Sometimes working in an ER is a lot like flying an airplane: hours of uneventful flying interspersed with moments of extreme challenge. Just when you are finding yourself relaxing into the routine flight, you are jarred into attention by a blaring alarm. This is what it was like for me one night as I was about to walk into a room to stitch up a patient who had “attempted suicide” by slashing her wrists, again.
“This one’s worse!” said the nurse as she was wheeled a patient behind me into the stabilization room. I turned and saw a woman in the wheelchair covered in blood. Her head hung down, she had long hair, and I bent down to see her face, except it wasn’t there.
Blood was draining from a great cavity where her face should have been. Her chin was in two pieces hanging on by remnants of facial tissue at the level of her upper chest. The nose and left eye were gone. Her right eye was open, wide open, and expressing terror.
What? What am I seeing? How? What?? Nothing in my training had prepared me for this sight. This was my second year of residency and my first night moonlighting in an ED on my own. Quickly my training kicked in, pushing aside my shock of this image of another human being so violently traumatized. ABCs.
First, we got the patient to stand and we assisted her onto a stretcher, head elevated so she wouldn’t lose her airway from the bleeding. Immediately, I asked for the Trauma Team to be called. The trauma surgeon on call, any available residents, extra nurses, x-ray and lab people were summoned.
ABCs. Airway was not adequate because of the bleeding, but the patient was able to breath in a sitting position. Oxygen 100% by nonrebreather mask could not be directly applied, so I had a nurse hold it close to the center of what had once been the face, until we could get a endotracheal tube placed. Attempts were quickly made to start two large bore IVs. These attempts were unsuccessful.
Before I had a chance to sort out how I would intubate this patient, the trauma surgeon arrived as well as a surgical resident. They started on a central line and I started a venous cut down at the ankle to introduce an IV. This was at a time before intraosseous access was common. The patient was intubated consciously then immediately sedated and paralyzed as soon as the ET tube placement was confirmed and the tube secured. This was a difficult intubation because of the bleeding and loss of landmarks. The fear was if the patient was paralyzed before placement of the tube, as is standard in a crash induction, we would not be able to ventilate the patient if intubation was not successful.
After the patient was stabilized, she was transferred to the OR. There she underwent a marathon surgery to reconstruct her face. We got reports of bits of wood being found in the deep structures of the face. We had assumed it was a shotgun blast.
Turns out she had been riding at high speed and struck some sort of wooden structure or post with her face when leaning out the window. Her friends had dumped her at the front of the hospital. She staggered into the hospital and a janitor had the presence of mind to put her in a wheelchair and take her to the ED.
This case haunted me for years. The patient at least had the good fortune to stagger into a tertiary care trauma hospital. What would have been the outcome, and how would she have been managed in one of the small rural hospitals that I spent much of my career in? Where the only staff available are a doctor (often on call from home) and a nurse. This level of trauma can show up anywhere and does. When faced with a shocking trauma such as this one, always start with your ABCs.
