Literary Grand Rounds Clinical Vignette

1. Literary Grand Rounds Clinical Vignette Barry Crittenden, MD PGY2 March 18, 2009

2. Chief Complaint The patient is a 30 year old female admitted as a trauma victim after being struck by an automobile.

3. History of Present Illness The patient was standing on a street corner when she was struck by an SUV. She was pinned against a metal post by the vehicle. At the scene, she lost consciousness, but maintained a pulse and spontaneous respirations. Once she was able to be removed from the post, bystanders applied pressure to her right leg. EMS arrived within 10 minutes and rushed the patient to Bellevue Hospital.

4. Additional History Past Medical History: none Past Surgical History: myomectomy Social History: the patient is a singer-songwriter in New York City. She denies any toxic habits. Family History: non-contributory Allergies: penicillin Medications: none

5. Physical Exam General: awake and alert, in severe pain Vital signs: T 98.0 BP: 70/palp HR: 130 RR: 32 O2 sat: 100% on NRB Abdomen: large transverse laceration of her lower abdomen with visible portions of her bowel and bladder. Extremities: right leg partially amputated at the groin with active bleeding. Skin: pale and cool Remainder of physical exam was normal

6. Laboratory Findings CBC: WBC 3.9, Hgb 7.6, HCT 22.8, platelets 166 after initial resuscitation Basic metabolic panel: within normal limits Hepatic panel: within normal limits Creatinekinase: 1528

7. Hospital Course Hospital Day 1: The patient was intubated immediately and taken immediately to the operating room. Massive volume resuscitation was initiated; she received a total of 10 liters of NS, 2 liters of LR, 30 units of packed-RBCs, 15 units FFP and 5 units of cryoglobulin. She underwent complete amputation of her right lower extremity. Consults in the operating room included orthopedics, vascular surgery, urology, and gynecology.

8. Hospital Course Hospital Day 2: • The patient underwent a diverting loop colostomy and a right hip wound debridement Hospital Day 4: • The patient underwent completion of her right hip disarticulation by orthopedics with a partial wound closure by plastic surgery Hospital Day 7: • The patient was weaned from the ventilator Hospital Day 8: • Psychology, physical therapy and rehab medicine consults became involved in the patient’s care

9. Follow-up The pt began a challenging recovery Music therapy helped with voice recovery Diverting colostomy was reversed 4 months later Despite the extent of her lost limb, the patient is able to walk on a prosthetic limb She resumed a successful singing career She does public speaking and community service, including motivational work with other amputees