Best Intentions (3)

New methods incidental appearance

(8) It is more easy to care for seriously traumatized patients in anaesthesia and early ventilation improves the prognosis of these patients, which explains my affinity to intubate responsive trauma victims. In a personal study of my anaesthesia techniques, 76 of 227 intubated patients without cardiac arrest were not comatose. By a serious traffic accident with several injured persons, it was in particular an elderly man who was multiply traumatized, and he was already moved to the ambulance as I arrived. I asked one of the paramedics to survey the other patients while the other one should prepare the old-fashioned anaesthetic, thiopental, which I then (1983) still used for induction. The man was obviously nervous as he tried to carry out the order, his back to the patient, so I decided not to ask any further questions. I caught view of another anaesthetic, etomidate and injected that through an i.v. line which was obtained immediately after my arrival. Then I intubated the patient and secured the tube. Only then did the paramedic turn around and offered me what had been left of the projected 20 ml of thiopental – exactly 8 ml. Call me arrogant if you want: I took the syringe, thanked, pored it out on the street through the open door and was simply happy that he had not disturbed me for so long time. In the future, I only utilized etomidate to avoid any delay of the intubation - only gradually did I recognize the other advantages of this drug for prehospital use. Fortunately, none of the other trauma victims needed my help, so that I could concentrate on this man, who survived his serious injury after a few days of ventilation. Also other new techniques can be referred to singular emergencies:

(9) I was called to an occupational accident: in a deep pit, one earth wall had suddenly tumbled down and partly buried two workers, who both of them broke a leg on that occasion. One of them was freed rather easily, so I established an i.v. line on him, injected a pain killer (analgesic) and let the firework bring him up with their rescue sledge. The other man was buried to the middle of the chest and complained of strong pain under the right knee [Figure 2]. I realized that it would be easier to liberate him in an anaesthesia, which at that time included the intubation for emergency patients. This was prepared for and the analgesic and etomidate was injected, but then one of the firemen came to me and said: "Please hurry up, doctor, I am afraid that the other wall will also come down soon!" I had no intention to share the fate of the partly buried man who was, therefore, now simply taken vertically up under his shoulders, anaesthetized but without the tube. It is indeed easier to work on a patient who does not scream. He was placed on the rescue sledge and the pit fast emptied from people. Now, on safe grounds, I could have continued my anaesthesia but the rough liberation had straightened the broken leg, so I let the man wake up instead.

Fig. 2: The first ‚Pirate Anaesthesia‘ (9)

Afterwards I raised the question, why not utilize this method somewhat more often. It was a matter of avoiding vomiting and, simultaneously, keep the natural respiration upright for about five minutes. This was the first "pirate anaesthesia," to be followed by many more in- and outside the hospital. I chose this name to express that the method violates all rules and can be carried out on high sea, if necessary during the battle. Of course, a certain risk remains for this method in acute cases but the risk of an intubation is probably bigger. Only a few drugs can be combined with etomidate to produce the desired effect, and this lasts but 4-5 minutes. Unfortunately, I have steadily found my colleagues modifying the method without first understanding its delicate preconditions. Superficially, it appears so easy, that is the dangerous part of it.

At least, the prehospital use of "antagonism" (the use of certain drugs, antagonists, in order to abolish certain drug effects) resulted in one of the rare discussions with the colleagues. Here, my recommendation to wake up some of the intoxicated patients with the new drug, flumazenil, instead of intubating them, was violently contradicted at a larger symposium in 1987. There was only one person supporting me while one of the others mocked: "Mr. Schou, if you cannot intubate, perhaps it is better not at all to take part in the rescue service." A few years later, and quite contrary to the presentations at that symposium, nobody could remember that there was any other use of the drug than to relieve an intended or accidental overdose of a certain group of drugs, benzodiazepines, and now they cannot remember that I mentioned it then.

(10) One of the first patients we decided to wake up was already then known to abuse whatever drugs he could get hold of (plus alcohol), in addition he was feared for his aggressive behaviour when he was awake. Now he had, among others, ingested benzodiazepines and he was deeply unconscious with impaired breathing. I decided to remove the influence of these drugs by using flumazenil and the first cautious dosage did provide useful results. But then we remembered that it was better not to wake up the comatose man completely and, just to be on the safe side, he was attached to the stretcher with various straps before he received the second dosage of flumazenil. In a comparatively awake and still calm condition, he was delivered in the nearest hospital, from where he escaped 3 hours later. On that occasion it became evident that the antagonists could act "too good," tempting the doctor to avoid certain detoxification manoeuvres at a time where this would still have been possible.

Then we continued against the alcohol, by far the most frequently abused "drug" and met in the field in the most different emergencies. It can certainly not be taken to my credit that the ancient drug physostigmine, known since 1864, can be used against alcohol intoxication as well as against numerous other (real) drugs.

(11) A young man had swallowed a large amount of benzodiazepines and drunk a whole bottle of vodka. When I arrived, the paramedics ventilated the man with bag and mask, he was unconscious and rather cyanotic (blue discoloration of the skin indicating lack of oxygen), indicating that this was a case not calling for antagonism, but this is where human aspects were given some importance: the man lived in the fifth stock without any lift and I had pain in my back. I therefore decided at least to try waking him up, so that he could walk down himself. He started to breath after flumazenil and gained a better skin colour but remained comatose, probably a consequence of the alcohol. Then he was given physostigmine, upon which he woke up some minutes later. Still somewhat blurred, he walked down the long way to the ambulance, supported by the two paramedics. There is, however, a regrettable adverse effect to physostigmine: it brings movement to the stomach. Without any warning, but now on the stretcher of the ambulance, he suddenly vomited a large see of stinking gastric contents over one of the paramedics. I laughed over it and ‚comforted‘ him by saying, "Jetzt wissen Sie was es bedeutet wenn Jemand sagt: ‚Du kotzt mich an‘" [now you know the essential importance of the old speech, ‚I could vomit over you‘]. The patient turned against the sound – and gave me the rest.

(12) In the middle of the night, I was called to a man about whom it was claimed that he had fell out of the balcony at the third floor. He was comatose, with an intense smell of alcohol, but not really injured as one would expect after such a deep fall. While establishing an i.v. line, I asked if actually anybody had seen him fall, but this was denied. I suspected that he had taken the stairs down below the balcony, where alcohol had then brought him to sleep, so I decided to try to wake him up and ask himself about it. Indeed, he woke up rather promptly after physostigmine and could then give proper information: Yes, he had drunk a lot of whisky and yes, he fell out of the balcony, but being a routined parachuter, he knew how to land too avoid worse injuries. Upon this information, we found it better to take him to the hospital, from where he was discharged the following day without offering any further problems.

The third antagonist which we introduced was nalbuphin. We did not need to introduce it into prehospital care where it has long been preferred as an analgesic (i.e., for pain therapy) by many rescue centres because it is more safe (but perhaps also less effective) as other opioids - indeed, it is my preferred sedative and analgesic to patients of severe chronical respiratory distress. However, for opioid antagonism, doctors have long preferred another drug which in all aspects (too short a duration and a high amount of adverse effects) is inferior to nalbuphine when given to drug addicts. The strange thing is, that most colleagues still prefer the inferior drug. Indeed, the sedative (sleep inducing) properties of nalbuphine, augmented by a cautiously dosed and later given benzodiazepine, is one of the techniques we have taken into the hospital after having developed it prehospitally, among others for gastroscopy. It was the manufacturer itself who "killed" their own drug in recommending it for analgesia after anaesthesia with too high opioid doses. Since antagonism overweighed analgesia and other analgesic mechanisms had been blocked by the high opioid doses, patients woke up screening and the anaesthetists agreed that it was a bad analgesic – without understanding the complexity. In the absence of other opioids, the drug acts differently and even later application of the other opioids leads to an additional, though weaker effect. Difficult to understand? Well, also the anaesthetists have failed to cope with it.

(13) One yuppie was found at home comatose with a lot of different drugs but neither flumazenil, nor physostigmin produced any awakening effect. There were no vacant respirators in Lörrach county and as I was forced to intubate, I had to admit the patient to Basle. For anaesthesia (regardless of the level consciousness since it serves the purpose of making the intubation itself safe) I use a combination af nalbuphin and etomidate, and this served its purpose as usual. However, on the way down to the waiting ambulance, the now intubated patient woke up and proved rather difficult to keep calm. Of course, they could not understand in Basle why this awake patient had been intubated at all, so they removed the tube at once. Only on a later occasion did the police explain that also an opioid had been antagonized on this occasion.

(14) This antagonism has now become a standard therapy for the treatment of drug addicts in our area: I was called by the paramedics to a village 10 km away in the beginning of the night. Having stumbled out of bed and down to the turnout car takes some time, and as I reported over radio, one of the paramedics told that this was probably a drug addict and we agreed that he would inject a vial of nalbuphine intramuscularly. A few km later they told me that the patient was now awake and I could return – which I refused; having been woken up, I preferred to drive the last few km. It is anyhow difficult for the paramedics alone to decide that a patient should not be admitted, so in this case you may see my justification in avoiding an unnecessary transport and hospital stay; it then remains difficult to explain the social security that they still have to pay for this mission, they seem to prefer an intubated patient on the intensive care unit.

(15) One of my colleagues refused to believe that it could be so uncomplicated to wake up the drug addicts. Called to one of these with a serious overdose, he intubated and ventilated the patient, took his time to find a vein still permitting an i.v. line and transported him to the hospital. In the emergency room, the other antagonist, naloxone, was injected. The patient was instantly awoken and regained forces, which he used to drag out the tube and i.v. line. He beated the nurses and destroyed part of the equipment after which he escaped from the hospital, leaving only scars, wounds and a deep impression. Exactly one week later, the same colleague was called again to the same patient in the same condition, but now he had got the message: nalbuphine was injected in a muscle while the patient was ventilated on a face mask, possibly an additional dose was given in a neck vein if any (without providing for an i.v. line), then the man awoke slowly and peacefully and disappeared without any transport.

In the enthusiasm for antagonism, one should not forget that there are cases where this should not be utilized. Of course, it did not always work as intended, but most intoxicated patients were only found after many hours when an injection for test could be tried. Then, however, there were some cases which demanded fast (gastric) elimination as fast as possible.

(16) A 14 year-old girl had swallowed a long-acting benzodiazepine - in itself an indication for antagonism through flumazenil - but also an insecticide in a larger dosage. When I saw the bottle, I immediately decided for intubation, although the girl was still responsible and required anaesthesia for making this possible. Thereafter, a thick stomach tube was placed with intermittent aspiration of the stomach content and injection of medical coal in tap water. As usual for such missions, the ambulance suggested a coal mine accident, but it turned out to be worth the trouble: the girl had ingested 25 times the mortal dosage of the insecticide. The elimination of the poison was continued in the paediatric department and the tube could be removed the day after with the respirator, when all danger to the girl’s life were proven to be abolished.

Next chapters:
Could they have been saved?
Novel techniques vs. old standard
Frustrations with fire