Best Intentions (4)

Could they have been saved?

My compatriots, the Danes, believe that German motorways (highways) must be the leading source of occupation for the ambulances and accounts for the air rescue, of which the country of 400 islands in the North is not in a possession (leading to the conclusion that it is also not necessary). Indeed, all European rescue services are more often dealing with non-traumatic than traumatic conditions and even among the latter, highway accidents are rare. In our study [see  publications 1.29], utilizing a statistic of the police from 1980 to 1996, only 20 of 430 traffic accident fatalities were found on the two motorways in our county, including 3 pedestrians who were not supposed to be there. In my own 15 years, I have been called only four times for serious accidents on the motorways. Two of these missions are described in the following. First a serious accident occurred in the middle of the night, and the one who caused it was in possession of the three typical features characterizing such accidents: alcohol abuse, high speed and no safety belt.

(17) On the highway A5 in direction North, shortly before the deviation to Mulhouse (France), a serious accident was reported: a "ghost driver" had collided with one or more cars and I was required simultaneously with two ambulances. A bit too late, a drunken driver had suddenly noticed that he was approaching the French border (then guarded by customers) in contrast to his intentions to go South. Probably, he also did not want to open the window at the border and then turned and took some way back. Indeed, he went South, but on the wrong lane and his driving was short. I overtook the first ambulance early and arrived first at the spot, a deed not to be recommended since you feel solemn if you are used to get any help. Being unable to survey the accident immediately, I saw one patient trapped in a car, comatose with impaired breathing. The patient was dressed for the winter so, without wasting time in searching for an IV line, he was intubated through the side window. This was successful and would have to do for the first while I went to the next patient who was screaming some 100 meters away. In the meantime, one ambulance had arrived and I gave them orders of requiring out helicopter (which also flyes in the night) and take care of this man.

The screams came from a man who was seriously burned. Firemen had arrived and turned the fire of his burning car wreck out, but nobody had dared using the water for the injured man (the importance of simple water for burns is not understood in Germany). When finally persuaded, a terrible smoke came from the man’s clothes, indicating that there had still been glows. I found a vein and gave an anaesthetic drug called ketamin, realizing that such a widespread and deep burns injury could not be taken care of with water alone. One of the firemen were told to keep the infusion bottle and another to add water from time to time. Then the police led me to the third and last victim, a young women, whom I could not help as she had died instantly.

I ran back to the first patient but now the second ambulance from Mülheim arrived with another emergency physician. We agreed that he should take care of the "first" patient who seemed stable and should be driven to Basle while I flew the patient with 95% burns to Zürich, one of the few burns centres in Europe where he could survive his trauma. Coming back to him, I discovered that the man who should keep the infusion bottle had stepped one meter back, thereby removing the precious IV line, while the one who should have provided for surface water had disappeared completely. My only chance was now to establish a central IV line through burned skin and then sew the new line to avoid repetitions.

With the liberation of the first patient, the situation was completely altered. He was showing signs of internal haemorrhage and shock. My colleague therefore suggested a change in priority, to which I agreed. Only fast operation could save this man, while the chances for the other, even in Zürich, would be very small. To permit liberal use of anaesthesia, also this man was now intubated. Then they went off in direction Freiburg while the helicopter landed. We flew the man to Basle but he died shortly after during an emergency operation, while the burned patient died the following day. Nobody survived the big accident, so what was the point of being there, you might ask?

This is a good example to show that we are not only dealing with saving lives. The patient with serious burns did indeed profit from anaesthesia in being relieved from his terrible pain. I believe now that I could at least have controlled the other patient’s intra-abdominal bleeding – typically being expressed after he was no longer compressed in his car – by a method, to be described in the following case-report. But two other comments are important: we altered the priority when the condition of the first patient deteriorated; and it proved to be him who had caused the accident (most accidents are not just happening, they are caused, as my friend Dr. Chockalingam (of Madras, India) once stated), not the other one as had been told. Not that it really mattered, but it is a small lesson for emergency physicians to deal with accident victims as patients only and leave it to the police to decide about, who was guilty and who was the victim.

I mentioned the statistic of accidental death from the traffic police. I was involved in 60 of these cases, of which exactly 30 died on the spot (excuse the round figures, but that is how it was) while three were seen only during secondary transport (i.e., from one hospital to the other). Of the remaining 27 victims, 13 were not instantly comatose and 9 of those died shortly after admission; 2 of them from thoracic injury, against which we are currently helpless, but 7 patients had an intra-abdominal bleeding. All these patients were recognized to be in haemorrhagic shock and all were brought to a trauma centre (5 to Basle and 2 to Freiburg) without any delay. So, having eliminated other, previously common causes of accidental death (suffocation, pneumothorax and spinal destabilization), a quarter of my patients could have been saved if the intra-abdominal bleeding had been controlled. Indeed, also 3 of the 14 primarily unconscious patients (including the one just reported on) might have survived if their cranial injury was not setting other limits – which one cannot know afterwards.

(18) A 17-year-old girl drived as passenger on a motorbike which collided frontally with a car, more than 20 km away from Lörrach. She was thrown off the road and some 3 meters down an adjacent meadow while her companion was lying on the road and screaming from pain due to a fractured leg. As I arrived, the girl had lost consciousness and was in a deep circulatory shock, so I ordered the helicopter for transport, carried out the usual therapy which includes a tube to the airways, which I am used to lead through the nose. Now an old general practitioner passed by and offered his help. I asked him to establish an infusion on the other patient up there so that he finally could get something against pain, but the practitioner claimed that he did not need any. The same answer was given as I repeated and specified my demand. Then I realized that the man was not able to establish any infusion, which he expressed in this way. Since the helicopter had not yet arrived, I then asked him to ventilate the other patient, planning then to do the other thing myself. He had probably learned that somewhere, because as he arrived, he removed the disturbing tube a bit (fortunately without dragging it out) and started to make an artificial ventilation by the mouth-to-mouth method. I dragged him away and told him that this was not necessary any more, with a tube already in the airways; however, I did not dare to leave the patient in the hands of this clown, so I ordered the young man brought to the nearest hospital (from which he later was transferred to our) without any sort of therapy. Then the helicopter arrived and we flew the girl to Basel where she died about one hour later during an emergency operation. At that time, I had flown back to Lörrach while the police brought my turn-out car back.

(19) A similar outcome awaited a bus driver who had not braked his vehicle and was, standing backwards to the bus and thinking of something else, hit by this. It was, of course, not driving very fast, but the man was pressed against some bushes which finally stopped it. I was required by the paramedics who found the patient in shock and with strong pain. While preparing the following intubation and requiring the helicopter, he could tell the telephone number to his wife and also mention that he had a small son. The branches had torn an open wound in the belly from where it was bleeding. After anaesthesia induction and intubation, I transferred responsibility to the doctor who had now arrived with the helicopter. Then I was called to another serious accident nearby, this time to intubate a comatose patient and in so far interesting that I had to wait for the helicopter from Villingen-Schwenningen, 85 km away and this patient, since Basle was now occupied by the patient of my last mission, was admitted to the other trauma-centre in Freiburg. Later that day, I learned that the bus driver had died due to uncontrollable bleeding less than an hour after admission, in spite of immediate operation.

This should be enough of the tragic, I hoped. There must be a method of exerting a pressure on bleeding veins or organs in the stomach of people, when for several hundred years (before the introduction of controlled studies!) this could be achieved peripherally, simply by exerting a digital pressure. It turned out to have been invented already but, unfortunately, it was marketed under the wrong name of ‚Anti-Shock Trousers,‘ causing physicians to believe that it is a universal method to be used against all types of shock. Moreover, it is often used wrong (preferably without preceding intubation) and on patients where it acts negatively, in particular those with bleeding processes in the chest. Such is apt to occur in countries where gunshot and stab wounds prevail above blunt trauma. No wonder then, that under these conditions the so-called "controlled studies" will yield a negative conclusion, a problem met elsewhere in attempts to improve the therapeutic aspects of prehospital care. Although I was able to publish a few studies  against the tendency, to ignore logical conclusions if a controlled study reaches the opposite conclusion, I must accept to have lost this battle. Concerning the logic of this particular problem, we were able to publish two cases (a third was encountered afterwards), who were about to die in short from bleeding aortic aneurysm but then could be stabilized by the so-called antishock trousers (in a new, non-pneumatic fashion) with preceding intubation, then operated in Basel, in all cases with survival and discharge home to follow. Layman may think that if a modest pressure can stabilize bleeding from aorta, it may also stop bleeding from veins and organs with a much lower vascular pressure. Most physicians prefer not to believe it, for the reasons given above. Real science may be tolerant but belief is always dogmatic.

Novel techniques vs. old standard

I experienced similar frustrations with my interest in a new, improved resuscitation system, which was developed on the background of a case-report from San Francisco. American doctors are, perhaps, not the ones who invent a novelty themselves, since such would automatically be in conflict to existing guidelines. To their excuse, the system was invented by laymen without any medical interest, until very suddenly:

A man suffered cardiac arrest at the toilet. The wife had learned something about resuscitation, but being unable herself to transport the husband away from the toilet, she grasped the { plumber's suction device present there, donating heart massage without caring for the ventilation. It lasted at least 10 minutes before paramedics arrived and continued resuscitation in a more conventional, professional way, with subsequent success, as the story continues. I can imagine that they laughed heartily of what they had seen.

Half a year later, the patient suffered another cardiac arrest, now alone with his son. The latter had learned the conventional way of resuscitation, but apart from exhausting himself, no effect to his father could be seen of it. He then remembered that the mother had utilized the suction device with a good result. He ran to the toilet and back again, resuming resuscitation accordingly. Again, it lasted at least 10 minutes after alarm before the rescue service arrived, and again a complete resuscitation followed. It would probably again have been forgotten, had the son not suggested the same evening that such suction devices should be available at each bed on the intensive care unit. Imagine what the doctors answered; it could have been something in direction of "listen, my good man, at first you should learn how to resuscitate correctly before you attempt to invent something new," at least this is the attitude of contemporary physicians. Being unable to talk the man off the double success, one of the doctors pondered further about the case. Suddenly he realized that this way of resuscitation solved a problem created by the traditional method, in relieving the increased pressure in the chest. This method, called, alternative compression-decompression (ACD), produces (when correctly used, se my  German instructions for use of ACD ) four effects: 1) resuscitation is improved in that more blood is suctioned to the heart before it is pressed out again; 2) both the relieve of venous blood flow back to the heart (through the decreased intrathoracic pressure) and the improved arterial circulation leads to improved brain and kidney functions; 3) also the heart in itself profits from this mechanism and becomes easier to bring back into normal rhythm; and finally, 4) ACD creates a certain ventilation, among other with the consequence that "Patient One" survived without separate ventilation in the first 10 minutes.

I was shown this novelty on a congress in Budapest in the Summer of 1992 and got hold of the first device of its kind in Germany. In the following year, we could present our preliminary beneficial results on 3 international congresses, with reference to experimental studies confirming the above mentioned effects. But now problems arose: it was demanded that ACD should only be used according to existing guidelines from the American Heart Association (wrong use) and its possible superiority then confirmed in survival-studies involving a control group, indirectly employing an insufficient power of the studies and an in-hospital time much longer than the prehospital phase actually considered (wrong study). Before I got hold of my own device, I had realized that it should be used with a much lower frequency (40-60/min) than conventionally (80-100/min), and, moreover, ventilation should be given simultaneously with the compression in order not to compromize the second phase ("suction" of blood to the heart). No wonder, the majority of the erroneously conducted studies led to the conclusion that ACD does not improve resuscitation and in 1998, its further use was prohibited by the FDA in USA.

(20) An example of the limiting area of resuscitation, in which I believe that ACD made the difference, is given in the description of a mission I had to a small village in "Markgräflerland", the land between the Rhine and southern Black Forest. A woman had collapsed during a stroll and did not move any more. It lasted 11 minutes after the alarm had been received at the Central before the nearest ambulance arrived. During this time, the woman had neither moved, nor had she been touched. I needed another 2 minutes, and not because I was driving particularly slowly. It looked absolutely obsolete to perform a "ritual desuscitation" (abbreviated: resuscitation) under these conditions, but we practised the new device and thought that all paramedics should have their chance. And then we managed rather fastly to achieve a stable heart rhythm. I was not the least proud of this result and would rather have excused it at the moment. But having now intubated the patient, the problem was to find a hospital with free capacity for ventilation. The fifth request from the Central was positive, but then far away. I rejected the suggestion to utilize the helicopter, this mission had been expensive enough already and the long-lasting lack of oxygen to the brain made it highly improbable that it could be considered a success. Later on, I was forced to revise this attitude: the patient got rid of tube and ventilator the following day. Her brain had indeed been damaged, a month later they considered to transfer her to a nursery, but another two months later she was discharged home in a functionally sufficient condition. Although such a course is rare under conventional CPR, it is not quite unique. The critical time of anoxia (lack of oxygenation) to the brain, after which cerebral resuscitation seems impossible, is obviously much longer than the 4-5 minutes as was previously assumed. Remains the question why some survive the long anoxia whereas others do not wake up again when resuscitation was commenced fastly (and primarily successfully) after cardiac arrest.

We did not need any studies in order to see the value of ACD. It suddenly became interesting to measure the oxygen saturation during resuscitation, a parameter which appeared beyond comprehension during conventional CPR but even in some obsolete cases, a saturation curve (then with lousy values) was obtained. It looked as if this value also had an important prognostic importance, that is, only a good oxygenation after a few minutes of ACD-CPR would result in success, but further studies were abandoned. Anyhow, it proved impossible to publish our results. Instead, I entered a discussion about prehospital science, contradicting doctor's ambitions when associated with publishing studies.

In the 1980ies, prehospital fibrinolysis was a problematical topic, and I was forced not to admit patients to one of our hospitals which had denied to continue the treatment I had initiated, although I had restricted it to complicated cases of suspected myocardial ischaemia accomplished by cardiac arrest or shock. This restriction was again made necessary by the limited amount of fibrinolytics which I had begged from the industry. Not wanting to restrict the indication to definite signs of a myocardial infarction, it soon became clear that it was possible not only to minimize such but in selected cases even to avoid one:
(21)  A 48-year-old man with coronary vascular disease for many years experienced a severe and persistant attack of angina pectoris. Finding frequent ventricular extrasystoles and a blood pressure of 80/- upon their arrival, the paramedics called for a physician. In spite of severe pain and beginning shock, the patient was able to inform me that this attack was more severe and completely different from any previous heart attack he had known, also in being unresponsive to nitroglycerine. We were only in the possession of a single-channel ECG-device for arrhythmia diagnostic and defibrillation, so I could not evaluate any standardized ECG-contour. Following vainful use of analgesia and an antiarrhythmic drug, fibrinolysis was begun. Already during the (rather long) transport, through which we passed the mentioned hospital and headed for another one, the patient recovered completely and did not make the impression of having suffered a life-threatening event recently. Still, fibrinolysis was now continued, and good so since a new deterioration the following day made a helicopter-transfer necessary to another clinic for acute coronary vascular intervention, from which he again completely recovered.
In the second clinic, it was criticized that fibrinolytics were started without being in possession of definite signs of a myocardial infarction. Today, it is an applauded effect when it proves possible to prevent one (this succeeded another two times, including a case complicated by ventricular fibrillation). Moreover, due to the „gaze-delay“ in the clinic for the decision to start a fibrinolysis, prehospital therapy is started on the average more than an hour earlier, so there is more time to gain (and thereby more tissue to save) than one would expect merely from the transport time to the hospital. The new question is, if some patients (but only among those living near to a cardiac catheter centre) are better off with coronary vascular intervention if such can be offered immediately upon admission.

Frustrations with fire

Burns have always given me the frustration that I know what helps (an area where Danish physicians have previously made a big effort) but it is not correctly used. Perhaps because it is just cheap and non-patency-protected tap water, long enough. Everybody who have burned a finger - and therefore nearly everyone of us - knows how relieving it is to keep it in a cold glass of water, and the pain produced when it is removed convinces you to keep it there for about an hour. By somewhat more extensive burns, you would therefore also start with a similar cooling but after a few minutes, you leave for the hospital and soon regrets that you had left the water source. However, at the most serious burns, a doctor may come who does not believe in such simple means or, as common in Germany, fears hypothermia associated with the cooling action (which may indeed be a problem in children). There are no modern studies for the topic and there is no firm to support the case and earn money upon their product. The physician may believe that only the first 15 minutes matters for cooling, so when he finally arrives (or the patient in the hospital), it is assumed to be too late.

Without wanting to tire the reader with medical details I want to mention that local cooling not only relieves the pain and put out remaining fire in the clothes, it also reduces the extension of the effect in the depth and the degree of burns at all. Moreover, the tissue reaction is affected, both what extravasation of water and production of systemic humoral mediators are concerned. This does, however, have a long-lasting cooling for about one hour as its precondition. There are indications in experimental burns (older studies) that consequent cooling leads to an improved survival of severe burns, even when a considerable hypothermia simultaneously takes place. For that reason, I have preferred to use this hour on-site when I met an isolated, serious burns case, rather than hurrying to the hospital as expected by on-lookers. It is therefore reasonable to regard an example where at least the analgesic effect of water could convince:

(22) On a very hot and sunny summer day, a 40-year-old woman told that she would pour gasoline over her and ignite it. Nobody believed, so she did it. An unusually clear alarm followed, resulting in my alert simultaneously with the ambulance. Since I should drive some 15 km, I utilized the radio to demand permanent rinsing of the burned areas as soon as possible and at least until I arrived. Fortunately, a garden tube had already been used to turn out the fire, so it was only necessary to continue what had already been initiated. Upon my arrival, I was surprised to see the patient almost completely (100%) burned but complete conscious, turning herself around to get water to all parts of the body and then not having any serious pain. It was therefore no big task to persuade her to continue, while the Central was looking for a burns unit to admit her and I installed an infusion. With a certain delay (to avoid their arrival too soon), we called the helicopter. While it was clear that the extensive burns in the long run would make an anaesthesia necessary and in order to facilitate analgesia during the transport, I performed a nasotracheal intubation.

Fig 3: The anaesthetized patient is brought to the helicopter (22).

Now you can imagine which effect it has, on a warm sunny sunday, with everybody outside without any pressing tasks, when suddenly an ambulance, the fireworks, police, the emergency physician and somewhat later the helicopter comes with an acoustic announcement that here is something to look at (perhaps I should have sold my books upon that occasion). When the helicopter landed, the patient was anaesthetized and the garden tube replaced by humid towels. In a way a perfect mission, had it only been rewarded by a positive outcome.

The next day, they called from Basle and asked me to get the patient back to our own intensive care unit. With these most extensive 3rd degree burns, they did not see any chances for her recovery. Of course, we arranged the transfer immediately; Basle is in another country and when they had finished their extensive trauma care, it was also in our interest to relieve their intensive care unit as fast as possible, aside from formal reasons to bring dying patients back to their native country. The patient was still intubated and was receiving a continued anaesthesia with ketamin, at least she was prevented from feeling pain in this way. She died a few hours after the transfer.

Next chapter:
Rescue Techniques

Revised May 15, 2001