Asphyxies et blesses

Surgical Rounds®, February 2008, Volume 0, Issue 0

Bernard M. Jaffe, Editor-in-Chief

Bernard M. Jaffe, MD

Professor of Surgery

Department of Surgery

Tulane University

School of Medicine

New Orleans, LA

Restaurants can be dangerous places, aside from their supply of dietary indiscretions. Several years ago, I successfully resuscitated a patron at an adjacent table who had arrested, for causes unrelated to his meal. My most recent restaurant adventure occurred in a small village in France that Marlene and I have visited annually for more than 30 years.

My wife and I were seated outside on the patio, enjoying a delicious meal, when we were surprised by the sudden appearance of a bright red ambulance inscribed with the phrase "secours d'urgence aux asphyxies et blesses." These vehicles, also known as VSABs, provide emergency assistance for people who are asphyxiated (in respiratory distress) and injured. I watched as two emergency medical technicians (EMTs), identifiable by their badges and uniforms, tended to a kitchen employee. It seems that when the chef lit a fire to fry some chicken, the fire flashed and severely burned her hands and face. When the team left with the burn victim 17 minutes later, she had petroleum-jelly dressings on her face and hands (in the shape of mitts) but no IV and no oxygen, and she had received no care for her respiratory system. I could not imagine what the EMTs had been doing for 17 minutes, because little was accomplished.

You may wonder why I paid so much attention to the duration of their visit and the degree of care. Ever since the death of Princess Diana in Paris, I have noted a major difference in philosophy between American and French prehospital care. The French believe in treating victims on site, employing a lot of resuscitative measures at the scene, whereas the American method can be described as "scoop and run." American ambulances take as little time as possible picking up the patient, and EMTs administer care while rapidly transporting the patient to the trauma hospital. Some American traumatologists have criticized the French ambulance attendants who arrived at the Paris scene of Diana's tragic death for spending too much time at the crash site. Some believe that, under ideal circumstances, Diana's injuries might have been survivable. What I had been watching from my restaurant table with such fascination was a prime example of the cumbersome French style of prehospital care.

All surgical residents in the United States are required to have experience caring for the injured, and the Residency Review Committee carefully monitors programs to be certain that the trauma rotations provide the necessary education. Prehospital care, on the other hand, is neither required nor recommended, and I think this is a real deficiency. When I was a medical student at New York University, I was required to accompany EMTs on several ambulance trips, transporting patients to Bellevue Hospital. I vividly recall being summoned to the scene of a street knifing and, on another occasion, carrying a stretcher that held an elderly patient suffering from a coronary occlusion down three flights of stairs from his Lower East Side tenement home to the ambulance. These trips were exciting and educational. Requiring this type of experience would be useful for all medical students and certainly for surgical residents.

Modern ambulances are incredibly well-equipped, including the one we saw in France. My most recent ambulance ride occurred about 10 years ago. The Society of University Surgeons was meeting in New Orleans the weekend before Mardi Gras. An attendee mistook the pecan crust on redfish for breading. He was highly allergic to pecans and had an immediate anaphylactic reaction, which left him unable to breathe. When an epinephrine injection failed to relieve his profound bronchoconstriction, I knew he was in trouble. I hurriedly located an emergency vehicle staffed with EMTs whom I knew, and we sped to Tulane University Hospital along the parade route, dodging the floats. I was concerned that I might have to intubate the visiting surgeon en route and saw that the ambulance had all the necessary equipment. Fortunately, we got him to the hospital quickly enough to avoid intubation, and a few moments after receiving a steroid infusion, my colleague was breathing normally.

My most memorable ambulance trip was in 1979. I was commuting between St. Louis and New York, preparing to assume the role of chairman of surgery at SUNY Downstate Medical Center. Due to a blizzard, we overflew St. Louis and landed in Tulsa, Oklahoma. While retrieving my luggage, I watched as a morbidly obese woman tried to lift a heavy bag and promptly arrested. I immediately started cardiopulmonary resuscitation and invited a fellow-passenger—a firefighter—to initiate mouth-to-mouth breathing. I was astonished at how soon an ambulance arrived at the scene. The technicians quickly loaded the patient into the ambulance while I continued performing chest compressions. A mechanical thumper took this over for me, and I was able to intubate the asystolic patient. I was very proud of my ability to insert an endotracheal tube while bumping along Tulsa's streets at very high speeds. Even more impressive, however, was the EMT's ability to insert two large IV lines into her enormously obese arms, especially with her lack of functional circulation. Because the thumper and ventilator performed much of the work mechanically, the EMT and I had our hands free to provide additional care. Amazingly, some time after administering epinephrine and dopamine (ordered by the receiving emergency department physician because I did not have an Oklahoma medical license), the patient's heart restarted. By the time we arrived at the hospital, she had a pulse and a blood pressure and was fighting the ventilator. The incident offered a great lesson on how much medical care can be provided in a moving, well-equipped ambulance with well-trained personnel.

Looking back at this success story, I find it difficult to understand the French concept of stabilizing patients at the scene. I certainly hope the French burn victim did well. On the whole, despite excellent equipment and skillful EMTs, I do not think she received ideal care from the team responsible for "secours d'urgence aux asphyxies et blesses." In this case, I just don't think the phrase "Vive la France" pertains.