Riassunto
Un operaio di 32 anni precipita da un’ impalcatura di 4 m e sbatte al suolo con il fianco destro. La squadra d ’ emergenza valuta il paziente, che appare sveglio ed emodinamicamente stabile, e lo trasporta nel pronto soccorso dell ’ ospedale più vicino per altri accertamenti. Il medico d ’ urgenza che lo accoglie è particolarmente impegnato, perché deve gestire sei pazienti contemporaneamente, mentre altri aspettano ancora di essere visti. Al suo arrivo, la pressione arteriosa e la frequenza cardiaca del paziente sono nei limiti, con un ’ auscultazione del torace normale. Il suo principale disturbo è un dolore localizzato alla parte destra del torace, peggiorato dai movimenti e dall ’ inspirazione profonda. Si esegue una radiografia del torace (RxT) nel dipartimento di radiologia ma il tecnico, abituato a identificare i pazienti soltanto con il cognome, consegna immagini sbagliate. Il paziente ritorna in pronto soccorso con l ’ RxT normale di un ’ altra persona con lo stesso cognome. È accompagnato da un allievo infermiere al quale è stato dato il compito di sorvegliarlo, mentre il resto del personale è impegnato con un ’ altra emergenza. Nella mezz ’ ora successiva, il paziente presenta una dispnea ingravescente e comincia ad agitarsi. Lo studente chiama il medico d ’ urgenza per farlo rivalutare. Il medico controlla la radiografia e, avendo eliminato un problema toracico o polmonare, prescrive boli di morfina per il controllo del dolore. Poco dopo la somministrazione morfina, il paziente diventa soporoso. Il monitoraggio messo poco prima dall ’ infermiere segnala una saturazione dell ’ ossigeno al 79%. S ’ inizia immediatamente la ventilazione con un pallone di Ambu.
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St.Pierre, M., Hofinger, G., Buerschaper, C., Simon, R., Daroui, I. (2013). Organizzazioni e incidenti. In: Gestione delle crisi in medicina d’urgenza e terapia intensiva. Springer, Milano. https://doi.org/10.1007/978-88-470-2799-2_14
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