Don't settle if you're right

I still can't help but think that the only thing I did wrong was try to save his life.

My 6-foot, 400-pound, helmetless, motorcycle-riding patient became a quadriplegic, and then died after four years of helplessness and pain. Did I miss something? Did I do something to cripple him? Kill him? I spent long days wondering.

He was riding his motorcycle to work at two in the afternoon when the accident took place. A car suddenly turned in front of him, and he rammed into the side of it, reportedly at 40 miles an hour or higher. He landed on his head without any apparent loss of consciousness.

His post-intubation chest X-ray showed a bilateral pneumothorax. When his blood pressure began to drop, chest tubes were placed on both sides. He quickly began to stabilize. For the next two hours, he was in the radiology department being scanned from head to toe, literally. Then he was transferred to the ICU. He had received several units of blood and twice as many liters of fluids while in the ED. Within 30 minutes of arriving at the ICU, he became hypotensive and unstable.

Six hours in the ICU: We did everything we could

I stayed at his bedside in the ICU for six hours, feverishly searching for the reason for his continued hypotension. His injuries went beyond bilateral pneumothorax. Rib fractures with a flail chest. A fracture of the left scapula. Right open wrist fracture. Right-thigh laceration, 20 by 10 centimeters. Pelvic fracture with a symphysis diastasis of 10 centimeters. Left closed ankle fracture. CAT scans revealed that there were no skull fractures, intra-cranial injury, cervical fractures, or abdominal injuries. He was tachycardic; had warm, moving extremities; and no evidence of spinal fractures or cord injury.

We worked systematically to make sure we weren't missing a reason for his state of shock. We had blood and fluids running through his IVs, along with dopamine to keep his blood pressure up. I replaced his bilateral chest tubes to treat the continued pneumothorax. We did a direct peritoneal lavage to rule out any delayed intra-abdominal bleeding. The orthopedic surgeon closed and splinted the right wrist fracture. I had already closed the right-thigh laceration. The cardiologist ruled out cardiogenic shock with a transesophageal echo. We ruled out neurogenic shock clinically. The only major injury that could account for his continued state of shock was the open-book pelvic fracture from which he was hemorrhaging. Throughout all of this he remained in spinal precautions.

Herein lies one of many dilemmas. How do you keep a 6-foot, 400-pound man who lacks a visible neck in cervical spinal precautions? We had no collar on hand to fit him. He was as strong as an ox, and shook his head violently whenever he wasn't chemically paralyzed. We had to remove the head rolls to place a central line and perform a transesophageal echocardiogram. A nurse had to hold his head and neck in line to maintain C-spine precautions.

Metabolizing paralytics faster than we could get them into him, he would periodically move. Any sedative or narcotic would drop his systolic BP below 90. An intensivist, an anesthesiologist, a cardiologist, and an orthopedic surgeon were working beside me to keep him alive. Working to get him transferred to a level one trauma center, where they had the expertise to place the external fixature to control pelvic bleeding.

At one point we thought we'd have to go to the operating room to apply an external fixature, despite our lack of experience and equipment. We couldn't transfer an unstable patient. The nurses and operating room staff scrambled to put two OR beds together to fit his enormous girth and weight. Fortunately, he stabilized, and we summoned a helicopter to transfer him. The flight nurses walked into the ICU, took one look at the patient, and said he was too big to transfer by air. It took us more than an hour to find an ambulance big enough to take him. It was the same one that had brought him in 11 hours before. We moved him cautiously to the gurney, and sent him off wrapped tight for the one-hour ride. He was on dopamine, paralytics, blood, and fluids.