A 41-year-old man is brought to the emergency department by ambulance after a motor vehicle accident. He was driving a car with his 6-year-old daughter in the back seat when they were broadsided by a large truck traveling at high speed. The patient is conscious during transit to the emergency department. He appears oriented to date and time, and informs paramedics that he is a Jehovah's Witness and does not want blood transfusions for himself or his daughter. Soon after, he begins moaning and writhing and is clearly in distress. He complains of feeling nauseated and thirsty. A facemask is placed to administer 100% oxygen. Initial assessment indicates his temperature is 37 C (98.6 F), blood pressure is 100/58 mm Hg, pulse is 132/min and thready, and respirations are 34/min. There are numerous lacerations on his scalp, trunk, abdomen, and extremities. The patient's skin is cool and clammy. Chest auscultation shows tachypnea and tachycardia but is otherwise normal. His abdomen is diffusely tender to palpation and guarding is present. Rectal examination is normal. The patient's blood pressure begins to drop rapidly and approaches 60/15 mm Hg. The trauma surgeon advises that an immediate exploratory laparotomy is warranted to ascertain the source of the internal bleeding. Hemoglobin is 5.5 g/dL. The patient's 6-year-old daughter was also severely injured in the accident. She suffered a significant crush injury to her chest and is now unconscious and bleeding profusely. At initial assessment, her temperature was 37 C (98.6 F), blood pressure was 72/38 mm Hg, pulse was 154/min, and respirations were 42/min. While her chest wound is examined externally, her blood pressure declines precipitously. Two large-bore intravenous catheters are inserted and fluids are administered aggressively, but the child becomes increasingly hemodynamically unstable. Her hemoglobin is 6 g/dL. She is intubated and chest tubes are placed. Which of the following is the most appropriate next step?

Question

A 41-year-old man is brought to the emergency department by ambulance after a motor vehicle accident.  He was driving a car with his 6-year-old daughter in the back seat when they were broadsided by a large truck traveling at high speed.  The patient is conscious during transit to the emergency department.  He appears oriented to date and time, and informs paramedics that he is a Jehovah's Witness and does not want blood transfusions for himself or his daughter.  Soon after, he begins moaning and writhing and is clearly in distress.  He complains of feeling nauseated and thirsty.  A facemask is placed to administer 100% oxygen.  Initial assessment indicates his temperature is 37 C (98.6 F), blood pressure is 100/58 mm Hg, pulse is 132/min and thready, and respirations are 34/min.  There are numerous lacerations on his scalp, trunk, abdomen, and extremities.  The patient's skin is cool and clammy.  Chest auscultation shows tachypnea and tachycardia but is otherwise normal.  His abdomen is diffusely tender to palpation and guarding is present.  Rectal examination is normal.  The patient's blood pressure begins to drop rapidly and approaches 60/15 mm Hg.  The trauma surgeon advises that an immediate exploratory laparotomy is warranted to ascertain the source of the internal bleeding.  Hemoglobin is 5.5 g/dL. The patient's 6-year-old daughter was also severely injured in the accident.  She suffered a significant crush injury to her chest and is now unconscious and bleeding profusely.  At initial assessment, her temperature was 37 C (98.6 F), blood pressure was 72/38 mm Hg, pulse was 154/min, and respirations were 42/min.  While her chest wound is examined externally, her blood pressure declines precipitously.  Two large-bore intravenous catheters are inserted and fluids are administered aggressively, but the child becomes increasingly hemodynamically unstable.  Her hemoglobin is 6 g/dL.  She is intubated and chest tubes are placed.  Which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Explanation: In providing medical care, clinicians must seek to balance the autonomy of the family with the welfare of the child. In urgent situations such as this, clinicians must act to preserve the child's life, even if such actions contradict parental wishes. In general, a competent adult can sacrifice his or her life for religious beliefs, but, as a parent, cannot refuse life-sustaining treatment for a child who has not reached the age of consent and has not chosen to adhere to the religion. Therefore, it is best to proceed with immediate blood transfusion. Obtaining approval from either the child's mother (Choice A) or the court (Choice D) requires the luxury of time. This is an urgent situation, and it is more important to act to save the child immediately. When the child requires intervention within the next few days but is currently stable, it would be appropriate to seek approval from the courts to proceed with medically necessary treatments. (Choice B) The hospital ethics committee should be consulted when a clinician is confronted with an ethically difficult but nonemergency situation. (Choice C) Administering fluids instead of a blood transfusion would be an acceptable choice if the patient were a competent adult. However, because this patient is a child and considered unable to fully understand the consequences of making such a choice, it is standard practice to act to preserve the child's life despite parental wishes. Educational objective: Clinicians must act to preserve the life of a child, even if such actions directly contradict parental wishes. A prime example is the standard practice of administering emergency blood transfusions to the children of Jehovah's Witnesses. References: Jehovah's Witnesses in the emergency department: what are their rights? (http://www.ncbi.nlm.nih.gov/pubmed/16299196)

A 41-Year-Old Man Is Brought to the Emergency Department by Ambulance