Case of the Month
March 2005

58-year-old male — MVA/decreased LOC

On a rainy morning at 0830 hours, your engine and aid unit are dispatched to a motor vehicle accident located near a highway underpass. You arrive at the scene and find a car off the side of the road, in a ditch, with extensive damage to the front end. The car has struck a support column of the overhead highway.

Prior to approaching the driver, who is a middle-aged male, you evaluate the safety of the scene. There appears to be one patient only. The car is stable where it rests and there are no other safety issues. The car's front end is crumpled almost to the passenger compartment.

As you approach the vehicle you notice the patient's head is down but that he seems to be breathing adequately. He does not respond to you. The airbag has deployed. You gently squeeze his earlobe to deliver a noxious stimulus and he moans loudly and lifts his right hand. Due to the patient's decreased LOC and the condition of the vehicle, you request a medic unit. You do a rapid trauma assessment checking for bleeding and obvious injuries and quickly obtain a set of vital signs. Your findings include:

LOC	—	Semi-conscious, moans to painful stimuli
RR	—	24/min
HR	—	100 full and regular
BP	—	180/palp
Skin	—	Pale, cool, mildly diaphoretic
HEENT	—	Equal eyes that are sluggish in reacting to light

The crew decides on an appropriate approach for extrication and uses a long backboard to do so. There is further discussion as to why he has a decreased LOC but there is no obvious head trauma. The medic unit is still ten minutes out.

A detailed physical exam is under way as the medic unit arrives. No new injuries are found. His wallet has identification but no medical alert information. The medics arrive and ask you to place him on their gurney in the back of the medic unit.

The medics attach a heart monitor, measure his oxygen saturation (98%) and obtain a blood glucometry reading of 105 mg/dl. They start an IV and transport for the reason you requested them: decreased level of consciousness and significant mechanism of injury. During transport the patient's LOC slowly improves. The medics ask if he has diabetes, seizures, heart problems or various other ailments which he denies.

At the hospital the emergency department physician determines that the patient takes Tegratol and Neurontin. He asks the patient, "you told the medics you don't have seizures, but these are seizure medications." The patient replies, "That is correct, I do not have seizures because I take those medications!"

The EMS providers and the ED physician surmise the patient had a seizure that led to the accident. The patient is fully evaluated, found to have no significant injuries and is sent home follow up with his private physician for further seizure/medication monitoring.

Lessons from this Case

#1. Always consider that there might be a medical element in a trauma setting.

Most trauma scenes are fairly straightforward. However, when you are dealing an altered level of consciousness or the patient seems much sicker than they should be, start looking for something more (read: a medical condition).

In this scenario the damage to the car is extensive, but the passenger compartment is in good shape. Newer cars are designed to crumple in a front-end impact, resulting in less energy, and therefore less harm, transmitting into the passenger compartment. Airbags and safety restraints also decrease the extent and severity of injury in motor vehicle accidents when they are utilized.

#2. Information from bystanders is often helpful, but can also be misleading.

Take the information that is given you into consideration, but also take the time to draw your own conclusions. Hone your skills and work with your team members to make good decisions and care plans in the field.

#3. Word your questions carefully so that they are fully understood.

A question that seems perfectly clear to you may not be understood the way you intend. An example is the classic question 'Do you have chest pain?' Seems simple, right? Often the discomfort associated with a heart attack is a pressure sensation, which many people would not describe as a pain. A better wording might be 'Do you have any discomfort in your chest?' In this case the patient was asked 'Do you have seizures?' Of course not! He has medications that keep that from happening! Maybe he doesn't realize that 'breakthrough' seizures can occur. Asking 'Have you ever had a seizure?' would give you a more appropriate answer.

Be safe.