5 minutes from home my bluetooth phone rings. Assuming it's MrsRRD, checking on my arrival ETA, I answer with a "Hi, Darling!!" After all, who else would be ringing me?
Control are quite surprised at my friendliness, but it doesn't stop them from tasking me, to a pedestrian hit by a car, in MilesFromAnywhere Town. They tell me that the crew are having difficulty with the airway. I sheepishly begin to explain my forwardness, then give up and hit the blues and twos, and set off.
I find myself on the M25. What on Earth am I doing here?? Fortunately, my faithful Sasha (the SatNav - don't you have a name for yours??) is just avoiding all the traffic on the small roads around MilesFromAnywhere Town, and I am grateful for the decision when I come off at the next junction, and see the tailbacks behind me, presumably from the accident I am now racing towards. My bladder gently reminds me of the last decision I made before leaving work, and I shift uncomfortably in my seat.
I arrive on scene: well, the point at which Sasha tells me I am on scene. Nothing. Just queues of traffic. I keep going, thinking that, if the patient has an airway problem, I cannot waste any time. Fortunately, round the corner is a police roadblock, and I am swiftly directed around the police van to the waiting team of ambulance crews.
This girl is in a bad way. She is lying on her back, blood around her mouth, a paramedic bagging her. I rush over and assess the situation:
Airway: well, at this moment in time she doesn't seem to have one. There is very little of the precious oxygen getting into her lungs, despite the efforts of the crew.
Breathing - wait a minute, you all know the drill now. If there is a problem with airway, it needs sorting, and straight away.
I unzip my trusty Thomas Pack and reach for my intubation pouch, grab a laryngoscope and prepare to have a look. I can't see much, as there is so much blood in the mouth. I use the suction proffered me, without me even asking (good crew, know what I need before I do) and clear the view. She coughs and gags as I do, and I breathe a small sigh of relief - at least there are still some signs of life. I have a good view of the cords, and a tube in my hands. Despite the fact that I have given her no drugs at all at this stage, I decide that she has been starved of oxygen long enough, and I am not going to delay any further. The tube goes through the cords, and she coughs and gags plenty more. That's not good for raised intracranial pressure, what you get when you have a serious head injury, but, then again, nor is not being able to breathe.
I quickly grab some sedation and paralysing agent and do what I would normally have done prior to intubating the patient. She is now still, and we are able to ventilate her with ease.
Phew!! On to the next stage.
Breathing: Well, at least we are now doing that for her. I think about my next decision - do I perform bilateral thoracostomies? For those who don't know what I am talking about, a brief synopsis. Those who do can skip to the next paragraph. When there is chest trauma, the lining around the lung can be punctured, allowing the entry of air from the lung into the space between lung and ribcage - a pneumothorax. If someone is pumping air into your lungs, as I am now doing with this lady, the air is also pumped out of the hole in the lung and its lining, and fill up the space between the chest wall and the lung, compressing first that lung, then the heart and other lung, leading to fairly rapid death - a tension pneumothorax. By making a small (well I think it's small, you might disagree) hole in the chest wall with a scalpel, I can equalise the pressure, and stop the heart and lungs being compressed into inactivity.
So, back to the story. I have to decide about how this girl's breathing will be best managed. She has a tube in place, and we are breathing for her. Her chest rises symetrically on both sides, and she has normal breath sounds. However, she did have a lot of blood in her airway, and her oxygen saturations are in the low 80's, instead of the 100% I would expect / like to see. I have a careful feel - I cannot see any signs of chest injury, and there doesn't appear to be any broken ribs or surgical emphysema. Surgical emphysema is the result of having air in the tissues of the chest wall, and feels like cornflakes under the skin (honest). This would be a certain indication that she had a lung injury requiring a thoracostomy. But, no corn flakes can be felt. Also, her blood pressure is good, and, if she had a tension pneumothorax, her heart would be compressed so much that her blood pressure would be very low indeed. And it's not.
So, decision made: I will not cut this girl's chest, and watch carefully for any signs of deterioration. If she does deteriorate, I will make the incisions.
Next, circulation. Well, her blood pressure is high, and her pulse rate is high. A high pulse rate can be due to blood loss, or lack of oxygen. But, then again, the high pulse rate and high blood pressure could equally be due to having a tube stuck down your throat without an anaesthetic. I decide to give her more sedation, and the pulse rate and blood pressure stabilise to normal.
And now I have the big decision - where are we going. I look around me. We are really in the middle of nowhere. She definitely needs a Major Trauma Centre, but how far is that? Blank looks from the crews and the police when I ask them driving time to MTC. One of the police runs off to plug the address into his version of Sasha, and returns a few minures later with the news: we are an hour away. On blue lights you might knock off 10 minutes or so. 50 minutes does not sit comfortably with me, especially with oxygen saturations like she has.
What about helicopter? There is one available. I ask them to lift, while we look at getting her packaged and in the ambulance. I ask for an update of how long the flying time to us will be, and the answer comes back: 30 minutes. Where the hell am I, that it will take half an hour to get here by helicopter?? Turns out that the only helicopter available is in Cambridge. Fair enough. I leave them running while I consider my options.
Closest hospital by road, my old stomping ground: 15 minutes
My own hospital by road : 15 - 20 minutes
Major Trauma Centre: by road: 50 - 60 minutes
Major Trauma Centre by air: 30 minutes for helicopter to arrive, 10 - 15 minutes to hand over and load, 20 - 25 minutes to fly back (they will go back to Cambridge)
I make my decision: we are going to my hospital, with the knowledge that we can stabilise and continue our journey to the Major Trauma, probably within an hour or so of arriving there.
I get into the ambulance, my full bladder reminding me that my first choice of the evening wasn't so hot. I hope and pray that the rest of them turn out to be better ones.
So, back to the story. I have to decide about how this girl's breathing will be best managed. She has a tube in place, and we are breathing for her. Her chest rises symetrically on both sides, and she has normal breath sounds. However, she did have a lot of blood in her airway, and her oxygen saturations are in the low 80's, instead of the 100% I would expect / like to see. I have a careful feel - I cannot see any signs of chest injury, and there doesn't appear to be any broken ribs or surgical emphysema. Surgical emphysema is the result of having air in the tissues of the chest wall, and feels like cornflakes under the skin (honest). This would be a certain indication that she had a lung injury requiring a thoracostomy. But, no corn flakes can be felt. Also, her blood pressure is good, and, if she had a tension pneumothorax, her heart would be compressed so much that her blood pressure would be very low indeed. And it's not.
So, decision made: I will not cut this girl's chest, and watch carefully for any signs of deterioration. If she does deteriorate, I will make the incisions.
Next, circulation. Well, her blood pressure is high, and her pulse rate is high. A high pulse rate can be due to blood loss, or lack of oxygen. But, then again, the high pulse rate and high blood pressure could equally be due to having a tube stuck down your throat without an anaesthetic. I decide to give her more sedation, and the pulse rate and blood pressure stabilise to normal.
And now I have the big decision - where are we going. I look around me. We are really in the middle of nowhere. She definitely needs a Major Trauma Centre, but how far is that? Blank looks from the crews and the police when I ask them driving time to MTC. One of the police runs off to plug the address into his version of Sasha, and returns a few minures later with the news: we are an hour away. On blue lights you might knock off 10 minutes or so. 50 minutes does not sit comfortably with me, especially with oxygen saturations like she has.
What about helicopter? There is one available. I ask them to lift, while we look at getting her packaged and in the ambulance. I ask for an update of how long the flying time to us will be, and the answer comes back: 30 minutes. Where the hell am I, that it will take half an hour to get here by helicopter?? Turns out that the only helicopter available is in Cambridge. Fair enough. I leave them running while I consider my options.
Closest hospital by road, my old stomping ground: 15 minutes
My own hospital by road : 15 - 20 minutes
Major Trauma Centre: by road: 50 - 60 minutes
Major Trauma Centre by air: 30 minutes for helicopter to arrive, 10 - 15 minutes to hand over and load, 20 - 25 minutes to fly back (they will go back to Cambridge)
I make my decision: we are going to my hospital, with the knowledge that we can stabilise and continue our journey to the Major Trauma, probably within an hour or so of arriving there.
I get into the ambulance, my full bladder reminding me that my first choice of the evening wasn't so hot. I hope and pray that the rest of them turn out to be better ones.
Interesting case. One of the things that draws me to pre-hospital care is the decision-making processes that you outline in your post, which are often difficult and sometimes involve choosing the 'best of a bad bunch'.
ReplyDeleteI'm interested by your choice to intubate without drugs. I suspect from what you describe the patient had upper airway/facial/head injuries, and you were able to get a good view with your laryngoscope despite these. Withdrawing your laryngoscope, giving an induction agent + relaxant would have taken a minute or so, but from what you describe you may have had an obstructed airway during that time. I'm interested for my own learning really - would you do the same again, with the knowledge that the patient will become hypertensive (and thus raise their ICP)?
Keep up the good work - I always enjoy reading your posts.
Hi, Scott. It's a good few months since this case, but my recollection is that we didn't have any intravenous access when I first arrived on scene. Also, unlike the HEMS crew, who go out with already drawn up drugs in syringes, I have to break open each ampoule, draw up the drug, dilute it as appropriate, all before being able to start the rapid sequence induction that would precede an intubation.
ReplyDeleteAs you say, part of the particular challenge of pre-hospital care, and one which my post served to illustrate, is that of the need for an immediate decision. Standing there, being unable to choose what to do is no use whatsoever. Sure, there are occasions when time is on your side, but not when there is an obstructed airway.
Were my choices right that day? I can't really answer that. She stayed on ITU for a couple of months, before finally succumbing to multiple organ failure.
RRD thanks for your reply.
ReplyDeleteI pondered this case yesterday after my post and, although I cannot put myself in your shoes at that particular moment in time, I think I would go down a similar route when presented with that situation, given all the details you've noted. I'm aware that you don't have pre-draws (although forgot this yesterday), and equally I'm aware that you're on your own rather than with a HEMS paramedic with whom you train regularly and is used to RSI etc, thus slowing the process.
As you say, this wasn't a time for indecision, and without doubt your rapid action did ensure that the patient survived the time she did. The difficulty with pre-hospital care is that very few cases are ever alike, and although we can ask ourselves the question 'would I do anything differently next time' it's often the case that we will never have that 'next time' as it will be different in some subtle (but critical) way.
I have learned a great deal from hearing the discussion of cases at clinical governance days / M&Ms. Your decision-making in pre-hospital care is rather different from in-hospital and it's not so easily taught (although certain protocols help) - thanks for continuing to share your experiences, they are insightful and often poignant and I'm sure they educate a large number of people (myself included).
I am surprised that you would publish such questionable clinical management in an open forum.
ReplyDeletePresumably as the patient had not died prior to your arrival, she was still breathing despite having a soiled airway?
Therefore you had time to draw drugs and perform a safe anaesthetic. It is both inhumane and unsafe to intubate a patient without drugs except in arrest/periarrest situations, which from your description she was not. Yes she had a soiled airway, but the fact that she coughed on insertion of the laryngoscope/suction should have been a clue. The very fact that you did not have your drugs for intubation
meant that you therefore did not have your emergency or post intubation drugs prepared/accessible. What if she had gone into laryngospasm or bradycardia etc?
Yes airway is a priority, but there is almost always time for a rapid primary survey prior to intubation, did you even know the patient's GCS prior to inserting a laryngoscope?
In the head injured patient, a high quality yet CVS stable anaesthetic will provide safe intubating conditions with minimal surge in ICP. Which you also negated to consider until after the event.
Your decision making regarding hospital disposal is also highly questionable. Given her presentation a significant head injury is very likely and therefore protocol states direct transfer to a major trauma centre. Transferring her to a DGH (though might make you feel better in the short term) will only delay her reaching definitive care. This is unacceptable if she had a time-critical expanding intra-cranial haemorrhage.
I will not list them all but there are so many aspects of this case and others that you have written about that fill me with deep concern (and I am writing as a full time pre-hospital care doctor albeit overseas). Not only your management, but the casual style in which you write about your misdemeanours is worrying.
I am fully aware of the easy position that one has to read and criticise in retrospect. But there are certain things that just simply are unsafe
and unacceptable - I am surprised that you write about them with such fervour. What you describe I'm sure impresses your readership but represents low quality pre-hospital care.
Hi Boris, and welcome to my blog. I was surprised to see your response to this post, both because of the comments themselves, and the length of time since I wrote this: 3 and a half years ago!
DeleteYour comments would all be justified, except for one fact - I was there and you weren't! I make my decisions based on the available information. I don't provide all the information in the posts - both because that wouldn't make great reading, and because of patient confidentiality.
The purpose of this blog, when I wrote it, was two-fold. One was to find an outlet for a stressful, often painful, part of my work. By writing here, by creating a story, I was able to cope with the pressures of dealing with death and despair.
Secondly, I wanted to raise the public awareness of pre-hospital medicine and the work of volunteers such as myself. I've done that, and ensured that BASICS doctors around the country are recognised for what they do, unpaid and unknown. I have done that, and am proud of that.
You mentioned all manner of potential risks to my actions. I can assure you that I had considered them all, and in the reality of the situation, I was prepared for them all. Please remember, these are stories, meant to provoke interest and discussion, based on real cases, but not accurate, factual accounts.
Thank you for giving me a reason to come back here - it's a place dear to my heart.
Dear RRD,
DeleteThank you for taking the time to read and respond to my post; I am sure you are pleased that your blog is still sparking debate!
Firstly I should say that I can fully sympathise with your need for a coping strategy / outlet for dealing with the stress of your work.
I am glad you found my clinical concerns to “all be justified”, though I am surprised by your explanation - it seems I have misunderstood the intention and scope of your blog. However, this in turn leads me to new concern. If as you state, your practice was indeed better than that written and the account was incomplete, this has a couple of significant implications.
Firstly, while I understand that this is not intended as an educational blog, your readership clearly hold you in high regard and perhaps hang on your every word! Some people may be misguided by your descriptions.
Secondly, having spent time with BASICs myself, I appreciate your endeavours to increase awareness of the charity. But I can’t help but worry that without a clear disclaimer (to the effect of your recent reply), these sorts of accounts do more harm than good and only serve to add to certain people’s view that BASICS are “have-a-go heros” providing non-evidence based / cavalier care. (This is clearly not a view I subscribe to) but you can see how it is possible that if I have misinterpreted your blog, many others could do too.
I hope you can see my point of view (as I have yours); it seems you have had the best intentions but not perhaps the desired effect?