a collapse joker

70 years old man, alleged RTA and sustained laceration wound of left lower lip. no LOC, no SOB, walked in to green zone comfortably. also complained of right shoulder pain and few abrasion wounds over legs and right arms. otherwise, no other complaint. no anemia symptoms. no abdominal pain, no chest pain, no headache. he also known case of HPT and DM on medications.

on examination, alert. GCS 15/15. speak in full sentences. not tachypneoic. no stridor. SpO2 98% under room air. BP 190/100 heart rate 70bpm.
lungs clear, equal air entry. CVS = DRNM. abdomen. soft non tender. no cervical tenderness, no spine tenderness. Hb 15, Hct 44

the lip. degloving injury of left lower lip. big clot on top of the wound. no oozing of blood but still bleeding. able to open his mouth. no foreign body noted.

referred to plastic surgery MO for further management. plan for admission and to repair under anesthesia.

half and hour later, (patient was not yet admitted to the ward, was sent to treatment room for ATT injection and change of dressing), patient collapse, presented with stridor, tachypneoic. pushed to red zone. ENT was reffered for anticipating difficult intubation KIV tracheostomy. anesthesist was there for intubation. during intubation, noted vocal cord edema. epiglottis not edematous and not inflammed. patient successfully intubated and hooked to oxylox ventilator. dentist was reffered for further assessment. TRO any facial bones fracture. no obvious fracture can be concluded and laceration wound repaired by dentist. patient hemodynamically stable. plastic surgery's side? happily let go the case as no plastic surgery intervention. (lip already repaired ma...)

GCS E4VtM6. unable to safely extubated in view of vocal cord edema. hence planned to ventilated in the ward. after several hours of playing "tai-chi", at last dental accepted the case and is now ventilated in ortho ward.

the questions?
1) what would be the possible causes of patient's sudden deterioration?
- foreign body obstructing the airway and causing stridor probably from the big clot?
- surround soft tissue injury resulted from the RTA causing upper airway to be edematous?
- hyperventilating due to pain and bleeding?
- other non trauma cause. MI?

2) what are the take home messages
- in this case, patient needs closer monitoring. facial trauma can be life threathening. he was supposed to be seen in yellow zone and maybe a longer observation is needed before we can safely say that the patient can be sent to ward for further management. yes, in this case, inadequate ressucitation.

- taichi may be very good for your health but "playing taichi" is not good for your patient. yes, in this case, it is very difficult to determine who should take this patient for further management. not clear cut ENT problem, no dental problem, and plastic surgery's problem already settled. so, what to do? let the patient stranded in ED? but unfortunately, you will see a lot of medical practitioner here in HUS like to play taichi, like to cover their assess with thick pillow (yes, the ass is the biggest asset) and always bring along a rambo knife ready to backstab whoever on their way. sigh~

- your eyes cannot see what your brain doesn't know. yes. knowledge and experience are equally important. need to be able to recognize very sick people, emergency and life threatening cues and act reflexly to those kind of situations. be safe.


now you know? sigh~ my tension went down dramatically today. after kene lectured by my MOs. being label as negligence and stupid. i hate to hear the statement again. "you are now a 5th poster". as if like keep on reminding me that i am a girl. or i am 25. again to reemphasize the thing that you've already know and nothing you can do about it. so what if i am a 5th poster. i am still a HO. and you expect us to be a paediatrician? i feel like want to stapple their mouth. not a word ladies!!... again, what we HO supposed to do when they bomb us? shut up and drive. the wound will heal by itself by time.

ahh...ED is totally stressful and boring. again one good thing about it is, you only suffer for 7hours a day.