Sunday, September 28, 2008

Coup-Contra-Coup



Four-wheelers, trampolines, and skateboards. Job security. Pictured above is the brain of a patient who, as Foghorn-Leghorn said, is about as sharp as a sack of wet mice. Said patient was having a grand old time standing on the back of her friend's four wheeler as he zipped around a parking lot. I'm not sure if alcohol was involved but the magic eight-ball says, "Signs point to 'yes'". Unaware of the juice that was about to be applied to the throttle said patient was not prepared to be tossed backwards onto her noggin, sustaining the injury shown above. What's a helmet?

Even though she hit squarely on her occiput the injury is in the frontal lobe of the brain on the right (conveniently marked with an arrow and touched up by our professional graphic design guy). This injury is known as a coup-contra-coup and the link is a good one.

At her baseline she was a bit off... this according to her family, but after this blow she was a bucking bronco on loco-weed. Twenty milligrams of etomidate, 100 micrograms of fenanyl, and 150mg of succinylcholine later she was quiet as a mouse and on a ventilator.

The CT shows blood in the anterior portion of the right frontal lobe, and for you non-medical types, the frontal lobe is the portion of the brain that serves as a kind of filter and behavior regulation system. Off to the Mecca she went and I hear she did well in spite of her attempt to make the Darwin Awards.

17 comments:

  1. On the same principle, last week as I was barreling down the freeway, I was passed as if I were parked, by two people on a motorcycle. I assume they were very poor since they only had one helmet to share and the pilot was wearing it. His girlfriend, in the back, had no proctection. He must have loved her very, very much...
    I just had a nice warm feeling when I realized that the closest hospital was only 3 blocks away.

    As a (biker) relative once said to me: if those idiots don't wear a helmet, that's the best proof there really is nothing to protect.

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  2. Ahh yes. Fourwheelers. Standard EMR template 22: no helmut, drunk, and the universal phrase "Watch this!!" was uttered. What could possibly go wrong? Well, nothing some quality vent time and an ICP probe can't cure.

    And, btw - that link to the coup/contra-coup movie... I thought it depicted my CEO at a Joint Commission meeting. Whoa... explains a lot. Bucking bronco on loco-weed. Nailed it!

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  3. You sure thats not Matt Staffords Grape after Saturday Night's Gang Rape in Athens??

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  4. Ran a call once where a motorcyclist hit a wall. He was wearing a helmet, but, if you can believe this, the helmet wasn't much help in a 180mph collision with ensuing fireball.

    The impact was so hard and so violent that his brain was literally running down his back. Of course, he had matching safety gear. Lit by sodium lamps on the interstate, the pink foam of brain bits stood out sharply against the matte black leather.

    Safety conscious guy I guess. Well, except for that 180mph attempt to occupy the same space as a wall.

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  5. Whoa whoa whoa did that crash happen on US 27?

    There is a crash that matches that exact description/speed that's a little famous down here.

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  6. I had a crotch rocket as youngster, and wore my helmet religiously, except for the times I'd recreate those helmetless scenes from Top Gun, and "Officer and a Gentleman". Hitting a bug at 120mph will knock you silly.

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  7. I'm not sure if alcohol was involved but the magic eight-ball says, "Signs point to 'yes'".

    :D
    Nice to have a reason to smile amidst all the tension of exams..

    Great post!

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  8. Mr SuperbadJack,

    No, it happened somewhere else. Interestingly, it would appear that this type of event is more, not less, common. Your comment definitely seems to indicate that work in EMS is a growth field. It's Good for Business.

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  9. We had a dude hit the back of a parked 18-wheeler going...really fucking fast. His head went through the back door of the rig. He was just dangling there, his feet barely touching the ground... *shudder*

    Doubt I'll ever get that image out of my mind!

    Gotta love the magic 8-ball quote!

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  10. I'd be interested to find out how this patient was handled prehospitally, being that her "filter" was compromised. Were the medics able to maintain c-spine precautions? Do they have RSI in the field? How much iatrogenic damage was done to this patient in simply getting her to the hospital?

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  11. they did not, though they could have, RSI'ed in the field. this was a difficult call because she was very angry and making sense for an angry person BUT my preference would have been to put her down in the field and get good Cspine. as it turns out she did not have a Cspine injury but if she had she would have pithed herself flailing around on the board.

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  12. Do you see many trampoline-induced injuries where alcohol is Not involved? I'm not asking for me...I'm asking for my "friend" who has a 15-foot trampoline.

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  13. 20 of etomidate and 100 of fentanyl!?!
    I realize that sux and a tube were included in the package, but shoot those doses would make me nervous. We generally only use 5-10 of etomidate for our cardioversions and the pts are out. She musta had some prior up regulation of her receptors. Or was her BP so high that it tolerated those doses?
    CardioNP

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  14. standard RSI doses. we are not consciously sedating them, we are intubating. neither 20 of etomidate nor 100 of fentanyl will do much to the vitals signs or respiratory drive.

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  15. I hate when Nurses try to play doctor, 20mg of Etomidate is only 1/2 of a 20cc syringe, and 100ug of fentanyl? nothing a plastic tube in the trachea won't fix. My favorite was this Polish Attending who had what he called his "Master Blaster" a 30 cc syringe with a Propofol/fentanyl/Rocuronium mixture that he'd inject all at once.

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  16. Brought back (not so) fond memories of my husband partying too hard with his buddies and then falling in our driveway. He hit the back of his head hard enough to give himself 2 black eyes. The part where I really wanted to nominate him for the darwin award was when he and his best friend (both of them drunk again) decided that using rusty pliers from the garage to remove the staples was better than paying a doctor to do it. Idiots.

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  17. What you need is a "student doctor". I have a student teacher this year, and she does almost all my work. It's the opposite of craptacular.

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