Thursday, 19 March 2009

Quick Thinking

Before I start this post proper, may I say a real big thank you to Tom Reynolds, from, for his commenting on my blog - my hits have gone through the roof since. Just shows how influential the great man is...

My work at the roadside, as anyone who has read the last entry or so would know, requires me to do quite a bit of quick thinking and rapid decision-making. Do I intubate, how much fluid does this patient need, and so on. Whenever I am put in such a situation, there is often a lot of soul-searching afterwards. Did I do the right thing? Today, however, I was in totally different situation where I needed to think quickly, and where, if my choice was wrong, lives would be affected. I will put it to you, my readers, to decide.

Today I was attending a Coroner's Inquest. The specifics are not all that important - maybe I will talk about those at another time. Suffice it to say, when I arrived on scene I was presented with a very unwell man, with severe injuries. He was deeply unconscious, and I treated him rapidly, and got him to the hospital alive. Unfortunately, he died a few hours later.

I was asked to look at the time it took for me to be called by the Ambulance Service and the time it took me to get to the scene. The Coroner then asked me the $1000,000 question: "If you had arrived on scene earlier; if the Ambulance Service or Police had activated you sooner, would he have survived?" I felt I was on safe ground at that stage, and said that, as I was unaware of the post mortem results, I could not answer that question. I was handed the PM report.

As I scanned the report, looking closely at the injuries to various systems; the brain, the heart, the lungs, the spine; I came to an awful conclusion. These were survivable injuries. He had not suffered a massive brain injury. His lungs and heart showed little more than bruising. Sure, he hadn't escaped with minor injuries. But they were survivable.

What to do? I was being asked a question that, in my heart, I knew the answer to. For those who may not know, the Inquest is an open Court, and the family were sitting there, right in front of me. I have sworn, on a Bible, to tell the truth, the whole truth, and nothing but the truth. But, do the family need to know that their son, their brother, could have been alive today, had the speed of response been better?

So, there I am, with seconds to spare, and a decision to make.

My answer: "Yes, if I had been able to get there much earlier, he might have survived." What was initially scheduled as a 15 minute appearence to give a precis of my actions at the scene turned in to a gruelling hour of questionning. How much earlier would I have needed to get there to save his life. 5 minutes? 10 minutes? Would he have survived if you had arrived when he was still conscious and talking? Why didn't the police call you? Should they have that knowledge to be able to determine that he needed more help than a paramedic crew? Could I have driven faster? And so on, and so on. Balance of probabilities, explanation of Revised Trauma Scores (more about them in another post, maybe) and Glasgow Coma Scores (definitely more about them!). I was relieved when the Coroner thanked me for the evidence I had given, and I was allowed to leave the witness stand.

The Court was adjourned after my evidence, but, before he left, the Coroner looked at the family and apologised for the way in which that evidence had been presented to them, how distressing it must have been for them, as he was himself surprised with the answers I had given.

And so I left the Courtroom, hurrying to my car, head down, trying not to catch anyone's eye. As I was getting into my car I felt a tap on my shoulder. I turned, with sinking heart, and found myself face to face with one of the family. He looked at me, with tears in his eyes. "Thank you," he said.


  1. I came here because of Tom Reynolds, but I'm staying because of you. Blogs like these are what makes the Internet the democratic and educational force it is. So; Thank you! And take care, I hope you can keep it up without burning out.

  2. Thank you very much for your comment, Nils. I started this blob because of Mr Reynolds, so it all fits together!

    I'll try not to burn out.

  3. What a tough situation. You definitely did the right thing by telling the truth. You never know by admitting that if you had been called earlier the patient would have survived could end up helping save many other people's lives in the future.

  4. telling the truth during an inquest is the best policy. while it was painful to hear, the family, just by attending an inquest, would expect to hear details they might have preferred not to. as to how much earlier would have ensured survival--that seems to be an unanserable question. educated estimates can be provided, but to be definate? if natasha richardson had gone directly to hospital,would she have survived? not possible to know as there are too many variables in play.

  5. Peteoskystone is, of course, completely correct in his comment, when he says that there are too many variables to make any definitive comments. However, I was asked specifically, on the balance of probabilities, would the patient have survived if I had arrived while he was still conscious and talking. The balance of probabilities was explained to me as being more or less likely than 50% to have survived. With survivable injuries I had to err on the side of survival.

    In answer to Lily's comment, I went to an inquest about 6 years ago, when I had just started as a BASICS doctor. I wasn't called for an hour and a half, and the chap died just as I turned up. Again, very definitely survivable injuries. I said exactly the same in that Court as I did yesterday, but with even more authority - 90 minutes is a long time in trauma - and yet there has been no change in the Government's attitude to pre-hospital care.

    Thank you for all your comments and continued interest in my blog

  6. Hi Rapid Response Doc,

    I have a couple of points to make and a couple of questions. I am not doubting anything to do with the case, but purely looking at it from a paramedic in a service without BASIC docs and from a position of having to do without the intervention of Docs on scene.
    1) Why were you called to the scene? was the patient trapped or was it purely on potential injuries and MOI?
    2) Did the patient in effect, wait on scene for your arrival and specialist skills before moving off to hospital?
    3) The good old argument of stay and play or load and go. Would it have been more beneficial for the crew to just load the patient and get going to the A&E department for the patients "definitive care" and ultimately, potentially life saving surgery?

    Its a horrendous thing to have to state the facts that you did, but I find it impossible for you to be able state facts about the potential survivability based on the time of your arrival.
    Not knowing much about BASICs, I may be completely wrong but I would have thought that there is only so much you can do on scene or in the back of the ambulance other than stabilising the patients condition and preventing deterioration.

    I hope this comment hasn't come out wrong, as it isn't meant to question the impact of a BASIC doc on scene.

  7. Hi medicblog999, and thanks for joining the conversation.

    In answer to your initial comments, I was at scene about 15 minutes after the ambulance arrived, and so they had assessed and loaded by the time I had arrived. There was no question that they were waiting for me to arrive. I agree that there is a great worry about the time spent waiting for a doctor to arrive, when the patient could have been in the hospital by the time one gets on scene.

    As far as stay and play goes, I am never one to advocate such a technique. We left scene 15 minutes after I arrived, with a tubed and ventilated patient, with bilateral thoracostomies. (I am beginning to sound very defensive, and I don't mean to be, just presenting the facts)

    As far as whether or not I can definitively say that a patient would have survived or not, based on time to definitive ABC care (secured airway and open thoracostomies), I clearly cannot give specifics of this case, because of confidentiality, but let's say that I see a patient on scene with a fractured femur and a flail segment (for those non-medics, this is a section of chest wall that has multiple fractured ribs, and doesn't move in the right direction during breathing.) If I get there when he is conscious and breathing, and I determine that he has the beginnings of a tension pneumothorax (collapsed lung, with increased pressure in the chest outside the lung, collapsing the lung and the heart as well - not a good thing), he is likely to, and is expected to, survive these injuries. If I arrive when he has a Glasgow Coma Score of 5, he is unlikely to survive the same injuries, even if the paramedics on scene have determined that he had a tension, and had given the best treatment they can.

    In terms of what a BASICS doctor can provide on scene (sorry to the non-medics) there is RSI, open thoracostomy, central venous access, ketamine sedation and thoracotomy. All of the above are no less (and often a lot more) than what is provided when a patient arrives at an A&E department, and with a lot less faffing around.

    Once again, thank you for your comment, and I hope I didn't get too defensive...

  8. RapidResponseDoc,
    Thank you for the extra information and it certainly paints a more rounded picture of what actually occurrd on scene. I was thinking of asking what interventions you performed on scene but then there is that wonderful fine line of blogging where you want to tell the whole story but you know you have to leave (or change) some pertinent facts to ensure patient anonimity.
    I hope you didn't feel I was being accusatory,on the contrary, I would love to have the assistance of a good doc at my side on a variety of cases that I have attended and no doubt the outcome may well have been different for them if BASICs was active in the north east.
    Knowing the interventions you performed makes it much clearer to see how those vital minutes may have helped and changed the outcome. It seems a weird thing for the coroner to focus on though??
    You never know though, It may help the drive to get more BASIC doctors out and about for when you are needed!
    Thanks for the reply!

  9. Doc,
    Not sure how I came across your blog, possibly by means of Random Reality, but actually think it was more by chance. However, I'm staying! It's good to read that there are doctors out there who have an understanding of the Ambulance world as well. All too often we seem to be at loggerheads rather than working together. I have used BASICS doctors on several occasions, and have always found that we work well as a team, and I hope it continues. This post, along with the others shows the human side to our job and that we're not all just unfeeling robots. I'll be keeping a close eye on your writings...