Clinical Case(s) 033: Disaster strikes

[This week, a special treat.  I am handing over the reins to Dr Tim L. from KI-Docs who will  be moderating a discussion on the scenario below.  Tim is a rural GP with an interest in trauma, bush-tucker, and anything to do with making training and service of bush docs better.  So let Tim know your comments and he will entertain you I am sure.  Over to you Tim…..]

As part of their oncall responsibilities, it’s not uncommon for rural doctors to be asked to attend motor vehicle crashes (like the BMJ, I won’t call them accidents). Such responses by local doctors are usually in addition to State ambulance or retrieval responses, and may not be formalised (unlike the UK’s BASICs). Dr Tim from Kangaroo Island teaches on EMST and has a particular interest in trauma (especially wildlife-vehicle collisions. Check out his roadkill recipes!). Here’s a case from sunny Kangaroo Island…

So, imagine the scene. You are halfway through a morning clinic when your receptionist puts a call directly through to your consulting rooms “It’s the Hospital. They’ve had a call from the ambulance service and ask if you can attend a car crash 25km outside of town”. Apologising to your patient, you head out the door, telling the receptionist that you’ll be back ASAP but in the meanwhile to cancel appointments until further notice.

(i) What information do you want to know before you head off, and what equipment do you need?

(ii) What systems are in place locally for rural doctors to respond? Who looks after hospital patients if the oncall doctor is busy ‘in the field’?

On arrival, you are confronted by a horrific scene. Two cars and a motorcycle have collided and are being attended by ambulance services (one ambulance, two volunteer paramedics). The community fire service (also trained volunteers) are on scene. One policeman is marshalling traffic and there is a small crowd of bystanders.

(iii) What are your immediate priorities?

There are six victims, details as below (assume all have possible spinal injuries):

1.  23 yo male motorcyclist.  Laying in road attended by police officer.

Injuries: head injured (helmet shattered) with open compound fractures both femurs and degloved L hand.

Obs : RR 4 HR 140 radial pulses absent but carotid palpable, GCS 3

 2.  20 yo female pillion passenger.  Laying on the verge attended by another motorist.

Injuries: Helmet intact. Clinically R flail chest, L ankle fracture-dislocation with neurovascular compromise

Obs: RR 24 HR 140 palpable radial pulse, GCS 12

3.  59 yo male driver of delivery van (he is your local newspaper agent). He is trapped in his van which is on it’s R side. Attended by fire officers who are trying to gain access.

Injuries: Tender belly, femurs driven backward into pelvis by engine block. Trapped by lower limbs.

Obs : RR 32 HR 140 Radial pulse palpable (just), GCS 11

 4.  35 yo female driver of family sedan (she is a local hairdresser). Slumped by side of the wreck, attended by two bystanders.

Injuries: Suspected head injury and clinically L tension pneumothorax

Obs : RR 34 HR 130 Radial pulses palpable, GCS 9

 5.  40 yo male passenger (he is a farmer whom you know socially). Laying on road, attended by one of the volunteer paramedics who are applying pressure to arterial bleed.

Injuries: partial amputation left lower leg and likely bilateral pneumothoraces

Obs: RR45 HR 110 palpable radial pulses, GCS 13

 6.  8 yo female rear seat passenger (she attends swim classes with your daughter and you recently attended her birthday party). Attended by the other volunteer paramedic – who is her aunt.

Injuries: Extensive scalp lacerations with boggy depressed skull fracture over occiput. Muffled heart sounds.

Obs: RR 4 HR 150 carotid pulse just palpable, GCS 5 (flexion to pain ie: decorticate)

 

(iv) Retrieval service are already in the air and will be with you in 38 minutes, with a single rotary-wing carrying doctor and retrieval nurse. Neither of the volunteer paramedics can insert an IV. You have the contents of your prehospital pack and the ambulance. Another ambulance is en route and expected in 20 minutes. The hospital is 15 minutes away but has limited capabilities (two units packed cells and…er…that’s it. Theatre staff are on remote call and take 30 minutes usually. There is no surgeon.) Did I mention you are on an Island?

What useful interventions can you make and for whom? How do you decide?

There is a compelling story at Australian Doctor about a similar incident in NSW a few years back.  Check it out, this could be your town.

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