Medical Records from 8/7/20

Back in May Brigham requested his medical records from McKay Dee Hospital. 

Here are some of the notes from the injury date 8/7/2020

Dr. C:

 I was present throughout the time the patient was in the ED which was 16 minutes and spent an additional 5 minutes taking the patient up to the OR so the total time spent with the patient was 21 minutes.

 Assessment/Plan 

1. Shock due to trauma 

2. Acute blood loss anemia 

3. Contact with powered saw as cause of accidental injury 

4. Injury of right femoral artery

5. Leg injury- major

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Dr. H:

HISTORY OF PRESENT ILLNESS: 

This is a 21-year-old male presenting here to the emergency department via LifeFlight. We have received urgent calls from them prehospital to alert us of the patient's initial concerns. We have assembled level 1 trauma team as well as vascular surgery at bedside upon the patient's arrival for emergent intervention. It is reported to me initially that the patient had an accident with a powered saw of some kind while working construction sustaining a large laceration to his right proximal thigh with active extravasation. LifeFlight team reports that the patient has been diaphoretic, syncopal, hypotensive tachycardic with extensive bleeding. They report that the injury is too proximal for tourniquet. They have initiated IVs, blood product administration, TXA and have responded promptly to the emergency department. It is later reported to me by father that the patient was utilizing a powered skill saw of some kind cutting boards for a job that they are working on. The patient does not recall how this happened though he is currently awake and alert. He reports his pain is 10 out of 10 he states "just put me to sleep I feel terrible". EMS reports that the patient has improved with his mentation since arrival and administration of blood and plasma products.

DIAGNOSIS: 

1. Hemorrhagic shock due to trauma 

Hemorrhagic shock decreases the amount of blood circulating to the body's organs, making it more difficult from them to get the oxygen they need to live. To counteract this effect, the heart will beat faster, the receiving tissue will absorb more oxygen from the blood, and the body will reallocate blood supply toward essential organs like the brain.

2. Acute blood loss anemia 

3. Contact with powered saw as cause of accidental injury 

4. Thrombocytopenia 

A condition where abnormally low level of platelets are observed. It causes nosebleeds, bleeding gums, blood in urine, heavy menstrual periods, and bruising.

5. Lactic acidosis 

6. Injury of right femoral artery 

MEDICAL DECISION MAKING/DIFFERENTIAL DX: 

LifeFlight has asked us to meet them on the tarmac here at McKay Dee Hospital for a hot load as they report the patient is not doing well and is hypotensive. Myself as well as nursing staff and security have met the patient on the tarmac to continue ongoing pressure at the bleeding site of the right proximal femoral artery and vein. This has aggressive bleeding, the patient is pale, diaphoretic, Dr. V and Dr A with trauma and vascular surgery respectively are at bedside upon the patient's arrival for immediate evaluation. I have activated massive transfusion protocol, given the patient 70 of ketamine, the patient's blood pressure maintained at 80s systolic, and the patient was intubated as a matter of saving time prior to emergent OR intervention. Surgeons upstairs are prepping and scrubbing for the patient's arrival to the operating room.  I have updated the patient's family here in the emergency department after the patient's transfer to the OR and updated them on known status and the critical nature of the patient's injuries.

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Surgical Notes from Dr. A

PREOPERATIVE DIAGNOSES: 1. Traumatic large laceration of the right proximal thigh with transection of the femoral artery, nerve, and vein. 2. Partial transection to the right quadriceps muscle. 

 POSTOPERATIVE DIAGNOSES: Same. 

 PROCEDURE PERFORMED: 1. Right common femoral, profunda femoral, and superficial femoral artery thromboembolectomy. 2. Right femoral vein thromboembolectomy. 3. Harvest of right greater saphenous vein. 4. Right common femoral to profunda femoral and superficial femoral artery bypass graft with reversed saphenous vein. 5. Right femoral vein to common femoral vein bypass graft with non-reversed saphenous vein. 6. Right leg 4-compartment fasciotomy. SURGEON: Faheem Akhtar, MD. ANESTHESIA: General endotracheal. CO-SURGEON: Victor Varela, MD. INDICATIONS: This is a pleasant 20-year-old gentleman, who sustained an injury to the right proximal thigh while working with a skilsaw and had active extravasation from the right proximal thigh laceration. The patient is being emergently taken to the operating room for control of bleeding as well as possible repair. The patient was not consentable and no family members were present for consent. 

Hematologic: Patient with significant blood loss, he had massive transfusion requirements thus far. To our count he has had 9 units of packed red blood cells, 2 units of FFP and 2 units of platelets.