Unbreakablea Family Medicine Case Presentation Abad, Imperial, Javate, Palma, R. Uy, Valencia ASMPH 2012
Objectives • To discuss the family profile of Pradel family • To establish the family diagnosis using family assessment tools • To present a case of trauma secondary to a vehicular accident • To discuss the impact of vehicular trauma to a family • To briefly discuss the road safety and legal issues pertinent to the case
Index Case Profile • MP • 17 years old • Female • Occidental Mindoro
Chief Complaint • Abdominal pain
Vehicular Accident • NOI: Vehicular Crash (Motorcycle vs Tricycle; Motorcycle vs Truck) • TOI: 2:30pm • DOI: December 8, 2010 • POI: San Jose, Occidental Mindoro
Primary Survey • Airway: Patent • Breathing: • RR = 26bpm • Symmetric chest expansion and clear breath sounds • (-) dyspnea • Circulation: • HR = 94bpm • (-) neck veins (-) murmurs • Disability: • (-) sensory or motor deficits • GCS:15 E4,V5,M6 although irritable and uncooperative • Pupils 2-3mm EBRTL • Exposure: Contusions, both eyes. Abrasion, chin. Hematoma, lateral forearms
Secondary Survey • Signs and Symptoms • Abdominal pain (3 days PTA, after VC): diffuse, cramping and sharp pain; 8 – 10 / 10; Aggravated by palpation • Allergies: none • Medications: none • Pertinent Past Medical History: • (-) previous hospitalizations / surgeries • Last Oral Intake: more than one day • Events leading to the incident
Events leading to the incident • 3 days PTC • Returning a motorcycle she borrowed • Wearing a helmet • Going fast, attempted to overtake • Last motorcycle to overtake, sideswept • Off-balance, veered to opposite lane • Crashed head-on to a decelerated truck • Said to have been unconscious • No witnesses available on interview • Reliability of father = 75%
Events after the incident • Brought to a nearby hospital in Mindoro • Admitted, but family opted to transfer to a better facility • 2 days PTC • Admitted at Batangas General Hospital • Cranial CT was said to be unremarkable • Subcapsular hematoma, liver • Lipase: 2000+ • Advised ICU stay, but patient was uncooperative
Events after the incident • 1 day PTC • Transferred to Paranaque Doctors Hospital • Family opted transfer to EAMC • Transfer to SMPCH
Past Medical History: • Sepsis (11 days old) • Family history: • Asthma – mother • DM - grandmother • Social history: • College student • Claims (-) smoking, drinking, drugs • Active in church (Born Again)
Physical Examination • Conscious, irritable, not in cardiorespiratory distress • BP: 110 / 70 mmHg • Temp: 36° • HR: 94 • RR: 26
Physical Examination • Skin • brown skin color, good turgor, no rashes, multiple abrasions • HEENT • (+) periorbital hematoma, bilateral with edema, anictericsclerae, pink palpebral conjunctiva, no TPC, no CLAD • Pulmonary • Symmetric chest expansion, clear breath sounds, no rales, no wheezes, (+) tachypneic • Cardiovascular • Adynamicprecordium, apex beat at 5th ICS LMCL, NRRR, distinct S1 S2, no murmurs
Physical Examination • Abdomen • Flat abdomen, hypoactive BS, no masses, no organomegaly(+) direct tenderness all quadrants, (+) involuntary guarding • Genitourinary • No CVA tenderness • Extremities • (+) Hematoma, forearm bilateral, no cyanosis, no edema, full and equal pulses
Clinical Impression • Multiple injuries secondary to vehicular crash • Acute surgical abdomen secondary to blunt abdominal trauma secondary to vehicular crash
Medical and Surgical Managment • Admitted; IVF, NGT, Foley Catheter • Emergency Explore Laparotomy • Evacuation of hemoperitoneum • Ligation of bleeders • Reactive Appendicitis • Appendectomy • Pancreatitis secondary to trauma • ICU • Cefuroxime / Metronidazole / Imipenem • Omeprazole / Ketorolac / Vitamin K
Family Genogram PRADEL FAMILY Diabetes Mellitus 5 7 Multiple injuries secondary to vehicular crash
Family Life Cycle • Family with adolescents
Vehicular Accident • Type of illness: acute severe • The greater the severity, the greater the stress • Lack of emotional preparation • Lack of financial preparation • Illness brings out the best, but may also surface pre-existing dysfunctions
Impact of Illness to the Family • Stage I - Onset of Illness • Stage II - Reaction to Diagnosis • Stage III - Major Therapeutic Efforts • Stage IV - Early Adjustment to Outcome • Stage V - Adjustment to the Permanency of the Outcome
Impact of Illness to the Family • Realization that their daughter sometimes disobeys them • Centripetal • Family drawn closer together despite physical distance • Belief Systems • “Love offerings” from fellow parishioners • “God is good to us” • Family Resiliency and Coping Mechanisms • Adaptability • Hard work and cooperation • Forgiveness
Individuals, families, and communities form a dynamic support system against the inevitable stresses of life "Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Influences of Resilience "Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Resiliency and the Individual • From an early age, individuals learn resilient behavior at home and in their communities. • Overall, the children’s health and success in school, relationships, and jobs correlated with: • their disposition, intelligence, communication skills, and internal locus of control • parental warmth and support, and positive relationships with siblings or other adults • and support systems in school, church, or community clubs that rewarded competence and provided a value system. "Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Resiliency and the Family • Families that learn how to cope with challenges and meet individual needs are more resilient to stress and crisis. • Healthy families solve problems with cooperation, creative brainstorming, and openness to others. • Social support and connectedness (vs isolation) contributes to family resiliency. "Family Resiliency: Building Strengths to Meet Life’s Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011 <http://www.extension.iastate.edu/Publications/EDC53.pdf>.
Family Adjustment and Adaptation Response Model (FAAR) • used to explain how families react to and manage change. • Adjustment phase • Adaptation phase.
Adjustment Phase Steps • Period preceding a family stressor event • Prior strains produce changed family demands • poor communication • hardships • economic circumstances • Family appraises the relationship between their existing resources to adjust to the change before defining the stressor event • Deciding upon a plan to manage the new situation
Adjustment Phase Steps • Families experience either stress (positive) or distress (negative) when they conclude that the situation is either unpleasant or undesirable. • The family will respond in one of three ways. • Avoid, deny or ignore the stressor and its resultant demands hoping it will resolve itself • Eliminate the demands by changing the stressor or altering its definition • Accept the demands of the stressor and make changes accordingly (assimilation). • The first two actions may protect the family unit by minimizing the changes required, • HOWEVER, they are more likely to lead to maladjustment. • While assimilation may involve the reallocation of resources it is most likely to result in a satisfactory outcome or nonadjustment.
The Family Adaptation Phase • The occurrence of a crisis is not a signal that the family has failed or is dysfunctional. • The adaptation phase is characterized by the family’s recognition of the need to make change • Modifying established rules, roles, goals and/or patterns of interaction. • Occur in two distinct levels. • Restructuring • Consolidation
Level 1: Restructuring • One or more family members become aware of an inability to meet the combination of established and new demands (the pile up or aA factor). • They share an understanding of the problem (cC) and have a realistic view of the availability of resources (bB). • They are able to agree on and implement solutions that influence the family’s transition through the phase. • Ex. using resources to solve problems, correctly appraising and accurately defining the situation families are able to maximize the solutions available. • The family’s problem-solving efforts and structural changes are aimed at: • management of specific demands • changes to accommodate demands • restoring organization and stability to the family unit.
the pile up or aAfactor realistic view of the availability of resources (bB). understanding of the problem (cC)
Level 2: Consolidation • After initiating change that results in some restructuring. • This may involve such things as a previously unemployed family member obtaining paid work or a change of residence. • Focus is on attempting to mold the family into a coherent unit. • One or more family members become aware of the family having made significant change. • Attempt to facilitate a shared family awareness + acceptance of the restructuring. • Success at this level involves all members of the family unit. • Changes are implemented (by trial and error) in the action phase.
Level 2: Consolidation • Synergizing: family’s attempt to coordinate and pull together as a unit • Interfacing: Acknowledging interactions between the family and community when attempting to redefine their role • Needs and resources with community needs and resources is critical for successful adaptation • Compromising: A realistic appraisal of family circumstances and a willingness to accept a less than perfect solution. • System maintenance relies upon optimal levels of morale and esteem of family members.
Legal &Road Safety Issues Legal Violations Underage/unlicensed driving of a borrowed motorcycle (P750 penalty to driver Allowing an unlicensed person to drive MV (P750 penalty to owner) • Road Safety Issues • Unskilled & unlicensed driver • Risk to self • Risk to others • Speeding and overtaking (risk taking behavior) prompted accident
Conclusion • MP suffered an acute and severe illness • The Pradel family is highly functional and resilient • Poverty may limit the family from giving MP the best possible treatment • The family’s religious affiliations provide good support system