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Mon Jan 8 12:24:56 GMT 2007

Tough call, Lance, 'cause we weren't there, and that counts for a whole
lot.  Now, having said that, first move was appropriate - pre-oxygenate.
 While I understand that the flight was going to be a long one, and I
too would be concerned enough, given the circumstances and presumed SCI
with the possibility of ascending edema and further respiratory
compromise, to consider intubation.  The good news is that the patient
was - by your report - maintaining his own airway with a SO2 of 94% on
60% mask.  Couple of questions - did you or the doc have a bougie or LMA
available?  How about a CombiTube?  I think - and again being there is
half the battle when you are asked to be the Monday morning quarterback
- those might have been reasonable options in a fellow that was
maintaining his sats and was easy to breathe with a BVM.
Given the fact that you are a paramedic, and the doc was not able to
intubate, forgive me for being a bit harsh when I say that I think that
he should have left his ego at the door after 3 failed attempts and at
least given you a look, as long as you were able to maintain adequate
oxygenation - and I must stress that last part of the statement.  If you
weren't then going to a cric would have been appropriate. 

Just my long distance 2 cents.

Take care,
Ron 

>>> "LanceO Oosthuizen" <LanceO at sedibeng.gov.za> 1/7/2007 1:46 PM >>>
Hi All

I am an ALS paramedic from SA just south of Johannesburg. Just recently
I received a call of a male patient 29 who came off a quad bike in a
remote area just out side the town where I live. The mechanism was that
he veered off the road and hit a wire fence and well cemented pole next
to the road. He was not wearing a helmet.

O/A I found the patient lying supine about 4 m from the point of
impact. The patients vitals were as follows:

GCS = 12/15
BP = 110/45
Pulse = 64 bpm no significant pathology on the ECG tracing
HGT = 5.4 mmol/l
SpO2 = 94% with 60 % re-breather.

H-T revealed that the patient has no neurological function from the
shoulders down, even to deep pain stimulation. there were areas of
mottling and the patient had parasthaesia over the left anterior
abdominal area. There were abrasions to the hands and the left flank.
The patient had an ethanol smell on the breath and bystanders mentioned
that he had been drinking.

My immediate action was to control c-spine manually and fully
immobilize the patient, insert bilateral large bore I.V. lines. We were
about 100 km from the nearest facility with a neurosurgeon. My reaction
was to task the medical helicopter to cas-evac the patient to the
hospital.

When the Chopper arrived the attending Doctor assessed the patient and
elected to RSI the patient, due to the distance (20 min flight) and
patient was intoxicated. After administering etomidate and sux  the
Doctor then proceeded the intubation, first attempt was unsuccessful the
patient was then pre-oxygenated to a sats of 99%. Second and third
attempt was also unsuccessful, but managing to pre-oxygenate the patient
after each failed attempt. He mentioned that the patient has a difficult
air-way and was difficult to visualize the cords.

After the third failed attempt the Doctor then elected for an
"emergency cric" on the patient. I requested one more attempt by my self
and he refused me to have an attempt, I made it known to him that I
thought to go for an cric was a bit of a harsh move now. None the less
he still proceeded. Several attempts were made at the cric, but with no
success, I then stood in and lost my temper a bit and told the Doctor to
stand aside and that I would take over now and attempt to intubate the
patient orally. I managed to intubate the patient on the first attempt
visualizing the cords with ease. I would score the patients air way a 2
for difficulty at the most as he did have a rather large tongue and the
epiglottis was also larger than usual.

I am just requesting the view of any one on this call, on the 24th
January 2007 I will be attending a M&M on this matter.

Regards,

Lance
Critical Care Assistant Paramedic South Africa.

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