Thursday, January 01, 2009

new year's eve triage

triage is taught to us all, but unless you find yourself in a war, you don't use that skill too often. when it is needed, somehow all those lectures don't seem to help.

i was working on new year's eve in casualties in qwaqwa. the local population was about one million and the average income was pretty much on the bread line. the bread line, for those who don't know, is way above the alcohol line and significantly above the knife line. there was no shortage of drunken stabbings.

as can be imagined, that night was busy and the later it got, the busier it got. the early evening was only much worse than an average night. but by ten pm all hell had broken loose. the stab wounds started coming in. initially they came in at a rate of about one every twenty minutes, but soon they were walking or being carried through the doors at a rate of one every two to five minutes. there was no way of keeping up. also standard clinical parameters where less helpful. everyone passed out just after lying down (thanks to good old recreational ethanol).

the nurses took vitals as fast as they could, but they could not get to everyone. one of the reasons is there were not nearly enough beds so the bodies lay on the floor so thickly they blocked up the passage. you could literally not walk down the passage because you would stand on the patients.

our triage became fairly coarse. at a stage, looking for a place to plant my next foot between the bodies on my way down the passage, a patient looked up at me and asked;
"when are you going to get to me? i'm in pain!" the simple fact that the patient could speak meant that he was in a much better condition than almost everyone there. the fact that he was making a nuisance of himself meant he was going to wait a very long time.

but the ability to speak was only present in about one percent of the patients, so how did we triage the rest? in the end what it came down to was one thing and one thing only. if the puddle of blood around the patient was growing in size, that patient would get attention first. all the rest were done in the order of how they lay. the ones closest to the suturing room were treated first moving gradually away. one of the reasons for this is the people working in the suture room were figuratively snowed in by the bodies. they had to dig themselves out by suturing the patients and sending them on their way. even if they wanted to treat someone else first they literally couldn't get to him.

finally that night came to an end. everyone was exhausted and limped away from casualties. some of the patients limped too.

7 comments:

rlbates said...

I'm amazed that you and the nurses were able to create some "order" out of that chaos.

storkdok said...

Wow, thanks for your recount of your experience here. I remember similar experiences when my husband and I did a medical student rotation in Papua New Guinea back in 1993. We would hear of a tribal battle in the Highlands, then the bodies, carried by their tribal members, would start pouring in to our clinic. We saw arrow wounds and stone ax wounds the most.

What was the survival rate that night?

Bongi said...

storkdok the drunken stabs aren't usually too bad. the stabber and stabbee are equally drunk so immediately after the initial contacts, both fall down. the injuries are usually on the scalp or face so the bleeding can be impressive, but not too life threatening. wounds inflicted by sober people in battle like you saw would be much worse. i take it you saw head injuries from the stone axes. the arrow wounds would have triaged themselves long before they got to your clinic, so an occasional intercostal drain and a delayed laparotomy and all would be well.

this is a long winded way of saying we did not lose a single patient that night. i doubt you lost too many either back there in papua new guinea. the modern gunshot wound that i see today is much more challenging as far as losing them in casualties or shortly after.

take a look at
http://other-things-amanzi.blogspot.com/2008/01/revenge.html

Jabulani said...

I sincerely doubt you meant this post to amuse, however, as I read this account, I was instantly reminded of the last line of the Volkslid (well, the one that WAS the Volkslid when I still lived there!), with one small amendment:
"Ons sal lewe, ons sal sterwe" ... afhangend van hoe vinnig die dokter by ons kan kom!
The fact that you didn't lose a patient is, for me, testimony to your sheer dedication as medical practitioners in hellish circumstances. Inspirational ...

Anton said...

this was also a very funny line:

"the bread line, for those who don't know, is way above the alcohol line and significantly above the knife line. there was no shortage of drunken stabbings."

storkdok said...

Bongi, it is a testament to your excellent triage and surgical skills that they did so well!

We had an excellent surgeon from the Soloman Islands and a junior surgeon from Australia. There is so much "revenge killing" between tribes in PNG that a surgeon must be from a very far away place or they will be targeted. I enjoyed working with them very much, I learned so much. Like you said, most of the arrow wounds were easy to repair, but one that was into a young man's neck was very bad. It had broken off, but was deep, about 4 inches, right into the vascular structures. Our surgeons did a marvelous job of repairing the damage while my husband did the anesthesia for them, and I assisted and also got blood donations from the relatives. The young man lived and did very well.

There was a tribal fight right before we left between one tribe who were the police for our area, and another. The police chief got a stone ax to his head multiple times, the x-ray looked like a cracked egg. We thought we would have a huge war because on of the other tribe members was also brought it, we put him on another ward after a laparotomy for the GSW. The police surrounded the place with guns, the other tribe was there with bows and arrows and axes. We were able to get the government to airlift out the chief to a larger hospital in Goroka, where he died. Our other patient died as well, he got septic and the antibiotics weren't enough to help him. There was an all out war, the police decimated the other village, then there were a lot of revenge killings, it was so sad to hear. I still keep in touch with some of the nurses there.

We have had some drunken stabbings up here in my little corner of the USA, and they were pretty benign as well. One fellow stabbed himself in the chest right outside the L&D unit with all my patients watching and screaming. He was yelling to his girlfriend that he really wasn't a child molester and to prove it he stabbed himself. Then he beat on the front door with his shoe until someone opened it. Our surgeon got an x-ray, looked okay and pulled it out in the ER. Then on to the psych unit.

I saw a lot of stabbings in medical school at one of our hospitals, we were just outside Los Angelos, CA. Some were pretty bad, even drunk, a machete can do a lot of damage between gang members. But they had better outcomes than the shootings, that's for sure. One of my residents at the time got stabbed in the stairwell by a gangmember. She didn't realize it until she got outside and saw the blood. She said her roll of abdominal fat saved her, it was a short knife and it never went farther than the subcutaneous fat.

In my inner city medical school rotations, it sometimes felt like a war zone, we had so many injuries every night. But they didn't pile up like your night on call.

Anyway, I salute you! A job well done!

DHS said...

fortunately local violent trauma is minimal - the one shooting victim I've seen this year (shotgun injury to the axilla --> brachial plexus) was an accident from negligence.

storkdok: when I was a student I was about to leave the ED to see the bourne movie (about 6pm on a Friday night -- it was a sort of date). suddenly a guy walks in with a soaked cloth over his anterior chest stating he had been stabbed. the ED consultant grabbed me as an assistant flunky and we did the usual resus stuff but as we were trying to get the ICC in there was a lot of difficulty getting through the pleura. the pt was turning white as a ghost. cardiac surgery (we were a heart transplant centre and so had CT on call 24/7) were still about 20 minutes away, so the consultant shoved it in blind and sent him through the scanner.

in the end it turned out he was saved by his gynaecomastia. the ICC actually tunneled through subcutaneous fat up into the axilla.