Scenario – 58yo male (Phil) with probable spinal injury following fall from height in the Blue Mountains.
Scene – Local paramedics have accessed remote bush scene by foot. AW139 responded with doc and para from Bankstown. Para & Doc winched into scene.
Patient – Denies any LOC but complains of lower leg parasthesiae and weakness. Local crew have already provided C-collar, bilateral IV access and 2.5mg morphine by time helo team arrive. Medical assessment consistent with isolated spinal injury, GCS 15, haemodynamically stable. Patient packaged accordingly with KED and “Roman” (a handled sleeping bag used for thermoprotection, comfort, and handling) into stretcher. Accompanied stretcher winch performed. En route to RNSH patient begins to vomit and becomes increasingly agitated. Loses both IV cannulae. Obstructs airway following emergency IM sedation.
- Patient’s size: stretcher is not long enough for a patient of Phil’s height. Very uncomfortable for the awake patient. Heavy to roll/lift with spinal precautions given limited personnel on scene.
- Managing vomiting in a spinal patient without a secure airway while in the air.
- Controlling a combative/agtitated patient in the air when IV access is lost.
- Managing airway in flight.
Learning points from debrief for clinical practice :
- Spinal immobilisation and stretchering can be very uncomfortable (just ask Phil). Try to optimise positioning, padding, analgesia.
- Consider anti-emetic before winching/flight. This raises the question of what agent is most suitable? Is Promethazine the only agent with an evidence base for motion-sickness?
- Once a spinal patient starts vomiting we need to be able to roll the stretcher (not possible if 4 point side restraints are connected) and reach the suction. If the doc and para are both seated in the rear jump-seats access to suction is awkward.
- Controlling an agitated patient without IV access is difficult in flight. We do not carry pre-drawn drugs in a concentration appropriate for IM. There are pointy needles in the para’s thigh pouch or primary pack we could use to deliver IM if don’t have any on us. Alternatively could consider interosseous, intranasal, buccal routes. Pros and cons of each with respect to specific patient, onset of action etc. In this scenario 15mg Midaz was given IM (from the 15mg/3mL vial in red pouch).
- Options for maintaining airway patency in flight include simple manoeuvres and adjuncts (jaw thrust/Guedel etc). LMA might be considered also. Intubation will require landing at a suitable site.
Learning points from debrief for Simulation practice:
- Try not to drop the winch hook on the patient.
Thanks to Lucas Fox (doc), Greg Kirk (para), Pat Crowe(aircrew), Phil Parry(actor), Ruby (SRC), Rory (STAR)
Interested to hear if you routinely consider the use of a nasogastric tube for the non-intubated spinal patient. Was an NG considered an option in this scenario?
Good question Dave. We didn’t focus specifically on this issue in the scenario but it is certainly something that needs to be considered.
Placing an NGT would be standard practice in the case of the intubated spinal patient (provided there were no contraindications eg. suspected base of skull fracture).
However, I think the decision to insert an NGT in the non-intubated spinal patient needs to be made on a case-by-case basis where the risks & benefits to the particular patient are weighed up. For instance, the risks (including gagging, vomiting, micro-aspiration) of placing an NGT in an awake patient without a secured airway might outweigh the anticipated benefits in the case of a low spinal injury and low risk of ANS dysfunction/paralytic ileus. Mode of transport and distance to travel might also be important considerations.
I would be keen to hear other points of view.