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?


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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