Critical illness is part of the remit of rural doctors, albeit encountered relatively infrequently – which of course makes it all the more challenging! Moreover rural doctors have to deal with such cases with limited staff, no backup and paucity of lab tests and definitive care.
Perhaps one of the most commonly encountered true emergencies in the bush is dealing with major haemorrhage. Our patients work on farms, in heavy industry, or are involved in road crashes.
Let’s consider a hypothetical case and see how FOAMed could help.
It’s Tuesday morning and you are busy working through a routine Primary Care Clinic in anticipation of the afternoon off. The local Rotary are hosting a BBQ at the nearby football oval and you’ve been invited as a guest speaker on the pros & cons of prostate cancer testing.
Clinic is rudely interrupted by a loud “BANG” from the direction of the footy pitch – looking out the window you see a pyre of smoke and decide to abandon Clinic to investigate.
On arrival you see the local bank manager, a proud Rotarian, lying on his back. Community members tell you that the gas BBQ exploded, igniting other gas cylinders. He was thrown some 8m backwards through a window, impacting a goalpost in his rotund abdomen & is now flailing around on the footy pitch with an obvious source of bleeding…
A – Crying in pain, hoarse voice, obvious facial burns
B – RR 26 bilateral BS, PN symmetrical, trachea central
C – obvious traumatic amputation. P 120 BP 80. Cap refill 3 secs. Tender in LUQ.
D – localises pain, groaning only, eyes open spontaneously
E – clothing tattered. Numerous glass shards embedded in zone 2 of neck and across the shoulder girdle.
Q1 : What are your priorities in managing this patient?
Yes, we’ve all done EMST/ATLS courses. But does this approach really work?
Q2 : What equipment is available in YOUR hospital (or prehospital pack) to help manage his bleeding?
Circumstances will differ – I’m interested in your answers!
Q3 : The patient has a history of non-valvular atrial fibrillation. Some bright spark (not you) decided to start him on dabigatran 3 months ago. What next?
Like it or not, there’s a whole gamut of new blood thinners out there – which affect trauma management.
Q4 : Retrieval services are flat out elsewhere in the State and will take at least 2 hours to arrive. Is there anything else that can be done locally?
Again circumstances will differ – some rural hospitals will have theatre capability and access to blood – some not. Interested in your responses