Dr Ashutosh Wanchu, India

It was one of those therapeutically slow days in the Emergency Department (ED), one fortuitous afternoon when the team was lazily standing around the counter briefly discussing trauma care and the essence of Advanced Trauma Life Support (ATLS) in treating trauma shock nowadays.

The idea was essentially discussing that now trauma has become beyond ATLS and how we should be broadening our horizon on dealing with trauma.

Then, ominously, the doors swung open with a vigor we knew only too well, and in came a gurney with a hypothetical relatively petite figure contained over it. On primary examination in resus, we noticed the patient was drowsy but rousable verbally. I noticed that her heels were massively lacerated and bleeding, and she kept mumbling about how her back had completely broken.

She could provide no further information despite repeated efforts, so after placing a three-way cervical collar and securing two 18-gauge cannulas with Tramadol, I went out to get a complete history. Unfortunately, the people who brought her—her parents and her colleagues—just told me that school had just ended, and after the final bell had rung, a few students came and informed them that she was found on the floor, fallen.

I was informed that she had Bipolar Disorder and was mentally challenged, but no further history was available. Even on probing her parents, who were nonchalant about her mental condition—since we obviously live in a yet regressed society—neither knew what condition she had, nor knew what medications she was on. After an irritating segment, I just asked for her old records.

On the management front, we got a splint in both her legs after covering her open wound and placed a pelvic binder for her immediately on arrival. We initiated pain management, IV Tranexamic Acid 1Gm stat, and an infusion over 8 hours. The patient was slightly hypotensive on arrival, but having a vital set of BP – 90/50 mmHg, Pulse – 119 beats per minute, and holding a saturation of 94% on Room Air, I was content with this in view of permissive hypotension.

After slightly settling the pain from a score of 9/10 to 4/10, I thought it best to get a Computed Tomography (CT) scan done for trauma protocol to look for pathologies. I had completed a bedside Extended Focused Assessment with Sonography in Trauma (E-FAST), which was positive for fluid in the Morrison’s pouch.

Now, my idea was to find pathology as soon as possible because, despite what literature states, few surgeons actually take an unstable bleeder to the Operating Room stat, especially without a CT scan—such is the plight. Mind you, by this time, her blood gas had shown a compensated metabolic acidosis, and her hemoglobin had yet to fall.

I have been taught all too well to base my assumptions on the first blood gas. “The First pH and Hemoglobin is always about normal, Ashutosh!!” bellowing words, forever ringing in my ears from my mentor in residency. A massive transfusion protocol was already announced, as my running primary diagnosis was fall from height.

On shifting the patient to the CT with utmost fragility, we did the customary check of vitals just to find that the patient had a non-recordable BP and a slowly climbing pulse of 133 beats per minute. I immediately ordered the nurse to initiate a Noradrenaline infusion for the patient with a target systolic BP of 90 mmHg.

This is where the fork in the road comes. One of my senior colleagues said Noradrenaline would worsen her condition and that she should be loaded with a Normal Saline Bolus of 1 Liter, as stated by the ATLS protocol. I jumped in with the utmost humility and asked her not to give fluids, and that Noradrenaline would be a better fit as fluids would worsen the Diamond of Death in Trauma Shock.

I even explained the ACOTS trial and had to show her written proof, and despite her saying, “Just because of one trial, we can’t change our practice from the guideline which is set up!” I pleaded with her to trust me. Blood was on its way, and I’d initiate it by the time the fluid could be started. She reluctantly trusted me.

Noradrenaline pumped the BP, and the scan was done, showing an intra-abdominal bleed which had now stopped and long bone fractures in both lower limbs and multiple spine fractures in all except the cervical spine. MTP was initiated while still maintaining permissive hypotension to prevent disruption of any clotting internally.

When we reached back, the surgical teams all ganged up and wanted to intubate the patient and also wanted a systolic BP of about 140 mmHg. Again, the arguments and again, the order for Normal Saline was barked out.

Despite explaining many times that there’s nothing normal about normal saline, the myopic orthodox treatment modalities just don’t quit coming into the fray. I even explained the Milkshake Paradigm, which was coined by my mentor.

He explained—imagine you have called in guests to your house and have prepared milkshake for the five people called. When they reach you, they brought their own friends. Now you have ten people to feed the milkshake to. Do you make a fresh batch? Or do you just add water to the existing one?

It’s the same with blood and trauma.

When they still didn’t listen, I inadvertently blurted, “Would you give blood in a patient with diarrhea?” They all looked confused and said no. I said, “Exactly, you lose water, you give water; she’s losing blood, I am giving her blood.”

Anyhow, after two more hours of MTP and pain management, the blood gas, which eventually showed an Hb of 4.8 mg/dL, rose up to 9.1 mg/dL, and her acidosis ended. Her mentation got better, and the patient was tapered off the Norad support and was completely oriented.

After this, we shifted her to the ICU, where she was later taken up for surgery for her lower limb and spinal trauma.

The idea of this piece was to depict how guarded and orthodox the trauma protocol still is. There remain apprehensions to move beyond ATLS when it comes to trauma, and vehemently so. No one wants to agree to newer guidelines.

A simple maneuver, such as giving calcium to trauma patients, had to be argued for since it was not going to save her life and could be given later. The concept of permissive hypotension is often argued over.

Early fluid therapy should be stopped, and it is prudent to discontinue Normal Saline, especially. Doctors also need to understand the difference between a guideline and a law. Guidelines can be flexed a bit when newer data shows the merits and demerits of certain treatment modalities.

Being a slightly newer specialty, I feel it is difficult for the ED to get things put out in stone, but it is an uphill battle—and an important one at that—because our patients’ lives depend on it.