Day for Knight

Notwithstanding the fact I think Kellie Martin looks way too young to be a third year medical student and the additional fact that sad puppy-dog look got really annoying about ten minutes into the episode, I'm going to do my best to be objective about the whole thing and comment strictly on the medicine. I will say, however, that if she's the newest person to do the World's Longest ED Clerkship, I'm not very optimistic about my being able to stomach most of the season.

I get the feeling I'm going to rag on Lucy Knight today, so we might as well start with the most obvious medical gaffe of the episode -- her very first patient. And what luck, it's one of my pet peeves, too. As some of the folks on alt.tv.er and the guy with the bike helmet pointed out, never move the neck of a trauma patient until you've established there's no neck injury. If nothing else, hold the patient's head with your hands to make sure they can't move. (Frustrating point: all too often, after telling someone not to move their head, they nod and say, "Okay.") One would hope that Ms. Knight, ostensibly a third year medical student, would know better than to stick something under a patient's head, but apparently not. Nothing terribly unusual by way of management; he's checked over for blood chemistry imbalances and cardiac arrhythmias that might have led to him fainting.

The drug pusher brought in had gun shot wounds to the chest, neck, and face (if I heard correctly) and had arrested twice. Traumatic arrest has a horrible prognosis, though you have a marginally better chance of surviving if your trauma is penetrating as opposed to blunt. Because more than 60% of cardiac output is destined for tissues below the diaphragm, the chest was opened in a thoracotomy (see the FAQ entry) -- they may have also cracked to repair injuries directly to the heart or the great vessels; it was kinda hard to tell.

Emile Fernandez fell 20 feet onto concrete and lost consciousness. He also stopped breathing, so they intubated him and began ventilating him with a bag-valve mask. Lucy screwed up on the GCS, as Matt Warren pointed out to me in e-mail (before I'd even seen the show!) -- eye opening isn't worth 5 points, it's worth 4. At any rate, the signs pointed to either a subarachnoid bleed, a subdural bleed, or axonal shear injury. The first two can be corrected surgically (drill a hole in the head and let the blood out), the third has a terrible outcome and can't be directly treated. The best way to deal with this is to treat the rise in intracranial pressure and hope for the best, but with axonal shear injuries, the brain is essentially destroyed, so there isn't much that can be done. Mark wanted to give him corticosteroids to control the swelling and hyperventilate him, the theory behind the latter being that you can cause vasoconstriction by blowing the arterial PCO2 down below 30 mmHg. I can't really think of anything I would have done differently, except added mannitol to the drugs Emile was receiving. This said (and being fully pragmatic), Emile is almost the perfect organ donor. He's young, in very good shape, and strong. He's also destroyed his brain, but the rest of his body is working fine. Definitely an excellent candidate for the transplant team.