Sunday, 29 March 2009

Tock (warning, contains scenes of a graphic nature!)

So, when I left you last, I was doing what I definitely don't do best; running! I had picked up my Thomas Pack (25kg) and my patient monitor, and was jogging round a rather obstructive fire appliance to the incident on SmallRoad. I had already been informed that there was one patient, with a severe leg injury. In fact, the actual information was a partial amputation of the foot.

I arrive, only slightly breathless, to see a young girl, already out of the wreck of a car, lying on her left side, screaming in pain. Not a nice sight, but screaming is always better than silence, when you are on the road. She's not all that far from the car. Well, actually, she is lying right next to the car, with a foot that is hanging on by not much, and in a very unanatomical position. Purple isn't a good colour, either.

So, in true ATLS (Advanced Trauma Life Support, the way in which one manages serious trauma) fashion, I ignored the obvious, and went through my ABCD's:

Airway - well, screaming usually means that you haven't got a problem with your airway, so I move on to:

Breathing - again, you need to be able to breathe in to be able to breathe out enough to scream. There is no point in listening to the chest, as there is so much noise around, so on to:

Circulation - a bit of blood on the ground under her head, but no gushing from the foot. No need for my nonexistent tourniquet, then! Phew!! Pulse - 130!! Eeek! Pelvic trauma?? Abdomen?? Let's get a blood pressure while I move on to:

Disability - she's talking, in between screams, even being able to tell me her name, Samantha, and her address. But she is slurring her words, and not terribly coherent. There is a vague smell of alcohol. "Been drinking tonight?" I enquire. "Not much," is her reply. The car accident seems to refute that. She is able to wiggle her toes in the uninjured foot, and is moving her legs, so I am not too worried about a spinal injury, but we would still like to keep things as still as possible - not easy, as she pulls off her cervical collar. Her blood pressure comes back as very high, so I feel that her pulse is due to pain rather than blood loss.

Decision time. She has a severe injury, and is in agony. I have strong painkillers available to me, but they will alter her conscious state. She has drunk a lot of alcohol, despite what she has told me, and so may vomit. Do I intubate her (pass a tube into her windpipe) after giving her anaesthetic agents, or do I give her the pain killers? If I give her the anaesthetic agents and then fail to intubate her, or if she has an as-yet unidentified injury, she may die at the roadside, as a result of my interventions. Also, she is right up close to the car, and on her side; to move her into an easier location will be excruciatingly painful for her. I think about the distance from FarAwayTown to hospital; probably around 20 minutes. Oh, hell, I'm prevaricating, the clock is ticking, and I need action!

I get the painkiller out my pocket, look at it, look at her, and put it away again. "Alright folks, it's a tube and ventilate jobbie." I'll need all hands on deck for this one. Quickly, I draw up the necessary drugs, one to paralyse her so that I will be able to pass the tube easily between her vocal cords into her windpipe, and one to put her to sleep. I gather my equipment, including a long introducer that I keep in the car - bum! another run, back round the fire engine to get it out of my messy boot, and then back to the patient.

I organise the troops. One will need to assist me with the intubation, one will need to be holding the head still, to ensure that the neck is protected, and one will need to press on the front of the neck; to close of the oesophagus to prevent any regurgitation of stomach contents and stop them going into the lungs before I pass the tube. Oh, wait a sec; this one's on her side. I will need to give the drugs and then she will need to be turned on to her back, AND be moved away from the car so that we ll have room to move. And all this needs to happen, and the tube passed, before the patient's oxygen level drops to a dangerous point. Oh well, all in a day's work for the fire and ambulance crews I have around me.

Drugs in, patient rolled, tube passed and secured. Tick! We scoop the patient onto the ambulance trolley and load her in.

Right, monitoring on. Tick! We are almost ready to roll.

One more thing to do before we go. Anyone?? Yep, just the small matter of the foot. We can't wander into a hospital with it looking like that, now can we. So, I look to one of the paramedics. "Want to give that a tug?" I ask. "Me?" I guide her through the very satisfying job of relocating a nasty, open, fracture dislocation of the ankle. Minutes later, the foot is pink, and there are pulses in the foot. Tock! We're off!


  1. This comment has been removed by the author.

  2. Loving your blog... You are who I wish to be when I "grow up" ! :D

  3. thank you, Darkside. I wish I knew who I want to be when I grow up!!!

  4. Paramedics often discuss the liklihood of us eventually being able to do Rapid Sequence Induction for Elective intubation. Its on its way in the North East (with the advanced practitioner degree).
    Personally, I think it would have been of use to me maybe 4 times in the last 8 years (not often enough to keep up to date with it).Its a huge step from tubing someone in cardio-respiratory arrest, to someone who is maitaining their own airway and is achieveing good oxygen saturation. To take that away is a risky business, especially for a paramedic with maybe only one other person their to help them.
    I used to be a theatre and anaesthetics nurse prior to joining the service so I am very familiar with RSI, but it still scares the willies out of me when I think of maybe having to do it at the roadside one day.
    Hopefully by then BASICS will be fully active in the North East and you guys will always be there to bail us out!!!

  5. nicely done! trust the girl is properly grateful that she has a foot left at all!

  6. Nice job, that's what it's all about. Do what needs to be done and GLF to hospital

  7. Medicblog999, without in any way denigrating the work of the paramedics (who, in my case, have saved my bacon hundreds of times out on scene) I do not believe they should be trained to perform RSI. If, as you suggest above, they will be performing this once every two years, they will never be able to retain the necessary skills; nor will they be able to get themselves out of trouble. If I have a "can't ventilate, can't intubate" I will have a chance of getting away with it, but only because I do an RSI about once a month, after having spent 18 months as an anaesthetist and 9 months on HEMS in previous years. I am worried about BASICS docs without the necessary experience doing RSI, and there are some of them around, let me tell you!

  8. Ah the good old Paramedic RSI debate. I agree with you RDD. To be honest the only way (I believe)a Paramedic would be able to perform RSI (effectively) is to a have dual role in theatres and work along 'The Gas man' doing 50% on the street & 50% theatres. Having said that, what's the point when you have experienced BASICs DRs like your good self and those on the various HEMs around the country who do it as part of their everyday work. We don't see the required case load that warrant RSI. Also there are many BASIC DRs that don't/can't RSI due to not being able to get the necessary experience/theatre time, although they are still a valuable member of the team (probably from a GP background & they would be the first to agree I think).

  9. You may be interested to look at our local BASICS team ( Much the same, but pro-active at the weekend, being on standby in a well equipped Volvo V70 T5. Ambulance Control Cat A calls are monitored in the vehicle, and response can be immediate to any point in West Yorkshire.

  10. Interesting debate on Paramedic RSI, we use it over here (New Jersey) and it’s definitely a double edged sword; fear of airway loss vs. definitive airway control with easier pt. management. I appreciate your concerns RRD (love the blog by the way!) and in many ways agree with you – skill degradation with infrequent use of the technique can result in disastrous outcomes. The oft-quoted “San Diego” study on pre-hospital- RSI (can’t find the citation for it now - sorry) was hampered by the fact that >500 medics were taught the technique but relatively few got to perform it at all.
    Here in NJ Paramedics respond only to ALS calls in 2-man cars and (by state law) work for a hospital based system. As a result ALS skill maintenance is relatively high (typically a few tubes and >10 IV’s per week for the average medic) and since RSI was rolled out statewide 3 years ago there have been relatively few complications. The training was extensive and we work under “active medical command”, in other words we have to get permission from a base doctor to perform it (flight crews are exempt this requirement) and have a salvage airway available (LMA, needle cri... Mommy!!) for a “can’t intubate - can’t ventilate” scenario.
    One of the biggest problems we have, and this is just personal opinion, is the younger, more aggressive medics way overuse it (have you seen this with the younger doctors you train? I’ve noticed our “hot-shot” ED residents can’t wait to paralyze and tube) You can train anyone to perform a technique but the real skill is knowing when it's appropriate...thats the challenge.

  11. Very interesting debate and one we have regularly in the crew room. I think I tend to agree with RRD regarding the use of RSI for paramedics, especially in my rural area where we have even less call for it! But who knows whats going to happen with the intoduction of more critical care practitioner pathways??

    I was however interested in everyones opinion on the recent recommendation of JRCALC to prevent para's from intubating? Opinions I have come across range from very grumpy anaethetists (one apparently refused to let recently graduated para's do their in-hospital tubes in their hospital cos they didn't agree they should be doing it!) to very disgruntled para's! I've read their paper and have a few concerns of my own, most of which are summed up in the College of Paramedics statement of reply! Apologies if this has been covered in another post?