Why you should always wear a helmet. And not drink and drive.

Thailand is beautiful. And hot. In the dry season it doesn't rain for 8 months straight and it certainly never snows. So getting around via motorbike is an ideal form of transportation, and as you can imagine, a lot of people do it. A lot of people also do NOT wear helmets, and a lot of people also think it's a good idea to get on their motorcycle unhelmeted after having a few cocktails. Inherently, this leads to a lot of fun for us in the ER here at KRCH. Recently I've taken care of two young men who suffered traumatic brain injuries that probably wish they hadn't had that extra drink, or that at least they were wearing some cranial protection. 

The above patient was a 38 year old male who presented after being found down next to his motorcycle. His family brought him in, obviously intoxicated. It is unclear how long he was down, as he could not provide any history. My first impression of him was when he fell off the stretcher in the ER trying to sit up aka he was very drunk. But, he was mentating alright and responding to some questioning. He also had blood dripping out of his left ear, which is always an ominous sign. Other than his altered mental status, and bleeding left ear however, he was doing okay. 

At home in the US, this sort of patient automatically gets a full body CT scan. No question. But here, that sort of thing would cost a family their entire life savings...for the next 10 years. So after a prolonged conversation with his frustrated and overwhelmed wife, the decision was made to "admit and observe", which is always a fun option when you're the one on call and you're anticipating the midnight call from the nurse about an abrupt change in mental status. Fortunately, around 5pm the wife had a change of heart, and we obtained the above head CT which revealed a large epidural hematoma with minimal midline shift. At this point, his mental status was still stable enough to put off intubation. We packaged him up (with mannitol and dilantin) and sent him along to the referral hospital. Hopefully he made it okay. 

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This next patient was not as fortunate, however. Our EMS team (one of our ER nurses and the ambulance driver) responded to a report that there was a motorcyclist down in the middle of the road, unresponsive. On arrival to the ER the patient was unresponsive, with an obviously blown and unresponsive right pupil. He appeared to be in his early 20s. 

I immediately intubated him on arrival and we were able to get a head CT before sending him along to the small referral hospital 20 minutes away. His CT as shown below, revealed a right sided subdural hematoma with significant midline shift.


Unfortunately we were not able to identify him prior to transport, but through some of the staff here I was able to find out that upon arriving to the large government hospital in Kanchanaburi the family opted NOT to pursue surgical intervention due to cost. I am not sure what happened after that, but I assume that without attempting surgical decompression this is likely not a survivable injury.


And don't forget this injury in a 16 year old male while drinking and driving:


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