Mark Nettleton can count on my support. When I started serious Immediate
Care back in 1988 I still had a lot to learn, and unlearn. The major thing
to unlearn was that only anaesthetists should sedate casualties.
The logic is overwhelmingly in support of sedation or anaesthesia with RSI
if you have the confidence. The head injured and restless casualty is using
a lot of his remaining brain and using oxygen. Hypoxic brains swell. He
isn't controlling his airway properly because he isn't aware he needs to,
and he is usually ventilating inadequately as he strains to fight you. He
oftens performs a Valsalva to splint the thorax and enable better use of
his pectorals and raises ICP with it. Raising the JVP encourages bleeding.
He isn't guarding his C. spine, and his movements are not only aggravating
limb injuries but also increasing his pain and restlessness.
I not only think these casualties need to be flattened but I think it is
bordering on the inexcusable not to. The Immediate Care doctor is closer to
the Fire fighters and Ambulance crew than the Hospital Consultants when it
comes to the way situations are handled. The only consultants who have a
right to comment on Immediate Care are those who have looked after the
critically injured at night, in a ditch or a field, with horizontal sleet
coming through the broken windows. Those guys, and there are enough of
them, I will listen to.
Vic Calland.
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