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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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
1) when did this occur? How many victims? Any deaths? How far out of town? Is the scene safe? what is my retreival pack? do I have IO? If another doctor available in town have them set up a receiving centre as rotary wing retreival service at max can evac two patients and we will likely have 4 coming to the hospital. If no extra doctor get the most senior nurse to set this up. I would bring along one (if available) one of the more senior nurses who can do IV lines etc and generally help out.
2) In some places I worked we had duel hospital coverage so being called out was not a big disaster but still need to get help. If this happened where I used to work I would call the nearest hospital 75klms away and get a few doctors via police to scene for assistance.
First thing is probably wish you had an extra day off. This is worse nightmare stuff. Minimal resources middle of no where. First question do we have a walking blood donor bank? If we do activate it. Do we have blood transfusion bags? If not grab normal saline litre bags give our donors 500ml then have them donate 500ml of blood.
Can we get more help? Nurses/doctors/paramedics/med students if yes call them get them ready. Activate everyone in town!
In this scenario you would be trying for the greatest number of lives saved. But you would need to make tough decisions.
For all patients make shift spinal precautions may be required
Sheets/blakents/cardboard/papers or if we have them C-spine collars
Is the scene safe??? Once the scene is established to be safe I would then go through the following.
Patient 1) Palliate
Severe head injury likely continuous vegetative state
2xfemur fractures at least 2 litres blood lost on the road likely more
Injuries not survible in this context with your resources and lets face it he had this accident outside a trauma centre in the city he likely would not survive
Patient 2:)
Likely GCS 15 ?
Splint chest
Ketamine patient if available quick reduction fix with cardboard splints or just cardboard boxes
If no ability with having sedation/analgesia just reduce fracture!
Patient 3)
Entrapment – Could bleed out before getting out of vehicle
Continue on to other patients
Possible head injury
Likely liver/spleen injuries
Bilateral femur fractures
Patient 4:) Decompress tension with large gauge needle
Quick finger thoracostomy followed by either using IDC in chest or ETT as quick chest tubes
Patient 5) Torniquet (defence force style or Blood pressure cuff)
Quick placement of IDC in chest or ETT
Patient 6)
Head injury
With possible cardiac temponade
Likely non survivable but young so could
However attempt cardiocentesis
Attempt control of bleeding from head lacerations
But given the resources the extent of injuries and location likely to have very poor outcome. Consider analgesia ketamine good agent to use.
I would constantly reassess these patients if any changes adjust priorities.
Ok, I’ll bite…
1) Estimated number of victims and severity. What rescue services are on site, is there any backup expected. What is available for patient evacuation (ambulance, rotor, fixed wing)? How far is the nearest hospital? Is there an adequatly staffed emergency room, a OR with a surgeon, a blood bank? Regarding equipments: IV and IO access, some fluids, lots of morphine and ketamine, suxamethonium, airway equipment (LMA and/or ETT), O2, monitoring, tourniquet.
2) Working in an european urban setting, I have no idea how emergency and disaster response are organized in rural Australia… 😉
3) First thing first, asses scene safety. Then, after a quick survey of each patient as described, I would conclude that each of those 6 patients are critical. Notify and update the retrieval team and the local hospital on the situation. There is an obvious disproportion between the needs and the means immediatly available so though decision are to be made.
– I would categorize patients 1 and 6 as expectant, although this can be reevaluated once other patients have been attended to.
– Left chest needle decompression for patient 4, bilateral needle decompression for patient 5.
– Hemorrhage control for patient 5, by direct pressure or tourniquet if necessary.
– Ankle reduction for patient 2
– Priority for patient 3 is rapid and safe extrication.
– spinal precautions for all.
– Make sure airway remains patent in patient with altered mental status. O2 if needed.
– After all this done, repeat primary survey for each patient, then secondary survey. Emergency airway management if needed. IO acces and fluids only for patients with severe hypotension. Analgesia/sedation can be provided with IO/IM morphine and/or ketamine if needed (establishing yourself IV access for all patient will be too time consuming and there are other priorities).
– Concert with retrieval team and local hospital for patients evacuation (which one first? how? Where to?)
Great answers Ray and Matt…I get the feeling you guys walk-the-walk, not just talk-the-talk.
First up, we thought about what further info you’d need and kit required.
In early stages of any incident communication lines can become confused – establishing them early and communicating clearly will help concentrate resources appropriately. As Ray said, there will need to be a large mobilisation of resources…ambulance, police, fire, local available medical personnel, blood bank (and yes, walking donors may be an option) as well as retrieval services and disaster services.
Hopefully the ambos will have sent comms a sitrep, often using the ETHANE mneumonic
Exact location
Type of incident
Hazards at scene
Access and Egress
Number of casualties at scene
Emergency services present and those required
For individual patients, the ambos use an MIST handover
Mechanism of injury
Injuries
Signs
Treatment
…and of course for clear communication between clinicians on the scene and retrieval, aN ISBAR approach can be used
Identity
Situation
Background
Assessment
Requirements/Readback
Moving on, we need to think about kit. Most hospitals will have a prehospital kit…do you know what is in yours? Can you get access to the sux (fridge) and drugs like morphine/fentanyl/midazolam/ketamine in a hurry (who’s got the drug cupboard keys?) and do they have to be signed out for a named patient?
There’s good discussion on the proposed contents of a standardised prehospital kit at http://emj.bmj.com/content/27/1/62.abstract – of course one can adapt for local needs (addition of a combat application tourniquet is one I’ve made locally) – but I’d realy encourage rural doctors to familiarise themselves with the local protocols used by their State retrieval services for drug infusions – makes it a loss less hassle to be using the same volume/concentration for vasopressors/sedation/paralysis etc…this might even extend to using the same pumps (i’m a convert to the T34, a pump sp easy to set up that even I can use it from scratch without having to read the manual or learn from someone else)
Of course there’s also opportunity for local doctors to become involved with their ambulance service (particularly important in regions like mine where most of the ambos are volunteers). Being able to drive the ambulance, operate a radio and know the capabilities/limitations of the ambo crews can be a help. In South Australia Dr Peeter Joyner has recently set up RERN (rural emergency reponders network) – a bunch of rural docs who are willing to be contacted by the ambulance/retrieval service if needed and assist on scene, carrying their own ambulance-issue equipment and cross training.
Anyway, that’s enough on logistics.
The clinical cases presented difficult clinical decisions – not so much the nuts n bolts of primary survey, but the shock value of six critically injured patients, some of whom are known personally to you.
Ray palliated patients 1 and 6. How did you come to that decision and are there any other tools to help you prioritise between treatment and transfer options for these six ‘fully sick’ patients?
Perhaps Minh will come along to help us out.
We should talk about finger thoracostomy too at some stage – I agree using an ET tube to improvise a chest drain can work quite well…not so sure about an IDC…
Over to you…
Patient 1)
GCS 3 + Shattered helmet = Severe head injury
Bilateral Femur fractures = at least 2-3 litres blood loss
add open femur fractures to the mix would be much more
no radial pulse but faint carotid = this guy is likely to be bleeding out
Degloved left hand = likely radial / ulnar artery lacerations
I have 2 bags of blood not sure of walking donor bank = Cant really help
plus 5 other patients
Patient 6) Not a easy decision
GCS 5 decorticate
Head injury severe – likely fracture skull + intracranial haemorrhage
Muffled heart sounds likely cardiac tamponade = massive chest trauma
likely has pulmonary contusions or pneumothoracies +/- tensions
Going in to a Respiratory arrest resp rate should be in high teens to 20 when normal or higher if in pain.
With these in mind likely not survivable considering extent of the trauma.
But could be wrong.
Re: IDC chest tube I think it should work to help with a pneumothorax if you don’t have the right equipment the problem of course is the possibility that it could be clotted off. But could be a good temporising measure as it is quick to insert relative to a formal Chest tube. I would use a 20+ french IDC. But a ETT would be much better larger tube easier to insert with a nice cuff to stay in the right place.
Ray is right. There have been a number of case reports of successful inflight pneumothorax drainage using an IDC ..this is on commercial aircraft, usually long distance flights.
Tim, this case reminds me of the NSW multi cas MVC at Warialda in 2007
http://www.abc.net.au/news/2007-10-28/husband-and-wife-named-top-rural-doctors/2579140
I think it is good of you to pose the issues of serious trauma in a small rural town…yes you often know the people involved. One thing they found at Warialda, reading the accounts was the fact lots of town folk turned up at the hospital and there was a need to try to manage the gathering.
From a retrieval viewpoint, if you were on scene and gave that initial sit rep, I would be tasking a second aircraft, helo or fixed wing, with more staff on board..maybe a surgeon but not always easy to get. The guy trapped in the car will need field amputation to survive so sending a surgeon will be useful but you as the first doctor on scene may need to do that under phone guidance.
I agree with Matt and Ray’s initial assessments, two patients are expectant, a couple need some simple procedures to improve their conditions.
Fact is you need more help and you gotta make a decision of sending patients to the nearby hospital where more help can be marshalled or asking people to come to the scene and setup a treatment post.
SOMEONE NEEDS TO TAKE SCENE CONTROL AND TRIAGE>>>You might have to do it yourself initially
in my experience, its better to find a safe port in a storm. I would tourniquet the arterial leg bleeder, thoracostomy the tension pneumo and insert a 7 ETT into the pleural cavity to maintain the drainage, if any sign of pneumothorax in the flail chest patient then she gets the same thoracostomy procedure and pleural ETT insertion.
NO ONE GETS IV ACCESS at this point…
I get the ambos to bundle those three patients up and get going to the hospital…get police to call in extra nursing and medical staff to attend at the hospital. They can get IV access at the hospital and do some basic obs and assessment.
You stay on scene with the 2 expectant patients and the entrapped patient. Whilst it might seem logical to do nothing for the expectant patients this is a cruel decision as you might feel compelled to at least try something . I don’t think this is unreasonable.
You can tube the low GCS patients…not too hard when they are deeply comatose..get a police officer to do neck immobilation , give some fentanyl and have a careful look. If impossible view then do a surgical airway…they are already comatose. Alternatively you drop in a LMA and leave it at that..airway done. GEt IV or IO access in humerus and you can give some fluids, small boluses. Kid with cardiac tamponade…difficult to know what to do…once airway done and IV access established..kid will be next patient to go to rural hospital once transport arranged. Nothing fancy..you can wait for ambulance to return or get a private ute with tray back and scoop load kid onto that. Nurse escort with airway in and IV access back to hospital.
Helicopter en route should be told to go to hospital and see and treat patients there.
Landing at the scene whilst sounding sensible is not going to help and is risky. Land at helipad at hospital and retrieval team can be driven out with police to scene. refer to Warialda case for a similar logistical process.
Now you got to make a plan for entrapped patient…needs urgent extrication..likely need for field amputation. no heroics..no trying to intubate whilst sitting up etc, priority is to gain IV access..or IO.. give some ketamine and prepare for amputation..one doctor and assistant can do this. need two tourniquets..combat ones the best, wire saw or hacksaw, large knife/scalpel, beta dine, lots of sterile pads/gauze pads. depending on site of entrapment on limb might not need to go through bone..disarticulation through knee is acceptable in life threatening situation.
I think its important that for the most critically injured, even the expectant ones then either a nurse or ambo get assigned to look after them one on one. In a small town it looks good that no one is left to die alone and something was attempted to intervene.
On the point of “no one is left to die alone”. I was called to a 19yo cardiac arrest pateint at a mine site several years ago. By the time I got there he was down for at least 45 mins. Never had cardiac output, PEA and intermittantly VF on monitor. 10mg of adrenlain. I made the decision to get him into the ambulance and then call it off once i was moving. I felt that it was disrespectful to call it at the scene for all the people who had provided CPR and did a great job.
As has been mentioned above as the doctor in small communities you are guaranteed to likely know the patient. This will make being objective much much harder. The other part of this is even if you are a locum and never been to to the town before, your paramedical staff (nursing/ambo’s/radiographers etc) are likely to know the patient. This may impact the care provided but will definately impact on the feelings of how the team performed and can lead to some serious self doubting and PTSD.
Great answers fellas…and this is pretty much what happened. Patients 1 and 6 classified as ‘expectant’ and palliated on scene…although moved to back of ambulance (second crew arrived). Difficult decision at best of times, let alone for rural docs (and ambos/fireys etc) who may know the patient or be family members…
Is everyone familiar with these categories? The concept of separating patients into those needing immediate treatment, those who need urgent attention (but not immediate), then those in whom treatment can be delayed, those who are deceased, and those who are expected to die with resources available – your local hospital should have coloured tags for this purpose.
Helo tasked to scene, patients 2 and 5 to local hospital then fixed wing out. Finger thoracostomy for tension PTX then ICC…the pillion passenger with flail also got chest tubes as intubated when dropped her GCS to 6.
I’ve improvised with ETT as chest drains, but now I’ll consider an IDC if all goes pearshaped (hang on, wasn’t that the infamous condom-IDC-coke bottle chest tube on a flight to London about 10 yrs ago?)
Crowd control and media also an issue needing management. In a small community, even a couple of patients in a rollover are enough to overwhelm resources and qualify as a ‘disaster’ for services…let alone a multicasualty prehospital situation like this.
Courses like EMST, MIMMS and PHTLS can help rural docs keep up to date with the basics of trauma management…but not cover scene safety, extrication and other nitty-gritty.
I’m wondering if Cliff Reid’s prehospital courses will be popular with rural docs as well but retrieval registrars? See http://careflight.org/medical/pre_hospital_trauma_course/
Of course, in the UK we have the BASICS scheme, training and empowering physicians to support ambos at the roadside, value-adding before retrieval services arrive. Whilst rural docs may be called by default, they will not always be up to speed with prehospital issues.
Minh, Ray and Casey, do you reckon a similar setup in Australia would have legs?
Anyhow, great answers all and I hope has been a useful discussion of not just the nuts no bolts of trauma management, but the difficulties of many patients, limited resources and perhaps making difficult decisions with personal overlay. We’ve also touched on systems and training…two of my bugbears. Logistics vs strategy!
thanks Tim
I figured the helo went to the scene..thats usual practice for trauma cases..I am not convinced it is always the best thing and it is risky…look up the Warialda case and see what happened to the Helicopter! Kudos for the retrieval team though who kept on with the mission!
Did the entrapped guy need field amputation or did they cut him out in time?
In answer to your question about an Australian BASICS scheme, I think it is a grand idea and interested rural docs like us might as well be the nucleus for formation!
I
Excellent review of the Warilda incident here – the vehicle crash, the retrieval service crash and the aftermath for the community
http://www.australiandoctor.com.au/news/f2/0c04c2f2.asp
Respect to the retrieval team and bush doctors!
Great case Tim.
I think a BASICS scheme is needed as all rural docs will either or have been called out to out of hospital arrests or trauma’s.
No field amputation (thank heavens). Useful video on ‘how to do it’ over on Cliff Reid’s resus.me blog
With regard to BASICS, lets talk! Dont want to reinvent the wheel, nor impinge on other agencies. but I reckon the rural doc cadre can value add to prehospital – provided they are trained, equipped and willing. Rather than the current ad hoc arrangements…