Comments

[Tom Riley]

In light of the request for more comments, From a scared Lurker - with the 
proviso that there are definitely many more qualified people here than me 
(feel free to skip it!):

<Sal – Impediments to Angiography>
Angios: I'm aware of at least one hospital, generally great for trauma 
(where I'd ask to go), where the angiosuite is at the end of a very long 
corridor a long way from the OR & A&E resus which reduces the number of 
unstable patients going there.

<Level 1 versus Level 3 – RIP 2 hours later in CT>
Just out of interest was that the patients *second* CT? – the first posting 
of the case included a report of a CT. If so what was the rationale given 
for doing a CT again?

The reason for most delays in critical patients is a hospitals culture. Most 
hospitals I’ve experienced are organised and judge themselves against 
targets for non-emergency care not to deal with critically injured patients. 
It needs to be a hospital wide attitude -  to get the best management of an 
unstable patient you need a “sharp” ED [a sharp radiological team (to say 
no!)] and a “sharp” surgical department. One won't do and it needs to be all 
aspects of the departments, nursing and doctors. If this isn’t the case the 
sharp departments or parts of departments tend to become frustrated and give 
up.

If there’s nobody in a department who’s interested in Trauma it won’t get 
looked at. Also many hospitals that are good in office hours can be really 
poor out of hours when everyone goes home. Again most of the time they get 
away with not being that quick and if they don’t it’s often not questioned 
in depth it’s just that “she/he died of that injury, we couldn’t save 
her/him, too bad” or “it was out of hours”.

Just out of interest what are the guru’s advice for junior doctors who find 
themselves working in departments which aren’t very “sharp”?

<Selective spinal immobilisation>
My personal opinions on spinal immobilisation:
There are definitely many patients who are immobilised who don't need it - 
the statistics from the EMJ article posted state only 4% have an unstable 
spinal fracture (I'm surprised it's this high). However spinal 
immobilisation is a "precautionary" measure - it doesn't treat anything, 
similarly wearing gloves is precautionary against infection - most of the 
time you'd be fine without them... Not immobilising the patient would 
therefore be fine 96% of the time. However I recall (memory!) from the PHTLS 
manual that 70% of the people who are left quadriplegic post trauma are due 
to their handling after the incident – so better safe than sorry?

As it’s only 4% incidence any study (e.g. NEXUS) looking into this needs 
*thousands* of patients to be statistically significant and then the 
pre-hospital environment is so variable who's to say it's applicable? One 
patient I immobilised was drunk in the stands of Twickenham rugby ground on 
a freezing November afternoon, how many studies are going to cover that to a 
statistically significant degree?

Similarly there's no point in immobilising the c-spine if it’s going to 
result in a corpse, there are numerous examples of people who've died in RTA 
/ MVCs due to not having their airways opened by first aiders who didn't 
want to move them (the 7mins response from an ambulance - too late). 
Similarly London HEMS recently attended a pedestrian who'd been pushed 
through a wall by a car and on arrival was under the front of the car and 
arrested, they rapidly pulled them out with MILS alone and successfully 
resuscitated them – he could have been quadriplegic but he’d definitely have 
been dead otherwise.

Another question – I was taught that with penetrating knife trauma and 
asymptomatic neurology the risks of an unstable spinal injury were 
negligible and it was unnecessary to immobilise a patient. In the case given 
the patient was drunk so you could argue the neurology was unreliable but 
I’m interested to know - would other people have immobilised him had they 
known he’d been stabbed?

Conversely - I have been *ordered* to immobilise someone who was walking, 
felt a pain in their back whilst reaching across a table with a previous 
history of a fractured coccyx, tender over the ipsilateral infraspinatus 
muscle with & paraesthisiae in right hand. Quite the most embarrassing 
handover of my life.

<Is the spine board/Long back board effective?>
I'm not a great fan of the rescue board (aka long backboard, spinalboard 
etc.) for spinal immobilisation - if you strap someone on it and then roll 
it 90 degrees you can see how much lateral movement there is (and it's 
American:-)). I much prefer the scoop stretcher (British:-)) which you can 
split reducing the amount of logroll required and get less movement once 
they're on it, plus you get it back quicker when you deliver the patient:-). 
Vacuum mattresses are also great once someone's on a trolley/Bed, very 
comfortable fewer/no pressure worries, but I'm not convinced you can really 
safely pick someone up on one with just two people and they do make it more 
difficult to examine the patient.

Rescue boards are great for sliding people onto during extractions, under 
trains or carrying people up flights of stairs. I'm also a great fan of TED 
or similar jackets, for taking people out of cars/seats - especially single 
seater racing cars.

<British System of ED care>
After recent experience of Australian EDs, *most* of the British EDs are 
definitely more “casualty” than emergency medicine. It’s interesting that in 
Australia most Intensive care specialists have an Emergency medicine 
background rather than the Anaesthetics background in the UK. Although the 
common stem in the MMC training scheme may alter this.

<Mathew – The great pre hospital v hospital, doctors “out of their 
environment”>
As someone who sits (hides?) on both sides of the fence (with a physics 
degree:-)). The laws of physics aren't different outside of hospital but 
they do affect medicine in different ways - there's no rain/snow/hail/wind, 
noisy traffic, sirens, dark, casualties with a smashed up car wrapped round 
them/down a hole/up a mountain/3 stories down in an underground rave/on the 
6th floor in a dodgy housing estate with all the neighbours/bystanders 
regarding you, in a uniform, as a symbol of authority which rightly or 
wrongly they're blaming for what's happened. This does make it a much more 
difficult environment to work in - is that anaesthesia/paraesthesia in his 
hands are they just numb from cold? Are there absent breathsounds or is it 
just I can't hear them over the music/traffic/siren? How do I achieve a 
platinum 10/diamond 5 (or whatever pointless number) when the front of the 
crashed car’s sitting on the patients lap?

Plus there's only one paramedic/technician in the back of an ambulance, or 
the two crew initially for potentially many patients - versus all the staff 
in ED.

But the medicine and physiology *isn't different* and hospital doctors are 
better trained, very capable and very practised at doing things that 
paramedics just don't do or deal with that often. There’s nobody to handover 
to for them - For example ITU/Anaesthetists do multiple intubations, 
cannulations and deal with people being sliced open & losing blood and being 
unstable routinely every day. Vascular surgeons routinely take legs off.

I'm not saying you don't get bad examples in both fields: Examples I've seen 
- A&E doctor with patient post blunt head trauma having cranial nerves 
examined without any C-spine precautions/clearance, "turn your head against 
my hand" "OW! that hurts my neck". The Paramedic crew "immobilising" a 
patient (pedestrian v car, 30mph, bulls eye impact pattern on the cars 
windscreen with his hair in the outside of it. No symptoms available - 
patient only spoke chinese) Picking him up by one arm each and dragging him 
on his back onto a board then taping his head down with blanket rolls. No 
collar, no straps. Lifted onto cot, loaded and drove off...

But in general both prehospital and hospital do a great job, both really do 
know what they're talking about and deserve each other's respect, even when 
you think they don't know what they're talking about it's quite possible 
they know more than you and really should be listened too and yes I do take 
my own advice - that's why this is only my second ever posting - I stand to 
be corrected and please don't flame/abuse me too much:-)!

Tom Riley
Scared Medical Student, volunteer ambulance crew, Former Physicist, MAU and 
A&E care assistant.

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