CASE 5
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Incident
A 45-year-old male construction worker on a building site has been struck on the head by a scaffold pole. The patient is confused and combative and access to scene is by crane only.
Relevant information
▪ Aircraft: Rotary-wing landing site 1 km (0.6 miles) away
▪ Ground resources: One land ambulance. Police Service
▪ Retrieval options: Major trauma hospital 25 minutes by road
▪ Other: Senior construction-site personnel available on scene
Questions
5.1 What is your initial pre-hospital plan?
5.2 Briefly describe your approach to this particular scene.
Clinical information:
• P 110.
• BP 140/80 mmHg.
• GCS 13 (E4, V4, M5).
• Confused and combative.
Discussion
Scene
Note that this is an atypical scene. The risks of working at height should be considered.
Patient
Getting a confused and combative adult male off a roof will be challenging. The requirement for pre-hospital anaesthesia is a distinct possibility. The patient will also require spinal immobilisation.
Destination
This should be to a neurosurgical centre at least. This job is going to take some time regardless of the efficiency of the team.
5.2 There are clear safety implications for the PHR team in this scenario. Locate the most senior construction site personnel available. Establish that the only way to access the patient is via the crane (e.g. ask questions, such as: are there stairs or a builder’s elevator on the side of the building? How safe is the location of the patient – near the edge, weak floors etc? What extra PPE is required – are fall arrest harnesses appropriate?).
Remember scene safety is the PHR team’s responsibility. If the scene is too unsafe for the team to enter, the patient will have to be brought to you by the builders in the safest way possible. You can assist in this process by offering advice verbally as required. If time allows, the Fire & Rescue Service may be called to assist in planning a more formal extrication.
5.3 Essentially, the different options in this patient’s case relate to whether or not rapid-sequence induction (RSI) and intubation is appropriate. Pre-hospital RSI is a difficult and complex procedure even for the skilled practitioner. Correct patient selection is paramount. Suggested indications for pre-hospital RSI are outlined in the box below.
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