Falling head over heels – Part two

The cliff divers of Acapulco
The cliff divers of Acapulco

Last time we learnt about a young man who had the misfortune to fall from a great height into a heap outside the medical centre., all in the name of love. We discovered he had a head injury, an obvious open/fracture dislocation of his elbow, some broken ribs and a suspiciously tender C6. We also discovered that the quickest way from A to B is still a straight line and aeromedical retrieval is not always an option. It would have been easy to manage him in the tertiary referral centre that I just worked at. He would have been through the scanner within half an hour of arriving but that was not an option. So what did we do? Let’s go over his injuries…

Head injury

The bilateral epistaxis and a large haematoma to the occiput was concerning but we had  no way of looking inside his head. I was partially reassured by his climbing GCS from 14 to 15/15, lack of seizure activity lack of neurological findings but his level of consciousness was our only real indicator of brain function. Unfortunately the cruise ship industry had not gone so far as to equip the medical centres with ultrasound when I left.  Otherwise we could have measured optic nerve sheath diameter as our surrogate for raised intracranial pressure.

Open fracture/dislocation of the elbow

You didn’t need an x-ray to see that something was wrong but the ketamine on board made it easier to wash the wound thoroughly, reduce  and plaster the elbow whilst awaiting definitive treatment. The limb remained well perfused and a good washout and IV antibiotics reduced the risk of infection.

Rib fractures

There was no pneumo- or haemothorax on the chest x-ray and the only respiratory compromise was due to pain. Aliquots of opioid analgesia augmented the local anaesthetic blocks without adverse effect on conscious state.

Possible cervical spine injury

It wasn’t even worth trying an x-ray with the ship bouncing around so we made sure he wasn’t going to suffer from sea sickness and maintained immobilisation with good pressure area care for 36 hours.

Then all we could do was wait, and watch closely for any change and make arrangements to be met at the other end.

Romeo had been very lucky. His brain was fine other than a small contusion. He had sustained a couple of cervical spinous process fractures as well as a couple of thoracic fractures. His elbow required a prolonged course of antibiotics and a long operation but was functional last I heard. But we were very lucky we were not further out. By the time he arrived in hospital he had already developed more signs of pulmonary contusion and basal atelectasis that warranted a prolonged ICU stay.

There is a limit to what you can do in the middle of the Tasman. I learned a lot from the case (and from the hospital discharge summary). You treat what you can see but you have to assume the worst. You have to assume the slow intracranial bleed,the unstable cervical fracture, and the impending pneumothorax. You have to assume that your patient is going to deteriorate and be prepared to deal with him when he does. I was fully prepared to intubate this man, ventilate him, and insert bilateral chest tubes should they be needed to ensure me complete his trans-Tasman journey. But I wasn’t going to be performing emergency burr holes in the middle of the sea with neurosurgical back up not even visible on the horizon. Even my MacGyver medicine has its limits.

Dr. Andrew Tagg left the shipboard life in 2009 to settle down and lose weight. He is currently an advanced trainee in EM working in Melbourne’s western suburbs. He still has the uniform. Contact him via Twitter @andrewjtagg

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