Last week in M&M (weekly morbidity and mortality conference) an interesting case was presented. It was especially interesting because of the approach our attendings took. They presented it purely as a matter of learning, without any attempt to name or blame the residents involved.

A patient was transferred to our trauma center from some distance away. The report we received (bear in mind how unfactual these reports often turn out to be) stated that he had been involved in a high-speed car accident several hours previously. He was being transferred mostly because of the number of different injuries he had sustained, including a pelvic fracture, a large scalp laceration, an open tib-fib, and general abdominal tenderness, with no diagnosis attached at the outside facility. Sort of as an add-on, the presence of a “small, stable right-sided pneumothorax” was mentioned. So preparations were made to receive him, according to the usual trauma protocol, but with the general impression that he had been stabilized prior to transport (pelvis fairly stable, scalp lac closed with staples, tib-fib fracture splinted, abdominal CT showing no drastic problems).

When he arrived in the trauma bay, he at first seemed to fit this picture. He was alert, talking, obviously in some pain, but not too bad, as long as you didn’t touch his leg. There was dried blood all over his head, consistent with a fair amount of bleeding before the lac had been closed with some fairly hefty staples, with no particular attention to cosmesis. Plain films were repeated, and the pelvic fracture seem like a pretty soft call. There was no noticeable instability, or pain, on exam.

After about half an hour in the trauma bay, things seemed to be under control. Ortho had seen the patient, and had called for an OR to be opened so they could deal with the open fracture (which counts as an orthopedic emergency due to the high risk for infection). While waiting for that to open up, a few members of the trauma team decided to clean up the scalp lac. The attending and most other members of the team moved on to other jobs.

Then the patient decompensated. He started to complain of shortness of breath, and seemed to have some difficulty speaking. His pulse ox dropped to the 70s, and did not improve when a face mask was quickly placed. His level of consciousness seemed to decrease, and his blood pressure began to trend down.

The junior resident who was now pretty much alone in the room came to the conclusion that the large doses of narcotics he had been given for pain control had suddenly become too much for him, perhaps in addition to severe blood loss from the scalp lac and open fracture. He called for nursing assistance, and performed a rapid-sequence intubation.

As you may perhaps be guessing, the patient’s oxygenation did not improve. In the course of listening for breath sounds to assess tube placement, it became clear that he was lacking any breath sounds whatsoever on the right.

Around this point the attending arrived, and a needle decompression of the tension pneumothorax was performed, quickly followed by chest tube placement. The patient did survive the whole ordeal.

The point in M&M, of course, was to discuss airway management and pneumothorax in trauma patients. Any doctor – or medical student – reading this may be thinking, “That was a completely textbook presentation. There should have been no question about what to do first – and intubation was clearly wrong.” (The positive pressure ventilation would worsen the pneumothorax, and the time wasted on this useless intervention could have proved fatal.)

I know the resident who was involved. He’s a smart, conscientious guy. If that were on a test, he would never have missed it. I can only speculate about the level of pressure that caused him to choose the wrong course of action.

Life is not as black-and-white as the textbooks or the tests, and sometimes there’s no time to think things through. I’m not looking forward to being in that position myself, in only a few months.

(And just for the curious, I made up this story to simulate the event which actually occurred. Maybe I made the scenario too clear. It was plain in retrospect, but tricky while it was happening. Which is also why there’s no discussion of narcan to reverse possible narcotic effects.)

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