back to directory

next post

The patient arrived and we went to work.  He was breathing on his own, but not very well, so we intubated right away.  He was not opening his eyes, he was not talking at all, and he was not moving.  That does not predict a good outcome.  But, until we could find out more, we did our thing.  He was intubated and started on high flow oxygen.  His initial blood pressure was good.  We got an IV and started giving him fluids.  Check him head to toe.  He had a small entrance wound above his left eye; we would need to do a CT scan to know the extent of the injury.  No other injuries were apparent.  We took an x-ray of his chest to look for internal injuries.  One of the surgeons went to work putting in a central line (a large type of IV that goes in a larger vein).  Our anesthetist started on an arterial line (an IV that goes in an artery to help monitor blood pressure).  Our respiratory tech managed the airway.  Our medics monitored the blood pressure.  The ER nurse started the drugs - mannitol and dilantin - to help protect the brain.  The patient was quickly stabilized.  The next most important step was CT scan and the patient was ready to go.  As the patient was being taken to the CT scan, it occurred to me that went quite well and rather quick.  I looked at the clock, it was 1423.  I looked at the ER sheet, the patient arrived at 1405.  18 minutes.  We did a lot of things in that 18 minutes.  In head injuries, every minute counts.  The quicker the patient can get to the neurosurgeon the better the chances are.  18 minutes is pretty quick.

I wish I could say that our initial efforts were instrumental in saving this patient's life.  However, this patient sustained a very bad injury.  The CT scan revealed that a piece of shrapnel had entered the front of the head just above the eye and traveled through the entire brain causing massive damage.  This was an unsurvivable wound.  The best brain surgeon in the world could not have helped this unfortunate soldier.  There was nothing that could be done.

This is a very difficult part of medicine - watching a patient die and not being able to do anything about it.  We have seen a few of these, fortunately not a lot, but it never gets easy.  We admitted the patient to the ICU and gave him medications to make him comfortable.  He managed to hang in there long enough for his entire unit to come in and say their goodbyes.  He must have been quite a soldier, because a lot of soldiers lined up to see him, some waiting as long as two hours.  That kind of loyalty and camaraderie is inspiring but sometimes makes these situations harder.