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.
Given the circumstances, 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. 
Given the circumstances, which of the following is the most appropriate next step?

Quizplus · Accepted Answer

Explanation: It is important that medical personnel honor the principle of patient autonomy when competent adult Jehovah's Witnesses indicate that they do not want to receive blood transfusions. However, other supportive measures should be implemented whenever possible to maximize the likelihood of a successful outcome. For instance, some surgeries can be performed successfully using blood-sparing techniques or erythropoietin. Similarly, in cases of blood loss, intravenous fluids and vasopressors should be used. (Choices B and D) Because the patient is a competent adult, it is inappropriate to seek the permission of his wife or the courts for a blood transfusion. The patient has already made his wishes clear. In addition, seeking permission from his wife or the courts is impractical due to the urgency of his condition. (Choice C) Halting all further intervention would be premature, as the administration of intravenous fluids and vasopressors may stabilize this hypotensive patient. (Choice E) Ordering a blood transfusion in this patient would be in direct violation of his wishes and therefore invites litigation. However, had the patient been unconscious (and his desire to avoid blood products unknown), medical personnel would not have been held legally liable for proceeding with an immediate transfusion. Educational objective: Intravenous fluids and vasopressors are important supportive measures that should be administered to Jehovah's Witnesses who have suffered significant blood loss. 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