Indexing Title: JMDEGUZMAN’s Medical Anecdotal Report [04-6]

 MAR Title: Under Pressure

 Date of Medical Observation: July, 2004

 Narration:

            A 22-year-old male was brought in at the emergency room dyspneic. Patient was bloated from head down to scrotum. His vital signs were stable and normal except for the increased respiratory rate. A 0.2cm punctured wound was noted at the left antero-lateral neck area, Zone II. Clinical chest findings showed shallow, rapid respiration, stridor with equal breath sounds. Due to progressive dyspnea we tried to intubate the patient but we had difficulty, so we sought the help of Anesthesia Department to no avail. We directed the patient to the operating room, did a tracheostomy and proceeded with a neck exploration.

Intra-operatively a punctured cricoid cartilage was noted at the left side and eventually repaired. Apparently the injury did not cross the midline and no other injuries were noted. The operation went smoothly.

Post-operatively, patient again developed dyspnea with decreased breath sounds at the right lung field. Chest radiograph requested revealed pneumothorax on the right. Closed tube thoracostomy was then performed. 

Patient’s condition improved at the ward and was discharged with no morbidity, alive and contended.

Insights (Discovery, Stimulus, Reinforcements)

            In any emergency situation especially if life is at stake prompt intervention based on sound decision is essential. However, making a decision is not always easy if never at all. In dealing with such cases, emergency physician should always possess composure and be organized to arrive at a diagnosis and institute proper treatment. Fortunately, we at the Department of Surgery, OMMC are continuously trained how to react in this situations. Our decision-making is guided by a process. This “Patient Management Process” (PMP) was introduced to us no less by the one who pioneered it, our chairman. This was utilized throughout in managing the patient, pre-operatively, intra-operatively, and post-operatively. We never claimed that PMP is perfect process, no one is, but when employed correctly it often lead us to plausible evaluation, management, and decision-making even under pressure.