Trauma/Acute Care Surgery

M&M Presentation Form

Patient Name: Niam Ziad

Mechanism: GSW to face
Arrival Mode: EMS

MRN: 45955430
Trauma Code: Level 1
Admit Date: 06/26/2015

Reason for Presentation: Death

Brief Clinical Summary: Patient was a 42 year old gentleman who presented as a Level 1
by EMS s/p GSW to face. He arrived as GCS3 with BVM, and was intubated on arrival. He
presented with severe trauma to face and hypotension. In the bay he was packed with combat
gauze and rhino rockets for his nasal and oral injuries and received 1/1. Secondary survery
revealed facial fractures including b/l nasal bone and septum as well as severe damage to the
hard palate and maxilla, IVH, SAH, hydrocephalus, bullet fragments in the optic nerve, C1, the
esophagus and aspirated fragments in the lung. He received an EVD in the ED per neurosurgery
which had an opening ICP of 35 and was taken to the IR suite where he underwent embolization
of the R ICA sphenopalatine. Throughout the procedure he continued to bleed from his facial
wounds and EVD. He was taken for a CTA which then revealed a R internal maxiallary
pseudoaneurysm. He was then transferred to the STICU where he continued to hemorrhage from
his facial wounds and EVD and continued to have unstable vital signs. In the STICU, packing was
removed with the plan of identifying and ligating the bleeding vessel but it appears no absolute
source of bleeding could be visualized and the patient was once again packed with combat
gauze. The patient received a second massive transfusion protocol in the STICU. His ICP had
risen to the 60s and various interventions were attempted to lower ICP and maintain CPP
incluyding multiple salt bombs, morphine drip, propofol drip and norepinephrine drip. On the night
of the 26th discussions began with the family, NSGY, ENT, and trauma service abdout goals of
care. The films as well as lack of improvement convinced the team that the situation was futile. A
DNR was signed and non-escalation of care with comfort care measures was ordered. LifeGift
was informed of the situation and reached out to the family about possibly donating. On the 28 th a
cerebral blood flow study was performed consistent with brain death. With his clinical exam the
family was informed the patient had passed away and they made the decision to donate.

Journal reference: Blunt Cerebrovascular Injury Practice Management Guidelines: The

Eastern Association for the Surgery of Trauma

William J. Bromberg, MD, Bryan C. Collier, DO, Larry N. Diebel, MD, Kevin M.
Dwyer, MD, Michelle R. Holevar, MD, David G. Jacobs, MD, Stanley J. Kurek, DO,
Martin A. Schreiber, MD, Mark L. Shapiro, MD, and Todd R. Vogel, MD

This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee
Privilege contained in the TEXAS HEALTH AND SAFETY CODE 161.031 & 161.032, or Medical Peer Review under the
Medical Practice Act, TEXAS OCCUPATIONS CODE, 151.001 et. seq.; and the Medical Peer Review privilege provided by
federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
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Trauma/ Acute Care Surgery M&M Attending Review Form

Memorial Hermann Hospital - Texas Medical Center
Patient Name: Niam, Ziad

MRN: 45955430

Responsible Attending Name: Dr. Chong

Responsible Resident Name: Louis

Carrillo MD
Reason for Review: Death

Mortality Classification:
Clinical Cause of Death
Hemorrhage
Cardiac
N/A- not a death
Head
injury
Iatrogenic
Mortality without opportunity for improvement
MOF/Sepsis
Respiratory Failure
Anticipated mortality with opportunity for improvement
PE
Other
Opportunity: ____________________________________ _____________________________________
Unanticipated mortality with opportunity for
Withdrawal of care
DNR at time of death
improvement Opporutunity: ________________________
_______________________________________________
SSI:
NA not a SSI
Onset Date_______ Infection site:___________________________________
TYPE:
Superficial incisional
Deep incisional
Deep organ
If yes to infection, indicate how diagnosed, check all that apply:
Culture
Drainage
Edema
Redness
SCIP guidelines followed Y N
Contributing Factors: Recommended Action: Physician Peer Review Grade
Delay in diagnosis

Counseling

The medical care and treatment provided by the physician

(s) met the applicable standard of care consistent with
recognized best practices and evidence from the medical
literature.

Delay in intervention

Credentialing Action

Error in diagnosis

Education

Error in technique

Guideline/Protocol

Patient refusal

Refer to Trauma PI

Error in judgment

Refer to MSQR

Nature of disease/injury

Refer to:____________

Pre-existing disease

Track/Trend

Yes
Yes, but there was opportunity for improvement
(See Reviewers Comments)
No

Other ______________
______________________

Adverse Outcomes:
A- None
B- Minor
C- Major

System Issue(s):

FPPE
None

This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee
Privilege contained in the TEXAS HEALTH AND SAFETY CODE 161.031 & 161.032, or Medical Peer Review under the
Medical Practice Act, TEXAS OCCUPATIONS CODE, 151.001 et. seq.; and the Medical Peer Review privilege provided by
federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
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Trauma/ Acute Care Surgery M&M Attending Review Form

Memorial Hermann Hospital - Texas Medical Center
Comments:

Recommendations for next time:

Reviewers Signature: ______________________________ Date Reviewed:_______________

Definition - The Applicable Standard of Care

The applicable standard of care means doing what a reasonably prudent physician with equivalent
background and privileges would have done under the same or similar circumstances, taking the
current applicable evidence-based principles into consideration in determining and providing
evaluation and treatment of the patient.

This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee
Privilege contained in the TEXAS HEALTH AND SAFETY CODE 161.031 & 161.032, or Medical Peer Review under the
Medical Practice Act, TEXAS OCCUPATIONS CODE, 151.001 et. seq.; and the Medical Peer Review privilege provided by
federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
C: Trauma.case.revew.new1.doc
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