Managing An Unconscious Patient (by Dr JB Lim)

Dr Lim Ju Boo providing training for Basic Trauma Care 02 in 2004 for HUKM

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The blogger’s note:   After posting Dr JB Lim’s comment on “Doctors Refused To Treat” earlier (see http://taionn.blogspot.com/2012/08/doctors-refused-to-treat-comment-by-dr.html), the blogger received an email from Dr Lim requesting to delete because the comments were “very casual remarks and loosely written”.  He has rewritten the article “with a little bit more details and explanation to make it more presentable, but still very simple to understand so that outside visitors of this blog will find the article more professional”.   In addition to that, Dr Lim also provided some interesting slides which he used to train others for St John Ambulance Malaysia for the purpose of illustration in this blog.

The blogger cannot express how appreciative and grateful he is towards Dr Lim the true 'Great Sifu' for the latter's most considerate contribution.  The blogger further feels that the original version was already well presented and needs not be deleted.  That earlier posting serves to be a proof of how earnest, prudent and professional a scientist-cum-writer Dr Lim really is.  Such remarkable and noble traits should indeed be looked up on and exemplified by everybody.
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Look at this:

http://thestar.com.my/news/story.asp?file=/2012/7/30/nation/11755473&sec=nation

How can they ever do this? What has become of this, supposed to be a life saving profession? It has now become a life-destroying business.

Maybe it was not the doctor or nurse who did this, but the hospital because doctors are just employees in hospitals normally run by businessman.

Hospital administration:

Doctors working in hospitals, especially the private ones are powerless against hospital policy, management and their administration. They often have to follow rules and regulations set up by the management of the hospital, and they cannot have their own ways.

But there are also many cases of doctors running their own private clinic who refuses to treat a patient. They just ask them to go to a hospital especially emergency cases where they cannot manage or do not have the facility to do so. Some have personal reasons.

An example:

For instance, many years some doctors undergoing a course in Trauma Life Support together with me at Selayang Hospital, and later at the Emergency Dept of University Hospital Kebangsaan Malaysia told me of a number of cases where doctors working in their own private clinics refused to attend to emergency cases for personal reasons.

They cited a case of a child who was unconscious, not breathing, and was rushed into a private clinic somewhere in KL.

My course mates told me of doctors who refused to attend to the child because the child had vomitus in his mouth. The doctors refused to apply mouth-to-mouth respiration on the child because they said they were afraid of getting their mouths dirty and smelly with the child’s vomitus.

The parents were asked to take the child to the hospital instead. This is very ridiculous and highly unprofessional since the child was already unconscious was already not breathing.

Death within minutes:

Naturally the child died within minutes in the parents arms because the brain cannot stand without oxygen for more than 3 minutes due to cerebral anoxia leading to brain stem death as the brain requires about 3.3 ml of oxygen per 100 g of brain tissue per minute for adequate perfusion.

Airways & face masks:

Having vomitus, fluid, water or blood in the mouth or face and not wanting to apply mouth-to-mouth respiration instantly is no excuse. If the child or any patient is brought into his clinic, this should not be a problem. The doctor could have used a special face mask called a laryngeal mask airway to ventilate the patient in an emergency.

Ventilating devices:

A laryngeal mask airway can be used in an emergency airways management during resuscitation efforts even by first responders. The doctor or first responder could the blow into the ventilating tube provided with the face mask. Alternatively, he could also use a suitable sized Ambu bag to ventilate the child.

Yet another alternative method is to use an oxygen mask or a Bag-valve mask attached to an oxygen cylinder with a demand valve. All these are simple emergency ventilating devices which should readily be available even in a small private clinic.

Non-emergency cases only:

Unfortunately most doctors would rather not have them as there are problems dealing with trauma and emergency cases alone with an untrained nurse employed in a private clinic. They would rather prefer to treat ‘cold cases’ like coughs, cold, fever, diarrhea, vomiting and chills, uncomplicated diabetes and high blood pressure Anything beyond that, they ask the patient to go to a hospital.

First-aid and pre-hospital management:

In an unconscious patient whether in a child or in an adult, the important thing is to ensure the airways are not obstructed. This can easily be done by merely tilting the head and lifting the chin (head tilt-chin lift procedure), and then blow into the lung twice if not breathing by looking at the rise and fall of the chest, listening and feeling for the breath (look, listen and feel).

Ensure establishment of ABC (Airways, Breathing and Circulation). If not, instantly tilt the head and lift the chin to (head tilt, chin lift) to open up the airways, followed by two puff of expired air from the rescuer into the mouth of the victim after pinching the nostrils of victim closed, and sealing the victims mouth with the rescuers mouth and blow into the chest.

Look for a rise in the chest as air is being blown in. Check for circulation over the carotid pulse after two puffs of air. If no pulse is detected, commence immediate chest compression with 30 compressions at a rate of 100 times per minute before giving another two puffs of expired air into the victim’s lungs.

AHA Guildlines:

However, according to the American Heart Association (AHA) latest guidelines, the emphasis should now be more on cardiac compression –airways and breathing (CAB) rather than ABC. Even feeling for circulation is also now considered not important according to the AHA, as it is sometimes difficult to feel the carotid pulse within 5 seconds.

For adults and children the carotid pulse should be used to check for circulation, whereas in an infant the brachial pulse should be used. If the AHA latest guidelines are followed, the emphasis should now be on providing high-quality chest compressions

This immediate simple procedure could have saved the child’s life with or without the vomitus present. Any fluid, blood or vomitus in the mouth, throat or airways can easily be sucked out with a tube under vacuum by intubation with an oropharyngeal airway (oral airway, OPA or Guedel airway) or via a nasopharyngeal tube.

Simple rescue devices and CPR:

Even a small private clinic should be equipped with at least an Ambu bag, and some form of emergency airways management devices such as B.V.M used with mask, tracheal tube, and other airway adjunct.

Even without these adjunct, just head tilt chin lift, pinch the nose tight, seal mouth of rescuer and mouth of child or any casualty, can do the job well with two puffs of expired air from the rescuer, and apply chest compression with 2 or 3 fingers over the centre of the chest, away from the xiphoid process at rate of 100 times per minute over to a depth of 3 ½ cm (1.5 inches) or about 1/3 the depth of the chest for an infant or small child. In adult, the chest compression should be to a depth of about 5 cm (2 inches)

Activate EMS immediately:

The doctor or rescuer should get someone to activate the EMS (Emergency Medical Service) for an ambulance such as St John Ambulance Malaysia

Unfortunately most doctors in private clinics do not want to attend to such emergency cases. They also do not want any ambulance to go to their clinic because this is bad for business for them. We all know about this.

Moreover, most doctors are also not well trained in emergency medicine unless they work in an emergency department of a large hospital before.

There is no time to ask the casualty or his relatives to send him to a hospital on his own. It totally makes no sense.

The Crucial Minutes:

The critical 3 minutes of cerebral hypoxia (oxygen insufficiency), or worse still, a total shut-off of blood supply, oxygen and perfusion to the brain (cerebral anoxia) determines life or death within minutes.

Ignorance on first-aid:

Worse still, most doctors do not know first-aid or pre-hospital care. In first-aid they are supposed to use only their brains, eyes, ears and bare hands for immediate resuscitation, but unfortunately doctors must have needles, syringes, tubes and drugs.

Without them they are helpless and cannot manage. There is no time for all these needles, tubes and medicines. For what are these in cardiopulmonary resuscitation (CPR)?

Almost all doctors do not know first-aid. A trained and qualified paramedic can do the job far, far better.

The Golden Hour:

There is also just no time to ask a casualty to go, or be sent to a hospital. It is the first hour – dubbed “The Golden Hour” especially in trauma case or in acute myocardial infarction (heart attack) before the casualty can reach a hospital that counts. Time is exceeding crucial for the survival of a patient.

The Triage System:

In Government hospitals in Malaysia today, they introduce the ‘Triage System’ which determines the priority given to patients according to the severity of each case, especially in mass casualties when resources are insufficient. The cases are sorted out using colored codes or into coloured zones, or coloured labeling for patients such as immediate treatment (red), serious, but can be delayed a bit (yellow), those are conscious and can walk about, considered as minor (green), and those who are already dead (black or white).

This is a very beautiful system found in almost every Medical Emergency Department of a Government hospital in Malaysia today. The term ‘triage’ is a French word to mean ‘to sort out, to separate, or to prioritize’ for emergency treatment.

Unfortunately in a private hospital this system is not there at all. Instead, the more important ‘system’ is to ask for a cash deposit or for your credit card first. Money obviously is more important than life in any private enterprise.

All this is very unfortunate.

Lim ju boo, BSc (Physiol) MSc Postgrad Dip Nutr MSc MD PhD (Med) FRSPH FRSM

Advanced Cardiac Life Support

Regional Staff Officer for Training

St. John Ambulance Malaysia

(Note:  All illustrations above are provided by courtesy of Dr JB Lim)

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Feedback from Dr JB Lim:

Friday, 10 August, 2012 8:30 PM

From: lim juboo

Dear Sifu Ir. Lau,

Aiyah! Why you 'glorify' me in your blog? It is nothing, just my simple hobby to write something casual to share, else Alzheimer's disease, the un-welcomed visitor waiting next door will come a-knocking at my door. I hardly can afford such a visitor.

All my life I have been a medical researcher confined to lab work, and sometimes clinical work in the field and rural areas. Now on retirement I might as well make full use of my training and apply them in a more dramatic clinical setting such as giving my service in pre-hospital care, trauma and emergency medicine.

Else life is very static and boring, other than practicing my violin on some concerto pieces and symphonic works by great composers. I wish I was a concert violinist, a mathematician, an astronomer, a nuclear physicist or a pilot. Those were actually my childhood love, and still yearn for them. Leopards can never change their spot, the adage says.

Unfortunately an ill-wind kept blowing me to land on the wrong runway.

regards

jb lim

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The blogger replies as follows:
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Friday, 10 August, 2012 9:47 PM

Dear Great Sifu,

The more unassuming and modest you are, the higher level of respect we must salute you with.

I always find your responses and/or remarks in many of your emails to your e-buddies forceful, witty, humorous and inspiring, in spite of also being sarcastic at times (like when you take those bogus professionals and internet junk mails to task). Although sometime you write in a very casual way, the contents are to me very amusing, enlightening and worthy of sharing with others.

Do allow me to continue to post your writings (not limited to medical care or nutrition only, but also other topics/hobbies you are equally versatile and excellent at) as and when suitable.

Thank you.

A faithful blog 'publisher'