Best intentions (7)

The largest accidents

(38) Father knew that he should not drive when he had drunk too much, but he was most unsatisfied with his wife's way of driving. After a loud discussion, he decided to stop the car by removing the key. It did indeed stop, but quite unexpected and without activating any braking light. As a result, quite a number of cars collided at the main road. I was brought by the police and never saw the colleague on call there, he was taking care of two children in a rescue ambulance. When you arrive too early at a big accident, it is practically impossible to survey who are involved in it, so I started in the rank of order as I met them and they seemed seriously injured (later the problem is that there are too many helpers in order to make a survey of them, while the patients may disappear in the crowd). The first I met had a complex fracture of the thigh and strong pain, so she got an analgesic and was left again, since there was no vital danger. The firemen told that there were at least 10 injured (eventually there were 17), so I asked the police to transfer this information to our dispatch Central, leaving it to them to get further enforcement. They sent a number of ambulances, two helicopters and further two physicians. Then I tried to establish a place for triage of the injured, in order to survey their therapy and select the urgency and mode of transport to different hospitals. In practice, it did not work well, since many of the victims were still confined in the car wrecks while others were already brought into different ambulances. It therefore became necessary to forbid any ambulance to drive away without a doctor ordering it, the reason of this precaution to be described later.

Having given these orders, I came to the next patient, entrapped and with multiple fractures but about to be liberated. A "pirate anaesthesia" as previously described speeded up liberation. This was repeated at the next car wrack. Then followed two vitally threatened patients in need of intubation and fast transport, but then the worst was taken care of and I was about to see what it was all about. I saw some other patients, unfortunately still remaining in the ambulances. Then I returned to what should have been the collecting place where only three patients were found, two , apparently less injured and the before-mentioned woman with the complex fracture but still persistent serious pain - no wonder by this fracture. Under other circumstances, I would have started an intubation anaesthesia, to be carried on for the operation, but these surroundings did not invite for maximal therapy, so instead she received a pirate anaesthesia for transferral to the vacuum mattress and simultaneous provisionally setting of the fracture. The other two were given lowest priority for transport.

The helicopter from Basel landed and took care of one of the children which was brought to the Children's Hospital in Basel while the other was taken to the paediatric unit in Lörrach by my colleague, who had intubated both within the ambulance. One of the intubated patients were transferred to a colleague from Schopfheim, for the other one the helicopter was approaching and another colleague had almost arrived, as my personal radio receiver gave another alarm. I ran to the turn-out car (I had arrived with the police but all 5 consultants had a key for it) and was ordered to a new mission, just a few km away where a train had hit some people. Later, I realized that it was a mistake to leave this mass-accident and it had been more suitable to send the other emergency physician who had not yet arrived, but I cannot change that now. I utilized my car-key and went on the new mission, without the assistance of any ambulance.

An elderly woman had tried to prevent a friend from throwing herself in front of the train. She had not succeeded and was, in addition, herself hit by the train. Her friend had died, so I informed the dispatch central that there was only one patient, but she was seriously injured. She was in a profoundly shocked state and was confused but not unconscious and resisted all attempts to help her. Simply in order to proceed, I was forced to start a "wildcat anaesthesia" (an injection of ketamin into a muscle). Some minutes later, it was possible to establish an i.v. line, which was used for an intubation anaesthesia - my sixth open-air anaesthesia that evening. Shortly after, a rescue ambulance did turn up. We brought the patient to Lörrach for immediate operation but she died two hours later due to internal bleeding.

From the big accident, all 17 wounded patients survived, which may cause wonder when you see how many were vitally threatened. Nevertheless, I must confess, with a certain regret, that the most seriously injured was the one who left the place with the last ambulance, whom I had given lowest priority. He was transferred to the hospital in Rheinfelden where they found a traumatic, thoracic aortic aneurysm near the heart. He was then flown to Freiburg and operated there. My colleagues and I have experienced this phenomenon, the the most seriously wounded was to be found among the ones who were best off after the accident, on several occasions. Acknowledging that you cannot avoid it, this is the reason for recommending all apparently less injured patients examined another time when the others have gone, which means that you should take care to avoid any participants in mass-accidents and catastrophes disappearing from the accident site - they also need attention!

Although this was not the biggest accident I have dealt with as emergency physician, it does illustrate the need for other peculiar dispositions on such occasions. Generally, only few patients need speedy operation, but exactly for them, there must be an ambulance (or a helicopter) kept ready. Many more will need some help at the site, e.g. for liberation or setting of fractures, but may then be kept for a while on the site. For that purpose, manpower of the paramedics who arrived with ambulances are necessary. Instinctly, however, many paramedics will transport the patients in their rank of appearance, hoping that it will then be easier to survey the remaining. Not objecting that there may be some who can only be saved by acute operation, it is necessary to let a doctor on the spot make this decision and therefore forbid unauthorized transport. Finally, the old tradition of "importing the catastrophe to the nearest hospital" should be discouraged. Again, it is preferable it a doctor decides what is the appropriate clinic for a given patient (they do not all need a trauma centre). In this case, 8 hospitals received patients and none of them were stressed beyond reasons. Of course, everything could have been done better, and doing better next time is the purpose of analysing all mass-accidents afterwards.

(39) A group of French soldiers camped on the right side of the Rhine and unexpectedly ignited a fire just over a bomb from the 2nd World War. Following the subsequent explosion, one of the young men were instantly killed and several others seriously injured. It was not far from the city of Müllheim, from where the first emergency physician arrived, who subsequently required enforcement, leading to my arrival with a helicopter. The Swiss helicopter, I had arrived with, flew one of the soldiers after minimal treatment to Basle while I was left to take care of two others. Nearby, a big French transport helicopter (Alouette Puma) had landed and I was informed that another German helicopter was on its way. Having brought my own emergency bag along, I had enough equipment to establish a venous line and intubate both soldiers, of whom one was unconscious with a cranial trauma while the other was in a state of shock and an opened stomach. Unfortunately, I was only in possession of one ventilation bag, but my technique permitted nasotracheal intubation without necessarily ventilating the patients. I required the Puma for flying both of these soldiers to Colmar and we got them on board along with some of the less injured. Normally, we would say that our rescue helicopters had everything except room in them, but in the Puma, it was completely reverse: lots of room and nothing else. Anyhow, I thought, Colmar was not far away, on the other side of the Rhine. It did indeed only last some 5 minutes to reach Colmar, but then another 10 minutes to find the hospital from the air. I was slowly finding it embarrassing only to be able to ventilate one of the patients. Shortly after having admitted the soldiers, who all survived their meeting with the bomb, the REGA helicopter picked me up again and informed me that there was no reason to go back again.

Only later was I informed about, what had happened to the crew from the helicopter of Bremgarten. They had received another soldier in a critical condition but in the meantime, French gendarmes had arrived. They asked where he was going to be admitted and they explained that his condition called for immediate operation in a trauma centre, for which they had foreseen (German) Freiburg . In response, they were shown a machine-gun and told that "this is a French soldier, accordingly he is going to France!" Understanding that medical arguments were secondarily towards patriotically ones, the crew responded that of course, it was also possible to fly him to Strasbourg, another 30 min flight away. They were permitted the takeoff and flew first over the Rhine, in direction of Strasbourg, but soon made a long bow backwards towards Freiburg. Also this young man survived, for which the gendarmes cannot be granted any thanks.

(40) In 1988, some pilots performed a very low flight with a fully boarded new Airbus over Mulhouse's old airport by Habsheim, where an air show was simultaneously being carried out. It could have been a record if they had gone it up again but instead the tail was caught by some trees and the plane was grounded in the wood just North of the roll-off track. Astonishingly, only three passengers were killed upon that occasion while about 150 passengers and crew members were evacuated to the nearby preliminary terminal. This was now used for triage according to an old-fashioned catastrophe-medical principle.

It lasted half an hour before the near situated Euroairport Basel-Mulhouse were informed. Through REGA, information was transferred to German and Swiss units. With one REGA-helicopter, two physicians were brought from the University Hospital of Basle while I and a colleague were flown there from Germany. I shall never forget the view of the crowded building, including some stewardesses with tears in their eyes (whether due to relief or despair, I do not know). Then, however, a doctor approached us and told politely that all seriously injured patients had already been removed to one of the two big hospitals in Mulhouse (in the meantime they have been fused) and there was no need for us any more, but thanks for coming. I asked if we could perhaps use our helicopters in these hospitals for a better distribution to other hospitals (a key point in the management of several victims) but again, he denied that there was any use for that, after which he kindly showed us the way out so that he could continue his registration. Completely unemployed in this chaos, where ambulances where howling for- and backwards, we strolled into the wreck, which had burned out completely, not revealing how many had been burned with it. The gendarmes starred suspiciously upon us but we were tolerated as long as they anyhow were using one of our helicopters to make area pictures. Then we flew empty back and could just notice that at least our own hospital had mobilized a sufficient amount of helpers who were sent back home. Later that day, the University Hospital of Basle informed that they had received a considerable number of patients with stable vertebral fractures (the typical injury pattern of a severe, axial deceleration) who had been brought with private cars after the blunt landing. Again a hint of that who appears to be well off may not be so, after all.

And then we were better off than a disaster team from German Bad Krozingen which were stopped at the border. I reported this abortive mission in a critical report which was discussed with both the administration of the Euroairport and doctors of the French SAMU-68 (Societé Ambulances Medicalè et des Urgences) in Mulhouse. Perhaps this friendly discussion was not very fruitful but I made the point that even if our help was never needed in France, we should gladly welcome theirs whenever necessary.

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Revised May 15, 2001