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A 22 year old victim of a car accident unconscious with head injury, chest injury, limb injuries. Very common presentation.
Who removes or extricates him from the car? Police or bystanders. No awareness of airway or spine protection. Do you remember the way it is done in the US shown in Discovery channel? With a spine board, with a neck collar, straight into a waiting ambulance. Why aren't we training our police and fire personnel properly in these life saving first aid procedures?
Who are manning most of the ambulances here? Mostly technicians or so called paramedics who have recieved no training in emergency management.
Okay, so this victim has somehow managed to reach the emergency room of a hospital. First person to see. The casualty medical officer or the duty doctor. Neither has any proper training in emergency management.
The patient is now bleeding continously, blood pressure is not recordable and his breathing is getting shallow. The duty doctor has called the anesthetist on the phone. Fluids have been started.
Anesthetist comes into the scene after 5 minutes. Intubates the patient. Notices the head and limb injuries, calls the neurosurgeon and the orthopedician. Orthopedics guy comes in within 15 minutes, closes the limb wounds and splints the fractures. Anesthetist notices the BP is not going up, orders blood. Neurosurgeon comes in after half hour. Why? Because he's a superspecialist and obviously we won't find him sleeping in the hospital's duty room. He orders a CT scan and neck x-ray. Orthopedics wants a pelvis and limb x-rays. Now the victim goes and comes back from radiology.
CT is showing a bleed which has to be operated. Neuro wants clearance from the anesthetist. Anesthetist sees a hemothorax (blood in the chest cavity) on the chest x-ray due to the chest injury. He will not give clearance till cardiothoracic guy puts in the chest tube to drain the blood. So he's called. He comes within half hour. Time is 2 hours after our patient came in. Chest tube placed. Anesthetist still does not give clearance because BP is not good enough. Abdomen is distended now.
Ultrasound takes another half hour. Blood in the abdomen and liver is injured. Its almost 3 hours now. General surgeon is called. Another half hour. Victims relatives are told that his condition is very serious and he will be operated with 'grave risk'.
Victim dies of blood loss and hemorrhagic shock in the ICU before going to theatre. Its been 4 hours. Now what? Relatives are told that he's dead. Why? Because he came in with serious injuries, that's why. "We did everything."
Another young man is dead because of a road traffic accident. He included in the Government mortality statistics. "As on 10th April 2006, 337 persons have died in the city in road traffic accidents since January 1st 2006" (Actual stats of a south Indian city). Thats it. End of story.
Or is it? Emergency medicine is going to change this.
You may be interested in knowning how this particular victim is managed by emergency medicine.
Victim is extricated by trained paramedics on a stretcher will a spine protection and neck collar. He is intubated and his airway is protected on the accident site itself. Breathing is supported by the paramedic with a bag mask and oxygen. Intravenous line is secured and fluids are started in the ambulance itself.
Patient is recieved in the emergency department by the emergency physician. He rechecks airway tube, detects the blood in the chest, continues the IV fluids and orders blood. He fully evalutes the patient , within minutes detects the head, chest and limb injuries. He also detects the injury to his spine. He orders the portable x-ray, portable ultrasound to the emergency department.
Blood is confirmed in the chest and also detected in the abdomen. Neurosurgeon, general surgeon, orthopedics are all called at the same time. This is known as simultaneous referral.
The emergency physician meanwhile inserts the chest tube and drains the blood. BP is just good enough to do the CT scan. CT shows bleed around the brain. Now the three specialists have arrived, all within half hour. Time since the patient came 1 hour.
Anesthetist is called in for pre operative assessment. He's here in 5 minutes. All the specialists decide together based on clinical injuries and the completed investigations. BP is not picking up but just enough to take into the operating theatre. All decide to operate simultaneously under high risk.
Patient is wheeled into the theatre 1 hour 20 minutes after coming into the emergency. The surgeon detects liver injury and bleeding in the abdomen. He secures it and stops the bleed. BP picks up and normalizes. Neurosurgeon operates and evacuates the intracranial bleed while the orthopedics fixes the fractures. He's wheeled out, still alive, shifted to ICU.
ICU consultants trained specifically in critical care look after him. Patient recovers after 10 days. Discharged after 3 weeks. Supreme effort by the entire team.
Just a life saved? Well it makes a difference to this 22 year old who just is beginning to see this world. He could have been the be a CEO of some huge company. Emergency medicine and emergency medical services do play an important role of keeping him alive till he is given specialist care. It makes a difference to every single victim in a medical emergency.
There are 6 victims, just like this young man, requiring emergency care every single minute in India. This is just trauma. Imagine all the emergencies put together. Now you realize what our health care system lacks. A proper accident and emergency system.
No doubt, there are excellent doctors out there who render care like this without specific training in emergency medicine. But they are hardly a handful.
Unbelievable story? Believe it. All this is really happening.
Dr. Imron Subhan, FEM (CMC, Vellore), Senior Resident, Dept of Emergency Medicine, Apollo Hospitals, Hyderabad.
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