I usually start any PFC lecture I give with one or more of these cases to drive home the realities of the operational context; a small team operating in the middle of nowhere dealing with a very sick patient with little to no support.
Remember the “Rules”
Cases are intentionally vague.
There is no “right” answer, it’s a discussion.
You will have each patient for 24 to 72 hours.
Plan for the worst-case scenario. Murphy’s Law is in effect.
No crazy CT or MRI studies. You might possibly, maybe, have an ultrasound. You are in an austere environment and have what a medic would bring. If you aren’t familiar, search the site for “PFC Pelican Packing List” for a basic layout. (It’s at the bottom of that page.)
We want to improve morbidity as well as mortality. Imagine the patient is your own family member.
You will likely have to fly with your patient for 8 hours on a “slick” (no med crew or equipment) aircraft. Be sure to consider both patient and equipment preparation.
You have one junior medic and a handful of non-medics as helpers.
Local blood supply and pharmacy are questionable at best. The primitive lab in town has a turn-around of at least 4 hours for the most basic tests.
Feel free to address the “no-evac-possible” scenario.
Now, on to the case…
A U.S. service member sustains a TBI / Closed Head Injury from an ATV crash (a very common MOI for deployed Special Operations Forces). The patient had a transient loss of consciousness, without any other significant associated injuries. The patient complains of a severe headache, and the medic notices a decreasing trend in GCS while waiting for evacuation…
I’ll add some of the concerns we need to address directly on the blog post this week in the case that you are reading this on Facebook or another site:
Does the medic have a strategy to secure his airway without RSI medications?
Does he know how to properly task his team to help?
Will he devote one person to watch the airway at all times?
What is the plan to keep the patient comfortable with his ET tube for the next 24 hours?
Will he call for help? Will he remember the Clinical Practice Guidelines for management of the head injury?
Does he know how to properly trend a GCS?
What other concerns do you have?