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Emergencies
Last updated October 4, 1998
The Cascade Hospital is a resource website designed specifically to help FANFIC and other FICTION WRITERS who want to make their stories more medically authentic. It is NOT for people seeking answers to personal medical questions -- that is a job for your private physician.
ER
What would happen if Jim or Blair were seriously injured and had to go to the hospital? Following is a generic description of what usually happens. . . (we'll leave it to the fanfic writers to add in the angst and smarmy scenes).
Please read the Sentinel and Medical Disclaimers.
1. Ambulance or life flight helicopter notifies ER by radio that they are bringing a patient to the hospital. The paramedics give a short history about the patient (age, problem, what happened) and information about the patient's current condition (vital signs -- blood pressure, pulse, respirations, temperature) and what has been done so far (CPR, oxygen, etc.). The hospital gives the paramedics further directions on what else to do to stabilize the patient (give them medications, start IV fluids).
2. The trauma team is called ("activated") if the patient sounds like they are injured seriously enough to meet certain criteria determined by the hospital. The trauma team usually includes trauma surgeons, radiologist and radiologist technician, lab technicians to draw blood and someone from the blood bank to bring up blood, anesthesiology, etc. These people all help to assess and treat the patient. This large group of doctors and technicians converge on the ER, put on gowns and gloves and masks, and are ready when the ambulance arrives. When it does, some of the ER doctors and nurses go out to meet it and help the paramedics rush the patient on the gurney into the ER.
3.
Primary Assessment (the ABCDE's of trauma resuscitation) -- this
happens in seconds to minutes. The paramedics may have done some of this
before the patient arrived at the ER, and many of these things happen simultaneously.
Airway -- if the patient is having trouble breathing, the mouth and trachea must be checked to see if anything is blocking it (tongue, foreign object, secretions) and needs to be removed or suctioned. If that doesn't work, the patient may have to be intubated (a plastic tube stuck down the nose or mouth into the windpipe to keep the airway open). If the patient has severe injury to the airway (mouth, throat), the patient may need an emergency cricothyrotomy or tracheostomy (a hole is cut in the trachea just below the Adam's apple with a knife or other sharp object and a tube inserted so the patient can breathe). Even if the patient seems to be able to breathe OK on their own, they are often given oxygen by a mask or nasal cannula (that tube that goes past your nose and wraps around your face to behind your ears). Oh, also very important is that during this whole assessment, if there is any possibility or doubt that the patient might have a neck injury, the patient's neck must be immobilized (head taped securely to a stiff board +/- a foam neck brace). Usually the paramedics have already done this. The trauma board is very hard and uncomfortable, and the patient is buckled/strapped to it firmly so they can't move.
Breathing
-- if the patient's airway is clear and he/she still can't breathe
on their own, the patient is "bagged" (a mask is put over
the patient's nose and mouth and someone squeezes a rubber bag to breathe
for the patient). The patient may have to be intubated and hooked up to
a ventilator. At this time the doctors look for any immediately
life threatening injury, such as a pneumothorax or hemothorax or cardiac
tamponade (see Trauma page for description) and treat the injury.
Circulation -- any obvious external bleeding must be controlled with direct pressure over the site. A nurse or other team member puts at least two large IV's into the patient's arms (or whatever is available) and starts normal saline running "wide open" (at the maximum rate). Someone draws blood from the patient for lab tests and to determine blood type in case they need blood. The patient gets hooked up to a monitor with all kinds of wires -- EKG to monitor the heart, blood pressure and pulse, ventilator if the patient is on one, pulse ox (a rubber or cloth thing wrapped around the end of one finger that measures the oxygenation of the blood), to name a few. Medications are given (usually via the IV) as needed. Also a Foley catheter (a "Foley" -- a tube in the bladder to collect urine) is usually placed to measure urine output accurately. If the patient happens to be vomiting, a nasogastric tube ("NG tube") is often inserted into the patient's nose and down into the stomach to suck out the stomach contents and stop the vomiting. If the patient's circulation and/or heart are very unstable, a "central line" may be put in (a small plastic tube that you put into a person's neck vein (internal jugular or subclavian) or the femoral vein in the groin). The central line goes all the way to the heart and provides a way to inject fluid and medications directly into the patient's circulation. At this point the doctors may send the patient to the operating room if they need immediate surgical intervention (severe chest or abdominal injury, internal bleeding).
Disability -- the patient's neurological status is quickly assessed (mental alertness, sensory and motor function, etc.) and assigned a score on the Glasgow Coma Scale ("GCS") out of 15 points (a normally alert person has a score of 15, a dead person has a score of 3). The patient's pupils are looked at to see if they dilate and constrict appropriately.
Expose -- the patient is undressed completely (if they haven't been already), cutting off clothes if necessary, so a full body examination can be done to see if any other injuries were missed.
Brief History -- from the patient if able, or from family/friends/ bystanders/ paramedics. Basically you want to know the person's age, what happened, any other medical problems, are they taking any medications or drugs, are they allergic to any medications, and when was their last meal (in case they have to go to surgery).
4. Secondary Assessment -- once the patient is stabilized, a full physical exam, x-rays, and other tests are done.
Physical exam -- I didn't think anyone would want to know a lot of detail, but it involves looking for any obvious injuries (scratches, cuts, wounds, bruising, funny-looking bones that might be broken), listening to the lungs and heart and abdomen for abnormal sounds, and feeling (palpating) for areas of tenderness (broken bones, internal organ injury, etc.).
X-rays -- for a patient with multiple trauma, three standard x-rays are the chest x-ray, the "lateral c-spine" (x-ray of the patient's neck from the side), and pelvis x-ray, plus x-rays of anything obviously broken or injured. The main thing these tell you is where the fractures are and if the lungs have collapsed, although you can see other things also. The lateral c-spine is important because if it's okay and the patient's neck feels okay, then they are considered "cleared" and the doctors can take them off that really hard, uncomfortable back board and/or neck brace. Patients really appreciate that!
5. Definitive Treatment
Once the patient is stable, it must be decided where the patient is to go next -- to surgery, to get a CT scan, to the intensive care unit (ICU), or wherever they need to go.