It Never Gets Any Easier

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It Never Gets Easier

 

You’d think the mowing the grass in your own front yard would be a relatively risk free afternoon activity. Sure you need to be a little careful with a blade spinning at 3500 RPM, but modern dead man clutches make accidental injury unlikely. Sometimes, even the mundane can turn deadly. Last Saturday I was on Trauma call and a page came through for an incoming trauma code, car vs pedestrian incident, intubated in the field, unresponsive. I was expecting the usual combination of head and extremity injuries that we often see when people are hit by moving cars. Instead, my patient was a 60-year-old man with no obvious external signs of trauma, unconscious and intubated with no responses to any stimulation. His pupils were 5mm, not dilated but not normal and fixed, meaning they didn’t contract in response to a bright light. This is a bad sign, usually indicative of severe brain injury, bordering on brain death, unless the patient has gotten paralytic drugs, say for a surgery or intubation.

“Did he get drugs in the field?” I asked hopefully.

“No, doc. He took the tube without bucking or gagging, no drugs needed.” Again a bad sign.

Then we got the whole story. He had been mowing his front yard, near the sidewalk, when two cars got involved in a minor fender bender in front of his house. As one of them tried to avoid the accident, it went up on the sidewalk and as the other car hit it, its rear fender brushed against my patient. It was a low speed impact. The car was almost stopped when it clipped him. But speed is less important than force in this case and since force is dependent on mass, the barely moving car knocked the man down. Had he fallen to the grass, he would have had nothing more than a bruise on his thigh. Instead, his head struck the engine housing of the mower. The engine cut off as soon as his hands left the dead man clutch, but the engine is made of tempered steel and aluminum, both much harder than the human skull.

We hurried him off to CT where the scan confirmed a basilar skull fracture with a massive intracranial hemorrhage. His brain was already starting to herniate. That means that the pressure of the bleeding in his skull was pushing the base of his brain into the opening that allows the spinal cord to exit. Herniation = death. The neurosurgeons rushed him off to surgery to take the top of his skull off and give the brain room to expand upward instead of down.

He’s still not responding and may be brain dead. Now I have to talk to the family about organ donation and eventual withdrawal of care if the flow studies show his brain is indeed dead. They’re obviously in shock. His son keeps saying, “He was only cutting the grass”.

This job never gets easier.

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