Teamwork vital for intensive care

Press, 8 March 1984, Page 21

Teamwork vital for intensive care

In 1981 — the latest year for which figures are available — 13,170 people involved in road accidents were admitted to New Zealand public hospitals. This was 23 per cent of all accident victims admitted as inpatients. Their aggregate stay in hospital was 130,751 days. DENIS DWYER, information officer for the Canterbury Hospital Board, describes the scene in the intensive care unit at Christchurch Hospital.

More than most other places, a hospital depends on good teamwork, especially a large city general hospital, and especially the parts of such a hospital which are treating patients who have lifethreatening conditions. The Intensive Care Unit of Christchurch Hospital is dependent on the service of the supply staff, orderlies, engineers, medical physics staff, pathology and other support staff, besides its nursing staff and medical staff of many specialities. The unit is always working, 24 hours a day, with precision and purpose, against the clock, drawing from resources throughout the hos-

pital as necessary. Frequently there is very great pressure on all staff involved, such those severely injured in road accidents are admitted.

On a recent Saturday night, two men injured in traffic accidents were admitted to the Intensive Care Unit The first came in at 7.55 p.m., and on arrival was almost dead. He was deeply unconscious with enlarged pupils, and no pulse could be felt He had a severe compound fracture of his left thigh bone, which was protruding, and he had bled heavily from this, with at least one major artery lacerated. He also had extensive bruising on his chest and abdomen. Three medical staff and three nurses began emergency procedures. A tube connected to a ventilator was passed into the windpipe so that air could pass in and out He was then resuscitated, which involved six large tubes, through which fluids can be passed, being inserted into the veins. Each of these and some subsequent procedures required a sterile dressing trolley to be set up and brought by the nursing staff. After he had received about eight units of blood and six litres of saline, his blood pressure had risen to a level where pulses could be felt

By this stage his leg wound had again started to bleed profusely but this was controlled by clipping the large vessels which were Needing and then applying a tourniquet around the top of his thigh. Resuscitation was continued with large volumes of blood and saline, and after his blood pressure had risen further he began to regain consciousness, which encouraged staff to believe that he had probably not sustained a severe head continued Resuscitation, however, it became obvious that he

had abdominal bleeding. His abdomen was swelling and staff could not catch up with blood loss. After he had received about 18 units of blood and 12 litres of saline, it became necessary to take him to the operating theatre for a laparotomy (opening of the abdominal cavity) to try to control the bleeding. It had been two hours since he was admitted to hospital. One and a half hours after the admission of the first patient, and at the height of his resuscitation, the second motor injure patient arrived in the Intensive Care Unit. He required the constant attention of at least one doctor and three nurses, and this put a very severe strain on the unit’s staffing. The theatre was organised for the laparotomy of the first patient. Two anaesthetists were required, one to manage the anaesthesia and monitor the patient’s condition, and another to manage the various drips and squeeze in bottles of blood. One nurse was required to scrub, one to run for instruments, and one to help the anaesthetist. Because the patient’s condition was so parlous, there were also two nurses from intensive care to help the anaesthetist, plus one of the unit’s medical staff.

At laparotomy it was found the patient had a ruptured spleen. It was removed, and his bleeding abdominal vessels were tied, which took about two hours and involved the transfusion of another 20 units of blood.

Meanwhile, the staff in the Blood Bank were kept busy continuously cross-matching blood. In addition, biochemistry and other laboratory staff had been monitoring serum electrolytes (ionised salts in the blood) and the radiographers had been taking x-rays of his chest, head, pelvis, and femur. Also a consultant radiologist had been called in because of the probable need for angiography (x-rays of the blood vessels in the leg using dye injections to define the extent of vascular damage) and he was waiting throughout the whole of the laparotomy until the angiogram was required. After the laparotomy, a team of vascular surgeons repaired the damaged blood vessels in the leg prior to the angiogram, and then a team of orthopaedic surgeons repaired the femur because it had to be stabilised to avoid further damage to the blood vessels if the leg was moved about After nine hodps in the operating theatre the patient was again returned to the Intensive Care Unit

By this stage he had developed serious lung problems and needed artificial ventilation and special techniques to improve his oxygenation. Also, he was not passing urine. Because of his severe lung abnormalities it was not possible to use standard monitoring procedures to estimate his blood volume, so a catheter was passed through the right side of the heart and into the pulmonary artery to measure the pressures in the left side of the heart.

Medical staff were then able to manipulate his fluid therapy and other drug infusions to try to improve his kidney blood flow and prevent him developing acute kidney failure. This process is often successful, and is frequently used in intensive care.

On the Sunday night the patient again began to bleed and had to return to the operating theatre. It was found that he was bleeding from his pancreas, and a partial removal of the pancreas was performed. He continued to bleed quite profusely after this because of clotting deficiencies and very low platelet counts, and it was necessary to get blood donors to come in the middle of the night to be bled.

It was also apparent by this time that the procedures to prevent the development of acute kidney failure had been unsuccessful. On the Monday morning the vascular surgery team inserted an arteriovenous shunt (enabling arterial blood to go directly into the veins) to enable haemodialysis to be performed for his renal failure, and then dialysis took place. The patient then went on to daily dialysis, daily x-rays, biochemistry and haematology monitoring, frequent replacement of blood and platelets and fairly intensive management from the intensive care nursing staff and from physiotheraEists. He is now progressing well, i all, 22 medical staff were involved in his care and he has required many hundreds of manhours of medical, nursing, and other attention.

The second patient was admitted unconscious and severely shocked, and also required vigorous resuscitation, connection to a ventilator, and the placement of tubes through which fluids could be passed. He was transfused with about eight units of blood and six litres of saline. A stomach washing was then performed and this showed that he had gross aWominal bleeding. His initial resuscitation took an hour and a half, with constant

attendance from one of the intensive care unit’s medical staff and two or three nursing staff. A laparotomy was performed in a second emergency operating theatre. By 5 a.m., after three

hours in the theatre, the patient had started to improve. But then he showed a sudden deterioration, and became severely shocked over a few minutes and it was impossible to resuscitate him.

He died. A post mortem examination showed that he had developed a rupture from the right ventricle of the heart into the ventricular wall, which had impaired the pumping efficiency of his heart.