I work in the operating room. Have previous ICU experience. Never floated to ER, so here's what I need to know:
Saturday afternoon a 24 yr. old male transported to ER by ambulance, involved in motorcycle crash (approx. 50mph), wearing helmet,no other riding gear. Patient flipped 6-8 times after having ridden motorcycle through sideways slide. No loss of consciousness. Spine stabilization in place. Alert and oriented x 3. NP evaluates patient, RN gives 10mg Morphine. X-rays are ordered (flat plate, no CT scan). Patient given another 10 mg Morphine (approx 30 min. later, before radiology visit and because of no pain relief). Patient comes back from radiology, still no pain relief, minus C Collar, radiology cleared spine.
ER MD comes in states no broken bones. Road rash 2nd and 3rd degree burns. Dress the wounds and will be allowed home. ER RN starts dry wiping debris from back (rocks, gravel, sand, dirt). Patient screams, begs her to stop, request made for additional pain medication. She stops, shrugs her shoulders and states she'll just have to apply the dressing over the wounds and patient will just have to clean it off when he takes a shower, the doctor didn't order any more medicine. (Wounds on both shoulders (most severe), full back, bilateral kidney areas around to sides (most severe). Both knees with less severe wounds, both arms, hands with scrapes, cuts. Left ankle sprained, no skin wound. Open wounds covered with tubes of Bacitrain ointment, adaptic sheets applied, wrapped in kerlex rolls. Discharged with Rx Tylenol IV, orders to see primary care physician in 2-3 days (patient has no primary care physician).
This patient is my son. I'm ashamed to say I was not an RN or advocate for him in the ER. I was just a mom, thankful her son was alive. My nursing knowledge was not a benefit for him or me at this time. :bluecry1::bluecry1:
Later Saturday night my nursing knowledge kind of kicked in enough to make me realize I needed to be monitoring him for internal injuries, etc.
Monday, unable to find a doctor to see my son, no one accepting new patients. My charge nurse at work contacts a surgeon who indicates he will see my son in his office the next morning (he is in operating room all this day).
Tuesday, the surgeon's first response was to take my son to O.R. to debride and clean out the wounds (I could not get it all out, pain too severe). (My son refused, not understanding that he would be put to sleep for this procedure, and I did not know that he didn't realize that. The doctor decided we would continue with wound treatment with Silvadene, abdominal pads and kerlex wrap, and appropriate pain medicine an hour before dressing changes. Concern with possibly needing skin grafts later. Come back in one week.
I am thankful to say the dressing changes have been going much better.
At least now I am not skinning my son with every dressing change.
I guess I am just venting, now that I feel my son will be getting better.
I am disappointed in my hospital's care delivered to my son. I feel that he should have been CT scanned, I feel he should have had a trip to the OR, I feel that he should have been admitted at least overnight, or transferred somewhere else, I feel that the dressing was inappropriate (no silvadene applied or prescribed, adaptic dressing stuck and pulled skin off when being removed), no dressing supplies were supplied or suggested where they could be purchased in bulk.
Do you all think this was appropriate standard of care? Am I just being an upset Mom? As a RN myself, I am horrified at how things were handled and ashamed of myself!
Mechanism of injury however, does indicate the level of trauma for the pre-hospital folks to relay to the accepting hospital.
At any rate to the OP - I hope your son is recovering. As a mom I am so sorry for the worry this has caused you.
And based on the information in the original post and care he recieved he was probably not at trauma center. If he was the state and the American College of Surgeons should be yanking their trauma designation.
And based on the information in the original post and care he recieved he was probably not at trauma center. If he was the state and the American College of Surgeons should be yanking their trauma designation.
What is that hospitals trauma designation?? Level 1,2,3??
Does sound like he was triaged to a fast track area is he was seen by a NP from the start. Although his MOI would have made him a trauma ALERT at our hosptial and he would have been evaluated by the trauma team which consist of 3 surgery residents, & a staff ER physician. He would have gotten 2 large bore IV's, a foley and a NG. Chest and pelvis plain films in the ER room, and then to CT for head and c-spine. Followed by more plain films of T and L spine. If everything checked out OK, he probably would have gone to tub room in our burn center for debriebment. And probably an oberservation admisson, again due to the MOI, AND 3RD DEGEE BURNS.
Thank you all for your input. My son's wounds look like they are getting better. He is still in severe pain, but now is manifesting other s/s.
Our hospital is not designated a trauma center as you all have figured out. However, they do have an emergency department and accept patients.Appropriate emergency care should have, but was not, provided. I'll deal with those things after we are on the upswing in recovery.
This town has two hospitals. I intend to take him to the other ED this morning to be examined by a doctor. I am not convinced there isn't something else going on. Severe pain in left kidney area, extreme bruising, mild swelling. I now do not believe he was even given a physical exam by the doctor in ED. (I was not with him the whole time, they had to have their paperwork, you know). X-rays included flat plate of cervical, thoracic, lumbar and sacral spine, abdomen. My son does not remember being examined.
Careful here when you say "standard" then that means that all places that either don't do it or don't have the capacity aren't providing "standard" care.... CT is NOT the standard of care for spines at this time. It is an adjunctive diagnostic tool. The history and clinical exam are the standard (meaning everyone gets this), the plain films or CT are based upon your findings or further investigation. I refer you to research the Canadian C-Spine rules or the NEXUS criteria for imaging of the spine in trauma. These tools have been validated and thoroughly researched over the years, and Mechanism of Injury alone is not criteria for imaging the spine.....
Do we xray and CT more than we should - definitely.
Do some clinicians use xrays and CTs in lieu of poor assessment and inadequate clinical decision making -YES (I am guilty of this sometimes also I admit)....
But does that make it acceptable to connotate xrays and CT's of the spine as "standard" - NO
All I'm saying is just be careful to not get in the trap of thinking what is "standard" versus not.
In my level I, university/teaching, trauma center, 115 bed ER with 180,000 ER visits/year - this definitely is not standard care.
Hope this helps!
-MB
You MUST admit that this MOI.....MCC rollover with significant road rash should and would have been considered a Trauma Standby at the very least until the secondary assessment as completed and then downgraded from that point.This should have been started as a Trauma Standby. (This case will be brought up in review within the trauma system) A CT scan is both common and needed in this situation but the EMD chose not to based on his assessment. If a Trauma Surgeon would have been entitled to assess this patient he/she would have ordered a CT SCAN, but they weren't because of the designation. To just Cover his butt, he should have ,since ejection from an MCC regardless if a helmet was used is of concern for internal trauma. Sure the disposition is after the fact, but you must admit...if it were your son.......I would think a simple CT to rule out would have been something you would have wanted. I'm not certain what level trauma center you work at or had worked....but I think the trauma designation would have been made in a Level II, Level I Trauma Center based on MOI alone. Patterns of injury with MOI >>>Ejected over the motorcycle, strike fence and chest on handlebars, internal big time injury, lower legs may be trapped, cranial and cervical injuries, inside leg fractures and soft tissue injury, ect. This patient would have been made a Trauma Standby @ the very least @ my ER is rated amongst the top 100 in the nation. This EMD was remiss.....plain and simple. We have a new state of the art 65 bed trauma center and see over 190,000 a year....EMS call, designation to Trauma STandby, radiology to CT, then downgraded from there.....Good Trauma Care..plain and simple!
Specializes in ER, Trauma, ICU/CCU/NICU, EMS, Transport.
We have a new state of the art 65 bed trauma center and see over 190,000 a year....EMS call, designation to Trauma STandby, radiology to CT, then downgraded from there.....Good Trauma Care..plain and simple!
...how about FAST exams?
You could use that instead of all the radiation as a first level screening tool....plus less risk for complication during intrafacility xport.
Question: Do you do your Trauma CT's with or without oral contrast???
-if you do them "with" how do you justify giving a pt PO contrast who might have a perforation or internal disruption???
-if you do them "without" oral contrast, how do they see hollow organs on the scans???
You could use that instead of all the radiation as a first level screening tool....plus less risk for complication during intrafacility xport.
Question: Do you do your Trauma CT's with or without oral contrast???
-if you do them "with" how do you justify giving a pt PO contrast who might have a perforation or internal disruption???
-if you do them "without" oral contrast, how do they see hollow organs on the scans???
...how about angio for vascular integrity?
We do both, depends on the patient and the Surgeon or EMD. It's a risky business you and I both know. We do have bedside US too. I guess my first concern was the initial assessment as to why this kid wasn't made a trauma standby at the very least.
Fast exams have become a standard assesment tool during a work-up in our ER. And the MOI of speed, and becoming thrown from vehicle would make him a trauma ALERT!
We do not give oral contrast for abd/pelvic trauma CT's . Non-trauma yes, and sometimes rectal contrast....a ER favorite!! Any decent CT scanner can give enough of a clear image that they can see abnormal vs normal.
:bluecry1:
The doctor decided we would continue with wound treatment with Silvadene, abdominal pads and kerlex wrap, and appropriate pain medicine an hour before dressing changes. Concern with possibly needing skin grafts later. Come back in one week. 
traumaRUs, MSN, APRN
87 Articles; 21,287 Posts
Mechanism of injury however, does indicate the level of trauma for the pre-hospital folks to relay to the accepting hospital.
At any rate to the OP - I hope your son is recovering. As a mom I am so sorry for the worry this has caused you.