Mrs. Rickety has just finished eating dinner in the Hospital cafeteria. She was placing her meal tray on the return conveyer when she slipped and fell, striking her head. You just sat down to a tainted egg salad sandwich when you witnessed her fall. Instinctively, you spring into action following the Nursing Process which courses through your veins.
What is the Situation?
Finding Mrs. Rickety unconscious, you dispense with the normal questions you ask to assess neuro status, and proceed in determining the Mechanism of Injury (MOI). The MOI is important because it enables you to estimate the extent of your unconscious patient’s injury. You note a skid mark, and tracing it back, you notice it — a green bean!
Now, look closely. Is it a Blue Lake #45 Green Bean or a Stringless Green Bean? This may seem absurd to a bystander, but by consulting your pocket trauma code book, you’ll note that the Blue Lake #45 can generate speeds of eighteen meters per second, while the Stringless Pole Bean can exceed 32 meters per second.
You feel your gut tighten because you know that the pole bean she stepped on sped her head to the cafeteria floor at a rate capable of snapping a two inch tempered steel rod in two pieces.
What’s Your Assessment?
Mrs. Rickety does not respond to pain– assessed by pinching and nipple twists. You note that her respirations are rapid, irregular, and shallow — Neurogenic Hyperventilation in response to Increased Intracranial Pressure!
What Must You Do Immediately?
Knowing that Mrs. Rickety is in imminent danger of uncal herniation from her intracranial bleed, you act with undaunted medical skill. You intubate her immediately with the #8.0 oral endotracheal tube which you carry in your back left pocket. You hyperventilate her with the manual resuscitation bag you carry over your left shoulder at all times.
Rationale: You know that hyperventilation will lower her CO2 and constrict her cerebral arteries.
By now you have a crowd applauding your efforts, so you send the guy breathing down your neck to summon more help.
While you are waiting for help, you visually detect Mrs. Rickety’s head expanding. Using the IV start kit you carry in your back right pocket, you play an eighteen gauge peripheral IV in her left arm.
Rationale: Most people are right handed, and you don’t want to restrict movement of their dominant extremity.
Fortunately, you always carry an emergency drug box with you, and you infuse a twenty percent mannitol solution over three to five minutes.
Rationale: Mannitol elevates plasma osmolality, enhancing flow of water into extracellular fluid thus decreasing intracranial pressure.
What Should Be Done Later?
Now that you have stabilized the patient, you transport her to the emergency room using the stretcher which you constructed out of cafeteria furniture. You provide the ER staff with the patient’s complete medical history which you obtained from a distant relative in the crowd. You calmly explain all of your interventions to ensure continuity of care.
Three days later, when you visit the Neuro-surgical ICU, you find Mrs. Rickety eating her dinner. You introduce yourself, and she replies, “Yes, they told me how you saved my life. I would like to thank you for allowing me to enjoy this world a little while longer.” As you return to your unit, you feel warm inside just knowing that you were able to make a difference in at least one person’s life.
Reflecting back on what happened, you contact the manager of the cafeteria to insist that warning signs should be placed strategically in the dining room.
Rationale: They will be serving those pole beans again next Tuesday.
By Harold E. Stearley, RN, BSN, CCRN
