Saving the Unseen Patient

AJN, American Journal of Nursing:
September 1996 - Volume 96 - Issue 9 - p 80
Reflections
Lindsay, Carol RN BSN CEN

he confusion at the crime scene was evident in the report received by the emergency department. The paramedics initially called the patient critical, then dead, then critical again. With two gunshot wounds to the face, she had an agonal heartbeat, no pulse, and no respiration. When the ambulance arrived at the ED, the paramedics were performing manual chest compressions and using a bag and mask for ventilation. They were unable to intubate her.
"Load her up and bring her in," the ED physician directed. "We'll decide what to do after we evaluate her."
The slender 33-year-old was carried in strapped to a backboard, her dark hair matted with blood, her mauve crushed-velvet shirt torn to shreds. Gold hoop earrings hung on either side of her blood-covered face. On her feet were a pair of blue slippers.
We tried several times to intubate her, but the tube would only go in about halfway. Between attempts, we ventilated her with the bag and mask while continuing chest compressions. Intravenous epinephrine and atropine were administered. Finally, her heart started beating again and her pulse returned.
As I cut off the patient's clothes, a police officer took them and hastily stuffed them in an evidence bag. He filled me in on what had taken place. The woman's boyfriend had called the police and reported an "accidental shooting." When the officers arrived, they heard shots. The boyfriend explained that he was "unloading his gun into the carpet." Though the paramedics hadn't been able to identify any exit wounds, the police believed two of the bullets they found embedded in a wall had passed through the patient. (Figure 1)
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Image ToolsI pulled the cricothyroidotomy tray out of the cupboard and blew the dust off the cover. After checking the expiration date, I set the tray on a bedside stand. Turning to face the patient, I heard a strange flatulent noise each time she was bagged. As I slipped my hand under her back, I felt crepitus. The skin on her upper back and neck was filled with free air. I slid my hand across her shoulders toward her neck and my fingers disappeared into a gaping hole.
"I found an exit wound!" I said. My index finger rested on something sharp, which turned out to be the remains of her fourth cervical vertebra. X-rays later showed her entire third and fourth cervical vertebrae were blown away.
I removed her Saint Christopher's necklace and the physician made a deep incision into her cricoid space. The yellow cartilage of her trachea lay deep beneath the edematous tissue of her neck. We tried several different sizes of tubing before we succeeded in inflating her lungs without losing oxygen through the hole in the back of her neck.
With a secure airway in place and oxygen being administered, her pulse became stronger and her blood pressure rebounded. But it was getting harder and harder to compress the bag. A portable X-ray showed what looked like a left-sided pneumothorax. We inserted a chest tube, but it didn't help. We placed a second chest tube in the right lung. Still no improvement.
Finally, withdrawing the endotracheal tube half an inch eased the resistance. I inserted a nasogastric tube with extreme caution-worrying that it would thread into her brain-and then catheterized her bladder.
By now we were wading through paper, boxes, syringes, trach tubes, linen, and blood. All the major trauma trays had been pulled out of the cabinet and strewn on the floor in our haste to find the ones we needed. I was scribbling notes on the backs of wrappers, to be transcribed into the chart later.
An hour after she arrived, the patient was stable. She was ordered transferred to a nearby trauma center. As we put her in the helicopter, I handed a police officer a plastic bag holding her blood-covered earrings and necklace.
"Was she pretty" he asked.
"I don't know," I answered. "I never looked."
The next day I called the trauma center and learned she'd been pronounced brain dead. Her parents had agreed to organ donation, and her heart, liver, lungs, and both kidneys were successfully harvested.
I never learned her name or anything about her. But I do know that our work was a success, because our patient gave five other people the chance she never had-the chance to live.
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