like the thread started by betts this will be an exercise in critical thinking and clinical assessment/decision making. what i will do here is relate day by day a patient story. each time i post i will disclose more information just as would occur in real life. your responses will not affect the story. what will make this challenging for all is that the setting is rural/remaote area nursing.

place: small country hospital 3 hours drive from nearest "base" hospital. you do not have access to ct only x-ray machine -operated by rn's with "x-ray certification". no full time medical officer - local general practitioner "covers" the hospital for after hours on-call emergencies.

the story:- john p is escorted by police to your hospital at 2315. the background stroy you get from the police is that he has been in a drunken argument after consuming a "large amount" of beer at the local pub. john p has a large profusely bleeding scalp wound. he has slurred speech - reeks of alcohol and has a glasgow coma score (gcs)of 11/14. eye opening - 3/4 will only open eyes when you call him. verbal response 4/5 - confused, mostly slurrd swearing and abuse. motor response 4/5 not obeying but he is scored at this because every time you ask him to "squeeze your hand" he becomes abusive and tells you where to go. the medical officer is notified. he does not come in to see the patient. the wound is cleaned and sutured by the nursing staff and the patient is admitted "for observation" overnight.

Sounds a lot like a typical Saturday night in our ER so far....lol

Did he fall or was he struck? I would ask the officer to clarify the incident.

We draw BAL every few hours on someone in toxicated. As the patient sobers the clinical picture gets clearer

Excellent response Sanakruz but remember - this was a remote area hospital - nearest laboratory was 3 hours away by car.

How about breathalizer?

On refelction - with 100% hindsight that would have been a choice but as far as I know it is not routinely done over here in our rural hospitals.

As for asking the police - they at this stage only knew it was a fight they had not interviewed the witnesses.

P.S I am trying to "play this out" as it actually happened but I think Sanakruz - you might already see where this is going.

How about a bleed in the brain from head trauma?

Monitor his vital signs as you would any head injury. Here we call these neuro checks and most facilities have protocol.(q15 min x1 h ,then q30 x 1 hour,then q hour x2, then q2 h.)

This guy could have a bleed somewhere.

Seizure precautions?

NPO.

0430 patient had been on 1/2 hourly observations since admission. gcs remained static - between 11 - 12/14. pateint still had slurred speech, confused and abusive. pupils equal and reactive.

He's still drunk. But what do his vitals say? Low bp or high?

At this stage his vitals are all still normal - not a blip on the radar screen.

did anyone do a fingerstick to check blood glucose?

0500 gcs dropped from 11 to 6/14 - very difficult to rouse requiring deep and prolonged noxious stimuli to get his eyes to open., he is no longer making any sounds and he is only showing abnormal flexion with application of painful stimuli. pupils are now unequal. the local gp is contacted immediately

0600 he is being flown by air ambulance to the nearest base hospital.

0700 the police inform the nursing staff the mechanism of injury. he was thrown head first into a brick wall.