You are an attorney who is litigating a case of Louis Nikoia, a man who slid off a roof. What can you expect the medical records to reveal about the care this man required during the emergency department evaluation? What occurs during the first hour in the emergency department can mean the difference between life and death.

Rescue Squad Records and Trauma
Rescue squads are taught to make a quick assessment, stabilize the patient and transport him as fast as possible. You can expect that the squad will give the patient oxygen at a high flow rate (15 liters per minute) by the mask. After assessing the mechanism of injury, they will most likely stabilize the spine if they suspect a spinal injury. They will put on a hard cervical collar and strap the patient to a hard long board. They’ll look for a vein and often prefer an easy to find one in the inner part of the elbow (antecubital fossa). Meanwhile, they are taking vital signs and communicating with the emergency department to describe the patient’s condition and receive orders. Sometimes they give Morphine. While they are en route to the hospital, they are reassessing and reassuring the patient.

The Primary Survey in Trauma
“We’re getting a trauma. Get the team.” The anesthesiologist, traumatologist, orthopedic surgeon, emergency department physician, residents, and nurses start thinking ahead when they hear Louis is coming in. When they know the mechanism of injury, they begin to anticipate the types of injuries Louis may have sustained and the tests they’ll need to perform.

When Louis’ stretcher rolls through the door, the team springs into action and starts thinking “ABCDE”.

Airway
The first priority is to make sure Louis can breathe. Blood, vomit, loose teeth or food can block the airway. The team suspects Louis has a cervical spine injury. They use a jaw-thrust maneuver to open his mouth while stabilizing his neck. Because Louis is semi-conscious, the anesthesiologist carefully intubates the patient using a fiberoptic technique to avoid hyperextending Louis’ neck. He rapidly administers sedation and paralytic medication to intubate the patient and attach him to ventilator. He also inserts a gastric tube to decompress Louis’ stomach.

Breathing
While examining Louis, the staff are also examining his ability to breathe. They are most concerned fractured ribs which could have damaged the lung resulting in a collapsed lung or accumulation of blood. A person who is having severe respiratory distress and a collapsed lung needs an immediate insertion of a chest tube to allow the lung to re-expand.

Circulation
The next piece of assessment is to check the circulation – the blood pressure, pulse, skin color, and level of consciousness. The staff obtain baseline (first set of vital signs) to use as a comparison for other measurements. Louis is bleeding from an open fracture of his leg. The staff apply direct pressure to control the hemorrhage. Tourniquets are used only if there is severe bleeding and the need to use this method to save the patient’s life. A tourniquet may cause death of a limb. The staff raise his legs 6 to 8 inches to improve circulation to the heart. A nurse starts a second large diameter intravenous needle to administer rapid infusions of intravenous fluids and blood. Since typing and crossmatching blood may take 30 to 40 minutes, this may be too long for Louis to wait. He receives type O Rh positive blood since he cannot become pregnant (and get sensitized to the Rh factor). Each unit of blood will raise his hemoglobin by 1 gram per deciliter unless he continues to bleed.

Disability
The staff perform an initial Glasgow Coma Score and reassess this periodically. The score evaluates the patient in three key areas:

• Eye opening: the amount of stimulation needed to get the patient to open his eyes
• Verbal response: whether the patient is oriented or confused or makes intelligible speech
• Motor response: Whether the patient can follow directions or localize (identity the source of pain) or withdraw from pain or assume abnormal body postures.

Louis has a Glasgow Coma Score of 10: He opens his eyes to pain, (2), is confused (4), and withdraws from pain (4). Louis has unequal pupils, which lead the medical team to suspect he has suffered head trauma.

Exposure
The last part of the Golden Hour ABCDE rule is to expose the patient’s body to look for injuries. The easiest and least traumatic way to remove it is to cut it off with trauma shears. The temperature in the trauma room is raised to prevent heat loss and rewarm the patient.

Now that the primary survey is complete, the staff starts the secondary survey. Patients live and die based on how well the staff detect injuries and take action to save lives. Medical records tell the story of the Golden Hour.

Med League nurses have expertise in summarizing medical records of trauma patients to help attorneys understand injuries and treatment. Contact us for help with your next case.