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Clinical Case 095: Smashmouth vs. Surgeon

Gday, it has been a few weeks since the last clinical case.  Today I have a rural trauma case with a twist.  I have been doing a lot of pondering around logistic and practical matters with regards to managing trauma in a smaller hospital.  I keep getting stuck on a few points – so I thought I would throw out this case to you all and see if you have any pearls for me.

Setting the scene:  this case occurs in a medium-sized remote rural hospital.  Single GP-Anaesthetist covering ED overnight, there is a general surgeon and a few colleagues on-call from home.   A CT or plain films are possible if you call in the Xray tech.  The local operating theatre is really geared up for elective general surgery and Obstetric stuff.  Not much sub-specialist kit on site.

The local surgeon is out of town on a  fishing trip but there is a locum covering over the weekend (you have never met him – lets call him Mr. Highpants!)  The gossip from the theatre nurses on Mr Highpants is that he seems competent, but is maybe a bit demanding and high-maintenence for a friendly little rural hospital!

The closest tertiary centre with specialist surgeons (Plastics, Max-facs, Ortho etc is about 6 hours from door-door)

At 10:30 PM you get a call from the Ambos – they are attending to a 21 year-old Swedish backpacker who has had a few drinks and attempted to ride his Vesper back to the hostel.  He was doing about 60 kph when he hit an unseen kerb which catapulted him over the handle bars – his face has impacted the kerb.  He was wearing a helmet and did not lose consciousness.  They found him sitting on the roadside some 10 metres from the  Vesper holding his bloody face in his hands.  He is moderately intoxicated, in a lot of pain but denies any other injury other than his face.  Specifically, he denies neck pain.

Initial assessment – he has intact airway, breathing and a mild tachycardia of 100 – with otherwise normal numbers.

His face is a bit of a mess with a deep laceration extending from his top lip up into the nostril which is bleeding at a slow trickle.  He is missing his maxillary incisors and there is a open wound through the gingival mucosa at the base of the wound.  His eyes and scalp are otherwise intact.  Neuro assessment is normal.

So we do the usual thing – IV access, analgesia and call in Xray to get some images.  He is not particularly keen on a C-spine collar, but compliant with the nurses’ requests to “lay still” and allow his head to be sandbagged.  The epistaxis is bad enough that you decide to insert a nasal packing device in an attempt to tamponade it.

As you are waiting for the Radiographer to arrive… Mr. Highpants wanders into the RESUS Bay.  He opens with:  “I would like to assess this wound old chap – do you mind getting me some gauze and a bottle of saline.?

This is a bit confronting – (A) you did not call for the Surgeon!  (B) the patient has not really been assessed re: C-spine fracture  (C) No introduction – just the assumption that you are no longer the team leader!

The young Swede has a look of terror as Mr. Highpants approaches his face with a probing, gloved hand and a pair of disposable forceps.

So – TIME FREEZE.  Lets choose  your next move:

(A)  Do nothing – allow Mr. Highpants to probe and “assess” this man’s face without anaesthesia etc

(B)  Tap Mr. Highpants on the shoulder and request a brief “hallway planning moment” in which you spell out the order of priorities for this patient’s care.

(C)  Grab Me Highpants by the belt and tell him to sod off out of your RESUS bay!

(D)  Choose your own response here….

Now FAST FORWARD an hour or so.  The CT of his neck, head and face are remarkably (luckily) normal – i.e. there are no bony injuries, just a few avulsed teeth.  No C-spine lesion.  His facial bones are intact aside from a displaced nasal fracture.  He has quite a bit of swelling around the wound.

Our Scandanavian survivor appears to have an isolated nasty facial laceration with some dental trauma.

Just as you are discussing the CT results with the distal radiologist – Mr. Highpants wanders back into the department.  This time he is a bit more “team-oriented” in his demeanour….

Great news! No fractures, just a big cut really!  What say dear fellow – lets take him of to theatre and clean that out and make it all like new again?

Hmmm….  is this really a good idea?  Is it appropriate to attempt to repair a complex facial injury in a young man in a small, under-resourced hospital late at night?  Will this get our patient the best outcome possible?

You decide to engage Mr. Highpants in a bit of banter in order to assess his capacity for such a task – after all, in the past the surgical locums have been quite variable in their experience and skills…  After telling a few war stories it is clear that he has been doing gall-bags and hernias for the last 20 years in suburbia.  He did do a “spot of Plastics as an SHO back in the NHS… in the 80s” and is really looking forward to trying out his skills in the bush – one of the reasons he took the job was to “have a bit of a go at some trauma…”

You excuse yourself for a moment to pop out and get some air, have a chat to one of your mates and consider where you might draw the line here…  however, when you walk back into the department Mr. Highpants is getting the still drunk, not-really-English-speaking patient to sign a Surgical Consent form!

“OK, my man!  Young Sven here is happy to proceed!  Now I just need to find out who the damned Anaesthetist on-call is and we’ll be off to theatre…”

Your response:   “Ahhhmmm… That would be me!”

Where do you go from here?

OK.  END of STORY.

Let me know.  What would you do in this situation?

1.  Ethics of the local Rx vs. transfer to tertiary care…?

2.  How would you deal with the C=spine whilst awaiting imaging – collar? Bags, other?

3.  Do you have any cool tips on managing nasty facial injuries with epistaxis?

4.  Would you be happy to Anaesthetise this patient on the basis of a normal CT of his C-spine?  What if it were a normal plain film (3 good views, reported as normal.)?

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Comments

  1. hi mate!
    if you have a credentialled surgeon willing to do the repair, a CT scanner with reported imaging and available anaesthetist.. why wouldnt you offer definitive care in said rural hospital? This situation is similar to Mt Isa and I think such a case would be done at Mt Isa hospital.
    Yes you do get locum surgeons of varying quality but same with locum anaesthetists! the point is this is a facial wound that will do better with early primary repair and all else being equal , it can be safely done in said rural hospital.

    As for facial lacerations and epistaxis, try TXA topically. I think ALiEM did a post on this recently. Also QuikClot gauze works well if you have it.
    C spine immobilisation is tricky but at least patient is conscious albeit intoxicated. let them find the most comfortable position and do best to keep still. a soft neck collar is alternatiive. they use this routinely at a Brisbane ED in preference to rigid collar now.

    Does the pt need a GA for the repair? I assume it was too complex a laceration to use local anaesthsia infiltration and facial blocks?
    If you cleared the C spine in CT scan as well as clinically, then not a concern for a GA/ETI. I guess the thing to consider is delaying the GA for fasting if not urgent operation. this will also allow intoxication to wear off, to enable a safer anaesthetic and more reassuring clinical exam of C spine

    now for the surgeon and his approach to the case. yep we all have had to deal with challenging colleagues. Cliff Reid gives a few good tips in his making things happen lecture. trying to give them something to do is helpful. a touch on the arm appropriately during a suggestion. be polite. but clear reminders and statements about patient care priorities often is enough to prompt everyone that there is a plan of care and it is best to stick to it. As duty anaesthetist you can declare your concerns about airway and c spine injury and focus the team on that.

  2. Muhammad Umer Shehzad says:

    Hi ,
    Thanks for sharing this with us.Very interesting case.
    Firstly, C spine can not be cleared till a clinical exam in a fully awake (not inebriated) patient is done.
    He ALSO has a distracting injury- apparently a complex facial laceration.
    Yes CT rules out bone, but does not rule out ligamentous injury. For that one needs a clinical exam, and if the patient still having mid-line pain while moving neck, he will need an MRI.

    People trotting into ED with their own suggestions without considering over all condition is not uncommon. You can try subtle suggestions like “Let us address airway first and rule out other injuries first before we look at facial lacerations” etc. It differs case to case. But one theme is common: “Be clear without allowing any grey areas” . IF you want them out of the way, be clear that this is what you want (in subtle ways). Otherwise it will only spiral into a bigger problem.
    The facial lacerations per se should not be an issue for repair if someone is available to do them at a particular location with enough backup. It is the possibility of other occult injuries that sometime manifest only later. That is why tertiary survey is done and trauma is many a times admitted for about 24 hours observation before ‘clearing’ them esp if they are intoxicated.
    Regarding nose bleeds, Rapid rhino with ant and posterior packing is good. Kaltostat is another haemostatic dressing that helps clotting. IF its a real arterial spurter bleeder, then that has to be tied off.

    I would certainly not rule out C spine on Xray films. They miss too many fractures. However, if the patient was not inebriated, then yes we can think of doing that clinically.
    Face is very vascular. Applying pressure works but as soon as you touch it again, it will start bleeding like hell. I am presuming of course that laceration is complex enough to warrant a General Anesthetic.
    Spinal precautions while awaiting imaging can be tricky if the guy is just too drunk. One can put a collar on, but they rip it off. If he is aware enough to understand, I would put on a Philadelphia collar and ask him to lay still.

  3. Great case Casey
    Several issues worth discussing:
    1) CT Brain, facial bones & C-spine mandatory, down to T4. (“No” to c-spine xray!). Potentially needs a chest x-ray and thoraco-lumbar plain films as well. FAST is of limited use if not shocked, but worth recording now. If CT normal, Philly collar overnight and clearance when sober in am. The mechanism and associated head injury is high risk for occult spinal injury, I wouldn’t cut any corners.
    2) His injury: What’s the rush? It’s likely just an isolated facial lac/dental injury, which in my mind does not need urgent repair. He should be admitted overnight, with head injury/neuro obs, and a tertiary survey and formal c-spine clearance done the next morning when he’s sober. Analgesia, ADT & antibiotics, +/- fasting/maintenance IV fluid for possible theatre.
    3) The surgeon: I’m a full-time locum, so I’m acutely aware of the variety of skill level that bubbles up around the locum scene, especially in far-flung places, away from the supervision and scrutiny of colleagues. Locums vary from extremely capable, to the frankly dangerous, and having been burnt by assuming competency before, whilst not wanting to offend him, there are several other reasons to delay the surgery while his credentials are checked, (holes in swiss cheese lining up) and you liaise with the nearest facility with plastics/max-fax, possibly send them some photos of the wound (and do whatever you’d normally do in this case when you don’t have anyone available), and ensure that local repair is appropriate. Transferring him out for a facial lac repair seems excessive, but I’d want to be sure there weren’t any potential hidden complications/nuances of his injury that Mr Highpants may not be appreciating before proceeding locally.
    4) Consent: That’s nice that the form’s been signed, but your patient can’t provide informed consent for a non-life-saving procedure whilst intoxicated, language is an issue and he may be concussed. It can wait til the morning til he’s sober, his capacity can be assessed & a phone interpreter can be arranged.
    5) Resus room management: Not such an issue as this isn’t a high-stress “resus” situation as such. This is more of a communication/personality management issue. It sounds (and looks from the photo) that Mr Highpants may be a tad “old-school” in his approach, and may be feeling the relaxed, tropical, anything-goes vibe up north, which has allowed him to stroll in without having been formally referred the patient. Also, I know you’re probably busy overnight, but this isn’t a big city, KPI-focused ED where you would love surgeons to come in without being asked and whisk your patients away! In this setting, I just thank the visiting clinician for their input, then come up with my own plan, explain it to them, and that’s the way it’s going to happen. Full stop. Maintain an appreciative demeanour, and keep the “well I’m the anaesthetist, and he aint goin’ to theatre tonight” ace up your sleeve in case it escalates, but you catch more flies with honey… Keep subjective/judgmental comments out of it, keep it patient focused, and you can’t go too far wrong.

    As far as epsiatxis Mx goes
    1) Co-phenylaine+++, or straight 1:10,000 adrenaline soaked gauze/cotton-ball pledgets up each nostril (if anterior)
    2) “Buck Plug”
    http://www.edexam.com.au/epistaxis/
    3) Rapid-rhino (once base of skull # ruled out on CT), I think these are better than merocel, but that’s just my opinion.
    4) IDC’s -- can be tricky/slippery if you’re not familiar with technique -- again, ideally not before CT.
    5) Vaseline impregnated ribbon gauze -- actually not that hard to do
    6) If hosing & patient choking, sometimes you need to intubate & pack the nose & pharynx
    7) In the setting of trauma, a persistent, or recurrent “posterior” epistaxis can be from a lacerated anterior ethmoidal artery, that spasms (bleeding stops) and then hoses (spasm relaxes), which can require ligation (and in the worst case, ligation of the external carotid!).

  4. Dr. R. Lewis says:

    Hi Casey,
    1) I don’t think a specialist should see a patient unless asked/ consulted / extremely urgent
    2) Full thickness lip lacerations are nothing special: 3 layer closure starting with the muscle (orbicular oris) then mucosal sutures (all 3/0 vicryl), then skin with 6/0 prolene. The key is to get the vermillion aligned properly. Likely to be able to do this with adequate local infiltration.
    3) Epistaxis: Different bleeds will require differing levels of treatment. Inflatable packs eg rapid rhino are better for bad bleeds than merocel. I sometimes use 2 packs in each nostril e.g. 2 merocel or 1 merocel plus a rapid rhino. Lots of Co-phenylcaine spray and then on a ribbon gauze after blowing all the clots out.
    Posterior bleeds are usually the sphenopalatine artery (SPA), from the ECA via the maxillary artery. The anterior ethmoidal can bleed, though much less commonly. It can’t be embolized as it arises from the ophthalmic artery, but we can easily clip it off in the orbit. The SPA is easy to clip off in the nose, and usually stops bleeds. however good tight packs inserted right back to the posterior choanae will stop most bleeds.
    4) I don’t know much about Cx spines, but enough to know they take priority over a facial lac.
    5) Finally, did you check the surgeon’s car for Vesper dents?

    • Thanks Richard
      Did we ask for your comment? Hehehe
      Glad we got it -- great surgical pearls.
      In my head it is all about mechanism initially ( pre CT )
      60 kph face plant into kerb must mean cspine and nasty facial fractures -- Le fort something…
      So the initial level of concern was high, definitely not one to see up in ED.
      Even after the CT, lac was extensive- through upper lip up into nostril -- like a facectomy,
      So I thought it unwise to attempt sewing under local in drunk pt.
      Cosmetics -- is this something we need to think more about in ED, or can it be fixed later?
      Casey

  5. As above.

    If i was the anaes, wouldnt have allowed him to go to theatre ( and hey, in South Australia we have a separate consent form for anaesthetic anyway!)

    Easy to get the old gimmer to reminisce about the NHS and exert my Jedi-mind tricks on him that way…

    Otherwise, pretty much what the other fellas said.

  6. Muhammad "Umer" Shehzad says:

    People who have no exposure to “critical care” and “anesthetics” simply do not realise what they do not know.
    Since all here seem to be people who are well versed with “critical care” issues, and have the ability to actually see beyond facial lacerations, I will share a real anecdote from my own anesthetic term (as an ED trainee).
    Imagine the scenario:
    The patient has been given succinylcholine and is paralyzed on Theater table;
    I have the laryngoscope placed in the vallecula with the ETT in my left hand.
    I am introducing the ETT through oral cavity , and just as I am about to pass the ETT through the cords, the enthusiastic Ortho Registrar starts checking for cruciate ligament stability!!! The guy simply does not know- Eyes cannot see what the mind doesn’t know!
    Without moving a millimeter I had to shout “Can you STOP doing that!!”.
    That was my ONLY option.
    Einstein surmised pretty well when he said:
    “Those who have the privilege to know, have the duty to act.”

  7. I just stumbled on this fascinating discussion. As both a Theatre RN and Lawyer. The big ‘elephant in the room’ is the issue of informed consent!

    It is my understanding that this fellow does not have life threatening injuries, is from a NESB and remains under the influence of alcohol.

    Simply… Give the fellow, sufficient fluids and analgesia, let him sober up and give him the choice of treatment, after all he’s not a guinea pig.

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