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Abad, Imperial, Javate, Palma, R. Uy, Valencia ASMPH 2012 Slide 2 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 Slide 3 Slide 4 Index Case Profile MP 17 years old Female Occidental Mindoro Slide 5 Chief Complaint Abdominal pain Slide 6 Vehicular Accident NOI: Vehicular Crash (Motorcycle vs Tricycle; Motorcycle vs Truck) TOI: 2:30pm DOI: December 8, 2010 POI: San Jose, Occidental Mindoro Slide 7 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 Slide 8 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 Slide 9 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% Slide 10 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 Slide 11 Events after the incident 1 day PTC Transferred to Paranaque Doctors Hospital Family opted transfer to EAMC Transfer to SMPCH Slide 12 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) Slide 13 Physical Examination Conscious, irritable, not in cardiorespiratory distress BP: 110 / 70 mmHg Temp: 36 HR: 94 RR: 26 Slide 14 Physical Examination Skin brown skin color, good turgor, no rashes, multiple abrasions HEENT (+) periorbital hematoma, bilateral with edema, anicteric sclerae, pink palpebral conjunctiva, no TPC, no CLAD Pulmonary Symmetric chest expansion, clear breath sounds, no rales, no wheezes, (+) tachypneic Cardiovascular Adynamic precordium, apex beat at 5 th ICS LMCL, NRRR, distinct S1 S2, no murmurs Slide 15 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 Slide 16 Clinical Impression Multiple injuries secondary to vehicular crash Acute surgical abdomen secondary to blunt abdominal trauma secondary to vehicular crash Slide 17 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 Slide 18 Slide 19 Family Profile Name of Family Member Relation to Patient Age/SexOccupation MP Patient 17 / F College Sophomore GP Mother 39 / FHousewife JP Father 47 / MBaker JP Younger brother 15 / MHigh school senior KP Youngest brother 12 / MHigh school freshman Slide 20 5 7 Diabetes Mellitus PRADEL FAMILY Multiple injuries secondary to vehicular crash Family Genogram Slide 21 Family Life Cycle Family with adolescents Slide 22 Family Map Slide 23 APGAR MP patient GP mother JP father ADAPTATION Akoy nasisiyahan dahil sa nakakaasa ako ng tulong sa aking pamilya. 222 PARTNERSHIP Akoy nasisiyahan sa paraaang nakikipagtalakayan sa akin ang aking pamilya tungkol sa aking problema. 222 GROWTH Akoy nasisiyahan at ang aking pamilya ay tinatanggap at sinusuportahan ang aking mga nais gawin patungo sa mga bagong landas para sa aking ikauunlad. 221 AFFECTION Akoy nasisiyahan sa paraang ipinadadama ng aking pamilya ang kanilang pagmamahal at nauunawaan ang aking damdamin katulad ng galit, lungkot at pag- ibig. 222 RESOLVE Akoy nasisiyahan na ang aking pamilya at ako ay nagkakaroon ng panahon sa isat isa. 222 OVERALL ASSESSMENT 10 9 Slide 24 SCREEM PARAMETERRESOURCEPATHOLOGY Social Good relationship between family members, neighbors and fellow church members Social activities of family are mainly church-related None Cultural Family is very proud to be a Filipino with no intention to leave the country. Family encourages children to participate in social welfare and church related activities None Religious Family is a religious Born-again Christian who devoutly respects the traditions of their church. Family takes pride that their children are very active in church groups both in school and in their local parish Fellow parishioners love offering is the primary source of financial support of the family at the moment None Slide 25 SCREEM PARAMETERRESOURCEPATHOLOGY Economic Family is usually self-sufficient, not dependent on other people for money Financial problems hitting the family because of MPs vehicular accident. Concerns by the father about the hopes and dreams of his other children who still wish to finish their primary schooling, and to continue on to future graduate courses Educational Parents are not college graduates themselves but they strongly encourage their children to finish their education. Family as a whole understands the value of education Continuation of schooling as a consequence of the expenditures they will incur at the end of the medical admission. Medical Familys view of health as an important aspect in the general well-being of their everyday lives help with preventing them from getting and developing some predisposed diseases Familys first and foremost concern is for MP to get well, even to the extent of spending beyond their means to avail of medical services in Metro Manila Financial problems limit the family from giving MP the best possible medical care. Slide 26 Slide 27 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 Slide 28 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 Slide 29 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 Slide 30 Individuals, families, and communities form a dynamic support system against the inevitable stresses of life "Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011. Slide 31 Influences of Resilience "Family Resiliency: Building Strengths to Meet Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011. Slide 32 Resiliency and the Individual From an early age, individuals learn resilient behavior at home and in their communities. Overall, the childrens 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 Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011. Slide 33 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 Lifes Challenges." Iowa State University Extension. National Network for Family Resiliency Children, Youth and Families Network CSREES-USDA. Accessed 12 January 2011. Slide 34 Family Adjustment and Adaptation Response Model (FAAR) used to explain how families react to and manage change. Adjustment phase Adaptation phase. Slide 35 The Family Adjustment Phase Slide 36 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 Slide 37 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. Slide 38 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 familys recognition of the need to make change Modifying established rules, roles, goals and/or patterns of interaction. Occur in two distinct levels. Restructuring Consolidation Slide 39 Level 1: Restructuring Slide 40 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 familys 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 familys 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. Slide 41 the pile up or aA factor realistic view of the availability of resources (bB). understanding of the problem (cC) Slide 42 Level 2: Consolidation Slide 43 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. Slide 44 Level 2: Consolidation Synergizing: familys 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. Slide 45 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 Slide 46 Slide 47 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 familys religious affiliations provide good support system Slide 48 Family Healthcare Plan Family MemberScreening Tests Immunizations/ Chemoprophylaxis Lifestyle ModificationCounseling Needs MP Screen for possible psychiatric morbidities from the trauma Screen for other medical problems as a consequence of the vehicular accident Tetanus toxoid, Influenza shots and other prophylaxis Reduce stress levels, exercise, and refocusing on studies. Debriefing from the traumatic incident that caused her to be admitted and operated on Awareness about her risk-taking behavior and legal violations that brought about the traumatic accident GP Glucose tolerance tests and blood pressure monitoring for possible DM and HPN Influenza shots and other prophylaxis Daily exercise, Refocus on taking care of daughter while still being admitted to the hospital Family counseling relating to feelings about the financial burdens of the medical costs from the accident Slide 49 Family Healthcare Plan Family MemberScreening Tests Immunizations/ Chemoprophylaxis Lifestyle ModificationCounseling Needs JP None indicated None indicated. As needed. Maintain good activity in work, and in keeping up relations with the family members despite the working hours Family counseling relating to feelings about the financial burdens of the medical costs from the accident Exploration of feelings regarding his wifes disagreement with him wanting to work abroad for better pay JP None Pediatric immunizations as indicated Continue focus on studies despite financial constraints None KP NonePediatric immunizations as indicated Continue focus on studies despite financial constraints None Slide 50 The End