Tuesday, 21 July 2009

Fall From Height

He lies there, at my feet: a broken man. He had jumped from the car park on top of the local shopping centre. I look up at the dizzying height of the roof above. How many times had I looked over the edge of Level 6 of the car park? I imagine the fall, can see his flight to death. The rain now falls on to his back, his head twisted at an angle incompatible with life, eyes sightlessly looking up at where he has jumped from.

For he is dead, of that I have no doubt. But, there are formalities to complete, before I can stand up, stretch out my back from kneeling awkwardly at his head, and say the words that will signify the end of this poor man's life: "Ok folks, I'm calling this one at... 16:43."

I gently roll him on to his back, and proceed to pass a tube in to his windpipe - the view is initially obscured by blood, and I use the suction to clear my way. Tube in place, I then make two cuts, one on each side of his chest, and push my finger through muscle and fascia, then between the ribs, into the chest cavity, in order to decompress any tension caused by a collapsed lung. That done, and still with no response, I stand, stretch out my back, and call it.


  1. Welcome back RRD! Ive been wondering where you have gotten to?
    Can I ask why you have to tube and decompress the chest when his head and neck are at an "angle incompatible with life"
    One of our indications for not actively resuscitating a patient is injuries that are incompatible with life. Is it not the same for you, or do you have to exhaust all of your advanced interventions first?

    As I said at the beginning, good to have you back!

  2. As a layperson I was going to ask why you did a procedure when you were so sure he was dead. I wasn't sure if it was a stupid question so i'm very glad to see Mr999 asked it first!

  3. Hi, sorry I've been absent for so long. My "Day Job" has been all consuming ovwer the past month.

    As regards the care this man received, I make it a point to ensure a patent airway and a decompressed chest in all but the most devastating injuries. It takes moments, and excludes the remedial causes of traumatic cardiac arrest (I often pour in a couple of litres of fluid, too, to exclude exsanguinating haemmorrhage as well.) I have been doing this a long time, and there are patients who are breathing, yet I know that survival is impossible. But knowing is still not enough. What I was trying to get across in this post is the need to have a procedure, a set of tasks that is done, every time, without fail, so that it becomes automatic. So that it works in every circumstance. I have NEVER seen anyone in traumatic cardiac arrest survive, yet I always tube and decompress. It's what I do, and what I teach.

  4. RRD... I've got a follow-up question to MedicBlog999 - likewise, I was trying to figure out the "why" of your aggressive measures prior to determining death. In my case, though, once I start resuscitating, I've opened a can of worms, and it takes more effort to get permission to stop than to not start in the first place, if certain criteria are met. That said - I think your thought process makes a lot of sense.

    I'm trying to figure out HOW you are decompressing... it sounds almost like you are going through the motions of a chest tube, without a chest tube?

    Here in the US, paramedics decompress using needle thoracostomy... I guess what I'm trying to say is "why you wouldn't just do a needle decompression?"


  5. Thank you Jon. I personally do not believe in needle decompression. Just look at the size of the hole in the needle, compared with the potential hole in the pleura to make a tension pneumothorax (at least 1/3 of the diametre of the trachea.) Then think about the gubbins that is likely to get into the needle, and how easily it may become blocked. I have on many occasions performed a surgical decompression on a patient with a needle in place, and received a very satisfying hiss. So, I now do a surgical decompression, as you say, the motions of a chest tube without a tube. It takes me around 30 seconds from skin to pleura, so I don't have any worries about the time.