Why does it always feel like a battle between good and evil? You want to admit the 78-year-old male who had a syncopal event, but the internal medicine service feels that he can be worked up as an outpatient. You call your vascular surgeon early about a patient with a cold, ischemic foot, and he yells at you for calling before the ABIs and arteriography have been performed. And now, you are arguing over the phone with the OB/Gyn attending who refuses to come down to see a vag-bleeder with a hemoglobin of 6 who is soaking through a pad per hour and feeling faint. “I’ve seen worse…” she spouts out, as if that’s supposed to make you feel less concerned about the poor woman in front of you.

Just then, your charge nurse walks in to tell you that you have a sick trauma patient en route to your ED. In 10 minutes you’ll get a 49-year-old female who broke her femur while riding her bicycle. She was hit by a vehicle in the intersection and thrown off her bike. She’s hypotensive and tachycardic, but otherwise alert and without any other signs of trauma.

On arrival to your trauma bay, she appears rather pale and diaphoretic. She is screaming at the top of her lungs about her broken leg, and you realize this isn’t going to be the peaceful, straightforward case you were hoping to end your night with. Her initial vital signs demonstrate a blood pressure of 82/46 mmHg and a heart rate of 114 bpm. She’s tachypneic, but her oxygen saturation and temperature are within normal limits. Her primary and secondary survey are only remarkable for an obvious closed right femur fracture and some minor abrasions over both legs. You notice that she has a port on her chest, and discover that she has a history of breast cancer, currently being treated with chemotherapy and radiation.

During her resuscitation, she has a normal chest X-ray and a normal pelvis X-ray, and has already received 2 liters of normal saline wide open. Her abdomen remains soft and non-tender, and there are no other signs of trauma other than her right femur. It’s clear by her clinical presentation that your patient doesn’t have much reserve at baseline, and may not do too well with this injury.

She lies there in front of you screaming for dilaudid and fentanyl, but the trauma team is reticent to give her any IV narcotics secondary to her ongoing hypotension despite treatment with IV fluids. As the O-negative blood is being retrieved to begin a transfusion, you finish up your eFAST exam on the patient and decide to take a peek at the patient’s proximal thigh. You change over to the linear array transducer and obtain the following images.




What do you see? What can you do to help your poor patient? Conclusion on next page



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