Hypothetical A&E question

[RobotSquid]

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Hi all!

I have a question about an Accident & Emergency admission - if anyone with the relevant professional background could take the time to answer, it would help me with a scene in a novel I'm working on, and would be hugely appreciated. I'm going to describe a hypothetical admission to A&E, and what I'd like to know is, if you were the receiving physician, what would you do in this case?

Suppose you were working in the A&E at a hospital somewhere close to large expanses of wild, hilly country - hillwalking sort of territory. For the sake of concreteness, let's say Belford Hospital in Fort William, Scotland - the actual place-names given here are irrelevant, but they give you an idea of the sort of place I mean.

One morning, a call to emergency services is received from the reception desk of the Glencoe Hotel at about 6am. A girl, aged about 11, unaccompanied, wearing hillwalking gear and a backpack, staggered into the lobby of the hotel minutes previously. She was filthy, had a fresh cut and noticeable bruises to her face, was visibly shaking and relied heavily on the furniture and fixtures to keep upright. When the receptionist caught sight of her, she looked up, said "I made it ... I made it! ... hehehe ... I feel amazing!", then lay down on the floor and fell fast asleep.

She was taken to A&E by the air ambulance, where she was admitted to your care and did not wake up at any point on the way. There's no sign of concussion or cranial trauma, she's simply utterly exhausted and very soundly asleep. She has a lot of bruises all over her body, and her right leg is in a makeshift splint & cast hacked together from the internal support struts from her backpack and a roll or two of duct tape. You suspect she did it herself, and she's actually made a pretty decent job of it, given the materials she had. She has no ID on her, and doesn't match the description of any recent missing child alert. Her condition is stable, and there's no sign of hypothermia. Other than her recent injuries, she seems to be very fit and healthy, and a very very sound sleeper. If you need to wake her up, you're going to have to do something pretty drastic.

I presume that one of your first priorities is going to be to get an x-ray of her leg - (She in fact has a fractured tibia - it's a clean break, a closed single fracture, and she's done a very good job of splinting it, but she's presumably had to walk on it to get to the hotel from wherever she broke it the previous day) - but, do you let her sleep and do the x-ray when she wakes up, or x-ray her while she sleeps, or try to get her awake before x-raying her? (even if you do manage to get her awake, she'll just keep falling back to sleep)

What would be the most likely course of treatment in this case, and how much (if any) of this treatment would you administer straight away (with or without trying to wake her up), and how much (if any) would you save until she had got some good sleep?

I should mention, this isn't quite the scenario in the novel, which is rather more sci-fi than what I've described here, but knowing what would be the appropriate course of action in this case should tell me what I need to know.

Thank you for your attention!

 

[Apollyon]

What you may not realize is that, for most Americans, "A&E" is a TV network on cable (short for "Arts and Entertainment). Relatively few know that it is "Accident and Emergency" in the UK and Commonwealth nations. I'm not sure if referring to it as "Casualty" would change that!

As for the balance of your post, I kinda zoned after the first 2-3 lines.

 

[gro2001]

Medical student here going into EM, so not sure if that qualifies as 'relevant professional background', but I will give it a shot.

The first priorities of an EM doc are always ABCs: airway, breathing and circulation. It sounds from your description that she is breathing ok and protecting her airway, so that's alright. Would check for any bleeding anywhere, start an IV line and hook up some fluids and put her on a monitor. While getting the IV line in, would draw basic labs as well (and finger-stick her for glucose). I would of course try to wake her up to see if she can tell us what happened to her, her medical history, etc, but if she could not stay awake would not belabour that point too much.

Much more concerning than her fracture is the sleeping. Could be a sign of a head injury, so I would get a CT scan to rule that out. Maybe even extend the scan to the abdomen to check for other internal injuries. She does not need to be awake for the x-ray. In fact, unless the fracture is open (flesh over the break is disrupted by the bone) or it's compromising the blood vessels it's not really a top priority to treat. Can wait, especially since she has splinted it herself.

All of this can be done while she is still asleep. Preferable to have her awake so that she can tell us things like 'I am allergic to penicillin', but the A&E treats unconscious people all the time. If everything else is fine, she can be admitted to the floor and sleep it off there.

 

[Saladin MD]

As for the balance of your post, I kinda zoned after the first 2-3 lines.

lol me too

 

[Tiger26]

i'd probably give her some narcan . . .

 

[gro2001]

i'd probably give her some narcan . . .

Oh yeah

 

[RobotSquid]

Thanks, gro2001, that's extremely helpful!

Tiger26 - are you assuming she must be on opiates? If so, what tests would you run first? Or is there some other use of Narcan that I'm not aware of? (i.e., wasn't able to find on Google one minute ago) If she isn't on opiates, won't that just block the pain-supressing effects of her own endorphins? Which I presume, after she's spent the night and possibly much of the preceding day dragging herself off a mountainside with a broken leg, might be playing a role in the fact that she is actually able to sleep.

 

[gro2001]

Thanks, gro2001, that's extremely helpful!

Tiger26 - are you assuming she must be on opiates? If so, what tests would you run first? Or is there some other use of Narcan that I'm not aware of? (i.e., wasn't able to find on Google one minute ago) If she isn't on opiates, won't that just block the pain-supressing effects of her own endorphins? Which I presume, after she's spent the night and possibly much of the preceding day dragging herself off a mountainside with a broken leg, might be playing a role in the fact that she is actually able to sleep.

You are welcome.

Regarding Narcan: there are some things that tend to be given semi-indiscriminately (or at least without any form of formal testing to back up the decision) to people who are so out of it. Narcan is one. Oxygen is another. Very little downside, potentially life saving. Emergency physicians would care less about her comfort/sleep and more about not letting her die from what may well turn out to be an opiate overdose.

 

[RobotSquid]

Ah - I see. I would have thought it fairly clear that her injuries were from some sort of hillwalking accident the previous day, and that she was asleep due to sheer exhaustion, but I guess if you're not able to get any sensible answer out of her, you can't be totally sure.

 

[Zanegray]

YOU know that the injuries are from "hillwalking" because you know your character.

To an emergency physician all we know is a young girl showed up with cuts, a likely broken bone, and somnolent. She would be hooked up to a monitor and have IVs started. Her vital signs would also be immediately assessed. She would probably get some IV fluid. In addition to xrays of her leg, the head CT and blood work would be a must. Blood work would include a complete blood count, a metabolic profile, and maybe acetaminophen, salicylate levels. Probably have a urine drug screen, and if she won't wake up to get it they would catheterize her for it. Maybe she would get narcan. And I agree with a previous poster that she might get a CT of her chest abdomen pelvis as well, because she must have had a significant mechanism to break her leg, and we don't know why she wont wake up. We think, did she fall, did she overdose, did someone harm her? We do not assume anything is benign.

However, if her vital signs were okay and she could wake up enough to give some brief history before she fell back asleep, the workup might be less.

 

[RobotSquid]

Zanegray - thanks, this is very very helpful!

 

[dchristismi]

Not to mention, she's 11. That makes her a minor, so finding out who she is, who is responsible for her, and why she's alone (was she assaulted? Did someone harm her? Is she fleeing a dangerous situation/abuse?) is also important and would likely warrent getting the police and family services involved. I don't know what the policies are there, but here in the states, we are not allowed to treat a minor without parental consent unless there are life or limb threatening issues. Which there might be - as mentioned, we just don't know.

Agreed with Zane - if she'd wake up and talk to me, I wouldn't do as much. But a somnolent child who is utterly alone with significant injuries raises lots of red flags.

 

[RobotSquid]

Thanks, dchristimi. You probably could wake her up for long enough to get sensible answers out of her. Basically, she is as soundly asleep as you would expect of a chid who is a sound sleeper generally, has not slept all night, and who has just been through an exhausting and painful ordeal. With persistence, you could probably get her to answer a couple of questions.

 

[Tiger26]

the issue is that people with bad extremity fractures typically don't sleep well . . .

 

[RobotSquid]

Ahh - I see. Hmm. I realise the physicians wouldn't know this, but by the time she makes it to safety, she'll have been awake for about 30 hours, and that time has involved a great deal of physical exertion. Setting aside for the moment the question of the appropriate medical response just for the moment, is it still implausible, with that in mind, that she should be able to sleep well?

 

[The right Path]

Hi all!

I have a question about an Accident & Emergency admission - if anyone with the relevant professional background could take the time to answer, it would help me with a scene in a novel I'm working on, and would be hugely appreciated. I'm going to describe a hypothetical admission to A&E, and what I'd like to know is, if you were the receiving physician, what would you do in this case?

Suppose you were working in the A&E at a hospital somewhere close to large expanses of wild, hilly country - hillwalking sort of territory. For the sake of concreteness, let's say Belford Hospital in Fort William, Scotland - the actual place-names given here are irrelevant, but they give you an idea of the sort of place I mean.

One morning, a call to emergency services is received from the reception desk of the Glencoe Hotel at about 6am. A girl, aged about 11, unaccompanied, wearing hillwalking gear and a backpack, staggered into the lobby of the hotel minutes previously. She was filthy, had a fresh cut and noticeable bruises to her face, was visibly shaking and relied heavily on the furniture and fixtures to keep upright. When the receptionist caught sight of her, she looked up, said "I made it ... I made it! ... hehehe ... I feel amazing!", then lay down on the floor and fell fast asleep.

She was taken to A&E by the air ambulance, where she was admitted to your care and did not wake up at any point on the way. There's no sign of concussion or cranial trauma, she's simply utterly exhausted and very soundly asleep. She has a lot of bruises all over her body, and her right leg is in a makeshift splint & cast hacked together from the internal support struts from her backpack and a roll or two of duct tape. You suspect she did it herself, and she's actually made a pretty decent job of it, given the materials she had. She has no ID on her, and doesn't match the description of any recent missing child alert. Her condition is stable, and there's no sign of hypothermia. Other than her recent injuries, she seems to be very fit and healthy, and a very very sound sleeper. If you need to wake her up, you're going to have to do something pretty drastic.

I presume that one of your first priorities is going to be to get an x-ray of her leg - (She in fact has a fractured tibia - it's a clean break, a closed single fracture, and she's done a very good job of splinting it, but she's presumably had to walk on it to get to the hotel from wherever she broke it the previous day) - but, do you let her sleep and do the x-ray when she wakes up, or x-ray her while she sleeps, or try to get her awake before x-raying her? (even if you do manage to get her awake, she'll just keep falling back to sleep)

What would be the most likely course of treatment in this case, and how much (if any) of this treatment would you administer straight away (with or without trying to wake her up), and how much (if any) would you save until she had got some good sleep?

I should mention, this isn't quite the scenario in the novel, which is rather more sci-fi than what I've described here, but knowing what would be the appropriate course of action in this case should tell me what I need to know.

Thank you for your attention!

The very first part that I bolded seems extremely far fetched. Yeah, someone reaching her destination and buckling to the floor, that I could see, but then saying she feels amazing and falling into a dead sleep right away? Er.... that sounds improbable and dare I say it? Cheesy. Sorry.

Head/cervical injury are always assumed/addressed when you have a patient that is obtunded and has traumatic injuries. Absence of superficial bruising and/or lacerations don't in any way rule out those possibilities.

Others did a really good job of covering how emergency care is prioritized.

I'll also throw in that it's highly dubious that anyone that isn't intoxicated, septic, traumatically or otherwise neurologically impaired would be that somnolent while they are under the bright lights of the trauma bay in the process of examination, clothes being cut down, IV's inserted, palpation of a fractured extremity, etc. I'm not sure what you envision as "drastic" (sternal rub, trap squeeze, orbital pressure?), but for a neurologically intact (albeit exhausted) person, the above mentioned stimuli should be more than adequate.

I thought that part about sleep was amusing and cute. Examination and treatment (generally) takes priority over sleep. Despite best efforts, frequently patients get very little uninterrupted sleep.

 

[The right Path]

Ahh - I see. Hmm. I realise the physicians wouldn't know this, but by the time she makes it to safety, she'll have been awake for about 30 hours, and that time has involved a great deal of physical exertion. Setting aside for the moment the question of the appropriate medical response just for the moment, is it still implausible, with that in mind, that she should be able to sleep well?

Yes. Being awake 30 hours under physical exertion is well.... ask any of these residents on this forum.

 

[VeerTheTIGuy]

I would just like to add that a lot of the above investigation/treatment plans are from a very American-style practice of EM, and that in a true UK A&E many of these things will not occur within the 4-hour time limit (although this is now being scrapped), and will have to wait until the patient is transferred to SAU (Surgical Assessment Unit) or ITU (Intensive Treatment Unit) or to another hospital where P[a]ediatric expertise is available.

 

[RobotSquid]

Thanks, The right Path! No need to say sorry for speaking bluntly, either - when I ask a question to a bunch of emergency physicians on a forum, I'm not expecting gentle treatment ;-)

I guess the thought behind the "I feel amazing" bit was the combination of a lot of endorphins (it is established earlier in the story that she already has an uncommonly high sensitivity to endorphins), and the realisation that she had made it to safety and was not in fact going to die. Possibly also a bit loopy from the exhaustion.

I was deliberately imprecise when I said "drastic" - I wanted to get a feel for what you would consider drastic, in the circumstances - but no, not as drastic as trap squeezes etc. About as much as it you would expect it to take to wake up someone really tired getting their first sleep in ages, is what I had in mind.

I should say, the scenario in the actual book differs from what I've portrayed here in a lot of respects - far more sci-fi, for one thing; so I carried over what I thought to be the clinically salient details into the "hillwalking" scenario (the fractured tibia, the splint, the self-administered duct-tape cast, the long hours without sleep under exertion, her behaviour on reaching safety) partly because I thought I would learn more from presenting a more this-worldly scenario (and certainly I have learnt a lot of useful stuff - thanks to everyone!), but mostly because I'm a bit cagey about posting bits of the plot of an unpublished work on the internet. Suffice to say, the actual novel is set centuries in the future, and it's not a trauma bay in a hospital that she ends up in, but a fully robotic medical suite controlled by a fully sapient AI, so a lot of the initial procedures needn't been done in a manner quite so likely to wake her up. For instance, the med AI can see perfectly well from the sub-millimetre to the ultra-violet, so dimming the lights in the 300-700nm range is a possibility, as is much more detailed four-dimensional imaging than is available today.

PS - @VeerTheTIGuy Hi! Nice to bump into another St. Andrews person here 🙂