Anatomy of a car-crash crisis on ‘Grey’s’
“Grey’s Anatomy,” season premiere, “Dream a Little Dream of Me”; ABC, Sept. 25.
After losing control on a road covered with black ice, a limousine with three injured women inside arrives at Seattle Grace Hospital. The limo driver has muffled heart sounds, low blood pressure and distended neck veins (jugular venous distension), a trio of symptoms known as Beck’s triad, which a doctor says is a sign of hemopericardium (blood surrounding the heart) and impending cardiac tamponade (in which the heart is compressed by the blood). He soon dies.
The women’s husbands arrive in a second limo, which had also lost control on the ice, accompanied by Maj. Owen Hunt (Kevin McKidd), a military surgeon who has jabbed a pen into one of the husband’s trachea to keep him breathing.
While the victims are being triaged, an icicle falls and embeds itself in Dr. Cristina Yang’s (Sandra Oh) abdomen. Hunt suggests that they don’t remove the icicle before checking an X-ray to determine its precise location lest it be near a blood vessel or organ. The X-ray is inconclusive, and Hunt finally pulls the icicle out.
Meanwhile, one of the husbands has sustained a depressed skull fracture and is found to have blood in his abdomen. The skull fragments are removed during surgery, and an exploratory laparotomy reveals a tear in a renal artery. The doctors repair it, but he dies of complications.
Another husband has had his lower cervical spine crushed and can’t feel his legs. He undergoes surgery to decompress his spine, but he is still paralyzed. Hunt suggests infusing cold intravenous fluid to reduce his core body temperature to below 90 degrees, and his sensation slowly returns.
The medical questions
Can impending cardiac tamponade be diagnosed with only a physical? Can someone keep a patient breathing by stabbing a pen into his trachea? If an icicle is embedded in the abdomen, can its location be determined by an X-ray? Would the source of a life-threatening abdominal bleed be discovered during surgery, or with a previous bleeding study? Does hypothermia help an injured spinal cord recover?
* Impending cardiac tamponade can be diagnosed with certainty only by ultrasound, though the Beck’s triad would suggest it, according to Dr. Mark Adelman, chief of vascular surgery at Langone Medical Center at New York University.
* Trauma to the face can create an upper airway obstruction that warrants an opening in the trachea. “But a pen will never go through the skin no matter how hard you push,” says Dr. Demetrios Demetriades, director of trauma/surgical critical care at USC. “You will need to cut the skin with a sharp instrument and then insert the tubing of the pen into the trachea.”
* An X-ray would not show the precise placement of a shard of frozen water embedded in the abdomen. The icicle could be removed in the operating room while monitoring the condition of the wounded, but, according to Adelman, in most cases it would melt before a patient could be brought to the OR.
* Removing skull fragments after a depressed skull fracture is sometimes necessary, and Adelman says that an exploratory laparotomy is often needed to find the source of bleeding in an unstable patient. But Demetriades points out that renal artery injuries from blunt trauma are extremely rare. “In one of our studies, the incidence in almost 1 million trauma patients from the National Trauma Data Bank was 0.05%,” he says.
* Finally, creating hypothermia has not been shown to help an injured spinal cord patient recover, though Adelman points out there is evidence that “cooling neural tissue can prevent nerve death.” “Science fiction,” Demetriades says.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University’s School of Medicine. He can be reached at email@example.com.