Scenario – 35 year old male kicked in head by horse. Found unconscious in stable (unstable-sic)
Scene – Fading evening light. Landing site 100m away at the top of a field. Stable interior not illuminated, only hand-held lighting available. Single road paramedic crew on scene.
Patient – Airway occasionally polluted by vomitus. Rapid breathing with right sided chest injury evident. Cool peripheries. GCS E3,V4,M5=12/15. PEARL. Facial, forehead and right chest bruising and abrasions. Becomes increasingly unstable and following intubation develops a righ-sided tension pneumothorax.
Challenges – Lighting, access and positioning all better at the aircraft than in a pitch dark stable. Complicating this were the unstable patient, the difficult terrain to traverse en route to the aircraft and the conflict between rapid extrication and more comprehensive assessment. The clinical challenges of identifying the obtunded patient requiring a secure airway, ventilation and a thoracostomy seemed less challenging to our super-slick team than the physical environment they encountered.
Learning points from debrief for clinical practice :
- “Sharing your mental model” – as often as possible with your team and particularly when changing circumstances change your model
- Carriage of an independent personal light source on your person can be critical when you find yourself in a dingy farm outbuilding…alone in the dark
- Awareness of terrain issues as you access the patient will always simplify egress planning
- The AW139 provides a well lit, positioned, equipped and partially sheltered environment for performing an RSI
- The AW139 may pose the hazard of a hot ‘night sun’ attachment on the door side routinely used for the head end in an East-West patient configuration
- The vehicle suction and lights are dependent on the vehicle battery so always have a plan B for battery failure on these items
- The EC145 offers shelter and lighting with substantially less space and more awkward positioning for performing an RSI
- Communicating the likelihood of an intubated patient can mean the aircrew may attach ventilator to ceiling and have the monitoring bridge out of the rear cargo bay ready
Learning points from debrief for Simulation practice :
- A ‘voice in the ear’ approach to describing the imagined scene geography as walking through it can give the paramedic much more to go on for operational planning of access and egress
- Utilisation of our operational aircraft for medical simulation means the entire team can be involved and adds worthwhile fidelity to any job being simulated. It also means we can benefit from both pilot and aircrew contributions to the debriefing process