Thursday 18 September 2014

Most injured

I may glamorise my job from time to time (read: all the time) to make myself and what I do seem more interesting.  The sad reality (from my own skewed point of view) is that the majority of my patients are only mildly injured (and sometimes not injured at all).  Most patients get worked up in A&E/ER/ED/casualty department and sent home the same day with stitches, staples, splints, bandages, and/or a stern lecture from me about how to prevent this sort of thing, whatever it may be, from happening again.  For me repeat customers, though good for the bottom line, are bad for business.  If that makes any sense at all.

But who the hell wants to read about someone who was in a minor car accident but was brought to me just as a precaution?  Who wants to know about the old lady who loses her balance and bonks her head on an end table and ends up with nothing but a bump on the head and a mild concussion?  Who cares about yet another drunk guy who falls off his bar stool, spends a couple of hours with me sobering up, and then endures a real sobering drive home with his wife appropriately yelling at him from the driver's seat?  Is anyone even remotely interested in any of that?

I'm certainly not, but I have no choice in the matter.  But I spare you good people the details about the mundane and boring people who come in with minor injuries, mainly because if I didn't you would all run away faster than teens from a Wiggles concert.  No?  Ok, faster than men from a Taylor Swift concert.  Still no?  Ok, faster than sane people from a Miley Cyrus concert.  

Yes.  Perfect.

Anyway, this next guy is not one of those boring people.

I mentioned Orville (not his real name©) briefly in a prior post (he was Victim #2) and promised I would get back to him, so now I'm keeping my damned promise.  Orville is in his mid-20s, and like many young men his age he hasn't outgrown the immature belief that he's immortal and/or indestructible.  Seat belts are too good for him, apparently, because he wasn't wearing his when the car in which he was a passenger went off the road at around 160 kph (100 mph) and struck a tree.  As usual, the tree won.  The tree always wins.  Orville was thrown from the car and landed somewhere near the orbit of Venus, I believe.

When Orville got to me, he wasn't moving at all and was obviously close to death: his heart was beating around 160 times per minute because it was trying to compensate for his dangerously low blood pressure.  About 60 seconds later, his heart gave up and stopped. 

With CPR, several units of blood, and some medications, we restarted his heart a few minutes later, and we continued transfusing even more blood as we were finally able to start our evaluation.  The first and most obvious thing I noticed is that his head looked completely uninjured, unusual for someone in such a severe accident. 

"He is a complete mess," I mentioned to one of the assistants.  "But at least his head looks ok.  But that's about the only thing that looks ok."

Unfortunately looks can be deceiving.

Ultimately his workup revealed the following injuries:
  • 5th cervical vertebra fracture
  • 5th thoracic vertebra fracture
  • 5th lumbar vertebra fracture
  • cervical spinal cord injury
  • Sacrum fracture
  • Open-book pelvic fracture
  • Three rib fractures on the left
  • Left hemopneumothorax (bleeding, punctured lung)
  • Cardiac contusion
  • Bilateral (both sides) severe lung contusion 
  • Bilateral scapula (shoulder blade) fractures
  • Bilateral acetabulum (hip socket) fractures (left side shattered)
  • Bilateral Grade IV (that's bad) kidney lacerations
  • Urethra laceration
  • Bladder laceration
  • Mesentery (blood supply of small bowel) laceration
  • Multiple small bowel and colon contusions
  • Multiple deep left arm lacerations and abrasions
  • Subdural haematoma (bleeding under the dura mater, the tough covering over the brain)
His liver (and all the other internal organs) suffered contusions and/or ischaemic injuries from his initial haemorrhagic shock.  There are only a few things on his entire body that weren't injured.  I would say that his arms and legs were uninjured (other than innumerable lacerations and deep abrasions on his left arm), but since he ended up quadriplegic (unable to move his arms and legs due to his spinal cord injury), that doesn't seem to matter quite so much.

It always amazes me when I hear idiots claim that getting thrown from a car is safer than staying in it.  Would you rather get thrown out of a car and deal with all the kinetic energy of hitting the ground, or would you rather stay in the car where all the seat belts, airbags, roll cages, and crumple zones surrounding you and keeping you safe are?



  1. God, that's horrible. I'm glad I've never driven anything, and even more glad I always wear a seatbelt - even if we're only driving a couple of blocks. At eighteen, I can't imagine my life practically being over before I've had a change to live it. Especially because of an idiotic error of judgement and lacking common sense. Thank you Doc, just reading that list really made it stand out how important safety - especially on the road - matters. - *Kisara*

  2. Hey Doc, as someone who always wears a seatbelt in the car, which would be worse (for a patient, not a doctor - since you like exciting) a)not wearing a seatbelt and flying or b)having the person behind you not wear a seatbelt and have them fly into you?
    And have you ever seen a patient where the latter happened?

    1. At the Trooper Higbee trial c.2007, one sister struck the other when hit by the troopers car. Passenger was killed with severe head injuries resulting from hitting the driver, forcing her partially out the drivers window. Van then sideswiped another taller vehicle. Horrific. My sister in law was partially ejected from drivers window, then the car rolled. Or the unbelted who thought holding her two month old in her lap was safe. Until the baby was between her flying body and the dash. She will live that day forever. Yes. You can get stuck, yes you can get injuries from the force of the belt stopping your body. But you will likely survive...

  3. You had me with: not his real name©

  4. and on top of all that damage, do you really want to take the risk of MY colleagues not finding you? First thing I do when I get to an accident scene is check the driver's seat - and I can count an immediate 4 times when the driver was missing. 3 of the 4 times we found the driver. the 4th, we hope someone gave the driver a ride.

  5. As a professional, do you think that the shoulder harness has improved survivability more than seat belts? Air bags can give a nasty jolt too. Just wondering.

    1. the shoulder harness has absolutely improved survivability. airbags - while uncomfortable, have been proven to convert fatal injuries to painful injuries - and that is a win in my book. while it is still quite possible to hit something hard enough to kill yourself even with your seat belt on, you have to hit it a hell of a lot harder than if you aren't wearing your seat belt.

      I've seen seat belt burns, I've seen airbag bruises, and I've seen faceprints in windshields.

      more personally, I've been sideswiped at 55 MPH - and was still behind the wheel and in as much control of my vehicle as physically possible. (the impact destroyed a rear wheel, bent the axle, and locked up the differential)
      I borrowed another car and went to work.

    2. Had a friend who released her seatbelt to reach back to retrieve a toy her child had dropped.

      She lost control, went off the road, and rolled her SUV several times as she bounced her arm off the road and her body against various interior parts of the vehicle (fortunately she remained inside)

      Permanent injuries: scarring on the arm, a couple of fused vertebrae.

      Her child, belted in, had a minor bruise from the shoulder harness.

  6. When a person has so many serious injuries, where do you start? What do you treat first?

    1. form the fire/rescue side - we try to control bleeding, pour the patient onto a gurney, and sic the call gods on Doc Bastard. - the faster we can get the patient to the trauma surgeon, the less bad his chances of survival are.

    2. I'm not a doctor, but my guess is that bleeding on the brain and two shattered kidneys are both potentially fatal pretty quickly. If you had this complete list in front of you then maybe you would start with those, followed pretty quickly by the punctured lung and bleeding bowel. However, I suspect in the real situation you deal with the potentially fatal issues (there seem to me to be quite a few of those) in the order that you find them.

      My heart sank when I read cervical vertebral fractures. Poor kid. Only in his 20s and unable to move.

      Like the doc' says - there are so many ways to dissipate that excess energy built into a modern car but they only work if you're in your seat! 100 years ago cars were built like tanks and it might have been safer (marginally less lethal) to be thrown clear. Not so now. This guy sounds like he fell on his ass from a 3-storey building. A few bruises from a seatbelt and a punch from an airbag have to be better than that!

    3. the basic rule of triage - start where you are. I'd guess it is the same with trauma surgery - is he actively dying from it? yes = patch it. no = move on.
      you can be pretty AFTER you deal with the things he is actively dying from.

    4. When injured people come into the trauma bay I am pretty sure they start with ABC...

      A: Airways.
      B: Breathing.
      C: Circulation.

      I think Doc has written about it somewhere...

  7. Damn. What a terrible outcome for the poor bastard (the kid, not you).
    Is there any chance he'll regain movement or is this sort of thing always permanent?

    1. I think if there is any gain it's minor. For instance let's say they start out with no shoulder movement. Later they might get some shoulder.

  8. So sad that yet another young male falls victim to his immature basal ganglia. Looks like only his teeth came out unscathed.

  9. Orville was thrown from the car and landed somewhere near the orbit of Venus, I believe.

    That made me laugh out loud. It so something that would come out of my mouth...

  10. Honestly? I find that immoral. A person with that many injuries and a heart that already gave up. Why bring him back to more misery? A body can clearly not survive that many injuries without "some medications". And is not meant to. Does the medical personnel have to prove something to themselves by bringing him back, or what? Sorry, but I consider this a curse and immoral. Not everything you COULD do you SHOULD do. ***Shiver***. And that "no CPR" can be ignored, is the worst of all.

    1. What a fascinating perspective. You think it is immoral to save a life? Seriously? Do you think Stephen Hawking should be put to death because he is wheelchair-bound? I sincerely hope you're not in health care.

      Let me explain something: I'm a doctor and a surgeon, and my job is to save lives. My job is not to decide who lives and who doesn't, it is to save EVERYONE who is salvageable. Except for the most extreme circumstances where I have no other choice, I cannot morally or ethically let someone die.

      This is possibly the most inhuman comment I've ever gotten here. Congratulations.


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