Case Study: Ben Casey – Part 1 Summary Patient Background: Mr Ben Casey is a 38 year old male who was brought in by ambulance and presented with injuries to the UTS Emergency Department following an MVA. Ben appears to be a fit and healthy 38 year old electrician who has his own business and employs another electrician and one apprentice. Ben goes to the gym and likes to surf when he can. Ben lives in a 2 bed room unit close to the beach south of Sydney with his partner and 2 year old son. Ben’s parents divorced when he was 16 years of age. His mother and sister live in Melbourne and his father lives North of Brisbane. After their divorce, Ben lived with his mother until he was 18 when he then decided to move out on his own Ben’s passion is his motorbike and has been known to be a bit of a risk taker when younger and used to race his motorcycle at a local racetrack twice a month. Since the birth of his son he has been less frequently. On the day of his accident he was driving home from a mate’s house and he confirmed with staff that he had been “drinking a lot” at another friend’s bucks party and can’t remember much about going back to his mates place. Ben reported that he was driving on a relatively quiet street when he hit an object (unidentified) on the road lost control of his bike and skidded into a metal fence. His left leg took most of the force when coming into contact with the fence. Local residents came to his aid and rang for an ambulance. He reports never losing consciousness. Ben was wearing jeans, shirt and leather jacket; riding boots and his helmet. Treatment at the scene included splinting his left leg to help stabilize the fractures and applying a pressure dressing to the wound on his left shin. A mild amount of blood loss was estimate at the scene by the paramedics (approx. 750-1000mls). Admission Data (ED): Ben was brought in by ambulance to the Emergency Department. His time of arrival was documented at 08.30hrs on Sunday morning. He was triaged and admitted to ED. His condition on initial assessment was documented as: HR 120 BPM BP 130/78 Resps. 24 BPM O2 Sats. 96% RA LOC Alert and orientated to time, place and person. GCS 15/15 Pupils Equal and reactive to light Pain Self-report a pain level of 9/10 in the left leg Limb Left Limb appears to be injured; weak pedal pulse; limited mobility; sensation present in foot. Wound Open wound on left shin, #tibial bone can be seen; wound is full of dirt and gravel from the road. X-rays of his left leg and blood work including cross match (group and hold) was ordered. Ben was seen by the Orthopaedic Registrar on duty. X-Rays revealed an oblique fracture of the left femur and open displaced fracture of the left tibia which was compromising blood flow to his foot. As a result he was scheduled for urgent surgery to reduce and fixate the fractures. Further assessments revealed no further injuries or abnormalities. Ben signed a consent form for Open Reduction Internal Fixations for both his Left Femoral Fracture and Left Tibial Fracture. Blood results included the following: FBC Hgb: 85 g/L Hct: 35% WBC: 7 x 109/L (SI units) Platelets: 300 x 109/L (SI units) Urea 6.0 mmol/L (SI units) Electrolytes NAD UEC NAD Blood Alcohol Concentration (As per Road Transport Safety and Traffic Management Act 1999) 0.06g /100mls (In Australia, the legal maximum BAC is 0.05% for licenced drivers in private vehicles – See more at: http://www.druginfo.adf.org.au/topics/bac#sthash.oGD1idID.dpuf) Group and Hold – B+ Perioperative Data: Ben arrived at the Operating Theatre department ready for surgery at 1000hrs. He was checked into the department by the Anaesthetic Nurse and taken straight to OR 10 (Emergency Theatre) for the procedure. Ben had a FG 20 cannula inserted in the left Cubital Fossa preoperatively. Ben was given a general anaesthetic including muscle relaxant. Once anaesthetized, he was intubated with a 7.5 ETT and commenced on intermittent positive pressure ventilation (IPPV). 1L of Hartmann’s was commenced through a fluid warmer. A forced air warmer was placed on upper torso. TED stockings and SCDs were placed on his right leg and a diathermy plate was stuck to his right thigh. He was then prepped and draped for the procedure. The procedure took 3hrs to complete and was documented as uneventful. Ben lost approx. 750mls of blood during surgery. He had an intramedullary rod inserted into the left femoral canal with 2x proximal end nails and 2x distal end nails to fixate the femoral fracture. His surgeon also used an AO straight, 12 hole, locking compression plate and 12 screws (2x 6.5mm cancellous lag screws and 10x 4.5mm cortex screws) to fixate the tibial fracture. A FG 14 bellovac drain (not stitched) was inserted into the left thigh to drain blood away from the femoral surgical site. Ben was then given Anaesthetic reversal. His ETT was removed by the anaesthetist in the OR and Ben was transferred from the OR table to his ward bed. Ben arrived in recovery at 1340hrs unconscious with a Guedel airway insitu and receiving O2 via a Hudson mask at 6L/min. (Further details of the surgery can be found in UTSOnline). PACU Handover: It is Sunday and the time is now 1500hrs – you started an evening shift at 1330hrs. Ben arrived on the orthopaedic ward at 1450hrs after being in recovery for 1hr. The TL and RN’s take handover from the PACU Nurse: I: This is Mr Ben Casey, he is a 38 year old male who was brought in by ambulance this morning and presented with injuries to the UTS Emergency Department following an MVA. S: CXR-ray revealed 1 fractured ribs on his left side with a small haemo-pneumothorax. An ICC with UWSD was inserted in ED. This having good effect. X-Rays revealed a fracture of the left Femur and open fracture of the left Tibia which was compromising blood flow to his foot. As a result he was scheduled for urgent surgery to reduce and fixate the fractures. The procedure took 3hrs to complete and was documented as uneventful. Ben lost approx. 750mls of blood during surgery it was also documented by paramedics that he lost an estimated 750-1000mls at the scene. He has had an intramedullary rod inserted into the left femoral canal and plates and screws inserted to fixate the tibial fracture. He has had 1000mls IV Hartmann’s running at 250mls per hr. which has just finished, he is written up for saline to follow. He has a FG 14 bellovac drain (not stitched) insitu in the left thigh which has drained 150mls of blood. He has received 25mg of Morphine IVI in recovery and he states his pain is bearable with a score of 4/10. He has a POP back slab on the left leg with crepe with an island dressing on the tibial wound underneath. The dressing to his left thigh wound is dry and intact with a small amount of ooze. B: Previously fit and well, nil history of note. Lives with partner. A: His vital signs have been stable, his limb observations have been normal with a strong pedal pulse. He is alert and orientated. His last set of observations were: Last obs in PACU: HR 120 BPM BP 100/75 Resps. 24 BPM O2 Sats. 96% on 2 litres oxygen LOC Alert and orientated to time, place and person. GCS 15/15 Pupils Equal and reactive to light Pain Self-report a pain level of 6/10 in the left leg Limb: Left foot observations Strong pedal pulse oFoot is pink and warm to touch oCapillary refill < 3sec oMovement in toes present oSensation present There have been nil complaints of nausea. R: Observations – As per Operation Report. The anaesthetist decided to write up a morphine PCA order for the patient as his pain had been quite severe after surgery. The order is in his charts; however the PCA has not been set up yet. IVABs as charted Bellovac drain to be removed in 24hrs Commence morphine PCA IV fluids as charted Full diet as tolerated Routine post-operative obs and neurovascular obs TEDS/Calf compressors – right leg
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