This week's post is courtesy of Tricia J. O'Brien. She has a BBQ (Broken Bruised Question) about the ribs. Sorry if that made you hungry. But it got your attention, didn't it? :)
One of my characters has fractured a rib and has a contusion on her lung. She is taken to ER where she is scanned. Can you tell me what the ER doctor would do first? Once it's determined she is in danger of respiratory distress, would she be put in ICU? And what would they do to a semi-conscious, weak person with such an injury--oxygen, IV, any thing else?
Great question. I'm not sure what caused the accident, but someone with rib fractures and a pulmonary (lung) contusion probably recieved a strong, blunt trauma to the chest. These days the most likely cause is a motor vehicle accident.
In the ER, when a person comes in with trauma, shortness of breath, chest pain and a history of blunt trauma, several things will probably happen at once. The sicker the patient looks, the faster it happens. If they came in by ambulance, some things may have already been done (neck immobilized in a hard brace; IV running already, part of the history obtained.) They might be strapped to a hard board to keep their spine straight and help transfer the patient.
1. A nurse (or several nurses) will get vital signs. The patient be hooked up to a monitor to show blood pressure, heart rate, breathing rates, and an oxygen monitor will be placed on their finger. A nurse or technician will probably try to insert an IV and obtain blood tests. Likely oxygen via facemask or nasal cannula will be given. Once the IV is in, fluids will probably be administered. The neck may be immobilized until there is evidence that there is no cervical spinal injury.
2. A doctor or triage nurse will obtain a history about what happened. If the patient can't tell, the family, witnesses, or ambulance crew will be giving this info.
3. Another doctor will start examining the patient while this is all going on. They'll assess how the patient is breathing, check the vital signs, listen to the heart and chest, and check for signs of trauma to the head and neck, do a neuro exam.
4. As for scanning, a portable chest X-ray might be done in the middle of this. The team will scatter to avoid the radiation for a few seconds and come back to the bedside. In some major trauma centers, if the patient is stable enough, they'll just take them directly to get a CT scan of the chest. Sooner or later, the CT will eventually be done.
5. Some trauma centers may also do a bedside ultrasound to look for air between the lung and the chest wall (pneumothorax) or fluid around the heart (pericardial effusion or tamponade).
I'd assume that this patient is so sick that they have signs of a pulmonary contusion (blunt damage to the lung) and AT LEAST 3 broken ribs. If the ribs are broken each in two places, they might have something called a flail chest, when a chunk of the ribs don't move in concert with the rest of the rib cage.
If the patient is very short of breath, has low oxygen sats (hypoxia), they'd need to be admitted for observation. If the breathing problems are very severe, the patient would need to be intubated or put on a breathing mask to help. Anyone intubated would automatically be in an ICU setting. There, they would receive IV pain medicine and fluids. The respiratory status would be closely monitored. Antibiotics would be given if there are signs of infection (fever, developing pneumonia).
If the patient is semi-conscious, there has to be a reason for this. Pain medicine making them sleepy or a little fainting is one thing; semi-concious because of the accident is a signal that head trauma may be a factor, and that's a whole other kettle of fish! (or post, whichever!)
More likely, the patient will be anxious, short of breath, and in terrible pain. If you want them to have head trauma, you'll have to write that in too!
Hope this helps Tricia. And I'm sure I didn't answer all your questions, but if you have more, feel free to email me!
Please keep in mind this post is for writing purposes only and is not to be construed as medical advice!
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