Playing safe....

I had this traumatic case during my last shift. A middle-aged male who had rammed his car onto a bridge pier was sent over by the EMT. He was in comatose state when the EMT recovered him. The patient was un-arousable when I saw him and gasping for air. The initial resuscitation was intubation and follow by IV infusion. The BP was ok with bradycardia of 60/min. I did a FAST (Focus Assessment with Sonography for Trauma) and there was no fluid in the abdomen. The possible diagnosis was possible intracranial bleeding. However I had also ordered chest and abdomen CT just in case I am wrong.
The head and neck CT was clear but the abdomen CT revealed a intraabdominal bleeding with hematoma at the intestine. I was wrong and luckily I did everything.....

The patient crushed and resuscitation was done and with fluid/blood infusion we were managed to get the SBP back to 80mmHg. I could do nothing and further more in the ED and sent the patient to ICU.

Minutes later a lady came and asked about the patient condition. She had indentified herself as a friend and I told her that I need authorization from family for the surgery as it was a high risk surgery and most probably the patient would not survive. The lady had asked me if we could proceed with the surgery before anyone could be contacted. I told her that surgery might not save the patient life and I need consent and fully communication before

I proceed with anything. The lady had requested to see the patient and told me that she would tried to do something and I had to sent the patient to ICU pending decision.

The patient had passed away hours later just after the family arrived.

Unlike the bigger hospital, the place I worked in does not have a 24 hrs in house consultation. I had to call the physician/surgeon and they had to take a 1 hr drive from their home for the consultation after office hour. Imaging that I had called the surgeon/anesthetist for surgery and the family had refused the ops when they arrived; it would be another 1 hr drive back home…..I had to decide if the patient need surgery instead of calling the surgeon to come over and decide further management.

At one moment, I had struggled if to call my surgeon to come and do the surgery and give the patient a chance but as the patient BP had crushed and gone into arrest once in ED, I doubt that the patient would make it through the anesthesia. Unlike the other surgeon I knew, our surgeon CJ is an aggressive person who would do laparotomy straight then guessing in front of the CT scan whether to observe to see if the patient could improve. The decision is cruel as I had just signed the death warrant for the patient… but yet in Taiwan, doing surgery without family consent could ended up with a medico-legal suit that last many years..CJ is that kind of person that would go for it and I just don’t bare to drag him down with the possible risk. Well, I am too old for those hanky panky and tried to play by the rules for the shake of my family….