Best Intentions (6)

A Dirty Job

(29) It is not a fancy occupation being an emergency physician. One time I arrived to what proved to be a superfluous mission to a child after having attended the opposite, with Danish colors on my clothing (blood and white). The parents of the febrile child looked at me with disgust and open criticism, indicating that my clothes would leave some wishes open. I could, of course, have explained that there had not been any time to change clothes after the previous mission and I could have added that their alarm, resulting in an emergency physician, had been somewhat exaggerated. Instead, I told that I could also come in fine evening clothes, but that would cost extra.

(30) At another mission to a burning house, there also proved to be no need for an emergency physician but once being there, I decided to observe the extinguishing work near from, as it was not permitted the many spectators. It was indeed interesting to see the firemen in special dresses approach into the house without being able to see anything. As it was no longer so interesting, I decided to drive home. Coming into the turnout car, my nose betrayed an intense smell of smoke. I went directly to get a shower and changed all my clothes, so that other people might stand me, at least what the smelling was concerned. The car still smelled of smoke in the coming days. From that night on, I was difficult to get me very near to burning houses.

(31) Still, another mission carries the label of being the most dirty one. It had rained for several weeks and we talked about a European version of the Monsun and it was about time to get this ark put together in the back garden. In spite of this weather and associated working conditions, a gas pipeline was being constructed, now going upwards a steep hill. Suddenly, one of the big machines used for this particular purpose slipped in the mud and rotated down the hill. The first alarm told that five workers had been buried under it, so the Central sent all it had with wheels on. Counting more accurately, only one worker had been hit as the machine came tumbling down. Generally, survival would be impossible when you were hit by such an instrument but it was probably the slippery ground, which had caused the accident, that also, in turn, saved the man in pressing him down into the mud. I arrived in what seemed to be new ballet shoes and was helped ascending by a fireman with more suitable boots. Arriving at the spot, the man was lying hidden; he was responsive but suffering heavy pain from various fractures. A brief examination did not reveal anything serious, but the injury was of a type which made, among others, spinal fractures possible - I had passed the machine on my way upwards, - and demanded utter caution with the further rescue. Five meters to the wrong side (according to the one we should eventually descend), there was firm soil in the form of a wood, and there the vacuum-mattress was prepared. In the meantime, an intravenous line was established and an analgesic applied through it. With the help of a scoop stretcher, the patient was cautiously lifted, still with his head downwards, and carried over to the wood [Fig. 12]. In the meantime, the helicopter was alerted, fire workers were building an interimistic bridge over the pit around the gas line, and I had asked the workers (all wearing heavy boots) to form a double chain, to help our descend later on. As we reached firm soil, I injected etomidate; 15 seconds later, the anaesthetized patient was turned around onto the vacuummattress and, another few seconds later, had a tube down through the nose to the airways. The helicopter crew arrived and took further charge of the patient. The bridge worked perfectly and also the rescue chain was functioning [Fig. 13], except that it proved impossible to prevent the whole rescue team from utilizing this aided descend (it should only have been the patient and the doctor performing ventilation thus transported). The patient was flown to Basel from where he was discharged after several weeks.

Fig 12: Interimistic bridge (31).

Fig 13: Rescue-chain (31).


(32) Pain can be terrible but the feeling of suffocation is probably worse. Whenever possible, appropriate drugs are attempted but then there are cases simply calling for immediate intubation. Such a case was that of an 18-year-old man who experienced a sudden and serious asthmatic attack. It was just a km away but when I arrived, the patient had a dark blue skin color and was hardly conscious any more. I was lucky to find a vein immediately but then decided to use it for etomidate instead of an antiasthmatic drug. Now the patient did not experience his condition, without having it otherwise improved. Again, it may be called luck that blind nasotracheal intubation succeeded instantly. With the application of a certain type of ventilation and, of course, now also the intravenous drugs, the young man's life could be saved. I cannot help pondering of the outcome if I at first had tried to avoid intubation. Asthma appears to occur more often and also with a more frequent fatal outcome than was previously the case. I have also witnessed some such cases; undoubtedly, the worst was that of a 30-year-old woman living in a flat together with her two fatherless children. The alarm was that of cardiac arrest. Although intubation also succeeded instantly here, it proved practically impossible to get the air into, and in particular out of the lungs. For this purpose, it should be possible to let the patient „inhale“ suitable drugs, not just the uneven distribution following injection of epinephrine through the tube which we, of course, also tried. The development of such a system is one of the challenges which a rescue service can raise on the industry. It will not help the young mother who died on site after energetically resuscitation attempts, but perhaps it can help other asthmatics.

(33) I was called to a case of epilepsy, far away near the highest mountains of the Black Forest. At first, I wondered why the helicopter was used for such an emergency since convulsions have mostly ceased long before the physician arrives. In this case they had not, they had indeed continued for at least 50 min, the longest I have ever experienced. Besides, this was really far away from every village and the air transport proved to be most reasonable, also because of an acute vital threat to the patient who had dark blue colors from lack of oxygen in addition to the general exhaustion and biochemical changes following prolonged muscular activity. Also spectacular was that this was the first case in which I utilized the intramuscular route of midazolam, then a new benzodiazepine (the first one being water-soluble for rapid absorption), since the patients movements were too rigid to get a venous access. Just a few minutes after midazolam, the convulsions almost ceased and the patients ventilation improved instantly. Having secured an i.v. line and a small additional dose of midazolam to stop the remaining muscular movements, the patient was found to remain deeply comatose, and I decided to perform an intubation before the air transport to Lörrach. When this was removed four hours later, a right sided paresis remained for another day, indicating how serious the condition had been. He was discharged a few days later but kindly requested not to stay in such desolated places, in case another attack of epilepsy would occur.

(34) I was called to an old people’s asylum where an elderly lady had complained of breathlessness and, as the paramedics arrived, now had lost consciousness. A distinct respiratory stridor was heard but it was difficult for me to decide if that was her normal condition, having never seen her before (a general handicap in rescue services). Similarly, the nurse on-call had her first service that day and could not contribute further. It was never my intention to postpone a fatal outcome in the high age if, e.g. cardiac arrest had already taken place, but here was neither a clear-cut condition, nor suitable diagnostic hints available, so I decided „in doubt for the accused“ at least to perform an intubation, „in order to facilitate transport,“ as I excused myself. This actually solved the problem, the old patient tolerated the nasotracheal tube without the usual subsequent ventilation and was admitted to our hospital while I was leaving for another mission. The next day, I was called to the medical intensive care unit where they had just removed the tube, thereby being convinced of its persistent necessity. If I would kindly repeat the intubation, now that I become acquainted with the route. A subsequent chest X-ray showed the cause: a huge but almost entirely intrathoracic struma which was compressing the airways but proved to be relatively simple to operate upon. Afterwards, I had a talk with her; it was very impressive to hear her report of repetitive suffocation attacks, but nobody seemed willing to investigate her problems further. A serious warning which, although it has not altered my attitude to resuscitation in high age, illustrates the necessity to help before cardiac arrest is actually present.
 The frequent resuscitation calls to old-prople’s asylums has indeed turned into a problem of its own. Fortunately, I have always responded to the calls there promptly, including the case where it was a nurse assistant who had become a heart attack. The site in itself is no guarantee of, who is actually needing help.

Problems are arising

(35) I have indicated that the colleagues in other rescue services were more thorough than me, but for that reason also rather slow. This created some tensions, which culminated as I one day arrived to a man who had dropped down from a roof. He was intubated and the Central requested to inform our hospital about what they could expect. That proved to be a rather long list, so I was asked if I, under these conditions, would not prefer the helicopter. My answer, ”No, the patient's condition demands immediate transfer,” was heard over radio on the helicopter base, and their reaction was negative in accordance. In the end, I went to Basel with a provoking lecture about „diagnosis vs. therapy with respect to time consumption“. The rescue service calls for compromise, a superficial presence is of no value when field stabilization is attempted, but too thorough an action causes a delay in our on-scene time, which causes a few of our patients (under the given premises, with frequent use of arms even much more) to develop an increasing blood loss, resulting in decreased chances of survival. On this background, it is preferable to listen to the colleagues in the university hospitals who knows everything better. The arguments were accepted, Basel started to monitor the on-scene time and effectivize rescue, which is a necessity for our continued excellent cooperation over the borders.
Also without a call, my presence could be demanded. We were not only responsible for the anaesthesia service in two hospitals but also the rescue service with the car and (initially also) the helicopter, so sometimes, there would be somebody missing - somewhere.

(36) Chased by the police, a car collided with high speed in another after midnight. In consequence, 6 patients were wounded, four of them seriously. The emergency physician on duty required support from the helicopter with a Swiss doctor plus a colleague – and that turned out to be me. The police brought me to the „battlefield“ in Weil – and also the police utilizes the short way through Switzerland when they are in a hurry. When I arrived, the helicopter was about to start transporting the most seriously injured patient to adjacent Basel. It was not a long flight, but utilizing the helicopter on this occasion provided for an extra vehicle with an emergency physician. My fellow consultant joined one of the three patients who were admitted to the two hospitals in Lörrach while I took care of another two patients, scheduled for Mulhouse in France, one of them was fortunately able to sit. The hospital in Mulhouse is difficult to find when you are not coming there frequently, so I requested help from the French police, who met us on the border and escorted us the 25 km as demanded. Although it had ruined my night’s sleep, I was satisfied with this mission, on which occasion we had distributed 6 patients to 4 different hospitals in 3 countries. But then I wanted to drive the big rescue-ambulance back home, just for fun. The local rescue organization did not share the fun and a conflict seemed to result, doctors were not supposed to drive ambulances. This dispute had, however, a completely different background: I had criticized that the emergency physician was often activated too late in spite of a rather clear-cut alarm, and occasionally with fatal consequences for the patient. Now, the rescue service is organized differently: the doctor is sent out to everything, anytime, and still without any attempt to create an effective organization through a more keen analysis of the alarms.

(37) Being called to a train that had been stopped, it was not the medical part of the mission which was interesting, it was finding the train which was very peculiar as it had been stopped far away from everything. The comatose patient was a drug addict who was woken up the usual way as previously described. Then I asked myself why I should pick him up at a distant field, rather than gather him on the next station. The explanation is rather simple - too simple, one might say: emergency in train = emergency brake. Then you might ask, when a red painted emergency brake had done anything good in a modern train the last time, an emergency communication to the driver would probably be more useful.

Next chapter:
The largest accidents

Revised May 15, 2001