History’s Mysteries

Attack One’s crew members are in the work area of the emergency department, cleaning up their equipment following a transport. As the paramedic completes the patient care report and finalizes verbal communications with the charge nurse, an ED security guard requests assistance getting a person out of the backseat of a car. The guard tells the nurse someone walked in and announced that a young woman was in a car outside and “wouldn’t wake up.” It’s 2 o’clock on a Sunday morning, and possible causes of this problem race across the minds of both the experienced ED nurse and the paramedic.

The Attack One crew offers to assist, and the three of them join the nurse at the car, which sits outside the ED entrance. They find three individuals outside it and a young woman in the back passenger seat slumped over and unresponsive. She breathes slowly and responds only by holding her eyes open momentarily when the paramedic opens them for her. Her pupils are midsize, and there is a smell of alcoholic beverages on her breath.

As she is unresponsive to any verbal stimuli, the paramedic asks the crew members to get him a backboard to assist in getting the patient out of the backseat. They grab one from the EMS storage area, obtain a stretcher from the trauma bay and rapidly slide the patient out of the backseat and onto the stretcher. The paramedic notes the patient doesn’t respond at all when he grasps her hands to put them across her abdomen for the transfer.

On a hunch he tells the other crew members, “Please get a collar, and we’ll strap her onto the board with the collar in place.”

They package the patient quickly and move her into the trauma bay. The nurses are busy across the ED, so the crew members start to take vital signs, with the charge nurse assisting and initiating the ED documentation.

One of the Attack One EMTs asks the nurse, “Could there be something wrong with this blood pressure cuff? I’m only getting a BP of 70.”

The nurse rechecks the BP and gets the same result. The patient’s skin is pink, and her heart rate is about 70.

The nurse asks the crew, “What is her name? I only heard her friends call her Marti. And how old is she?”

The crew all look at each other—no one has talked to the friends. They were caring for the patient. They all look at the security guard, who enters the trauma bay to collect the patient’s belongings.

“I didn’t talk to the friends either,” he says. “They all got back in the car after you got her out, and I thought they were moving the car out to the lot. I’ll go see if they’re in the waiting area.”

The young woman is responsive only to painful stimuli to the face. She has small and minimally reactive pupils. The crew finds an abrasion to the right ear and a contusion to the scalp just above the hairline. There is reddened skin over her sternum, as though someone had tried to do a sternal rub on her chest. The rest of her chest and abdomen have no signs of trauma. As they note the low blood pressure, the crew members and nurse find that distal pulses are not palpable. They detect no other signs of trauma, needle marks or movement.

The security guard pokes his head back in and reports, “The car that dropped her off and all of the people with her are gone.”

The emergency physician enters the room and asks for a quick assessment. The nurse reports the sketchy details they have on this patient: “She has a blood pressure of 70, a pulse rate of 68, and only reacts to pain and stimulation around the face. The people who dropped her off gave no information about what happened, and we only have a name they spoke at her. We noted a couple of contusions to her scalp and ear and a smell of alcohol on her breath. It also appears someone tried to do a sternal rub on her before she arrived. We removed her from the backseat of the car and packaged her on a board only because she’s so unresponsive.”

The physician checks also and finds no distal pulse. With no eye movement, the young woman groans on painful stimuli to the face and does not move her extremities. He strokes the bottoms of her feet from the heel to the toes, and there’s no reaction of legs, feet or toes. He puts on a glove and finds the patient has no rectal tone. He asks for a temperature and finds her rectal temperature is 95ºF.

“You immobilized her as you brought her out of the car?” he asks.

“Yes—was it too much to do?” the paramedic asks.

“No, it appears appropriate. I think she has a spinal cord problem, and you did exactly the right thing if you immobilized her. We have no history at all?”

The nurse and crew report the details of the friends just standing there, then apparently taking off as soon as the patient was moved into the building. The only injuries they find on a complete exam are to her ear and scalp. They all carefully roll the patient to examine her back.

The physician orders a fluid bolus, a complete set of x-rays, a set of blood and urine tests for alcohol and drugs, a pregnancy test, and that the woman be maintained in spinal immobilization. He also requests warmed blankets be kept on her until they get the warming setup brought to the ED.

With just that history, the crew offers to help the nurse by documenting the interaction with the friends, how they did the immobilization, and that there was no significant movement of the patient’s spinal column as they moved her onto the stretcher and board and into the ED. When that’s done, the Attack One crew returns to their original work of getting their equipment and documentation done on their original patient.

As they prepare to return to service, the ED nurse calls them back into the trauma bay. By now the trauma team has assembled and looked at x-rays of the young woman’s neck. The emergency physician asks the EMS crew to come forward.

“This patient has a fracture of her fifth cervical vertebrae, which is obviously new,” he tells them. “We are finding no injuries anywhere else except on her scalp, and that small contusion is probably where she hit something or was hit by something. You did a great job in immobilizing her even though you had no history. We have no identity yet, so we are treating her as a Jane Doe.”

The paramedic advises that he will contact the local police, since this is possibly an assault and officers might be able to help in the search for an identity. They call the communications center and advise the dispatcher they will remain at the hospital and out of service until they talk with police.

Law enforcement responders arrive, and the ED and EMS personnel relate the story. The young woman still hasn’t awakened, and the trauma team is now treating her for neurogenic shock. They’ve found an alcohol level that is not very high and no other drug or drug byproducts, and she is not pregnant. Her x-rays show no injuries other than the cervical spine fracture, and she has no internal blood loss. Her brain CT scan shows a contusion to the front of her brain and no other injury. Her blood pressure does not respond to three liters of fluid, and the trauma team initiates a drip of norepinephrine, which improves her perfusion. They’ve placed her in a firm collar, and the neurosurgeon now works toward a method of stabilizing her cervical spine. The patient is more responsive as she leaves the ED but still does not verbalize or move.

The law enforcement team has found a possible cause: Several miles from the hospital, an abandoned car has been discovered after a significant impact with a tree. The windshield is starred on the passenger side, and there is no one around. There is no blood in the car, which was stolen earlier in the day.

Hospital Course

A criminal investigation ensues, and a break comes when a family comes to the police in the morning hours to report their daughter missing. At the hospital they identify her as their family member. She was a passenger in the wrecked vehicle.

After weeks of treatment, the patient recovers some spinal cord function and is released to a rehabilitation facility.

Case Discussion

This is an example of a patient presenting to emergency providers without a good history and with several hidden problems. She was ultimately found to have a terrible injury to her spinal column and spinal cord and to be in neurogenic shock.

The classic presentation of neurogenic shock includes low blood pressure and a heart rate under 80. The presentation of shock results from the spinal cord injury causing a loss of signals to the blood vessels to maintain their tone. When the blood vessels lose the signal to contract, they dilate, which causes pooling of blood in the periphery. Clinically the patient does not have the pale appearance or mottling of the skin that appear in other forms of shock. The relative dilation of the blood vessels in the skin can also cause the core of the body to lose heat, and victims of neurogenic shock are often in mild hypothermic states.

There is always an initial concern in trauma patients that the cause of shock is hemorrhage. Management of the trauma patient is to treat for shock, seek signs of bleeding, keep the patient warm and manage neurogenic shock when other causes have been ruled out. The initial EMS management protocol for these patients includes spine immobilization; airway protection; appropriate ventilation; bolus with fluids; maintaining body temperature; and monitoring carefully. In the hospital, perfusion is maintained by using vasopressors after a full evaluation for blood loss, cardiac injury and other causes of shock.

This patient was found in the backseat of a car with no good history. The “friends” who dropped her off disappeared before she was even identified. The management of unidentified patients with unknown problems for uncertain periods of time represents a significant challenge for both EMS and emergency department providers. These patients receive temporary identifications, and their management is guided by physical examination and any clues to possible etiologies.

This incident also points out the need for cooperation with law enforcement. Those connections allow more pieces of the puzzle to be found. In this case officers ultimately located the family.

James J. Augustine, MD, FACEP, is medical advisor for the Washington Township Fire Department in the Dayton, OH, area. He is director of clinical operations at EMP Management in Canton, OH, a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, and an editorial advisory board member for EMS World. Contact him at jaugustine@emp.com.