Questions about trauma I witnessed. (LONG)

[GermPhobe]

On the way into work on Sunday, I came upon an accident scene before the paramedics arrived. I'm a new RN, with less than a year of experience (no trauma experience), and I'm still a bit shaken by the whole thing.

A woman had been thrown from a motorcycle, and was lying face-down on the pavement. She was unconscious, had a compound fracture of the femur, blood coming from her mouth and nose (helmet was intact), and her spine was twisted in such a manner to indicate that a spinal cord injury was likely. There was also some tan matter coming from either the mouth or nose. My first thought was OMG, that's brain tissue. But now I wonder if it was just vomit.

There was another RN on the scene (we were just a couple blocks from the hospital). She supposedly worked in ER. She claimed the victim had a pulse and respirations, and was phoning into work to tell them she'd be late, and that the victim would be arriving soon. She told me they were not going to move the victim, due to the potential SCI. The victim's husband was holding pressure on the leg wound.

I only had a minute or so before the paramedics arrived, but it felt like an eternity. The woman looked dead. The only thing I did was offer to hold pressure for the husband, who was trembling almost uncontrollably (he rufused). I felt the victim's rib cage for respirations, and felt none.

I read in the newspaper on Monday that the woman died "of her injuries" at the hospital.

I keep wondering if I should/could have done more. The other RN acted confident, but she wasn't doing anything for the patient. I wonder if she knew the patient was hopeless or dead, and just didn't want to traumatize the husband by performing CPR in the field.

I have so many questions. I feel like I was completely useless, and I never want to feel that way again. I don't know who else to ask these questions, so I'm hoping those of you with trauma experience can help:

* Did the other RN recognize this as a hopeless case? If so, Is it ever appropriate to do nothing?

* Should I have reassessed the patient myself? I'm thinking that even if the victim had a pulse when initially assessed, in such a horrific trauma, she could have arrested at any time.

* In general, is an unconscious/unresponsive patient more likely to have a pulse/respirations? Or more likely not to?

* Is it likely that was brain tissue? (Not to be gruesome, but what would I expect brain tissue to look like? I've only ever seen it "preserved.")

* If it was brain tissue, is there any point in resuscitation efforts?

* Should I have remained on the scene after the paramedics arrived? If so, what would my role have been?

My first task on Monday was to put together a kit to keep in my car, in case this type of thing ever happens again. I want to be as prepared as possible, so please tell me what I should keep in the car. So far, I have a small backpack with: CPR mask, stethoscope, tourniquet, disposable gloves, ABD pads, and VetWrap (had it in the barn!). I'm thinking I should have some Emergency notecards, too, with instructions for care.

Thanks for listening. I really need to talk this out.

[WVUturtle514]

There was another RN on the scene (we were just a couple blocks from the hospital). She supposedly worked in ER. She claimed the victim had a pulse and respirations, and was phoning into work to tell them she'd be late, and that the victim would be arriving soon. She told me they were not going to move the victim, due to the potential SCI.

Wow....what a terrible situation to find yourself in. I'm so sorry that you felt as helpless as you did, but with experience comes confidence and you will definitely gain that with time. Coming from a former ER nurse, as far as the quote above, all nurses are trained in BLS to know their ABC's. Screw the spinal cord injury......if a patient is not breathing and does not have a patent airway, then you're not doing them any justice by not moving the patient "due to potential SCI." I'm not saying that initiating CPR on this woman would have saved her, because it sounds to me like she was pretty bad off to begin with.....but just for future reference, airway ALWAYS trumps everything, including any potential for other injuries. If the patient is not breathing and oxygenating, then nothing else matters. Best of luck to you!!

[GermPhobe]

Screw the spinal cord injury......if a patient is not breathing and does not have a patent airway, then you're not doing them any justice by not moving the patient "due to potential SCI."

Agreed and understood. But I also understood from the other RN that the patient WAS breathing and pulsatile. I still think I probably should have done my own assessment, though.

[likemike, BSN, RN]

Sorry you witnessed this.

As a former Paramedic and Navy Corpsmen Nurses arent trained for rock solid pre hopsital care. I know cause I am one now :)

ATLS states, airway with c spine control.

I ride a MC as well and there is a right way and wrong way to deal with airway and helmets. If you are not trained to dc a helmet, dont do it. But ABC, ABC etc.

In reality if you need to ventilate this patient what are you gonna do, mouth to mouth....yech.

Sadly, people die, you did the best you could.

You may find it actually fun to take a basic EMT course and never again would you feel self doubt. You would be an asset to the class given your knowlege base and will learn a lot.

The MOST important rule of pre hospital care is "Is the scene safe?" Lots of Nurse's get killed doing the Florence thing. No worries if you position your vehicle safely, direct traffic as you put out flares and make the scene safe for the victim and rescuers.

Sorry you had this horrible experience.

[trjpw]

Live brain tissue is pink/white, and freashly exposed like you said would be bloody.

Always remember ABC. If no A, then B and C don't matter. (Airway first priority)

Remember, you had no equipment to do the rescue. The hospital was minutes away. Had you moved the patient as she was, you could have triggered a seizure and death on the scene, with no medications to counter it with. The internal injuries were probably also traumatic, and ruptured internals. . . she was going to bleed out when moved anyway.

The ER nurse did the right thing, and she probably had an idea where this case was going. She gave the husband something he could do so that he wouldn't have to think that he did nothing while his wife died. She had two patients. . .how was he?

[EricJRN, MSN, RN]

Agreed and understood. But I also understood from the other RN that the patient WAS breathing and pulsatile. I still think I probably should have done my own assessment, though.

It sounds like you guys did the best you could under some really unexpected and shocking circumstances. I'm sorry for what you had to see. I can't blame you for not doing your own assessment. You wouldn't usually walk in on another nurse's pt at the hospital and start listening to lungs and assessing for edema (unless they asked you for your opinion), and along the same lines it would have been kind of awkward to second-guess the assessment of an experienced ER nurse in this case.

Remember, too, that in the prehospital setting, the vast majority of massive blunt trauma pts found pulseless are going to remain pulseless. CPR in a major blunt trauma pt is just not the same as CPR in the witnessed arrest of your medical patient in the hospital. Even if the ER nurse was wrong and the pt was pulseless, it's likely that no care in the world would have made a difference. If we were talking about an isolated head injury, that's one thing. From the sound of it though (deformity of the spine) you had a massive blunt trauma patient. CPR in these trauma patients is so futile that, based on BTLS/ITLS recommendations, many EMS providers will pronounce a patient on scene if there's a combination of asystole and massive blunt trauma.

Again, I'm sorry for the traumatic experience.

[GermPhobe]

The ER nurse did the right thing, and she probably had an idea where this case was going. She gave the husband something he could do so that he wouldn't have to think that he did nothing while his wife died. She had two patients. . .how was he?

That's what I was thinking. Poor man. He had some major abrasions on his upper arms, but was treated and released. The newspaper said his wife was a passenger on the motorcycle, and that the man had "lost control" of the bike. My thought was that the wife flew off the bike first, at high speed, and that he was able to regain some contol before stopping and coming to her aid.

Live brain tissue is pink/white, and freashly exposed like you said would be bloody.

Please forgive my insistence on this part of the question. But it's something I need to know. What I witnessed was rather wet and formless. I wonder if brain tissue would have been more solid. I'm sorry this is so graphic, but I really would like to be certain what I'm seeing if, God forbid, something like this ever happens again.

[gr8rnpjt, RN]

Please forgive my insistence on this part of the question. But it's something I need to know. What I witnessed was rather wet and formless. I wonder if brain tissue would have been more solid. I'm sorry this is so graphic, but I really would like to be certain what I'm seeing if, God forbid, something like this ever happens again.

I think what you are describing (tan, rather wet and formless) coming from the nose or mouth was most probably something that came from the stomach. whether it was vomited, or ejected from blunt force abdominal injuries, it most likely originated from the stomach contents.

[tencat]

Oh, what a horrid thing to witness. I agree with another poster who said that you might want to consider taking a basic EMT course. I was an EMT for a couple of years, and it sure does sound like this woman was beyond any help. There is such a limit to what one can do in the field, and if you don't have equipment (Oxygen, airway kit, etc.) it's hard. I also agree with others that have said that if you are going to stop for an accident, make SURE that you will be safe. It sounds like you did everything you could. You witnessed a traumatic thing.....be gentle with yourself for a few days. It's normal to rehash the event in your mind, and it's normal to feel any physical symptoms such as nausea or shakiness or trouble sleeping. It takes time to process. Hang in there!

[MrsWampthang, BSN, RN]

I know that was traumatic, but you did the right thing and stood back. The ER nurse probably knew as soon as she saw the lady, if she didn't witness the accident, that the lady was dead right there. Trauma codes are never brought back. As for thinking that you should have done your own assessment. No, that would have been rude and unprofessional. The ER nurse did the right thing in doing nothing. She was probably shook up too. It would have been rude and unprofessional of you to step in and flip this lady over and begin doing CPR on her saying "screw the SCI." There are safe ways to move a possible SCI and the ER nurse knew it and she also knew that EMS probably wasn't far away and in this women's case, it sounds like it wouldn't have made a difference how long it took for them to get there, she wasn't going to survive no matter how aggressive anyone got and the ER nurse, from experience, probably knew this. And it was probably vomit coming from the lady's mouth and nose. Blood from the ears is a bad sign too. As for a first aid kit, don't carry a tourniquet. There's no reason too. The first rule of first aid is NEVER use a tourniquet on bleeding! You could cause more damage to the tissue distal to the tourniqet than you realize by cutting off circulation to it. Use pressure instead. Even if the limb is severed, use pressure above the injury to slow the bleeding. The best thing you can do on the scene of an accident if EMS is already there is to stay out of the way. They know how to handle accidents and don't have time to worry about the unexperienced getting in their way. If no one is there yet, remember your ABCs, but NEVER move a possible spinal cord injury!!!!!! Let the professionals do that!!!! I hope you don't have another experience such as that one, and as for this one, contact the ER where you work, they may have a critical incident stress debriefing team. It sounds like you need to talk to someone who can help you deal with the trauma of what you saw. Good luck.

Pam

[SilentfadesRPA]

I think you both did the best you could have given the situation.

I agree a traumatic code has very little chance and less give the situation you describe.

A nurse can not declare a person is dead. The other RN may have known -- she allowed the husband some delay until a proper safe place to have his grief reaction. Can you imagine if he had been tole there ?

If there is obvious bleeding as you described from the ears nose and mouth and NO ONE is required or obligated to put themselves at risk for hiv hep b or hep c.

Frankly I would not except for a child.

WE DONT ALWAYS CONTROL DESTINY BUT YOU DID THE BEST YOU COULD --- REMEMBER THAT

My thoughts are with you

Marc

ps consider getting some debrief counseling it can and does help.

[gauge14iv, MSN, APRN, NP]

Actually - in some states, RN's can pronounce death.