A few days before Christmas, I was on call. Dr. Faile and I were down in the theater preparing to do a surgery when a man was wheeled in on a gurney. A cloth was wrapped around his head – his body covered in blood. He looked like an extra in a zombie movie. His face was painted with dried blood. His white shirt was now red. Even his pants were covered in blood. Dr. Faile and the theater staff started IV fluids in an attempt to replace the fluids he had lost.
The men who wheeled the patient down to the theater said that he had arrived to the hospital alone after falling off his bike. Other than the fact that he wreaked of some kind of local brew, we knew nothing else about the patient. We asked the patient his name. He quickly sat up on the gurney, stated his full name with a degree of intensity, and slowly laid back down with our prompting. He continued to talk and the theater staff began to laugh. I’m not sure what he was saying, but it seemed to be nonsense.
Once the IV fluids were flowing, we wheeled him into the minor procedure room and uncovered his head. The skin and muscle on the right half of his forehead flapped away from his skull. Although the muscles were severed, they were still able to contract. Instead of raising his eyebrows, the contraction now pulled the brow down, unnaturally away from the skull.
His skull however was amazingly still intact. Blood continued to spurt from a few severed arteries. Dr. Faile clamped the bleeders with hemostats as I donned my sterile gloves in preparation for suturing his head. I picked out a thick suture, which in hindsight was much larger than necessary. I first cleaned the area, draped his head with sterile towels and injected the site with lidocaine. I had to trim the jagged edges of the wound before I could begin to suture. I approximated the corner of the wound then sutured each side, leaving the area of the largest bleeder for last. Hoping that the hemostat would help to clamp down the vessel.
Once I sutured the wound and controlled the bleeding, I admitted him for further IV fluids and observation. After the surgery with Dr. Faile, I went back through the wards for my final rounds for the night. The patient was sleeping on a mattress on the floor with a blanket over his head and the stench of vomit filling the air. The nurses stated that he had become restless, pulled out his IV and had vomited, but was presently resting quietly. I asked for his most recent blood pressure and it was very low. I took the blood pressure again and got 50/nill (normal = 120/80). I ordered that the IV line be replaced, IV fluids restarted, and typed and crossmatched a unit of blood to be transfused. I did not yet have the results of his hematocrit (blood cell level), but due to the amount of blood he had lost and his low blood pressure, I made the order. I also asked the nurses to keep a close eye on him overnight.
The next day, I found out that his hematocrit was 26% pre-transfusion. (normal is 30-45 with the transfusion point usually <18 at the BMC). I guess I jumped the gun on the transfusion, but I made the decision based on his clinical presentation and vital signs. I wanted to err on the safe side. I believe that I build confidence in my own clinical judgement by making such decisions, whether right or wrong, as long as I learn from the decision and the patient isn’t harmed.
The patient did well and was discharged in a couple days. He returned to see Dr. Faile for follow-up. I don’t claim to be a plastic surgeon, but I think the result looked alright.