The Decisions We Make

It had been a high-speed motor-vehicle accident. One car. A twenty-something male driver without passengers. No seat belt. And now, this same driver had no movement from his waist down and no sensations below his mid-abdomen.

According to bystanders, he had been driving his sedan dangerously fast, some estimates of nearly 100 m.p.h., before losing control. The car veered off the roadway to the right, flipping mid-air before smacking head-on into a magnificent tree. It was unclear if the driver had been thrown from the vehicle or eased out of it by witnesses at the scene.

The prehospital call came from an experienced paramedic who's shallow, rapid breathing and abbreviated sentences clearly defined the dire circumstances of this patient. "We are bringing you a male patient, approximate age twenty, involved in a single-car MVC (motor vehicle collision). The patient's vital signs are stable. He has no, I repeat--no, leg movements and cannot feel us touching him on his abdomen." The paramedic took a deep breath before she continued. "The patient also has priaprism."

"Is the patient talking?" the charge nurse taking the radio call asked.

"If it weren't for the forehead laceration and his neurological deficits, you wouldn't even know this guy was in an accident," came the reply.

From this short conversation, we were able to garner some very important information. One, the patient had an obvious spinal cord injury. With his leg weakness and loss of sensation below the abdomen, we could assume that the level was somewhere in the thoracic or lumbar area. Two, his vital signs were stable, which went against an injury above T6. A spinal cord injury above this area can result in neurogenic shock, where the patient may exhibit extremely unstable hypotension and bradycardia. The paramedic had told us the patient's vital signs were stable. And three, this patient had priaprism--a persistant erection that, in this circumstance, was indicative of a spinal cord injury.

It was not sounding good for this patient.

We prepared the trauma room for this patient's impending arrival. He was being flown directly to our facility from the scene of the accident, about an hour away by car. Just minutes by chopper. A trauma alert was called, which ensured that the CT scanner was vacant and ready, that the trauma team would respond and work hand-in-hand with our ER team, that respiratory therapists would bring a ventilator and intubation trays, and that all other services were placed on high-alert to immediately respond as needed.

Within minutes, the chopper landed on our parking garage rooftop and the patient was rushed into our department, Trauma Room 18. Surpisingly, just as the paramedic has described, he did not appear to be acutely ill or injured upon first impressions.

He had sandy brown hair with matted bangs from the clotted blood of his forehead injury. His eyes were brown and frightened. He was covered in pale gray blankets, monitors and wires poking out from different angles. He was on a transport board with a hard supportive neck collar wrapped tightly in place to prevent him from moving his head.

Our eyes met. I walked up to the head of the bed as the nurses began obtaining new vital signs and my ER resident and the trauma doctor began their exams. "Hey, buddy," I said, bending down and talking calmly into his ear, "everybody in this room is going to be working hard to help you with your injuries. You are going to be getting poked and prodded and asked a million and one questions, but you have to bear with us. Okay?" He nodded at my words. After a moment's hesitation, he spoke, his voice soft, quiet, disheartened.

"Can somebody call my mom and dad and let them know where I am and what happened?"

"Of course," I assured him, calling in our case manager to his bedside to get a phone number. "We'll talk to them and let them know that you are here in our ER."

I performed my exam, first checking to make sure that his vital signs were stable. They were. I listened to his heart and lungs. All was normal. I palpated his abdomen, impressed by the horizontal line of xxx's that the flight paramedic had drawn across his abdomen to show the loss of sensation below. I did a motor strength test of his arms, which were strong and without deficit, and his legs, which were thick and heavy and without movement. It is quite disconcerting to have a young, healthy, strong patient lay in bed and not be able to move his legs at your command. I held his legs in the air, six inches from the cot, and told the patient to hold them there when I let go. They dropped with a thud. I pinched his great toes, we poked his feet with a clean pin, and still, nothing. He had absent reflexes of both legs.

Finally, my ER resident gained my attention by clearing his throat. He was standing at this patient's right side, lifting the gray sheets from the patient's torso. Sadly, he was showing me the patient's priaprism.

I can assure you that, of all of the telltale signs of sustaining a bad injury, priaprism is one of the worst. You can get priaprism from many various causes (sickle cell disease, medications, etc.), but when it happens hand-in-hand with trauma and some form of paralysis, the results are usually not favorable. Hell, the results are devastating, pure and simple.

I went back to the head of this patient's bed to speak to him. I explained all our clinical results on exam, and told him he would be going to the CT scan immediately. He nodded, wiped a tear from his right eye, and spoke. "My parents are going to kill me."

This patient returned from CT scan with the devastating results that we were expecting. He had sustained a vertebral fracture in his mid-thoracic region that had transected his spinal cord, cutting off all nerve innervation to the rest of the body below that area of injury.

Damn it all.

Neurosurgery was called, the OR was placed on standby, and the patient was emergently transferred to our ICU. Although we could do nothing about the permanence of the complete transection of his spinal cord, this patient would need surgery to stabilize his vertebral fractures. He had a long road ahead of him.

Imagine being this patient's mother and father. Imagine that phone call that came their way at 2 a.m. It is every parent's worst nightmare. Imagine driving an hour to arrive at a hospital you are not familiar with, only to find out that your child has just become a permanent paraplegic. How do you survive such devastation?

You raised a son, giving him your best through his formative years, wishing for all of the world's best offerings to come his way. Unfortunately, due to some poor decision-making, he wrecked his car, becoming an instant paraplegic. That little boy who jumped on his bed after bedtime stories, that young teenager who ran and played ball with the family dog until both passed out from sheer exhaustion, and that brave high-school graduate who walked sheepishly across the graduation stage just a few short years ago--that life would remain in the past, all those dreams and hopes tidied and packaged into the box of life's disappointments.

To be visited time and time again.

Ironically, as I wrote this post last night on my back deck, several medical helicopters flew overhead, I'm sure following their path along the lake's edge towards our hospital. I can only hope all was well...As always, big thanks for reading. See you soon.