unit (PACU)
“Thank you, Lydia and Bassam. That went better than I expected. I’m going to go speak with Aaron’s mother.”
“Sounds good, Dr. Lai, and I’ll take him to the PACU,” Lydia says. “Dr. Lai, are you ready?”
“Just give me a couple more minutes to fill out the record here and organize the pumps.”
“Ok. I’ll phone the PACU and give them our ETA.”
Ten minutes later, with the aid of a porter, Dr. Lai and Lydia push the stretcher into the PACU.
“Hi, Lydia. Is this Aaron Knoll who you told me about?”
“Morning, Joannie. Yes, this is Aaron Knoll, MVC from last night. Let’s transfer him to your monitor and settle him in before I give you the full report. Dr. Lai and I have been up all night and are feeling quite tired.”
Joannie and Lydia push Aaron’s bed closer to the wall. They remove the OR ECG leads and attach the PACU ECG leads. Joannie levels and zeros the arterial line. Once that is done, both nurses step back with Dr. Lai and look at the vital signs on the monitor.
The monitor shows a regular sinus rhythm (RSR) of 90 per minute, BP 100/75, RR 14, and SpO2 99 on .5 FiO2 via a T-piece.
|Day: 1||Pulse Rate||Blood Pressure||Respiratory Rate||Temperature||O2 Saturation|
|Time: 07h00||90||100/75||14||36.5° C||99% on .5 FiO2|
Dr. Lai lets out a sigh. “He’s reasonably stable right now. Lydia, do you want to give a bit of history and the OR report, and then I’ll follow with the anaesthesia report?”
“Sure,” says Lydia. “So you know he was in an MVC. That was about nine hours ago. Fire rescue had to cut the roof and doors off the car to extract him and the passenger. We think the passenger is his girlfriend and we don’t know her condition. He was unconscious at the scene and slowly began to wake up before he went to surgery. Never fully awake. All vitals were at the shocky end of the spectrum and he received a lot of NS before surgery. He had a CT which showed no head injury, no cervical injury, but a large laceration of his spleen. We were unsure of how big, until we cleared out some of the blood. Dr. Labinski didn’t feel the minimally invasive approach would work, so we did an open left flank approach. The surgery went reasonably well and only part of his spleen was removed. We were able to save a significant portion of it. There was a lot of blood in the abdomen and we used a lot of sponges. Dr. Labinski was satisfied with the count, but as a double check he would like an abdominal flat plate, just in case something was missed. Over to you, Dr. Lai.”
“Patient was supported with fluid on arrival in the OR,” the doctor began. “Hemoglobin was 70 which did not leave much room for any further bleeding. I gave him another two liters of ringers lactate and three units of blood during the surgery. There is one more PRC in the fridge up here, in case it’s needed. Latest HGB just before closing was 95. I inserted a right radial art-line for monitoring which, if BP stays above 100, can be removed before leaving the PACU. BP during surgery hovered around 70 to 80 systolic. Once I reversed anaesthesia, the blood pressure improved to what you see now. I have him on a morphine drip, but we should look at changing that to a PCA before he goes to the floor, especially if he becomes more awake than he was prior to surgery. Urine output was minimal during surgery, so I hope it improves now that we’re done and the anaesthesia is clearing. He has a #8 OETT in situ, as I wasn’t sure how he would breathe post surgery. But after reversal he was taking some good breaths, so I left him on T-piece. He can be extubated at the RT’s discretion. I would like a chest X-ray post extubation to make sure he has not aspirated or anything untoward has occurred that we didn’t see prior to surgery. Anything else?”
Joannie looks down at the anaesthesia record and sees the type of general anaesthesia used and the estimated blood loss of two liters. “No, I think that works for me. What about parents?”
“Dr. Labinski is going to talk with the mother. He will let her know that she can visit in here, but not for about an hour.”
“Oh, he does not have to limit her coming in,” Joannie says. “I imagine she is very concerned. I can easily work around her visiting her son.”
“So, Joannie, here are my orders for the time being as we discussed. I’m going to grab a few minutes sleep, but if there is anything you need, let me know. I am covering for a while longer until Dr. Stacey shows up.”
“Thank you. And both of you go get some sleep, eh?”
Lydia and Dr. Lai move off towards to OR doors and Joannie turns back to look at Aaron on the stretcher. Joannie efficiently completes her PACU assessment and records it.
He looks stable right now, she thinks. BP holding and maybe slightly better since arrival. RR is up by three breaths per minute. I think now is a good time for the abdominal X-ray.
Walking over to the main PACU nursing station, Joannie asks for a portable X-ray for Aaron Knoll, as requested by Dr. Labinski.
Jackson, the RT covering PACU, comes into the unit to check on the patients requiring oxygen. After looking at each patient in the PACU, he finally comes to Joannie and Aaron Knoll.
“Hey, Joannie, who do you have here?”
“Good morning to you, Jackson. This is the MVC from last night, Aaron Knoll. He had a partial splenectomy by Dr. Labinski and is quite slow to wake up post-MVC and surgery.”
“Right. We got the report on him from the Emergency RT. Pretty lucky guy. I understand they tore the car apart to get him out.”
“That’s what I hear and his girlfriend was the passenger, but I have no information on her as of yet.”
“Ok. How is he doing?” asks Jackson.
“From a respiratory standpoint, his RR is about 16 to 18, so the anaesthesia is beginning to really wear off. He has coughed a couple of times, but has not really appeared to be bothered by the OETT.”
“I’m going to have a listen, then draw an ABG to see how he is doing. Chest X-ray?”
“Dr. Lai wants one post extubation. Extubating is at your discretion.”
“All right, then. Looks like a bit longer for pulling the tube, but let’s get a gas and see where we’re at.”
Jackson auscultates Aaron’s chest and finds that his chest is clear with a few fine crackles at the bases. Jackson then places a gauge over the OETT to measure tidal volumes, which are normal for someone Aaron’s size. Blocking the inhale valve, Jackson measures the maximal inspiratory pressure and notes the gauge goes to 75 cm H2O. When he releases the valve, Aaron coughs but settles on his own after a few seconds.
“Joannie, Aaron is breathing ok. Not sure he’ss awake enough to take the tube out, as his efforts are a bit weaker than expected. I’ll draw the ABG now and send it to the lab. I’ll come back in an hour and see if he is a bit more awake, and if he is, we will extubate.”
“I agree, tidal volumes are ok, but his cough is quite weak. Not sure he could protect his airway without the tube.”
“Yeah, that is my thinking as well. Hopefully in an hour he will be more ready.”
Time: 09h00 (10.5 hours post-MVC / 2 hours post-op)
“Yes, Mrs. Knoll, you can talk to him,” Joannie says gently. “I would like you to tell him where he is and what has happened to him. If he hears it from you, a familiar voice, he may understand and not be quite so confused. He is waking up and starting to move around quite a bit more, which is a good sign, but I would like him to not get too worked up.”
Mrs. Knoll holds her son’s hand and explains what happened to him and where he is. Slowly Aaron’s eyes start to open and stay open a bit longer each time. Mrs. Knoll asks, “Are you in pain?”
Aaron looks at her and weakly shakes his head ‘no’.
“Joannie, I think he’s a bit more awake. He nodded his head.”
“That’s an excellent sign. It will take him a bit longer to wake up. He was significantly injured.”
“I understand. I’m just so relieved that he’s waking up. I was worried that he would not wake up and it would be like he just stayed asleep and never woke up.” Mrs. Knoll continues to hold Aaron’s hand.
“I can appreciate that concern. We will certainly know more as more time goes by, and so far it looks quite positive.”
Joannie looks up. “Hi, Jackson. Back to see Aaron again?”
“Most definitely. The ABG I drew about 45 minutes ago shows slight acidosis. The PaCO2 was 45. High normal, but if he is starting to wake up and take some deep breaths, the CO2 will be lower. Do you mind if I have a listen and check his vital capacity?”
“No, not at all.” Joannie turns to Aaron’s mother. “Mrs. Knoll, this is Jackson. He’s a respiratory therapist and is going to check Aaron out. If things look good, we’ll take that tube out.”
“Oh, that would mean he could talk. That’s fabulous. I need to have some breakfast and phone my husband and my work. I’ll let you do what needs to be done and be back later.”
“Thank you. I have your cell number in case something changes. I>m hoping in the next two hours to move him to the surgical floor.”
“I’ll phone before I come back in case he has moved. Thank you again for all your help.”
“Our pleasure. Enjoy your breakfast. I would try the little café around the corner and not the cafeteria.”
“Oh, is that a recommendation?”
“They have great food and the prices are pretty good.”
“Thank you, again.”
After Mrs. Knoll leaves the bedside, Jackson moves closer to Aaron, introduces himself and checks to see how awake Aaron is.
“Aaron, can you take a deep breath for me?”
Aaron responds by taking a deep breath, but grimaces partly through his breath.
“Joannie, he might be having some pain and guarding here that is stopping him from taking a full breath.”
“Thanks, Jackson, I’ll give him something extra after you’re done. I want him to be as awake as possible.”
“Sure. Ok, Aaron, I am going to measure your volume that goes in and out with each breath.”
Placing a gauge on the end of the OETT, Jackson notes the tidal volume of 425 cc.
“Awesome. Ok, now I am going to block your airway for a few seconds to see how strong your breathing muscles are.”
Jackson then holds a switch on the gauge and sees the needle move around to show -150. Aaron begins moving on the bed and reaching up to Jackson’s hand and the OETT.
“Ok, ok, Aaron. All done. Just relax, buddy. You are doing very well. It looks like we can take this tube out.”
Jackson nods over to Joannie. “Looks good here. Why don’t we pull the OETT and get him sitting up a bit more. I see you have an oxygen mask all ready.”
“Yeah, I was being positive. Let me come around to the other side and help you.”
Together, Joannie and Jackson explain the removal to Aaron, who nods that he understands.
Jackson then cuts the ties holding the tube in and Joannie deflates the cuff on the OETT. Then Jackson tells Aaron to take a deep breath. As Aaron blows the breath out, Jackson quickly removes the OETT.
“Awesome. Your voice will be a little hoarse. I’m going to put an oxygen mask on you. It’s more for the humidity to help your sore throat out. As you get a bit stronger and more awake, we will take the mask off.”
“Thanks, Jackson. Can you stay and help with the X-ray? We can take a look at the results together and see if we need to call Dr. Lai or Dr. Stacey.”
“Will do. I’m just going to finish my charting over at the nursing station, so give me a shout when the X-ray comes.”
Time: 10h00 (11.5 hours post-MVC / 3 hours post-op)
Jackson and Joannie are huddled around the computer screen looking at Aaron’s recent X-rays when Dr. Lai and Dr. Labinski come up behind them.
“Anything interesting, Joannie?”
“Good morning, Dr. Lai. I thought you would have gone home by now.”
“Heading there now, but just wanted to check and see how Aaron is doing and if things are progressing.”
“Looking good, more awake, extubated about 20 minutes ago, and is on .4 FiO2.”
“Great. Is this his chest X-ray?”
“Yes, it is.”
Leaning in, Dr. Lai looks closely at the X-ray. He points out the little bit of fluid at the bottom of each lung close to the diaphragm. He also points out the small amount of black below the diaphragm. “See that?” Jackson and Joannie nod. “That is air trapped below the diaphragm, most likely from the surgery. If he didn’t have surgery, air would be an indication for possible surgery.”
Dr. Labinski smiles at the group. “I guess that is a segue to me, eh? Do you have his abdominal X-ray?”
“Yes, we did that X-ray a few minutes after I settled him in this morning.” Joannie quickly changes the X-ray to the abdominal one taken three hours ago.
“The count was correct for all the instruments and sponges, but I felt that an abdominal X-ray was warranted to make doubly sure, as we used a lot of sponges and there was a lot of bleeding.”
All four lean in close to the monitor. Dr. Labinski points out the surgical site and the staples he used to radiographically mark the area.
“Ok, I am not seeing any sponges or any surgical tools left behind,” Dr. Labinski says. “Other than a little bit of air just below the diaphragm, everything looks good. He will have a CT in a couple of days to ensure the fix worked and then maybe discharged in five or six days if things go well.”
“I agree,” Dr. Lai says. “Joannie, if he meets all the discharge criteria from the PACU and you feel he would do well on the floor, please transfer him. If you have any concerns, call Dr. Stacey and have him put a referral in to high acuity.”
“Sounds good,” Joannie says. “He’s almost there. I think another hour or maybe two and he can go to the floor. Anyone going to update the family?”
Dr. Labinski nods. “I’ll update Mrs. Knoll once he hits the floor. I don’t have anything to add right now. Please let me know, as well, if he doesn’t go to the surgical floor. I have informed them to expect him and have discharged a couple of patients in prep for his PACU discharge.”
“Will do. Thank you both,” Joannie says.
Time: 11h30 (13 hours post-MVC / 4.5 hours post-op)
“Ok, Aaron, I’m just going to remove these ECG leads. Everything is looking good. You are ready to go to the floor. I’m going to let your Mom know and the surgical floor to expect you shortly.”
Aaron waves his right hand in the air and whispers hoarsely, “I’m having a bit of pain.”
“If you are feeling pain, just push this button.” Joannie touches Aaron’s hand that is holding the PCA button.
“Right, I forgot. My girlfriend?”
“Sorry, Aaron, I don’t know anything. Maybe your Mom knows.”
Aaron slumps down in his bed, looking quite sad.
Joannie moves off to the nursing station to phone the surgical floor to give her report.