Jana Turnbull is a 23-year-old patient who is brought to a university teaching hospital and trauma center via ambulance after a multivehicle motor vehicle accident in which she was a restrained driver with intrusion into the vehicle on the driver’s side.
The EMT gives the following report to the ER physician and nurses assuming care of Jana at 3:00 pm:
“This wreck was a mess. A dump truck crossed the median and hit a semi, and about 10 cars piled up. Her car was a little sedan, and she had a direct intrusion of a max duty pickup into the front driver’s side panel. Fire Department had to extricate her with equipment, but a fire erupted before they could get to her inside the driver’s compartment so she has some bad burns on the right lower leg. She is also complaining of abdominal pain. She was restrained, and the airbag deployed. She was placed in a c-collar and on a board at the scene, we started an IVs and hung a bag of normal saline. HR 120’s, blood pressure in the field was 100/60. Normal mental status throughout.
VS: T 95.1F HR 135 BP 90/60 Sp02 99
Initial exam done by ER physician, with findings reported verbally to team as exam is conducted. Jana’s backboard is lifted to the stretcher and her remaining clothes cut off to evaluate additional injuries. Jana is crying and shaking in pain and interacting with the team appropriately. She is covered with shallow abrasions and several small bleeding lacerations, and is burned with blackening and peeling of the top layer of skin with whiteness of the underlying areas. The burn covers the anterior surface of both legs from the ankle to the mid-thigh as well as some medial surface and posterior surface of the left leg. She says the burns “kind of hurt” but that her abdominal pain is worse than the pain from her legs. She has bruising visible over the left upper abdomen and is tender to palpation with guarding on palpation. Her lung sounds are symmetric and clear bilaterally, and her distal pulses are palpable.
An additional large-bore IV is placed with a second liter of crystalloid now infusing and the Trauma service is paged to the ER to help evaluate and treat the patient.
The trauma team assesses Jana’s airway, looking for singed hair of the nose and face, hoarseness or black mucous. They determine that she is able to maintain her airway and agree with the lung findings. She is bruised and tender on her left chest wall
VS update: T 94.9F HR 150 BP 80/40 Sp02 99%
Two additional liters of crystalloid are given and a focused assessment using sonography for trauma (FAST) exam is performed.
Bedside ultrasound screens of the pericardium, thorax, and abdomen are done with free fluid visible in the left splenorenal view
The trauma attending orders 2 units of packed red blood cells to be given immediately and additional ringer’s lactate to be given as a bolus. She explains to Jana that based on her examination and vital signs, she is very likely bleeding internally and needs emergency surgery. This surgery will open up her belly and allow the surgeons to look for and stop the cause of the bleeding. What is bleeding, or what is needed to stop the bleeding, isn’t known yet, and they may have to remove an organ or part of an organ to stop her bleeding. There isn’t time to do more tests to look for the cause of bleeding before operating based on her vital signs and the ultrasound findings; waiting longer to be sure could mean that she would become unstable and is riskier than going ahead with a surgery to explore the cause of bleeding. Jana consents to the surgery.
While the team is setting up OR 4, she is logrolled and her spinous processes are palpated with no pain from C7-sacrum. A rectal exam is done with no blood and normal tone. The backboard is removed but her C-collar is left on.
Labs were drawn at arrival and have returned:
|Blood type A||Coombs negative|
An indwelling urinary catheter is placed, with return of yellow urine.
Jana’s abdomen is full of blood when opened. This is suctioned and the abdominal contents explored with the discovery that the spleen is ruptured. The splenic artery and vein are clamped, and the spleen removed. No other intraabdominal injuries are found, and her abdomen is closed. Estimated blood loss is 2000 cc’s. She receives an 2 additional units of PRBC’s in the OR and her blood pressure stabilizes. Next, her burns are examined under anesthesia. As feared, the majority of the burn area is full-thickness.
Silver sulfadiazine cream is applied, with plans to return for formal debridement within 24 hours.
A nasogastric tube is placed and attached to low wall suction. Vital signs at the close of her operative case are: T 96.1 HR 100 BP 100/60 Sp02 99%. Anesthesia is discontinued and she is transported to the surgical ICU for monitoring.
Postoperatively, X-rays of the chest and pelvis are done. See drop-down box for X-rays 1 and 2 under The Case tab.
Jana awakens normally from the anesthesia and is given a patient-controlled analgesia pump for pain that dispenses morphine at a steady rate as well as on demand. A Tdap booster is given as she cannot remember if she had her last tetanus shot within 5 years. She is also continued on IV lactated ringer’s at a rate of 500 cc/h. She is kept NPO, and also started on an IV antacid. The next morning, Jana’s labs show:
2 additional units of PRBC’s are ordered and her transfusion starts at 9:30 am. The transfusion is finished at 12:30 pm, and as the ICU nurse is removing the transfusion setup she notices that Jana’s oxygen saturations are now 91%. Jana also reports feeling more short of breath. Vitals show: T 101.3 HR 115 RR 20 BP 80/40. The on-call resident is called and examines Jana, noting that she now has crackles in both lung bases. A chest x-ray is ordered. See drop-down box for X-ray 3 under The Case tab.
Jana is placed on a venturi mask at 60% FiO2 with improvement in her oxygen saturations but continued tachypnea in the 20’s and reported dyspnea. An arterial blood gas shows a Pa O2 of 65 and a PaCO2 of 30 with a pH of 7.50. Jana is treated with supportive oxygen therapy over the next couple of days and gradually improves until she no longer needs supplemental oxygen.
Over the next week in the hospital, Jana is kept on IV fluids, steroids and IV broad spectrum antibiotics requiring placement of a central venous catheter and taken back to the operating room repeatedly for debridement and skin grafting of her burns. Her return to normal diet is delayed due to concern about her respiratory status. On hospital day 4, she is allowed to try sips of water and once she is able to keep those down, her diet is advanced to regular food. She remains in the SICU for intensive burn care. On hospital day 10, she is noted to be febrile and blood cultures are collected at 8 am. She is tachycardic but has normal blood pressures, so cultures of her urine, blood, and sputum and an antigen assay for C. difficile are sent and a chest x-ray is ordered, which is read as normal.
The surgical resident on call is then paged at 10 pm and told that there are gram-negative rods growing in one of her blood culture bottles. The lab then pages him again at 11 pm and he is told that there are gram-negative rods growing in the other blood culture bottle. The resident starts IV meropenem and gentamycin and examines Jana’s burns, which do not appear to be infected. The remainder of her physical examination is also normal. Her central line is pulled at this time and the tip cultured. The resident also orders her urinary catheter removed.
Her cultures, including the central line catheter tip culture, return positive for Pseudomonas aeruginosa susceptible to meropenem and tobramycin. She completes a 7-day course of these antibiotics. Jana is moved to the regular hospital floor on hospital day 12 and then orders are placed for discharge home once her antibiotic course is concluded on hospital day 18. At discharge, her nurse administers the Pneumovax and Menactra vaccines and instructs Jana to get her flu vaccine each year when it becomes available without fail.
A week after discharge, the attending physician is contacted by hospital administrators and asked to call the patient’s insurance company. The insurance provider is refusing to pay any care costs or extension of stay caused by the bloodstream infection, stating that it was a preventable complication. The attending physician makes the call and argues that infections are a known complication of burn care, but the case reviewer states that the central line could have been removed earlier in her care and contributed to a preventable infection and thus this segment of her care will not be covered.
6 months later, the university teaching hospital is notified by Medicare that its overall rates of bloodstream infections are in the top quarter of all hospitals within their comparable class and that reimbursement for all Medicare patients will be cut by 1%. This results in the hospital laying off 75 employees, mostly nurses, techs, and assistants, and cutting back on plans to purchase advanced diagnostic imaging equipment in the radiology department.