PHARM Historical Case Studies

Prehospital and Retrieval Medicine Podcast

A tale of two traumas, two women, two continents and two approaches to prehospital care.

Introduction

In 1996, Lady Diana was in a serious car crash at over 85mph in a Paris tunnel. She and her bodyguard were the only survivors, on arrival of the French prehospital services within twelve minutes. She arrested on extrication and had to be resuscitated by a prehospital doctor. Despite clearly a critical traumatic arrest, it took over ninety minutes from the time of the accident to arrival at the trauma hospital a few miles away. In the ambulance ride, a dopamine infusion was started after the arrest to treat hypotension. The ambulance was stopped during the transport, due to a drop in blood pressure and the dopamine infusion adjusted. Lady Diana died despite all efforts from exsanguinating thoracic injury to left pulmonary vein. Her bodyguard was the sole survivor and was the only one wearing a seat belt.

In early 2011, Senator Giffords was shot in the head with a 9mm pistol at close range during a community event at a shopping centre in Tucson, Arizona. Her intern rendered immediate first aid. Prehospital services arrived within ten minutes of the shooting. Paramedics quickly triaged Giffords to a rapid road transport to the nearest trauma hospital and she arrived there and was undergoing a decompressive craniectomy within thirty eight minutes from wounding. She survived the assassination attempt and made a steady recovery and paid tribute to those killed that day, at the one year anniversary ceremony in 2012.

Discussion

Two prominent women , on two different continents, suffering life threatening trauma with two very different prehospital systems of care. One doctor based, utilising specialist doctors and nurses in mobile intensive care units, the other paramedic based. One strategy of bringing the emergency room care to the patient, versus the other of transporting the patient quickly to the emergency room. Of the two victims of trauma here, one survivor. Did rapid transport make the difference here? What are the lessons if any that can be gleaned from comparing these two trauma cases and the optimal prehospital care for the critically injured?

Its a complex question and in the past has been oversimplified by the expression : Scoop and run or stay and play?

If one were to argue that clearly Senator Giffords case demonstrates the superior North American prehospital strategy of rapid transport for severe trauma versus trying to provide advanced resuscitation procedures at the scene, then the pitfalls of such an approach need to be highlighted. Gifford’s intern is credited with saving her life by providing immediate haemorrhage control and airway clearance. Without this , no matter how quick the transport, she would have likely died. So clearly there are life saving interventions that need to be done as soon as possible.

The longer the transport time, the more need of early and ongoing critical care resuscitation for the critical trauma patient. For example if the shooting had occurred on a cruise ship in the middle of the Pacific and helicopter retrieval was going to take several hours, then no one would question the need to provide early advanced airway support and ventilation and perhaps even resuscitative surgical interventions under remote guidance/advice.

Take home messages

1. Basic trauma first aid might be more effective than a dopamine infusion in the haemorrhaging trauma patient
2. If you are in Paris or Tucson and suffer a critical injury, it might be better to get to a trauma hospital within twelve minutes, than ninety minutes
3. There is no one size fits all answer to severe trauma

Stay safe

Dr Minh Le Cong

Lady Diana references

http://downloads.bbc.co.uk/news/nol/shared/bsp/hi/pdfs/14_12_06_diana_report.pdf

Chapter Eight, page 511 onwards

http://abcnews.go.com/Health/HealthCare/t/story?id=8437560

Senator Giffords references

http://en.wikipedia.org/wiki/2011_Tucson_shooting

http://www.wwlp.com/dpp/health/healthy_living/study-chopper-trauma-transport-improves-survival-chances

http://m.jems.com/article/priority-traffic/northwest-fire-rescue-district

My brief audio recording of personal views and analysis of the learning points from these trauma cases is below link:

http://traffic.libsyn.com/emcrit/prmp-tale-of-2-traumas.mp3

Right Click and Choose Save-as to Download