Editor

Volker Wenzel

Case Studies in Emergency Medicine

A Collection of Memorable Clinically Relevant
Cases with Clinical Pearls
Editor
Volker Wenzel
Department of Anesthesiology, Intensive Care, Emergency Medicine and
Pain Therapy, Friedrichshafen Regional Medical Center and Tettnang
Hospital, Friedrichshafen, Baden-Württemberg, Germany

ISBN 978-3-662-67248-8 e-ISBN 978-3-662-67249-5

https://doi.org/10.1007/978-3-662-67249-5

Translation from the German language edition: “Fallbeispiele

Notfallmedizin” by Volker Wenzel, © Der/die Herausgeber bzw. der/die
Autor(en), exklusiv lizenziert an Springer-Verlag GmbH, DE, ein Teil von
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Preface
There are experiences in emergency medicine everyday life which one does
not forget for professional or human reasons. Unfortunately, colleagues
from other regions can hardly learn from these extraordinary experiences,
because they are usually only communicated in the immediate environment
—they “usually” do not fit into a scientific article, “standard operating
procedures” or even clinical guidelines. Despite missing this trigger
threshold, these experiences illustrate that emergency medical care can not
always be forced into templates of a guideline; this will regularly fail.
Rather, the experiences described in this book show how important personal
experience, clinical skills and wise assessment of complex situations by the
emergency physician are in unpredictable situations in order to optimize the
care of the emergency patients entrusted to us.
In the present book, authors with cumulatively several hundred years of
experience in emergency medicine have described experiences that they
will not forget. But it’s not just real descriptions of extraordinary missions,
but they also show the courage and sincerity of the authors to tell about
their disappointments, fears and even their personal failure. Based on
difficult situations, one can develop personally and professionally much
better than if everything went well by chance—then one is patted on the
shoulder by everyone. Each of us can become better personally, in the
family and professionally; regardless of age, profession, rank or life
experience. A prospective decision is much more difficult than retrospective
assessment; hopefully this book will facilitate a fruitful discussion of
difficult experiences and ultimately decisions in difficult situations.
All authors have written their book chapters in their spare time, on
weekends or on vacation, for which I can not thank them enough; I am
proud to work with them. Dr. Anna Krätz has helped my idea for this book
at Springer Publishing house with good arguments to the “Go” and has
driven the project continuously and always on schedule together with Axel
Treiber. Dr. med. Dipl.-Päd. Martina Kahl-Scholz has excellently
supervised all chapters as a lecturer.
As in emergency medicine, it is the team performance of many different
people with very different talents that makes the decisive difference with
this book—many heartfelt thanks to all of them! I would like to thank my
wife Dr. Regina Wenzel and our daughters Katharina, Anna and Clara for
their patience, support and love. You raise me up to more than I can be.
I am very pleased about constructive criticism of this book—science
and thus clinical treatment strategies are always in flux and it is never too
early to plan the next edition of this book ([email protected]).
I wish you a lot of fun and excitement while reading!
Prof. Dr. Volker Wenzel
Friedrichshafen
in fall 2023
Contents
1 Forearm Fracture in Afghanistan
Björn Hossfeld
2 24-Year-Old in a River
Sven Wolf
3 Serious Traffic Accident in Fog
Martin Messelken
4 80-Year-Old Patient with Devastating Chest Pain
Luise Schnitzer
5 Unconscious in Industrial Area
Joachim Koppenberg
6 The Final Exam
Volker Wenzel
7 Injuries from Heavy Machinery
Hans-Richard Arntz
8 Blood Pressure Crisis
Martin Dünser
9 Buried Under Concrete Slabs
Bernd Domres and Norman Hecker
10 Emergency on the Fairground
Hans-Richard Arntz
11 Inferno on the Highway
Peter Hilbert-Carius
12 Collapse While Doing Barn Work
Martin Dünser
13 Fall into Icy Water
Luise Schnitzer
14 Choking Attack in Nursing Home
Peter Hilbert-Carius
15 Traffic Accident in Construction Area
 Sven Wolf
16 Unconscious Woman in Bathroom
Martin Messelken
17 Collapse During Tennis Match
Hans-Richard Arntz
18 Bus Accident in South Tyrol
Hermann Brugger
19 Shortness of Breath in Nursing Home
Luise Schnitzer
20 A Black Day for the EMS
Martin Messelken
21 The Four Development Phases of a Medical Doctor
Joachim Koppenberg
22 Fall into Garden Pond
Luise Schnitzer
23 Two Pathologies
Hans-Richard Arntz
24 High-rise Building on Fire
Sven Wolf
25 Child with Head Injury
Martin Dünser
26 Resuscitation of an Elderly Patient
Volker Wenzel
27 Emergency Cricothyroidotomy
Sven Wolf
28 65-Year-old Patient with Shortness of Breath
Luise Schnitzer
29 Status Epilepticus
Martin Dünser
30 A Pale Patient
Frank Marx
31 Collapse During Seniors’ Hike
Joachim Koppenberg
32 Serious Kick Injury
Frank Marx
33 Student with Heart Problems
Joachim Koppenberg
34 Fall While Downhill Mountainbiking
Martin Messelken
35 Serious Head Injury
Peter Hilbert-Carius
36 A Nearly Deadly Tea
Hermann Brugger
37 Abandoned Newborn
Peer G. Knacke
38 Accident While Shredding
Björn Hossfeld
39 Avalanche Burial
Hermann Brugger
40 ACS in 75-Year-old Patient
Peer G. Knacke
41 Carried Off the Road
Hermann Brugger
42 Dangerous EMS Scene Call
Volker Wenzel
43 Shortness of Breath in Steam Room
Norman Hecker and Bernd Domres
44 Swallow and Brake Failure
Hermann Brugger
45 Injury From Power Line
Jan Breckwoldt
46 Person Trapped
 Frank Marx
47 Cardiologist with Heart Attack
Jan Breckwoldt
48 Fall From Tree House
Peter Hilbert-Carius
49 Thrombolysis
Franziska Böhler
50 5000 m / 16400 feet
Bernd Fertig
51 Hyperventilation
Björn Hossfeld
52 Hybrid-ECMO
Marc O. Maybauer
53 Stop
Urs Pietsch
54 Less is More
Urs Pietsch
55 Quiet Voice
Sylvi Thierbach
56 Quarantine
Petra Tietze-Schnur
Editor and Contributors
About the Editor
Prof. Dr. med. Volker Wenzel M.Sc. FERC
is Chairman of the Department of
Anesthesiology and Intensive Care Medicine,
Emergency Medicine and Pain Therapy of
Medical Campus Lake Constance-
Friedrichshafen Regional Medical Center and
Tettnang Hospital.
He is the author or co-author of more than
330 peer-reviewed articles and 40 book
chapters, co-editor of two books and editor of
the emergency medicine section of the journal
“Die Anaesthesiologie”. He is Courtesy
Professor of Anesthesiology at the University of
Florida in Gainesville, Florida, United States.
He looks back with pride on the successful supervision of 44 M.D. and
Ph.D. thesis.

Contributors
Prof. Dr. med. Hans-Richard Arntz is an internist and cardiologist; he
has been working as a senior physician at the Department of Cardiology
and Pulmology at the Free University Berlin Campus Benjamin-Franklin
and later at the Charité University Medicine Berlin, Germany since 1987.
For 24 years, he was the medical director of the Emergency Medical
Service Helicopter Christoph 31 and the physician-manned ambulance 4205
in Berlin-Steglitz, as well as of the early defibrillation program in Berlin.
He is the author of 141 peer-reviewed articles and 31 book chapters, as well
as the initiator and coordinator of several large clinical multicenter studies.
Franziska Böhler is an intensive care nurse and worked for 13 years in
an anesthesiological intensive care unit in Frankfurt, Germany and now as
an anesthesiology nurse in outpatient surgery. She published the Spiegel
Bestseller “I’m a nurse” in 2020 and is active on Instagram as
“thefabulousfranzi”, where she has 280,000 subscribers. She has been a jury
member of the Queen Silvia Nursing Award since 2019 and has appeared
on breakfast television, HR, Kölner Treff, among others.

Priv.-Doz. Dr. med. Jan Breckwoldt MME was between 1998 and
2012 senior physician in the Department of Anesthesiology and Intensive
Care Medicine at Campus Benjamin Franklin University Hospital of the
Berlin Charité University Medicine and responsible there for the emergency
medical service. After completing a master’s degree in “Medical
Education”, he was also teaching coordinator and member of the project
management for the model degree programme Medicine of the Charité
University Medicine in Berlin, Germany. From 2013 to 2017 he headed the
study dean’s office of the Medical Faculty of the University of Zurich; since
2018 he has been senior physician in the Institute of Anaesthesiology at the
University Hospital in Zurich, Switzerland. In parallel to his scientific core
area of resuscitation, he is committed to competency-based medical
education, including EPAs.

Priv.-Doz. Dr. med. Hermann Brugger is vice head of the EURAC

Institute for Alpine Emergency Medicine in Bolzano, South Tyrol, lecturer
at the Medical University of Innsbruck, Austria, member of the
International Commission for Alpine Emergency Medicine ICAR
MEDCOM and mountain rescue physician, emergency physician and
general practitioner in Bruneck, South Tyrol, Italy.

Prof. Dr. med. Dr. h.c. Bernd Domres was professor of surgery at the
University Hospital Tübingen, Germany from 1980 to 2003. From 1985 to
1988 he headed the surgery department of the King Khaled Hospital in Hail
/ Saudi Arabia. His focus is on trauma and disaster medicine. Since 1975 he
has been a physician in numerous disasters—including in Nigeria,
Cambodia, Lebanon, Armenia, Congo, Iran, Turkey, Italy, Haiti, Chile and
Pakistan. He is president of the German Institute for Disaster Medicine and
the Foundation of the German Institute for Disaster Medicine. He was
president of the German Society for Disaster Medicine and was awarded the
Federal Cross of Merit first class in 2012.

Priv.-Doz. Dr. med. Martin Dünser is a senior physician in the

Department of Anesthesiology and Surgical Intensive Care Medicine at the
Kepler University Hospital Linz, Austria. After completing his training as a
specialist in anaesthesia and intensive care, he worked at the Department of
Intensive Care Medicine at the University Hospital in Bern, Switzerland, at
the Paracelsus Medical University in Salzburg, Austria as well as at the
University College of London Hospital and the London's Air Ambulance,
both in London/United Kingdom. In addition to his scientific activities in
the treatment of critically ill patients, he was chairman of the Section
Trauma and Emergency Medicine and the Global Intensive Care Working
Group of the European Society of Intensive Care Medicine ESICM. He has
worked a total of two years in emergency and intensive care in Africa and
Mongolia.

Bernd Fertig is a certified paramedic (SRK) and holds a B.Sc. in

interdisciplinary emergency care and a M.Sc. in EMS management. Since
January 2020, he has been a visiting professor at the Faculty of Medicine
San Ferndando, the Universidad Nacional Mayor San Fernando in Peru and
the autonomous University Gabriel Renè Moreno in Santa Cruz de la Siera
in Bolivia. Bernd Fertig is building a competence center for EMS and air
rescue in Lima, Peru with the support of the German federal government.
He is currently supporting the treatment of Covid19 patients with a German
and Peruvian team. Training as a certified paramedic in Switzerland and
Seattle Medic 1 in Seattle. He is a teacher in the EMS and is currently
heading a master’s program for medical directors in Peru and Bolivia. He is
also setting up a professional emergency medical service training according
to German standards in Peru and Bolivia.

Dr. med. Norman Hecker is a specialist in anesthesiology, emergency

medicine and clinical acute and emergency medicine. He holds the
qualifications of emergency physician, senior emergency physician,
medical director of emergency medical services and tele-emergency
physician. Since 2018, he has been Chief Physician of the Department of
Acute and Emergency Medicine at the Protestant Hospital Gelsenkirchen,
Chief Emergency Physician of the City of Gelsenkirchen and Site Manager
of physician-manned ambulance 30-1 at the Gelsenkirchen-Horst site. He
attended Medical School at the Universities of Cologne and Valetta (Malta).
From 2007 to 2013, he was project manager for emergency medicine at the
German Institute for Disaster Medicine in Tübingen. He was also part of
international disaster missions several times. Furthermore, he has been
leading the bilateral Sino-German Institute for Disaster and Emergency
Medicine (SGIDEM) at Tongji Hospital in Wuhan (Huazhong University
for Science and Technology, Hubei, People’s Republic of China) of the
Sino-German and German-Chinese Medical Societies since 2015. He is one
of the Hanno Peter Honorary Laureates of the German Society for Disaster
Medicine (2015), Graduate Visiting Professor of the oldest continuously
operating university in the Americas (Universidad Nacional Mayor de San
Marcos UNMSM, Lima, Peru) in the field of Emergency and Disaster
Medicine, member of the Scientific Advisory Board of the German-Chinese
Society of Medicine, Post-Graduate of Karolinska University in Stockholm,
Sweden (Medical Response to Major Incidents) and on the User-Advisory
Board of the EU Horizon 2020 project Nightingale.

Priv.-Doz. Dr. med. Peter Hilbert-Carius (DEAA) is a senior physician

in the Department of Anesthesiology, Intensive Care and Emergency
Medicine at the BG Trauma Hospital Bergmannstrost in Halle, Germany.
He is medical director of the DRF air rescue station in Halle (Oppin) and
spokesperson for the Trauma Network Saxony-Anhalt South.

Priv.-Doz. Dr. med. Björn Hossfeld is a senior physician in the

Department of Anesthesiology and Intensive Care Medicine at the Federal
Armed Forces Hospital in Ulm, Germany, as well as a Leading physician of
the Emergency Medical Service Helicopter „Christoph 22“ and leading
EMS-physician for the district of Ulm / Alb-Donau. He took part in several
overseas deployments of the German armed forces in Afghanistan, Kosovo,
Libanon, Mali, Niger, and the Congo.

Dr. med. Peer G. Knacke was already active in the noncombattant

service and during his Medical School time in the Emergency Medical
service; after graduation, he worked for three years in surgery and pediatric
surgery; since 1988 he has been working in anesthesia. He is senior
physician in the Department of Anesthesia and Emergency Medicine at the
AMEOS Hospital Eutin, Germany, medical director of the Emergency
Medical Service Ostholstein, representative of the leading emergency
physician group and medical director of the EMS Helicopter „Christoph
12“. So far, he has carried out over 15,000 independent emergency medical
service scene calls in ground and air rescue services.

Dr. med. Joachim Koppenberg is Chairman of the Department of

Anesthesiology, Pain Therapy and Emergency Medicine in Engadin /
Switzerland since 2004. For over 22 years he has continuously worked in
ground-based emergency medical services and also in air rescue—first with
DRF in Germany, then with ÖAMTC in Austria and now with REGA in
Switzerland. He has been Lead Emergency Physician and Station Physician
of the Alpine Rescue Switzerland. In addition to numerous publications in
emergency medicine, he is also editor of the Psychrembel AINS, section
editor of the journal “Der Notarzt” and co-editor of the German translations
of the AHA resuscitation guidelines (BLS, ACLS, PALS). At the same
time, he is course director of the AHA for ACLS courses. His other areas of
interest and research focus on risk management and patient safety. He is
also CEO of the Unterengadin Health Center in Switzerland.

Prof. Dr. med. Frank Marx is a board-certified physician in

Anesthesiology and Intensive Care. He has been working in the emergency
medical service at various locations since 1992. After his medical training,
he led the Institute for Emergency Medicine at Duisburg Hospital in
Germany until 1997. As medical director of the emergency medical service,
he was with the Duisburg Fire Department and served also on the
emergency medical service helicopter “Christoph 9” and various other
emergency medical services. As part of the foreign disaster relief of
Malteser International, he has been active in Africa, Asia and North
America. He now teaches at the Health Department of the TH Mittelhessen
in Gießen, Germany Emergency Medical Service Management.

Prof. Dr. med. Marc O. Maybauer EDIC, FCCP, FACC, FASE

Studied medicine at the Justus Liebig University in Giessen, Germany. His
dissertation (M.D.) and habilitation (Ph.D.) both engaged with the
management of acute lung injury and ARDS. He is an internationally
renowned physician who received training in anesthesiology at the
University Hospitals of Mainz and Ulm, Germany, cardiac anesthesia and
transesophageal echocardiography at the Oxford Heart Centre, Oxford, UK,
and Critical Care Medicine at the University of Texas Medical Branch at
Galveston, USA. He served as director of the ECMO services at
Manchester Royal Infirmary, Manchester, UK and the Integris Baptist
Medical Center in Oklahoma City, USA. He recently was appointed as
Professor and Chief of Critical Care Medicine, Executive Director for the
Critical Care Organization, and Program Director for Adult ECMO at the
University of Florida College of Medicine in Gainesville, USA. In addition,
Professor Maybauer is holding a professorship at the Philipps University in
Marburg, Germany, and an honorary professorship at the University of
Queensland in Brisbane, Australia. He is the author of more than 200
scientific publications and winner of numerous awards. Professor Maybauer
is the editor of the textbook: “Extracorporeal Membrane Oxygenation – A
Problem-Based Learning Approach” with Oxford University Press.

Dr. med. Martin Messelken is board certified in Anesthesiology with

the additional designation of Intensive Care Medicine and Emergency
Medicine. From 1980 to 2013 he was responsible for the emergency
medical service in Alb-Fils-Hospital Göppingen (formerly Klinik am
Eichert) and in the last years of his career he was working as a leading
senior physician. From 2005 to 2013 he was also an emergency physician
on the EMS helicopter “Christoph 51”. The publication and further
development of the Minimal Emergency Medical Data Set (MIND) goes
back to his initiative. In 2010 he received the Rudolf Frey Award for
Emergency Medicine in Germany. He has been involved in the
establishment of the German Resuscitation Registry as a member of the
Organizing Committee from the beginning.

Priv.-Doz. Dr. med. Urs Pietsch DESA/EDIC is a senior physician in

the Department of Anesthesiology and Intensive Care at Kantonsspital St.
Gallen, Switzerland and medical director of the Resuscitation and
Simulation centre Rea2000 in St. Gallen. In addition to his many years of
prehospital work as an emergency physician (Air Zermatt, Switzerland), he
is scientifically involved in the fields of simulation, alpine rescue medicine
and alpine helicopter rescue.

Dr. med. Luise Schnitzer is board-certified in Cardiology, Emergency

Medicine and Psychotherapy. She has been working in the Department of
Cardiology and Pulmology at the Free University Berlin, and later at the
Charité University Medicine Berlin, Germany Campus Benjamin Franklin
since 1980, has been an emergency physician at the Emergency Medical
Service Helicopter “Christoph 31” and physician-manned ambulance 4205
in Berlin-Steglitz since 1987 and has been leading emergency physician
since 2001. She has been working mainly in the emergency service since
1995.

Dr. med. Sylvi Thierbach after attending Medical School at the

University of Hamburg, she was a resident at the Federal Armed Forces
Hospital Bad Zwischenahn; after further stations as a troop and flight
physician in Leer/East Frisia and Koblenz, she served as a resident at the
Federal Armed Forces Hospitals Koblenz and Ulm, Germany since 2012.
Board certified in Anesthesiology since 2015. Since January 2021 senior
physician at the Department of Anaesthesiology, Intensive Medicine,
Emergency Medicine and Pain Therapy at the Federal Armed Forces
Hospital Ulm (additional qualifications in Emergency Medicine and Special
Intensive Care Medicine); numerous overseas deployments from 2009 to
2020, e.g. in Afghanistan, Mali and northern Iraq.

Dr. med. Petra Tietze-Schnur completed a degree in human medicine in

Hannover, Germany, then specialist training as an anaesthetist and
emergency physician in Bremen. Since 1997, she has worked in ground and
air-based emergency medical services in northern Germany. Since 1997, she
has been a practising Anesthesiologist in Bremerhaven, Germany. Since
2009, she has been a member of the Board of Directors of the Association
for Outpatient Surgery.

Dr. med. Sven Wolf is board certified in Surgery, Orthopaedics and

Trauma Surgery, Emergency Medicine and specialised Trauma Surgery.
Prior to attending Medical School, he trained as a paramedic. He was senior
physician in the Accident and Emergency Department at the
Diakoniekrankenhaus Friederikenstift in Hannover, Germany and is now
Chairman of the Department of Emergency Medicine at the DIAKOVERE
Friedrikenstift and Henriettenstift in Hannover. Since 2004, he has been
leading Emergency Physician of the Region/City of Hannover, Germany.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_1

1. Forearm Fracture in Afghanistan

Björn Hossfeld1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Federal Armed Forces Hospital Ulm, Ulm,
Germany

Björn Hossfeld
Email: [email protected]

There are several topics in all areas of modern medicine which have
“always been done” and that are sometimes questionable in their sense—
especially in the middle of the night. Quickly forgets that our modern,
western medical care is still far from self-evident everywhere in the
world and we should ultimately be grateful for the ubiquitous medical
care. The present case shows that the conditions for many people can be
quite different, or much worse.

“It’s annoying!”—The clock shows 3:17 h and your eyes have just
fallen shut a few minutes ago, after you as the on-call anesthesiologist had
been busy for more than 11 h in the OR for countless patients. Now the
surgical colleague, from the sound of his voice assumingly no less tired to
conclude no less tired than yourself, is on the phone to explain that he
urgently needs to make a fasciotomy to avoid a compartment syndrome in
the patient with the forearm fracture already operated hours before. The
question of why this is now necessary, is answered lapidar that the surgical
chief physician wants it that way and—even worse—that one would have
always done so.
 If we are honest, there are things in all areas that “have always been
done”: In anesthesia, we teach the young colleagues to look into the
patient’s eyes during anesthesia recovery, even though the pupils dilated by
excitement are practically no longer visible thanks to modern drugs.
Similarly, we all learn in Medical School that a circular plaster must be split
longitudinally around a fresh fracture to minimize the risk of a compartment
syndrome caused by swelling.
During the deployments in Afghanistan, the field hospitals of the
German Armed Forces have also treated civilian local patients as part of
their free capacities. In order to be treated by the NATO physicians, the
patients and their relatives often undertook arduous journeys lasting several
days. I remember Chafla, a small patient in the particularly cold winter of
2008. Despite the considerable snowfall and the high avalanche danger, her
father set out to bring his little daughter three days long on his shoulders
over difficult paths to our camp in Feyzabad. Via our interpreter we learn
that the child had broken her right forearm about 10 or 12 days ago in a fall
and had been treated by a local healer with a circular splint. In the following
days, the little girl had complained of terrible pain, but the family had
explained this with the broken bone. Then the pain had subsided, but the
girl had become increasingly ill and had developed a high fever. The little
patient is drowsy and tachycardic. Already during the inspection we notice
the livid to black discolored fingers that protrude from the distal end of the
circular bandage. The removal of this bandage reveals the full extent of the
tragedy: The arm is necrotic up to the elbow, the child was clinically and
proven by the laboratory results highly septic.
It is quickly clear that a timely amputation of the arm is the only option
for saving our little patient. The father is informed via the interpreter and is
surprisingly composed. This is an experience that we often make in this
country: for the population, fatal or disfiguring diagnoses are obviously
more widespread than in our Western world with medical care at the highest
level available at any time of day and night and the self-image and claim to
healing of our patients that has developed from this. The procedure goes
smoothly and after a few days Chafla can be transferred to the Feyzabad
hospital in good general condition and with unobjectionable wound
conditions for further treatment, where she is still introduced to the German
physicians during their joint visits with the Afghan colleagues.
 Discussion
The forearm fracture is the most common bone fracture in children. In
general, means the repositioning of closed fractures and subsequent
immobilization, ideally in a plaster, is the correct procedure.
Compartment syndrome in children is an expression of a rare (approx.
1%) multi-factorial tissue pressure increase, which is observed at the
extremities, especially after trauma [1]. This can lead to compression of
nerves and vessels in the affected muscle location with subsequent
muscle contractures and neurological damage caused by muscle atrophy.
In a well-structured medical environment with regular controls and
reliable timely re-appointment of the patient with complaints, a circular
plaster today offers no disadvantage compared to a primarily
longitudinal split plaster [2]. It is important to recognize and correctly
evaluate warning signs of complications such as pain that is barely
controllable by analgesics, paresthesias and venous congestion in a
timely manner. In particular, in children, the clinical signs can be
unspecific or difficult to communicate; the most reliable signs of an
evolving compartment syndrome were pain and increasing swelling of
the extremity in one study [3]. The conservative treatment then includes
above all the early splitting of constricting bandages. If the compartment
syndrome is already pronounced, an emergency fasciotomy is required,
the outcome is usually very good in children.
If these measures are not observed by the treating physician, this can
lead to irreversible damage, as described in this case report, up to
pulselessness with ischemia and necrosis. In the already septic state in
which the child we treated was presented, amputation was the only
causal treatment option.

1.1 Conclusion
Whenever a surgeon asks me for anaesthesia to perform a fasciotomy at
night, I always remember Chafla. With her story in mind, I am always
happy to get up, convinced that we can avoid the pictures our ancestors still
knew.
References
1. Neiman R, Maiocco B, Deeney VF (1998) Ulnar nerve injury after closed forearm fractures in
children. J Pediatr Ortho 18:683–685
[Crossref]

2. Schulte D, Habernig S, Zuzak T, Staubli G, Altermatt S, Horst M, Garcia D (2014) Forearm

fractures in children: split opinions about splitting the cast. Europ J Ped Surg 24:163–167
[Crossref]

3. Seifert J, Matthes G, Stengel D, Hinz P, Ekkernkamp A (2002) Kompartmentsyndrom – Standards

in Diagnostik und Therapie. Trauma Berufskrankh 4:101–106
[Crossref]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_2

2. 24-Year-Old in a River
Sven Wolf1
(1) Department of Emergency Medicine, DIAKOVERE Friederikenstift,
Hannover, Germany

Warmth, warmth, more warmth!

For we are dying of cold
and not darkness.
It’s not the night that kills,
but the frost.
de Unamuno 1972 [8]

Accidental hypothermia is generally most commonly associated with

accidents in connection with bodies of water, ice, snow and severe
trauma. However, the classic “accidentally hypothermic, non-multiple
trauma patient” in Central Europe usually only had direct contact with
water or snow in about 30% of cases. About 45% of cases even occur in
the “warm months” of April to September. The following example
shows which aspects need to be considered in emergency medicine in the
specific case.

On a cold November evening, ambulance, physician-manned ambulance

and the fire department’s diving team are called to a large river. In the
middle of the river, which is about 100 m / 330 feet wide at this point, a 24-
year-old man is swimming and calling for help. The outside temperature is
4 °C (39 °F), the water temperature is about 6 °C (43 °F). The
circumstances, whether a crime or an accident, could later not be
determined. In accordance with their service regulations, the fully equipped
divers do not go into the water without their accompanying boat. However,
this has to be carried with all participants over the stony riverbank in a
time-consuming procedure. In the meantime, a policeman swims from the
other riverbank to the victim. Only 17 min after arrival at the scene, both
swimmers can be pulled into the inflatable boat. At hospital admission, the
policeman shows signs of mild hypothermia (34.8 °C (94.6 °F) rectally) and
can be discharged after outpatient warming. Somewhat somnolent, but still
oriented in space and time, the 24-year-old is taken to the ambulance. Blood
pressure 95/-, pulse 64. ECG: sinus rhythm with widened QRS complexes.
No known comorbidities, injuries or intoxications. The target hospital now
offers a possibility of maximal care 2 km / 1,2 miles away and a hospital of
specialized care with cardiac surgery being 8 km / 5 miles away. The
emergency physician chooses the nearby hospital. Due to the “centralized
venous conditions” and the “short distance”, no venous access is
established. After removing the ECG cables, the young patient is
transferred to the hospital by “packing, 4 men/4 corners” and moving him
into the prepared intensive care bed. Immediately afterwards, he becomes
unconscious and the ECG shows ventricular fibrillation. Cardiopulmonary
resuscitation (CPR), acidosis correction, epinehrine and various
antiarrhythmics make it possible to achieve a ventricular replacement
rhythm 60 min later. Passive rewarming at an initial body core temperature
of 26.8 °C (80.2 °F) (rectally) is carried out with blankets and heated
infusion solutions. This makes it possible to achieve an average increase in
body temperature of 1 °C (34 °F) per hour. In the following 10 h, there are
recurrent episodes of ventricular fibrillation with CPR and the need to inject
antiarrhythmics and to attach an external pacemaker. In the end, when
ventricular fibrillation was refractory, therapy was stopped at a body core
temperature of 36.9 °C (98.4 °F). Medico-legal investigation attributed the
fatal outcome to resuscitation damage as an indirect accident consequence
of extreme hypothermia.

Discussion
Accidental hypothermia is defined as an unwanted lowering of the core
body temperature (CBT) to below 35 °C (95 °F). The staging system has
now been largely standardized internationally:
mild 35–32 °C (95–89.6 °F),
 moderate 32–28 °C (89.6–82.4 °F),
severe/extreme: <28 °C (82.4 °F).
Accidental hypothermia is generally most often associated with
accidents involving water, ice, snow and severe trauma. However, the
classic “accidentally hypothermic, non-multiple trauma patient” in
Central Europe usually had direct contact with water or snow in only
about 30% of cases and is usually referred to as an “urban” hypothermia.
About 45% of cases occur in the “warm months” of April to September.
In approximately 70% of cases in Germany, the initial disease is
alcohol/drug abuse or a psychiatric underlying disease [10].
While uninjured patients usually tolerate mild core body
temperatures well and can be rewarmed relatively complication-free,
there is a significant increase in post-traumatic complications in multiple
trauma patients at a core body temperature <34 °C (<93.2 °F), primarily
coagulopathy [1]. The incidence of accidental hypothermia in multiple
trauma is given as 12 to 66%, the increased mortality in the coincidence
of both is between 30 and 80% [3, 5].
With decreasing core body temperature, stage-related tables with
pathophysiological changes, such as somnolence and unconsciousness,
can be found in textbooks. However, in pre-hospital emergency medical
service practice, the clinical parameters of the inhomogeneous patient
population rarely correspond to the textbook tables. So foot-walking
29.2 °C (84.6 °F) cold patients are just as likely to be found as
completely conscious, subjectively symptom-free homeless people with
a core body temperature of 26.7 °C (80.1 °F) [9]. In addition to
influences on vigilance, reduced metabolism rates/cytoprotective effects,
reversible thrombocyte/thrombin and fibrin function disorders,
electrolyte shifts and changes in myocardial membrane potentials are
observed with resulting rigidity, increased irritability and high risk of
life-threatening rhythm disorders (especially ventricular fibrillation) by
mechanical and thermal triggers. The latter also pathophysiologically
prepares the ground for the so-called “rescue death” [1, 9]. Even in
clinical suspicion of moderate or severe/extreme accidental hypothermia,
rough manipulations of the patient by turning over, lifting from the
horizontal or even the position for rectal temperature measurement must
be avoided. Both directly by the manipulation and indirectly by the
backflow of cold “shell blood” from the periphery to central, in addition
to a further drop in core body temperature, the increased cardiac
irritability can lead to malignant arrhythmias/ventricular fibrillation as
mechanical and thermal triggers. Swimming, severely or extremely
cooled patients are also subject to another pathophysiology of the
“rescue death”: With centralized circulation and reduced cardiac
function, the hydrostatic pressure of the surrounding water can be the
decisive factor for a just sufficient cardiac output. A sudden rescue from
the supportive hydrostatic pressure conditions in combination with an
increase in orthostatic pressure during vertical rescue (e.g. hoisting by an
EMS helicopter) and an increased demand on cardiac output can lead to
a decisive reduction in coronary perfusion with heart failure [2, 4].
Further, with accidental hypothermia associated terms such as
“afterdrop” and “rewarming shock” are phenomena of clinical therapy
and should not be discussed here.
In particular, in the case of drowning accidents in cold water, the
tolerance to hypoxia is increased by hypothermia. Duration and speed of
cooling are among the decisive factors for the outcome. The lowest
recorded accidental hypothermia is 13.7 °C (56.7 °F) [1]; successful
passive rewarming from extreme hypothermia with continuous CPR for
more than 4 h with uneventful neurological outcome has also been
described [6, 7]! The well-known saying results from such case reports:
Nobody is dead until rewarmed and dead.
It should be mentioned at this point that confirmed submersion or
hypoxia times of significantly more than 60 min also have no chance of
a complete recovery in extreme hypothermia. Tympanic
thermometers/ear infrared thermometers are already available more often
for temperature measurement on site. Even if they do not exactly
correspond to the esophageal and deep rectal measurement, for example
in the case of water in the ear canal, they can confirm the suspicion of
accidental hypothermia. If only a conventional stick thermometer is
available and if the external circumstances (“Environment”) alone justify
the mere suspicion of a significant hypothermia, rectal measurements on
site must be omitted and the patient must be hospitalized as quickly as
possible with the provisional diagnosis “severe hypothermia”.
A significant decision for the later outcome of the severely/extremely
hypothermic patient is made by the emergency physician on site with the
choice of the target hospital [1, 9]. Sufficient rewarming is hardly
 possible and promising prehospitally, except on board of larger rescue
cruisers. The priority is to maintain heat with blankets, ambulance
heating, warmed infusion solutions and, for example, in traffic accidents
with 1000-watt spotlights from the fire brigade. In the hospital/intensive
care unit, rewarming rates of 1 °C (34 °F)/hour are generally possible
with all conceivable external methods, even during resuscitation [9].
However, during resuscitation conditions, a significantly increased
personnel requirement is inevitably unavoidable. With an extracorporeal
circulation on a heart-lung machine, warming rates >11 °C (52 °F)/h are
possible.

2.1 Conclusion
The prehospital diagnosis of “accidental hypothermia” can sometimes be
significantly hampered if the external circumstances do not immediately
draw the attention of the emergency physician. A complication-free
diagnostic certainty is offered here by the commercially available ear
infrared thermometer. In case of suspicion of moderate or severe
hypothermia, all gross manipulations and repositioning of the patient must
be avoided. Once the indication for CPR is given, it must be consistently
and comprehensively continued throughout transport. An important
decision for the outcome is already made on site with the selection of the
target hospital and the potential possibility of extracorporeal
circulation/heart-lung machine.

References
1. Andruszkow H, Hildebrand F (2014) Akzidentelle Hypothermie/schwere Unterkühlung. Notarzt
30:7–15

2. Golden FS (1982) Der heutige Stand der Unterkühlungsbehandlung. In: Unterkühlung im

Seenotfall – 2. Symposium 1982 in Cuxhaven der DGzRS, Symposiumsband, DGzRS Bremen

3. Gregory JS, Flancbaum L, Townsend, et al (1991) Incidence and timing of hypothermia in

trauma patients undergoing operations. J Trauma 31:1247–1252
[Crossref][PubMed]

4. Hauty MG, Esrig BC, Hill JG, Long WB (1987) Prognostic factors in severe accidental
hypothermia: the hood tragedy. J Trauma 27:1107–1112
[Crossref][PubMed]
5.
Hildebrand F, Probst C, Frink M, Huber-Wagner S, Krettek C (2009) Bedeutung der
Hypothermie beim Polytrauma. Unfallchirurg 112:959–964

6. Lexow K (1991) Severe accidental hypothermia: survival after 6 hours 30 minutes of cardio-
pulmonary resuscitation. Arctic Med Res 50(Suppl 6):112–114
[PubMed]

7. Roggero E, Stricker H, Biegger P (1992) Akzidentelle Hypothermie mit kardiopulmonalen

Stellstand: prolongierte Reanimation ohne extrakorporellen Kreislauf. Schweiz Med Wochenschr
1:161–164

8. de Unamuno M (1972) The tragic sense of life in men and in nations. Princeton University Press,
Princeton

9. Wolf S (1996) Akzidentelle Hypothermie in Norddeutschland (1983–1993) – Eine

therapeutische Herausforderung -. Inaugural-Dissertation Georg-August-Universität Göttingen

10. Wolf S (2000) Kältetod – Wie oft schlägt er wirklich zu? Inzidenz, Mortalität und Morbidität der
Hypothermie. In: Turner E, Kaudasch G (Hrsg) Unterkühlung im Rettungsdienst – Prä- und
innerklinische Therapie der akzidentelle Hypothermie. Pabst Science Publ., Lengerich.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_3

3. Serious Traffic Accident in Fog

Martin Messelken1
(1) Bad Boll, Germany

Martin Messelken
Email: [email protected]

In emergency medicine, one often encounters situations that do not

develop as expected and therefore require improvisational skills. The
good or bad environmental conditions also play a corresponding role. In
the present case, the situation of a triage at the accident site after a traffic
accident is presented, as well as some possible difficulties that may arise
in this constellation for the deployment team.

A car occupied by a young family has an accident on a foggy Sunday

morning in the early 1980s. The accident site is at the outer edge of the
rural EMS service area; therefore, a travel time of 17 min for the ambulance
and EMS is not unusual. Based on the accident report, the EMS dispatch
center sends the only available physician-manned ambulance and two
ambulances. The following scene presents itself to the arriving EMS
workers: The car had overturned in a long left-hand bend and was back on
its wheels on a sloping meadow. The driver (mother) is slightly dazed but
apparently physically largely unharmed; the probably intoxicated passenger
(father), on the other hand, is hanging lifelessly in the safety belt. He has
vomited and his cervical spine appears unstable. Given the fact that two
unconscious children, aged 4 and 6, are lying motionless on the back seats,
any cardiopulmonary resuscitation attempt of the man is omitted. After this
triage and the prospect of not being able to receive any support from a
helicopter EMS (fog) or a nearby physician (busy with different emergency
case) at the moment, the children are brought individually into the
ambulance and treated one after the other by the doctor. The older of the
two girls has a clear pupil difference with a Glasgow Coma Scale (GCS) of
6, she is first given analgesia and then intubated. The manual ventilation is
handed over to an experienced paramedic. After the second girl (also
Glasgow Coma Scale of 6) has been given analgesia and intubated, both
endotracheal tubes have been clinically and auscultatorily verified and fixed
in their correct position, the monitoring of the circulatory system in both
children does not give any indication of further injuries or a volume deficit.
In the responsible hospital for maximum care, two ventilated children with
isolated head and brain trauma are then registered; the transport takes place
in a convoy. During the transport, the physician constantly informs himself
by radio contact regarding the situation in the other ambulance; a stop is
made for visual inspection of the findings in between. The mother arrives at
the hospital in a police car, where she is given pastoral care.
The trauma surgery hospital has gathered the usual personnel available
on a Sunday morning, as well as the on-call staff of the anesthesia and
children’s hospital, in the emergency room; the handover takes place about
70 min after the accident. The radiological diagnosis in the 6-year-old girl
with manifest anisocoria shows the finding of a subdural bleed, which
results in a craniotomy carried out quickly. However, despite maximum
therapy, the death within the first 24 h as a result of the brain injuries could
not be averted. The 4-year-old sister has a clear contusion with brain
edema; after adequate intensive care treatment, she can be discharged
6 weeks later without any residuals and today lives with her own family.

Discussion
Triage at the scene of an accident (i.e. sorting and classifying the
medical assistance needed) has the highest priority in the event of a fully
occupied car. Due to the unfavorable existing structures (weekday =
Sunday, weather = fog, personnel and vehicle availability = severe
restrictions), there was already a significant imbalance of personnel and
material from the outset, which could not be improved in the course of
the event. Therefore, the care provided by the only emergency physician
and the ambulance teams focused on the seriously injured children; all
other decisions, such as driving to a single destination hospital, are due
 to this fact. From today’s perspective, two ground-based emergency
medical systems and one EMS helicopter would be the appropriate
staffing to establish a 1:1 care situation. In the absence of suitable
transport ventilators and ventilation monitoring, ventilation was carried
out manually and without accompanying capnometry. The possible and
to be assumed hyperventilation condition could not only be
disadvantageous in this case—a mild hyperventilation during controlled
conditions is to be aimed for in the initial treatment of a patient with
craniocerebral trauma. The distribution of patients to several hospitals or
a trauma center would have been the next logical step. The fact that two
seriously injured children had to be admitted to one hospital—and on a
Sunday morning—is unfavorable and only justified by the fact that a
convoy had to be transported without delay. Today, however, a strategy
of spatial dislocation would be clearly favored. When I was the first
arriving EMS helicopter physician [1] years later, this question did not
arise at all; there were sufficient ground-based emergency physicians
available within the specified time frame, so that the patients, including
two children with severe head trauma, could be transported to different
hospitals with EMS accompaniment.

3.1 Conclusion
There will always be situations in EMS that require a considerable amount
of improvisation. Good structural quality and trained processes that can be
oriented to established algorithms are very helpful in actually implementing
a “Plan B”. Early communication with the medical facilities to which you
transport seriously injured patients is also very important.

References
1. Gries A et al (2008) Time in care of trauma patients in the air rescue service: implications for
disposition? Anaesthesist 57(6):562–570
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_4

4. 80-Year-Old Patient with Devastating

Chest Pain
Luise Schnitzer1
(1) Charité University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

This case very clearly shows that it is not always easy to put the
symptoms present together at the place of use to form a coherent picture
and that it must not be underestimated how often a selective perception
makes the past medical history more difficult, in the sense of: “What
may not be, that can not be!”

We are alarmed at 2:47 pm with the message “severe chest pain” and set
out to treat a “routine case”. We are received by the patient’s husband, who
introduces himself as a retired physician and leads us to his wife, who is
lying on the sofa, groaning quietly and very pale. The patient only reacts
with the groaning already heard. I try to quickly assess the circulation
parameters and have to conclude that no pulse is palpable. As a result, I
arrange for our patient to be placed on the floor so that a good starting
position for an effective resuscitation attempt is created. The woman reacts
to these measures with groaning: we raise the legs to improve the
circulation first. Meanwhile, I try to get information about the starting
situation, to access the patient and to write an ECG. The technical processes
run smoothly, but the past medical history is difficult.
According to the husband, the 80-year-old patient has always been
healthy and does not take any medication. The evening before, she had felt
a little weak for the first time and had once vomited blood. After that she
had felt better again. She had not complained of any pain and therefore the
couple had gone to bed. It may be surprising that the retired physician
husband underestimated the situation to such an extent, but sometimes the
desire and the will are stronger than the mind: “What may not be, that can
not be”. “His wife had always been healthy and mobile, had taken care of
him and supported him in everything—and now it is simply impossible that
she could be sick and can no longer do it!”
During the day she had felt a little weak and therefore he had suggested
to her to get some fresh air. They had also set out for a walk, but his wife
had fainted after a short distance, had vomited or coughed up blood again,
so they had broken off the walk and started the way home. On the last stage,
however, he had to “pull” his wife almost home. I only receive these details
with difficulty because the helpless husband does not fully understand the
situation and keeps asking his wife for confirmation, which she can not give
him because of her condition.
In the meantime, the ECG was written: unremarkable finding, no end-
point changes, no rhythm disorders and no evidence of ischemia. However,
the patient is relatively bradycardic with a heart rate of 57/min, the blood
pressure is now measurable at 50 mmHg systolic, the oxygen saturation
cannot be detected at the low blood pressure. Overall, the review of the
circulatory situation does not reveal any significant change, so that, based
on the previous history and the patient’s pallor, a severe gastrointestinal
bleed moves to the forefront of the differential diagnoses, especially since
the patient is now vomiting fresh blood again. A second, large-lumen
intravenous catheter is inserted and infusions are running through both
intravenous lines. An inspection of the skin does not reveal any evidence of
liver disease, such as spider naevi or increased and thickened veins on the
abdomen in the sense of a caput medusae; the liver is palpable at the costal
margin, not hard or enlarged. Questions to the husband do not reveal any
evidence of past hepatitis or increased alcohol consumption. My thoughts
are interrupted by an increasing bradycardia and then an asystole, so that I
now put the patient into anesthesia, have chest compressions performed and
intubated, and to my surprise have to find that fresh blood has to be
suctioned out of the trachea as well.
After injection of 2 mg of epinephrine in total, the heart rhythm remains
stable, the blood pressure also rises again to 50 mmHg through the infusion
of 2000 ml of crystalloid solution, and I arrange for the transport to the
hospital. I am aware that I cannot achieve any significant improvement here
on site and that a diagnosis is urgently required to find the source of the
bleed—it just doesn’t become clear where the blood loss is coming from. A
bleed from an ulcer ventriculior duodeni is quite possible, but the course
seems too fulminant to me. With an oesophageal varices bleed I would have
expected a correspondingly larger visible blood loss. The bleed from the
trachea completely confuses me—this seems to be more in total than the
vomited blood. Fresh blood has to be suctioned off again and again.
A pulmonary bleed, such as from vessel erosion in bronchial cancer, can
be significant and could explain the patient’s overall condition. However,
the past medical history does not suggest a pulmonary condition—neither
cough nor exertional dyspnea. Within 10 min—at 3:35 PM—we reach the
hospital, and, due to my pre-registration—“unclear severe bleed with
unstable circulation—possibly pulmonary or gastrointestinal,” everything is
prepared. A blood gas analysis shows a hemoglobin level of 8.5 g/dl, the
pH is 6.96, pCO2 46 mmHg, pO2 249 mmHg—after 1 h 105 mmHg. The
chest X-ray shows a heart of normal size, the mediastinum is not widened,
no effusion or infiltrate, but a finding left basal, which is compatible with
an aspiration pneumonia.
In the CT of the chest, there are several penetrating ulcerations in the
distal part of the atherosclerotic-changed descending aorta over a length of
approximately 5 cm at the level of thoracic vertebrae 10/11. In addition, an
accompanying intramural hematoma and a questionable covered perforation
to the left lateral lobe are shown, no pleural effusion and no ascites. As on
the chest X-ray, an aspiration is shown in the left lower lobe. Due to the
questionable covered perforation to the left lateral lobe, the patient is taken
to interventional radiology without further delay and treated with a thoracic
stent; in rehabilitation treatment, the patient ultimately recovers completely
without further complications and is discharged home.

Discussion
This case has remained particularly memorable to me because I found it
so difficult to interpret the findings and to put them into an
understandable context. A cardiac cause was unlikely due to the ECG
findings, and the findings of coughing up and vomiting blood spoke
against an aortic dissection. The amount of blood that was visible did not
fit with the circulatory collapse, nor did the bradycardia, which rather
 pointed to a cardiac event than to massive bleeding. An aortic aneurysm
with fistula formation in the esophagus or trachea is a very rare
complication and is associated with a high mortality rate [1]. The
literature reports an incidence of 0.35–1.6%—and in most cases it is a
late complication of an aneurysm operation [2, 3]. Many patients with a
thoracic aortic aneurysm initially have completely non-specific
symptoms and are often treated for completely different diseases, such as
back pain or upper gastrointestinal bleeding, without evidence of a
bleeding source. The symptoms are also difficult to interpret because the
pain can radiate to very different body regions and can be bilateral, so
that the diagnosis, as in this case, can only be made by the acute
deterioration. Here the question arises quickly how the patient is to be
treated—does the thoracic aortic aneurysm have to be operated on by
cardiac or vascular surgeons or is an endovascular treatment possible in
interventional radiology [3, 4]?
A small side issue in this case may also be the dramatic
underestimation of his wife’s illness by her husband, the physician. How
is it possible to overlook such signs? It must not be underestimated that a
selective perception often makes the past medical history more difficult
—which colleague has not already experienced that, despite a thorough
and comprehensive anamnesis, the decisive hint is only mentioned in a
banal aside or—even worse—during the chief physician’s round.
Certainly the case would have been better and less dramatic to treat if the
husband had presented his wife to the hospital the evening before.
However, this question can only be answered speculatively—a bleeding
source would probably not have been found by gastroenterologists. A
CT or MRI scan would probably have detected the ulcerating plaques,
but the question remains whether an indication for surgery would have
been made.

4.1 Conclusion
A thoracic aortic aneurysm can cause a variety of non-specific symptoms,
but can then lead to extremely rapid blood pressure drops in the event of
(covered) rupture. In this case it was important to drive quickly to the
hospital in the unclear situation in order to initiate a targeted therapy
quickly.

References
1. Kokatnur L, Rudrappa M (2015) Primary aorto-esophageal fistula: Great masquerader of
esophageal variceal bleeding. Indian J Crit Care Med 19(2):119–121
[Crossref][PubMed][PubMedCentral]

2. Chiba D, Hanabata N, Araki Y, Sawaya M, Yoshimura T, Aoki M, Shimoyama T, Fukuda S

(2013) Aortoesophageal fistula after thoracic endovascular aortic repair diagnosed and followed
with endoscopy. Intern Med 52(4):451–455
[Crossref][PubMed]

3. Hyhlik-Dürr A, Geisbüsch R, Hakimi M, Weber TF, Schaible A, Böckler B (2009) Endovaskuläre

Aortenchirurgie: Management sekundärer aortobronchialer – und enteraler Fisteln. Chirurg
80:947–955

4. Chad Hughes G (2015) Management od acute type B aortic dissektion: ADSORB trial. J Thorac
Cardiovasc Surg 149(2 Suppl):S158–S162
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_5

5. Unconscious in Industrial Area

Joachim Koppenberg1
(1) Department of Anesthesiology, Pain Therapy and Emergency
Medicine, OSPIDAL – Center da sandà Engiadina Bassa, Scuol,
Switzerland

Joachim Koppenberg
Email: [email protected]

In the present case it becomes clear that one has to accept in some
exceptional cases that the patient’s situation deteriorates initially through
the measures taken, but this may be unavoidable in order to save him.
And sometimes a second attempt is necessary to achieve the desired
goal.

As a motivated junior resident in anesthesia and with 2 years of

experience as an emergency physician in ground-based emergency services,
I had a previously quiet ambulance service on a Monday after a free
weekend—including a hearty breakfast and the latest “gossip” from the
weekend with the on-duty paramedics. Around 10:00 clock the EMS
control center alarms us to an “unconscious person” in a forwarding
company. Since the forwarding company is located a little outside the city
in an industrial area and we are on the way in a compact physician-manned
ambulance from the university hospital, the EMS control center alarms an
ambulance stationed about 6 min from the scene of the accident in parallel.
So the journey continues to be relaxed: A vanguard is on the way, so there
will be twice as many paramedics at the scene of the emergency as usual,
and in the case of unconsciousness it is probably once again one of the
numerous urban hypoglycemias or epileptic seizures that would be awake
again when we arrived. So: “Everything is relaxed”! My relaxation is
quickly gone after our arrival 14 min later. The ambulance crew arrived a
few minutes before us and presented an initially very confusing situation:
An approximately 40-year-old worker is lying with severe, bleeding facial
injuries on his back a few meters from a truck. Near the loading area is a
large pool of blood, a blood trail leads from there to the lying patient. There
are no further clues to the accident at this time, as the only witness to the
accident is under severe “shock” (here the unfortunate term of shock is
meant as it is described in the newspaper). Several employees of the
forwarding company are running around excitedly. The ambulance crew has
already attached an ECG (heart rate 44/min) and taken a blood pressure
measurement (systolic 80 mmHg, diastolic unmeasurable), the oxygen
saturation is 66%. During the first orienting examination, a Glasgow Coma
Scale (GCS) of 3, a shattered lower jaw, multiple fractures of the middle
face and blood loss from both ear canals are found. Further injuries cannot
be ascertained in the short time available. The nose-throat-space is
completely filled with blood and more and more blood is gushing out of the
mouth. Respiratory mechanics can only be determined to a limited extent.
Due to the existing findings, it is quickly clear that the patient needs an
airway securing as soon as possible, independent of the accident mechanism
or other injuries and further differentiated treatment measures, since the
pronounced hypoxia already induces bradycardia and announces an
impending cardiac arrest. Due to the shattered lower jaw and the severe
bleeding, the Swiss army knife and the ballpoint pen for the emergency
cricothyroidotomy are going through my head—I had never performed this
measure before, except on a dead sheep. Fortunately, one of the older
paramedics hands me the laryngoscope and a tube and says calmly: “Try it
—I’ll get the cricothyroidotomy set from the ambulance while I’m at it.”
Before starting an IV or administering any drugs with a Glasgow Coma
Scale of 3, the oral intubation is surprisingly easy and problem-free, with
simultaneous suctioning. In the case of a suspected fall from the back of a
truck, we carry out intubation while manually stabilizing the neck. While
the intubation is being carried out, a paramedic is able to successfully insert
a 16-gauge needle into the left forearm. Despite the overall more difficult
personnel management (four paramedics are working from two sets of
equipment and there are several excited workers around the treatment area),
after the airway is secured with an unexpectedly easy intubation and the IV
is in place, I slowly start to feel again: “We’ve got this under control!” After
checking the correct endotracheal tube placement with capnography, the
difficult tube fixation due to the heavy bleeding in the face, and the
application of a neck brace, a large amount of blood can be suctioned
through the tube. After ventilation with 100% oxygen, the peripheral
oxygen saturation rises to 94% and, as a result, the heart rate gradually
increases to 122/min (physiology should be right again), while the blood
pressure remains systolic at 80 mmHg. With the working diagnosis of
“severe head injury”, it is clear that we need to aggressively treat
hypotension in order to maintain cerebral perfusion pressure (cerebral
perfusion pressure = mean arterial pressure minus intracranial pressure) and
get to the hospital as quickly as possible (the principle of “load and play”).
The already inserted IV access “runs well” (already 1000 ml of full
electrolyte solution and 500 ml of balanced HAES solution have flowed
through) and so the idea is to prepare for transport, to insert a second IV
access. I feel a certain inner satisfaction—everything is going well. But
before I insert the second access, the patient suddenly becomes bradycardic
and shortly afterwards even asystolic. At the same time, one of the many
paramedics hangs on the already inserted venous access and pulls it out
unintentionally. Both happen so quickly that I am speechless and helpless
for a short time. However, I quickly have to admit that this is probably not a
good time to rethink my career choice. The only good news: The bleeding
has stopped! After I have accepted the new situation internally and the
paramedics have already started chest compressions, I motivate myself with
the fact that it is at least an observed cardiac arrest from the perspective of
cardiac arrest and the patient is already intubated. So we only need a new
IV access to fulfill the “duty” resuscitation, which is quickly done. The
initiated cardiopulmonary resuscitation runs smoothly and in accordance
with the guideline Asystole—there are also enough rescuers on site. After
the mandatory part of the resuscitation runs well, we come to the elective:
Why did the patient have a cardiac arrest? So we go through the classic H’s
and T’s of the potentially reversible causes:
Hypoxia?—The patient is well oxygenated, the tube is still in the right
place.
Hypovolemia?—With the bleeding in principle possible, but we treat it
already aggressively.
 Hypothermia? This is extremely unlikely due to the sudden accident and
so slowly we were not at the scene of the accident.
Hypo-, hyperkalemia, hypokalemia? This is also unlikely as the trigger of
the accident in a 40-year-old worker.
Pericardial tamponade? In principle possible, but the leading injury is in
the head/neck area.
Intoxication? There are no indications for this.
Thromboembolism? Also very unlikely due to the accident.
Tension pneumothorax?—There are no obvious injury indications for
this, but we do not know the accident mechanism yet.
On re-auscultation, there is a significantly weakened left breathing
sound compared to the auscultation after intubation, and it seems that the
ventilation pressure is increasing on the ventilator bag. So the working
hypothesis is tension pneumothorax, and I puncture in the sense of a (test)
or relief puncture with a 14-G needle in the second intercostal space
medioclavicular left (Monaldi)—promptly and pleasingly there is the
expected hissing escape of air. But unfortunately, the target size of a relief
puncture is not “hissing escape of air”, but the improvement of the
cardiovascular situation, which does not occur. The patient remains
asystolic and resuscitation-worthy. After this new disappointment,
resignation now sets in for everyone—we unsuccessfully resuscitate a 40-
year-old multiple trauma patient and begin to discuss the meaning of our
efforts or the termination of the measures. After a short pause, I decide to
give the patient a proper thoracic drainage by means of a blunt
minithoracotomy in the front axillary line in the 4./5. Intercostal space
(chest tube) and, if the situation remains unchanged, to discontinue the
resuscitation attempt. After piercing the pleura with the index finger, there
is again a hissing escape of air—but now, contrary to my expectation, a
prompt transition to a sinus rhythm (heart rate 90/min) with ejection and a
blood pressure of 60 mmHg systolic. Now we transport the patient to the
hospital as quickly as possible and try to stabilize systolic blood pressure as
well as possible with volume and catecholamines during the journey;
diastolic, however, no blood pressure is measurable anymore. In the
hospital, the patient is quickly massively transfused, tracheotomized and
operated upon—but unfortunately dies shortly afterwards from the
consequences of the severe head injury.
Discussion
This intervention taught me some important things that I could only
really understand after several conversations and literature research, but
which have had a lasting effect on my understanding and approach to
severely injured patients. First, the question arose as to why the patient
could develop a tension pneumothorax so quickly, which even caused a
cardiac arrest. As it turned out later, when unloading the truck, a so-
called jumbo pallet fell on the patient’s head/chest area, which was
immediately lifted away by a forklift driver to free the patient. This is
how the obviously severe head injuries and, as the autopsy showed, a
single isolated rib fracture originated. There was probably also a
minimal pleura injury. However, since the patient hardly or not at all
breathed spontaneously due to the other injuries, no relevant tension
pneumothorax could develop at first. But then we—the rescuers—
intubated the patient and carried out positive pressure ventilation and—
oh wonder—operated the tension valve mechanism with each ventilation
stroke. So we actively triggered the tension pneumothorax, which drove
the patient into cardiac arrest. The pressure generated by the ventilation
creates a constantly increasing pressure in the pleural space. And why
didn’t the relief puncture with the 14-gauge needle produce a better
result? Well, we were basically right, but again: The target size of the
relief of a pneumothorax is not “hissing escape of air”, but an
improvement in the cardiopulmonary situation. The following reasons
can explain the failure of the needle puncture method: Either the pleura
closed the plastic cannula again or it bent it over or there was a
hemopneumothorax and we only relieved a small, non-relevant part of
the pneumothorax [2–4]. However, the decisive finding is that in the
event of an unsuccessful needle relief puncture, a “proper” thoracic
drainage must always and consistently be placed, as a needle puncture
can not be sufficient. Especially in the resuscitation situation, the S-3
guideline multiple trauma therefore recommends the consistent
exclusion of a tension pneumothorax as the cause of cardiac arrest by
possibly also placing a thoracic drainage on both sides [1].

5.1 Conclusion
The switch from spontaneous to mechanical ventilation after intubation can
trigger a tension pneumothorax! This means in concrete terms: Whoever
intubates a patient with thoracic trauma must practically wait for the tension
pneumothorax (circulatory depression, increase in ventilation pressure) and
then treat the resulting tension pneumothorax consistently—otherwise the
rescuer unintentionally triggered cardiac arrest! If there is suspicion of a
tension pneumothorax, a needle-relief puncture can be carried out first.
However, if this does not show the desired clinical effect, a sufficient
thoracic drainage must be carried out on both sides.

References
1. Deutsche Gesellschaft für Unfallchirurgie (2022) S3- Leitlinien Polytrauma/Schwerstverletzten-
Behandlung. awmf-Register Nr. 187-023, www.awmf.org. Accessed 15 July 2023

2. Dominquez KM, Ekeh AP, Tchorz KM et al (2013) Is routine tube thoracostomy necessary after
prehospital needle decompression for tension pneumothorax? Am J Surg 205(3):329–332
[Crossref]

3. Inaba K, Branco BC, Eckstein M et al (2011) Optimal positioning for emergent needle
thoracostomy: a cadaver-based study. J Trauma 51(5):1099–1110

4. Mistry N, Bleetman A, Roberts KJ (2009) Chest decompression during resuscitation of patients in

prehospital traumatic cardiac arrest. Emerg Med J 16(10):738–740
[Crossref]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_6

6. The Final Exam

Volker Wenzel1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine,
and Pain Therapy, Friedrichshafen Regional Medical Center and
Tettnang Hospital, Friedrichshafen, Germany

Volker Wenzel
Email: [email protected]

Studying human medicine, like many other courses of study, is a great

challenge for the young people studying it. The present case is concerned
with the fact that this challenge cannot be mastered by everyone without
support and accompaniment and can become overwhelming.

A colleague told me that he had got to know a very smart medical

student when he was on duty as an emergency physician who was looking
for an M.D. thesis; however, he was just busy with tedious exams, so we
planned to include him in a project six months later. He was then very
pleased to get to know the scientific side of his studies and worked on his
M.D. thesis with a huge amount of energy and personal commitment. The
M.D. thesis developed excellently. He had an extremely good sense of
humour—for example, he said that he would need an exit clause in a
residency physician contract in case he could become a soccer coach at a
well-known club. Once he asked me to postpone an appointment by one day
just before he handed in his M.D. thesis because he had to help out in the
EMS. The next day he came into the office with sunburn on his arms and
face. In response to my ironic question as to whether work in the EMS had
been very hard, he replied with disarming honesty: We were lying in a
deckchair and fell asleep in the sun—whether on standby in the EMS
station or in the mountains, he left charismatically open. I thought to
myself: That was a white lie!, but obviously he wanted to break out once
more just before the end of his time in Medical School, before the working
day started. I also recognised a little of myself in this M.D. thesis student
and was therefore also lenient with him: Like him, I lost my father as a
child, like him, I had to work a lot during my time in Medical School to
finance everything. A little later the M.D. thesis was finished and I sent it to
the dean’s office. The next day I got a call: “We cannot process this M.D.
thesis, after all, most of the course certificates are missing!” I called the
M.D. thesis student and left a message on his mobile phone asking for
clarification. The next day he called back and said: Everything clarified—
he was confused, as was also the case with a fellow student, because the
Dean’s office had moved. The following day, the Dean’s office called me
again and they told me: “We have checked everything again, but it remains
the same: Going forward is not possible at this time because most of the
coursework is still missing.” I was completely shocked. Every attempt to
reach the M.D. thesis student failed; he also did not call back the next day.
Another day later, he did not show up at his part-time job at an EMS
station, which had never happened before. The research showed that he had
not returned from a mountain hike as announced. The mountain rescue
service was deployed and searched the mountains all night; the next
morning, a helicopter flew over the area. They finally found him dead at the
foot of a cliff; he had fallen about 150 m. The call about his death hit me
like a lightning bolt. I was paralyzed. Every year, dozens of recreational
athletes die in the Tyrolean mountains—tobogganists and skiers collide
with trees, climbers lose their grip, the altitude in combination with great
effort causes heart attacks, paragliders crash, kayakers drown—often bad
equipment or an unfortunate assessment of the weather and the mountains
was an important factor that led to the accident. But our M.D. thesis student
had always been very conscientious on his mountain hikes and he was
extremely experienced. All circumstances undoubtedly pointed to the fact
that this was not a tragic accident, but a carefully prepared suicide. We
researched that our M.D. thesis student probably wanted to gain time with a
lie about successfully completed exams at the time of the aforementioned
“annoying exams” in order to escape his exam anxiety. Since his
descriptions of these (allegedly successful) exams were absolutely
plausible, the facade worked—possibly even to his own surprise. Of course,
he received messages from the Dean’s office at the beginning of each
semester about outstanding exams, but he paid his semester fees reliably
and thus did not stand out in the system. We had not asked for a copy of his
coursework in our research laboratory for his work, because he worked on
his project with great joy, commitment and success—no wonder, after all,
he did not have to take an exam with us, but only write an M.D. thesis—
which he did brilliantly. In this way, a double life developed, which he was
able to maintain due to his high intelligence and his impressive charisma.
But of course the air got thinner and thinner; one year before his death, he
announced the end of his studies “in two semesters”. In this time he
bloomed again through a variety of great leisure experiences—only one
colleague noticed one week before his death that he looked very thoughtful
for someone who had actually just successfully completed Medical School.
But at that time our M.D. thesis student had probably already decided that
there was no way back into the real world—there were dozens of
opportunities when we could have helped him. Everyone in his large circle
of friends and colleagues and I would have immediately dropped everything
to help him. But he decided to continue his legend, which he probably
considered to be irreversible at some point—he deceived to avoid
disappointing his entire environment—and paid for it with his life.

Discussion
In the USA, there are very detailed studies on the suicidality of medical
students [1]. In a survey at the University of Michigan in Ann Arbor,
46% of medical students said they had had depressive phases, 15% had
been diagnosed with depression once, and 4% had seriously considered
suicide during their medical studies [2]. Compared to earlier (approx.
1960–1980) reports from German universities with suicide rates of 35–
61 per 100,000 students, the Innsbruck figures with 36 suicides per
100,000 medical students are lower, but still more than twice as high as
in the age-appropriate comparison group (approx. 17 per 100,000) or in
American medical students from an earlier study (16 per 100,000) [3].
Important risk factors for suicide are depression, bipolar disorder,
schizophrenia, and borderline personality disorder; 90% of suicides have
one of these conditions [4]. Student life away from stabilizing social
structures, financial dependence despite higher age, the high pressure of
work in a mass study, the predominant and one-sided “mental work”,
identity problems, fears of the future and of existence, and an unclear
social status were also identified as important risk factors for suicidality
of students. The exact reasons for a student suicide therefore appear to
be diverse; a fatal combination of character traits, life circumstances,
mental state and stressful events seems to be decisive. There are hardly
any clear signs in the run-up to suicides as with other diseases; doctors,
friends and relatives are often unsure and therefore cannot clearly assess
how serious the danger actually is. People in emotional distress often
lack the necessary courage to seek professional help [5].
In addition to the classical risk factors, deep narcissistic injuries with
fears of social reputation loss can also be causes of suicides—especially
in highly respected medicine. Our performance society favors
competition and winner types, which can create a tension field between
unrealistic expectations and personal performance. Overwhelming ideals
of how one should be can be dictated by both external and internal
factors. The higher the target state is set, the deeper the humiliating crash
in the form of a final failure in the study can be.
The allocation of Medical School slots is largely based on the final
grade or the Medical Aptitude Test and thus selects people who can
quickly learn theoretical subject matter. Other important key
qualifications such as sociability, empathy, social competence and
(self-)organizational talent are thus left out of account, but are very
important for the study success of a medical student and for the further
professional success of a physician. In Medical School, the acceptance
and coping with failure in exams may be an unexpected and drastic
change for which, up to that point, the performance-oriented and
success-spoiled high school graduates usually did not have to learn any
coping strategies. Furthermore, a disillusionment often develops during
Medical School, because the private and professional future is
increasingly assessed as realistic and therefore demotivating due to high
workload, moderate salary and high sacrifices in private life [6].
A way out of this dilemma of an increased suicide rate among
medical students is primary prevention in order to mitigate the effect of
stressors in studies within the framework of a solidary coexistence.
While fellow students can assess each other’s living conditions well in
order to, for example, notice excessive alcohol consumption or social
 withdrawal, university staff are among others required to request
explanations for lack of progress in studies carefully and binding. For
this it is necessary to de-taboo the topic “psychological stress” in
Medical School. An open approach to the topic could serve the transfer
of coping strategies for stressors and remove the reluctance to seek
professional help. Likewise, university staff should not only convey pure
subject matter, but also with the student's life goals and tasks beyond
profession and career and promote them in their personal development
process or refer them to appropriate counseling centers [7]. Two years
later I examined a student who submitted a confident performance in the
internship, but had a complete “blackout” in the formal examination. I
asked her to solve this phenomenon with professional help, because
otherwise she would always be below her actual value in a pressure
situation. Weeks later she reported back and told me proudly that she had
solved the problem with the help of the psychological student
counseling. Counseling and help is therefore possible, but one has to talk
about it—one only gets help if one asks for it. The Corona pandemic has
shown that personal encounters and leisure activities have been
significantly restricted by the different lockdown levels, which in turn
potentially unstable people further unsettled. Consequently, it has
become even more difficult to assess the real well-being of another
person.

6.1 Conclusion
Our M.D. thesis student’s case shows that trust in people is good, but a
check is required to confirm the trust—whether a check of the course
certificates would have saved this life, however, is unclear. The suicide risk
of medical students compared to the general population appears to be
increased, but we do not know whether our observations can be transferred
to other universities because of missing comparative data. Apparently, it is
not a single specific event that moves medical students to suicide, but a
combination of individual risk factors and the social environment.
Unfortunately, this problem is currently not receiving the necessary
attention. The Corona pandemic has made digital meetings much better and
available, so that better help can be given—if it is also used.
References
1. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, Durning S, Moutier C,
Szydlo DW, Novotny PJ, Sloan JA, Shanafelt TD (2008) Burnout and suicidal ideation among US
medical students. Ann Intern Med 149:334–341
[Crossref][PubMed]

2. Schwenk TL, Davis L, Wimsatt LA (2010) Depression, stigma, and suicidal ideation in medical
students. JAMA 304:1181–1190
[Crossref][PubMed]

3. Kamski L, Frank E, Wenzel V (2012) Suicide in medical students: case series. Anaesthesist
61:984–988
[Crossref][PubMed]

4. Hawton K, van Heeringen K (2009) Suicide. The Lancet 373:1372–1381

[Crossref]

5. Schernhammer E (2005) Taking their own lives – the high rate of physician suicide. N Engl J Med
352:2473–2476
[Crossref][PubMed]

6. Jurkat HB, Reimer C, Schroder K (2000) Expectations and attitudes of medical students
concerning work stress and consequences of their future medical profession. Psychother
Psychosom med Psychol 50:215–221
[Crossref][PubMed]

7. Voltmer E, Kieschke U, Schwappach DL, Wirsching M, Spahn C (2008) Psychosocial health risk
factors and resources of medical students and physicians: a cross-sectional study. BMC Med Educ
8:46
[Crossref][PubMed][PubMedCentral]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_7

7. Injuries from Heavy Machinery

Hans-Richard Arntz1
(1) Charité, University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

Head injuries can, as this case shows, very quickly become very
dramatic, especially when “heavy machinery” is used. This case also
shows that you are not immune to terrible situations as an emergency
doctor, which you might assume to be a one-time occurrence, and that
you have to relive them again.

Without a doubt, every emergency physician remembers scene calls

after several years of service that he or she will never forget. It is especially
astonishing when two unusual events happen one after the other, which,
moreover, have not lost their horror even after a long period of time.
The first emergency call came in the afternoon on a quiet weekday. The
fire department dispatched us with the keyword “serious injury” without
further information on the type of injury to a villa area in Berlin. After a
few hundred meters of driving with lights and sirens, the fire department
reports again with the more detailed information that it should be a neck
injury. Of course, a head cinema immediately arises with possible
scenarios; one of them is—as I remember—a gaping neck wound after a
fall into a glass door, as they are often found in the villas in Berlin—safety
glass was not common back then. Hardly has this image been created, the
fire department reports again, now with the message that it is a chainsaw
injury to the neck. The joint reaction of our physician-manned ambulance
team is that it could possibly be a violent crime—at least our hair stands on
end at this thought.
 Arriving at the scene of the accident, our imagination seems to be
confirmed at first: in front of the entrance of the house there are numerous
policemen who look a little confused and, when asked what happened or
where we can find the injured person or persons, silently point to the open
front door. When we enter the house, we see a bloody person sitting in a
chair in a room behind the hallway; the chair and the carpet underneath are
soaked with blood. The person is—recognizable by the gray stubble beard
under the blood—an older man with a huge gaping and heavily bleeding
wound on the neck and several other cuts lower down on the neck. Despite
the proximity to many large blood vessels, a spurting blood loss is
surprisingly not detectable. Despite sitting position and massive blood loss,
the injured person, as gesturing attempts show, is obviously at least partially
conscious. The possibly completely severed trachea hangs down in front of
the large wound, with blood flowing into the trachea and apparently also
being aspirated. Despite many years as an emergency physician, I have
never experienced such a situation.
While I am determined on the one hand to treat the patient’s fear of
airway obstruction by aspirated blood and hemorrhagic shock as quickly as
possible by induction of anesthesia, I also want to know on the other hand
how the situation came about. When cleaning the blood-smeared arms in
search of a venous access, I notice numerous large scars on both forearms
that originate from longitudinal cuts in the arm. This initially seems to
suggest that it may be a suicide attempt. After induction of anesthesia, the
patient is intubated and ventilated directly into the outwardly hanging
trachea and an infusion therapy is initiated. Only now do I notice other
policemen in the room who, after “forced” questioning, point to a half-
standing, terror-stricken and petrified-looking older woman who seems to
be clinging to the wall. As it turns out, this is the patient’s wife, who
discovered the situation and first alerted the fire department, which then
alerted the police in addition based on the description of the situation. When
we ask what happened, the woman silently points to a blood-smeared power
saw (so-called “cut-off grinder”) lying on the ground with which the patient
apparently tried to cut his own throat. However, after the first cut attempt on
the neck, which fortunately did not open the carotids, the power saw
apparently fell out of his hand. The request to the policemen to help us with
the transport of the seriously injured person ends with a typical
complication for the following hectic situation when a policeman’s boot
gets caught in the monitor cable and infusion line, resulting in a loss of the
venous access. The new venous access is quickly found despite the blood-
smeared arms and the patient can be brought to the hospital after pre-
notification for anesthesia and ENT without further incidents. After primary
treatment in the emergency room, the patient is operated on immediately,
allowing the continuity of the trachea to be restored.
The patient’s central problem and his determination to end his life even
by using extreme violence against himself are of course not solved by this.
The prognosis for such structured and aggressive suicide attempts is
generally critical because the probability of success increases with the
number of initially failed violent self-destruction attempts [1]. The extent of
violence in this sad case makes survival seem more like a miracle anyway,
since the large arteries in the neck were only narrowly missed. Intensive
psychiatric therapy is of course necessary afterwards; however, I have no
knowledge of its results.
Now one thinks that one would experience similar things—if at all—
only after a longer period of time, but far from it: Hardly 4 weeks after this
terrible deployment, I am again alarmed as the on-call emergency physician
at the EMS helicopter on a warm summer afternoon with the keyword
“severe injury” to a construction site in Berlin. I can’t believe my ears when
I hear the additional information “Chainsaw injury in the face”. During the
approximately 10-minute flight, we of course develop the most terrible
ideas about the situation that awaits us.
We find a young worker at the emergency site who has been lying on a
blanket by his colleagues as part of first aid. You can see a wide wound that
was partially torn off by the chainsaw links at the edges, which ran from the
inner right eye corner, near the nose, over the right cheek, split the upper lip
and also injured the lower lip and parts of the chin. It is not clear whether
there were also injuries to the eye; just as unclear is whether there were
deep jawbone fractures or injuries to the row of teeth. What happened? The
worker was not sawing from top to bottom as usual when working with the
chainsaw on wooden beams, but setting the saw under the beam and sawing
it up. When the saw passed through upwards, there was a sudden
uncontrolled movement of the approximately 50 cm long saw blade towards
the unprotected face of the worker with the described injury consequences.
The entire protective equipment of the injured consists only of safety shoes
and leather gloves—unfortunately he has dispensed with safety clothing and
a helmet with integrated face protection despite the danger.
Since the severity of the injury cannot be determined exactly on site, the
young man is conscious and despite clearly high blood loss, circulatory
stability seems not to be life-threatening. At the emergency site, we are
particularly happy to be able to forego intubation of the airway in order to
secure it, as it cannot be ruled out that a necessary strong mouth opening
and traction on the lower jaw during laryngoscopy could lead to additional
injuries. After sterile wound coverage, insertion of a venous cannula with
infusion of a crystalloid solution and sufficient analgesia for the treatment
of severe pain, the logical transport destination in view of the complex
injury pattern and the specialist disciplines required for further treatment
(Ophtalmology, ENT, maxillofacial surgery, plastic surgery) is a hospital of
maximum care with our EMS helicopter in order to avoid time losses. With
the now possible exact determination of the exact extent of the injuries with
optimal examination conditions under anesthesia, it turns out that the young
man has had enormous luck in misfortune: the eyeball and the tear duct are
uninjured, as is the row of teeth; only the oral cavity is open. Otherwise,
only soft tissue injuries are present, but also nerve lesions to a lesser extent,
so that only a temporary impairment of facial expression is to be expected.
Almost 2 weeks after the event, the patient can be discharged home with a
result that is also satisfactory from a cosmetic point of view.

Discussion
It is amazing what curious mechanisms people come up with for a
suicide, but it seems to simply correlate with access to the method. In a
country like the USA with approximately 200 million firearms in private
households, the risk of dying from a firearm suicide is 10 times higher
than in a household without a firearm [2]. Physicians, on the other hand,
tend to poison themselves with drugs when they attempt suicide because
they have easy access to it and know the mechanisms of action [3].
However, what is much more important in the first case is to keep a cool
head in the face of the dramatic situation and not to worsen the situation
with imprudent therapy approaches—unfortunately there are a number of
cases in which, for example, patients have died as a result of botched
airway management, who had survivable injuries [4].
 The second case shows with what everyday carelessness work is also
carried out with dangerous tools, which again and again leads to serious
injuries. The mechanism of injury in our patient is typical for chain saw
injuries [5], as well as injuries up to amputations of the lower
extremities. Careless handling of the regulations, for example the
statutory accident insurance for protective clothing and injury prevention
(www.dguv.de), among other things specifically when handling chain
saws, certainly does not always end as successfully as in our case. By the
way, forester's offices often offer very recommendable, usually
inexpensive or even free courses for the correct protection and the safe
handling of chain saws for private individuals. As much as one wonders
about the carelessness of the injured construction worker, so much is
everyday carelessness in the life of an emergency medical service
evident: EMS employees or emergency physicians who appear for duty
in sneakers, ride motorcycles without helmets, run into burning houses
without protective equipment or assume when treating injured people on
the highway that they will be seen well by other road users. While
accidents with physician-manned ambulances that occur in practically
every emergency medical center are only discussed in the local press,
accidents with helicopter EMS are also analyzed in the scientific
literature [6, 7]. All participants in an emergency medical team should
address careless behavior and try to prevent it.

7.1 Conclusion
Injuries to the face and neck cause very rapid and severe blood loss; the
balance between shock and airway management must be very carefully
considered in order to avoid further blood pressure drops and/or respiratory
disaster.

References
1. Giner L, Jaussent I, Olie E, Beziat S, Guillaume S, Baca-Garcia E, Lopez-Castroman J, Courtet P
(2014) Violent and serious suicide attempters: one step closer to suicide? J Clin Psychiatry
75:e191–e197
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2.
Miller M, Hemenway D (2008) Guns and suicide in the US. N Engl J Med 359:989–991
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3. Schernhammer E (2005) Taking their own lives – the high rate of physician suicide. N Engl J Med
352:2473–2476
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© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_8

8. Blood Pressure Crisis

Martin Dünser1
(1) Department of Anesthesiology and Critical Care Medicine, Kepler
University Hospital, Linz, Austria

Martin Dünser
Email: [email protected]

This case very clearly shows that a good diagnosis should always also
take into account the symptoms and the general condition of the patient
before the gaze wanders to the monitoring. This is indeed an important
accompanying diagnostic parameter, but by no means the only one.

I am just on night duty and am immersed in the thick medical history of

a patient who has been treated on our intensive care unit for weeks, when I
am called to admit a patient. An 82-year-old man with fever and a dramatic
deterioration in his general condition is brought to our emergency
department. Despite several underlying health conditions (arterial
hypertension, coronary heart disease with myocardial infarction, chronic
heart failure with moderately reduced ejection fraction, non-insulin-
dependent diabetes mellitus), the patient lived independently with his wife
at home. He is sufficiently resilient for everyday life with only minor
restrictions (climbing stairs). Two days ago, the patient developed
unspecific illness symptoms with general weakness, became subfebrile and
finally febrile (on arrival at the emergency department: 38.9 °C (102 °F)).
When the patient was confused this morning after waking up, his wife
alarmed the EMS, which brought the patient to the emergency department.
The clinical examination does not reveal any indications of focal
neurological deficit, neck stiffness, suspicious pulmonary rales, abdominal
guarding, joint pain or infective skin changes. A right-sided flank pain and
a 3/6 systolic murmur over the Erb’s point are conspicuous. With the
absence of peripheral endocarditis signs and turbid urine with the detection
of leukocytes (+ + +), erythrocytes (+ +, eumorphic) and positive nitrites,
the provisional diagnosis of “sepsis with urinary tract infection” and
probably “pyelonephritis” is formulated. Differential diagnosis cannot rule
out endocarditis. Laboratory analysis shows leukocytosis with left shift
(17% neutrophils and toxic granules) and severe thrombocytopenia (67 g/l).
After obtaining microbiological cultures, empirical antibiotic therapy is
initiated with an aminopenicillin. A renal ultrasound does not show any
evidence of obstruction of the renal pelvis or renal calyx system. The
patient presents somnolent. He is oriented to person and situation, but does
not know what day it is or where he is. His skin is cool and shows a re-
capillarization time of 5 s. as well as a skin mottling over the knee. The
neck veins are not congested and peripheral venous filling (e.g. on the back
of the hand) is reduced. Even manual compression of the liver bed over
10 s. does not lead to dilation of the neck veins. The heart rate is 110/min
and the arterial blood pressure 75/30 mmHg. After fractionated
administration of 1.5 l crystalloid fluid, the patient shows good peripheral
perfusion. His skin becomes warm, the re-capillarization time normalizes to
values around 3 s and the skin mottling disappears. The neck veins are
visible in supine position 2 cm above the jugulum. Hepatojugular reflux is
still not induced. Although the heart rate has dropped to 95/min, the blood
pressure remains low at mean arterial blood pressures of 45 mmHg. Much
too low compared to the international recommendations of the sepsis
societies. Although the nurse at the bed is pleased about the course of the
increasingly awake patient, I cannot share this enthusiasm at all. The blood
pressure is simply too low! A vasopressor is needed! I start a
norepinephrine infusion with the goal of raising the mean arterial blood
pressure to values around 65 mmHg. Shortly after the start of the infusion,
the blood pressure starts to rise as desired and I return to my medical
history. When I reassess the patient after 2 h, the nurse reports that, in order
to achieve the desired mean arterial blood pressure, she had to increase the
norepinephrine to 0.2 µg/kg/min. The patient is no longer as responsive as
before and begins to fidget with his catheters uncoordinatedly. The hands
and feet are again cool and the skin mottling over the kneecaps is again
clearly visible. The heart rate has risen to 115/min and the diuresis has
completely ceased during the last hour. Obviously, the patient is just
“slipping” into a severe septic shock. I ask the nurse to continue to
administer fluid boluses. Just before the morning handover, the patient is
agitated and wants to get out of bed. The lactate has risen to 8 mmol/L, the
fingers are already blue and the diuresis is now completely gone. The
norepinephrine dose has to be increased to 0.41 µg/kg/min. This will result
in mean arterial blood pressure values between 60–70 mmHg in order to
save what is left of the kidney from sepsis! I start a dobutamine infusion
and change the antibiotic to a carbapenem. Exhausted, I report the
mentioned patient with progressive severe shock to the experienced
intensive care physician during the morning handover. With the bad feeling
that I have done everything right, but still overlooked something, I leave the
hospital. When I come back to the ward the next morning, I immediately
look for the patient who has been on my mind until then. Expecting to find
an intubated, hemodynamically unstable patient on renal replacement
therapy, I am surprised when I find a conscious patient. Pleased but also a
little disbelieved, I shake his hand and introduce myself. He reacts
promptly, smiles and I shake his warm, well-perfused hand in greeting. The
experienced colleague comes up to me, smiles and shows me the course of
yesterday’s events using the automatic computer records. Immediately after
taking over, he had performed a transthoracic echocardiography and seen
that the ejection fraction of the left ventricle was severely impaired and the
patient had a relevant mitral valvel insufficiency. Therefore, he gradually
reduced the norepinephrine infusion. Although the blood pressure fell back
to the initial values of 45 mmHg mean arterial blood pressure, diuresis
improved and lactate fell. I am completely astonished when a sodium
nitroprusside infusion, a potent but short-acting vasodilator, is started and
the mean arterial blood pressure even begins to rise slowly. This is
associated with a further increase in diuresis. In the afternoon of the same
day, I receive the microbiological finding of the urine or blood culture, in
which a pansensitive E. coli was detected in each case. I de-escalate the
carbapenem to an aminopenicillin. The patient is discharged to the ward in
good general condition 2 days later.

Discussion
As described in Ohm’s law, blood pressure is the product of flow and
resistance or, physiologically simplified, of cardiac output and vascular
resistance. Although arterial blood pressure is often equated with blood
flow and, thus, with organ perfusion in practice, studies of the past 10
years have impressively shown that this assumption is not always correct
[1, 2]. In several clinical studies, no relationship was found between
blood pressure and microcirculation or other markers of organ perfusion.
Furthermore, clinical studies have shown that a large proportion of
patients with sepsis still have impaired tissue perfusion after
norepinephrine-mediated increase of mean arterial blood pressure to
target values of 65 mmHg [3, 4]. The example of our patient is
particularly impressive because the sepsis-induced circulatory
dysfunction is worsened by poor left ventricular function and relevant
mitral valve insufficiency. But that’s just how it is in clinical practice -
not only in individual cases, but if you look closely, in a majority of
cases! Both cardiac pathologies are known and it is also known that they
usually deteriorate with an increase in left ventricular afterload. That is
what happened in our patient’s case. After initial improvement due to
fluid therapy, the liberal and blood pressure value-controlled
norepinephrine infusion eventually led to a significant deterioration of
the patient’s condition, who then showed almost all signs of systemic
hypoperfusion. As a result of the alpha-mediated vasoconstriction, the
vascular resistance and, thus, the afterload of the left ventricle were
significantly increased. This led to a critical reduction of cardiac output
due to deterioration of pump function and increase of mitral
insufficiency. Even the small beta-mimetic effects of norepinephrine or
administration of dobutamine could not change this. Although blood
pressure increased to recommended values of 65 mmHg under this false
therapy for the patient, tissue perfusion (peripheral perfusion, lactate
concentration) and organ function (urine output, confusion) deteriorated
dramatically. Only after stopping the norepinephrine infusion was the
afterload reduced again, which caused the pump function to increase and
the mitral valve insufficiency to decrease. Although this led to a decrease
in mean arterial blood pressure, it was accompanied by an increase in
cardiac output and tissue perfusion. Therapy with sodium nitroprusside
further reduced vascular resistance and, thus, led to an additional
increase in cardiac output. The improvement of (organ) perfusion under
 this therapy was evident from the normalization of peripheral perfusion,
the re-establishment of urine output and the decrease in lactate
concentrations.

8.1 Conclusion
This patient’s case changed my view of hemodynamic therapy for acutely
and critically ill patients significantly. It led me back to the textbooks of
physiology, taught me to understand the real meaning of cardiac afterload,
and demanded that I keep my promise to learn echocardiography from
scratch. Today I am convinced that blood pressure at low values is mostly a
marker of disease severity and must under no circumstances be set to
arbitrary target values with noradrenaline, in blind faith in a number on the
monitor. The clinical picture and the examination of the patient is still the
essential decision-making basis for controlling circulatory therapy in
hemodynamically unstable patients, despite all technical innovations.
Norepinephrine for the treatment of arterial hypotension should only be
used in exceptional cases (critical coronary, aortic and/or carotid stenosis,
right heart failure) if there are clinical signs of increased vascular
resistance. The underlying problem, which is caused by systemic
hypoperfusion in many cases of sepsis, must be treated causally and as
quickly as possible. Furthermore, the understanding that there is only a
small relationship between blood pressure and tissue perfusion taught me
that many patients can be in severe shock despite normal or even increased
blood pressure and have a life-threatening tissue hypoperfusion. So let’s
focus primarily on the patient, his/her clinical signs and only then on the
monitor [5] in the future!

References
1. De Backer D, Creteur J, Preiser JC et al (2002) Microvascular blood flow is altered in patients
with sepsis. Am J Respir Crit Care Med 166:98–104
[Crossref][PubMed]

2. Lima A, van Bommel J, Sikorska K, van Genderen M et al (2011) The relation of near-infrared
spectroscopy with changes in peripheral perfusion in critically ill patients. Crit Care Med
39:1649–1654
[Crossref][PubMed]
3. Rady MY, Rivers EP, Nowak RM (1996) Resuscitation of the critically ill in the ED: responses of
blood pressure, heart rate, shock index, central venous oxygen saturation, and lactate. Am J
Emerg Med 14:218–225
[Crossref][PubMed]

4. Lima A, van Bommel J, Jansen TC et al (2009) Low tissue oxygen saturation at the end of early
goal-directed therapy is associated with worse outcome in critically ill patients. Crit Care
13(5):S13
[Crossref][PubMed][PubMedCentral]

5. Dünser MW, Takala J, Brunauer A et al (2013) Re-thinking resuscitation: leaving blood pressure
cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based
approach. Crit Care 17:326
[Crossref][PubMed][PubMedCentral]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_9

9. Buried Under Concrete Slabs

Bernd Domres1 and Norman Hecker2
(1) Foundation of the German Institute for Disaster Medicine, Tübingen,
Germany
(2) Department of Emergency Medicine, Protestant Hospital,
Gelsenkirchen, Germany

Norman Hecker
Email: [email protected]

Natural disasters pose great challenges for external rescue forces;

especially in developing countries. The local treatment options usually
do not correspond to the treatment strategies that are common in western
industrialized countries. Although doctors in developing countries often
have outstanding improvisational talent, they can benefit from our help,
for example in treatment algorithms.

A mother has just come home from work and is setting the table for
dinner. Suddenly there is a growling, then deafening noise: walls and floors
of the apartment shake and sway, windows and dishes shatter, the ceiling of
the apartment and the multi-storey building collapse. Our patient is buried
deep under the rubble, a heavy concrete slab is lying on her left arm and
leg.
An earthquake of magnitude 7.2 on the Richter scale, with the
hypocenter at a depth of 17 km (10.6 miles) and 25 km (15.5 miles)
southwest of Port-au-Prince in Haiti, destroyed large parts of the capital
inhabited by more than 2 million people; more than 200,000 residents lost
their lives and more than 1.8 million people were homeless [1]. Due to the
chaotic conditions, a precise registration and identification of the victims
was not possible, so that the number of victims could only be estimated.
About 250,000 apartments and 30,000 businesses were destroyed; the
damage amounted to more than 5 billion Euro or US Dollars, which
exceeded Haiti’s gross domestic product- extrapolated into Germany this
would be an earthquake damage of 2500 billion Euro or US-Dollars. This
makes Haiti 2010 the worst earthquake in the history of North and South
America, as well as the worst earthquake of the twenty-first century
worldwide. At first, relief workers mainly come from neighboring countries
such as the Dominican Republic and Cuba, before some days later also
relief workers from Europe arrive; the US Navy sends a hospital ship and
an aircraft carrier off the coast of Haiti to transport injured people by
helicopter to non-destroyed hospitals.
It is not until January 15, 3 days later, that rescue workers manage to
rescue our patient from the rubble and only by amputating the already
lifeless arm with a tourniquet applied using a concrete cutter. The femur of
the left leg, which was trapped under the concrete slab for 3 days, has
suffered an oblique fracture and, with severe swelling, paresthesia and
motor paralysis, shows the signs of a manifest compartment syndrome. Our
patient is taken to a hospital by the rescue team to have her left leg
amputated there because of the compartment syndrome with beginning
crush syndrome. Our team of doctors from the Humedica organization from
Kaufbeuren, Germany works in the hospital.

Discussion
Disasters do not follow personal schedules. They happen unexpectedly.
If you are on the other side of the world from a disaster, it usually starts
with text messages on your cell phone. So it was in January 2010:
“Earthquake in Haiti, sending first team. Tonight from Munich, feedback
in 2 h, duration 14 days. Second team will be set up within the next
2 days.”
In this specific case, this message means the immediate personal
decision about one’s own availability. For civilian forces, this is an
enormous burden, because only a few relief organizations have the
financial resources to provide a pool of experts who are always
available. Essentially, these are established physicians and specialist
nurses as well as specially trained organizers who are available on a
humanitarian and voluntary basis. They often provide essential medical
supplies such as drugs, spinal needles and vital monitoring or surgical
equipment from personal initiative.
The arrival in a disaster area in the immediate response is anything
but a trip planned in detail, but rather resembles a parachute jump. It
usually leads by plane as close as possible to the crisis area in order to
achieve ground contact there together with the official cargo of the relief
organizations and the personal luggage. It can then be helpful to carry
personally provided medical aid as hand luggage, as medical materials
have a tendency to be delayed at customs—especially if entry into the
disaster area leads through a third country. In the case of Haiti, large
parts of the aid taken along by the team were held in the Dominican
Republic for 2 days.
Disasters, especially earthquakes, often destroy infrastructure
dramatically. In the case of Haiti, the earthquake mainly affected the
region around the capital (Port-au-Prince) and thus the center of
resistance to disasters of the entire nation. Here were personnel and
materials from police, fire brigades, medical facilities and the United
Nations. Also, the region is the central axis of the transport connection to
and from abroad. Therefore, among the more than 200,000 dead and
injured of the earthquake were central forces of disaster prevention.
In 2010, the journey continued from the airport, often over long
distances, in jeeps, buses or trucks. In the destroyed region, sometimes
only rugged terrain and impassable side roads were left. The actual main
roads were destroyed or blocked by refugees. Such a difficult way can
take days despite only a few 100 km (62 miles). The actual mission for
the teams is at this point still a thought game, but with the arrival in the
mission area the work begins.
Here new challenges and unexpected hurdles await. Rarely are the
conditions on site similar to the clinical reality at home. Volunteer
civilian teams then orient themselves to the known clinical structures of
their homeland and organize the available infrastructure accordingly. The
teams are inventive, flexible and well trained in individual medicine, but
usually not practiced in teamwork and limited in their resources.
The indication for amputation in the case of manifest compartment
syndrome, as in our patient’s case, was made too often after the
earthquake in Haiti, in our opinion. After the patient’s admission, the
 examination by the Humedica team showed that the prognosis of saving
the leg was actually promising. The Humedica team made the indication
for dermo-fasciotomy of the left leg and for surgical stabilization of the
femur fracture after initiation of intensive care measures for the
treatment of shock and impending crush syndrome such as shock
treatment (potassium-deficient electrolyte infusion via 2 peripheral IV
lines), diuresis (furosemide), acidosis buffering (sodium bicarbonate,
until the urine pH is above 6.5), correction of hyperkalemia (glucose
infusion in combination with regular insulin), thrombosis prophylaxis, as
well as therapy of cardiac arrhythmias (300 mg amiodarone).
Fortunately, this made dialysis unnecessary, which would otherwise have
been difficult to organize [2]. According to the experience of an Israeli
army medical team, depending on the position of the earthquake debris
in Haiti, up to 25% of the rescued patients had a crush syndrome, of
which in turn 0.5–25% developed acute renal failure. If one considers
the many thousands of injured and that more than half of the patients
with acute renal failure need dialysis and thus have extremely good
survival chances, one can estimate how many people initially survived
after a catastrophic earthquake like in Haiti, but died due to the lack of
treatment options for acute renal failure [3]. Our patient recovered
quickly and was happy that she did not lose her left leg after losing her
left arm.

9.1 Conclusion
Our finding that the indication for amputation was too rigorously made in
the case of a compartment syndrome after the Haiti earthquake prompted us
to develop an algorithm for the indication of surgical measures in the case
of impending and manifest compartment syndrome in the event of a
disaster. If a compartment syndrome is impending, a dermo-fasciotomy
should be carried out within the first six hours if possible; if more than six
hours have elapsed, a re-evaluation should be carried out every four hours.
In the case of a manifest compartment syndrome within the first six hours,
it depends on whether an irreversible vascular or nerve damage, multiple
trauma, age over 18 years, diabetes or muscle necrosis is also present; if so,
an amputation should be carried out, if not, a dermo-fasciotomy and
possibly a necrosectomy can be performed. If the compartment syndrome
manifests itself more than six hours after the event and only one extremity
is affected and there is no crush syndrome, a dermo-fasciotomy and
possibly a necrosectomy may be sufficient. However, if in addition to the
compartment syndrome there is sepsis, several extremities are affected, a
crush syndrome, no dialysis possibility, a multiple trauma, diabetes or age
over 75 years, an amputation is usually the only option.

References
1. Rice MJ, Gwertzman A, Finley T, Morey TE (2010) Anesthetic practice in Haiti after the 2010
earthquake. Anesth Analg 111(6):1445–1449
[Crossref][PubMed]

2. Vanholder R, Gibney N, Luyckx VA, Sever MS (2010) Renal disaster relief task force. Renal
disaster relief task force in Haiti earthquake. Lancet 375(9721):1162–1163

3. Bartal C, Zeller L, Miskin I, Sebbag G, Karp E, Grossman A, Engel A, Carter D, Kreiss Y (2011)
Crush syndrome: saving more lives in disasters: lessons learned from the early-response phase in
Haiti. Arch Intern Med 171(7):694–696
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_10

10. Emergency on the Fairground

Hans-Richard Arntz1
(1) Charité, University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

Emergency calls are difficult when, from apparently complete health, a

life-threatening situation suddenly and unexpectedly arises without any
clearly recognizable or comprehensible cause, such as an accident. The
present case impressively shows how an intervention can occupy us even
after the end of the service, indeed even many years later.

On an afternoon around 4:00 pm, our physician-manned ambulance is

alarmed at the Benjamin Franklin Hospital with the keyword “sudden
unconsciousness”. The emergency address is a ride at the German-
American Folk Festival on Clay Avenue in Berlin-Zehlendorf. We take on
the approximately 4 km (2.5 miles) long alarm drive relatively relaxed,
assuming that we have to take care of a smaller, typical alcohol-related
problem at such a folk festival. However, the first difficulty arises already
upon arrival, at the several hundred meters / yards long, and partly fenced
outdoor area of the large festival grounds with several entrance possibilities.
Since we were not told which entrance to choose, we take the nearest
entrance and ask the security guard there for the exact emergency site, of
which he “of course” knows nothing. While the security guard is informed
by radio, we learn from the EMS control center that it is a cardiopulmonary
resuscitation attempt of a child or adolescent. Meanwhile, the security
guard has found out that the emergency site is practically at the other end of
the festival grounds. So we have an alarm drive across the whole square in
front of us, right through the numerous pressing people. Some of the
festival visitors apparently hold the physician-manned ambulance with siren
and blue lights on the festival grounds for an entertainment gag and behave
accordingly understandingless. Meanwhile, we are increasingly under
pressure in view of the information available to us and the slow progress.
Finally, after certainly more than 15 min after alarm activation arriving
at the emergency site, we get the following picture: a larger number of
curious people have gathered at the emergency site, which are pushed back
by the also arrived police. On the ground lies a boy aged 11 years. The
ambulance team, which had arrived earlier, had taken over the
cardiopulmonary resuscitation attempt from 2 first aiders and had laid the
child on a stretcher. As it turns out, both first aiders are companions of the
boy: one an uncle, who is a paramedic by profession, the other rescuer is
the spouse of the boy’s mother. Both have started the resuscitation attempt
immediately after the detection of the circulatory arrest at the exit of the
ride. The rescue team that arrived before us had already defibrillated 2
times with the semi-automatic defibrillator—ventricular fibrillation still
exists. After an immediate 3rd shock with maximum energy output,
ventricular fibrillation is eliminated, but there is an asystole in the ECG.
The further standard measures, such as orotracheal intubation and
venous access, can be carried out easily during continuous thoracic
compression; however, injection of epinephrine initially has no effect. After
several minutes of continuing cardiopulmonary resuscitation, re-injection of
1 mg epinephrine after further consistent thoracic compression over several
minutes shows effect in the form of a coordinated rhythm with initially
weak, then better palpable pulse and increase in end-expiratory carbon
dioxide concentration. When stabilization appears to be achieved, we make
preparations for transport, but in the monitor we first observe an increasing
bradycardia with rapid transition into a new asystole. The new resuscitation
attempt does not result in a circulatory reaction within the next 15 min.
Since asystole persisted despite all efforts, we finally discontinued
resuscitation at 16:50 h, after a total of 35 min aggressive resuscitation.
Every emergency physician knows this: it is all the harder to accept death,
the younger the deceased is. It often becomes an event that one never
forgets when the death of a child also occurs from apparently complete
health without any clearly recognizable or comprehensible cause, such as an
accident.
Discussion
What had happened? The ride is a small roller coaster “for the whole
family” with a maximum speed of 50 km/h (31 mph) and partly tight
curves. At the end of the ride, the passengers in each car automatically
shot a Polaroid photo for remembrance. The entire facility had been
checked and released by the TÜV (a technical supervision organization
in Germany) a few days earlier for technical and electrical safety. The
11-year-old victim was sitting on the front seats of one of the 4-seat cars
secured by bars next to his 10-year-old sister. An adult sitting behind the
siblings had observed that the boy apparently collapsed during the ride.
In fact, the Polaroid photo taken at the end of the ride showed the boy
slumped, with his head leaning against his sister’s chest. The boy’s
uncle, a paramedic, immediately recognized the situation and started
cardiopulmonary resuscitation immediately after the child was freed
from the car. Meanwhile, the ride operator had alarmed the fire brigade
and police. A thorough examination of the normally developed deceased
child showed no physical abnormalities, no injuries and in particular no
power marks that would have been possible with the electrically
operated ride system. The ride was closed immediately and examined by
an expert who found no defects. The questioning of the boy’s uncle and
the mother’s spouse did not reveal any indications of an acute or chronic
illness. The boy had not complained of any problems before the ride, on
the contrary they had a lot of fun.
Since I was asked to deliver the sad news of the sudden and
completely unexpected death of her son to the mother of the deceased
child, I tried to combine this difficult task with a questioning of possible
abnormalities in the medical history of the deceased and the family
medical history; e.g. with regard to unexplained fainting spells or even
deaths at young ages or in children. With the understandable excitement
caused by the ride on the roller coaster as a potential trigger of an
arrhythmia, one had to think of a genetically determined predisposition
to malignant arrhythmias, such as the Long-QT-Syndrom or
catecholaminergic polymorphic tachycardia [1]. We were particularly
sensitized by an unfortunate course in 2 young sisters [2]. Of the sisters,
the younger one died suddenly with initial ventricular fibrillation and
unsuccessful resuscitation attempts. In the medical history, there was talk
of a suspicion of epilepsy with repeated collapse states. The autopsy
showed no pathological findings. A few weeks later, the slightly older
sister of the deceased also died after initially successful resuscitation in
ventricular fibrillation: she also had a suspicion of epilepsy. On the
monitor of the initially surviving person, we saw Torsade de Pointes and
the typical signs of Long-QT-Syndrome on the intensive care unit and in
the ECG. The family medical history revealed further cases of
unexpected early death, including in children, and affected persons with
a history of collapse and the evidence of a genetic aberration typical for
Long-QT-Syndrom [2].
In our case, however, the mother’s survey did not result in any
suspicious clues; not even in the family of the divorced husband. Both
children had also grown up without any health problems so far. At least I
was able to convince the mother to have an ECG registered for herself,
her daughter and as many other close relatives as possible—but I have
not heard anything about the results. The body of the deceased child was
confiscated and a forensic autopsy was ordered. According to the
information of the autopsy physician, this did not reveal any pathological
findings or clues that could explain the sudden death of the 11-year-old
boy. My urgent request, also for preventive medical reasons, to have a
molecular genetic examination carried out, was rejected for cost reasons
and lack of competence. However, it was subsequently possible to learn
from the Institute of Legal Medicine that ECGs had been registered in
some family members, but these had been unspectacular. So the question
of a possible cause of death in this tragic case of an unexpected sudden
death remained unanswered—in particular, it was not clarified whether
disorders such as the Brugada syndrome or the polymorphic rhythm
disorders that can be seen under load in the case of adrenergic
polymorphic ventricular tachycardia (APVT) were possible causes that
could only be recognized with Ajmalin and pharmaceutical provocation.
The thought of this unanswered question oppresses me to this day.
Perhaps it would have been possible to have the deceased child and, if
necessary, also relatives examined genetically via the mother. All known,
genetically determined potentially fatal rhythm disorders can indeed be
successfully treated by influencing the lifestyle (avoiding stress),
pharmacologically (ß-blockers in Long-QT syndrome or APVT) and in
the case of documented high-risk or survived cardiac arrest by
implantation of an implantable defibrillator.
10.1 Conclusion
In unexplained deaths in infants, adolescents and young adults, a
genetically determined cardiac disorder must be considered. The family
history is essential (further unexplained deaths, atypical epilepsy, recurrent
collapse?).
Simple additional tests, such as a 12-channel ECG, can be helpful, but
are not particularly reliable, as in the case of a long QT syndrome.
Dangerous QT prolongations only become manifest in some patients—
especially in women—under the influence of certain drugs; e.g. a variety of
antiarrhythmics, macrolide antibiotics, antidepressants and other
psychopharmaceuticals, antimalarials, etc. A careful drug history is
therefore also important. If a Brugada syndrome is suspected, an Ajmalin
provocation test is necessary. Stress tests can also be helpful in uncovering
the propensity for malignant rhythm disorders.
At the latest in the case of additional suspicious cases in the family
history, targeted diagnostic steps should be taken in relatives for the sake of
potentially life-saving prophylaxis, and the need for a genetic test in a
younger patient with an unclear cause of death should be emphasized.

References
1. Beckmann MB, Pfeufer A, Kääb S (2011) Erbliche Herzrhythmusstörungen. Dtsch Ärztetbl
108:623–634

2. Witzenbichler B, Schulze-Bahr E, Haverkamp W, Breithardt G, Sticherling C, Behrens S,

Schultheiss HP (2003) An 18 year old patient with anti-epileptic therapy and sudden cardiac
death. Z Kardiol 93:747–753
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_11

11. Inferno on the Highway

Peter Hilbert-Carius1
(1) Department of Anesthesiology, Critical Care, Emergency Medicine
and Pain Therapy, Bergmannstrost BG-Hospital, Halle/Saale, Germany

Peter Hilbert-Carius
Email: [email protected]

The case described demonstrates how quickly the neglect of basic

emergency medical/tactical measures can lead to a very confusing
situation. An accident scene with multiple casualties always presents the
first-responding rescue team with special challenges.

On a clear, warm, and cloudless summer morning, the team of an EMS

helicopter receives a call from the rescue dispatch center for an incident on
a highway with the alarm code “traffic accident with multiple vehicles,
vehicles on fire, ground-based EMS and fire department on site”. It is
obviously a classic secondary alarm by the ground-based EMS for quick
patient transport, so the assumption of the EMS helicopter crew. Already
during the approach to the accident scene, a black column of smoke can be
seen from several kilometers away, and during the landing approach it is
possible to see that 2 trucks and 3 cars were involved in the accident. The
trailer of the truck that rear-ended the first truck and a car are on fire. So it
can be assumed that there are several injured people to be cared for.
The EMS helicopter lands at a safe distance from the accident scene and
near the two ambulances that are already on site. After landing, the EMS
helicopter’s emergency physician goes to the emergency physician who is
already on site and is to take over the role of the lead emergency physician
in order to obtain information on the number of patients, the assessment
category, and the further procedure. At this point, the first-responding
emergency physician is treating a patient in one of the two ambulances. In
response to the question of how many injured people there are and which
the EMS helicopter crew should take care of, the first-responding
emergency physician replies that he does not know and that he now has to
take care of this patient. This leads to appropriate irritation on the part of
the EMS helicopter crew. This is followed by the question of whether an
assessment and possible triage have taken place, to which the answer is
“no”. It is the impression that any further questions would not lead to any
gain in information. So far, it has not been possible or not possible for the
rescue forces on site to get a quick overview of the situation, the number of
injured people, and the assessment category of the injured people. Since this
has not been possible, the EMS helicopter team takes over the assessment,
which is more difficult than expected. There are obviously 5 vehicles
involved in the accident, as mentioned above, a truck trailer and a car are on
fire, while the fire department is just extinguishing the fire. The highway
has already been completely closed in the direction of the accident by the
police, while traffic in the opposite direction is still normal. The patient
being treated by the first-responding emergency physician is apparently the
truck driver of the second truck that rear-ended the first truck, whose trailer
is on fire. The driver of the first truck, which the other vehicles rear-ended,
is apparently uninjured. Any help comes too late for the 4 occupants of the
first car that rear-ended the burning truck (sedan); they are already burned.
A second car (medium-sized station wagon), which had also been set up,
can be saved by the fire department before ignition. The car’s airbag had
triggered. But there are no more occupants in this car and on the back seat
is an empty child seat (Group 1, 9–18 kg (20-40 lbs) age group 1 to approx.
4 years). Initially, it is not possible to determine who was sitting in the car
and whether a child was an occupant or not. A fifth vehicle, also a car
(medium-sized sedan), which apparently had tried to avoid the rear-end
collision and in the process had hit the guardrail on the shoulder, is only
slightly damaged. The airbag of this vehicle had not triggered. The driver is
next to his vehicle and looks unharmed. So far, the situation is: one injured
and one uninjured truck driver, one obviously uninjured car driver, 4
burned, dead car occupants and one vehicle with a child seat involved in an
accident, of which no occupants are known so far. When children are
involved in an accident, emotions are always a little more tense, the
colleagues of the highway police already on site and some firefighters are
asked by the EMS helicopter crew to search for and find the occupants of
the car. After a short time, the completely frightened older driver of the car
can be found. She had the child seat for her grandson in the car, which she
had previously handed over to her daughter, and she was therefore alone in
the car. This leads to the relief of all participants, since there is apparently
no injured child. The patient has some small abrasions on her forehead and
nose, which may be due to the airbag. After the end of the inspection and
forwarding of this information to the local EMS control center, the injured
truck driver, who is now immobilized by means of a vacuum mattress and
Stiff Neck, is flown to a regional trauma center. The frightened driver of the
second car with the child seat is also transported to a regional trauma center
in the company of the ground-based emergency physician. The diagnostics
carried out here for the truck driver reveal a thoracic trauma with lung
contusion, rib fracture 2-4 left and transverse process fracture of the
thoracic vertebrae 2 and 3. The driver of the car has no other injuries
besides her abrasions and the psychological trauma.

Discussion
The case described demonstrates how the neglect of basic emergency
medical/tactical measures can quickly lead to a very confusing situation,
even though there were actually enough rescue forces and EMS
personnel available at the accident site. An accident situation with
several injured people always poses special challenges for the first-
responding rescue team [1]. In such situations, it is necessary to deviate
from the usual individual medical care, as one is used to from emergency
medical services, i.e.: one injured/sick person, one treatment team. In
this case, it is about assessing how many injured/sick people are present,
how severe the injury/illness is, in order to alarm an appropriate number
of suitable rescue vehicles and possibly a leading emergency physician
and organizational leader subsequently. Only when sufficient rescue
forces are available should treatment of each individual injured person
begin. With damage situations involving several injured people, initial
individual medical criteria cannot be applied [2]. Rather, it is a matter
here of setting priorities and initially treating the patients who have a
high probability of survival. In order to make this clear, the patients are
classified into 5 sighting categories as part of the assessment and each
category is assigned a certain color, which also represents the treatment
priority:
In sighting category 1 (color red), there are seriously injured people
with vital endangerment.
Sighting category 2 (color yellow) includes seriously injured people
without vital endangerment.
Sighting category 3 (color green) refers to lightly injured patients.
Sighting category 4 (color blue) is intended for severely injured
people without a chance of survival (dying).
In the last sighting category 5 (color black), dead patients are
classified.
In the situation described above, the first arriving physician would
have had to gain an overview of the situation. After appropriate
inspection, it would have been clear early on that 4 patients of inspection
category 5 (black), one patient of inspection category 2 (yellow) and one
patient of inspection category 3 (green) were at the accident site. In this
context, it would have become clear more or less quickly that the
originally alarmed rescue forces (2 ambulances, one physician-manned
ambulance and the fire brigade) were sufficient for the management of
the accident. However, the reordering of the EMS helicopter appears to
be fundamentally sensible in traffic accidents or unclear damage
situations. Although the case described was far from representing a mass
casualty incident, emergency physicians should still deal with the
circumstances of such a scenario in advance, as it usually comes
unexpectedly and then basic knowledge is of advantage. Even if it was
not a mass casualty incident, the case still shows how important it is to
gain an initial impression of an emergency situation. To obtain this, a
structured approach is helpful. “Structured” means in this case: observe
self-protection, inspect and categorize the accident and the patients, and
after the first inspection, decide whether the available rescue resources
are sufficient (as in this case) or not. If they are not sufficient, the
appropriate rescue resources must be requested from the rescue control
centre.
For the case of a real mass casualty incident, some algorithms have
proven themselves in the treatment strategies [3, 4], which can not be
 discussed any further at this point.

11.1 Conclusion
In addition to self-protection and the provision of a quick overview in the
form of an inspection, it must be decided promptly whether the available
resources are sufficient or, if not, the appropriate forces must be requested.
This task and the management of medical care initially belong to the tasks
of the first arriving physician.

References
1. Beck A, Bayeff-Filloff M, Kanz K-G, Sauerland S (2005) Algorithm for mass casualties at the
accident site: A systematic review. Notf Rettungsmed 8:466–473

2. Beneker J, Marx FA, Mieck F, Reinhold T, Ekkernkamp A (2014) Großunfälle – Erfahrungen aus
drei Realeinsätzen. Notarzt 30:206–217
[Crossref]

3. Paul AO, Kay MV, Hornburger P, Kanz KG (2008) Mass casualty incident management by
mSTaRT. MMW Fortschr Med 150:40–41
[Crossref][PubMed]

4. Wolf P, Bigalke M, Graf BM, Birkholz T, Dittmar MS (2014) Evaluation of a novel algorithm for
primary mass casualty triage by paramedics in a physician manned EMS system: a dummy based
trial. Scand J Trauma Resusc Emerg Med 22:50
[Crossref][PubMed][PubMedCentral]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_12

12. Collapse While Doing Barn Work

Martin Dünser1
(1) Department of Anesthesiology and Critical Care Medicine, Kepler
University Hospital, Linz, Austria

Martin Dünser
Email: [email protected]

What is common in the hospital is often common—if you hear

hoofbeats, you should look for horses, not zebras—this often facilitates
the diagnosis, say American colleagues. But: There is always an
exception to this. You can assume a statistical number, but you must not
forget that there is always a “plus-minus” or simply a zebra.

Thursday, late morning on one of our intensive care units. The transfer
reports are written, the rounds are almost finished. Everything looks like
lunch before the postoperative admissions come from the OR. But then the
emergency room reports: a patient after cardiopulmonary resuscitation is to
be taken over. The 43-year-old lady collapsed while doing farm work.
According to the emergency physicians, lay resuscitation was started
quickly, which was continued by paramedics after a short time. When the
emergency physician arrived, there was pulseless electrical activity. Given
the young age of the patient and the lack of previous illnesses (the only
thing that can be raised: syncope 1 week before the event),
cardiopulmonary resuscitation was continued for a total of 60 min. After the
13th injection of epinephrine, asystole converted to ventricular fibrillation,
which could be successfully defibrillated. Despite the prolonged
cardiopulmonary resuscitation attempt, circulation is stable. With an
uneventful ST segment in the ECG, no regional wall motion disorders or
signs of right heart dilatation in the echocardiogram as well as a bland skull
CT (with contrast agent to exclude a basilar thrombosis), a conduction
disorder with preexisting left bundle branch block is the most likely cause
of the circulatory arrest. The “nice” thing about recordings of patients after
cardiopulmonary resuscitation is the standardized procedure that the
international guidelines give us: 1) targeted temperature management 2)
placement of appropriate IV accesses, 3) sedation and maintenance of
therapeutic hypothermia for 24 h, 4) slow rewarming and 5) stopping of
sedation usually 30–36 h after admission. This is followed by this moment
of uncertainty: the hope of awakening a neurologically intact patient, which
is often disappointed by the patient’s lack of response and makes way for
the sad, almost nihilistic feeling of having to make the diagnosis of hypoxic
brain damage again. Often this phase of anxious waiting is interrupted
earlier, namely by a cerebral seizure—just like our patient. A few minutes
after the sedation was stopped, the patient developed a generalized tonic-
clonic seizure, which could be terminated by the injection of lorazepam, but
then turned into a non-convulsive status epilepticus. This can only be
interrupted after 48 h by an antiepileptic triple therapy (levetiracetam,
valproic acid, lacosamide). The further EEG findings show what everyone
has already feared: slow theta-delta activity without reaction to exogenous
stimuli. The medianus-SSEP-evoked potentials can only be derived on one
side with a clear reduction in amplitude. All these electrophysiological
findings correspond to the clinical picture of the patient, who remained
deeply comatose with preserved brainstem reflexes. After the MRI
diagnosis of generalized diffusion disorders in almost all cortex areas and
the brainstem ganglia as well as the certification of a dismal prognosis by
the neurological consultant, the relatives who have been previously
informed about the poor course of the disease are confronted with the
option of discontinuing therapy. However, the religious multi-member
family cannot make such a decision to discontinue therapy and wishes to
continue intensive care therapy including tracheotomy and PEG feeding
tube placement. In the certainty that the patient will develop a (persistent)
vegetative state, repeated family meetings are held in which the lack of
possibilities for neurological recovery is pointed out. One of these always
open and friendly conversations took place as follows. I hear myself saying
the following sentence: “If it were my relative, I would not want her to
survive in such a state.” The deep belief of the family is ultimately stronger
than all our medical certainty of an irrecoverable hypoxic brain damage.
22 days after admission, the patient is transferred to neurorehabilitation.
The feeling that we have not done everything to protect the patient and,
above all, the relatives from the fate of a vegetative state, prevails among us
for some time until—about 2 weeks later—the neurologist reports surprised
and pleased at the same time that the patient would begin to react to her
environment. A short time later she is contactable and can leave
rehabilitation for the home environment after 2 months. The only
demonstrable neurological deficit at discharge is a cortical visual
disturbance. The patient has since visited us twice with her family and even
reported that she can return to her work on the farm. And both times I
apologized for my statement, because we have never been so far off in the
assessment of the neurological prognosis.

Discussion
Therapeutic temperature management after cardiopulmonary
resuscitation significantly improved neurological prognosis [1]. At the
same time, however, the assessment of neurological prognosis became
significantly more complex compared to the time before the introduction
of therapeutic hypothermia [2]. While in the past clinical signs, such as a
myoclonic or epileptic status, could predict a poor outcome after
cardiopulmonary resuscitation with a false-positive rate of almost 0%
[3], after the introduction of therapeutic hypothermia even previously
reliable signs for a poor neurological outcome could hardly be used
anymore. Thus, the probability of functional recovery could only be
estimated by interpretation of the neurophysiological test results together
with the repeated clinical examination. Only over time and through the
analysis of large international databases did we learn to better estimate
the neuroprognosis after cardiopulmonary resuscitation with subsequent
therapeutic hypothermia [4]. According to the current state of
knowledge, certain combinations of clinical-neurological,
electrophysiological and laboratory findings indicate a very poor
recovery potential (defined as death, vegetative state or severe physical
disability) [4, 5]. This puts the false-positive rate back in comparable
ranges as before the introduction of therapeutic hypothermia.
12.1 Conclusion
The course of the patient described also raises doubts about the findings of
a false-positive rate in predicting neurological recovery. Nevertheless, this
does not contradict the literature, which describes a false-positive rate (i.e.
the chance of a good outcome for a bad one) of 0% on average for the
observed finding constellation, but gives a confidence interval of 0-3% [4–
6]. This means that a small number of all patients who have these symptom
constellations still have a good neurological prognosis. There is currently
no indication of how to identify these individual patients. Maybe there are
subtle clinical hints that we have not yet recognized or interpreted, but
which nevertheless provide such valuable information that no therapy
should be discontinued. If there were such clinical or other signs, we
obviously overlooked them in the patient described.

References
1. Arrich J, Holzer M, Havel C et al (2012) Hypothermia for neuroprotection in adults after
cardiopulmonary resuscitation. Cochrane Database Syst Rev 9:CD004128

2. Rossetti AO, Oddo M, Logroscino G et al (2010) Prognostication after cardiac arrest and
hypothermia: a prospective study. Ann Neurol 67:301–307
[PubMed]

3. Young GB (2009) Clinical practice. Neurologic prognosis after cardiac arrest. N Engl J Med
361:605–611
[Crossref][PubMed]

4. Sandroni C, Cavallaro F, Callaway CW et al (2013) Predictors of poor neurological outcome in

adults of cardiac arrest: a systematic review and meta-anylsis. Part 2. Patients treated with
therapeutic hypothermia. Resuscitation 84:1324–1338
[PubMed]

5. Oddo M, Rossetti AO (2014) Early multimodal prediction after cardiac arrest in patients treated
with hypothermia. Crit Care Med 42:1340–1347
[Crossref][PubMed]

6. Kamps MJ, Horn J, Oddo M et al (2013) Prognostication of neurologic outcome in cardiac arrest
patients after mild therapeutic hypothermia: a meta-analysis of the current literature. Intensive
Care Med 39:1671–1682
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_13

13. Fall into Icy Water

Luise Schnitzer1
(1) Medizinische Klinik für Kardiologie und Charité University Medicine
Berlin, Campus Benjamin Franklin, Department of Cardiology and
Pulmology, Berlin, Germany

Luise Schnitzer
Email: [email protected]

In the case of an accident, in addition to the questions of injury, the

triggering mechanism is also important in order to be able to treat not
only the symptom, but also the cause. Sometimes the injury and
mechanism are completely evident, sometimes you have to ask
persistently- as in this case.

Our emergency call reads: “Person in water”. It is a cold November day,

it is getting dark. Passers-by have discovered a person in a canal and alerted
the fire brigade. The person is floating still in the water and does not move.
A thrown lifebuoy is already floating in the water, but has drifted too far
from the person. The rescue forces from the ambulance have re-alarmed a
rescue boat from the fire brigade and are now trying to help the person
floating in the water by throwing a rope to her, but without success. After
about 8 minutes the team from the rescue boat, which is quickly launched,
reaches us. They quickly approach the person in the water and call her. But
to our surprise, the patient now stirs and swims away from the rescue boat.
It takes a while until the crew finally reaches the person in the water and
can pull her into the boat with combined forces. The woman, completely
soaked and hypothermic, sits on the stretcher- we take off her wet clothes
and wrap her in a warm blanket. The physical examination does not reveal
any serious findings: her circulation is stable, blood pressure
120/70 mmHg, the heart rate 57/min, the body temperature 35.4 °C (95.7
°F). After the woman has recovered a little, she can, still shivering, answer
our many questions.
She is unmarried and has no close relatives. She had a beautiful job that
allowed her a sufficiently good pension. She has few, but good friends,
most of them her age, but also already a little frail and cared for by their
families. She has always been healthy and fit, but now her strength is failing
and the care of her household is becoming more and more difficult. Since
she does not want to be a burden to anyone, she has decided to take her own
life. Having always been an enthusiastic swimmer who had taken part in
many competitions in her youth, she felt the water to be the right element
for her purpose. She wanted to drown- and yet she was very surprised that
this did not work. Whenever she had submerged, the impulse to new
swimming strokes had been stronger and she had hoped to get tired and
drown eventually if she stayed in the water long enough. But then the
rescue boat and the doctor appeared… During the story, the patient becomes
more and more lively, she doubts herself and is also very pleased with the
care and interest she receives from the entire rescue team. With a
mischievous smile she then remarks that she is glad to have left her
dentures at home- because: “I can still use them quite well!”
The patient is being treated further in the hospital, special measures are
not required for moderate hypothermia. Several conversations with the
social service then lead to the patient being subsequently accommodated in
a nursing home. There she quickly settles in and is still happy today that her
suicide attempt was not successful.

Discussion
The rescue of a patient after a failed suicide is a sad reason for an
intervention, which—at least in this case—has its humorous sides and
has ended well. This makes it easier for me to have helped a patient in an
apparently hopeless situation. Suicide is always a doubly sad occasion
and occasionally I can’t get rid of the thought of whether I am really
acting in the patient’s interest when I try to save him. This is all the more
true for an older person who, in their mind, have lived their life and now
come to the conclusion that it is enough. Nevertheless, we must not
 forget that often in this situation it is not in the foreground that the
patient is really “tired of life”, but that external factors—such as the
desire not to be a burden to anyone—are often motivation for the suicide
attempt. And we have to keep in mind that by simply providing
attention, information and human interest these factors can be easily
changed—whether by accommodation in a caring nursing home, by
establishing contacts with relevant aid organizations or by therapeutic
measures. In many suicides—whether by young or old people—it turns
out afterwards that the triggering factors could have been controlled
from the outside, but the patient either did not have this help available or
did not have the courage or the strength to ask for it. Of course, one
cannot prevent a suicide-determined person from attempting suicide; but
many suicidal patients work on their situation successfully after a failed
suicide attempt and have a normal life expectancy afterwards.
A study by the WHO shows: the older people become, the higher the
risk that they will commit suicide. In 2011, 10,000 people took their own
lives in Germany, the proportion of people over 60 years was 40%. In a
Swedish study [1], family conflicts, serious illnesses, loneliness and a
depressive illness are mentioned as reasons why older people in
particular want to commit suicide. M. Wehr also finds these fears in her
diploma thesis [2]. These fears are understandable because they concern
our independence and our human dignity.

13.1 Conclusion
More people die in Germany every year from suicides than from traffic
accidents. The main reasons for a suicide are described in the Gotland study
[3]; in this study it could be shown that diagnosed depressions are often
treatable and that the suicide rate can be significantly reduced as a result—
90% of suicides have a psychiatric diagnosis or a corresponding illness. N.
Erlemeier [4] comes to the following conclusion in his book:
We cannot promise people to free them from their suffering in old age;
but offering to accompany them in their distress would make a lot of things
much easier.
References
1. Waern M, Rubenowitz E, Wilhelmson K (2003) Predictor of suicide in the old and elderly.
Gerontology 49:328–334
[Crossref][PubMed]

2. Wehr M (2007) Suizid im Alter. DIPLOMARBEIT im Fachhochschulstudiengang Soziale Arbeit.

Otto-Friedrich-Universität, Bamberg

3. Rihmer Z, Rutz W, Pihlgren H (1995) Depression and suicide on Gotland. An intensive study of
all suicides before and after a depression-training programm for general practitioners. J Affec
Disord 35(4):147–152.

4. Erlemeier N (Jahr) Suizidalität und Suizidprävention im höheren Lebensalter (Taschenbuch 29.

Sep 2011), Kohlhammerverlag.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_14

14. Choking Attack in Nursing Home

Peter Hilbert-Carius1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, BG Trauma Hospital Bergmannstrost, Halle/Saale,
Germany

Peter Hilbert-Carius
Email: [email protected]

How should one behave if one cannot be sure that something else is
available than what one would consider right in the first place in an
emergency situation? The present case deals with an important problem
that rescue forces can encounter and for which there is no universal
solution approach.

On a Sunday morning, the crew of an EMS helicopter is alerted by the

rescue control center with the mission report “unconscious person”. The
scene call goes to a nursing home on the outskirts of a large city. During the
flight to the scene call site, which takes about 5 min, it is not possible to
obtain any further information, except that an ambulance has also been sent
to the scene call site. The landing of the EMS helicopter is possible directly
next to the nursing home and from the air it can be seen that the ambulance
has already arrived. When the doctor arrives at the patient, the following
picture emerges: A man of about 70 years is lying on the ground and is
cyanotic. The first rescue team that arrived is already performing
cardiopulmonary resuscitation by means of chest compressions and mask
ventilation with reservoir bag and oxygen application. The patient is already
connected to the EKG monitoring, in which asystole can be seen in all
derivations. While cardiopulmonary resuscitation is still ongoing, the
following is to be learned from the nursing staff: The patient had breakfast
and suddenly complained of coughing and shortness of breath; shortly
afterwards he became unconscious. Furthermore, there is a past medical
history of diabetes and a high blood pressure. The patient has a living will
and does not want hospital treatment. When asked whether the patient is a
“bedridden nursing case”, this is denied and it is stated that the patient is
still very fit and takes care of himself to a large extent in the nursing home.
During the short collection of the history of the disease, an intravenous
access is placed during ongoing cardiopulmonary resuscitation by the
physician. This is connected to a balanced crystalloid infusion solution and
1 mg epinephrine is injected. Shortly afterwards, individual ventricular
complexes can be seen in the EKG. The patient was now intubated with an
8.0 mm ID tube under vision, the intubation site corresponding to a
Cormack/Lehane Score II and the intubation being carried out without
problems. However, it turned out that when pushing the tube forward at
about 18 cm dental row, a clear resistance could be felt and the tube could
not be pushed further against the resistance . When trying to ventilate via
the tube with the ambu bag, an extremely high ventilation resistance is
observed, which also persists after slight withdrawal; no sufficient thoracic
excursion can be achieved. Since the tube is safely in the trachea (intubation
under vision) and the history of the disease points to a possible aspiration,
the following further procedure is decided: The breathing connector of the
tube is removed, the tube is connected to the fingertip of the suction hose of
the suction pump and the tube is removed under maximum suction of the
suction pump.
In this way, 2 slices of ham, which are sucked directly into the tube, can
be removed. After readjusting for intubation, 2 more slices of ham can be
removed with Magill forceps. The patient can then be intubated again
without difficulty and the tube can be inserted without resistance. Even
ventilation with bilateral ventilation of the lungs is now possible. After tube
fixation and ventilation adjustment, asystole is again shown in the ECG.
After another injection of 1 mg epinephrine and continuation of
cardiopulmonary resuscitation with 100% oxygen ventilation via the
endotracheal tube, a spontaneous circulation with clearly palpable carotid
pulse can be recorded about 2 min after epinephrine injection. In the ECG,
supraventricular and ventricular heartbeats are initially shown, which
convert into a sinus rhythm a short time later. End-tidal carbon dioxide rises
from 15–18 mmHg during cardiopulmonary resuscitation (after the
successful second intubation attempt) to 35–40 mmHg during the regained
spontaneous circulation. The patient is already cooled prehospitally with
appropriate cooling packs, sedation with diazepam and fentanyl is initiated
and the patient is transported by the EMS to a hospital of maximum care.
Here the patient is circulatory stable, without catecholamines and with a
sinus rhythm. The cardiac diagnostics ordered in the hospital shows a
moderate coronary heart disease without massive stenosis or myocardial
infarction. The patient can be extubated on the 4th day after the event and is
transferred to a rehabilitation facility after 3 weeks in the hospital. At the
time of transfer, the patient is awake, oriented, but still slowed down in
cognitive performance.

Discussion
The case described demonstrates several important aspects that should
be considered in emergency medicine. First, you encounter an elderly
patient with a circulatory arrest and an advance directive. Here the
question arises as to whether initiation or continuation of
cardiopulmonary resuscitation is justified at all? This question is
basically difficult to answer and there is no “panacea” for this. Only a
few arguments should be listed here, which, in the opinion of the author,
also speak in favor of the initiation or continuation of cardiopulmonary
resuscitation in this or a similar situation. The event was observed and
the time window until the start of cardiopulmonary resuscitation by the
EMS team was short, which generally appears to be favorable for the
prognosis, although the initial asystole observed in the ECG rather
suggested an unfavorable prognosis [1]. The patient was elderly, but
according to the statement of the nursing staff still independent and
active. From the past medical history and the existing long-term
medication, no indications of limiting underlying diseases emerged. The
existence of a possible advance directive should also not be generally
taken as an occasion not to initiate cardiopulmonary resuscitation.
Furthermore, in a resuscitation situation, one will probably barely have
time to deal with the advance directive, to read it and to decide whether
the directive now also covers the present situation. As already mentioned
above, there is no “panacea” with regard to the initiation and/or
 termination of resuscitation and this is an extremely situation-related,
individual and partly difficult process. Even the current guidelines
initially recommend starting cardiopulmonary resuscitation in principle,
in order to then possibly discontinue it if the rescuers are presented with
an advance directive that limits the treatment [2]. In the situation
described (elderly patient with existing advance directive), we were glad
in retrospect that we had consistently carried out cardiopulmonary
resuscitation.

A second important aspect that is illustrated by the case is the fact that
circulatory arrest does not necessarily have to be of cardiac origin in the
older patient population. In addition to the purely cardiac causes, easily
treatable reversible causes should always be considered. These causes are
summarized with the 4 Hs “hypoxia, hypovolemia, hypo-/hyperkalemia,
hypothermia” and the 4 Ts “tamponade (cardiac), toxins, thrombosis
(coronary and pulmonary), tension pneumothorax” [3]. The present case
impressively shows that in this patient the cause of the circulatory arrest
was of hypoxic nature due to massive aspiration. That this is not so rare is
shown by the work of Sakai et al. [4], which showed that 466 (19.8%) of
2354 patients with aspiration developed circulatory arrest. If it is possible to
eliminate hypoxia in a timely manner through the initiated resuscitation
measures, the prospects for successful resuscitation are often very good. So
it could also be shown in the already mentioned work of Sakai et al. that if
it was possible to eliminate airway obstruction by using the Magill forceps
preclinically, this was a predictor of survival with good neurological
outcome [4]. The case described here confirms this impressively. The
anamnestic finding to be elicited from the history that the patient suddenly
developed a strong coughing attack with subsequent dyspnea during
breakfast and became unconscious a short time later must necessarily lead
to the suspicion of a possible aspiration. Also from this point of view, it
would not be justified to interrupt ongoing cardiopulmonary resuscitation
attempt knowing that there may be an easily treatable reversible cause for
the circulatory arrest.
The aspiration described in the present case must be described as
massive and unusual. Four slices of ham so deep into the trachea that were
not visible during laryngoscopy for intubation, while the described
Cormack/Lehane II score only allowed a view of a small subglottic part of
the tracheal posterior wall, is already amazing. This shows how intense the
patient’s breathing efforts must have been that such a high negative pressure
was developed that the ham reached so deeply into the trachea. Since no
foreign body was visible during laryngoscopy, the primary use of the Magill
forceps to remove the described airway obstruction made no sense.
Therefore, only 2 alternatives were left in the situation when it was clear
that ventilation via the lying tube was not possible. On the one hand, one
could have tried to push the tube further with a lot of force to push the
airway obstruction into the right main bronchus in order to enable
ventilation via the left lung. However, since the resistance felt on the tube
seemed very high, this variant was not chosen in order to proceed according
to the method described above. The removal of the tube under suction
turned out to be successful and can be considered for similar cases. The
described procedure has already proven itself several times during the
author’s emergency and intensive medical activities.

14.1 Conclusion
The existence of an advance directive does not necessarily mean the
renunciation of life-saving measures, especially if they are associated with a
high success rate. In the case of massive aspiration of solid food into the
trachea, as described, the possibility of removing foreign bodies by
continuous suction on the tube and slowly removing the tube should be
considered.

References
1. Andrew E, Nehme Z, Lijovic M, Bernard S, Smith K (2014) Outcomes following out-of-hospital
cardiac arrest with an initial cardiac rhythm of asystole or pulseless electrical activity in Victoria.
Australia. Resuscitation 85(11):1633–1639
[Crossref][PubMed]

2. Lippert FK, Raffay V, Georgiou M, Steen PA, Bossaert L (2010) Ethics of resuscitation and end
of life decisions. Notf Rettungsmed 13:737–744

3. Deakin CD, Nolan JP, Soar J, Sunde K, Koster RW, Smith GB, Perkins GD (2010) Adult
advanced life support of the European Resuscitation Council Guidelines for Resuscitation Notf
Rettungsmed 13:559–620
4.
Sakai T, Kitamura T, Iwami T, Nishiyama C, Tanigawa-Sugihara K, Hayashida S, Nishiuchi T,
Kajino K, Irisawa T, Shiozaki T, Ogura H, Tasaki O, Kuwagata Y, Hiraide A, Shimazu T (2014)
Effectiveness of prehospital Magill forceps use for out-of-hospital cardiac arrest due to foreign
body airway obstruction in Osaka City. Scand J Trauma Resusc Emerg Med 22:53
[Crossref][PubMed][PubMedCentral]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_15

15. Traffic Accident in Construction Area

Sven Wolf1
(1) Department of Emergency Medicine, DIAKOVERE Friederikenstift,
Hannover, Germany

Sven Wolf
Email: [email protected]

There are techniques and procedures that are not in any textbook, but
come from the years- or decades-long experience of other emergency
physicians. This case shows that these skills can save lives in the crucial
moment.

Late at night, a truck with a trailer collides head-on with a low-floor

articulated bus on an empty run in a construction area on a highway. Both
drivers are seriously injured and trapped, but responsive. 2 physician-
manned ambulances, 2 ambulances, 2 rescue squads and a crane truck are
dispatched. After lighting up a suitable landing site, an EMS helicopter is
also dispatched later. Both vehicles collided half-overlapped head-on at the
level of the vehicle drivers with a penetration depth of about 1 m. The bus
driver is trapped in the leg/pelvic area, circulatory stable, prima vista there
is a closed left upper arm fracture, a closed right lower leg fracture and a
decollement injury on the left thigh. The truck driver is trapped in the left
shoulder, thorax and pelvic area, the left arm is stuck up to the shoulder
(acromioclavicular joint) in the destroyed roof structures of the bus. Prima
vista there is a forehead wound, and a head trauma (Glasgow Coma Scale
13; conditionally responsive), an open left arm injury (at the level of the
upper arm, below the destroyed bus roof, a constant trickle of mixed
arteriovenous blood is visible as an indication of a fulminant vascular
injury); the blood pressure is 110/70 mmHg, the heart rate is 118 and
oxygen saturation is 95% at room air.
The initial assessment of the medical-technical dispatch assumes that a
technical rescue and medical treatment of the bus driver is urgent, but
without any significant expected problems. The vascular injury on the left
arm of the truck driver is not accessible at all; there is therefore no
possibility of manual haemostasis or application of a tourniquet. A crash
rescue is therefore absolutely indicated; however, a non-critical, quick
separation of both vehicles is not possible due to the unstructured impact
situation in the area of the truck/bus roof/arm of the driver—the
approximate time to remove the bus roof in the area of the arm by the fire
department is about 30–45 min.
After technical rescue and the medical first aid of the circulatory stable,
responsive and oriented bus driver, the transport takes place with an
ambulance and physician-manned ambulance to a hospital of specialized
care. The treatment of the truck driver is initially carried out with two 14-G-
accesses (venous) on the right arm (2000 ml Ringer solution) and
immobilization of the cervical spine. With increasing circulatory depression
(blood pressure 90/00 mmHg, heart rate 135, oxygen saturation 95% with 2
l/min O2 over nasal cannula), an indication for intubation of the sitting
patient is made, which succeeds easily with 15 mg midazolam and 0.2 mg
fentanyl. After a short discussion and weighing of the medical-technical
options (uncontrolled, inaccessible bleeding in a trapped patient), the
emergency physician decides on an open-surgical intervention in the area of
the left arm. After a spray disinfection on the left shoulder, the attachment
of a sterile gauze cloth to the clavicle fails at first due to the lying cervical
spine orthosis (stiff-neck); the sterile gauze cloth is then stuffed behind the
thorax. After palpation of the clavicle and the lateral boundary of the M.
sternocleidomastoideus, a 5 cm long longitudinal skin incision is made with
the scalpel directly on the cranial clavicle edge lateral to the
sternocleidomastoideus with division of platysma/fascia. Subsequently, the
artery is blunt-prepared or “drilled” with the index finger dorsally-medially-
caudally to the pulsating A. subclavia/brachialis up to the first rib; then the
artery is compressed with the finger on the underlying first rib. As a result,
the uncontrolled bleeding stops immediately. This position is maintained by
the emergency physician for 23 min, during which he has to change his
finger 3 times due to cramping during the technical rescue. The circulatory
situation remains stable at a low level. A perfusion pump with arterenol is
prepared, but is not used in the course. After the stepwise separation of the
destroyed roof parts with hydraulic scissors and spreader, in addition to a
closed ellbow dislocation fracture, a deep incision wound at the transition
from the medial proximal upper arm to the anterior axillary line is revealed,
which was caused by a torn metal edge of the roof. The mixed bleeding
from the A. and V. brachialis can then be controlled axially against the
humerus head up to the hospital by manual compression with the thumb or
the fist. The previously attempted placement of a tourniquet almost in the
area of the anterior axillary line fails due to the anatomical conditions. After
another 19 min, the patient is technically freed and rescued with a
spineboard over the work platform. The subsequently ordered EMS
helicopter then transports him to a hospital of maximum care about 50 km
(31 miles) away with continuously stable circulatory conditions. After
initial surgical reconstruction of the two vessels and parts of the brachial
plexus, a year later a good outcome is shown with moderate neurological,
motor-sensitive deficits of the left arm.

Discussion
The surgical intervention of the emergency physician described
resembles more an abstract “live-saving-procedure” of war surgery [3,
5], because of a problem in the middle of one of the world’s best rescue
service infrastructure. Undoubtedly, the emergency physician was faced
with an extreme “ultima ratio situation” [4]. Within the curriculum of
our emergency medical training and in interdisciplinary, partly
international course formats such as ATLS, easy-to-use decision
paradigms for prehospital procedures and emergency room management
are conveyed; for example “stop the bleeding”, “life before limb”, and
“treat first what kills first”. And therefore we also know about the
relatively high mortality of open, arterial extremity injuries [2]. The
emergency surgical access to a central extremity artery described above
is not found in any standard textbook or surgical procedure atlas. It was
conveyed to our emergency physician as part of a DSTC© course
[Definitive Surgical Trauma Care; ATLS© and DSTC© courses are
offered in German-speaking countries, for example, by the German
Society for Trauma Surgery (www.dgu-online.de)]. Based on the
 charismatic Johannesburg trauma surgeon Kenneth D. Boffard, the 3-day
course is basically aimed at all acute-surgical physicians [1]. Due to the
tactical focus, doctors of the German armed forces are often found in the
auditorium who are planned for deployment abroad. Sometimes
unconventional tips and tricks are conveyed theoretically and practically
on the basis of a very large experience with blunt, stabbing and gunshot
wounds. Most of the “skills”, such as the emergency room thoracotomy
with temporary control of a perforating cardiac injury using a
commercially available catheter, require surgical basic skills and at least
the infrastructure of an emergency room. Tourniquet and also emergency
amputations are repeatedly discussed and described in individual case
studies in our rescue service landscape [6, 7]. In the specific individual
case, after surgical intervention, the central extremity artery was
compressed manually against the first rib. This “live-saving procedure”
is and remains an extreme example; it will probably never find its way
into our regular curriculum of emergency medicine. And yet it was a
brave ultima ratio decision without any recognizable alternatives in this
case. During the post-mission debriefing, the question arose as to why, if
an emergency surgical intervention was already carried out, the artery
was not “clamped” immediately? This was not done in the specific
individual case for 3 reasons: In the immediate anatomical vicinity of the
A. subclavia is the brachial plexus and the pleural dome, the light or
visibility hardly makes this possible, and the anatomical site is at least
5 cm below skin level and, even with optimal surgical conditions
(Langenbeck hook, suction device, 2 experienced assistants, operating
light, vessel instruments, blood coagulation), is only difficult to
represent.

15.1 Conclusion
It is generally also worth looking beyond the “horizon” in EMS. Certainly,
ideas for alternative bleeding control are by no means as essential as
knowledge in alternative airway management. But even if only one EMS
patient were to benefit from it within 10 years, one would be on the winning
side!
References
1. Boffard KD (2007) Manual of definitive surgical trauma care. Hodder Arnold, London

2. Gümbel D, Naundorf M, Napp M, Ekkernkamp A, Seifert J (2014) Diagnosis and management of

peripheral vascular injuries. Unfallchirurg 117(5):445–459
[Crossref][PubMed]

3. Hodgetts TJ, Mahoney PF, Evans G, Brooks A (2002) Battlefield advanced life support. J R Army
Med Corps 152(2 suppl):4–64

4. Holcomb JB, Champion HR (2001) Military damage control. Arch Surg 136:965–966
[Crossref][PubMed]

5. Husum H, Gilbert M, Wisborg T (2000) Save lives, save limbs: life support for victims of mines,
wars and accidents. Third World Network, Penag

6. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr (1990) Objective criteria accurately

predict amputation following lower extremity trauma. J Trauma 30:568–572
[Crossref][PubMed]

7. Raines A, Lees J, Fry W, Parks A, Tuggle D (2014) Field amputation: response planning and legal
considerations inspired by three separate amputaions. Am J Disaster Med 9(1):53–58
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_16

16. Unconscious Woman in Bathroom

Martin Messelken1
(1) Bad Boll, Germany

Martin Messelken
Email: [email protected]

In this case, hypothermia management is in the foreground. The situation

at the scene plays a decisive role here, which the EMS and the
emergency doctor expect here. Drawing the right conclusions from the
circumstances is also associated with obstacles in this case.

Relatives alarm the emergency physician and EMS on a January

morning. The emergency physician and his team find a deeply unconscious,
poorly dressed obese young woman lying on her back on the tiled floor of
an unheated bathroom; she had last been seen 13 h earlier. Because of a
depression, she was in psychiatric treatment and had already had several
suicide attempts behind her. In the bathroom there are empty boxes of
Atosil−, Saroten– and Ludiomil tablets (tricyclic antidepressants), which
again suggest a drug overdose. All clinical findings point to an intoxication
with severe hypothermia (an exact temperature measurement is not
possible): medium-sized unreactive pupils, bradycardia and weak central
pulse as well as gasping. With extremely gentle treatment, for the therapy of
insufficient respiration and for the protection against aspiration, the patient
is quickly intubated and mechanically ventilated. Because of the prevailing
circulation centralization, a central venous access must be placed, which
succeeds without problems in the V. jugularis interna. However, the
subsequent intravenous injection of atropine does not work. Since the EMS
was not prepared at that time to use external heat, the patient is only
wrapped in blankets and transported to the ambulance under avoidance of
active and passive movement in order to be transported to the internally led
intensive care unit of the nearby hospital. There, a deep rectal measurement
of the body temperature results in 24.9 °C (76.8 °F).
With continuation of the controlled ventilation, a gradual rewarming
takes place, which is carried out by means of a hemofiltration technique and
a gastric lavage with 50 l (13 gallons) of warm water. In this way it is
possible within 24 h to wean and extubate the patient quickly without any
problems by balancing a fluid balance and restoring cardiovascular and
thermal homeostasis. Apart from a short passage syndrome, the patient does
not show any pathological central neurological symptoms. Since by now
also no somatic disorders have occurred and the patient is known in the
nearby hospital for neurology and psychiatry due to her past medical
history, a transfer is ordered soon [1].

Discussion
For the EMS and the emergency physicians, patients with deep
hypothermia always pose a significant problem because the unintentional
mixing of core and shell blood during the rescue procedures can lead to
the feared rescue death (Afterdrop). Therefore, careful handling of the
patient is of paramount importance in all treatments. First and foremost,
however, the central body temperature must be determined as early as
possible in order to assess the degree of danger. Hypothermia
thermometers are available today, but not at that time. Therefore, the
severity of the clinical symptoms was the only criterion for the degree of
danger. Taking into account the environmental conditions and the
clinical findings, a correspondingly deep hypothermia was to be
expected. The placement of a central venous catheter under these
preclinical conditions is now also assessed differently, since the
intraosseous puncture technique is available for efficient drug
administration. In principle, however, the injection of cardiovascular
drugs is critically seen because of an unpredictable effect in
hypothermia.
The handling of such hypothermic patients posed many problems for
hospitals at that time, since the sophisticated techniques and technical
support for temperature maintenance were (not yet) not routinely
 available. In this respect, the clinical use and administration of a
moderate veno-venous hemofiltration procedure was then and is now an
effective and targeted measure. Today, greater emphasis will be placed
on the assignment to a suitable hospital, possibly involving the use of air
rescue. If cardiac arrest occurs before or during the treatment of
hypothermia, immediate resuscitation measures are always indicated,
which, with the simultaneous use of extracorporeal support systems, are
the preferred option [2].

16.1 Conclusion
Even in our latitudes, life-threatening hypothermia occurs again and again
in patients with intoxication by alcohol or drugs. Recognizing a vita minima
should not pose a problem, rather it is patients with hypothermia-related
symptoms of exhaustion and paralysis. The situation of finding the patient
plays a decisive role, which should also make the EMS and the emergency
physician think of this differential diagnosis.

References
1. Meßelken M (1986) Tiefe Hypothermie bei suicidaler Tablettenintoxikation. Notfallmedizin
12:379–382

2. Brugger H, Putzer G, Paal P (2013) Accidental hypothermia. Anaesthesist 62(8):624–631

[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_17

17. Collapse During Tennis Match

Hans-Richard Arntz1
(1) Charité, University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

This case study shows how important consistent CPR can be, and how
surprisingly an emergency can run its course—even years after the event.

The July day is a blisteringly hot day with temperatures of about 39 °C

(102.2 °F) in the shade. This does not prevent the then 58-year-old patient
from playing tennis outdoors on a sports field in Berlin. Apart from
moderate arterial hypertension, he had never been seriously ill and able to
perform until that day. In the early afternoon, at the time of the greatest
heat, the EMS helicopter is alerted with the keyword “resuscitation”—it is a
follow-up alarm by an ambulance of the Berlin fire brigade already on the
scene. After a few minutes of flight time, we already overlook the situation
from the air: the ambulance crew is in the process of resuscitating a person
lying on the tennis court. Two other people are standing next to them. A
landing possibility is available on the court near the scene of the incident
and is immediately used by our pilot. On arrival at the patient lying on the
tennis court in the heat of the sun, we are informed by the firefighters who
are continuing to resuscitate (chest compressions, mask ventilation) that
they have already defibrillated the patient several times with their automatic
external defibrillator without success. After initiating the usual first
extended resuscitation measures (orotracheal intubation, venous access via
the external jugular vein), we can find out more: the patient suddenly
collapsed lifelessly while playing tennis. A physician assistant, who was on
a neighbouring court, immediately rushed to help and initiated lay
resuscitation with another person. Both persons left the scene shortly after
the arrival of the ambulance. It is unclear who alerted the EMS. The
patient’s spouse is sitting in the shade of a tree at the edge of the sports field
because she is unable to help.

Discussion
Further measures initially followed the Advanced Cardiac Life Support
Guidelines [1]: Epinephrine, repeated amiodarion, renewed attempts at
defibrillation, some of which resulted in brief success with demonstrable
perfusing very slow rhythm (carotid pulse safely palpable
intermittently). However, a blood pressure was only detectable for less
than one minute each time and ended in renewed ventricular fibrillation.
Spontaneous respiration was not observed. In the desperate situation, an
attempt was also made to influence the recurrent ventricular fibrillation
with lidocaine, but this was unsuccessful. Another problem proved to be
that the entire crew present, drenched in sweat in the sweltering heat of
the sun, despite taking turns at thoracic compressions, slowly fell into a
state of exhaustion with potential negative effects on the efficiency of the
chest compressions. Not only the crew, but also the previously used
defibrillator of the ambulance showed signs of exhaustion in the form of
increasingly long charging phases until it was ready to defibrillate. After
switching to the EMS helicopter defibrillator, we decided to prepare a
12-lead ECG while continuing the above-mentioned measures (i.e.
omitting some chest wall leads for the time being) in order to register a
complete ECG during one of the next phases with a perfusing rhythm
(the missing electrodes were then to be glued on quickly). At this point,
the EMS helicopter crew had already been involved in cardiopulmonary
resuscitation for 30 min, the ambulance crew for about 40 min. In
addition, the estimated time between collapse and arrival of the
ambulance was also about 10 min, partly bridged by lay rescuers. In
total, the duration of the resuscitation efforts was already approaching
1 h at this point. The status was still characterised by the sequence
ventricular fibrillation-defibrillation-occasional short circulatory phases
with a conspicuously slow pulse-again ventricular fibrillation. We saw a
chance, albeit a small one, of being able to diagnose a recent myocardial
infarction with the help of the ECG and stabilise the patient with lysis
therapy. At that time, we had seen very promising courses in some
freshly resuscitated patients with signs of infarction in the ECG still
registered on site—however, no experience in a case like this patient’s
[2]. Indeed, shortly afterwards, the opportunity for ECG registration
presented itself in a period with palpable pulse of just over 1 min
duration: the ECG showed the characteristic signs of a fresh inferior
myocardial infarction with massive ST-segment elevations in leads II, III
and AvF as well as opposing depressions in I and AvL. In addition, there
was a total AV block with a ventricular rate of approx. 30 beats/min—the
explanation for the strikingly slow pulse already felt beforehand.
Systemic thrombolysis therapy with concomitant medication (heparin +
aspirin) was then immediately initiated and the resuscitation attempt
continued unchanged. After two or three more attempts at defibrillation,
a stable, albeit very bradycardic, replacement rhythm was finally
established with persistent total AV block visible on the monitor. As the
systolic blood pressure was only 70 mmHg, we decided to use external
ventricular pacing, which also succeeded stably after some effort. Half
buried under the complex but necessary equipment, the patient could
then be transported by ambulance to the nearest suitable hospital with
invasive cardiology. However, a memorable scene occurred: the patient’s
spouse had been sitting in the shade at the edge of the sports field during
the whole time. As we walked past her with the deeply unconscious
ventilated patient on the stretcher, she asked with wide eyes if she could
talk to her husband again for a moment. Quite taken aback, I could only
tell her that it was not possible now, that her husband had been
resuscitated with a very small, but not excluded, chance of survival and
told her the destination hospital. After initial standard care, including a
passive invasive pacemaker, the course there was really unusual. As the
ST-segment elevation had already clearly regressed, coronary acute
intervention was not performed (which would certainly no longer be
considered optimal nowadays [3]). The ECG, including the V4re lead,
also showed ST-segment elevation there as an indication of right
ventricular infarct involvement, which was confirmed
echocardiographically and also clinically. The patient developed a septic
disease on the floor of a left basal pneumonia during already stable
circulatory conditions, so that he could only be extubated on day 9. The
neurological development was astonishing, especially considering the
resuscitation time of about 1 h: the patient only briefly showed minor
 signs of a transit syndrome with limited retrograde amnesia. A
coronarography was only performed 15 days after the event. The
findings in the area of the left coronary artery were largely unremarkable
and revealed a high-grade concentric stenosis in the area of the distal
third of the right coronary artery, which was treated with PTCA without
stenting. The echo at discharge showed hypokinesia
inferoposterolaterally as a relict of the infarction; all other findings were
largely normal. Exercise at 75 W on the ergometer was possible without
complaints at discharge. The patient was discharged to a rehabilitation
hospital for follow-up treatment.
I was all the more surprised when, a few months later, I received a
letter from the patient’s spouse on the tennis court, who had meanwhile
become his wife. In addition to the pleasant information about the
marriage, she reported on a very active life together without a disability.
Since then, at intervals of 3–4 months, I have received postcards from
the couple from various holiday destinations including reports of skiing
holidays etc.—most recently more than 16 years after this happy
outcome for all concerned.

17.1 Conclusion
As long as a patient has ventricular fibrillation, they have a chance of
survival.
The key to survival is in the hands of potential first responders. Without
the energetic initial intervention of the physician assistant and another
rescuer, the patient would probably not have survived. That the doctor’s
assistant or the second person had resuscitation skills is unclear, but
probable.
Equally important is the consistent continuation of the basic measures
of CPR. Without the obviously optimal performance of CPR by the rescue
forces involved, the survival of the patient during a resuscitation attempt
lasting approx. 1 h would be almost inconceivable.
The fact that the patient repeatedly developed short phases of palpable
circulation was certainly also important for his survival. It is conceivable
that at least during some of these e.g. longer phases the “clock was set to 0”
again.
 Thrombolysis therapy is not generally indicated as an uncontrolled
routine during resuscitation [3]. However, it should be considered in certain
situations, e.g. in patients who develop an unstable circulation in the
meantime. The lysis attempt seems particularly useful in patients in whom
it is possible to register a 12-lead ECG and demonstrate ST-segment
elevation myocardial infarction (of course, lysis is also the standard therapy
for fulminant pulmonary artery embolism in shock or when resuscitation is
necessary).

References
1. Wenzel V, Russo SG, Arntz HR, Bahr J, Baubin MA, Böttiger BW, Dirks B, Kreimeier U, Fries
M, Eich C (2010) Comments on the 2010 guidelines on cardiopulmonary resuscitation of the
European Resuscitation Council. Anaesthesist 59(12):1105–1123
[Crossref][PubMed]

2. Arntz HR, Wenzel V, Dissmann R, Marschalk A, Breckwoldt J, Müller D (2008) Out-of-hospital

thrombolysis during cardiopulmonary resuscitation in patients with high likelihood of ST-
elevation myocardial infarction. Resuscitation 76(2):180–184
[Crossref][PubMed]

3. Böttiger BW, Arntz HR, Chamberlain DA, Bluhmki E, Belmans A, Danays T, Carli PA, Adgey
JA, Bode C, Wenzel V, TROICA Trial Investigators, European, Resuscitation Council Study
Group (2008) Thrombolysis during resuscitation for out-of-hospital cardiac arrest. N Engl J Med
359(25):2651–2662
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_18

18. Bus Accident in South Tyrol

Hermann Brugger1
(1) EURAC Research, Institute of Mountain Emergency Medicine, Bozen,
Italy

Hermann Brugger
Email: [email protected]

A bus accident in the mountains can pose a great challenge to the rescue
forces and bring unpredictable problems with it. This case also shows
how important the prevention of major events is.

When I left Austria and settled in the Pustertal in South Tyrol/Italy,

there was no regular emergency medical service in South Tyrol yet,
although the number of accidents was shocking. Every day there were
serious traffic accidents on the narrow, poorly signposted and unsecured
roads, workplace accidents on remote mountain farms, or mountain
accidents. Injured people often had to wait a long time for first aid and
transport from the mountain valleys to the hospital could take hours. In
individual cases, military helicopters were used, which were more suitable
as troop carrier than an EMS helicopter. Shortly after my settlement, I
started to set up a makeshift emergency medical service with the help of the
local fire brigade and trained the best of the fire brigade to be EMS
assistants. The men who were used to fire fighting practiced for days in car
wrecks, learned rescue techniques, resuscitation measures and the
preparation of infusions and intubation, and helped to equip an emergency
vehicle for emergency medical care. I was called by telephone during the
day from my office and at night from sleep, after a few minutes I was in the
EMS vehicle, surrounded by my paramedics from the voluntary fire
brigade, a short briefing, then it went to the accident site.
Only a few days after the completion of the training and the beginning
of this improvised service, the telephone rings at 2 pm: “This is the fire
brigade, motorcycle rider crashed into a gorge. We’ll be with you in a
minute!” With the deep gorge of the deployment site in front of my eyes, I
take my prepared mountain rescue backpack from the storage and put on
the protective clothing. In the already waiting EMS vehicle I ask for the
first details. Now it says that a car has crashed, further details are unknown.
The valley with our deployment site is a deeply cut gorge into the
mountains for the drainage of the Dolomites. The road runs winding along
the river course, is cut in the rocks along the entire length, without tunnels
or other protection against rockfall and avalanches, high above the
watercourse. Just before we leave the Pustertal to turn into the valley, the
radio message reaches us: “fully occupied long-distance bus 100 m deep
crashed, number of accident victims unknown”. There are only a few
meters left to the entrance to the gorge, where there is no telephone and
radio connection anymore: the last chance to make an emergency call to
alarm additional forces. I give instructions to recruit additional physicians
from the hospital, put on the helmet and put on the climbing harness.
On the ride through the gorge, we see lifeless bodies drifting in the
floodwaters deep down in the gorge. We fear the worst. After a few
kilometers we reach the accident site: a broken guardrail, a steep rocky
slope with bent trees and bushes and about 50 m in the depth a totally
smashed tourist bus. It is located in the raging mountain stream, the seats
free, the roof hangs sideways on a rock block. Some survivors have reached
the road and are wandering aimlessly around, others are trying to climb the
steep slope, but a larger number of people are lying deep down at the
riverbank, partly lifeless, partly surrounded by survivors who are trying to
tie them to the shore so that they are not swept away by the floods. In
addition to the loud noise of the mountain stream, no sound can be heard.
No crying, no moaning, desperate silence, shock.
I ask all those present not to leave the road, have fix ropes installed and
mobilize mountain rescue, rescue personnel and doctors. I fix my rope to an
EMS vehicle and abseil with the emergency medical kit to the accident site.
There I see that the majority of the accident victims are children and
adolescents. Numerous people had no signs of life. The bus is unreachable
several meters from the riverbank in the raging flood. From the shore I can
see some lifeless bodies between the seats. Meanwhile, the first mountain
rescuers reach the scene and begin to abseil personnel and equipment. Now
the recently established South Tyrolean emergency call center issues a
disaster alarm throughout South Tyrol, which results in a chain of
uncoordinated local alarms. Teams are set in motion from all directions, so
that the narrow road can no longer hold the numerous vehicles. There are
hardly any opportunities to turn around, so that an immense chaos arises
during the transport of the injured, which hinders rescue efforts. In the air
you can hear helicopters circling, but in the gorge there is no landing
possibility and the use of the rescue winch directly at the accident site
appears to be too risky due to the narrowness of the gorge. To make matters
worse, due to the topography there is absolutely no radio or telephone
contact with the outside world. The first reports, requests and instructions
have to be given by couriers. There is neither an organized patient discharge
area nor a treatment area.
At the riverbank, I try to triage roughly and have my firefighters lift the
first severely injured onto the street where they are then taken over by the
hospital doctors. We are able to reach the bus by ladder for the first time,
which is dangerous during a flood. Together with 2 firefighters, I search the
wreck, but most people no longer show any signs of life, only an older
person lies deeply unconscious without any pain reaction in the middle aisle
of the bus, has a pulse, a blood pressure of 80/40 mmHg and insufficient
spontaneous respiration. After induction of anesthesia, intubation and
ventilation, we bring the woman ashore, lift her onto the street where she
suffers a cardiac arrest and dies after a resuscitation attempt. I go down to
the river again, search the shore once more and find, strangely enough, a
12-year-old girl, deeply unconscious, pale and shallowly breathing, a few
meters upstream. Meanwhile, the rescue chain is working better and the
child is placed on a stretcher and brought up by pulley. An anesthesiologist
and I try to do everything humanly possible to save the girl. We intubate,
give oxygen, volume and vasopressors. We are able to stabilize the child
and transport her by ambulance to the helicopter landing site, from where
she is flown to the hospital. Unfortunately, this victim does not survive the
accident either, but dies a few hours later from a rupture of the inferior vena
cava.
Discussion
In total, 18 members of a tour group died in this accident. 20 people
survived, some of them seriously injured. Taking into account the
difficult topography of the accident site, the inadequate logistical
preparation and the complete lack of disaster management, the
emergency medical care was carried out without coordination, but so
improvised that after about an hour all the seriously and moderately
injured were rescued, treated and on their way to a hospital. The entire
operation was made more difficult by the fact that EMS helicopters
could not reach the accident site directly in the gorge and had to fly to a
landing site that was approximately 5 km (3 miles) away at a valley
mouth. From there, the seriously injured had to be brought to the
ambulance first before they could be flown out.
In South Tyrol, the serious accident was like an earthquake that
shook the responsible persons awake. On the one hand, it became clear
at once how dangerous the journey was to one of the largest and best-
known holiday regions in the world. The international press was full of
negative headlines: “catastrophic road conditions, risky access to one of
the most famous ski resorts in Europe”. This alarmed the tourism
industry and the demand for remediation was taken up. In the following
years, the entire stretch of road was re-designed and a completely new
route was laid out, mostly in tunnels. Today this stretch of road is one of
the safest in the country and a crash into the gorge is virtually excluded.
On the other hand, there was a heated debate about the emergency
medical care in South Tyrol after the accident; this had been neglected
for years. No politician had reacted to the numerous night-time
accidents, drink-driving was a misdemeanor and a mountain accident
was a self-inflicted fate. Only one year before the accident, state law had
ordered the establishment of control centers in all provinces; one year
later, around-the-clock emergency services were set up in all hospitals
throughout the country and now, for the first time, medically equipped
physician-manned ambulances were deployed to emergencies.

18.1 Conclusion
It is a question of statistical frequency and geography when the next
disaster relief operation will take place in a densely populated country [1].
In the case described here, we were absolutely not prepared for it. The
example shows us how important it is to invest in safety and emergency
medical care in a forward-looking manner. Whether we are today prepared
for a mass influx of injured people of every size is still doubtful. The public
is not used to acting, but often only reacts when something has gone wrong.
The term prevention has its place in medicine, but less often in political
bodies. Laws are still often formulated only when it is too late.

Reference
1. Ciottone G (2006) Disaster medicine, 1st ed. Elsevier-Mosby, Philadelphia
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_19

19. Shortness of Breath in Nursing Home

Luise Schnitzer1
(1) Charité University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

This case shows very impressively how difficult—for all those involved
—the handling of the topic of advance directives and their
implementation can be. Often there are discrepancies between what is
desired and what is wanted.

Our alarm keyword is “shortness of breath”. We are already urgently

expected by the nurse in the nursing home—she seems a little hectic and
upset and leads us to a 96-year-old patient who is breathing heavily in bed.
She has her eyes closed, is cyanotic and does not react to address. We first
provide the patient with oxygen, which quickly brings her some relief, and
now I try to find out something about the course of the disease from the
patient. The nurse reports that the family doctor had already prescribed an
antibiotic therapy a week ago, but this did not change the condition of the
patient—on the contrary, it has now become worse and that is why she
alarmed us. She can no longer guarantee the care of the patient in the
nursing home and therefore asks us for hospitalization. The daughter of the
patient, who has been following the report in silence so far, now interjects,
clearly upset, with a trembling voice. It is clear that she is having a hard
time controlling her emotions. She reports that her mother was admitted to
the hospital several times in the last 3 months. After 1 week to 10 days she
was discharged back to the nursing home, only to be readmitted to the
hospital a few days later. She suffers from severe biventricular heart failure,
renal failure and, due to a case of pronounced obesity, from massive
congestion, edema on both legs and weeping ulcers on both lower legs.
Already at her admission to the nursing home 2 years ago, an advance
directive was created in which it was stipulated that the patient does not
want to be treated on an intensive care unit anymore, that she does not want
to be artificially ventilated or artificially fed and that she rejects any further
treatment in a state that offers no more hope. She had also expressed the
wish to die more frequently in recent weeks.
Only at my request does the nurse fetch the advance directive and now I
am really surprised that we were even called. The nurse insists on
hospitalization against the patient’s wishes and against the daughter’s
wishes, because she does not want the patient to suffer and “they always
helped her quite well in the hospital”. She always came back in a better
condition. In the meantime we have stopped the oxygen supply, the patient
continues to breathe calmly, the skin color remains slightly livid. The nurse
turns away indignantly and leaves the room. I talk to the daughter, tell her
that I respect the patient’s wish and that I will not take her to the hospital
anymore. Since the patient is obviously not in pain, no medication is
required. The daughter wants to stay with her mother and accompany her in
the dying process. We leave the patient’s room.
Out in the corridor, I meet the indignant nurse and try to calm her down.
I ask her why she can’t accept the patient’s wish. I explain to her that we
can’t really help the patient anymore because at this point, there is no cure
possible. She vehemently disagrees. “Medicine certainly has possibilities,”
she says, and now that the patient is no longer able to grasp the situation
and can no longer speak for herself, she feels obliged as a nurse to act as her
advocate. She argues that during her time on the intensive care unit she had
already experienced apparently hopeless cases that had then recovered well
and the same could be the case with this patient. I have many questions I’d
like to ask her, that I ultimately keep to myself, because I can’t expect any
insight from the young woman, and so I leave the nursing home agitated.
Although I don’t question my decision, the unsatisfactory feeling remains
that I haven’t ended the mission optimally, because I failed to give the nurse
an insight into my decision. I had the impression that the nurse “wanted to
do something good” for the patient. On the other hand, it could not be
excluded as a possibility that they wanted to “get rid of” a dying patient or
that the nurse was overwhelmed with the process of dying. The patient died
that same night; I did not have further communication with the nurse.
Discussion
The young nurse’s unshakeable faith and the apparent trust in medical
possibilities have confused and frustrated me. Doctors can heal, that is
correct, and extend life spans, but we can often unnecessarily prolong
the course of illness and suffering just as well [1–4]. It is no coincidence
that the term “chronic critical illness” has developed, because certain
illnesses can be treated but the patient can no longer be rehabilitated into
a self-determined state [5]. These patients, for example, can be
transferred from an intensive care unit to a ward, but often have to be
readmitted to the intensive care unit quickly due to an acute
deterioration. This “back and forth” between hospital and nursing home
also existed in this patient and is inhuman, but usually continues as long
as no one makes a decision. The boundaries of when we overshoot the
mark and do too much good are fluid and often creep in unnoticed [6, 7].
As doctors, we have the responsibility to ensure the welfare
(“beneficence”) of the human being, complying with the ban on causing
harm (“Primum non nocere”) and respecting the patient’s right to self-
determination (principle of autonomy). The principle of avoiding harm
(“nonmaleficence”) requires us to refrain from harmful interventions. It
is also necessary to take into account fairness (“justice”), i.e. to use
scarce resources sensibly and targeted. With the many developments in
medicine and the enormous possibilities at our disposal, doctors are
increasingly faced with ethical challenges. Do we have to treat every
patient—administer every antibiotic therapy, carry out every dialysis,
implant every pacemaker, carry out every heart catheterization [8]? Who
decides on the welfare of the patient if he is no longer able to do so
himself? I often experience the situation that patients are represented by
an advocate who neither knows the patient nor has sufficient knowledge
of his condition—but has to decide in a critical situation whether to
withhold or carry out treatment. In the vast majority of cases I have
experienced so far, the (legally appointed) representative has decided in
favor of further treatment in order to be legally protected—and not
always unjustifiably, as can be read in the press [9].

19.1 Conclusion
How far does the principle of non-harm (“Primum non nocere”) have to be
adhered to—when do therapies or omissions do “damage” to the patient? I
think the duty to inform plays a very important role. To show the patient
and the relatives the limits, to address the likely end and to discuss
appropriate options, is essential. That this can be successful is shown in the
admission to a hospice. Here dying is not taboo, death is expected and is a
normal process. The fears may be expressed, understood and thus leave
room for a dignified farewell. Such an open offer of conversation about the
expected course of the disease, about the wishes of the patients should be
required for all seriously chronically ill patients. Only the possibility to talk
about it, eases the decision for the patient (and the relatives) in regards to
how far the treatment should be advanced or not. In the hospital it is often
observed that outside of normal working hours intensive care units are
asked to take over patients who are in the process of dying when viewed
more closely. Rarely, there is a “do-not-resuscitate” order, although there
was enough time to discuss this with the patient. The cause is often a denial
of death by the medical staff, the patient and the relatives or the inability to
accept death. By continuing therapy regardless, new hopes are raised in
patients and relatives, which are by no means justified. It seems unworthy
to me to senselessly hurry a dying patient; each of us certainly imagines a
dignified death differently. This should always be in the minds of medical
staff: the dying process is part of our lives. With such a conversation the
relatives, who usually do not have sufficient knowledge of medical basics,
can also take away the fear of omitting something or feeling guilty.

References
1. Girshovich J (2014) Wem gehört der Tod? Vom Recht auf Leben und Sterbehilfe. Kein & Aber,
Zürich. ISBN 978-3-0369-5648-0

2. Bayertz K, Frewer A (2002) Ethische Kontroversen am Ende des menschlichen Lebens. Palm &
Enke, Erlangen. ISBN 3-7896-0584-0

3. Barmeyer J (2003) Praktische Medizinethik: die moderne Medizin im Spannungsfeld zwischen

naturwissenschaftlichem Denken und humanitärem Auftrag – ein Leitfaden für Studenten und
Ärzte, 2. stark überarb. Aufl. LIT-Verl., Münster, S 175. ISBN 3-8258-4984-8

4. Coors M, Grützmann T, Peters T (Hrsg) (2014) Interkulturalität und Ethik. Der Umgang mit
Fremdheit in Medizin und Pflege, Edition Ethik Band 13, Edition Ruprecht, Göttingen. ISBN
978-3-8469-0162-5
5.
 Janssens U et al (2013) Therapiezieländerung und Therapiebegleitung in der Intensivmedizin –
Deutsche interdisziplinäre Vereinigung für Intensiv- und Notfallmedizin. Med Klin Intensivmed
Notfmed 108:47–52

6. Trzeczak S (2013) Notfallmedizin: Ethische Kompetenz und praktische Erfahrung. Dtsch Ärztebl
110:A706

7. Trzeczak S (2014) The medical–ethical dilemma regarding resuscitation decisions in emergency

patients. Notf Rettungsmed 17:613–619
[Crossref]

8. Bathe J (2012) Notarzteinsätze in Alten- und Pflegeheimen – der physician-manned ambulance

als Lückenbüßer. Dissertation, Medizinische Fakultät Charité – Universitätsmedizin Berlin

9. Applebaum GE, King JE, Finucane TE (1990) The outcome of CPR initated in nursing homes. J
Am Geriatr Soc 37:197–200
[Crossref]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_20

20. A Black Day for the EMS

Martin Messelken1
(1) Bad Boll, Germany

Martin Messelken
Email: [email protected]

How much can an emergency physician really experience and carry in

one day? In this case it becomes clear that a series of serious
emergencies is possible on one day and represents an enormous
challenge, which also has to be processed by the present helping persons,
in order not to suffer any psychologically long-term trauma: even
emergency physicians may ask for help.

It is election Sunday in the 1990s; the incumbent is re-elected. In a

house attached to an authority, the family of the caretaker lives, who also
works as a police officer at the authority. He should have helped already in
the polling station; since his apartment door remains locked on several
rings, it is forced open at noon. Due to the dramatic first impressions, an
ambulance is alerted at 2:00 p.m. 7 min later, the following scene presents
itself to the emergency physician and his EMS team: In the large attic
apartment a breathtaking silence prevails, the first look falls on a huge
Märklin model railway. Then 4 children are found dead in different rooms,
they are between 8 and 15 years old. All lie face down in their beds and
have gunshot wounds to the head and neck. No defensive struggle seems to
have taken place anywhere, bloodstains that have already dried up can be
seen. In the bedroom of the parents, the dead husband is found in a semi-
sitting position with a pistol in his hand, he probably killed himself with a
shot to the head. Next to him sits his motionless wife, she seems to be alive,
although without any sensomotor reaction to the now people present. The
gunshot wound she sustained is in the area of the left eye socket, where the
blood that has flowed out there has already dried up. She remains
unresponsive and does not speak a word, but has normal vital functions.
Feedback is given to the EMS control center with the information that only
one patient is expected in the pre-alerted hospital. After rapid initial
treatment, the approximately 50-year-old obese patient is transported by the
ambulance to the emergency room of the responsible hospital of maximum
care; from there she is later transferred to a neurosurgical hospital.
Afterwards, the ambulance team returns to the scene of the accident
together with the officers of the criminal police to carry out the autopsy of
the 5 shot persons. The police investigations later reveal that the police
officer executed his family with the service weapon after coming home
from the night shift. Why this was possible without further ado was never
clarified.
For the ambulance team there is an immediate follow-up mission with
the message “child lies under collapsed wall”. During a celebration of a
family with a migrant background, children play on a fragile wall, which
collapses and buries one of the children. The adults have already freed the
lifeless 5-year-old child before the ambulance arrives. Cardiopulmonary
resuscitation is started immediately, which is discontinued after 30 min
without ever having at least temporarily established a spontaneous
circulation. The present large family accompanies the treatment with loud
sympathy, which of course does not leave the ambulance team and the
emergency physician unaffected. Because of the obviously not natural cause
of death, the police have to investigate here as well.
Shortly after midnight, another emergency call is required on a country
road between 2 towns, as a pedestrian has been hit by a car. After arriving at
the scene, the emergency physician can only determine the death with
injuries that are incompatible with life. Since the accident originator has
fled the scene, all that remains to be done is the documentation of death and
a physical examination; here, too, the police investigates.

Discussion
If firearms are in a household, of course there is the danger that they will
also be used in critical situations. Not only for the most justifiable self-
 defense, but also in situations of desperation and self-abandonment [1].
Family dramas occur again and again in such constellations. Apart from
the fact that in the cases described here only one human life could be
saved by emergency measures, the EMS and the emergency medical
team had to cope with a considerable psychological stress situation. At
that time in the 1990s, emergency chaplains or similar professional help
such as crisis intervention teams were not or not everywhere available.
Doctors, paramedics and police had to deal with such stressful situations
more or less alone. This was done in different ways and depended more
on the degree of socialization than on the need. Today there are excellent
approaches for the prevention and avoidance of psychological stress in
emergency and emergency medical services. Interestingly, the
psychological help for emergency patients also plays a major role,
because the more professional the dealing with the affected persons, the
lower the stress for the emergency services themselves. The acceptance
of psychological stress in the workplace has been given the appropriate
high priority in corporate health management [2, 3].
In addition, the autopsy is of considerable importance in connection
with non-natural causes of death such as crime or accidental death. The
emergency physician should document patient and environmental
findings as well as pre-mortal treatment sufficiently and rather leave the
determination of the time of death to forensic medicine [4]. Under no
circumstances should one be tempted to certify a natural death if there is
even the slightest hint of a possible opposite. Especially in connection
with the death of older people, individual police officers tend to want to
“close the files quickly”.

20.1 Conclusion
Emergency Physicians and EMS staff must also be well equipped for high
psychological stress, such as multiple child fatalities, even though the
proportion of fatalities amounts to only about 3–5% of all emergency calls.
In addition to a professional application of forensic principles and
compliance with the applicable burial laws, an event-oriented psychosocial
follow-up should take place not only in designated cases, but also in
everyday life. EMS staff and emergency physicians may also ask for help.
References
1. Wintemute GJ (2008) Guns, fear, the constitution, and the public’s health. N Engl J Med
358(14):1421–1424
[Crossref][PubMed]

2. D’Amelio RAC, Falkai P, Pajonk FG (2006)Psychological concepts and primary crisis

intervention in emergency care Notfall & Rettungsmedizin. 9:194–204
[Crossref]

3. Steil M (2010) Einsatzstress? So helfen Sie sich und anderen. ecomed SICHERHEIT, Landsberg
am Lech

4. Nowak R (2013) Medikolegale Grundlagen. In: Dirks B (Hrsg) Die Notfallmedizin. Springer,
Berlin, S 589–593
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_21

21. The Four Development Phases of a

Medical Doctor
Joachim Koppenberg1
(1) Department of Anesthesiology, Pain Therapy and Emergency
Medicine, OSPIDAL – Center da sandà Engiadina Bassa, Scuol,
Switzerland

Joachim Koppenberg
Email: [email protected]

Which development phases does a medical doctor go through after his

training in practice? And how can he deal with it if he is still in one of
the first phases while facing a difficult medical problem? This case
shows very clearly that even doctors should be aware of their humanity
and fallibility in order to make their decisions with the necessary self-
reflection.

The usual development states of a medical doctor after graduation can

roughly be divided into four phases, which can certainly also have
relevance for the type of treatment and the result of our patients. After
graduation, one usually begins with the phase of “justified uncertainty” (1),
which usually leads to the phase of “unjustified certainty” (2) after a few
years and near the end of specialty training. After experiencing one or the
other near-disaster or even real catastrophe in this phase, most people (apart
from a few hard-boiled ones) slip into the phase of “unjustified uncertainty”
(3). Only when one is then enlightened that, in addition to all the specialist
knowledge and technical skills, one must also take into account other things
between heaven and earth when making decisions, does one hopefully reach
the phase of “justified certainty” (4) at some point, knowing full well that
there will never be 100% certainty.
I am happy to report from my personal “Phase 2”: After a strenuous
routine operating day in cardiac anesthesia, I am suddenly called upon to
fill in for a sick colleague for the city’s physician-manned ambulance night
shift in the same hospital. On the one hand, I owe the colleague a swapped
shift, on the other hand I have just passed the specialist examination with
flying colours and: Whoever treats seriously ill and highly complex patients
in cardiac anesthesia during the day will probably also be able to adequately
care for a pre-hospital, urban emergency patient at night! So I am not
particularly excited when, after 3 h of sleep, the call “asthma attack” wakes
me up at 2 o’clock. After about 7 min drive, I enter the rather untidy-
looking apartment of the 57-year-old patient, who is sitting at the kitchen
table gasping for air. She looks very agitated, holding an asthma spray
(fenoterol) in her right hand. While taking the first medical history, a 12-
channel ECG (sinus rhythm, heart rate 138/min, no indications of a STEMI)
and a pulse oximeter (SpO2 = 97%) are attached, and the blood pressure is
measured (RR = 180/100 mmHg). Due to the severe shortness of breath, the
patient can only give “snippets” of information and confirms the reported
symptoms of “asthma attack” in the case of a long-standing asthma
condition (basic medication with inhaled corticosteroid, long-acting ß2
agonist and oral theophylline). While taking the medical history, 4 l/min
oxygen is applied via a nasal cannula.
According to the patient, she went to bed at around 11 pm and then
woke up spontaneously at midnight due to increasing shortness of breath.
This may be rather unusual, but asthma attacks usually come quite
irregularly and are not predictable. Therefore, she took another dose of oral
theophylline, as she could usually “adjust herself quite well”. In addition,
she has inhaled the short-acting ß2-mimetic (fenoterol) several times since
then, but the attack has become worse despite this. In addition, a still
ongoing history of nicotine abuse of 70 pack years can be determined,
which must suffice for me as a non-smoker as “receipt” for the current
attack. Lung auscultation reveals a weakened breath sound on both sides,
but without signs of spasticity or humming or whistling. A beginner would
probably have been suspicious here—but of course I interpret this in the
context of the severe asthma attack as “silent lung”—quite professional!
After the patient has practically administered all asthma medications
herself, I insert an i.v. access and consider what other treatment options are
left for such a severe asthma attack (prednisolone? Terbutaline s.c.?
Reproterol i.v.? Intubation with ketamine?). In the meantime, I also inquire
about allergies (none) and other comorbidities (poorly controlled
hypertension—as measured—and hypercholesterolemia). The patient
mentions left thoracic pain in conversation, which she attributes to forced
respiration. For the first time, I become alert during this intervention and
ask for more details. The pain is continuous, not related to respiration, and
cannot be influenced by palpation. The pain has increased steadily since the
beginning of the “asthma attack” and is currently rated at 6/10 on the Verbal
Rating Scale. In addition, this has a burning character, but no radiation is
denied. A repeat blood pressure measurement still shows values of
190/100 mmHg. For the first time, I leave my nightly “autopilot mode” and
go through possible differential diagnoses: Of course, it could also be an
acute coronary syndrome or a pulmonary embolism. So what’s next? Maybe
this is even more likely—isn’t the room air saturation at 97%? Why only
now do I notice that this does not fit a severe asthma attack at all! Now I
consider the intersection of the further therapy options, which can be
justified by both diagnoses. First of all, it would certainly not be a bad idea
to lower the blood pressure. After two doses of nitro sublingual, the blood
pressure decreases to 148/90 mmHg and the patient reports at the same time
a slight improvement in pain and shortness of breath—an asthma attack
does not usually respond to nitro spray! Thereafter, I fractionate (2 mg
each) morphine i.v. to the patient for analgesia until an improvement in
symptoms on the Verbal Rating Scale from 6 to 2. At the same time, a
nitroperfusor is installed, as I want to forego the injection of a beta blocker
and aspirin due to the known asthma history.
While on the one hand the actual problem of the patient (acute coronary
syndrome) is becoming increasingly clear to me, on the other hand I am
getting more and more angry about my own blindness and ignorance so far.
In parallel, the transport to the emergency room is prepared and carried out
with the suspicion of an acute coronary syndrome. There laborchemically a
Non-STEMI-myocardial infarction is confirmed, which is treated
immediately by means of a percutaneous coronary intervention.

Discussion
What had happened? Now first of all quite simply—the patient initially
had a nocturnal ischemic cardiac event, the symptoms of which she
associated with her long-standing asthma and therefore also treated
accordingly—with β-mimetics (fenoterol) and caffeine-like
(theophylline) drugs, which increasingly worsened the ischemia—these
drugs are not without reason in an acute coronary syndrome
contraindicated! And the worse the patient felt, the more of these drugs
she used—a real iatrogenic and exogenous vicious circle! But why
hadn’t I seen this mechanism before, let myself be deceived for so long
and, despite my current work in cardiac anesthesia, not immediately
recognized or at least considered the acute coronary syndrome? Also
quite simply—because it is human! In fact, we physicians are only too
human and are all too easily caught up in typical cognitive mistakes. The
reason for this is based in the so-called heuristic. Here, informal or fuzzy
rules are created from experience values, which in complex situations
leads to taking cognitive shortcuts and thus finding quick and pragmatic
solutions with limited knowledge under time pressure [1, 2]. This does
indeed often lead to adequate solutions, but unfortunately these
heuristics can simply and fundamentally be wrong. We want to take a
closer look at some typical pitfalls in the case described.
First of all, it all starts with the inner attitude, which I typically took
on in phase 2 (“unjustified security”). Self-confident and convinced that
I was experienced and saddle-fast, this did not exactly promote critical
self-reflection, which is always required in the medical profession. First,
the clinical picture “asthma attack” was confirmed by the situation on
site and the patient herself. Here I first fell into the “availability error”
trap (“availability bias”), which describes the tendency to take the
cognitively “most available” option—the most obvious one—[4]. This
was practically parallel to the “anchoring bias”, one of the common
cognitive pitfalls. This states that the first impression gained has a
disproportionate influence on further thinking behavior and that one is
reluctant to deviate from the first offered hypothesis. This goes so far
that contradictory information is ignored—as in this case a completely
normal room air oxygen saturation of 97% in an allegedly severe asthma
attack. On the contrary, the so-called “confirmation bias” was
committed: Here, hints are sought and perceived, which confirm one’s
own working diagnosis—in this case the bland pulmonary auscultation
 finding, which I reinterpreted as part of my working diagnosis “asthma
attack” to a “silent lung” in order to not have to call my working
hypothesis into question. Only a symptom that was no longer appropriate
at all (chest pain) had torn me out of my self-confidence and, in the
truest sense of the word, “awakened” me and made me think and search
for possible differential diagnoses.

21.1 Conclusion
The most important lesson I learned from this case was that, in addition to
the purely technical knowledge and skills, there are other skills needed for
optimal patient care, which I had not heard or learned about during my
studies and my previous medical training. What is really fatal is that these
heuristic errors influence our medical thinking on a daily basis and thus
have a decisive influence on the outcome of our patients. Although it is of
course extremely difficult not to be led astray by these heuristics, which we
have trained ourselves in all our lives, it is worth taking a closer look at
these modes of thinking and error models. The sharpest weapon we have
against these mental errors is “situational awareness”. This describes the
degree of agreement between our view and reality in certain situations,
which we can only increase by constantly questioning the situation and our
working hypothesis. One could also say quite banally: keep a cool head and
an overview [3].
In order to finally reach phase 4 of “justified certainty”, it is advisable
to follow the saying that has been hanging on my locker door since then as
a daily reminder: “Don’t believe everything you think!”

References
1. Gausmann P, Henninger M, Koppenberg J (2022) Patient safety management, 2nd edition. De
Gruyter, Berlin

2. St. Pierre M, Hofinger G (2014) Human Factors und Patientensicherheit in der Akutmedizin.
Springer Verlag, Heidelberg

3. Dobelli R (2011) Die Kunst des klaren Denkens. Hanser, München

4. Wachter RM (2010) Fokus Patientensicherheit: Fehler vermeiden, Risiken managen. In:

Koppenberg J, Gausmann P, Henninger M (Hrsg). ABW-Wissenschaftsverlag, Berlin
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_22

22. Fall into Garden Pond

Luise Schnitzer1
(1) Charité University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

Luise Schnitzer
Email: [email protected]

Interventions in which the patients are very small are always very
emotional for all involved and can also be quite stressful in terms of
debriefing. This case picks up on such a situation and also addresses the
developments that have changed over time.

2-year-old twins fall into a garden pond. After a maximum of 10 min,

during which the children are unsupervised, the older brother finds the two
lifeless and alarms the father, who rescues the children from the water and
then immediately alarms the fire department. When I arrive, I find two
lifeless children who are clearly hypothermic. The ECG shows asystole, the
pupils are maximally dilated in both children and do not react to light. The
members of the fire department are committed to performing chest
compressions on both children—my rescue assistants are working with high
pressure—I intubate the boy first, then the girl, place an intravenous access
one after the other in both and inject epinephrine. In both cases, a sinus
rhythm appears after a short time, but only with a frequency of 80/min and
they remain pulseless, the pupils remain maximally dilated. In the
meantime, reinforcement has arrived—a physician colleague takes over the
resuscitation attempt of the boy and I continue to take care of the girl. Both
receive epinephrine again and are constantly treated with chest
compressions and ventilated—interrupted again and again by suctioning the
large volume of water that the children have aspirated.
After about 15 min of cardiopulmonary resuscitation, we can feel a
pulse, but the heart rate remains insufficient at about 80/min, so the chest
compressions are continued. In the meantime, many professional
responders have arrived—even the press has gathered. I have never
experienced such focused and harmonious cooperation between
professional responders and the fire department: the media representatives
are shielded, the stretchers are prepared, the rescuers who perform chest
compressions are swapped out seamlessly, new oxygen bottles appear
before they are actually needed. Since both children are clearly
hypothermic, we decide to transport them while performing chest
compressions and take them to two different hospitals. After my handover, I
receive skeptical looks, but the hospital colleagues resuscitate with
commitment for another 2 h—the girl is even being resuscitated for a total
of 3 long hours—until the circulation is stable and the heart rate is
sufficient. The core temperature of the girl upon admission is <28 °C (<82.4
°F) and is kept at 32–34 °C (89.6-93.2 °F) and is only slowly raised in the
course of time, so that she only has a normal temperature 72 h after
admission to the hospital. After an initially encouraging course in her and
stable respiratory function, oxygenation deteriorates dramatically: in the
CT, increasing bilateral pulmonary infiltrates are detected, a sepsis with
multi-organ failure develops and finally the girl is treated with high-
frequency oscillation ventilation. On the 7th day we can breathe a sigh of
relief; the respiratory and organ functions improve and sedation can be
reduced. She recovers surprisingly quickly and can be transferred to a ward
on the 11th day healthy and without neurological damage.
The procedure proves just as dramatic at the other hospital—the boy has
been resuscitated for another 1½ h, his core temperature is <27 °C (<80.6
°F) upon admission, the pupils remain dilated and do not react to light. The
only significant difference to the current course of his sister’s illness is that
he has a seizure, which also occurs occasionally afterwards. His intensive
care course is much simpler than his sister’s; the temperature is quickly
raised to 37 °C (98.6 °F). He is ventilated without complications,
circulation is supported mildly with catecholamines as with his sister. He
can be extubated after 6 days. The dramatic thing is that after sedation is
stopped, the boy is diagnosed with a severe neurological deficit syndrome
with spasticity and muscle spasms.
This event has affected all those involved deeply. I was told by a
firefighter who was involved that he no longer felt able to continue on duty.
He was transferred to the rescue control center so that he would no longer
be affected by the direct course of events. The family writes me a small
update every year, reports on the well-being and progress of the children.
They invite me and my paramedic from the physician-manned ambulance
to visit them, which we are happy to do. Deeply impressed by the selfless
and loving care of the parents, we can experience a lively 5-year-old little
girl who likes to go to kindergarten and loves her brother very much. The
boy suffers from spasticity, looks very awake and curious, but can only
formulate incomprehensible words for us. Approximately 16 years later, I
receive an invitation to a lecture that the two “children”—now young adults
—are to give to a professional audience; the topic of their talk is:
Communication with each other—how we communicate. It is an honor for
me to attend this lecture. I sit in awe in the auditorium and experience how
the sister introduces and comments on the small lecture and the boy tells us
about his hobbies using technical means, how he practiced early on with
picture boards with his mother and later with his father how he was trained
in using computers. The young man is able to express his thoughts and
feelings; he can express his anger, for example, that people do not let him
finish. He types his sentences into a computer, which does take some time,
and a speech computer then translates his texts into speech for those around
him. I wish for myself and for everyone else, to muster that little bit of
patience to listen—because he and others like him certainly have a lot to
say.

Discussion
The children have been treated differently—therapeutic hypothermia was
maintained in the girl, in the boy this was not carried out; it is possible
that this made a difference in neurological recovery. However, we do not
know anything specific about the time of the accident in the two
children. It is possible that there were actually time differences in the
time of hypoxia that were decisive. The girl had a complicated course
with severe sepsis and multiple organ failure [1], possibly due to
hypothermia. The development and improvement of therapeutic
 hypothermia protects or reduces neurological damage [2, 3] and is now
standard in the post-treatment of cardiopulmonary resuscitated patients
[2–4]. It is conceivable that the differences in rewarming explained the
different course. The guidelines for cardiopulmonary resuscitation
recommend a rewarming after therapeutic hypothermia in an order of
magnitude of ≤0.5 °C (32.9 °F)/hour, a limit that (of course under other
conditions) was probably adhered to by the girl, but not by the boy.
However, a faster rewarming using a heart-lung machine or
extracorporeal membrane oxygenation in severe hypothermia, for
example after an avalanche accident, is also discussed [5]. The boy
recovered quite well after the initial severe neurological concerns. The
tireless care of the parents and siblings certainly played a decisive role.
Another aspect is the post-traumatic stress of this deployment in the
professional rescuers. Resuscitating two small children is a special
challenge for everyone involved, not only in the technical process, but
also in processing what has happened. “It could have been my child!”
was surely a thought on everyone’s mind involved; but also: “Did I do
everything right?”, “Did I miss something?”, “Was it my fault?” These
questions haunt you and have to be processed. Fortunately, today there is
the possibility—much more so than before—to cope better with such
traumatic events through conversations with trained personnel from
crisis intervention teams and not to repress them.

22.1 Conclusion
In addition to the assumption that unexpectedly excellent results happen
again and again, it is always difficult to classify and assess neurological
findings, especially in children, in a long-term perspective. Today we are
additionally able to develop hidden talents and compensate for disabilities
with technical aids. Only a decade earlier, the boy would probably not have
found a way to communicate with the outside world and would have been
limited to familiar domestic life. Today he has the opportunity to
communicate with everyone and to learn a profession according to his
personal abilities.
References
1. Vargas Hein O, Tritsch A, von Buch C, Kox WJ, Spies C (2004) Mild hypothermia after near
drowning in twin toddlers. Crit Care 8:R353–357
[Crossref]

2. Rittenberger JC, Callaway CW (2013) Temperature management and modern post-cardiac arrest
care. N Engl J Med 369:2262–2263
[Crossref][PubMed]

3. Peberdy MA, Callaway CW, Neumar RW et al (2010) Post-cardiac arrest care: 2010 American
Heart Association guidelines for cardiopulmonary resuciation and emergency cardiovascular care.
Circulation 122(Suppl 3):S768–786 (Errata, Circulation 2011; 123(6):e237, 124(15):e403

4. Palmers PJ, Hiltrop N, Ameloot K, Timmermans P, Derdinande B, Sinnaeve P, Nieuwendijk R,

Malbrain ML (2014) From therapeutic hypothermia towards targeted temperature management: a
decade of evolution. Anaesthesiol Intensive Ther 47(2):156–161
[Crossref][PubMed]

5. Mair P, Brugger H, Mair B, Moroder L, Ruttmann E (2014) Is extracorporeal rewarming indicated

in avalanche victims with unwitnessed hypothermic cardiorespiratory arrest? High Alt Med Biol
15(4):500–503. https://doi.org/10.1089/ham.2014.1066
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_23

23. Two Pathologies

Hans-Richard Arntz1
(1) Charité, University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

Hans-Richard Arntz
Email: [email protected]

Not always, as this case shows, are the symptoms clearly attributable to a
disease picture and not always is only one disease picture present—but
fortunately, as in this situation, there is a therapy that can treat two
pathologies at the same time.

We are alarmed with the keyword “sudden unconsciousness” on a

summer day early in the evening and, after a short flight with the EMS
helicopter, arrive at the patient’s house about 15 min after the event. A 58-
year-old patient—as we learn from the physician at the scene of the
accident—collapsed after a car journey of about 6 h, interrupted only by
short breaks, and was unable to get up again. The past medical history
reveals a slight hypertension and occasional migraine attacks. Both have
been completely stable for a long time with beta-blocker therapy, according
to the patient. We see a conscious, pain-free patient who is oriented in time
and space, but not in terms of her symptoms. There is an obviously acute
complete hemiparesis on the left and an indicated dysarthria. The patient
reports that during the car journey in the last few hours she noticed twice
short-term visual disturbances in the form of a flicker scotoma in the right
visual field and a tingling sensation on the right side of the tongue. Both are
known to her as prodromal symptoms in the event of an impending
migraine attack. After several attempts at explanation, the patient finally
agrees to be transported by our EMS helicopter to a neurological center for
immediate cranial computed tomography. The multiple explanation
attempts are necessary because the patient categorically denies the
diagnosis of a stroke with hemiplegia in the context of an apoplexy-related
acute neglect syndrome. We don’t want to lose a minute because of the
option of thrombolytic therapy. During the entire pre-hospital treatment,
including the helicopter transport, the patient remains completely stable and
pain-free. However, the neglect seems to be lost when the patient is
unloaded from the helicopter, because for the first time she anxiously asks
whether she really has a stroke.
Immediately upon being handed over to the neurologists who had been
alerted in advance and were already waiting—no longer under continuous
monitoring at this point—the patient apparently has a seizure. However, the
atypical pallor that sets in after a few seconds and the subsequent cessation
of breathing shortly thereafter prove that it is an Adam-Stokes attack. In this
case, the cause is an acute circulatory arrest due to fibrillation, as can be
seen on a monitor set up quickly; immediate cardiopulmonary resuscitation
was initiated. After a few minutes and one defibrillation, circulation is
stable and detectable again, but intubation and ventilation as well as short-
term sedation are necessary. The ECG registered at this point shows the
signs of an acute inferior myocardial infarction with ST-segment elevations
in II, III and aVF. Immediately afterwards, a cranial computed tomogram is
performed, which, like a transcranial Doppler sonogram, turns out to be
unimpressive. After a short discussion between cardiologists and
neurologists, despite the limited ability to assess the neurological status, the
decision is made to initiate systemic thrombolysis therapy and to forego
coronary intervention for the time being. The 100-minute time window
since the onset of the insult at this point gives hope for a good thrombolysis
result. The possibilities of coronary intervention, on the other hand, seem
secondary. In addition, the consideration that thrombolysis could also be an
effective therapy for myocardial infarction, i.e. both diseases could be
approached with the same therapeutic principle, plays a role. However,
thrombolysis must be carried out with a reduced dose for myocardial
infarction. In addition, because of the risk of massive intracranial bleeding,
the usual adjuvant therapy with aspirin and heparin for myocardial
infarction is not possible. Thrombolysis is initiated approximately 120 min
after the onset of neurological symptoms with rt-PA (0.9 mg/kg, initial
bolus 10% of the dose and administration of the remaining dose over
60 min). The patient wakes up spontaneously 2 h after the end of
thrombolysis and is fully oriented after a short time. Clinically and
neurologically, at this point there is only an internuclear ophthalmoplegia
on the right and an incomplete vertical gaze palsy upwards. There is also a
hemiataxia on the right and a slight hemiparesis on the left. All symptoms
largely disappear within the next few days, with the exception of a hand-
held disturbance of fine motor skills on the right.
In the EKG, Q-waves develop inferiorly as an expression of an ongoing
acute posterior wall infarction. The CK rises to a maximum of 186 U/l and
the CK-MB to 38 U/l; the Troponin-T rapid test is positive. There is
hypokalemia at the time of ventricular fibrillation of 3.3 mmol/l. Clinical
signs of heart failure do not develop. Rhythm disorders are also not
observed. In a cerebral MRI performed 5 days after the event, multiple
ischemic lesions are demarcated right pontine, left cerebellar and right
fronto-parietal. In the following cardiological follow-up examinations,
hypokinesia of the inferior wall of the left ventricle with discrete relative
mitral insufficiency grade 0–1 is found in the ventriculography during
cardiac catheterization. No significant coronary stenoses are detected. In the
transesophageal echo, after contrast agent administration, contrast agent
passage into the left atrium is seen as a sign of an open foramen ovale,
which is prophylactically treated with an “occluder”.

Discussion
This is the unusual case of successful simultaneous systemic
thrombolysis treatment of brain and myocardial infarction as a result of
the coincidence of these events; etiopathogenetically, 3 considerations
can be made. Cerebral infarcts are very rare complications of migraine
attacks; the incidence is about 1/100,000/year. Inflammatory changes in
the vessels, embolisms and arterial dissections are discussed. Although
the patient had experienced typical migraine symptoms for the first time
in years on the trip, the documentation of multiple ischemic lesions is an
important argument against the assumption of a migraine-associated
brain infarction. It would also be unusual for a migraine-induced insult
without anamnestic indications of a complicated migraine course (so-
called migraine accompagnée). Patients with this course of disease
 experience transient neurological deficits, equivalent to an increased risk
of ischemic stroke. The initial cardiac symptom-free course and
ventricular fibrillation in the context of an acute myocardial infarction
documented after ischemic insult also suggest that the infarction could
have occurred secondary to the stroke-associated acute stress situation.
However, the most likely cause is a paradoxical embolism. This is
supported by the fact that the brain infarctions occurred in multiple
locations with proven patent foramen ovale. Paradoxical brain
embolisms as the cause of so-called “cryptogenic strokes” are
predominantly observed in younger people under the age of 55 [1]. Our
patient was at least not far outside this risk age with 58 years. Although
very rare, a myocardial infarction caused by a paradoxical embolism is
possible. The triggering of the events by several embolisms of very fresh
“paradoxical” thrombi, e.g. from the leg vein area after prolonged sitting
during the car ride, is also supported by the excellent thrombolysis
effect.

23.1 Conclusion
The occluder prophylaxis used at the time for persistent foramen ovale is a
procedure used today primarily for patients with contraindications for
anticoagulation [2]. Prophylaxis with anticoagulation is preferred, for
which, in addition to the classical therapy with vitamin K antagonists,
several new drugs are now available [3].

References
1. Homma S, Sacco RL (2005) Patent foramen ovale and stroke. Circulation 112:1063–1072
[Crossref][PubMed]

2. Freixa X, Arzamendi D, Tzikas A, Noble S, Basmadjian A, Garceau P, Ibrahim R (2014) Cardiac

procedures to prevent stroke: patent foramen ovale closure/left atrial appendage occlusion. Can J
Cardiol 30:87–95
[Crossref][PubMed]

3. Gómez-Outes A, Terleira-Fernández AI, Calvo-Rojas G, Suárez-Gea ML, Vargas-Castrillón E

(2013) Dabigatran, Rivaroxaban, or Apixaban versus Warfarin in patients with nonvalvular atrial
fibrillation: a systematic review and metaanalysis of subgroups. Thrombosis 2013:640723. https://
doi.org/10.1155/2013/640723
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_24

24. High-rise Building on Fire

Sven Wolf1
(1) Department of Emergency Medicine, DIAKOVERE Friederikenstift,
Hannover, Germany

Sven Wolf
Email: [email protected]

This case shows that every emergency physician can also find
themselves in a situation where they have to make quick and competent
decisions in order to save the lives of the people involved. Therefore, as
is also very clear here, prevention begins in the head, namely before such
a situation arises.

The alarm of the on-call senior emergency physician in the event of a

mass casualty incident is received at 10:00 pm on a cold autumn day after
feedback from the first arriving fire brigade in a high-rise settlement. On the
2nd floor of a 7-story residential building, an apartment is in full blaze with
flames leaping to the 3rd floor. Both stairwells are completely smoked and
drive many of the reported 58 residents to the upper floors on their
balconies. A woman falls from the 3rd floor onto a lawn. The first arriving
physician is met by numerous residents from both stairwells. There is a
German-Russian language confusion, some residents cough loudly. Before
several passers-by pull the physician by the sleeve to the rear of the
building to the multiple traumatized “jumper”, he orders 2 policemen to
collect all residents on a nearby lawn. During intubation of the patient on
the lawn, the physician hands over the scene to the on-call senior
emergency physician. After ordering the immediate transport of the
multiple trauma woman in the company of the physician to a hospital of
maximum care, the senior emergency physician first needs 5 min to find his
responsible organizational leader of the EMS. This turns out to be just as
difficult as the subsequent joint reconnaissance, since the affected building
complex can only be reached from 3 sides by footpath. In the area of the
affected stairwells, the two policemen commissioned meanwhile intercept
15 residents from the house, but can only convince them with considerable
difficulty and language barriers to wait for the senior emergency physician
on the area of the affected lawn; a quick assessment of the 15 residents is
carried out under the usual local identification with red and white velcro. 2
elderly women on foot with coughing and dyspnea are handed over directly
to two ambulance crews, the remaining residents are initially marked with
“white”. Meanwhile, 2 more ambulance crews arrive from different
directions and report to the senior emergency physician about several
“clusters” of suspected patients around the building complex. After
consulting with the fire department’s overall incident commander, the EMS
organizational leader then determines a defined larger deployment area
“EMS” in about 200 m / 650 feet distance to the fire object via the EMS
control center, where an emergency response vehicle is being used as a
reporting center. A team of paramedics and 2 volunteer firefighters are now
“guarding” the patient drop-off area on the lawn, while the senior
emergency physician, the organizational leader of emergency services, and
a physician-manned ambulance team move in opposite directions around
the building complex to explore and assess the situation. They communicate
with each other using 2-meter radios. Both teams first requisition a man
who speaks German and Russian from the patient gathering point as an
interpreter. 2 factors make it very difficult for the teams to identify
additional potential patients: first, about 300 relatives, friends, and
onlookers are streaming out of the surrounding buildings to the scene of the
incident; second, it is starting to rain heavily. The large emergency response
vehicle from the fire department has now arrived in the easily visible
deployment area “EMS”. Due to the weather, both teams are now sending
the patients they have seen directly to the large emergency response vehicle
instead of to the patient gathering point on the lawn. The local rapid
response team with its EMS station now arrives in the deployment area. The
leader of the rapid response team estimates that it will take 45–60 min to
completely set up the EMS station in the area of the incident. Despite all the
difficulties, both assessment teams are able to identify and assess 22 more
residents of the affected house by then. Almost all of them fall into
assessment category III (slightly injured, postponed treatment priority). For
this reason, the senior emergency physician is foregoing the complete set-
up of the EMS station in favor of an inflatable quick response tent in the
area of the deployment area and large emergency response vehicle. About
20 min after the departure of the two assessment teams, they meet again on
the lawn in the entrance area at the original patient drop-off area. To their
surprise, there is now only one of the two firefighters who were originally
commissioned there. Upon inquiry, he reports that “someone” had come
and informed them about the “dissolution of the assembly point”. Before
they knew it, the 13 patients under their supervision had disappeared in all
directions. It is later not possible to reconstruct who this “someone” could
have been among the 155 emergency personnel. Since the large emergency
response vehicle also features a carbon monoxide-hemoglobin
measurement, it is now being used as an assessment point for the re-
evaluation of patients in the deployment area. In addition to the multiple
trauma woman, this allows 24 more residents who may have been exposed
to smoke to be assessed and categorized over the course of time (1 ×
assessment category I “red” acute vital threat => immediate treatment, 3 ×
assessment category II “yellow” seriously injured/ill => postponed
treatment urgency, 12 × assessment category III “green” slightly
injured/sick => later, if necessary, outpatient treatment). 8 people refuse
transport, the remaining 17 are admitted to the hospital. Fortunately,
retrospectively, no serious pulmonary complications occur among the non-
assessed, or non-re-evaluated, “disappeared” patients/residents.

Discussion
In the following maneuver review, it was difficult to define clear errors
or improvement suggestions from the complex course of the operation.
Essentially, the first arriving paramedic and the senior emergency
physician or the organizational leader of the EMS team did everything
right. The difficult and unsatisfactory course of the operation ultimately
resulted from a combination of several unfavorable factors, such as high
and unclear number of potential patients, very confusing location,
difficult order of the location, insufficient or missing cordon, language
barriers, weather (night, rain) and a variety of different emergency
services (regular EMS, rapid response team, fire department, police).
Although a mass casualty incident situation is very rare and difficult to
standardize, every paramedic should get used to the idea that he or she
usually has to take over the complete range of tasks as senior emergency
physician on the first arriving ambulance [1]! As a rule, there are no
“arrival or rescue deadlines” defined for the on-call senior emergency
physician so far, so that everything from 6 to 60 min is conceivable and
possible according to experience. Unlike in the individual EMS, there
are no comprehensive “guidelines” of the professional societies for the
senior emergency physician, but only general, guiding “cornerstones” of
action [2–4], which have to be adapted to the geographical and local
EMS structure of each deployment area. The individual screening
systems in the German-speaking area (e.g. mSTaRT [5]) are now adapted
to the local conditions, well established and tried and tested [3]. Not only
as on-call senior emergency physician, but also as on-call paramedic,
one should know the local “system” (quick screening, labeling, patient
attachment cards, rapid response teams infrastructure, etc.) with its
strengths and weaknesses. The latter is best crystallized in regular
exercises, war games and appropriate debriefings [4]. Regardless of the
local conditions, there are a few “cornerstones” [1, 2, 4, 6], which keep
reappearing for the (provisional) senior emergency physician: Never
separate from your organizational leader EMS (or physician-manned
ambulance driver), take a clear identification with corresponding (blue)
vests, observe local command and communication structures (e.g.
overall incident commander, lower incident sections, radio call names,
etc.). The core tasks of the senior emergency physician consist in the
quickest possible, structured screening, the core task of the
organizational leader EMS in maintaining communication and
documentation. The core tasks that leading paramedics and EMS
organizational leaders have in common are the order of the location,
coordination of medical or technical rescue, timely situation reports to
the rescue control center as well as requisition of additional forces and
expansion or withdrawal of the mass casualty incident level.
The space order is often underestimated and primarily left to the
EMS control center, but it is later only very difficult to correct [7]. The
potential provisional space “EMS” must be determined as quickly as
possible, ideally already on the approach, using maps/local knowledge
 and communicated to the rescue control center [6]. While the
determination of the deployment area for the rescue station can usually
be done at a later time after arriving at the scene of the accident, the
primary patient collection point (DIN 13050) must be determined
immediately. Ideal are weather-protected, fixed premises such as large
corridors, gymnasiums or courtyards. If only an outdoor area is
available, this is to be marked as quickly as possible to avoid the
disappearance of patients, “fenced in” and if possible shielded (flagging
tape, gauze, fire safety lines, blankets, “wagon fortress” with vehicles,
tents, etc.) [1, 2]. Pedestrian patients and those in need of help in their
distress and panic often tend to run to the first recognizable rescue
vehicle (“crystallization nucleus”). If there is no suitable patient support,
the senior emergency physician can take advantage of this and, for
example, position the first arriving ambulance in a well-visible defined
approach point/collection point near the damage site.
While patients in sighting category I and sighting category II must be
stabilized and transported as quickly as possible on site, patients in
sighting category III should be screened, cared for and then re-evaluated
near the scene of the accident. For example, in the event of
predominantly “care situations”, it may make sense not to set up the
EMS station at all, but to use the personnel of the rapid response team
situationally from the outset rather for care [7]. Appropriate tasks (-
changes) must be delegated clearly and binding by the medical operation
leader (senior emergency physician/EMS organizational leader EMS
service/possibly consultant medical care) [1, 6].

24.1 Conclusion
Any physician could unintentionally find themselves in the role of
(provisional) senior emergency physician. Unlike in the individual medicine
of the regular EMS, there are usually only framework guidelines for the
tasks of the senior emergency physician in the event of a mass casualty
incident. These mainly concern operational principles such as screening,
communication, documentation and order of the location. In addition to
these basic principles, it will be a great help for the affected (potential)
senior emergency physician if he (preferably together with his physician-
manned ambulance driver/EMS organizational leader ambulance service)
regularly informs himself about the local deployment structures in the event
of a mass casualty incident and corresponding special features. Prevention
starts here in the head [6]! Furthermore, it makes sense for the twosome to
think through and discuss randomly invented deployment situations and
scenarios “[(…) if there were an overturned bus there, where could we
define patient drop-off, staging area, etc.? (…)]” or to simulate them with
professional guidance in seminars [1, 8].

References
1. Pajonk FG, Dombroesky WR (2006) Panik bei Großschadensereignissen. Not Rettungsmed
9:280–286
[Crossref]

2. Adams HA, Krettek C, Lange C, Unger C (Hrsg) (2013) Patientenversorgung im Großschadens-

und Katastrophenfall: Medizinische und organisatorische Herausforderungen jenseits der
Individualmedizin. Deutscher Ärzteverlag, Köln

3. Beck A, Bayeff-Filloff M, Kanz KG, Sauerland S, AG Notfallmedizin der DGU (2005)

Algorithmus für den Massenanfall von Verletzten. Notf Rettungsmed 8:466–473

4. Schweigkofler U (2011) Katastrophenmedizin – ein etwas modifiziertes medizinisches

Versorgungskonzept. Tagung: Katastrophen und Großereignisse bewältigen. BGU + IVM
Frankfurt a. M.

5. Kanz KG, Hornburger P, Kay MV et al (2006) The mSTaRT algorithm for mass casualty incident
management. Notf Rettungsmed 9:264–270

6. Dirks B (2006) Management of mass incidents by the chief emergency physician. Notf
Rettungsmed 9:333–346

7. Beneker J, Marx F, Mieck F, Reinhold T, Ekkernkamp A (2014) Großunfälle – Erfahrungen aus

drei Realeinsätzen. Notarzt 30:206–217
[Crossref]

8. Roesberg H, Habers J, Oppermann S (2006) Simulation als Vorbereitung auf nicht alltägliche
Rettungsdiensteinsätze. Rettungsdienst 29:32–34
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_25

25. Child with Head Injury

Martin Dünser1
(1) Department of Anesthesiology and Critical Care Medicine, Kepler
University Hospital, Linz, Austria

Martin Dünser
Email: [email protected]

There is nothing that does not exist—this statement becomes very clear
in this case. A foreign country, poor treatment conditions and a special
injury meet and present the treating doctors with a special challenge.

It is hot—as every day. It is turbulent on the intensive care unit of the

hospital in Ifakara/Tanzania—as every day. Most patients treated here have
an infection: respiratory infections paired with malaria, obstetric
complications, preeclampsia and trauma are other common admission
diagnoses. Children are usually admitted to the intensive care unit due to a
malaria infection, a respiratory infection (±malaria), diarrhea with
dehydration or burns. Today is surgery day. We expect 5 patients after open
prostatectomy. The procedure only takes 15–20 min, but has a very high
complication rate. In particular, the “transurethral resection of the prostate”
(TURP) syndrome is very common due to postoperative bladder flushing.
The preparations are interrupted when I am called to the operating suite in
the other part of the hospital. Stay nice on the concrete sidewalks and don’t
shortcut over the grassy areas—there are snakes there.
In front of the operating room, a mother is sitting with an approximately
8-month-old child in her arms. The child is visibly scared. A wool cap
hangs from his head. Next to him is the surgeon, who has been waiting for
me and tells me the story: A collapsing fence with a protruding nail had hit
the child on the head. In the process, the nail pierced the wool cap and then
got stuck in the skull bone. The mother immediately removed the fence
with the nail; but the wool cap remained stuck in the wound. There was
never any loss of consciousness. The child is also uneventful on a gross
neurological level at the time of my examination. Therefore, a relevant
injury to intracranial structures seems unlikely to me. The surgeon is
concerned that the wool cap may have been displaced into the skull by the
force of the nail and that there may now be an intracranial injury during
removal. The detailed inspection of the head wound shows that the wool
cap is indeed deeply embedded in the wound located in the parietal area
(sutures and fontanelles are free and do not suggest increased intracranial
pressure). The wool cap cannot be removed by careful manipulation.
Although a radiographic imaging would be desirable, it is impossible. The
nearest computed tomograph is a day’s journey away. Since a skull x-ray is
not indicated due to the lack of radiodensity of the foreign body, we are not
bothered by the fact that no x-ray can be taken in the hospital on this day
anyway. The probability that a sharp nail could displace part of the wool
into the skull seems very low to me. Nevertheless, we make all the
preparations and bring the child into the operating room. With local
anesthesia, the wound is slightly enlarged and the wool cap is removed
under visual control. There is no bleeding to the outside. A few moments
after the removal of the foreign body, the child loses consciousness, shows
a bilateral gaze deviation directed cranially and a flaccid tone. Breathing
and circulation remain stable; the airways are well open after lateral
positioning. We transfer the child to the intensive care unit for further
monitoring, where he shows first spontaneous movements upon arrival. The
awakening phase is prolonged. When I come to the intensive care unit the
next day, the mother is sitting with the awake child in her arms on the bench
in front of the intensive care unit and looking into the green of the nearby
bush forest. The child also shows no neurological deficits on a detailed
clinical examination. After we observe the child for a few more hours, he
can be discharged. The wool cap, which only sustained minor damage in
this incident, is also taken by the mother. Still not understanding what
happened, I watch them leave the hospital and make their way home.
 To this day, I do not understand how a sharp object like a nail
could have displaced a soft material such as wool through
The skull into the neurocranium. Although we could not prove this to be
the case due to the lack of imaging, the acute disturbance of
consciousness after removal of the wool cap made this highly likely. The
pathophysiological cause of the disturbance of consciousness remained
completely unexplained. Perhaps a small bleed occurred after removal of
the foreign body, the cortex was irritated, or (non-convulsive) seizures
were triggered. A cranial computed tomography scan would have
certainly provided some insight here. However, at that time, there were
only two computed tomographs in all of Tanzania—one in the capital
Dar es Salaam and one in the northern city of Moshi. Both cities were at
least a day’s journey away—conditions that are quite typical for Africa
[1, 2]. Furthermore, the family could not even afford the treatment costs
in the hospital, let alone the possible transport of the patient to the
computed tomograph and the costs of the examination.
I am glad that in this situation we took the (for me at that time highly
unlikely) concerns of the surgeon seriously and removed the foreign
body in the operating room and with the best possible view after
enlarging the wound. This way we did the best possible under the given
circumstances, because there is nothing that does not exist!

25.1 Conclusion
Being a doctor in a low-income country is a special challenge in order to
help as many people as possible with few resources. Although one can often
compensate for a lack of material and technology with improvisational
talent at least to some extent, but if, for example, an oxygen generator fails,
then the inspiratory oxygen fraction inhaled by the patient will inevitably
fall if there is no oxygen cylinder as a back-up oxygen source. In daily
work, the unimaginable poverty of the people on site is evident, but at the
same time their unimaginable gratitude and resilience to overcome even
terrible fates. In the case described here, it was necessary to weigh the
therapeutic options in order to be able to help in the best possible way—
fortunately, local wound care was sufficient, as a penetrating head injury
would have meant a land transport of about 500 km (311 miles) on bad
roads to the nearest neurosurgical treatment with an uncertain outcome.

References
1. Baelani I, Jochberger S, Laimer T, Rex C, Baker T, Wilson IH, Grander W, Dünser MW (2012)
Identifying resource needs for sepsis care and guideline implementation in the Democratic
Republic of the Congo: a cluster survey of 66 hospitals in four eastern provinces. Middle East J
Anaesthesiol 21:559–575
[PubMed]

2. Jochberger S, Ismailova F, Lederer W, Mayr VD, Luckner G, Wenzel V, Ulmer H, Hasibeder WR,
Dünser MW (2008) „Helfen Berührt“ study team. Anesthesia and its allied disciplines in the
developing world: a nationwide survey of the Republic of Zambia. Anesth Analg 106:942–948
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_26

26. Resuscitation of an Elderly Patient

Volker Wenzel1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine,
and Pain Therapy, Friedrichshafen Regional Medical Center and
Tettnang Hospital, Friedrichshafen, Germany

Volker Wenzel
Email: [email protected]

What to do when death has already occurred, but then life suddenly
shows up again where none should have been anymore? This case shows
that there are phenomena in medicine that one cannot sufficiently
explain with scientific approaches and research yet.

I was a medical student and earned some money for Medical School as
an emergency medical technician in an EMS station. In addition, it was a
good opportunity to see (emergency medical) reality up close, which I often
missed in the partly very dry examination material with multiple-choice
questions in Medical School. The following happened at that time: After
hours of waiting for scene calls in the EMS station in the countryside, an
alarm comes for our ambulance in a village about 5 km (3 miles) away:
“Person collapsed, unresponsive”; a physician-manned ambulance is also
alarmed. This mission indication can be anything: people who fell after too
much alcohol and really could not get up anymore, homeless people who
were asleep, but also patients with a severe stroke. However, the family
member who instructed us in front of the emergency site had pure fear in
his face—this looked like a very serious situation. We know that the crew of
the physician-manned ambulance would arrive at the emergency site about
20 min after us and we would be first of all on our own. We are trained in
inserting an intravenous access, intubation and defibrillation but not drug
administration, but of course we have hardly any daily routine in these
activities—in this respect, a physician is always necessary in a
cardiopulmonary resuscitation attempt. The older patient is lying in the
bathroom on the first floor under the washbasin. The situation is clear to us
at first sight—sudden circulatory arrest, which requires immediate
cardiopulmonary resuscitation. We ask the relatives to leave the bathroom
and ask them to call the emergency number 112 again and confirm to the
EMS control center that we have initiated cardiopulmonary resuscitation
and that the physician-manned ambulance is urgently required; to save time
an EMS helicopter was dispatched. Cardiopulmonary resuscitation proceeds
smoothly, but we cannot restore spontaneous circulation in the patient. Then
something unexpected happens—suddenly the patient’s family physician
shows up in the bathroom, whom the relatives probably also called in their
fear for their grandmother’s life. After a short explanation from us (20 min
of cardiopulmonary resuscitation with defibrillation without restoring
spontaneous circulation), the family physician says: “It makes no sense
anymore—please stop cardiopulmonary resuscitation!” We tell the family
physician that we should then cancel the EMS helicopter; I am sent by the
family phsician to the telephone in the basement. In the living room I tell
the relatives that their grandmother did not survive the cardiac arrest despite
all efforts. Then I call the emergency number 112 to inform the EMS
control center about the family physician’s decision to stop
cardiopulmonary resuscitation and that the EMS helicopter is no longer
needed—the death certificate is to be issued by the family physician. The
dispatcher of the rescue control center then orders the EMS helicopter back
to the base—but it is already just before landing next to the fruit garden and
blows all the flowers off the cherry trees by the downwash of the rotor
when it turns around. Then I go back to the bathroom on the first floor to
my ambulance colleague and the family physician of our patient. To my
surprise, we have to find out that the patient starts breathing again—with a
low frequency, but there is no doubt. We can also feel a pulse—the family
physician says “It’s over soon.”, but we are completely overwhelmed—first
we determine the death of a patient, but then that’s not true?! We discuss
with the family physician what we should do, but after a short time and
further detailed examination it is clear—the patient breathes regularly and
has a stable circulation. We prepare for a transfer to the hospital and the
family physician says: “I can’t accompany the patient to the hospital, you
have to do that yourself!” We reply that we are not allowed to do this as
ambulance personnel with such a critically ill patient and suggest that we
ask for a physician-manned ambulance from the EMS control center. Again
I am sent by the family physician to the living room to make a phone call-
at that time, mobile phones did not exist. I tell the relatives that the
determination of death was an incredibly embarrassing misunderstanding to
me, and that we would now transport the patient to the hospital. The
dispatcher of the EMS control center is obviously surprised by the short
description of the situation and sends us the previously canceled EMS
helicopter again. The EMS helicopter’s emergency physician feels quite
brusque because of the request, cancellation and re-request, but
immediately realizes that a detailed discussion is completely pointless; we
then transport the patient to the nearest hospital with him. There the patient
is immediately transferred to the intensive care unit, where she dies two
weeks later without ever regaining consciousness.

Discussion
In extremely rare cases, it can happen that after the termination of a
correctly performed cardiopulmonary resuscitation attempt, spontaneous
circulation resumes—but in our analysis over a period of about 15 years
in Germany, Austria and Switzerland, not a single cardiopulmonary
resuscitated patient survived after such a phenomenon [2]. In a case
report of a 55-year-old patient with acute renal failure, cardiopulmonary
resuscitation was stopped after 35 min due to persistent asystole.
Surprisingly, the patient had a stable circulation again 7 min later and
was transported to a hospital where he died three days later from cerebral
edema [5]. In this case, it was assumed that renal failure-induced
hyperkalemia had caused cardiac arrest and was compensated by sodium
bicarbonate infused during cardiopulmonary resuscitation. In another
case, a 47-year-old man underwent cardiopulmonary resuscitation. After
about 45 min, the resuscitation attempt was stopped due to persistent
ventricular fibrillation. 15 min later, a police officer investigating the
case discovered that the patient was breathing; he was admitted to the
hospital in a stable circulatory condition, but was in a persistent
vegetative state and died three months later [3]. The authors could not
explain the mechanism in this case, but recommended that after the
resuscitation attempt has been completed, the patient should be
monitored for about 10–15 min to exclude a Lazarus phenomenon. This
case is remarkable because in humans, due to the size of the
myocardium, self-defibrillation is actually not possible, as it is in mice or
rats. Other possible mechanisms are hypothermia or intoxication. In our
analysis [2], we found one case in which the EMS workers mistakenly
declared death: A woman (age unknown) tried to commit suicide by
taking pills in her Hamburg, Germany apartment. The paramedics called
to the scene declared her dead. It was only the undertakers who noticed
that the woman was breathing; she survived the incident (Hamburger
Morgenpost, 21.02.1997). A 63-year-old woman was pulled lifeless from
the Rhine river in Bonn, Germany. After the examination, the emergency
physician declared the woman dead. 1½ h later, the undertaker noticed
that she was breathing and her heart was beating. However, she died on
the same evening (Berliner Kurier, 07.01.2004). Another possible
pathomechanism was discussed based on the cardiopulmonary
resuscitation attempt of an 81-year-old patient who had to be resuscitated
due to a rupture of the A. iliaca externa. Due to the serious underlying
disease of a thoracic aortic aneurysm, cardiopulmonary resuscitation was
stopped after 25 min and the ventilator was disconnected from the
endotracheal tube; about 2 min later, the patient had again stable
circulation. He was able to regain normal neurological performance in
the following, but died five weeks later [1]. A mechanism was discussed
as hyperventilation, which decreases venous return during
cardiopulmonary resuscitation by the increased intrathoracic pressure;
this would be plausible because after the disconnection of ventilation,
circulation was very quickly stabilized again—but the patient also had a
pacemaker.
It is unclear why the Lazarus phenomenon of a temporary stable
circulation after a terminated cardiopulmonary resuscitation attempt is so
rarely described—for this reason, we had an analysis of corresponding
reports from the lay press, which brought to light an astonishing number
of cases that were unknown in the medical literature. Possible causes
could be that the scientific explanations are insufficient, disbelief of the
involved EMS workers about the observed phenomenon, often poor and
incomplete documentation, fear of missing something and of forensic
 consequences [4]. Especially because of the case reports from very
different health systems in different countries, one must assume that the
Lazarus phenomenon exists—it shows that the path between life and
death does sometimes not work like a light switch, but sometimes there
is another way than one thinks—which can cause a hellish shock for the
EMS workers, which of course can quickly call into question the
professionalism and expertise of the involved EMS workers and
emergency physician.

26.1 Conclusion
Before terminating cardiopulmonary resuscitation attempt, remember that
the Lazarus phenomenon exists and exclude possible causes such as
hypothermia, intoxication, pulmonary hyperinflation, hypovolemia and
bradycardia. After the end of CPR, the patient should be monitored for
about 10–15 min; only then should the entry of death be communicated to
the relatives.

References
1. Duck MH, Paul M, Wixforth J, Kammerer H (2003) The Lazarus phenomenon. Spontaneous
return of circulation after unsuccessful intraoperative resuscitation in a patient with a pacemaker.
Anaesthesist 52:413–418
[PubMed]

2. Herff H, Loosen SJ, Paal P, Mitterlechner T, Rabl W, Wenzel V (2010) False positive death
certification. Does the Lazarus phenomenon partly explain false positive death certification by
rescue services in Germany, Austria and Switzerland? Anaesthesist 59:342–346
[Crossref][PubMed]

3. Kamarainen A, Virkkunen I, Holopainen L, Erkkila EP, Yli-Hankala A, Tenhunen J (2007)

Spontaneous defibrillation after cessation of resuscitation in out-of-hospital cardiac arrest: a case
of Lazarus phenomenon. Resuscitation 75:543–546
[Crossref][PubMed]

4. Maeda H, Fujita MQ, Zhu BL, Yukioka H, Shindo M, Quan L, Ishida K (2002) Death following
spontaneous recovery from cardiopulmonary arrest in a hospital mortuary: ‚Lazarus phenomenon‘
in a case of alleged medical negligence. Forensic Sci Int 127:82–87
[Crossref][PubMed]
5.
Voelckel W, Kroesen G (1996) Unexpected return of cardiac action after termination of
cardiopulmonary resuscitation. Resuscitation 32:27–29
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_27

27. Emergency Cricothyroidotomy

Sven Wolf1
(1) Department of Emergency Medicine, DIAKOVERE Friederikenstift,
Hannover, Germany

Sven Wolf
Email: [email protected]

Since MacGyver there has been the myth of emergency

cricothyroidotomy with everyday objects like a ballpoint pen. The
present case deals with the question of how far this myth has substance
in emergency reality.

On a sunny autumn day, an ambulance and a physician-manned

ambulance are sent to a 63-year-old patient with the call sign “respiratory
distress” from the EMS dispatch center. According to the EMS dispatch
center, the patient was hardly comprehensible on the phone, there are no
further past medical history hints. Both EMS vehicles arrive at the same
time. The door is opened by the neighbor, as the patient is already
unresponsive on the living room floor. In general, we expect many bad
things in the EMS; but with the full picture of a myxedema with
pronounced cyanosis, all 4 rescuers of the deployed vehicles can hardly
hide their horror. The face, mouth and eyes of the patient are balloon-like
swollen, the tongue bulges out of the mouth like a child’s fist. During the
initial monitoring (heart rate 89, blood pressure unmeasurable, oxygen
saturation 71%, sinus rhythm on ECG), respiratory and ventilation
measures are tried without any recognizable success. Neither a finger nor a
Guedel tube can be pushed past the tongue, a spiral tube already sticks at
the end of the nasal cavity. The mask can be sealed well in the edematous
face, but significant ventilation volumes can not be applied despite the
maximum raised lower jaw. On the orders of the emergency physician, the
surgical instruments are fetched and opened in the meantime. With an
estimated 100 kg body weight, the head contour of the approximately
160 cm tall patient leads almost neckless into the trunk, a classic “no-neck”!
The larynx is not palpable percutaneously. About 6 min after arrival at the
scene, the emergency physician makes a transverse skin incision about 8 cm
long, 3 fingers caudal to the chin with the scalpel. With both index fingers
he prepares or rather “wades” through a wide subcutaneous layer of fat to
the trachea and larynx. While holding the “situs” with the thumb and index
finger spread, he incises the tight band between the ring and cartilage with
the right hand, spreads the small opening with a speculum and inserts a 6.5
tube into the trachea. The patient can now be ventilated sufficiently at a
lower level. 500 mg steroid, 1 ampoule antihistamine and 2 mg epinephrine
are injected via a peripheral access; a stable circulation and ventilation
situation develops. The patient dies in the hospital 2 days later with hypoxic
brain damage. The background of the myxedema can not be clarified.
A few days later, the following happens: During car repair work in a
garage, there is a massive explosion of gasoline fumes. A 47-year-old
patient suffers severe burns (3–4° degree) in the area of the head, neck and
front chest wall, as well as an inhalation and smoke gas trauma. The
competent EMS services of the respective district are tied up in another
scene call, so that the EMS control center, due to the expected extended
travel time of ambulance and physician-manned ambulance, alarms a local
EMS employee from home as a “first responder”. This rescuer finds the
patient unconscious (Glasgow Coma Scale 3) lying in front of the garage.
Face and front neck/chest region show severe, partly leathery charred burns;
the vital parameters indicate profund shock (heart rate 108, blood pressure
90/00, flat, slow breathing movements of <8/min). The EMS employee
orders the cooling of the burned areas on the neck and chest with tap water
by the fire department, which has meanwhile arrived. At the same time, he
places a peripheral venous access (14G). Due to the apparently urgent
airway and ventilation problem, he decides to intubate. However, due to the
burns, even under considerable force, the mouth or jaw opening is only
possible to a maximum of 1.5 cm. The subsequent attempted assisted mask
ventilation fails due to gross leaks in the mask on the charred skin areas. As
a last resort, he then remembers the story of the “ballpoint pen
cricothyrotomy” told again and again by various “specialized trainers”. It is
not difficult for him to palpate the shield and ring cartilage of the slim
patient. However, his quite strong attempts to penetrate the leathery soft
tissues and the cricothyreoideum ligament (conicum) with 2 different
ballpoint pen models are frustrating; fortunately, however, no injury to large
vessels occurs. Meanwhile, the physician-manned ambulance arrives;
within 5 min, a safe airway is established using a QuickTrach™ -
cricothyrotomy set. The patient can be airlifted to a heavy burn center from
the nearby hospital of basic care on the same day. After 2 months and 12
surgical interventions, the patient is transferred to a rehabilitation facility.
And one final event: the 71-year-old resident of a nursing home
becomes a patient of the EMS as a result of a frontal fall with her face onto
a bedside table. Otherwise awake and oriented, she shows a Glasgow Coma
Scale of 3 during the initial examination. There are diffuse bruises,
lacerations and unstable facial bones in the area of the nose and the
zygomatic arch. The mouth can only be opened to about 1.5 cm with firm
contact, according to the information of the carers “this has been like that”
since a tumor operation on the jaw 1 year ago. The vital parameters are a
blood pressure of 110/70 mmHg, a heart rate of 63 and an oxygen saturation
with oxygen mask (6 l/min) of 87% with bradypnoea. Due to the deformed
facial skull, assisted mask ventilation is only possible to an unsatisfactory
extent. Secretions and blood clots are suctioned off through the narrow
mouth opening. The emergency physician decides on a classical open-
surgical emergency cricothyrotomy. Since the patient is already deeply
unconscious, the procedure is carried out without additional anaesthetic
sedation. Although the neck contour is very slender and the larynx is
already macroscopically well localized, the scalpel placed together with the
skin which is anything but tight slips sideways along the thyroid cartilage
several times. Only when the paramedic tightens the skin bilaterally does a
reasonable transverse skin incision at the level of the cricothyroid ligament
(conicum) succeed. However, the skin incision also cuts through a cranial
outgrowth of the thyroid gland with corresponding bleeding. This does not
impress the emergency physician at all, he incises the conicum ligament and
inserts a 6.5 tube. This allows sufficient ventilation of the patient. The
significant oozing of blood from the cricothyrotomy wound has to be
compressed manually with a compress up to the hospital. There a local
exploration of the wound and ligation of a lobe of the thyroid gland is
carried out. Clinically and radiologically, the already suspected complex
fractures of the middle face and an subarachnoidal haemorrhage are found
after the corresponding diagnostics that has to be surgically intervened.

Discussion
If you ask at symposia or workshops among experienced emergency
medical personnel for self-performed emergency cricothyrotomies, the
number of raised fingers is very limited [6]. Successful “ballpoint pen
operators” of an emergency cricothyrotomy are not known to the author,
nor are any serious scientific case studies in this regard. The combination
of skin and the tough, fibrous membrane between the ring and thyroid
cartilage (conicum/cricothyroideum ligament) renders perforation with a
standard ballpoint pen almost impossible. Even with a preparation
scissors, these layers are hardly penetrable in vivo and on a cadaver [5].
The exclusive use of ballpoint pens to create an alternative airway is
and remains a myth that should not be “set in the head” of physicians
and EMS personnel. The valuable time for these frustrated attempts is
better invested for non-medical personnel in an emergency situation in
an attempt to apply at least small air volumes orally or nasally with the
head extended (adults). Accurate numbers for pre-hospital emergency
cricothyrotomies in the 1980s and 1990s are not known [6]. In any case,
these surgical interventions have decreased significantly in recent years,
despite new, great technical aids such as QuickTrach™. “Cannot
intubate—cannot ventilate” situations now have a much greater
importance in training [6]. There are sufficient aids for the “alternative
airway” available (laryngeal mask, Kombitubus™, Larynxtubus™,
video laryngoscope etc.) [1], which certainly reduce the maximum
success pressure, especially for the less experienced “intubator”.
Nevertheless, the semi- and full-surgical techniques for emergency
cricothyrotomy, despite the relatively high possibility of complications
(e.g. tracheal injury, significant bleeding, aspiration), remain an
indispensable redundancy for ventilated patients with swollen or
destroyed upper airways [2]. In the 3 specific cases mentioned above,
although not practiced, the primary puncture of the cricothyreoideum
(conicum) ligament and jet ventilation with a 13- or 14-G cannula
provides a safe bridge for the minutes until definitive cricothyrotomy
 [3]. Even if the thyroid gland is palpably small and comes to be
positioned caudally of the planned incision, the prevalence of a thin, far-
reaching thyroid gland lobe (Lobus pyramidalis glandulae thyroideae) is
often transverse through the planned incision area (cricothyroideum
ligament). Here, good, tried and tested aids such as the QuickTrach™ set
offer a safe alternative to the classic full-surgical access with scalpel and
speculum [4]. The danger of significant bleeding from skin vessels and
incised thyroid gland tissue is also significantly reduced.

27.1 Conclusion
Emergency cricothyrotomy remains an indispensable redundancy for “can
not intubate—can not ventilate” scenarios despite modern “alternative
airways”. It requires quick, targeted action with knowledge of possible
complications. Exercises with emergency cricothyrotomy sets, e.g. on a pig
carcass or on a corpse, are very time-consuming, but they provide an ideal
practical basis. In any case, it is recommended to regularly deal with both
the anatomical normal variants (just palpate each ambulance driver) and the
instructions for use of the current emergency cricothyrotomy equipment.

References
1. Buonopane CE, Pasta V, Sottile D, Del Vecchio L, Maturo A, Merola R, Oanunzi A, Urciuoli P,
D’Orazi V (2014) Cricothyrotomie performed with the Melker™ set or the QuickTrach® kit:
procedure times, learning curves and operators’ preference. J Chir 35(7–8):165–170

2. De Koning Gans JM, Zwart DL, Kalkman JC (2010) Acute upper-airway obstructions in primary
care. Cricithyrotomie performed by the general practitioner. Ned Tijdschr Geneeskd 154:A1299

3. Hess T, Stuhr M, Knacke PG, Reifferscheid F, Kerner T (2014) Invasive emergency techniques –
cricothyroidektomie. Anasthesiol Intensivmed Notfallmed Schmerzther 49(4):230–236
[PubMed]

4. Mabry RL, Nichols MC, Shiner DC, Bolleter S, Frankfurt A (2014) A comparison of two open
surgical cricothyroidotomy techniques by military medics using a cadaver modell. Ann Emerg
Med 63(1):1–5
[Crossref][PubMed]

5. Senthiulkumaran S, David SS, Jena NN, Thirumalaikolundusubramanian P (2014)

Cricothyroidotomy and ventilation: physics and physology. J Emerg Med 47(5):131
[Crossref]
6.
Wong DT, Metha A, Tam AD, Yau B, Wong J (2014) A survey of Canadian anaesthesiologists
preferences in difficult intubation and „cannot intubate, cannot ventilate“ situations. Can J
Anaesth 61(8):717–726
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_28

28. 65-Year-old Patient with Shortness of

Breath
Luise Schnitzer1
(1) Charité University Medicine Berlin, Campus Benjamin Franklin,
Department of Cardiology and Pulmology, Berlin, Germany

Luise Schnitzer
Email: [email protected]

“Achieve a lot with very little” and “look closely and take seriously” are
2 central themes of this case, which is about taking a holistic view of
things.

Home nursing care alarmed us because a COPD patient—permanently

dependent on home oxygen—had developed increasing shortness of breath
and had become cyanotic. Upon arrival, we find a 65-year-old patient. The
room is darkened, the obese gentleman is sitting in bed and greets us
friendly and in a good mood. This is striking because people who
suffer shortness of breath are usually considerably strained and there is only
little room for “politeness” because all focus is concentrated on breathing.
The respiratory rate of only 16/min is also striking. We give him a little
more oxygen through a nasal cannula, but he remains deeply cyanotic.
However, when asked, he reports that he feels as good or as bad as always
and cannot report any change in his condition.
My confusion is increasing! Why were we called if his condition is
unchanged? Why is he so “cyanotic”? The nurse now reports that she found
the patient cyanotic during her daily routine visit and called the fire
department despite his protests. A physical examination reveals gurgling
and whistling over the lungs as well as coarse rattling noises, the oxygen
saturation is 95%, he can cough well, whereupon the coarse rattling noises
become less. He has no fever. His skin is blue all over and livid, the
fingernails are inconspicuous, but his fingers and hands are blue. Now I am
wholly confused. I can only find a somewhat absurd explanation for the
cyanosis and point to the bed linen. It is patterned in different shades of
blue, it is summer and warm outside, the room is darkened. The patient
finds my explanation amusing, my EMS assistant more or less holds his
breath and the nurse is extremely skeptical, but cannot and does not want to
accept my explanation. Myself a little unsure about my daring diagnosis, I
fetch a wet washcloth with soap and can easily remove the “cyanosis”.
Relieved to have helped the patient and the nurse so quickly and effectively,
we leave in a good mood, the patient remains with his speechless nurse in
his familiar environment. The first only necessary measure resulting is that
the new bed linen is to be washed.

Discussion
Sometimes it’s that easy: Although this case is an extremely unusual
anecdote, it shows that sometimes a little lateral thinking can be helpful.
As an emergency physician, you sometimes come across findings that
are not immediately explainable [1]. This is relatively typical in cases of
intoxication or drug abuse, especially when patients and relatives deny
any abuse. What is decisive are not the statements of third parties or the
patient, but the objective condition of the patient, which -in our case-
apparently showed a considerable discrepancy to the apparent finding of
cyanosis. However, unclear relationships are rarely as easy to clarify as
in our patient. Nevertheless, it is always necessary to admit a patient to
the hospital, even if only a trivial disease is suspected, be it to reassure
yourself or to avoid a long and perhaps fruitless conversation due to lack
of time. This is particularly true for patients who have a psychosomatic
background and who may not be willing to accept this. The access to the
patient is then doubly complicated if in the past there was an actual
disease with similar symptoms. This will be demonstrated by another
example.
A 32-year-old young woman suffers from an anterior wall infarction
due to obstruction of the ramus interventricularis anterior with otherwise
 uneventful coronary arteries. The damage can be kept small with quick
treatment with cardiac catheterization and stent implantation. In the
subsequent rehabilitation phase, the patient is doing well and she can
cope well with the stress. The difficulties begin when the patient is back
at home—without the layer of security that physicians and nursing staff
nearby offer, apparently typical angina pectoris complaints occur. She
presents herself in the emergency department of the hospital, blood tests
and a cardiac catheterization are performed again, which show an
uneventful finding. Nevertheless, the patient appears almost weekly with
the typical complaints, she is examined, the laboratory values are
uneventful and she is discharged home again. Only after the 3rd cardiac
catheterization, the treatments are reduced to an ECG and laboratory
tests during further visits to the emergency department—ischemia was
excluded each time. However, the patient’s suffering does not end. Only
after 9 months, the patient is recommended a psychotherapeutic
treatment, which puts her understandable fears in the foreground. She
has two small children and the idea of having a heart that no longer
works, possibly dying soon and leaving the children unsupervised, puts
the patient to. After she can also express her concerns, the frequency of
angina pectoris attacks drops sharply. Already after 2 weeks she neither
calls the number at EMS dispatch doctor, nor does she appear in the
hospital herself and has now been symptom-free for more than 4 years.
Regular visits to the cardiologist do not reveal any indications of
coronary sclerosis, she continues to do sports and is confident in her
performance.

28.1 Conclusion
Emergency calls can have very strange causes. Even if the emergency call
for help seems completely unfounded, it is important to take the patient’s or
his relatives’ and caregivers’ concerns and fears seriously and initiate or
help to organize appropriate help. Psychosocial emergencies are a rapidly
growing segment of emergency calls, which many emergency physicians
find difficult to deal with because they are primarily trained to treat
invasively—here, however, one can help a lot with very little.
References
1. Kosan geb. Bathe J (2012) Notarzteinsätze in Alten- und Pflegeheimen – der physician-manned
ambulance als Lückenbüßer. Dissertation. Medizinische Fakultät Charité, Universitätsmedizin
Berlin
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_29

29. Status Epilepticus

Martin Dünser1
(1) Department of Anesthesiology and Critical Care Medicine, Kepler
University Hospital, Linz, Austria

Martin Dünser
Email: [email protected]

The knowledge of the characteristics of a disease is essential for the

diagnosis and treatment—but, as this case shows, not always given and
self-evident. Even a corresponding treatment option, as shown here, is
not self-evident and can have fatal consequences for the patient.

Somewhere in a yurt in the steppe of Mongolia (about four and a half

times as large as Germany, but only about 3.2 million inhabitants): A 45-
year-old man with a known, poorly controlled epilepsy (antiepileptic
medication is only sporadically available) and weekly grand mal seizures
has been showing an increase in seizure frequency for a few days. One
morning the patient is no longer arousable. A doctor called in from the next
village examines the patient and, based on the disturbance of consciousness
without recognizable tonic-clonic seizure activity, suspects an intracranial
bleed. He recommends, due to the lack of therapeutic consequences (the
next hospital with computed tomography or neurosurgery is 700 km (435
miles) away) and the increased risk of transport on unpaved roads, to leave
the patient on site in the yurt. The patient’s state of consciousness does not
change after 2 days, so the family decides to take him by car to the 200 km
(124 miles) distant provincial hospital. These distances are hardly
imaginable for us, but Mongolia is, after the Western Sahara and Greenland,
the world’s most sparsely populated country. After more than 12 hours of
driving under anything but gentle conditions, the patient reaches the
provincial hospital. There he is admitted to the medical ward. A
neurological department or a neurologist is not available. The treating
physicians also assumed that a spontaneous intracranial bleed (e.g. an
intracerebral hypertensive mass bleed) was most likely to explain the
patient’s coma. The therapy is purely supportive—lateral position, oxygen
administration, and so on. Further intensive care is impossible due to the
lack of equipment, the lack of experienced personnel and the lack of space
for an intensive care unit. At the insistence of the relatives, the physicians
agree to transfer the patient who continues to be in coma to the university
hospital in the Mongolian capital Ulaanbaatar. The transport—this time
200 km (124 miles) of the total 500 km (311 miles) on paved roads—is
again carried out by private car. On the 6th day after the onset of
consciousness, the patient arrives in the emergency room of the university
hospital. A short time later I am involved to evaluate the admission to the
intensive care unit. Clinically, the patient shows a Glasgow Coma Scale of
5 (eyes 1, verbal 1, motor 3). The muscle reflexes are barely perceptible at
all extremities, the Babinski reflex is weakly elicitable bilaterally. The
pupils are medium-wide and react only slowly to light. On passive opening
of the eyelids, a weak, rhythmic twitching can be seen at the lower eyelid.
Based on the history of the family and clinical presentation, the diagnosis of
a non-convulsive status epilepticus is very likely. Differential diagnoses
include a brain (stem) hemorrhage or -ischemia as well as a metabolic coma
cause. After a cranial computed tomogram (the university hospital is one of
the few hospitals in Mongolia at this time that has a computed tomograph),
which shows signs of brain edema, an EEG is performed. This shows the
picture of a status epilepticus with a clear slowing of the background
rhythm up to phases of a burst suppression. Together with the neurologist,
we administer a total of 30 mg diazepam as well as carbamazepine and
phenytoin. A further escalation of the antiepileptic therapy, as provided for
in the stepwise algorithm for the treatment of status epilepticus, is not
possible. In addition to carbamazepine and phenytoin, no other antiepileptic
substances are available. Since the patient’s prognosis is judged to be very
unfavorable due to the long delay until antiepileptic therapy was started and
the evolving brain edema, we decide that another patient (32 years, septic
shock with peritonitis due to a perforated appendicitis) is admitted to the
intensive care unit bed with the possibility for mechanical ventilation. This
renders induction of a barbiturate coma, which requires endotracheal
intubation, impossible. The patient is treated on an intensive care bed
without the possibility for mechanical ventilation for another 5 days. His
state of consciousness does not change, but deteriorates step by step. In the
end, the patient has a Glasgow Coma Scale of 3. Since the chances of
neurological recovery are considered to be extremely low by all team
members and several other patients are waiting for intensive care unit
admission, the patient is transferred to the neurological ward for further
care. I visit him there a few days later. His condition remains unchanged.
He dies shortly thereafter.

Discussion
Non-convulsive status epilepticus is a common, although often
unrecognized, cause of altered consciousness. For all those, like the
initial physicians involved in this case, who have hitherto associated
epilepsy necessarily with tonic-clonic focal or generalized seizure forms,
this diagnosis does not exist. Thus, the correct therapy is not
administered, which—as in our case example—can end fatally. Non-
convulsive seizure forms were first described by Lennox in 1945 [1] and
considered a rare event for many years. First prevalence studies in the
1970s suggested that non-convulsive status epileptici made up
approximately 25% of all status forms [2]. Today we know that non-
convulsive seizures are very common in older people with vigilance
disorders (up to 30%). It is important to know that approximately 25% of
convulsive states transition into a non-convulsive status epilepticus after
the cessation of the tonic-clonic movement component (e.g. due to
medication). In addition to subtle clinical seizure clues (e.g. rhythmic
twitching of the eyelids during passive opening), persistent coma despite
tonic-clonic seizure symptoms have abated should be considered as a
potential indicator of non-convulsive status epilepticus [3]. If there is
reasonable suspicion, this can only be confirmed or ruled out by EEG.
The most common causes of non-convulsive status epilepticus are
similar to those of convulsive status epilepticus and include
ischemia/trauma, inadequate treatment of known epilepsy,
medications/withdrawal, metabolic influences (sepsis to intoxication),
neurodegenerative processes, central nervous system infections, and
 neoplasms. Identifying the cause of status epilepticus is essential and a
prerequisite for successful therapy. Antiepileptic treatment of non-
convulsive status epilepticus does not differ from that of convulsive
status epilepticus. However, the two seizure forms differ in their
response to antiepileptic therapy. While refractory convulsive states (no
response to first-line, i.e. benzodiazepines, and second-line, i.e.
phenytoin, levetiracetam or valproate, therapies) are observed in
approximately ¼ of cases, refractory seizure patterns have been
described in up to 90% of non-convulsive states [4].

In our case, it was most likely a deterioration of idiopathic epilepsy due to

inadequate antiepileptic therapy. The presented case impressively shows
how crucial knowledge of the existence of a non-convulsive seizure can be
and what consequences the failure to recognize this form of epilepsy can
have. In 2004—when I was involved in the treatment of this patient—the
knowledge of non-convulsive status epilepticus in Mongolian medical
circles was only rudimentary. One of the main reasons for this is probably
the lack of availability of EEG machines in most hospitals. The university
hospital was one of three hospitals in the Mongolian capital Ulaanbaatar
(approx. 1.3 million inhabitants) that had such a device at that time.

29.1 Conclusion
The suspected diagnosis of spontaneous intracerebral hemorrhage (e.g.
hypertensive mass bleeding) made by the treating physicians was unlikely
in view of the past medical history and presented clinical picture, even
though intracerebral hemorrhage was one of the most frequent causes of
sudden non-traumatic loss of consciousness in persons >40 years in
Mongolia. A high prevalence of untreated arterial hypertension among the
Mongolian population is likely to explain this. The fact that the loss of
consciousness due to the non-convulsive seizure occurred in this patient
outside the Mongolian capital, immensely worsened the chances of
treatment and healing of the patient. In 2004, intensive care was hardly
existent in Mongolia outside of Ulaanbaatar. Poor transport links and long
distances without existing transport facilities (e.g. ground or air-based
transfer options for critically ill patients) represented additional adverse
factors. Within the last 15 years, Mongolia has experienced a significant
improvement in its road and transport network as well as the availability of
EEG devices as part of its economic upturn.

References
1. Lennox WG (1945) The petit mal epilepsies: their treatment with tridione. JAMA 129:1069–1074
[Crossref]

2. Celesia GG (1976) Modern concepts of status epilepticus. JAMA 325:1571–1574

[Crossref]

3. Al-Mufti F, Claassen J (2014) Neurocritical care: status epilepticus review. Crit Care Clin
30:751–764
[Crossref][PubMed]

4. Mayer SA, Claassen J, Lokin J et al (2002) Refractory status epilepticus: frequency, risk factors,
and impact on outcome. Arch Neurol 59:205–210
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_30

30. A Pale Patient

Frank Marx1
(1) Intensive Care Helicopter Christoph Giessen, Malteser Hilfsdienst
Diözese Münster, Giessen / Münster, Germany

Frank Marx
Email: [email protected]

How to react when 2 lives are at stake and it is not initially clear what
the situation can be attributed to? And how to deal with the relatives
when a world collapses from one moment to the next? This case
impressively shows how important the topic of psychohygiene can be for
the emergency doctor.

On a November afternoon, the crew of an ambulance is ordered to

transport a pregnant patient in labor to the hospital as part of a planned
admission. When the employees see the patient in her apartment, she is
strikingly pale and reports severe back pain that is continuously present and
getting worse. The husband of the patient, who is a physician himself, and
the couple’s 6-year-old son are still present in the apartment on the second
floor of a multi-family house. When trying to transfer the patient from the
living room sofa to the prepared stretcher, she collapses lifeless. While the
paramedic immediately begins cardiopulmonary resuscitation, the rescue
worker runs back to his ambulance to request an emergency doctor.
At the time of the EMS dispatch, I am as the medical director of the
ambulance service by chance only about 3 streets away from the scene of
the accident. I decide to drive to the scene of the accident in addition to the
requested emergency physician and see upon entering the apartment, a
woman about 30 years old lying on the floor in the living room. Cardiac
compressions and ventilation are continuously performed since the collapse
of circulation. The husband states that his wife is in the 39th week of
pregnancy; during the initial examination, I notice that the woman is very
pale. The pupils are maximally dilated and not round. While I try to create a
venous access on the forearm, I ask the husband to call the EMS control
center again at the emergency number 112. The dispatcher receives a
precise location report from me and I ask him to send a gynecologist and a
surgeon for an emergency Cesarean section from a nearby hospital to the
scene of the accident. I can not puncture a peripheral vein and so I perform
a venous puncture of the V. jugularis interna with an 18G cannula. This
succeeds without problems and I inject infusion solutions and adrenaline
through this access. I make sure that the pregnant woman’s abdomen is
turned to the left to avoid a reduction of venous return during
cardiopulmonary resuscitation [4]. Meanwhile, an ambulance has arrived
and the paramedics retrieve additional emergency medical equipment from
the vehicle, including surgical instruments. Everything is prepared for the
emergency Cesarean section during cardiopulmonary resuscitation. About
10 min after the alarm, a gynecological assistant with advanced training and
a specialist in surgery arrive in the apartment. I briefly explain the situation
and ask the gynecological colleague to perform an emergency Cesarean
section. However, he hesitates and is not convinced by me to do this
immediately. Instead, he calls his chief physician from the nearby hospital
and he advises him not to perform the procedure on site. The already
intubated patient is therefore brought to the ambulance during ongoing
cardiopulmonary resuscitation and transported to the hospital 4 min away.
There, an ultrasound is performed and it is determined that there are no fetal
heart tones; at this time the resuscitation attempt has been going on already
for 40 min. As a result, resuscitation efforts are discontinued.
The patient’s husband is waiting in the waiting area outside the
emergency room. I report to him the sad news of the death of his wife and
his child. He leans on me, cries and sobs: “You’re a physician as well, can
you understand what I’m feeling right now?” During the whole operation I
was the organizer, the decision maker and I made decisions and followed
them up in a targeted manner—but here, certainly also by the physical
proximity to this weeping, completely desperate man, I struggle with tears.
At the autopsy of the corpse it turns out that there has been a rupture of the
abdominal aorta; accordingly, there are considerable amounts of blood in
the abdomen.

Discussion
In this case, all the promising conditions that can be present in a
cardiopulmonary resuscitation came together at first: trained staff of the
ambulance service immediately started cardiopulmonary resuscitation of
the patient [6] when she suffered a circulatory collapse and the first
physician was on site within 2 min of the event. An emergency medical
vehicle supported with additional personnel and with the material
required for an emergency Cesarean section arrived within 10 min,
bringing along a gynecologist and a surgeon. The hospital with the
department of gynecology and obstetrics was only 4 min drive from the
scene of the accident. There were several vehicles of the ambulance
service and the fire department at the scene of the accident; the transport
of the patient up the stairs to the ambulance took no longer than 2 min
even during resuscitation efforts. Although this sequence represents an
amazing speed of the rescue measures, it was still not fast enough. An
analysis of maternal circulatory arrest during pregnancy showed that the
emergency Cesarean section should have been performed within 4 min
of the event in order to achieve the optimum survival probability for the
child [3], which is practically only possible in the hospital. Even if these
numbers from the 1980s are cautiously considered due to the medical
progress, they are confirmed by current data. In a Swedish case series,
neither mother nor child could be saved by an emergency Cesarean
section after 30 min of CPR; in contrast, after 6 min of cardiopulmonary
resuscitation, both the child and the mother could be saved by an
emergency Cesarean section. In another patient in the 39th week of
pregnancy with spontaneous aortic rupture, an emergency Cesarean
section was performed after 10 min of cardiopulmonary resuscitation;
the child survived, but the mother died [8]. These experiences show that
our patient and her unborn child had no chance of survival when
realistically considered.
The patient’s conspicuous pallor already made me suspicious at the
first examination. The patient’s husband watched our resuscitation
efforts, venipuncture, intubation, repetitive injections of epinephrine and
ongoing cardiopulmonary resuscitation from the hallway with the son—
as a medical colleague, he certainly immediately correctly assessed that
the situation was almost hopeless. At no time during the
cardiopulmonary resuscitation over 40 min did ventricular fibrillation
occur; the patient remained in asystole until the end of the resuscitation
attempt—a sign that the patient was probably completely bled out. With
the arrival of the gynecological and surgical colleagues, I would have
expected an immediate laparotomy or emergency section and was
initially frustrated by his refusal to perform the laparotomy and develop
the child. Retrospectively, with the collapse of the patient’s circulation,
her death and the death of her child were determined by the
uncontrollable, intra-abdominal bleeding caused by a completely
ruptured aortic aneurysm. No matter how efficient cardiopulmonary
resuscitation was and no matter how excellent the team worked, they
could not have saved the child and the mother—even if the aneurysm
had ruptured in the hospital, it would not have been certain that these 2
lives could have been saved. About 50% of aortic ruptures in women
under 40 years of age occur during pregnancy. It was unknown whether
our patient suffered from a vascular disorder such as Marfan syndrome,
which predisposes to an aortic rupture [1]; but even in pregnant women
without cardiovascular pathology, fatal ruptures of the aorta have been
described [7]. In a Dutch study, only 13 maternal deaths due to aortic
rupture were described in over 3 million births, which shows the
extremely low risk (approx. 1:240,000) [5]—but even that was only a
weak consolation for the husband and son of this patient.
The technical and organizational aspects of cardiopulmonary
resuscitation are a trained procedure; dealing with relatives is more
difficult for the treating emergency physician, but certainly also for the
other rescue workers involved. While many professions use Balint
groups [2] and similar discussion groups for reflection, this is very rare
in the emergency medical field. It would be helpful to carry out
supervision for emergency physicians in order to enable the emergency
physician, but also the other involved forces, to carry out psychohygiene
on the one hand, but also to enable them to appropriately respond to the
patient, relatives and colleagues in extreme situations. It should also be
mentioned that the professional processing in the context of a case
discussion also helps to reflect and optimize one’s own decisions.
30.1 Conclusion
Aortic ruptures in pregnant women without vascular pathology are
extremely rare, but end with a very high probability of death if the rupture
is complete—even if resuscitation measures are taken very quickly. An
emergency Cesarean section can theoretically also save the child during
ongoing cardiopulmonary resuscitation, but must be carried out within a
few minutes, which is almost impossible in the EMS. Emergency
physicians should be aware that they will experience medically dramatic
and emotionally extremely stressful missions and should therefore not
hesitate to work out stressful situations in Balint groups.

References
1. Birsner ML, Farber JL, Berghella V (2008) Fatal aortic dissection in a patient with a family
history of Marfan syndrome. Obstet Gynecol 112:472–475
[Crossref][PubMed]

2. Hafner S, Otten H, Petzold ER (2011) Balint group work in Germany – results from a survey of
Balint group leaders. Z Psychosom Med Psychother 57:233–243
[PubMed]

3. Katz VL, Dotters DJ, Droegemueller W (1986) Perimortem cesarean delivery. Obstet Gynecol
68:571–576
[PubMed]

4. Kinsella SM (2003) Lateral tilt for pregnant women: why 15 degrees? Anaesthesia 58:835–836
[Crossref][PubMed]

5. la Chapelle CF, Schutte JM, Schuitemaker NW, Steegers EA, van Roosmalen J (2012) Maternal
mortality attributable to vascular dissection and rupture in the Netherlands: a nationwide
confidential enquiry. BJOG 119:86–93
[Crossref][PubMed]

6. Nolan JP, Soar J, Wenzel V, Paal P (2012) Cardiopulmonary resuscitation and management of
cardiac arrest. Nat Rev Cardiol 9:499–511
[Crossref][PubMed]

7. Srettabunjong S (2013) Spontaneous rupture of acute ascending aortic dissection in a young

pregnant woman: a sudden unexpected death. Forensic Sci Int 232:e5–8
[Crossref][PubMed]

8. Zdolsek HJ, Holmgren S, Wedenberg K, Lennmarken C (2009) Circulatory arrest in late

pregnancy: caesarean section a vital decision for both mother and child. Acta Anaesthesiol Scand
53:828–829
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_31

31. Collapse During Seniors’ Hike

Joachim Koppenberg1
(1) Department of Anesthesiology, Pain Therapy, and Emergency
Medicine, Center da sanda Engiadina Bassa, Scuol, Switzerland

Joachim Koppenberg
Email: [email protected]

This case shows that not only the place of use requires full concentration
from the EMS team, but also the handover to the emergency team in the
hospital: The patient remains in the responsibility of the deployment
team until a clear “Your patient!” has been said.

The follow-up deployment reaches us on the return flight from the

hospital to our Swiss Alpine base in the Engadin. I am just enjoying the
fantastic panorama of the mountains at sunset after a sunny and eventful
summer day—despite the now over 15 years of experience in air rescue. Via
radio we receive the message that it is a “collapse” of a hiker in the border
area between Austria and Switzerland—flight time approximately 9 min.
The deployment site is located at approximately 1.400 m / 4,600 feet above
sea level on an idyllic high plateau with a small mountain lake, so that we
can land near the deployment site without any problems. There is an
English hiking group of six seniors accompanied by a local hiking guide
who can give detailed information. The patient is a 67-year-old British
woman who was able to keep up with the previous hike of approximately
6 h without any problems and did not stand out in particular. For about
30 min she has now been complaining of discomfort and exhaustion, but at
first this was associated with the declining condition. Only when she could
really no longer walk and lost consciousness for a short time on each
occasion was an emergency call made. The hiking guide brought her into
the stable side position— breathing was always present. The patient is now
lying on a rescue blanket and does not look fit at all—pale and sweaty. She
is awake and responds to closed questions with yes or no, but according to
the hiking guide, the level of consciousness changes within a few minutes
from completely awake with a GCS of 15 to just awake. I can hardly feel
the slow pulse, so I quickly insert a venous access, while the paramedic
monitors the patient in parallel. The blood pressure is 78/35 mmHg, the
irregular heart rate is slow at 34/min and spontaneous oxygen saturation is
84%. The blood sugar determination shows a normoglycaemia. The
analysis of the ECG shows an intermittently occurring AV block III, which
can also explain the changing levels of consciousness of the patient. In
addition to a rapid oxygen supply with 6 l/min, I explain to the present
husband what the current problem of his wife is and that we would have to
provide her with an external, transcutaneous pacemaker undergoing
analgosedation next. The husband reported that his wife has been treated for
years for arterial Hypertension taking a β-blocker, but is otherwise healthy
and also well-tolerated. Meanwhile, we have glued the multifunction
electrodes for the pacer next to the ECG and drawn up Midazolam and
Morphine for sedation and injected the first dose. I set the pacemaker
frequency in the VVI mode (demand or demand mode) to 70/min and
slowly turn up the power. Already at 45 mA the pacemaker takes over
completely (capture), so that I can fix the power at 50 mA with a certain
safety margin. Within a few seconds the patient is completely awake, so
that I can also explain the working hypothesis and the measures taken
personally. The blood pressure now stabilizes at 115/80 mmHg and the
oxygen saturation is now 97%. Even if the patient describes the pacemaker
impulses as not quite as bad (verbal rating scale = 3–4/10), I deepen
analgosedation because the patient does not have to “endure” anything.
Once the situation has stabilized, we discuss the transport to the next
suitable hospital. It turns out that the hiking group started from Austria and
also wants to return there. Since the next hospital is on the Austrian side in
the place where the “car-free” couple is also on vacation, it is quickly clear
that we will transport the patient to this hospital after pre-registration. After
a short information of the Swiss and the Austrian rescue control centers, we
load the absolutely stable patient undergoing pacemaker therapy and
analgosedation into the helicopter and set off on the approximately 15-
minute flight. Such cross-border operations are not unusual in our region,
but my joy on this day increases again and it seems to be the perfect
conclusion to a perfect day. For a better understanding, I have to add at this
point that this is the base hospital of the Austrian emergency helicopter,
where I was allowed to work for some years. But since I have not been
there for a long time, I secretly hope to meet one or the other “old”
colleague from this time in the emergency room. And I should not be
disappointed! After an absolutely stable flight we land and with the typical
pick-up team at the landing site there is a big “hello”. “Nice to see you
again—but what kind of weird uniform are you wearing?” Or “Yes, yes,
really nice, but you get out of the wrong helicopter!” I immediately feel “at
home” again and can therefore also purposefully take the way to the
emergency room and the internal admission there. In the emergency room it
gets even better: I practically know everyone and almost everyone
recognizes me again—a “home game”! And then, of all people, the former
colleague whom I got to know and appreciate particularly during the
Austrian air rescue comes to hand over. After a first warm welcome, I
concentrate on the most important information about the absolutely stable
patient, the mission and finally do not forget to hand over the mobile phone
number of the husband who is still on the way back.
We have just started to reminisce about old times and exchange ideas
about what the children are up to when the attending nurse suddenly
screams and we have to realize that the patient is deeply unconscious. The
heart rate on the emergency room monitor shows an irregular heart rate of
34/min, the blood pressure is 65/25 mmHg and the oxygen saturation with
6 l/min is 90%. There are no pacemaker spikes to be found. I immediately
turn up the pacemaker’s power to maximum strength—but nothing changes.
How can that be? First we inject fractionated adrenaline i.v. 0.1 mg-wise
until the patient becomes more awake and the heart rate and blood pressure
rise slightly. At the same time we feverishly think about what to do. A new
external pacemaker is needed, which is quickly brought in from the nearby
emergency room. When this is connected and the corresponding current
value of 45 mA is reached, an immediate takeover occurs and every
pacemaker spike is followed by a QRS complex again. The patient
stabilizes promptly and is responsive again. After a short examination by
the admitting colleague, the patient is quickly transferred to the intensive
care unit for placement of a transvenous pacemaker. The further course is
uneventful and the patient can have an internal pacemaker implanted the
next day without any problems.

Discussion
After the patients have arrived safely in the intensive care unit, we go
through the possible sources of error for the interruption of pacemaker
therapy in the emergency room with all participants. The inspection of
the devices does not reveal any technical problems. After we have gone
through the situation again with the involved emergency room nurse, it
suddenly becomes clear to us. While we thought we were done with the
transfer, the emergency room nurse started to hang up the monitoring on
the emergency room devices as usual and started with the ECG. This
resulted in the pacemaker in our device’s demand mode receiving
feedback (“afferent limb”) about the device’s own ECG missing, as it
was now being derived from the emergency room monitor. Therefore, he
simply turned off his “efferent” pacemaker function [1]. When we re-
enacted the situation, we also noticed that our device also showed “check
ECG electrodes” in the top line—but this went unnoticed in the stressful
situation.
In fact, all manufacturers of monitors/defibrillators equipped with an
external pacemaker recommend that an ECG is also necessary for the
pacemaker function. In principle, pacing could also be carried out
exclusively via the multifunction electrodes on some devices, but then an
ECG derivation without any detection of the patient’s own frequency
with a rigid pacemaker frequency in the VOO or non-demand or fixed
frequency mode. This is hardly used today and should only be used in
extreme emergencies, e.g. when there is no ECG. So if we hadn’t had
another pacemaker available, we could have switched to the rigid VOO
or non-demand or fixed frequency mode until our problem was clarified.
Some devices even switch to this emergency mode automatically if the
ECG fails, but then have to be switched on again. But this would only be
the purely technical solution to a problem that was actually quite
different and basically avoidable [2].
The actual “turning point” was somewhere else entirely—namely,
the early extinguished attention to the patient due to other, in this case
personally motivated priorities after the supposedly completed transfer
 [3]. This was completed orally, but by no means carried out. In fact, this
is a phenomenon that can regularly be observed not only after reaching
the emergency room, but also during transfers to the intensive care unit:
you have finally reached the supposedly safe environment with sufficient
and competent support. Then, in addition to the oral transfer, the
monitoring or the infusion pump is hung up in parallel by several people
and the patient experiences a longer monitoring break and possibly also
a therapy interruption, e.g. of sedatives or even worse of catecholamines.
If monitoring is started again, the patient has deteriorated due to the
unnoticed and unmonitored therapy interruption (e.g. too awake due to
lack of sedation or hypotonic due to insufficient catecholamine infusion)
[4]. The taking over colleagues roll their eyes and take over the therapy
stressed, while the EMS colleague loudly assures “But the patient was
stable until just now!”, Which is probably true, but now no one is
interested or helpful anymore.

31.1 Conclusion
On the one hand, this case showed me once again that one must first get to
know the devices with which one works, including their quirks or “pitfalls”,
and that one must become familiar not only with their function, but also
with the error messages and possibilities (this also includes considering
possible “trouble-shoot” scenarios). On the other hand, it was once again
made clear to me that the patient is not automatically safe when he or she
reaches the emergency room, but that, on the contrary, the handover must
be considered a high-risk situation for the patient. Therefore, in addition to
a structured oral handover, what is needed above all is attentive and critical
accompaniment of the actual patient transfer (repositioning, monitoring,
infusion pump therapy, ventilation, etc.). Only when this is completed may
the patient be considered “handed over” safely and the responsibility for the
patient may be handed over to the emergency room team. Ideally, this is
communicated loudly and clearly to all involved: “The handover is
complete.” or “Your patient!”

References
1. Koppenberg J, von Hintzenstern U (2020) Risikomanagement im Notarztdienst. In:
Notarztleitfaden, 9th edn. Urban und Fischer Verlag, München

2. Scholz J, Sefrin P, Böttiger BW et al (2013) Notfallmedizin, 3rd edn. Georg Thieme Verlag,
Stuttgart

3. Lendemans S (2012) Interfaces in emergency medicine. Exemplified by treatment of the severely

injured. Notf Rettungsmed 15:300–304
[Crossref]

4. Siebert R (2009) Strukturierte Patientenübergabe. Star. Life 2:17–21

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_32

32. Serious Kick Injury

Frank Marx1
(1) Intensive Care Helicopter Christoph Giessen, Malteser Hilfsdienst
Diözese Münster, Giessen/Münster, Germany

Frank Marx
Email: [email protected]

Providing emergency care to patients who are very young often poses a
special challenge for rescue workers. And, as this case shows, it is once
again necessary to weigh very carefully which subsequent steps might be
the right ones.

On a warm autumn day, shortly before we sign off at dusk, we receive a

call from a hospital in basic and regular care, located about 15 min flight
time away, while we are on duty at the EMS helicopter “Christoph 9” in the
city of Duisburg. A 10-year-old child has fallen off a horse and then the
horse hit the child’s chest with a hoof; the child is unstable and has
difficulty breathing. 2 min after the alarm, our EMS helicopter takes off to
transport the child to a university hospital. We reach the destination area a
short time later and are then driven to the hospital, which is only a few
hundred metres away, in an ambulance with our equipment. In the
emergency department, surgeons, anaesthetists and nursing staff are caring
for the apparently seriously injured child. The chest X-ray shows a
haemopneumothorax, which has been relieved by chest drains on the left
and right; in addition, there is a suspicion of an aneurysmatic injury to
blood vessels near the heart. Only small amounts of blood are draining into
the drainage bags via both chest drains. Intravenous anaesthesia is being
maintained via peripheral venous accesses. In the language of traumatology,
the child therefore has a B and a C problem, because mechanical ventilation
requires peak pressures of 50 cm H2O in order to enable ventilation, and
circulation is unstable—only with norepinephrine can a blood pressure of
90 mmHg systolic be achieved. The child has a cyanotic skin colour and the
pulse oximetric oxygen saturation is barely 80% with ventilation using
100% oxygen. The check of the tube position and the chest drains shows a
correct position and yet the pulmonary situation is dramatically bad, despite
suction of the airways. A transoesophageal echo or computed tomogram is
not available. Objectively, the child is not transportable, but the therapy
options in the small hospital have been exhausted and correctly carried out.
Therefore, I decide to prepare the child for transport to the helicopter.
The child is transferred to our helicopter stretcher and I ventilate it with
a breathing bag to which a demand valve is connected, so that I ventilate
with pure oxygen. Before take-off, I call the emergency coordinator at the
university hospital and notify the child again, which was already registered
by the surgical department of the smaller hospital. In the dusk we then take
off for the university hospital, which is about 22 min flying time away. I
have initially connected the patient to the ventilator in the helicopter.
However, high peak pressures and a pulse oximetric oxygen saturation of
<70% show to me that I cannot ventilate the child in this way. I paralyze the
child again, deepen intravenous anesthesia and change the ventilation
parameters several times on the ventilator. However, no change in settings
leads to the desired success and I long for the end of the flight because I
feel that the situation is deteriorating from minute to minute. There is
indeed an arterial pressure measurement, but I cannot achieve a satisfactory
signal, which is probably due to vibrations in the helicopter. With the non-
invasive blood pressure measurement, I cannot achieve any measurements,
the device is constantly measuring, but no results are displayed. I cannot
feel a peripheral pulse and I guess a pulse on the A. carotis more than I
really feel it. The ECG shows a tachycardic sinus rhythm and the pulse
oximetry indicates with a value of about 70% and minimal pulse waves on
the monitor that the child actually still has circulation. In capnography, I
measure values above 60 mmHg, which supports this assumption. I now set
the norepinephrine in the perfusion pump even higher, without really being
able to measure an exact systolic blood pressure. Finally, I disconnect the
child from the ventilator and ventilate it manually as on the transport to the
helicopter. This is difficult for me because I have the impression that I can
hardly transport air into the lungs. The ventilation pressures are maximally
high and I am far from being able to offer the child a “laminar” air flow.
And yet my manual ventilation seems to work better than ventilation with
the ventilator, because the pulse oximetric oxygen saturation rises again to
values around 80%. So we fly into the dusk and, as planned, reach the
university hospital after what seems like an endless 22 min. Usually it takes
2 or 3 min from landing to unloading the patient, because the engines of the
EMS helicopter are supposed to cool down in idle mode in order to reduce
engine wear. In this case, however, I ask the pilot to shut down the engines
immediately. The rotor blades have not yet come to a standstill when the
paramedic already gets out and prepares to unload the child. The transport
of the stretcher by elevator to the emergency room of the university hospital
takes me agonizingly long. The child is still cyanotic, the skin marbled and
there is no talk of reasonable cardiorespiratory values. Only capnometry
shows high end-tidal carbon dioxide values, which makes me somewhat
confident. Pulse oximetrically, I no longer get any signals in the elevator; I
have the feeling that the 10-year-old girl is now dying.
Although I am experienced in the care of emergency patients, I am
nevertheless glad that I can hand over the child in the emergency room;
after a short examination, the child is taken to the operating room and a
thoracotomy is performed. Intraoperatively, there is an injury of several
bronchial branches and a large pericardial effusion is relieved. Several ribs
are fractured near the sternum. However, an aneurysmatic injury of large
vessels, as we suspected from the chest X-ray, is not present.
Postoperatively, the child recovers quickly in the next few days. 20 days
after the accident, it is transferred to the home hospital and 10 days later
discharged home; a longer rehabilitation phase follows and eventually the
child makes a full recovery.

Discussion
Injuries of children under 15 years of age while handling horses are
probably underestimated, but caused 13,000 admissions per year in US
emergency departments in one study. The Injury Severity Score was
higher compared to other injury mechanisms, but only in pedestrians hit
by cars [1]. Horses can weigh several hundred kg, run up to 50 km/h (31
mph) and suddenly change their running direction or react startledly to
noise—all factors that favor a fall. However, regardless of a fall from a
horse, additional hip injuries can be very serious, causing severe facial or
head injuries [2], cardiac rupture [3] and, as in our case, severe thoracic
trauma [4].
Only cardiorespiratory stable patients should be transported with an
EMS helicopter to avoid elaborate or impossible measures during
transport in the aircraft. Accordingly, one should treat cardiorespiratory
unstable patients thoroughly before air transport to spare the helicopter
crew coping with precarious situations with difficult conditions during
the flight. However, when we stood in the emergency department of the
small hospital and this severely injured child was lying in front of us, I
came to the conviction that there was no further treatment option on site.
The child was, according to Powell et al. [5], in a situation in which a
delayed transport to a trauma center and thus a delayed causal therapy
makes survival less likely. Especially a transport with an EMS helicopter
can help in such a situation to gain life-saving time in a severe thoracic
trauma, for example, to enable only at a trauma center possible treatment
options such as extracorporeal membrane oxygenation [6].
The chest injuries suggested that serious intrathoracic injuries had
led to a tension pneumothorax, but since the two thoracic drains were
properly placed and radiologically controlled, I did not know of any
other approach to improve the pulmonary situation. The circulatory
situation deteriorated increasingly after my arrival at the referring
hospital and it might actually have been an option to perform a
pericardial puncture—but due to the lack of imaging possibilities this
diagnosis could not be made. However, the problem with such punctures
is that it is usually not possible to achieve sufficient relief by blood
clotting in the pericardium in most cases. Paramedics of the London Air
Ambulance have been able to save 11 patients with subsequent good
neurological outcome in a total of 71 cases of pre-hospital circulatory
collapse after trauma by thoracotomy directly at the accident site; in each
of these cases a pericardial tamponade was evacuated. [7]. But our little
patient had no circulatory arrest and I would not have dared to take such
drastic measures without prior training—even for surgeons this measure
is a rare challenge and a high decision hurdle.
What makes such an intervention an event that one will never forget?
In this case it was a very moving letter that I received months later from
 the patient and her mother, accompanied by an invitation to visit her.
And when I did that later, I met a completely healthy, now 11-year-old
girl who was physically and mentally fully capable and had no memory
whatsoever of the accident, the dramatic hours and the strenuous days
afterwards. How nice if you can say that as a patient.

32.1 Conclusion
Horse riding accidents can be extremely dangerous. A thoracic trauma can
take a dramatic course due to the simultaneous influence on the lung and
cardiac function. The decision between stabilization on site and rapid
transfer to a trauma center must be weighed carefully in each individual
case.

References
1. Jagodzinski T, DeMuri GP (2005) Horse-related injuries in children: a review. WMJ 104:50–54
[PubMed]

2. Exadaktylos AK, Eggli S, Inden P, Zimmermann H (2002) Hoof kick injuries in unmounted
equestrians. Improving accident analysis and prevention by introducing an accident and
emergency based relational database. Emerg Med J 19:573–575
[Crossref][PubMed][PubMedCentral]

3. Alami A, Slaoui A, Drissi-Kacemi A, Maazouzi W (2003) Right atrial rupture following a hoof
kick to the chest wall. J Cardiovasc Surg (Torino) 44:65–66
[PubMed]

4. Bruck E, Stiletto R, Botel T, Gotzen L, Moosdorf R, Leppek R (1996) Blunt thoracic trauma with
aortic rupture and lung contusion caused by hoof kick in a 15-year-old girl. Diagnostic and
therapeutic management. Unfallchirurg 99:901–904
[PubMed]

5. Powell DG, Hutton K, King JK, Mark L, McLellan HM, McNab J, Mears D (1997) The impact of
a helicopter emergency medical services program on potential morbidity and mortality. Air Med J
16:48–50
[Crossref][PubMed]

6. Voelckel W, Wenzel V, Rieger M, Antretter H, Padosch S, Schobersberger W (1998) Temporary

extracorporeal membrane oxygenation in the treatment of acute traumatic lung injury. Can J
Anaesth 45:1097–1102
[Crossref][PubMed]
7.
Davies GE, Lockey DJ (2011) Thirteen survivors of prehospital thoracotomy for penetrating
trauma: a prehospital physician-performed resuscitation procedure that can yield good results. J
Trauma 70:E75–E78
[PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_33

33. Student with Heart Problems

Joachim Koppenberg1
(1) Department of Anesthesiology, Pain Therapy, and Emergency
Medicine, OSPIDAL – Center da sandà Engiadina Bassa, Scuol,
Switzerland

Joachim Koppenberg
Email: [email protected]

“Face your fears” is the motto of this case, which makes it very clear
how important it is to face up to a situation or to prepare for it
preventively if one is particularly afraid of it, but that too much
theoretical knowledge implemented can sometimes also be detrimental
to the patient and the treatment.

Each of us probably has our own medical preferences and hobbies, but
also our absolute horror scenarios of a call-out. In addition to the child
emergencies, which are certainly also the case with many other colleagues,
these were long-term patients with cardiac rhythm disorders for me. On the
one hand, one had to really understand the ECG and how it came about
here, and on the other hand, these were all patients in whom one could
make a wrong diagnosis or take the wrong measures and thus make things
worse (the classic: Isoptin in an unrecognized WPW syndrome). Since one
cannot, of course, choose the call-outs and patients in an emergency service,
I had, according to my personal motto “face your fears”, at some point
studied all the common Lown classifications and other rhythm
classifications as well as the available, mostly Greek-sounding
antiarrhythmics intensively and differentiated. So I felt well prepared and
hoped for an early call-out!
This call-out came about two months later and manifested itself in the
form of an attractive 24-year-old student in her equally attractive 4-woman
flat share. I knew that I could now reap the rewards for my intensive
preparation and efforts and appear competent and justified. The student
reported that she had been feeling an intense heart palpitation for about an
hour, which had suddenly started. She denied any pain or shortness of
breath. Since she actually wanted to go to sports with her friends, a friend
had called the emergency services to ask whether the heart problems could
be serious, which is why we were alarmed. The blood pressure was
115/65 mmHg, peripheral oxygen saturation was 99% and the 3-channel
ECG (at that time there were no 12-channel ECGs on the ambulance)
showed a regular, narrow and tachycardic rhythm with a frequency of
148/min. While I tried to insert a venous access in rather difficult vein
conditions, the further past medical history did not reveal any special
findings: Such an episode had never occurred before, no relevant previous
illnesses, no allergies, no regular medication, non-smoker, no and especially
no recent drug use, no current psychological emergency situation, no fever,
no infection, no pain—in short, everything bland. So a young, healthy
student with palpitations for an hour with a regular narrow complex
tachycardia. But she was fortunately helped—after all, I had learned my
EKG rhythm lessons and she was lucky that I was on duty today! The
patient probably saw this after the second attempt at a venous access at this
point. After the venous access was finally placed with some effort, I first
explained to her and the interested bystanders in detail and with as many
important sounding foreign terms as possible that the first step in therapy
according to the algorithm was the Valsalva maneuvers. The present ladies
were initially very impressed, but the mood tipped more towards the
ridiculous when my complex representation resulted in successive
unsuccessful massage of the neck, closed eyes, whistling and drinking of
cold water. I felt how my competence was increasingly called into question,
although I was really extremely well prepared! But of course it wasn’t over
with the medical art yet—according to the algorithm, the medicinal
measures were now used. I explained to the audience that I would now use
a very short-acting medication (adenosine) to stop the heart for a short time
—this could also cause a short feeling of tightness in the patient’s chest. But
the patient really shouldn’t worry, because the heart “jumps” again and
again on its own and I would rather not speak of a short “asystole”, but
rather of a “pre-systolic pause”—this would sound much more hopeful! In
addition, we of course also had all the equipment for necessary advanced
resuscitation measures including artificial ventilation and defibrillation—so
nothing could go wrong. The cheerfulness in the room disappeared abruptly
and I could be sure of the respect of the audience again. After I had
discussed the procedure with the paramedics and checked all the equipment
again for their functioning, I therefore injected 6 mg adenosine
intravenously in a bolus and immediately flushed with the infusion. The
EKG rhythm became slower and slower and, as expected, the patient briefly
rolled her eyes and then, yes, then the heart jumped back into a sinus
rhythm with a frequency of 78/min. I had done it! There was great relief
among all those involved in the room and so there was no objection that we
would take the stable patient to the nearby emergency room of the city
hospital for further clarification. During the journey, the patient thanked me
several times for the successful treatment.
When I arrived at the hospital, I proudly demanded the on-call
cardiologist for the handover, after all, I also wanted to get the knight’s
accolade from the clinician. When he appeared reluctantly and I told him
the course and of my successful treatment, he remained silent until the end.
When I was done with my detailed and algorithm-based explanations and
waiting for the hymn of praise for the cured patient who was admitted to the
emergency room, he looked long at the 12-channel ECG that was just being
written in the emergency room and then turned to me: “And what did the
patient have?” I am confused and answer: “A regular, narrow complex
tachycardia—I said that already.” “Yes, but what was the cause? The
current 12-channel ECG is completely unimpressive—did you write a 12-
channel ECG before the measures to find the cause?” Now I realized that
the man had no idea of pre-hospital emergency medicine! “As you should
know, we don’t have a 12-channel ECG on the ambulance,” I replied
already somewhat unfriendly. “So, so” said the cardiologist in a paternal
tone “then you can just as well take the patient home again and we all wait
until she has such an event again and then hopefully an emergency
physician is called who either doesn’t know what to do in such a case or
knows it very well, but realizes that you don’t need to treat and endanger a
stable patient unnecessarily in the living room and thus screw up our
diagnostics at the same time! Have a nice day.”—and he was gone. I stood
there like a drowned poodle and couldn’t understand what he wanted to say
to me at all. Fortunately, an internal medicine emergency room resident
took pity on me and took over the patient, who in turn did not fail to thank
me again for the extremely competent help.

Discussion
It really took me a few days and several conversations to slowly admit to
myself how right the cardiologist was. But I only meant well—but “well-
intentioned” is not good enough for our patients. First of all, it is
certainly still not reprehensible to deal with the things one is afraid of
(“face your fears”) or to acquire in-depth knowledge, as in this specific
case with regard to ECG rhythm disorders and their therapy. However, in
emergency medicine, one must not automatically use what has been
learned everywhere and at all times, but always take into account the
external circumstances and use the knowledge accordingly
differentiated. First of all, I should have clearly stated from the outset
that the student was always cardiopulmonary stable and at no time vital
and thus not necessarily in need of treatment in her apartment. This is
what the guidelines of the American Heart Association and the European
Resuscitation Council agree on for this purpose, that in the case of stable
narrow complex tachycardias, a 12-channel ECG should be made first
for the purpose of diagnosis, which we did not have at that time on the
ambulance or physician-manned ambulance. After that, one should
weigh up very well whether one has to initiate a therapy at all, since each
of them can also act proarrhythmically and clinically worsen the
previously stable situation. Therefore, consultation of an expert is
recommended if possible—in our case the cardiologist in the emergency
room. Despite the knowledge of what would actually be done, I should
have simply monitored the patient, inserted an intravenous access and
brought her to the next emergency room—no more, but also no less.
Although it is certainly more difficult to omit something that one knows
or masters than if one has great respect for it. So it was great luck that
the medication therapy initiated in a spectacular way in the living room
was successful and the patient was not put into an unnecessary extreme
situation or endangered by my “too much knowledge”.
 Of course, one could argue whether one could not try the “harmless”
vagus or Valsalva maneuvers in the apartment nevertheless. Here the
second legitimate criticism of the cardiologist comes into play: Even if
these maneuvers are successful in up to 25%, we would still not know
what was the cause of the rhythm disorders (differential diagnosis in this
case: sinus tachycardia, AV node reentry tachycardia, atrioventricular
reentry tachycardias due to WPW syndrome, atrial flutter with regular
AV conduction, focal atrial tachycardia) and whether the patient needed
further clarification or therapy before the therapy. Therefore, one should
only initiate the therapy in stable patients if one has a diagnosis or has
written a 12-channel ECG for later evaluation. In addition, a 12-channel
ECG must be connected during the therapy measures, as some rhythm
disorders can only be safely identified in the phase of unmasking. Of
course, this procedure is only recommended for cardiopulmonary stable
patients. If the patient is or becomes unstable, a medical or electrical
therapy (cardioversion) must be initiated immediately according to
guidelines. But then it is the case that the patient or his condition forces
us to an immediate therapy. The decisive factor is therefore that we
always treat the patients as a whole and never just an atypical ECG
picture, even if we can interpret it correctly!

33.1 Conclusion
This case led me for the first time in my career as an emergency physician
to the realization that even the renunciation of treatment in the interest of
the patient can be right and often “less is more”. Our performance is not
always measured by the number of actions. This is—to be honest—not easy
to control, because we are usually (especially emergency) medicine strong
action- and impulse-triggered and the perceived quality of our work often
correlates with the number of measures taken. But we must never only treat
individual values or ECG images, but always look at and treat our patients
as a whole. And this even when a much younger colleague in the
emergency room indirectly suggests ignorance to us later, because we
would have treated this obvious symptom long ago! Finally, it should be
emphasized once again that it is not bad to deal intensively with the things
that scare us, according to the motto “face your fears”.
Further Reading
1. Deakin CD, Nolan JP, Soar J et al (2010) Advanced life support for adults. Notfall Rettungsmed
13:559–620
[Crossref]

2. Neumar RW, Otto CW, Link MS et al (2010) Part 8: adult advanced cardiovascular life support.
Circulation 11(suppl 3):729–767

3. Soar J, Böttiger BW, Carli P, Couper K, Deakin CD, Djärv T, Lott C, Olasveengen T, Paal P,
Pellis T, Perkins GD, Sandroni C, Nolan JP. European Resuscitation Council Guidelines 2021:
Adult advanced life support. Resuscitation. 2021 Apr; 161:115–151. https://doi.org/10.1016/j.
resuscitation.2021.02.010. Epub 2021 Mar 24. Erratum in: Resuscitation. 2021 Oct; 167:105–106.
PMID: 33773825.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_34

34. Fall While Downhill Mountainbiking

Martin Messelken1
(1) Bad Boll, Germany

Martin Messelken
Email: [email protected]

In this case, it is about a call to an outdoor application and the associated

adverse conditions found there, which are partly compensated by
personal commitment and improvisation of the respective teams, in order
to achieve a good result for the patients

The emergency call for the EMS helicopter is: “Mountain biker fallen in
forest; exact coordinates still to be determined”. Just under 2 min later, the
EMS helicopter is in the air for a 12-minute approach. The visibility on this
late summer morning is not restricted. The target area turns out to be a
densely wooded slope of a contiguous forest, no signals or people in need
of help can be seen. After the 3rd flyover, the pilot discovers a sight-seeing
platform on the slope that fits the specified target location precisely from
the control center. “Can you jump down if I only land with a skid on the
railing of the sight-seeing platform?” asks the pilot. I agree and get ready to
exit with the large emergency backpack. Much faster than I thought, I am
alone on the platform and my EMS helicopter has flown away without the
option to land—so I am alone, without a radio and cut off from
communication, as there is no mobile phone signal at all. Fortunately, a
cyclist emerges from the forest and leads me to his injured comrade. The
25-year-old cyclist had underestimated a jump hill while riding downhill,
lost control of his mountain bike and crashed heavily on his buttocks and
back; but he was conscious all the time. Except for painful bruises, nothing
serious was found during the cranio-caudal body check (ABCDE). I put on
a neck brace, prepared an infusion, injected 0.1 mg fentanyl intravenously
and was glad when two paramedics arrived a few minutes later—their
ambulance is 500 m (547 yards) away on a forest path. With their radio we
can contact the EMS helicopter; due to the circumstances of the accident,
we decide to transport the patient to the ambulance with a Spineboard via
the narrow forest path. The four of us should be able to do that. When I
look at the unlucky bike, I notice a Garmin outdoor navigation device on its
handlebars and ask: “Why didn’t you give us the GPS coordinates of the
accident site? You can read them there. We could have found you faster.”
“Actually, that’s right,” was the answer, “but how does that work?” The
ambulance transports us with the patient to the EMS helicopter landing site
in an industrial area; there we unload the injured and fly to the next trauma
surgery emergency room. This is routine.

Discussion
After this call, there was, of course, a lot to discuss. This was mainly due
to the explicit absence of a preparing and the abrupt team separation.
This was associated with a critical restriction of communication means
and therapy options. Fortunately, this did not turn out to be a specific
disadvantage, as our patient was not seriously injured—but it could have
been quite different. As a consequence of this incident, a few days later a
small, easy-to-handle backpack for mobile first aid was equipped and
carried along to begin initial cardiorespiratory therapy and monitoring in
such cases with a self-inflating ventilation bag, intubation material,
venous access and infusion, pulse oximeter and blood pressure
measurement (anesthetics are always carried along personally anyway) .
Mountain bikers often have accidents in inaccessible terrain due to
self-induced falls. The accident risks are comparable to those of alpine
skiing [1]. The timely alarm of the EMS, the determination and reaching
of the accident site often take place under non-regular conditions—all
deviations are due to an Outdoorsituation and life-threatening is not
necessarily compatible. Nevertheless, fatal accidents are rather rare. The
outdoor navigation wearables carried along in many cases provide GPS
coordinates at the touch of a button. If the mountain bikers had
familiarized themselves with the function before and transmit this data to
 the EMS control center, valuable time can be saved in the search for the
intervention site. This can be life-saving in particular if hypothermia sets
in and a search for the possibly single-track victim at night is difficult
and time-consuming. In some communities, such as Innsbruck, Austria,
the EMS control center even provides a free app for smartphones with
which you can extremely accurately inform the rescue workers of your
own location after turning on the GPS function.

34.1 Conclusion
The description of my unforgettable emergency interventions represents
only a small part of the spectrum of an emergency physician active for over
3 decades [2]. With a view to the limited treatment options of earlier years,
special attention is paid to structural weaknesses which were partly
compensated by the personal commitment and improvisation of the
respective teams in order to achieve a good result for the patients. The
medical and operational documentation in connection with intensive data
analysis has been further developed since then and led, via applied quality
management, to measurable improvement of the result quality in many
cases [3]. The rapidly developing information technology was a constant
companion—so at the beginning of my work as an emergency physician we
did not even have a pulse oximeter and 30 years later GPS-supported
interventions were possible.

References
1. Armold M (2005) Mountainbiken. Orthopade 5:405–410
[Crossref]

2. Bernhard M et al (2006) Spectrum of patients in prehospital emergency services. What has

changed over the last 20 years? Anaesthesist 55(11):1157–1165

3. Messelken M et al (2010) The quality of emergency medical care in Baden-Wurttemberg

(Germany): four years in focus. Dtsch Arztebl Int 107(30):523–530
[PubMed][PubMedCentral]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_35

35. Serious Head Injury

Peter Hilbert-Carius1
(1) Department of Anesthesiology, Intensive Care, and Emergency
Medicine, BG Trauma Hospital Bergmannstrost, Halle / Saale,
Germany

Peter Hilbert-Carius
Email: [email protected]

What to do when several problems have to be solved at the same time?

Where to start, where to continue, where to stop? In this case, many
problems come together that the rescue and emergency room team have
to master.

The emergency room team of a regional trauma center is informed by

the EMS control center that a severe open head trauma will arrive in about
10 min. In addition, it is transmitted that the patient is being ventilated. A
short time later, about 2 min before the patient arrives, the EMS control
center receives another information that the patient is now undergoing
cardiopulmonary resuscitation (CPR) and will reach the hospital within a
few minutes. Shortly thereafter, the patient arrives in an ambulance with an
emergency physician and is received by the emergency room team at the
ambulance. CPR of a patient with asystole is ongoing. The airway is
secured with a laryngeal mask, but no thoracic excursions are visible during
CPR during ventilation; an end-expiratory CO2 measurement is not
connected. The patient is then transported to the emergency room with
ongoing CPR. As part of a first quick Primary Survey according to ATLS®,
the following problems quickly become apparent:
 A (Airway)—secured by means of a laryngeal mask, but no ventilation is
possible;
B (Breathing)—no ventilation of the lungs on both sides;
C (Circulation)— circulatory arrest with asystole;
D (Disability)—GCS 3, pupils on both sides wide without light reaction;
E (Exposure/Environment)—ongoing CPR, right frontal head injury, no
other signs of injury.
There are therefore several serious problems, so that first an attempt is
made to solve the problem with the highest priority, the A-problem. For this
purpose, the laryngeal mask is removed and the patient is intubated with
direct laryngoscopy, which succeeds without problems on the first attempt.
After intubation, the tube position is checked by auscultation and equal-
sided respiratory sounds and parallel good visible thoracic excursion as well
as expiratory CO2 of 18 mmHg is recorded during ongoing CPR. It has thus
been possible to solve the existing A and B problems, but circulatory arrest
is still present. With continuation of CPR and after the second injection of
1 mg epinephrine intravenously, ventricular action is first seen on the ECG,
which converts to sinus rhythm after a short time. The end-expiratory CO2
rises to values of 80 mmHg and a carotid pulse is palpable. With a
continuation of a low-dose catecholamine therapy with 0.01 µg/kg/min
norepinephrine, circulation remains stable in the further course. Then a re-
evaluation of the condition is carried out with the following result:
A – intubated ventilated, correct tube position;
B – lungs ventilated on both sides, peripheral oxygen saturation of 100%
with FiO2 of 1.0;
C – circulation stable with low noradrenaline requirement (blood
pressure 115/85 mmHg, heart rate 106/min);
D – GCS 3, pupils still dilated on both sides without light reaction;
E – known head injury.
In the blood gas analysis, severe combined acidosis with pronounced
respiratory and only minor metabolic component is shown, which is slowly
compensated by adjustment of ventilation. In the whole-body CT, in
addition to the known head injury, no further injuries are visible. The
following past medical history of the accident is to be learned from the
emergency physician: The patient was an inmate of a penal institution and a
known epileptic. He probably had another attack today and fallen in the
process, injuring his head. When the emergency physician arrived, the
patient was somnolent and had a Glasgow Coma Scale of 8. Due to the
suspected head injury and the Glasgow Coma Scale of 8, an indication for
intubation was made. After induction of anesthesia, intubation was not
possible in several attempts, so that a laryngeal mask was used as an
alternative strategy. With this, the patient’s ventilation was initially possible
and, under the suspicion of a severe open head injury, transport to a regional
trauma center was initiated. On the way there, ventilation problems
occurred at first and, in the further course, cardiac arrest with the need for
resuscitation. After completion of the diagnosis and treatment of the patient
with all necessary invasive lines, he is transferred to the intensive care unit,
treated there for 24 h by means of hypothermia and then slowly rewarmed.
Despite these measures, the patient only wakes up very delayed and is
transferred to a rehabilitation hospital after 3 weeks with a pronounced
neurological damage.

Discussion
The case demonstrates how a chain of unfortunate circumstances and
decisions can lead to deleterious consequences that would most likely
have been completely avoidable. First, the patient, known to be an
epileptic, has a seizure and falls. This is not entirely atypical, and that
one might sustain a head injury in such a fall does not seem so unusual.
The postictal somnolence that often follows most seizures, which can
vary greatly in length and intensity, is then of course difficult to
interpret. The somnolence of the patient was probably more likely seen
by the emergency physician as a result of the supposed head trauma and
the possibility of a postictal state considered less likely. Consequently,
the decision to intubate, which should be done according to various
guidelines in the event of a head trauma with a Glasgow Coma Scale of
≤8 [1, 2], was the logical consequence. Unfortunately, conventional
intubation also failed outside of the hospital in several attempts, so that a
laryngeal mask was used. This strategy was initially also successful and
the patient could be ventilated and oxygenated with the laryngeal mask.
The chosen approach after failed intubation to switch to a supraglottic
airway such as the laryngeal mask is in line with current
recommendations for prehospital airway management [3] and proved to
be initially practicable. Regardless of the initial successful use of the
laryngeal mask, problems can also occur when using supraglottic airway
devices. Some of the most important problems are only mentioned here
by way of example: airway obstruction by dislocation, aspiration, gastric
distension, hypoventilation, injuries (bleeding, tongue swelling), and
unnoticed dislocation. An interesting case series of possible problems
with the supraglottic airway alternative laryngeal tube was described by
Bernhard et al. in a publication that can only be recommended to the
interested reader [4].
Apparently, a problem occurred during transport that made
ventilation more difficult and eventually impossible. Since this problem
was obviously not recognized or eliminated, there was pronounced
hypoventilation and hypoxia with subsequent cardiac arrest in the further
course of the transport. The fact that a paCO2 of 80 mmHg (10.6 kPa)
was present in the blood gas analysis taken shortly after elimination of
this problem clearly demonstrates the hypoventilation. Ultimately,
problems with ventilation led to the catastrophic outcome of this case.
Therefore, clinical control (inspection, percussion, auscultation), pulse
oximetry and capnometry/-graphy as well as the control of volumes and
airway pressures must be demanded as EMS basic measures for
monitoring ventilation. The fact that diagnostics, with the exception of
the already pre-hospital visible head injury, did not reveal any trauma
consequences makes the case even more tragic, since ultimately
misinterpretation of a postictal drowsy state after seizure was responsible
for the subsequent events. Ultimately, however, misinterpretation could
have remained without negative consequences for the patient if the
problems that had occurred in the pre-hospital course had been
recognized and treated adequately as part of airway management and
mechanical ventilation. Therefore, it can only be appealed again and
again that every colleague working in emergency and intensive medicine
intensively deals with the topic airway management and ventilation and
anticipates possible problems in advance [5].

35.1 Conclusion
An important aspect that should be emphasized is the fact that after the
supposed solution of a problem (here securing of the airway), one must re-
evaluate in the further course whether the problem has really been solved or
remains and whether perhaps a new problem has arisen. This re-evaluation
is a basic pillar of ATLS® (Advanced Trauma Life Support) and PHTLS®
(Prehospital Trauma Life Support), which in the context of trauma care
suggest a priority-oriented approach according to the A, B, C, D, E scheme
[6, 7]. If there are several problems at the same time (see above), the one
with the highest priority, in our case the A (Airway) problem, is solved
before the other problems are addressed. In line with the principle “Treat
first what kills first”. Under early consideration of the basics and principles
of ATLS®/PHTLS®, which are actually nothing more than well-known
basics of emergency medicine, a re-evaluation of supposedly solved
problems in the described case would have quickly made it clear that the
unsolved A-problem ultimately led to the need for resuscitation and not the
“open head injury”.

References
1. Deutsche Gesellschaft für Unfallchirurgie e. V. (DGU) (2011) Polytrauma/Schwerverletzten-
Behandlung. AWMF-Register Nr. 012/019 Klasse: S3

2. Donaubauer B, Fakler J, Gries A, Kaisers UX, Josten C, Bernhard M (2014) Interdisciplinary

management of trauma patients: update 3 years after implementation of the S3 guidelines on
treatment of patients with severe and multiple injuries. Anaesthesist 63:852–864
[Crossref][PubMed]

3. Timmermann A, Byhahn C, Wenzel V et al (2012) Handlungsempfehlung für das präklinische

Atemwegsmanagement. Für Notärzte und Rettungsdienstpersonal. Anästh Intensivmed 53:294–
308

4. Bernhard M, Beres W, Timmermann A et al (2014) Prehospital airway management using the

laryngeal tube: an emergency department point of view. Anaesthesist 63:589–596
[Crossref][PubMed]

5. Bernhard M, Bein B, Böttiger BW, Bohn A, Fischer M, Gräsner JT, Hinkelbein J, Kill C, Lott C,
Popp E, Roessler M, Schaumberg A, Wenzel V, Hossfeld B (2015) Handlungsempfehlung zur
prähospitalen Notfallnarkose beim Erwachsenen. Anästh Intensivmed 56:317–335

6. Helm M, Kulla M, Lampl L (2007) Advanced trauma life support(R): a training concept also for
Europe. Anaesthesist 56:1142–1146
[Crossref][PubMed]
7.
Thies KC, Nagele P (2007) Advanced trauma life support(R) – a standard of care for Germany?:
no substantial improvement of care can be expected. Anaesthesist 56:1147–1154
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_36

36. A Nearly Deadly Tea

Hermann Brugger1
(1) EURAC Research, Bozen, Italy, Institute of Mountain Emergency
Medicine, Bozen, Italy

Hermann Brugger
Email: [email protected]

Intoxications present the emergency medical team with a difficult task: is

the intoxication source known? And if so, is there an antidote? In this
case, it is also about the resource question and how to act as effectively
as possible with the few options that are available.

Half of the Pustertal valley in South Tyrol, Italy lives of one ski
mountain. The Kronplatz, centrally located between primeval rock and the
Dolomites, stretches its white tentacles in all directions in winter. In the
north and east they reach to Bruneck and Olang, in the south to the
municipality of Enneberg with the village of St. Vigil. In this region, new
lifts, hotels, guesthouses and whole new settlements sprang up. During the
ski season, all houses are booked up, the skiers are during the day on the
mountain and in the evening in restaurants and nightclubs. High season is
also for the EMS, which shuttle 24 h a day between the holiday resorts and
the district hospital Bruneck.
In the off-season spring and autumn, however, there is lonely peace
here. This affects the restaurants and hotels, but also brings us emergency
physicians a breather; the absolute low point of the statistics is the month of
November. The ski season has not yet begun and hoteliers and restaurant
operators are lying on the beaches in the south or in the mud of the Abano
thermal baths; only a few remain. So it is quite possible that you can sleep
through the night in the emergency service. Quite different on this Monday.
At 2:00 am the alarm rings. Medical emergency, deployment location in a
small village. We start in the physician-manned ambulance, inquire on the
way for further details and learn that the local EMS is already on site with
an ambulance with a driver and paramedic and has found 3 unconscious
youths in a new settlement. According to the information of the first
arriving paramedics, all 3 affected persons have spontaneous respiration. I
give the first instructions over the radio: stable side-lying, observation,
exploration of the environment. After about 30 min drive through the
narrow valley we arrive. The settlement, indeed the whole village is
deserted, light is only visible in the affected apartment. When I enter this
with my paramedic, the following picture presents itself: 2 male youths lie
motionless in the kitchen, another female person in the living room, all on
the floor, brought into stable side-lying by the local paramedics. At the first
vital check I can determine a carotid pulse and spontaneous respiration in
all, but only the girl reacts specifically to pain stimuli, makes
incomprehensible sounds and opens her eyes on request (Glasgow Coma
Scale 11). The two boys show an uncoordinated pain response and open
their eyes to pain stimuli, but one of the two has no verbal response
(Glasgow Coma Scale 9 and 6), while he only breathes flat and irregularly.
Systolic blood pressure is around 100 mmHg in all, oxygen saturation is
97% in the girl, 88 and 90% in the boys. In all of them we notice wide light-
fixed pupils.
Now several questions arise: can and should I secure the airways of
these unconscious young patients for transport in several vehicles? A phone
call to the EMS dispatch center makes it clear that a second emergency
physician is not available; per EMS vehicle, only one patient can be
transported lying down. If I intubate 2 patients, the paramedic in the EMS
vehicle would have to take care of an intubated patient alone, which I do
not want to burden them with. An intubation and mechanical ventilation of
all 3 patients is therefore not an option, not only because of the lack of
personnel, but also because of the lack of a additional ventilators. I
therefore request another ambulance with oxygen and monitor.
The second question is at least as urgent as the first: what happened that
3 young people are suddenly deeply unconscious? None of them smells of
alcohol, a metabolic cause is unlikely in view of the simultaneous onset of
unconsciousness, the blood sugar test is normal in all of them, there is no
indication of a gas leak such as carbon monoxide. An external agent is more
than likely and the wide pupils make us think of an intoxication. I first
decide to anesthetize the worst of the 3 young people with a muscle relaxant
and propofol with the assistance of my experienced paramedic, intubate and
mechanically ventilate him. All 3 young people are monitored and provided
with an intravenous access. I send my paramedic to the second boy with the
request to continuously observe breathing, pulse and oxygen saturation and
to immediately notify me of any deterioration. I send another paramedic to
the girl for monitoring. At the same time, I ask the two paramedics of the
ambulance to search the apartment for drugs, suspicious food or medication
residues and to find possible witnesses in the neighborhood who may have
observed something. However, the search for suspicious substances remains
unsuccessful. After a while, one of the two paramedics comes back with a
housemate who has remained indifferent and unnoticed in his apartment so
far and says: “I only know one of the two boys; the parents are on vacation
and, as far as I know, unreachable, I don’t know the other two.” However,
he draws our attention to the fact that the trio has met here several times. He
has observed that they have been busy with flowers on the balcony several
times. Now we only notice that there is an empty teapot and half-full cups
on the kitchen table. One of the paramedics goes to the balcony and
immediately comes back with a funnel-shaped light yellow flower and the
triumphant exclamation: “Angel trumpet!” Now we also notice leaf residues
on the kitchen table. Maybe there is a plant poisoning? I know that angel
trumpets are poisonous, but I don’t know the effect. Well, I think, we know
what it is most likely, now we can prepare for transport. After a short
discussion with the paramedics and the driver of the physician-manned
ambulance, we decide to divide the patients into 3 vehicles and now drive
in convoy to the hospital: the intubated patient in the physician-manned
ambulance, the second boy in the ambulance and the girl in the other
ambulance, all with monitoring and oxygen. While the girl is somnolent and
largely stable, the non-intubated boy remains unconscious. Then I call the
Poison Control Center in Vienna, Austria and inquire about the effects of
angel trumpets and an antidote; they explain to me: “Angel trumpets are
highly poisonous and have an atropine-like effect; the antidote is
physostigmine intravenously 1–2 mg at 10 min intervals.” Unfortunately, I
can’t find anything like that in the ambulance.
 During the ride, my patient remains circulatory stable and I am in
constant radio contact with the other two EMS vehicles; I report our
patients to the hospital and request the antidote for the emergency room.
Shortly after arrival, we inject all 3 patients with 1 mg of physostigmine in
a short infusion and can see the condition improve after a few minutes. The
girl becomes responsive, and after repeating the dose, the second boy’s
condition also normalizes. The intubated patient remains sedated and can be
extubated the following day. 3 days later, all have left the hospital.

Discussion
Poisonings from angel’s trumpets primarily affect children and
adolescents for various reasons [1]. With small children, it can happen
due to the carelessness of the parents if leaves or flowers are taken into
the mouth and chewed. Adolescents, on the other hand, usually know
about the intoxicating effect and take plant parts intentionally; mostly in
the form of extracts as tea, by chewing plant parts, or smoking dried
leaves [2]. Extracts of the angel’s trumpet are also popular as intoxicants
among indigenous peoples of South America. In Europe, the angel’s
trumpet (Brugmansia) is an ornamental plant that is kept in gardens or as
a potted plant. All plant parts contain high concentrations (up to 0.5%) of
the poisonous alkaloids hyoscyamine and scopolamine, whose atropine-
like effects are known: 1–2 h after ingestion, there is a dose-dependent
euphoric mood, excitement, hallucinations, mydriasis, clouding of
consciousness, coma, circulatory insufficiency, and in rare cases,
circulatory failure. Aggressive actions have also been described [3], but
also long-lasting flashbacks with hallucinations. The angel’s trumpet is a
highly toxic plant with the highest natural content of alkaloids, where the
concentration in the plant parts is different and unpredictable—50 mg
can already be fatal. Therefore, uncontrolled ingestion or intake is
strongly discouraged; intravenous injection of a potent cholinergic such
as physostigmine is recommended as an antidote.
The actual problem of this intervention was less the emergency
medical treatment of intoxication than the absolute scarcity of resources
in a remote valley. Fortunately, the maximum effect of the toxin had
already been reached in all 3 patients when our EMS team arrived, so
that no deterioration occurred during transport. Otherwise, ventilation
and, in the worst case, cardiopulmonary resuscitation of several people
 would have been inevitable. I do not want to imagine what this would
have meant in practice; most likely it would have led to an EMS disaster,
since both the personnel and the equipment would have been lacking to
treat and monitor several intubation-dependent patients. First of all, it
becomes evident here how difficult the management of several
intubation-dependent patients can be in remote regions with long travel
times, especially if the situation is not evident from the beginning, but
only on site and the re-alarm of additional personnel and equipment
becomes the main problem. In our case, there was no background service
available; but even if that had been the case, the second physician would
have reached us in 30–40 min.
The following summer I returned by car from a mountain tour in the
Dolomites; I saw a man by the roadside who was hitchhiking home. I
picked up the hitchhiker, noticed that he looked familiar to me and asked
him where he was going—in fact he wanted to go to the village where I
had treated the 3. Slowly it dawned on me that he might be the intubated
boy. I asked in passing if he had been in hospital last winter? He said
spontaneously: “Yes, with a severe intoxication! I tell you—that was
terrible, I still have nightmares and I would not wish it on anyone … ”. I
said nothing and did not reveal that I was the emergency physician.

36.1 Conclusion
In patients with suspicious behavior or impaired consciousness up to coma,
one should not forget the possibility of plant poisoning. Contacting a poison
center can speed up the therapeutic effect, but of course it is of no use if the
antidote is not carried in the EMS or the intoxication is not recognized as
such. Even in non-traumatic events, it can happen that intubation-dependent
patients become multiple at the same time; in rural regions with long travel
times, this can turn into an event that is hardly manageable. Therefore, a
background service with a second physician available is particularly
important.

References
1. Francis PD, Clarke CF (1999) Angel trumpet lily poisoning in five adolescents: clinical findings
and management. J Paediatr Child Health 35(1):93–95
 [Crossref][PubMed]

2. Niess C, Schnabel A, Kauert G (1999) Angel trumpet: a poisonous garden plant as a new
addictive drug? Dtsch Med Wochenschr 124(48):1444–1447
[Crossref][PubMed]

3. Marneros A, Gutmann P, Uhlmann F (2006) Self-amputation of penis and tongue after use of
Angel’s Trumpet. Eur Arch Psychiatry Clin Neurosci 256(7):458–459
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_37

37. Abandoned Newborn

Peer G. Knacke1
(1) Department of Anesthesiology and Emergency Medicine, AMEOS
Hospitals Ostholstein, Eutin, Germany

Peer G. Knacke
Email: [email protected]

What if the patient who needs emergency care is not only a few days old,
but only a few hours old? What aspects of this treatment make it
particularly necessary for the rescue workers to think about? The present
case is very illustrative of this special situation.

Our EMS helicopter is the large Bell 212 with two rotor blades and the
therefore far audible “flapp-flapp”, which many people call the “sound of
rescue”. It is a wintery cold, but sunny November day when we are alerted
by the EMS control center. A physician-manned ambulance and an
ambulance are already on site; as an additional remark it is said that the
EMS helicopter should come without a stretcher. We discuss in the team
why this might be necessary. From a perforation injury with a large object
in our rural catchment area to the avoidance of a re-positioning or a very,
very obese patient, much is considered. But everything remains uncertain.
Further information about the mission is also not available via radio in busy
radio traffic the EMS control center. During the landing approach, the
physician-manned ambulance as well as 2 ambulances are visible on the
road, but no accident vehicle is to be seen. Near the vehicles we land, I take
our special equipment of the EMS helicopter as usual and we are curious
what awaits us.
 Then we are really surprised: In the ambulance, in addition to the first
arrived physician and two EMS assistants, an incubator is to be seen in
which a newborn lies and is ventilated with bag-mask ventilation.
Immediately our EMS helicopter technical crew member assistant is asked
to fetch the children’s emergency case. We did not expect that at all! The
physician describes that the infant had been found naked about 90 min
earlier in a garbage can at an outside temperature of −4 °C (24.8 °F). The
incubator had then been requested and brought to the scene of the accident
with the second ambulance; the request of our EMS helicopter without
stretcher had been made so that the incubator fits well into the EMS
helicopter. Our little patient is a hypotrophic appearing, mature newborn
boy. The examination shows clearly disturbed vital functions. Despite bag-
mask ventilation with oxygen and reservoir bag, there is a significant
cyanosis. The boy is completely limp, spontaneous respiration is not
detectable, nor is a pulse palpable with an EKG heart rate of 30/min. The
pupils are dilated on both sides and without light reaction, the already
determined blood sugar is at 100 mg/dl. A measurement of body
temperature is not possible because a thermometer with a measuring
possibility in the hypothermic range does not belong to the EMS equipment
at the time of the mission.
I intubate the boy with a Glasgow Coma Scale of 3 orotracheally
without problems with a tube (ID 2.5) at an insertion depth of 10 cm and
use the breathing apparatus of the incubator (Babylog®) known to me from
pediatric training for ventilation (FiO2 1.0; respiratory rate 35, maximum
ventilation pressure 20 mbar). With this, the child becomes pinker and the
heart rate rises to 45/min. Then a peripheral venous access is established on
the back of the hand, which fortunately succeeds on the first attempt. 30 μg
adrenaline and two fractionated doses of 30 μg atropine are injected via this
access. With still no palpable pulse, we infuse 10 ml HAES 6% and an
infusion of 40 ml glucose 5% with 10 ml NaCl 0.9% with 20 ml/h via a
syringe pump. Since there is still no pulse palpable, we decide to transport
the already ventilated child under thoracic compressions ground-based to a
hospital of maximum care with pediatric cardiac surgery and thus the
possibility of extracorporeal warming via a heart-lung machine. The pre-
notification “newborn resuscitation in hypothermia” is made via the EMS
control center, the estimated transport time is 20 min. With the necessary
repositioning and also during ongoing cardiopulmonary resuscitation, the
air transport proposed by the first arriving doctor offers no advantages. The
transport takes place without problems. The transfer takes place according
to the specification of the hospital directly on the pediatric intensive care
unit. There the rectal temperature measurement is 22 °C (71.6 °F). The
thoracic compressions are discontinued and the rewarming is slowly carried
out in the incubator under constant defibrillation readiness. Extracorporeal
circulation is not used for rewarming; the rewarming succeeds in the
incubator without problems. The mother immediately placed the child in the
trash can after the birth; therefore, the boy is given up for adoption. In the
clinical follow-up examinations, no neurological abnormalities can be
detected. Meanwhile, the boy lives healthy with his adoptive parents.

Discussion
The provision of deep hypothermic newborns is an absolute rarity in
emergency medical services and requires the team special skills and
knowledge. So the skills of endotracheal intubation, the establishment of
venous accesses and the administration of intraosseous cannulas can be
learned only by clinical experience as part of internships and training
courses. In addition, there are uncertainties and dangerous
miscalculations in the dosing of emergency drugs, as one can easily
miscalculate by a factor of 10 when calculating a dilution. To prevent
these problems, it is absolutely recommended to carry dosage aids for
pediatric emergencies in every pediatric emergency kit [1]. The
resuscitation recommendations for newborns from 2021 are to breathe
with room air first in the event of apnea and a heart rate <100/min with a
free airway, and to additionally perform chest compressions over the
lower third of the sternum if the heart rate is below 60/min and the lungs
are safely ventilated. Chest compressions and ventilation should be in a
ratio of 3:1 (compression frequency 120 per minute). If, despite effective
ventilation, there is no satisfactory increase in the pre-ductal pulse
oximetry-measured oxygen saturation, the oxygen concentration should
be increased [7]. In our case, we first performed chest compressions in
addition to the primary securing of ventilation in the event of persistent
low heart rate and undetectable pulse. At the time of deployment,
unfortunately, neither pre-hospital capnography nor a thermometer with
the possibility of accurate measurement was available in the
hypothermic range in the EMS. Both devices would have been very
helpful in assessing the overall situation and are now standard
equipment. The administration of HAES 6% nowadays requires a more
critical indication, buffered electrolyte solutions such as Ringer’s acetate
solution are 1st choice [2]. To avoid further cooling, newborns should be
primarily dried, wrapped in warm towels as much as possible, protected
from drafts and, if necessary, kept warm at home by existing heaters.
The first stage of hypothermia is at a core body temperature of 32 to
35 °C (89.6-95 °F) (key symptom: shivering, conscious). Between 28
and 32 °C (82.4-89.6 °F) the second stage (key symptom: no shivering,
consciousness impaired) is reached, the third stage is between 24 and
28 °C (75.2-82.4 °F) (key symptom: no shivering, unconscious, vital
signs present) and finally the fourth stage is defined by a temperature
below 24 °C (75.2 °F), in which case vital signs are usually no longer
present [3]. In adults, adolescents and children, mild hypothermia
initially leads to shivering, which subsides at lower temperatures;
especially if hypoglycemia occurs. Therefore, the absence of shivering is
considered a warning sign of deeper hypothermia. However, newborns
lack the ability to produce heat through shivering. The confirmation of
hypothermia should be carried out with a thermometer with a low
temperature range by rectal, esophageal or tympanic measurement. In
case of severe hypothermia, neither adrenaline nor other medications
should be administered according to today’s data until the patient has
been warmed to a core body temperature of above 30 °C (86 °F). Above
30 °C (86 °F) up to a temperature of 35 °C (95 °F), injection of drugs is
half as often as usual by doubling the time intervals between repeated
drug administrations. Epinephrine is given intravenously and
intraossarily to newborns at a dose of 10 μg/kg body weight [4].
It is not clear at which temperature and how often defibrillation
should be attempted in severe hypothermia. In case of ventricular
fibrillation and hypothermia, an attempt with maximum energy is
allowed, with a defibrillation dose of 4 J/kg body weight in children. If
ventricular fibrillation persists after three defibrillation shocks, further
defibrillation attempts should only be made when a core body
temperature >30 °C (86 °F) has been reached [7]. The bradycardia
observed in the newborn we treated may be physiological as part of
severe hypothermia; therefore, the infant was warmed in the incubator
without continuing chest compressions. We used a glucose-containing
 solution for fluid therapy. This should be avoided in case of
normoglycemia, as this can promote the development of cerebral edema.
In case of suspected hypovolemia, a fluid bolus of 10–20 ml/kg body
weight of isotonic saline solution is indicated. Infusion of HAES for
acute volume therapy is possible under very strict indications [6].
I have never been so surprised by the EMS. But in the end everything
was fine.

37.1 Conclusion
This case confirms the good prognosis (even in severe hypothermia) and
that children (as well as adults) must be warmed up in order to make a
meaningful decision about possible termination of resuscitation measures.
Survival of severe hypothermia is quite possible, as our little patient’s case
demonstrates, who had no neurological abnormalities in later neuropediatric
examinations. It is essential to protect infants and newborns from cooling
down.

References
1. Erker CG, Santamaria M, Mollmann M (2012) Tools for drug dosing in life-threatening pediatric
emergencies. Anaesthesist 61:965–970
[Crossref][PubMed]

2. Russo S, Timmermann A, Radke O, Kerren T, Brauer A (2005) Accidental hypothermia in the

household environment. Importance of preclinical temperature measurement. Anaesthesist
54:1209–1214
[PubMed]

3. Brugger H, Putzer G, Paal P (2013) Accidental hypothermia. Anaesthesist 62:624–631

[Crossref][PubMed]

4. Paal P, Brugger H, Boyd J (2013) Accidental hypothermia. N Engl J Med 368:682

[PubMed]

5. Knacke PG, Strauß J, Gräsner JT, Saur P, Scholz J (2008) Kasuistik interaktiv: Neugeborenes mit
schwerer Hypothermie Eine notärztliche Herausforderung. Anästhesiol Intensivmed Notfallmed
Schmerzther 4:260–263
[Crossref]

6. Reanimation 2021-Leitlinien kompakt. 1st edn. 2021. Deutscher Rat für Wiederbelebung
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_38

38. Accident While Shredding

Björn Hossfeld1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Federal Armed Forces Hospital, Ulm, Germany

Björn Hossfeld
Email: [email protected]

Some accidents do not immediately reveal the severity that they actually
entail and only show through modern imaging what has actually
happened. The present case also makes it clear that a team of rescue
workers functions best when certain decisions are made by the team as a
whole.

Autum fog is a nuisance for air rescue. On this day, we reported the
EMS helicopter ready for duty an hour late due to morning ground fog, but
now the stronger sunbeams have driven the fog away from our station and it
promises to be a beautiful day. The first alarm does not take long. A
neighboring EMS control center orders us to an acute eye injury. During the
approach, the prudent crew of the already arrived ambulance tells us that
they can hardly imagine that we will reach the scene with the EMS
helicopter: there is dense fog, they cannot see the sky. We fly in a bright
blue sky, but have to recognize soon that the ground fog increases under us,
the closer we come to the scene. Above the scene, which is secured by GPS
coordinates, it is not possible to land due to lack of visibility to the ground.
However, in a few kilometers distance, the extension of the road, on which
the scene is also located, appears from the fog on a hillside. Via radio, we
order the ambulance to this potential landing site. Since the patient is not
yet in the vehicle, a rescue assistant remains with the patient at the scene,
while the other picks us up with the ambulance. A few minutes later we
reach the scene and meet a municipal worker who is sitting in the lowered
front loader bucket of his tractor and has a bandage over both eyes, which is
bleeding on the right side.
The patient is awake and can report fluidly that he has shredded green
waste from the municipality for later composting with a funnel-shaped
shredder attached to the back of the tractor. While he fed more branches
into the funnel, he felt a blow to his right eye and, when wiping it with his
hand, found a bleed. He then turned off all the machines and informed the
EMS control center with his mobile phone. The question of pain is
dismissed with the remark “not so bad”, he only feels a little dazed. We put
the patient on the stretcher and take him to the ambulance. In order to
optimize blood clotting and inspect the wound, the bandage is opened
again. The upper lid of the eye is torn and shows a clear bleed; a perforation
of the eyeball cannot be ruled out. No foreign body can be seen; a body
check remains without further findings. While renewing the bandage, the
patient asks where he is and what we are doing. Since this question is quite
contrary to the previously reported course of the accident, I begin to
question the patient again: in contrast to the findings a few minutes earlier,
the patient is oriented to his own person, but not to time, place and course
of the accident. I assume that he was hit on the head by a larger piece of
wood, probably accelerated by the shredder, and caused a blunt head injury
in addition to the injury to the upper eyelid. Given the more complex
transport first to the EMS helicopter and then with the EMS helicopter to a
suitable hospital for maximum care, I decide to induce anesthesia on site.
The experienced rescue assistants first question this decision and consider
anesthesia for an eye injury to be exaggerated. However, they follow my
argument that the patient’s neurology has deteriorated rapidly in the short
time of our observation and a longer transport is pending. During an
extensive preoxygenation with maximum oxygen flow and tightly fitted
face mask, the further procedure is decided. Anesthesia induction and
subsequent endotracheal intubation are unproblematic, as is the further
transport to the emergency room of the admitting hospital. The computed
tomogram made there not only astonishes the colleagues present, but also
myself: Apparently, a metallic wire has penetrated deeply into the brain
through the eye. In a subsequent neurosurgical procedure lasting several
hours, an 11 cm long isolated copper wire can finally be removed from the
front skull cavity. The eye injury is so extensive that the eye cannot be
saved. 14 days after the procedure, the patient can be discharged to a
neurological rehabilitation hospital with short-term memory disorders.

Discussion
The decision to administer prehospital anesthesia and the discussion with
the emergency medical technicians might possibly be problematic in this
case, even though the procedure turned out to be correct in retrospect.
The induction of anesthesia and the resulting airway management is
significantly more difficult in the prehospital setting than in the
operating room, where there is always more technology, personnel, help,
space, and light available than in emergency medical services [1].
Therefore, several aspects must be taken into account when making the
decision to administer anesthesia in emergency medical services:
indication for anesthesia, duration and type of transport (ground-based,
air-based), conditions at the scene of the accident (e.g., patient’s position,
lighting, space), accompanying conditions of airway management (e.g.,
expected intubation difficulties, possibly trapped in a car), as well as the
training, experience, and routine of the EMS team [2]. The indication for
prehospital intubation resulted from the patient’s rapidly deteriorating
neurology. This also makes it clear that the condition of a patient in
emergency medicine is a dynamic process that requires constant re-
evaluation in order to avoid airway disasters [3, 4] that are often initially
deceptive. In a short transport to the target hospital, spontaneous
breathing might also have been possible, but this was not to be expected
in view of the location and weather conditions. The ambulance offers the
best possible conditions for administering anesthesia in the prehospital
setting because monitoring is complete and optimally positioned, and the
patient is ideally positioned on the stretcher. A difficult airway was not
to be expected, and the emergency physician had extensive routine in
administering anesthesia and airway management.

38.1 Conclusion
Even though the emergency physician has responsibility for the mission and
the patient, it is important to coordinate decisions (such as administering
anesthesia) in the team and to discuss the further course of action. The
assessment of the prehospital situation and the determination of suitable
measures require the collection of many aspects. Together, the emergency
team can use the experience of all team members. Communication is a key
factor, especially in critical decisions in emergency medical services.

References
1. Bernhard M, Bein B, Böttiger BW, Bohn A, Fischer M, Gräsner JT, Hinkelbein J, Kill C, Lott C,
Popp E, Roessler M, Schaumberg A, Wenzel V, Hossfeld B (2015) Recommended course of
action for prehospital emergency anesthesia. Anästh Intensivmed 56:317–335

2. Timmermann A, Byhahn C, Wenzel V, Eich C, Piepho T, Bernhard M, Dörges V (2012)

Recommended action for prehospital airway management. Anästh Intensivmed 53:294–308

3. Paal P, Schmid S, Herff H, von Goedecke A, Mitterlechner T, Wenzel V (2009) Excessive

stomach inflation causing gut ischaemia. Resuscitation 80(1):142
[Crossref][PubMed]

4. von Goedecke A, Herff H, Paal P, Dörges V, Wenzel V (2007) Field airway management
disasters. Anesth Analg 104(3):481–483
[Crossref]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_39

39. Avalanche Burial

Hermann Brugger1
(1) EURAC Research, Institute of Mountain Emergency Medicine, Bozen,
Italy

Hermann Brugger
Email: [email protected]

Many factors are decisive in an avalanche accident, whether the burial

can be survived and how the deployment proceeds. The present case
shows which factors are decisive in the rescue mission and how
dangerous such deployments can be in alpine terrain.

The three-member family from Germany is lying in front of a holiday

home on the summit of an almost 2500 m (8200 feet) high ski mountain in
the sun, it is March and the sun is already warming the south slopes. The
slopes are less frequented, skiers and snowboarders are sitting in front of
the ski huts and enjoying the warm day. A 5-year-old boy is playing a little
bit apart in the snow, when he suddenly starts to cry loudly and screams:
“My shovel is gone!” The father gets up from his deck chair, looks around
and sees the small plastic shovel in the snow of the steep slope, which
extends in front of the house towards the west into the depths and is clearly
separated from the sunbathing area by a red ribbon and a large warning sign
“Attention avalanche danger”. He lifts the ribbon and steps into the snow;
then a dull noise is heard, a piercing scream and the family father is torn
into the depths by an avalanche. The mother of the little boy and other
guests of the holiday home are completely horrified and call for help. When
the avalanche, followed by the gaze of numerous guests, reaches the outlet
at the bottom of the valley and comes to a standstill, nothing can be seen of
the father of the little boy.
I am sitting in my doctor’s office and taking care of the last patients
when the avalanche alarm sounds. I quickly apologize to the waiting
patients, exchange the white coat for the ski suit, get ski shoes, deployment
backpack with skis and furs and drive to the helicopter landing pad. During
the approach we receive a first layer report: “One person has fallen and is
buried by an avalanche on the west slope of a mountain, further forces are
being deployed”. In flight we approach the slope and see a 60 cm (24
inches) high fracture below the holiday home. From there a 50 m (55 yards)
wide and about 600 m (656 yards) long avalanche path leads over rocky
terrain, through a narrow steep gorge, a larch forest to the flat outlet on an
alpine meadow. No human being is to be seen, no trace—only huge masses
of snow. At the same time we notice that only a small part of the slope has
gone down and the majority of the snow masses are still hanging in the
steep slope. The temperatures are high, the sun is now shining directly into
the west slope and there are about 60 cm (24 inches) of fresh snow. I realize
that this situation is also dangerous for us, as the slope can be unloaded at
any time.
We land outside the avalanche and search the cone together as quickly
as possible; after a few minutes the mountain rescuer calls me. I run to him
and we see from a distance that something is moving on the snow surface: it
is the head of the buried person. His body is completely buried in the snow,
but the face is free and the man looks at us with big eyes, without saying
anything. About 35 min have passed since the avalanche occurred.
I ask him who he is and what exactly happened, what he can explain
exactly. While we dig him out of the snow in a hurry, I tell the man that he
has an unimaginably large guardian angel: 600 m (656 yards) fall in an
avalanche over rocks into the depths, buried by the wet snow (which is
already as hard as concrete) up to the neck and almost unharmed! His
answer is astonishing: “No, that’s not it, I’m in good shape”! We are
surprised at this carefree assessment. The patient only has a closed knee
injury, a mild hypothermia (core temperature epitympanal 34 °C (93.2 °F))
and no other injuries. We stabilized the leg, hoisted the patient into the EMS
helicopter and started. To fly back to the hospital, we have to overcome a
mountain ridge; I take one last look back and see how the entire west slope
of the mountain suddenly starts to move and a huge after-avalanche roars
down the valley. It fills the entire alpine floor, including the finding site of
our patient.

Discussion
The survival of an avalanche is primarily dependent on the degree of
injury and burial. A burial can only be survived for more than 35 min if
the avalanche victim is not fatally injured and can breathe [1]. This is the
case if either the head remains unburied, as in our case (partial burial), or
the whole body is buried (complete burial), but the airways are free and
there is a space in front of the mouth and nose (air pocket) to breathe [2].
Otherwise, an avalanche victim will suffocate within this short period of
time. With a complete burial, the probability of being alive in the
avalanche is strictly time-dependent. It remains until about 20 min over
85%, drops until 35 min to 34% and after 130 min is only 7% [3]. So
seen, the man had unimaginably great luck. The course of the survival
probability should also be taken into account in the assessment of the
danger. Up to about 35 min after the burial, it is justified to take a higher
risk to rescue buried people, as the probability of finding a victim still
alive is relatively high. After this time and especially after about 2 h, the
chance of meeting a survivor is much lower, so that a high personal risk
would not be justified.
But we rescuers were also very lucky. If we had only taken a little
more time when transporting, the entire EMS helicopter team and
several mountain rescuers would have been buried by the second-
avalanche, but we would probably not have been as lucky as the father of
the family, because the probability of being completely buried at the foot
of a slope is much higher than if you are caught high up at the break-off
and carried down the valley by the avalanche. We would not have been
the first mountain rescuers to be buried by an avalanche: in winter 2010,
two skiers were buried by an avalanche in the Bernese Uplands in
Switzerland; during the rescue efforts, a second-avalanche caught 12
mountain rescuers, 4 of whom died; including the EMS helicopter
physician (Berner Zeitung, 05.01.2010). In 2015, two members of an
avalanche commission were caught by a slab avalanche while digging a
snow profile, a standard procedure for assessing avalanche danger, and
pulled into the depths, one of whom died (Tiroler Tageszeitung,
08.01.2015). At a training course of the Austrian Mountain Rescue
 Carinthia at Hoher Burgstall (2800 m or 9200 feet) at the end of June
2015, five participants were buried by an avalanche, two of whom died
(Tiroler Tageszeitung, 22.6.2015).
A week after the avalanche, I went skiing on the same mountain
myself. I pass by the holiday home and it is hardly believable: the
rescued guest from our mission is already lying in the sun again and his
son is playing with a shovel in the snow (I did not ask if it’s the same
shovel)! The man is in good condition, holds up the plaster leg and calls
out to me friendly that he is looking forward to skiing again.

39.1 Conclusion
A partial burial by an avalanche is usually survived if there is no fatal
trauma. With a complete burial, however, survival is strictly time-dependent
and only possible with free airways and an air pocket after 35 min. Risk
management by the rescue team has the highest priority in the event of an
avalanche. Most avalanche accidents happen when the avalanche warning is
level 3 or 4, that is, when the avalanche danger is considerable or great. The
rescue teams are inevitably also exposed to this danger on the avalanche
cone. In recent years, numerous mountain rescuers have died in avalanche
rescue operations in Europe. All rescuers who go to the accident site must
be fully equipped; standard equipment includes an avalanche transceiver
worn on the body, probe and shovel, if possible also an avalanche airbag to
avoid a complete burial or a breathing device (e.g. AvaLung) to be rescued
in the event of a second-avalanche. It is quite legitimate to include the
expected duration of a complete burial in the risk assessment and to assess
the chances of survival depending on the time between the avalanche (or
alarm) and the rescue and to weigh up the risk against the risk to the rescue
teams. A short burial time (up to about 35 min) justifies a higher risk, after
that the risk must be very carefully weighed up.

References
1. Falk M, Brugger H, Adler-Kastner L (1994) Avalanche survival chances. Nature 368:21
[Crossref][PubMed]
2.
Soar J, Perkins GD, Abbas G, Alfonzo A, Barelli A, Bierens JJ, Brugger H, Deakin CD, Dunning
 J, Georgiou M, Handley AJ, Lockey DJ, Paal P, Sandroni C, Thies KC, Zideman DA, Nolan JP
(2010) European Resuscitation Council guidelines for resuscitation 2010 section 8. Cardiac arrest
in special circumstances: electrolyte abnormalities, poisoning, drowning, accidental hypothermia,
hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
Resuscitation 81:1400–1433

3. Brugger H, Durrer B, Adler-Kastner L, Falk M, Tschirky F (2001) Field management of

avalanche victims. Resuscitation 51:7–15
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_40

40. ACS in 75-Year-old Patient

Peer G. Knacke1
(1) Department of Anesthesiology and Emergency Medicine, AMEOS
Hospitals Ostholstein, Eutin, Germany

Peer G. Knacke
Email: [email protected]

Sometimes it is only a small hint, so to speak the “fine print”, which

provides the EMS team with a completely new differential diagnosis—as
in this case, in which everything is literally not as it should normally be.

I have carried out over 15,000 missions as an emergency physician. At

the first intervention today, the digital radio receiver shows next to the loud,
hardly stoppable beeping on the display the keyword “ACS”, i.e. an acute
coronary syndrome. A classic that I have to take care of and that is not far
away from the EMS station, so routine and certainly not terribly exciting. A
few minutes after the alarm, we reach the emergency site, a beautifully
located, very well-kept senior’s residence with the option of additional care.
Our patient is a 75-year-old, not seriously ill-looking, awake woman who
takes care of herself and receives daily visits from the nursing service,
which is also on site at the moment. When asked why an emergency
physician was called, the patient reports about a dull pressure in the
retrosternal area since the weekend. The question of radiation of the pain is
answered with “in the left arm and in the legs”. Then the nursing staff
intervenes and says that the leg pain always exists, only the pain in the chest
is new. The pain scale between 0 and 10 is answered with 2. The patient
also has occasional chest pain, but also wetted herself last night, which does
not usually happen. This actually sounds very confused! Auscultation of the
lungs is uneventful, the heart sounds very quiet, the legs show slight edema
on both sides. While trying to narrow down the acute symptomatology, the
vital parameters are recorded in parallel. With the exception of hypertensive
blood pressure values, these are uneventful (blood pressure 180/90 mmHg,
heart rate 87/min, blood sugar 194 mg/dl, respiratory rate 14/min, oxygen
saturation 100%), in addition, a 12-channel ECG is primary derived. This
does not show any conspicuous repolarization disorders at a normofrequent
absolute arrhythmia.
The nurse shows me a long list of prescriptions. It is originally sorted
alphabetically, but here it is already sorted by drug groups for better
overview: cardiovascular drugs (amlodipine, dihydralazine, metoprolol,
glycerol trinitrate, digitoxin), diuretics (xipamide, torasemide,
spironolactone), analgesics (morphine, novaminsulfone, oxycodone), the
antiepileptic drug lamotrigine, the proton pump inhibitor pantoprazole, the
bronchodilator tiotropium bromide, the anticoagulant rivaroxaban, and the
psychopharmacon lorazepam. A truly proud list of medications, which also
makes me think of drug interactions, since 25,000 people die from them in
Germany every year (according to a report by the Süddeutsche Zeitung
from 17.05.2010). But another drug shows me a clue: The patient takes the
antiepileptic drug lamotrigine, has wetted the bed at night, and is otherwise
not incontinent. Are the diuretics a problem or was it a seizure? The
targeted inquiry reveals that the patient has been suffering from epilepsy
since a stroke a few years ago. The last seizure was more than a year ago,
so the regular intake of lamotrigine is taking place. A look at the tongue
shows a classic lateral tongue bite. So at least we have a diagnosis: post-
seizure enuresis at night. The current neurological finding is unspectacular.
But is this compatible with the thoracic pressure? While I am just thinking
about this question, the pager beeps again with the question of our possible
availability for a heart attack in a neighboring town. The next physician-
manned ambulance will need more than 20 min and the EMS helicopter is
also not available. Since the patient we are currently treating is stable and
her apartment is located near the hospital, this is confirmed with the
stipulation that we can only start in about 4 min to finish therapy and
documentation. After the already existing peripheral venous access, the
patient receives two doses of nitroglycerin spray due to the complaints and
the hypertensive circulatory situation.
 While filling out the emergency medical services protocol and
reviewing the patient file of the nursing service, I notice the small note
“situs inversus”. The patient is asked whether the organs are really arranged
the wrong way around; she confirms this. The percussion confirms the
dextrocardia—then we have to write the ECG mirror image. This surprises
the present rescue assistants. In the ECG, there are clear ST depressions
over the front wall as signs of ischemia. The patient now receives 5000 IE
heparin and 250 mg aspirin intravenously, but she does not want an
analgesic for the minor complaints. After being handed over to the
ambulance, the patient is transported without problems to the nearby
hospital, while we are on our way to the new assignment. The physician on
duty of the local emergency room is informed by telephone about the
assigned patient with the specialties.

Discussion
A situs inversus is a rare, non-pathological anatomical variant, which can
however, as the case presented here shows, have consequences for
diagnosis and therapy. In the first ECG, our patient showed a heart
rhythm disorder, but no conduction disorders: These only became
apparent in the adapted mirror image ECG. In the event of necessary
defibrillation or transcutaneous pacemaker application, the electrodes
would also have to be applied in a mirror image [1]. Even appendicitis
would cause atypical symptoms in the left lower abdomen in the case of
situs inversus. In the case of dextrocardia, the ECG does not show the
typical increase in R-amplitude from V1–V6 in the normally glued chest
lead, but the size of the QRS complexes becomes smaller to the left. A
high R-amplitude in V1 is considered to be indicative of the diagnosis. If
the two arm electrodes are swapped and V2–V1 and Vr3–Vr6 are
derived instead of V1–V6, a normal ECG results for patients with situs
inversus.
The diagnosis of a heart attack from the standard ECG and
especiallyestimation of the infarct size and stages is often difficult in
patients with unknown situs inversus [2].

40.1 Conclusion
In emergency diagnosis, it is easy to be wrong if you believe the first
indications too much and are not alert when a finding does not fit the
suspected diagnosis. It is important to form a consistent picture from the
often complex picture of physical examination, medical history and the
available written documents and to make a good diagnosis.

References
1. Shenthar J, Rai MK, Walia R, Ghanta S, Sreekumar P, Reddy SS (2014) Transvenous permanent
pacemaker implantation in dextrocardia: technique, challenges, outcome, and a brief review of
literature. Europace 16:1327–1333
[Crossref][PubMed]

2. Richter S, Doring M, Desch S, Hindricks G (2014) ECG pitfall: anterior myocardial infarction in
dextrocardia. Eur Heart J 35:1887
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_41

41. Carried Off the Road

Hermann Brugger1
(1) EURAC Research, Institute of Mountain Emergency Medicine, Bozen,
Italy

Hermann Brugger
Email: [email protected]

What to do if an emergency treatment has to be carried out, but one is

not quite sure yet? And one does not know whether it really offers an
optimal treatment condition for the intended transport? The present case
provides answers to these questions.

At midnight the phone rings at the EMS operations center: operation in

the Gader valley, traffic accident with several victims, injuries of unknown
degree. In a few minutes we are on our way with the physician-manned
ambulance with lights and sirens. The winding road into the Gader valley
was built during the First World War, has seen many serious accidents and
has been out of service for some time. At the time of the accident, a
completely new route with numerous bridges and tunnels was built, the
traffic was therefore redirected in one-way regulations via so-called
“panoramic roads” on both sides of the valley over remote mountain
villages and farms, which means a much longer journey time. After 45 min
we reach the accident site at 1:00 a.m., at the end of a long curve. In front of
a building there are already numerous emergency vehicles from the fire
brigade, police and EMS. A large glass veranda of a restaurant is
completely destroyed. In the middle of the guest room is a smashed sports
car between tables, chairs and shards of glass. Firefighters are working on
the car and removing the roof. One of the two people in the car has already
been freed and is on the way to the hospital with minor injuries, the second
is being lifted out of the car with the scoop stretcher as we arrive. I notice
that the young man is unconscious but breathing and immediately have him
brought to the physician-manned ambulance for treatment.
The first examination reveals a Glasgow Coma Scale of 6 (1/1/4) with
spontaneous respiration, oxygen saturation 88%, blood pressure
90/55 mmHg, sinus rhythm 95/min, unilateral dilated pupil right and an
open fracture of the right thigh. Together with the paramedic, I insert a
peripheral venous access, sedate and intubate the patient, check ventilation
of both lungs and fix the tube. After the ventilator is turned on, I am just
about to give the driver the go-ahead when the paramedic draws my
attention to the oxygen saturation: 85%. After a few more minutes, oxygen
saturation continues to drop to 78%, whereupon I temporarily stop
departure to the hospital. I auscultate the lungs for the second time and can
now no longer detect any respiratory sounds on the right. I vent the cuff and
pull the endotracheal tube back slightly, assuming that I have mistakenly
intubated the left main bronchus. On the other hand, this is actually unusual,
I think to myself, because with a too low tube position, the tube normally
comes to lie in the right bronchus trunk because it slopes more steeply.
However, this new positioning does not change anything; I can still not
auscultate any respiratory sounds over the right lung and the oxygen
saturation is now only 72%. My working hypothesis is now that the patient
has developed a tension pneumothorax on the right side and that circulation
will fail parallel to the drop in oxygen saturation. I wonder if my surgical
skills are sufficient for an emergency thoracic drainage. When working out
the guidelines for the International Commission for Alpine Emergency
Medicine ICAR MEDCOM [1], I learned the surgical approach. I am also
aware of its indications in tension pneumothorax and multiple trauma
patients, but so far this intervention has not been necessary in any of my
missions. I fear that the patient will become cardiorespiratory unstable or
even die during the expected long journey of about 45 min if we do not
relieve the tension pneumothorax before we reach the hospital. My
paramedic looks at me questioningly, I nod affirmatively and he already
opens the surgical set and begins the preparations. After disinfection, I
make a skin incision in the middle axillary line at the level of the right
nipple, blunt the subcutaneous tissue with scissors, open the pleural space
and, with the help of a finger, insert the thoracostomy tube with 28
Charrière into the pleural space. We attach a bladder catheter with urine bag
to the tube, which immediately fills with air and some blood so that it has to
be relieved with a cut. I fix the drainage provisionally with a stitch. After
the saturation had fallen to 68% during the drainage and the blood pressure
had fallen to 75/40 mmHg, both values now rise slowly and the saturation
reaches an impressive 94% after about 10 min. The paramedic and I are
relieved. We still connect the capnometer, which indicates end-expiratory
carbon dioxide values of 35 mmHg, and set off. During the long journey,
we monitor the patient, but he does not cause us any problems and we reach
the hospital after three-quarters of an hour.

Discussion
The severe thoracic trauma is responsible for up to 25% of all fatal
trauma [2]: an important form of therapy of the “Deadly Dozen” of a
thoracic trauma is the relief of a tension pneumothorax with drainage.
The pre-hospital emergency treatment of a tension pneumothorax is
repeatedly discussed controversially in the literature [3]. In essence, two
methods are available: needle puncture with catheter (>14 Charrière) in
the second intercostal space in the mammillary line and surgical drainage
with a thoracic drainage tube (28–36 Charrière) in the middle axillary
line at the level of the nipple according to Bülau. Some authors are of the
opinion that in an intubated patient with tension pneumothorax and
cardiorespiratory insufficiency, surgical relief by means of a large
drainage for venting the needle puncture is superior [4]. The use of a
sharp trocar in emergency medicine should be avoided because of the
risk of injury to thoracic organs [3]. A valve supply (Heimlich valve) is
not necessary during mechanical ventilation. Some basic thoughts: if a
simple pneumothorax is found in a non-intubated emergency patient, this
does not necessarily mean the need for action. If the oxygen saturation is
acceptable, the circulation is stable and the patient is not intubation-
dependent, pre-hospital relief of the pneumothorax is not necessary. If,
on the other hand, a patient with a simple pneumothorax is intubated and
ventilated, the probability is very high that a tension pneumothorax will
develop with the risk of cardiorespiratory instability due to displacement
of the mediastinum to the healthy side. This can happen very quickly and
then the situation becomes acutely dangerous. In these cases, it may be
that puncture with small-caliber catheters in a reasonable time no longer
has the desired effect, especially if it is a multiple trauma patient who
has to be brought to a trauma center for surgical repair as quickly as
possible. Delayed action or half-hearted steps should be avoided, that is,
in this case it is advisable to seek efficient and lasting relief quickly. It
should also be kept in mind that auscultation of the lungs is hardly
possible due to the noise level on the way, especially if you are in a
helicopter. During a helicopter transport, it should also be kept in mind
in advance that during the ascent, for example when flying over passes
or ridges, the circulatory situation can deteriorate during the flight due to
the intrapleural relative increase in pressure, precisely when no therapy
is possible during the flight [5]. It is therefore better to carry out both the
diagnosis and the therapy of a pneumothorax before flying to the
hospital.
In order not to endanger the patient when setting up a thoracic
drainage, the personal experience of the emergency physician must
always be taken into account; there are fatal complications of thoracic
drainage in the literature, for example by laceration of large vessels, the
heart, the lung or the liver [6]. In an analysis of emergency calls in
Baden-Württemberg/ Germany, EMS helicopter physicians inserted a
thoracic drainage every 6 months, but emergency physicians in ground-
based EMS vehicles only every 77 months (approximately 6.5 years) [7].
This rare use of a potentially dangerous, but also life-saving intervention
such as thoracic drainage shows that the emergency physician should
make a good assessment of the patient’s clinical condition, his own
manual skills and experience as well as the availability of more
experienced colleagues—whether in another EMS vehicle or in the next
hospital.
One year after the accident, I receive a call in my practice: “Chiamo
da Milano e sono il padre del ragazzo …” It is the father of the injured
person who informs us that his 18-year-old son had to be neurologically
rehabilitated for months, but can now lead a normal life again and passed
the final exams the day before. Not only to his, but also to my great joy.

41.1 Conclusion
For the treatment of trauma patients, one should always be trained and
prepared for the relief of a tension pneumothorax, and above all take a
tension pneumothorax into a differential diagnosis. You can expect this
especially after endotracheal intubation with mechanical ventilation. The
lateral surgical approach is particularly advantageous over the relief with
needles if respiration or circulation is severely impaired, high altitudes are
reached or a long transport is pending.

References
1. Forster H, Zafren K (2007) Thoracostomy at the scene of an accident in the mountains. ICAR
MEDCOM recommendation 12. http://www.ikar-cisa.org/ikar-cisa/documents/2007/
RECM0012E.pdf. Accessed: 5. Mar 2015

2. Cipolle M, Rhodes M, Tinkoff G (2012) Deadly dozen: dealing with the 12 types of thoracic
injuries. JEMS 37:60–65
[PubMed]

3. Barton ED, Epperson M, Hoyt DB, Fortlage D, Rosen P (1995) Prehospital needle aspiration and
tube thoracostomy in trauma victims: a six-year experience with aeromedical crews. J Emerg Med
13:155–163
[Crossref][PubMed]

4. Martin M, Satterly S, Inaba K, Blair K (2012) Does needle thoracostomy provide adequate and
effective decompression of tension pneumothorax? J Trauma Acute Care Surg 73:1412–1417
[Crossref][PubMed]

5. Braude D, Tutera D, Tawil I, Pirkl G (2014) Air transport of patients with pneumothorax: is tube
thoracostomy required before flight? Air Med J 33:152–156
[Crossref][PubMed]

6. Schley M, Rossler M, Konrad CJ, Schupfer G (2009) Damage of the subclavian vein with a
thorax drainage. Anaesthesist 58:387–390
[Crossref][PubMed]

7. Gries A, Zink W, Bernhard M, Messelken M, Schlechtriemen T (2006) Realistic assessment of

the physician-staffed emergency services in Germany. Anaesthesist 55:1080–1086
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_42

42. Dangerous EMS Scene Call

Volker Wenzel1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Friedrichshafen Regional Medical Center and
Tettnang Hospital, Friedrichshafen / Tettnang, Germany

Volker Wenzel
Email: [email protected]

Physicians are in an enormous responsibility and not always make or

transmit the patients and their relatives decisions or results, which they
would like to hear. And that can—quite not rarely—lead to situations
that can be life-threatening for the physicians themselves.

The physician-manned ambulance is alarmed early Saturday morning to

a pub on the outskirts of the city with the message “unconscious person”. A
typical mission at this time and on this day of the week, only the locations
change during the night towards the bars, which offer breakfast as well.
Depending on the size of the area, each doctor has such a scene call on
weekends, insofar as the emergency physician expects nothing special on
the way to this emergency. Arrived at the scene, a man of about 30 years is
already in the ambulance next to a café, which is very popular with
motorcycle clubs. According to information from the paramedics, the vital
parameters are stable. Witnesses report that the drunk patient was involved
in a fight and after a blow to the chest fell backwards, hit his head on the
street and then became unconscious. Since the patient does not react to
address, nor to touch, the emergency physician begins with the body check,
whereby she finds injuries in the face. When trying to open the eyes for an
examination of the pupils, the patient suddenly begins to fight. The
emergency physician steps back, but too late—she is hit by the patient’s fist
with full force in the neck area. Neither the emergency physician herself nor
the present paramedics can react so quickly to prevent the fist. The restless
patient is taken to the local hospital for treatment of alcohol intoxication
and facial injuries. The emergency physician herself ends her shift several
hours later with mild headaches and neck pain. Only after several days later,
visual impairments occur and the headaches become stronger, the
emergency physician also goes to the hospital for neurological examination.
A dissection of the carotid artery with functional closure on the side struck
by the fist and a dissection of the vertebral artery on the contralateral side is
diagnosed. The emergency physician is immediately admitted to the stroke
unit and heparinized to prevent a stroke. Afterwards she is six weeks unable
to work. For months she is anticoagulated and the neck vessels are
continuously controlled. In the end, the dissection regresses and the
emergency physician can continue her work in anesthesia. However, there
is one thing she will probably never do again in her life—work as an
emergency physician in a physician-manned ambulance.
The perpetrator of the injury remains unpunished from a criminal point
of view, as at the time of the punch he could not assess the consequences of
his action due to alcohol intoxication and a concussion. He is acquitted at
the trial. What remains is very annoyed paramedics and EMS physicians.

Discussion
Aggressions against physicians have been described when healthcare has
not kept pace with population growth and thus ever-increasing numbers
of patients are coming into contact with ever-more overworked
physicians [1]. In January 2015, a man went to Brigham’s and Women’s
Hospital in Boston, USA, to speak to the cardiac surgeon who had
operated on his mother. When the cardiac surgeon entered the
consultation room, the patient’s son pulled out a gun and immediately
shot the cardiac surgeon twice and then shot himself. Despite emergency
surgery, the cardiac surgeon, a father of three children, could not be
saved. Suddenly, American physicians became aware of how vulnerable
they are to possible aggressions by patients disappointed with their
treatment in a country with more than 300 million firearms in private
hands [2]. In a study in the USA, there were a total of 154 shootings in
hospitals (91) or on hospital premises (63) between 2000 and 2011,
resulting in the deaths of 24 hospital staff, 12 nurses, 8 doctors and 4
pharmacists [3]. In autumn 2013, the police in Lower Austria were on
the trail of a poacher; at a police roadblock, the poacher immediately
opened fire on the officers, seriously injuring a policeman, and then fled
into the forest. About 1 h later, he shot a paramedic who was driving an
ambulance to take the seriously injured policeman to hospital. Another
hour later, the poacher stopped a police patrol car and shot the two
policemen; later, he shot himself in his house (Kurier 18.09.2013).
In a survey of doctors working in emergency departments in
Michigan, USA, 75% of doctors said they had been verbally attacked in
the last 12 months; 28% said they had already been physically attacked,
12% had been confronted by patients outside the emergency department
and 4% had been stalked by patients. Accordingly, 82% of these doctors
said they sometimes feel afraid of violence at work [4]. If one believes
that violence against doctors only occurs in overloaded healthcare
systems or in societies with extremely high levels of privately owned
firearms, one is wrong—doctors and paramedics are regularly and
increasingly being physically attacked in German-speaking countries,
with emergency departments, out-of-hours medical services, emergency
medical services and work in social hotspots being the most dangerous.
As shocked as those involved in aggressions against physicians are, so
little is said about it; possibly because of heightened and misguided
professional ideals that “a good and empathetic doctor is not attacked”
(Northern Lights current 09/2014). This is simply not true because even
in German-speaking countries (with extremely strict laws for guns in
private hands) physicians become victims of serious violence, many of
them with fatal outcome [5]. A neurologist and psychiatrist in
Saarbrücken, Germany was shot by one of her patients in her own office
(Frankfurter Allgemeine Zeitung 13.03.2015), an EMS helicopter in
Upper Austria was blinded by a laser upon landing on the hospital roof
(Die Presse 18.08.2011), a drunk man in Berlin, Germany stabbed a
knife into the neck of a helping paramedic (Tagesspiegel 06.08.2007), an
ambulance driver from Freising, Germany got a punch in the face from
the friend of an emergency patient in Fürstenfeldbruck, Germany, and
passers-by shot fireworks at firefighters who wanted to extinguish a fire
(Süddeutsche Zeitung 10.01.2012). These cases should only be the tip of
 an iceberg of violence against people in the healthcare industry, if one
reads the accounts of hospital employees in southern Germany
(Süddeutsche Zeitung 09.02.2015). In the Center for Sleep Medicine in
Nuremberg, a senior physician was beaten several times in the face
because the cure demanded by a patient was refused by a psychosomatic
hospital. In the emergency room of the Ingolstadt Hospital, two rival
groups went at each other; eight nurses had to be called to resolve the
situation. “In the end, everything was full of blood,” said a witness. A
hospital spokeswoman said: “In psychiatric hospitals, there has always
been such an aggression potential, but now even hospitals of basic care
are not spared.” In emergency rooms, it is now “attention to remove
everything that can be misused as a projectile.” A physician in a
Nuremberg Hospital in Germany says, “that the progressing barbarism of
society does not stop at the hospital—our physicians were long protected
by the white coat—but that is over.” In the same hospital, a resident
physician had to flee in front of 20 relatives in the geriatrics ward, but
could lock herself in a patient’s room. As the author of the Süddeutsche
Zeitung wrote on 09.02.2015, in German hospitals “barking, threatening,
beating and fondling” is present; but exact numbers are difficult to
obtain. It is only certain that aggressions arise more from male and
intoxicated patients. With age, one can not predict anything anymore,
because even 80-year-olds suddenly strike, as an analysis showed. In a
study by the Ruhr-University in Bochum, Germany, 900 paramedics and
firefighters were interviewed; almost everyone was already exposed to
verbal attacks, 59% also to aggressive attacks and 25% also to criminal
violence—in the last twelve months. While hospitals are happy to
communicate any new technology in detail, security aspects are rather
adapted silently—employees are sent to deescalation training or nurses
train in self-defense courses how they can escape from chokeholds
patient-friendly and security guards are mainly used at night to contain
aggressions.

42.1 Conclusion
Verbal and physical violence against physicians has increased and is more
common in the treatment of intoxicated or psychotic patients than in the
treatment of “normal” patients. But even over the course of treatment or
with treatment considered disadvantageous, frustrated patients or their
relatives can suddenly attack physicians, EMS and hospital staff, the health
consequences of which can be severe. In an emergency scene call, look for
opportunities or safe rooms to protect yourself from a sudden attack by the
patient, relatives or bystanders. Individual protection can be improved by a
self-defense course; a zero risk is not possible with open hospital doors and
emergency physicians responding to emergency locations without security
screening. Physicians should demand prevention measures against violence
from their hospital, emergency medical and EMS providers.

References
1. Xu W (2014) Violence against doctors in China. Lancet 384:745
[Crossref][PubMed]

2. Rosenbaum L (2015) Being like Mike-fear, trust, and the tragic death of Michael Davidson. N
Engl J Med 372:798–799
[Crossref][PubMed]

3. Kelen GD, Catlett CL, Kubit JG, Hsieh YH (2012) Hospital-based shootings in the United States:
2000 to 2011. Ann Emerg Med 60:790–798, e791

4. Kowalenko T, Walters BL, Khare RK, Compton S (2005) Workplace violence: a survey of
emergency physicians in the state of Michigan. Ann Emerg Med 46:142–147
[Crossref][PubMed]

5. Maulen B (2013) An ever increasing incidence of violence against physicians. MMW Fortschr
Med 155:14–16, 18, 20
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_43

43. Shortness of Breath in Steam Room

Norman Hecker1 and Bernd Domres2
(1) Department of Emergency Medicine, Protestant Hospital,
Gelsenkirchen, Germany
(2) Foundation of the German Institute for Disaster Medicine, Tübingen,
Germany

Norman Hecker (Corresponding author)

Email: [email protected]

Bernd Domres
Email: [email protected]

Not everything is as it seems and what it seems—as this case very

clearly shows. That is why a sound differential diagnosis is very
important, as well as the saying, “when you hear hooves, think horses …
and maybe zebras.”

There are often reports of deployment that suggest the suspicion of an

acute coronary syndrome on the way to the deployment site. One of the
most common deployment reports in the emergency medical service are
“chest pain and shortness of breath”, often with an acute coronary
syndrome. The term acute coronary syndrome includes the classic
myocardial infarction (STEMI; ST-segment elevation myocardial
infarction), the non-ST-segment elevation myocardial infarction (NSTEMI;
non-ST-segment elevation myocardial infarction) and unstable angina
pectoris. While the STEMI can be diagnosed relatively safely and clearly in
the pre-hospital phase and treated accordingly in accordance with the
applicable guidelines, the pre-hospital diagnosis of the other two disease
patterns is much more difficult and therefore much more dependent on the
experience of the emergency physician. All 3 disease patterns are the same
in principle. Typically, these are devastating pains in the chest area,
shortness of breath and heart rhythm disorders, cold sweats, dizziness,
nausea, vomiting or even a circulatory collapse are unspecific, but often
associated symptoms. Depending on other pre-existing conditions, milder
and less clear courses and causes can occur with the typical symptoms; so it
can be anything between psychosomatic complaints and a fatal myocardial
infarction.
On a cold winter day, the emergency dispatch center receives a call for
help from the local hot spring. The caller, an employee of the facility,
reports that a woman in her middle years has collapsed in the steam room
and is groaning in pain, gasping for air. As a result, the emergency
physician-manned ambulance and an ambulance manned by two
paramedics are alerted. Upon arrival, the EMS team encounters a 53-year-
old, approximately 165 cm tall, obese woman who is responsive but not
fully oriented and dazed. She has cold, sweaty skin, shortness of breath, and
reports a pressing pain in the epigastrium that radiates to the chest, back,
and left arm, which has been getting worse since this morning after
breakfast. The patient fell due to dizziness, but never lost consciousness.
There are no known pre-existing conditions, although blood pressure may
have been “high at times” in the past and she smokes about 15 cigarettes,
often when drinking coffee. Blood pressure is 110/60 mmHg, ECG shows a
sinus rhythm with a rate of 58/min with no ST-segment elevation, there are
occasional supraventricular extrasystoles, peripheral oxygen saturation is
98% with 17–20 breaths per minute. There are no contusions on the thorax,
the abdomen is distended and mildly tender to palpation in all 4 quadrants
without guarding, both kidney areas are free of percussion pain, the rest of
the body check is negative. After taking the history and physical
examination, the working diagnosis of “acute coronary syndrome—
suspicion of NSTEMI” is made by the emergency physician. Differential
diagnoses include a collapse due to syncope (e.g. due to cardiac forward
failure with sudden peripheral vasodilation from the hot thermal water) or a
dissection of a large vessel. The emergency physician initiates symptomatic
therapy with volume, antiemetics, oxygen, an analgesic, and monitoring.
The patient is then transported with the emergency physician-manned
ambulance accompanying the patient onboard to the nearest hospital that
has surgery, but no invasive cardiology.
There are good reasons to follow the working diagnosis of the
emergency physician in this case. On the one hand, the patient reports the
classical leading symptom of a myocardial infarction; namely, thoracic pain
radiating to adjacent regions. Pain radiation to the arms or shoulders is
typical of a myocardial infarction [1] and helps to distinguish it from other
causes [2]. Other symptoms such as shortness of breath and cold sweats are
also characteristic. In particular, if these symptoms are combined with
atypical symptoms such as nausea and collapse in women, the suspicion of
an acute myocardial infarction is likely [3]. On the other hand, there is no
ST elevation, but an extrasystole. Various ECG changes can indicate or
simulate a myocardial infarction, even in the absence of ST elevation [4, 5].
In combination with the clinical examination findings, the working
diagnosis of “acute coronary syndrome—suspicion of NSTEMI” appears
justified. The clinical examination confirms the findings of the emergency
physician, in particular the epigastric pain radiating to the thoracic region
and the intermittent extrasystole in the ECG; the admitting internist
therefore takes over the working diagnosis of the emergency physician.
However, the laboratory-chemical examination shows a normal blood
analysis, creatine kinase 122 U/L, CK-MB 7 U/L and troponin-T 0.12 μg/L.
This laboratory-chemical analysis combined with the lack of elevations in
the EKG excludes an acute myocardial infarction as the cause of the
symptoms with sufficient high certainty.
The actual decision of the emergency physician and the admitting
internist to diagnose a myocardial infarction is basically understandable and
comprehensible. A newly occurring angina pectoris is considered unstable
angina pectoris and would therefore remain open as a possible differential
diagnosis. In our case, however, it is not an acute coronary syndrome, but
the effect of a massive stomach distension—shortly after the patient was
admitted to the hospital, she had to vomit several times. This is because she
had drunk large amounts of latte macchiato shortly before visiting the spa
with a friend. Since she has been suffering from constipation for years, this
results in the diagnosis of a Roemheld syndrome [6]. The patient recovers
quickly after symptomatic therapy.

Discussion
In the Roemheld syndrome, the diaphragm is raised directly or indirectly
due to a passage disorder or bloating in the gastrointestinal tract and thus
exerts mechanical pressure on the heart [6]. The symptomatology of the
Roemheld syndrome can thus simulate the clinical picture of angina
pectoris in a surprising way; fortunately, in contrast to the “real” acute
coronary syndrome, the cause is often harmless and easy to fix. For the
emergency doctor, it is essential that myocardial infarctions are time-
critical events whose extent of damage and prognosis benefit
significantly from early and guideline-based therapy initiation. Even if
not every suspicion of an acute coronary syndrome is a real acute
coronary syndrome, the rapid clarification of a suspicion of NSTEMI or
unstable angina pectoris seems urgently necessary. The Roemheld
syndrome is certainly not the typical differential diagnosis for acute
coronary syndrome, but our case shows that despite the clinical and
economic importance of acute coronary syndrome, one must always
think of other possible causes. While we instill the motto in our medical
students that one should “think of horses and not zebras when one hears
hoofbeats” [7], this helps to separate the probable from the improbable,
but of course it cannot replace the expertise of the emergency doctor to
make decisions in complex situations. In a case with thoracic pain, a
heart rate of 170/min, consciousness disturbance and ST-segment
elevation, the patient was treated with the suspicion of a STEMI with
aspirin, heparin and clopidogrel and brought to the cardiac
catheterization laboratory, where no pathology of the coronary arteries
was found, but the diagnosis of a Brugada syndrome. The authors
concluded that when you hear hoofbeats, you should think of horses and
zebras [8]. In a Dutch study of 820 patients with the suspicion of a
STEMI who were referred to a university hospital for cardiology for
percutaneous invasive intervention, 19 patients (2.3%) ultimately had no
STEMI, but pericarditis (5), aortic dissection (3), subarachnoid
hemorrhage (2), cardiomyopathy (2), pneumonia (1), COPD (1),
mediastinal tumor (1), peritonitis (1), Brugada syndrome (1), coronary
aneurysm (1) or aortic stenosis (1). Tragically, the patients with aortic
dissection and subarachnoid hemorrhage were also anticoagulated
because of the suspicion of a STEMI and died [9].
43.1 Conclusion
The difficulty for the prehospital emergency physician is to ensure the rapid
start of therapy in the event of a manifest suspicion of an acute coronary
syndrome (so-called “Golden Hour”), but at the same time to choose the
clinical place of treatment so that differential diagnoses can also be treated.
Therefore, non-cardiac causes, and thus, for example, surgical diseases,
must also be considered. Here we remember aortic dissection, hiatal hernia
and pneumothorax. However, in the event of a high suspicion of an acute
heart attack, coronary intervention remains the essential therapeutic
element.

References
1. Albarran J, Durham B, Gowers J, Dwight J, Chappell G (2002) Is the radiation of chest pain a
useful indicator of myocardial infarction? A prospective study of 541 patients. Accid Emerg Nurs
10:2–9
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2. Sanchis J, Bodi V, Nunez J, Bosch X, Heras M, Bonanad C, Pellicer M, Merlos P, Minana G,

Llacer A (2011) Usefulness of pain presentation characteristics for predicting outcome in patients
presenting to the hospital with chest pain of uncertain origin. Emerg Med J 28:847–850
[Crossref][PubMed]

3. Coventry LL, Finn J, Bremner AP (2011) Sex differences in symptom presentation in acute
myocardial infarction: a systematic review and meta-analysis. Heart Lung 40:477–491
[Crossref][PubMed]

4. Wang K, Asinger RW, Marriott HJ (2003) ST-segment elevation in conditions other than acute
myocardial infarction. N Engl J Med 349:2128–2135
[Crossref][PubMed]

5. Yahalom M, Roguin N, Suleiman K, Turgeman Y (2013) Clinical significance of conditions

presenting with ECG changes mimicking acute myocardial infarction. Int J Angiol 22:115–122
[Crossref][PubMed][PubMedCentral]

6. Janner J (1956) Aerophagia and abdominal distention; Roemheld, Chilaiditi splenic flexure
syndrome. Schweiz Med Wochenschr 86:886–891
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7. Beales D (2008) Hoofbeats. Ann Intern Med 148:164–165

[Crossref][PubMed]
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Hudzik B, Szkodzinski J, Wozniak A, Nowowiejska-Wiewiora A, Polonski L (2011) When you
hear hoofbeats, think of horses and zebras: a 58-year-old man with chest pain and palpitations.
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9. Gu YL, Svilaas T, van der Horst IC, Zijlstra F (2008) Conditions mimicking acute ST-segment
elevation myocardial infarction in patients referred for primary percutaneous coronary
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© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_44

44. Swallow and Brake Failure

Hermann Brugger1
(1) EURAC Research, Institute for Mountain Emergency Medicine,
Bozen, Italy

Hermann Brugger
Email: [email protected]

When is a CPR really useful? And when should it be waited for? In

addition to this question, the present case puts the focus on how
important it is to secure the patient as well as the self-protection in the
EMS.

I am currently checking the expiration dates of the drugs in the

emergency medical kits with an ambulance driver and notice in the
background that the EMS vehicle is being dispatched. Minutes later, the
alarm sounds. “Circulatory arrest in a small mountain village”. This
settlement is a remote mountain village (elevation, 1.500 m / 4,900 feet
above sea level) with a dozen farms, reachable in the best case in 20 min by
a steep, winding road from our EMS station. The area made headlines in the
1960s when, in a wild raid, all male residents were taken away by police
and military and numerous houses were set on fire because a village was
suspected of being involved in bomb attacks against the Italian
“occupation” of South Tyrol. For a long time this area has been suffering
from emigration, but also from depressions and substance abuse. I had been
called as a general practitioner to certify the death of a single farmer who
had hanged himself in his living room only shortly before.
 Since our regular regular physician-manned ambulance is in repair, we
have to go out today with a replacement physician-manned ambulance. The
van is spacious, but it has already been on the road for many years and has
racked up a lot of mileage, and it winds its way up the steep road to the
scene of the accident at a maximum speed of 40–50 km/h (25–31 mph). I
estimate that we will need about 20 min to get there, and that the chances of
saving the patient are tending towards zero. When we reach the farm and
enter the living room, I see a man in his early fifties lying on the floor and
the EMS team performing cardiopulmonary resuscitation. There are no
relatives to be seen. I am told that the patient was already motionless when
the first team arrived, so an unobserved circulatory arrest, and, as expected,
probably very poor prospects.
I immediately order preparation for endotracheal intubation. I am
greatly surprised when, during laryngoscopy, I see that the glottis is closed
by a finger-thick piece of meat. With the Magill forceps, I pull the foreign
body out like a champagne cork, insert the tube into the trachea and
ventilate with 100% oxygen. The ECG shows asystole. It is worth trying
with epinephrine and shortly thereafter, a sinus bradycardia sets in. After
another 1 mg dose of adrenaline, the heart frequency normalizes, a carotid
pulse can finally be palpated and a systolic blood pressure of 90 mmHg can
be measured. We wait a few more minutes for the stabilization of
circulation and then decide on a quick transport to the hospital.
After we brought the patient into the physician-manned ambulance, we
set off downhill: The driver at the wheel, the paramedic in the cabin and me
with the patient. There are no complications, the heart is beating
rhythmically, the cardiac performance is sufficient, I am more than
satisfied, when on one of the steepest sections of the road the car suddenly
picks up speed, becomes faster and faster and the driver turns around and
shouts “hey Doc, the brakes have failed!” I think now we have saved the
patient and everyone falls into the abyss—instead of one dead, there are
maybe 4 dead! We immediately set ourselves with our backs to the direction
of travel against the wall of the cabin (the patient is anyway strapped in)
and hope that the driver will still get the situation under control. And
indeed, the professional truck driver and voluntary paramedic manages to
reduce the speed by shifting and operating the handbrake so that he can
cope with the steep section with the engine brake. However, now we only
continue in first gear and a speed of 20 km/h (12.4 mph), so we need almost
40 min to reach the hospital. To top it all off, we also crash into a concrete
pillar in the underground car park on the way into the hospital. We reach the
emergency room quite exhausted from this horror ride and hand over the
still circulatory stable patient.

Discussion
There are, against all statistics, sometimes exceptions to the rule. It is
known that a normothermic patient cannot survive a circulatory arrest for
more than 10–15 min. When estimating the chance of survival of a
circulatory arrest, we often assume a cardiac cause, where this deadline
actually applies. In this case, however, the circulatory arrest was not due
to a cardiac cause, but to an asphyxia caused by a high-sitting bolus. An
obstruction of the airways leads to alveolar hypoxia, coronary
hypoperfusion and secondary to cardiac circulatory arrest. Experimental
studies have shown that up to the onset of pulselessness 3 to 10 min can
pass [1, 2] and the time from the event to asystole can take up to 20 min
[3]. It is also not excluded that in our case the bolus did not hermetically
seal the airway and thus extended this “gallows period”.
The vehicles of the emergency medical service also take part in road
traffic and can thus be involved in an accident, especially when driving
with lights and sirens—regularly one reads reports about it in the
newspaper. Again and again we observe that physicians and paramedics
do not fasten their seat belts, especially when accompanying a patient in
the physician-manned ambulance. It should be noted that there are many
corners and edges in the patient compartment of a physician-manned
ambulance, which can cause considerable injuries if, for example, one is
thrown against it in an accident. The most important thing: While we
show our students that they have to pay attention to their own protection
at an accident site in addition to saving lives, we are often careless in
everyday emergency medical care. In Tyrol / Austria, the driver of an
ambulance was charged with negligent homicide because he drove into a
car, causing the transported patient to be so seriously injured that she
eventually died; (ORF, 11.04.2012) on the Internet you can quickly find
similar cases.
44.1 Conclusion
If there is a suspicion of obstructive asphyxia when finding an unconscious
person, one should also be careful in the assessment of the chances of
success of cardiopulmonary resuscitation in the event of an unobserved
cardiac arrest and not regard longer time intervals from circulatory collapse
to the beginning of CPR as hopeless. This mainly affects bolus death, but
also avalanche burial [3] and hanging. In general, this case confirms that an
optimistic attitude is not wrong in these resuscitation situations. But it also
shows that in emergency medicine one always has to expect everything, one
is never safe from surprises and emergency physicians can sometimes be
exposed to unpredictable risks. Sometimes it takes a good portion of luck to
bring both the patient and oneself safely into port. One should never forget
self-protection.

References
1. Safar P, Paradis NA, Weil MH (2007) Asphyxial cardiac arrest. In: Paradis NA, Halperin HR,
Kern KB, Wenzel V, Chamberlain DA (Hrsg) Cardiac arrest – the science and practice of
resuscitation medicine. Cambridge University Press, Cambridge, S 969–993

2. Varvarousi G, Xanthos T, Lappas T, Lekka N, Goulas S, Dontas I, Perrea D, Stefanadis C,

Papadimitriou L (2011) Asphyxial cardiac arrest, resuscitation and neurological outcome in a
Landrace/Large-white swine model. Lab Anim 45(3):184–190

3. Heschl S, Paal P, Farzi S (2013) Electrical cardiac activity in an avalanche victim dying of
asphyxia. Resuscitation 84:e143–144
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_45

45. Injury From Power Line

Jan Breckwoldt1
(1) University Hospital, Department of Anesthesiology, Zürich,
Switzerland

Jan Breckwoldt
Email: [email protected]

There are topics that are underrepresented in emergency medical theory

and practice, and communication of “bad news” definitely and
unfortunately falls into that category. This case provides some helpful
approaches to deal with it.

Late one beautiful summer day—not too hot, not too cold—we fly to a
large forest with our EMS helicopter. In addition to the approximate
location of the incident, our only information is “SI” (Severe Injury). From
the air, we can see an ambulance near a single-track railway line in a pine
and birch forest, with two paramedics and a person lying on the ground near
it; other than that, there is nothing but forest as far as the eye can see. We
land a short distance from the railway track and make our way up a gentle
hill. Now we see a ladder against an overhead power line of the railway,
from which the high-voltage technician has fallen about 5 m. As far as we
can determine, the patient had contact with 14,000 V of electricity and then
fell onto the relatively soft forest floor; a body check reveals no indications
of fractures of the large bones.
The patient is awake and responding appropriately; when asked, he
reports severe pain in his right leg but also in the corresponding arm. The
right trouser leg and right boot are completely charred, the affected
extremity is completely stiff, and the right hand shows clear signs of
electrical burns. The patient cannot give any account of the accident, but the
pattern of injuries suggests that the 14,000 V from the overhead power line
completely traversed the right side of the patient’s body, causing severe
thermal damage to the internal organs in the process. I have treated some
patients with such severe electrical injuries in the course of my years in the
emergency room of our university hospital, and I have always been very
affected by how clear-headed these patients were shortly after the electrical
accident, even though they had an injury that was almost certainly fatal.
Mechanistically, it was clear what needed to be done for this patient in the
forest: analgesia and air transport to the burn center. Because of the possible
hallucinogenic side effects, not to mention the bright sunlight and the
subsequent helicopter transport, I ruled out the option of ketamine for
spontaneous respiration. So we prepared for general anesthesia. While I was
talking to the patient, I had the feeling that he did not understand at all how
serious his situation was I certainly wouldn’t want to bet on it, but I was
convinced of an absolutely bleak prognosis. Should I tell him? In the end, I
decided against it, opting instead to get him pain-free and conscious for this
beautiful summer day. We then titrated the patient with fentanyl until he
was pain-free. When I asked him, just before induction of anesthesia, to
imagine something very beautiful, he spoke of his wife and children. Then
he fell asleep. For me, it was clear that these were probably the last
thoughts in his life.
He later died of the consequences of his injuries in the burn center,
without ever regaining consciousness.
The question that went through my head at the time, I still can’t answer
for sure. How “honest” should we be with the patients entrusted to us,
especially when our contact is short and brief, as is so often the case in
emergency medicine? In the end, I made the decision at the time because I
thought it wouldn’t have made any difference either way - neither for the
patient nor for the relatives. But maybe he could have left an important
message for his family? And was I really sure with my prognosis? And
could I really have conveyed the situation to him in such a short time? If I
were in such a situation again, I would probably ask if I should pass on a
message to his wife.

Discussion
A Medline search for the question of what and how to communicate
“bad news” in emergency medicine only provides results for
communicating with relatives [1], while disciplines such as oncology, in
which patients are accompanied for years, have a lot of experience with
direct communication with the patient [2]. Why communication of “bad
news” in emergency medicine is extremely difficult becomes clear when
looking at the probably most widespread model for conveying bad news,
the SIPKES model [3]. In this 6-step model, the conversation is first
prepared spatially and in content (“Setting”), then it is asked what the
patient and possibly his family already know (“[patient’s] Perception”),
it is checked how the information is to be handled (“Invitation”) and
only then it is announced that “bad news” are to be conveyed, including
the specific content (“[provide] Knowledge”). In the following steps, the
emotions are processed (“[addressing] Emotions”) and the goals and
priorities for further treatment and the exact plan of how this is to be
achieved are set (“Strategy and Summary”) [3]. Such a step-by-step and
careful communication is not possible in emergency medicine, on the
one hand because of the blatant time pressure and on the other hand
because an accurate prognosis often cannot be estimated. For the -
certainly easier - communication with relatives in the field of emergency
medicine, however, the SPIKES model offers a good basis and
corresponding content has now been included in emergency medical
training [4] and in student curricula [5]. Incidentally, a study on
conveying “bad news” in the emergency room showed that the
communication process was perceived more positively by the relatives
than by the physicians who conveyed the news [6].
For direct communication with dying emergency patients, orientation
to a stepwise model appears to be less suitable. Nevertheless, even in a
short time window, we can send positive signals to patients and their
relatives and avoid negative messages. As a patient cared for by
hematooncologists in Boston wrote, “you should never say ‘we can’t do
anything more for you,’ this ignores, the treatment of pain and creates a
feeling of being completely lost.” [7] Two oncologists from Germany
also consider communicating bad news to be one of the most difficult,
but also one of the most important medical task, regardless of the
specialty. In their article, they explain the decisive influence that
communicative skills have on the subjective well-being of patients and
 their relatives, as well as on compliance, emotional disease processing
and the ability to make decisions. [8].
The Swiss writer and architect Max Frisch wrote: “One should hold
the truth out to the other like a coat for him to slip into, and not slap it
around his ears like a wet rag.” [9] How we can best proceed under the
special conditions of emergency medicine in short conversations with
patients and their relatives is answered by general practitioners from
Houston, Texas: “Hope is always important for people. Physicians
should convey hope without raising unrealistic expectations.” [10]

45.1 Conclusion
Breaking bad news in emergency medicine is very difficult due to the time
pressure, unclear prognosis and largely absent intimacy. Instead, positive
communication should be used and hope should be conveyed, without
raising unrealistic hopes. If a patient with fatal injuries is still conscious
before induction of anesthesia, it is possible to ask whether any information
should be passed to the relatives.

References
1. Limehouse WE, Feeser VR, Bookman KJ, Derse A (2012) A model for emergency department
end-of-life communications after acute devastating events–part I: decision-making capacity,
surrogates, and advance directives. Acad Emerg Med 19:E1068–E1072
[Crossref][PubMed]

2. Cherny NI (2011) Factors influencing the attitudes and behaviors of oncologists regarding the
truthful disclosure of information to patients with advanced and incurable cancer.
Psychooncology 20:1269–1284
[Crossref][PubMed]

3. Baile WF, Buckman R, Lenzi R, Glober G, Beale EA, Kudelka AP (2000) SPIKES – a six-step
protocol for delivering bad news: application to the patient with cancer. Oncologist 5:302–311
[Crossref][PubMed]

4. Servotte JC, Bragard I, Szyld D, Van Ngoc P, Scholtes B, Van Cauwenberge I, Donneau AF,
Dardenne N, Goosse M, Pilote B, Guillaume M, Ghuysen A (2019) Efficacy of a short role-play
training on breaking bad news in the emergency department. West J Emerg Med 20:893–902
[Crossref][PubMed][PubMedCentral]
5.
Bächli P, Meindl-Fridez C, Weiss-Breckwoldt AN, Breckwoldt J. (2019) Challenging cases
during clinical clerkships beyond the domain of the „medical expert“: an analysis of students’
 case vignettes. GMS J Med Educ 36:Doc30

6. Toutin-Dias G, Daglius-Dias R, Scalabrini-Neto A (2018) Breaking bad news in the emergency

department: a comparative analysis among residents, patients and family members’ perceptions.
Eur J Emerg Med 25:71–76
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7. Dias L, Chabner BA, Lynch TJ Jr, Penson RT (2003) Breaking bad news: a patient’s perspective.
Oncologist 8:587–596
[Crossref][PubMed]

8. Schilling G, Mehnert A (2014) Breaking bad news–a challenge for every physician. Med Klin
Intensivmed Notfmed 109:609–613
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9. Frisch M (1983) Die Tagebücher, 1946–1949. Suhrkamp, Berlin, S 1966–1971

10. Whitney SN, McCullough LB, Fruge E, McGuire AL, Volk RJ (2008) Beyond breaking bad
news: the roles of hope and hopefulness. Cancer 113:442–445
[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_46

46. Person Trapped

Frank Marx1
(1) Intensive Care Helicopter Christoph Giessen, Malteser Hilfsdienst
Diözese Münster, Giessen / Münster, Germany

Frank Marx
Email: [email protected]

“Making decisions prospectively is much harder than retrospectively

evaluating.” Those who work in emergency services know very well
what is meant by this statement. The present case shows how difficult it
can be sometimes to make the “right” decision, as often one cannot be
sure which one this is.

Half an hour before sunrise and thus before the official readiness for
duty, the EMS control center calls the EMS helicopter station and asks if a
mission on a country road about 18 flight minutes (approx. 45 km (28
miles) by air) away in the rural part of the EMS helicopter’s area of
operations would be possible. We, that is a police officer and pilot of the
federal police, a rescue assistant of the professional fire brigade and I as an
emergency physician of the professional fire brigade Duisburg / Germany,
check the helicopter and 10 min later we take off with our “Christoph 9”
into the morning and arrive at the scene of the accident at 6:50 am. Already
on the approach we see the crashed car standing on a meadow in front of a
tree; the fire brigade has already cut off the roof of the car and the first
arriving emergency physician is trying to help the patient. We land on the
meadow about 50 m (55 yards) next to the accident site and then report to
the incident commander of the fire brigade and the emergency physician
who is with the patient trapped in the vehicle. Based on accident witnesses,
it turns out that the approximately 45-year-old patient drove her upper class
car into a road tree at full speed and without braking; we cannot determine a
cause of the accident. The front of the car has been so deformed by the
accident that direct treatment of the patient without removing the roof was
not possible. Between the accident and the removal of the roof, about
20 min passed; meanwhile, the rescue forces have been on site for about
35 min.
The engine room has pushed so deep into the passenger compartment
that both lower legs are pressed and fractured under the front seat. The front
seat is also raised cover-wise by the deformation of the passenger cell; as a
result, the upper legs are only limitedly visible. The patient’s respiration is
bradypnoeic with a frequency of 8 breaths per minute, the airways are clear.
Breathing is assisted with a mask and 100% oxygen and the cervical spine
is immobilized. A carotid pulse is palpable, but not pulses on the upper arm
and on the radial artery, which points to a severe shock state. The automatic
blood pressure measurement does not produce a result; the manual
measurement results in a systolic blood pressure of only 60 mmHg, since
the use of the stethoscope is impossible due to the exterior noise from the
power generator and the cutting device of the fire department as well as the
noise of voices from the rescue workers. The patient is unconscious and
reacts to strong pain stimuli with uncoordinated defense movements.
Several puncture sites on the arms testify to the frustrated attempts of the
first arriving rescue workers to create a venous access; I also cannot find a
vein on the arm. My puncture attempt of the right internal jugular vein also
runs—as expected—frustrated in the sitting patient. Therefore, I choose the
method of intraosseous puncture of the humerus head with a drill, since the
lower legs are not accessible to me as a preferred puncture site. The
puncture succeeds easily and after functional control an infusion with
hydroxyethyl starch 6% is connected; using the infusion pump, the infusion
runs freely in the beam. The emergency physician quickly injects 2 ml of
cafedrin / theodrenalin to raise blood pressure. However, this does not lead
to a significant increase in systolic blood pressure within 3 min, which is
checked closely by manual means. Therefore, we connect an infusion pump
with norepinephrine (5 mg/50 ml with 15 ml/h). We measure blood pressure
every minute while the fire department feverishly tries to free the patient’s
legs. As another 3 min later the blood pressure still does not rise, I double
the speed of the norepinephrine infusion pump to 30 ml/h. Now, with an
infusion volume of in the meantime 750 ml of hydroxyethyl starch, the
blood pressure rises to 85 mmHg systolic.
Probably due to improved cerebral perfusion, the patient suddenly
moves; in particular, she performs defensive movements with her arms,
which in turn leads to dislocation of the intraosseous cannula. The infusion
is then stopped and a new puncture is made in the area of the humerus head
on the contralateral side. This is done without problems and both volume
substitution and infusion of norepinephrine work smoothly. To avoid
movements, the patient is now anesthetized with 0.2 mg fentanyl and 15 mg
hypnomidate and subsequently paralyzed with 100 mg succinylcholine. The
subsequent intubation attempt fails several times in the upright patient, so I
decide to continue the ventilation manually with a breathing bag and the
Esmarch-handle behind the patient. With sufficient spontaneous respiration,
this synchronized intermittent ventilation with the self-inflatable bag works
quite well for me. I hold the mask with both hands and a rescue assistant
ventilates the patient with a tidal volume of about 400 ml. Another rescue
assistant carefully ensures that the patient does not move her arm. As soon
as the fire department arrived, they set up a number of halogen lamps to
have enough working light in the dawn and to avoid hypothermia of the
patient in view of the 5°C (41 °F) outside temperature. Finally, after 55 min,
the patient is freed from the vehicle; in the ambulance, anesthesia is
deepened and intubation is now successful. A naso-gastric tube is placed
through the mouth, as air has entered the stomach during mask ventilation.
Puncture attempts of the femoral vein and the left internal jugular vein fail;
a puncture of the left subclavian vein is done without problems and further
infusion solutions are now administered through this venous access. During
inspection of the patient, it is now noticed that the right pupil is much wider
than the left pupil and reacts slower to light. Both lower legs have open
fractures in several places; the thorax and pelvis have no abnormalities.
With a norepinephrine infusion of 3 mg/h, a systolic blood pressure of
80 mmHg is achieved; heart rate is 120/min. The patient is now transferred
to the helicopter stretcher; we plan to fly to a university hospital that is only
about 5 min away by helicopter. Treatment in the ambulance with venous
access, anesthesia, intubation, examination and wound care takes about
20 min, so that now about 90 min have passed since the accident.
 During the startup phase of the EMS helicopter, the patient suddenly has
ventricular tachycardia, which progresses into ventricular fibrillation. The
startup process is aborted and the engines are shut down. The patient is
defibrillated with 200 J and we perform chest compressions. This leads to
stabilization of the circulation within 2 min, which is recognizable by an
increasing expiratory carbon dioxide. A blood pressure measurement on the
upper arm does not result in anything. The patient is now transferred to the
ambulance; due to the unstable circulation, transport by helicopter is no
longer possible. When loading the patient into the ambulance, cardiac arrest
occurs again. In the event of asystole, we now start chest compressions
again and drive to a local hospital that is only 5 km (3 miles) away. Here an
automatic device for chest compressions is connected; 30 min later,
resuscitation efforts are discontinued. No autopsy was performed to
determine the exact pattern of injury.

Discussion
There are many aspects to consider this mission as unusual. Especially in
air rescue, the safety aspect is of great importance and therefore in
critical situations such as darkness and bad weather, a mission is more
likely to be rejected because of the associated risks, than it is carried out
with high risk for the emergency personnel [1]. Registration for daily
duty of the EMS helicopter at 07:00 AM is therefore also an established
procedure, from which is only rarely deviated. However, the pilot
estimated the light conditions at the expected time of arrival at the scene
of the accident and that was the reason why he was willing to carry out
this flight. While take-offs and landings at approved landing sites for
helicopters are relatively safe even in darkness or twilight, this situation
is completely different for external landings—too easily cables, wires or
ground obstacles can be overlooked, which can then lead to fatal
accidents [2]. In the USA, where EMS helicopter traditionally fly during
the day and at night, in 2008 the most dangerous profession was “pilot of
an EMS helicopter”, even before the traditionally very dangerous
professions of deep-sea fishermen, coal miners and loggers. In fact, in
2008 in the USA, 29 people died in 12 accidents with EMS helicopters;
so 2 fatal accidents occurred per 100,000 flight hours, while 1.3 fatal
accidents occurred per 100,000 flight hours in general aviation and only
0.08 in commercial aviation.
 It has been shown to be effective that the medical crew not only
introduces themselves to the EMS colleagues at the accident site, but
also to the fire department’s incident commander, in order to coordinate
the technical and medical rescue. After several attempts to rescue the
trapped patient with rescue shears and a rescue spreader failed, we
decided to pull the wrecked vehicle apart between 2 fire department
vehicles about 45 min after the rescue effort began; a time period that
often occurs for a difficult technical rescue [3, 4]. Finally, it was possible
to pull the front vehicle far enough away from the front seats so that the
patient could be lifted out of the vehicle sideways.
In the end, my decision to carry out a helicopter transport was
questionable; perhaps the immediate transport to the smaller hospital
nearby would have been more sensible, even though the resources there
were scarce and a subsequent transfer would have been necessary after
initial stabilization. This shows that a decision cannot be made
categorically when it comes to the question “stay & play vs. load & go”,
but is strongly dependent on the situation, for example on blood loss,
volume resuscitation and injury pattern [5]. The use of intraosseous
needles in emergency medicine has experienced a renaissance in recent
years [6]. Usually the anterior edge of the tibia is chosen because it is
easy to identify and because fixation of the needle usually works safely;
other puncture sites such as on the humerus as in our patient or on the
radius are also possible, but are not used as often. In our case,
intraosseous infusion was not sufficient to correct the volume deficit; it
was also not possible to insert a central venous catheter in the car,
probably because of the patient’s sitting position with a severe volume
deficit. It cannot be answered which outcome our patient would have had
without the entrapment in the car; but the duration of the entrapment
shows how fatal the time can be for the outcome in severe post-traumatic
shock [7].

46.1 Conclusion
Despite very good cooperation between medical and technical personnel, it
was initially not possible to rescue the trapped patient and then stabilize
circulation. Given these frustrations and a subjectively felt helplessness, one
must keep a cool head and be aware that one has to make decisions
constantly during such a mission, even though one can only assess many
unknown, indeed unpredictable variables to a limited extent. It is much
more difficult to decide prospectively than to evaluate retrospectively.

References
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crashes: what influences fatal outcome? Ann Emerg Med 47:351–356
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2. Hinkelbein J, Spelten O, Neuhaus C, Hinkelbein M, Ozgur E, Wetsch WA (2013) Injury severity

and seating position in accidents with German EMS helicopters. Accid Anal Prev 59:283–288
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3. Nutbeam T, Fenwick R, Hobson C, Holland V, Palmer M (2015) Extrication time prediction tool.
Emerg Med J 32:401–403
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4. Nutbeam T, Fenwick R, Hobson C, Holland V, Palmer M (2014) The stages of extrication: a

prospective study. Emerg Med J 31:1006–1008
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5. Wears RL, Winton CN (1990) Load and go versus stay and play: analysis of prehospital i. v. fluid
therapy by computer simulation. Ann Emerg Med 19:163–168
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6. Helm M, Schlechtriemen T, Haunstein B, Gassler M, Lampl L, Braun J (2013) Intraosseous

infusion in the German Air Rescue Service: guideline recommendations versus mission reality.
Anaesthesist 62:981–987
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7. Demetriades D, Chan L, Cornwell E, Belzberg H, Berne TV, Asensio J, Chan D, Eckstein M, Alo
K (1996) Paramedic vs private transportation of trauma patients. Effect on outcome. Arch Surg
131:133–138
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© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_47

47. Cardiologist with Heart Attack

Jan Breckwoldt1
(1) University Hospital , Department of Anesthesiology, Zürich,
Switzerland

Jan Breckwoldt
Email: [email protected]

What if physicians themselves become patients? How objectively can

they assess their own illness? And how should colleagues behave
correctly towards “physicians-patients”? The present case provides
approaches to address these problems.

The mission statement is “severe chest pain” in a well-to-do inner-city

area. At the mission address, we are let into a well-kept and elegantly
furnished new building by the patient himself. The man in his mid-sixties
has kept himself physically well, but shows the classic clinical signs of an
acute coronary syndrome. We work through our routine for the treatment of
an acute coronary syndrome quickly and while writing the 12-channel ECG,
we quickly get into conversation with the patient. He retired half a year ago
and has now moved to the city to enjoy the rich cultural offer. He was active
as an interventional cardiologist until the end. Meanwhile, the ECG strip
comes out of the machine and our joint visual diagnosis leaves no doubt
about the ST-segment-elevation infarction. The patient has seen and treated
such an ECG hundreds of times in his patients. With his symptomatology,
he probably suspected something, but is nevertheless surprised that now the
ECG strip clearly shows his own myocardial infarction. The work routine
of our physician-manned ambulance now always includes the question of
inclusion in the current myocardial infarction study, at that time a
randomized, placebo-controlled comparison of a thrombolytic agent within
the first 3 h of the myocardial infarction. The colleague refuses
randomization. So we continue to treat him conventionally, with prior
notice in the cardiac catheterization laboratory. When loading him into the
ambulance, he suddenly develops ventricular fibrillation, but after two
defibrillations including 2 min of chest compressions, he is
rhythmologically and hemodynamically stable again. If he had not regained
spontaneous circulation, we would have given him thrombolysis in
accordance with the guidelines. The patient receives multiple stenting in the
cardiac catheterization laboratory and recovers well.

Discussion
The treatment of physicians is a difficult field; British colleagues say
about it: “With medics, things tend to go wrong”; US colleagues say:
“Physicians are the worst patients”. The fact that disproportionately
many physicians do not have a family physician shows that many find it
very difficult to take on the role of a patient, probably because they do
not like to confront their own weakness. There is often an unspoken
mistrust that adversely affects the quality of treatment [1]. Many doctors
find it embarrassing to have to reveal their health concerns and needs,
their self-diagnosis may be wrong or they may have existential fears if,
for example, a depression or substance abuse spreads among colleagues
perceived as competition [1]. Furthermore, there is often a professional
skepticism towards treating physicians as well as fears that the
confidentiality of information is endangered, as can be read from various
reports on the treatment deficits in cases of illness [2]. In an English
study, 84% of the drugs that they had taken in the last five years were
self-prescribed by general practitioners [3]. When an external evaluation
of the selection and dosage of the respective drugs was carried out, this
self-medication was rated as wrong or insufficient in more than three
quarters of the cases. “Illness does not belong to us”, scientists from
London titled their study in which they asked general practitioners about
their own illness [4]; for example, a general practitioner with a
psychiatric illness felt guilty of being ill and saw himself as a failure,
two other general practitioners with a thyrotoxic crisis or hepatitis tried
to significantly reduce the medically prescribed rest period. A researcher
from Heidelberg / Germany describes the way physicians deal with their
own illness as a development in five stages [5]. While in medical school,
after learning about many diseases, a reactive hypochondria can develop,
the “hard” medical phase follows with dogmatic health, which gladly
represses disease signals. In the third phase, the physician does notice
annoying complaints such as headaches or insomnia, but avoids
consulting colleagues and prefers to treat himself. If, in the fourth phase,
a symptom makes the physician objectively unable to work, he seeks
collegial conversation, but remains inconsistent through “physician-
shopping” and lack of follow-up, which ultimately makes him feel
abandoned by himself. In the fifth phase, the physician is a suffering
patient who seeks a compassionate treating physician who is also able to
assert himself against him; only from here on are physicians normal
patients [5]. These mechanisms should be made conscious and also
discussed openly with “physician patients”. Even if you maintain a
professional distance, it can happen quickly that you omit certain
diagnostic or therapeutic steps or implement them half-heartedly or too
cautiously. In non-emergency situations, it is relatively easy to take a
step back and pass the task on to more experienced colleagues or to
emotionally less involved physicians. But this is not possible in the
emergency medical service.
The head of the Institute for Medical Health in Villingen-
Schwenningen / Germany describes ten recommendations for the
“physician patient” [6], namely:
1.
Seek help in time;
2.
consult another physician, not yourself;
3.
ask the treating physician to treat you as he would any other
patient;
4.
have a medical record made;
5.
get all the recommendations that “normal” patients get;
6. follow the normal course of examination and treatment;
7.
absolutely follow the recommendations (e.g. medication, diet, sick
leave);
8.
inform your family and friends;
9.
also inform your colleagues and
10.
reflect on your lifestyle in relation to your illness.
On the other hand, he also formulates ten recommendations for the
physician treating a sick physician, [6] namely
1.
thoroughly examine the “physician-patient”;
2.
pay attention to open and comprehensive communication;
3.
clearly formulate what you think is the best treatment;
4.
keep a medical record;
5.
follow your usual routine (no exceptions, no short-cuts, no VIP
bonus);
6.
ensure the confidentiality of the data;
7.
explain all recommendations thoroughly;
8.
only you decide on the duration of the hospital treatment and sick
leave;
9.
You are the treating physician, your colleague the patient and
10.
create a network in which physicians are treated well.
An emeritus neurologist from the University of Colorado comes to
very similar recommendations from his 43 years of experience in
 treating physicians [7]:
Do not accept patients with special status, for whom you feel
pressure or anxiety in their treatment;
carry out the examination and treatment as usual;
openly discuss the fears of the “physician-patient”;
define early and exactly your “physician-physician-patient”
relationship;
avoid excessive sympathy or empathy;
discuss the planned diagnostics and treatment in detail to reduce
anxiety;
insist on enough time to discuss your opinion and recommendations
well;
discuss personal matters and ensure absolute confidentiality;
proceed professionally and expect unjustified criticism as well.

47.1 Conclusion
From an emergency medical perspective, it is important to communicate
openly as early as possible in the treatment of “doctor-patients”, with regard
to the patient’s fears, one’s own safety and insecurity, the diagnostic and
therapeutic approach and absolute confidentiality. All processes should be
carried out and documented as carefully as with all other patients in order to
be able to act with sufficient professional distance.

References
1. Kay M, Mitchell G, Clavarino A, Doust J (2008) Doctors as patients: a systematic review of
doctors’ health access and the barriers they experience. Br J Gen Pract 58:501–508
[Crossref][PubMed][PubMedCentral]

2. Lam ST (2014) Special considerations in the care of the physician-patient: a lesson for medical
education. Acad Psychiatry 38:632–637
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3. Chambers R, Belcher J (1992) Self-reported health care over the past 10 years: a survey of
general practitioners. Br J Gen Pract 42:153–156
[PubMed][PubMedCentral]
4.
McKevitt C, Morgan M (1997) Illness doesn’t belong to us. J R Soc Med 90:491–495
 [Crossref][PubMed][PubMedCentral]

5. Ripke T (2000) The sick physician: opportunity for a better understanding of the patient. Dtsch
Ärzteblatt 97:A-237–240

6. Maulen B (2008) Physicians as patients–physicians treating other physicians. Dtsch Med

Wochenschr 133:30–33
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7. Schneck SA (1998) „Doctoring“ doctors and their families. JAMA 280:2039–2042

[Crossref][PubMed]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_48

48. Fall From Tree House

Peter Hilbert-Carius1
(1) Department of Anesthesiology, Intensive Care, and Emergency
Medicine, BG Trauma Hospital Bergmannstrost, Halle / Saale,
Germany

Peter Hilbert-Carius
Email: [email protected]

There are events that remain without words—like this one.

Felix is a happy, alert 9-year-old boy who plays on his small “tree
house” on an August day at 1:30 pm. On this vacation day, Felix, his
mother and his sister host a visit from a family friend and her daughter.
Felix’s father is working as an emergency physician on an EMS helicopter
that day, so he is not at home. Since “tree houses” are more for boys, Felix’s
sister and her friend decide to go to the pool and Felix plays by himself on
his house. Here he has a small pulley and a plate swing, the rope of which
he has wrapped around the railing of the “tree house”.
How exactly it happens, nobody can say, since the event happens
unobserved. Somehow the little Felix must have lost his balance and falls
from about 1.5 m from the platform of his “tree house”. In doing so, he
must have come across the neck on the rope of his swing plate in the fall.
After the fall on the lawn, Felix gets up again and wants to walk towards
the house. Since the family’s friend has noticed that Felix has landed on the
lawn, she runs in his direction to see if he has hurt himself. Felix takes 3
steps in her direction and expresses with hardly audible voice that he could
not get any air. Then he becomes unconscious and collapses. From his
mouth runs some bloody-foamy secretion. The family’s friend, who hurries
to Felix, is a trained nurse and recognizes the drama of the situation. Due to
the unconsciousness and the lack of breathing, she begins to revive the little
Felix. In parallel, the emergency call is made at 13:47 at the responsible
EMS control center. At 13:49 the physicain-manned ambulance and the
ambulance alarmed leave and reach the scene of the accident at 13:52. Here
Felix is still being resuscitated; the EMS team takes over the resuscitation
attempt and continues it. After connecting the monitoring, a bradycardia
with 30/min and a peripheral oxygen saturation of 84% is shown in the
monitoring device. To secure the airway, Felix is intubated by the
emergency physician, which apparently succeeds without problems, with a
lot of blood in the pharynx and larynx. When trying to ventilate via the
endotracheal tube, it becomes clear that the lungs are not being inflated on
both sides and with each attempt to breathe, a skin emphysema develops on
the neck. In parallel to the attempt to secure the airway, a venous access is
inserted in the right elbow. Due to the impossibility of ventilating via the
endotracheal tube, this is removed again and the CPR attempt is continued
with bag-valve-mask ventilation. It quickly becomes clear that there must
be a respiratory problem that is difficult to treat prehospitally. The attempt
at a surgical airway is omitted. Due to the proximity to a hospital of
maximum care, the decision is made to take Felix to the hospital with
ongoing CPR. At 14:07, about 20 min after the emergency call, the
transport is carried out with ongoing CPR. During the prehospital therapy
interval, Felix receives a total of 3 times 0.3 mg (= 300 μg) epinephrine. At
14:09 the team reaches the emergency room of the hospital informed in
advance. Here in the ECG already an asystole is present.
In the emergency room, the colleagues from ENT first try to intubate
Felix by means of a rigid bronchoscope, which, however, leads to the same
frustrated result as the intubation attempt by the emergency physician and
does not contribute to secure the airway. Despite ongoing resuscitation
measures and injection of epinephrine, asystole is still present in the ECG,
which is not surprising, since a minimum of oxygen is necessary for
successful resuscitation of a child’s heart, which has not yet reached the
child’s lungs at this point in time. Due to the frustrated intubation attempts
by means of a rigid bronchoscope, the decision is now made to carry out an
emergency tracheotomy. This is made more difficult by the massive skin
emphysema, but is successful. Even after it has now been possible to secure
the airway and oxygenate the child, all further resuscitation measures
remain unsuccessful. The ECMO set up in the meantime is also not used
and little Felix finally dies due to hypoxia that cannot be eliminated in time.
The forensic examination shows that Felix was actually a healthy boy who
finally died of severe hypoxia when the trachea was torn off 4 cm above the
carina.

Discussion
Traumatic tracheal injuries or tears are extremely rare, rarer than
iatrogenic injuries to the trachea [1], but life-threatening. Many of these
traumatic tracheobronchial injuries end up fatal outside of the hospital
and only a high level of attention can already raise the suspicion
prehospitally of these injury patterns [2]. Clinical signs that may suggest
the presence of a tracheobronchial injury after an appropriate trauma
include dyspnoea, cyanosis, haemoptysis, dysphonia/hoarseness, skin
emphysema, persistent pneumothorax, hypotension up to cardiac arrest
[1, 3, 4]. Prehospital diagnosis is extremely difficult and the definitive
diagnosis is usually only made in the hospital. In addition to radiological
methods, such as chest x-ray or appropriate computed tomography,
which usually only provide indirect evidence of the injury, endoscopic
methods are available with which the injury can be visualized itself. A
relatively new method is multi-planar 3-D reconstruction using multi-
slice computed tomography, which allows virtual bronchoscopy []2]. In
addition to the possible difficulties in prehospital diagnosis, the
prehospital therapy can be very difficult. The acute treatment begins, as
with any trauma, according to the ABCDE rules of PHTLS®/ATLS®.
Securing of oxygenation has the highest priority. Therefore, (if not even
should) in spontaneously breathing patients with good oxygenation,
intubation should be avoided as far as possible, because an imprudent
anesthesia induction and intubation can lead to the following problems in
a so far possibly still sufficiently breathing patient: In the context of
rapid sequence induction, problems may develop with upper airway
injuries resulting in difficulties in intubation up to a complete laceration
of the airway with its deleterious consequences and in the context of
paralysis, a loss of muscle tone can lead to an airway obstruction, up to
all catastrophic consequences [2, 5]. With increasing dyspnea, disturbed
breathing and oxygenation, intubation at the emergency site is however
 life-saving, because by increasing swelling, bleeding or skin and
mediastinal emphysema, endotracheal intubation may eventually become
impossible. If, as in the described case, oral intubation or ventilation via
the endotracheal tube is not possible, a tracheotomy or open tracheotomy
may be necessary at the emergency site [4]. In the described case, this
procedure could possibly have been life-saving, but this assumption
remains purely speculative. In dramatic situations, as they presented
themselves in the case of Felix, often only invasive “dramatic” treatment
options can yield the desired success. The basis for this is a mastery of
appropriate therapeutic measures. Therefore, at this point, only every
person working in emergency medicine can be advised to intensively
deal with invasive emergency measures in the course of their training
and to practice them accordingly [6]. The actual emergency itself is the
worst time for this. Another possible option at the moment when it was
clear that ventilation via the endotracheal tube was not possible, would
have been a battery-operated flexible bronchoscope. Perhaps one could
have seen the distal tracheal opening at the end of the tube and then
placed the tube under control by carefully withdrawing it. Unfortunately,
such bronchoscopes are only sporadically available on physician-
manned EMS vehicles [7, 8].

Conclusion above is lacking had to die with his young 9 years due to an A-
problem (airway) according to PHTLS®/ATLS®, because it was not
possible to treat this problem adequately outside of or inside the hospital in
a timely manner. A-problems have the highest treatment priority according
to PHTLS®/ATLS®, as the case shows in a sad and dramatic way
impressively. Furthermore, the case should remind us that all those working
in prehospital and clinical intramural medicine should intensively deal with
the management of A-, B-, C-, D-, E-problems.

48.1 Last Words

In memory of Felix (* 17.03.2005 – ✝ 11.08.2014), who was actually born
to live, but had no luck. The parents of Felix have expressly agreed to this
publication in the hope that this case discussion may be helpful in similar
emergencies.
 “It is hard for me to live without you, to give everything at any time
every day. I often think back to what was, to every so beloved past day.
I imagine that you are standing next to me and that you are
accompanying me on every one of my ways. I think of so much since you
are no longer there, because you showed me how valuable life is.
We were born to live, with the wonders of each time, never to forget
each other for eternity. We were born to live for the one moment, because
each one of us felt how valuable life is.
It still hurts to create new space, to let something new in with a good
feeling. At this moment you are close to me again, as on every so beloved
past day.
It is my wish to allow dreams again, to look forward to the future
without regret. I see a meaning since you are no longer there, because you
showed me how valuable my life is [9].”

References
1. Paraschiv M (2014) Iatrogenic tracheobronchial rupture. J Med. Life 3:343–348

2. Prokakis C, Koletsis EN, Dedeilias P, Fligou F, Filos K, Dougenis D (2014) Airway trauma: a
review on epidemiology, mechanisms of injury, diagnosis and treatment. J Cardiothorac Surg
9:117
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3. Palade E, Passlick B (2011) Surgery of traumatic tracheal and tracheobronchial injuries. Chirurg
82:141–147
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4. Welter S, Hoffmann H (2013) Injuries to the tracheo-bronchial tree. Zentralbl Chir 138:111–116
[PubMed]

5. Abernathy JH III, Reeves ST (2010) Airway catastrophes. Curr Opin Anaesthesiol 23:41–46
[Crossref][PubMed]

6. Zink W, Volkl A, Martin E, Gries A (2002) Invasive emergency techniques (INTECH). A training
concept in emergency medicine. Anaesthesist 51:853–862
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7. Thierbach A, Lipp M (1999) Fiberoptic intubation in an emergency. Notfall Rettungsmed 2:105–

110
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8. Wagner MP (1999) Fiberoptic intubation in an emergency. Notfall Rettungsmed 2:39–47

[Crossref]
9.
The Duke and Unholy. Born to live. Unholy. 29–1–2010. Vertigo Berlin. Ref Type: Sound
Recording
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_49

49. Thrombolysis
Franziska Böhler1
(1) Emma Hospital, Department of Anesthesiology, Seligenstadt,
Germany

Franziska Böhler
Email: [email protected]

I had thrown my notice of termination in the mailbox of my nursing

manager. After 13 years in the intensive care unit, many weekends and two
children who could only experience their parents together once a month, it
was time for a change. Late shift on Friday: The feeling of only working
here for six more months was strange, but I decided to suppress the pain of
separation. During the handover, I was assigned two monitoring patients
and a critical case. The critical patient had undergone major abdominal
surgery the day before and had already complained of shortness of breath to
the colleagues in the early shift. When I entered the room, the
approximately 50-year-old man was already sitting upright in bed, sweating
and gasping for air. Within minutes, his condition deteriorated dramatically
and we had to start resuscitation.
When the diagnosis pulmonary embolism was made, a decision had to
be made together with the surgeons, we decided to carry out a thrombolysis.
In the meantime, the man’s wife and two adult daughters were also
informed about the situation. I can understand from my own painful
experience how devastating such news can feel. In the stressful everyday
work life, one sometimes forgets in which extreme situations the relatives
are when they see a loved one in the middle of a highly technologized room
on the intensive care unit, surrounded by machinery and cables, have to
give up control and experience a possibly life-threatening situation. And
above all: Can’t do anything yourself but wait.
In a short stable interval, we let the relatives into the room. While the
man’s wife calmly took his hand, the oldest daughter collapsed crying at the
bed. I don’t have to say that the human component is actually nothing that
you could prioritize—but if there are two other patients to take care of, then
there is actually nothing left to do. In a short conversation, I tried to
describe the patient’s condition, but had to send the family away again
because the patient became bradycardic again. In the meantime, the surgical
colleagues had decided on an abdominal CT to detect any perfusion
problems. Due to the thrombolysis, the patient was now bleeding from the
bladder, nose, mouth and the surgical wound on the stomach. The resident
physician and I had a bad feeling about the thought of transport to the CT
over two floors, especially since the patient was highly catecholamine-
dependent and unstable. So I got the portable ventilator and started to
rebuild all connections and disconnections. Then we went.
We passed the exit door of our intensive care unit and brushed over a
small floor wave, so that the bed wobbled a little—the blood pressure
dropped sharply due to the minimal vibration. The elevator was already
there, we drove in carefully and chose the second floor, where the CT was
located. The patient suddenly became maximally circulatory unstable; the
elevator door opened and the monitor confirmed asystole. So we drove
quickly to the CT corridor and started resuscitating again. While the
resident physician ordered reinforcements by phone, I carried out the
thoracic compressions. The man was losing more and more blood, with
each thoracic compression I could literally see the blood dripping from the
wound. Meanwhile, a colleague and the senior physician had arrived to
stabilize the patient primarily on the corridor. We ordered more blood
transfusions, opened the emergency kit and finally stood in a huge pool of
blood.
While eight hands tried to generate a stable circulation again, I heard the
elevator going down. It stopped two floors later, someone got on, and the
elevator came back. The doors opened and in front of us were the relatives
of the patient. Since the CT would take a while, they had decided to get
some fresh air, the exit was on the same floor. The sight that greeted them
should not be experienced by any relative: four hospital employees, who
were busy drawing up syringes, injecting drugs, turning on the ventilator,
still resuscitating—and everything, really everything, full of blood. Both
daughters collapsed screaming at that moment. The despair and the pain
that came with it burned persistently in me. The man who happened to be in
the elevator with us pressed the button back to the ground floor. After what
felt like an eternity, we stabilized the patient and could start the journey
back to the intensive care unit. The relatives had meanwhile returned to the
waiting area, from there you could see the corridor on which we drove past
with the patients. Again the children broke into tears, screamed, cried and
loudly called “Papa!”, “Papa!”
Back on the ward, my resident physician decided to insert a Shaldon
catheter for dialysis and volume replacement. In the meantime, my
colleagues had taken care of the other two patients who had been assigned
to me. After the creation of two large-lumen intravenous lines, we also
started with hemofiltration. It didn’t look good. After a few years of work,
after so many patients, you get a feeling for some courses. We were all sure
that day or at the latest that night our patient would not survive this day.
I asked the relatives who had been waiting all day to come back to the
room in the evening. I had removed the (blood) traces of thrombolysis as
best I could; the patient seemed stable for a short time. I was tired. After
this shift, it was not just the eight hours I had been on my feet non-stop—I
was also psychologically exhausted. This extreme situation in which the
family was—which they carried to the outside, in which they tried to find
comfort with me, weighed me down at the end of the shift. Also because I
was sure that this man would not survive the night. And that made me feel
so incredibly sorry. When I came back for the late shift the next day, my
eyes quickly fell on the transfer sheet—the patient was alive. Since I only
came on duty every other weekend due to my part-time job, I could not
observe the course of this patient on a daily basis. After a few weeks,
shortly before Christmas, the patient was tracheotomized and planned for a
rehabilitation hospital. The first attempts with the speech cannula were
sufficient.
After some time had passed, I received an invitation: The family had
organized a party. Among the guests were, among others, the visceral
surgeon who had spoken out in favor of thrombolysis at the time, the
resident physician who resuscitated with me on the CT corridor—and me. I
had always tried to maintain professional distance in dealing with patients,
but this case had come so close to me that I gladly accepted the invitation.
In my last memory there was a weakened man, slightly icteric and still
tracheotomized in a white hospital bed. Nine months later, the same person
suddenly stood in front of me—with a broad grin on his face and a beer in
his hand.

Discussion
A family member in an intensive care unit is the maximum stress for
relatives for a variety of reasons; the most important are probably the
difficulty of understanding the situation, the powerlessness of almost
nothing to do and of course the fear that the illness or injury is fatal. In
Pittsburgh, Pennsylvania, 24 family members were interviewed about a
month after the death of a relative in an intensive care unit in a structured
interview. All of them experienced the inclusion in the therapy decision
as valuable, because in this way helplessness was reduced and a piece of
control over the situation was regained, and human suffering was
reduced [1]. Pediatricians in Miami, Florida, interviewed the parents half
a year after the death of 47 infants or children in an intensive care unit
about what helped the least and the most [2]. Compassion, sensitivity,
willingness to help, experience, competence, understandable
explanations as well as the inclusion of parents in therapy and decision-
making were perceived as positive. The parents saw the most negative
conflicts with the intensive care unit team (e.g. “I explained that to you
yesterday—didn’t you understand it?”) as well as insensitive
communication (e.g. “Your son had an accident. Are you willing to
donate organs?”). In a Norwegian study, the satisfaction with the
intensive care unit team understandably correlated with a good outcome;
but also with good, consistent information about the patient’s condition
[3]. In Paris, the relatives, the patient and the intensive care unit team
make daily notes in a diary, which has improved the mutual
understanding, trust and information within the family of relatives, but
also of the intensive care unit team in a very impressive way [4]. Such an
exchange can be very intense and fulfilling; a colleague told me a similar
story to the one above about a roaring celebration of life with all
relatives when a patient could be discharged home after a long
complicated intensive care stay.
49.1 Conclusion
Sometimes—possibly even too often—we exclude or neglect relatives in
our work. This is usually not done with bad intentions, especially in times
of nursing shortages, it is also a question of resources: If there is already no
time for patients to receive attention and care, then there is even less time
for relatives. On the other hand, sometimes we may also not think enough
about how our actions, our communication, our handling of situations
shapes the experience of relatives. I admit that I had to stand on the other
side myself—as a worried, hopeful, desperate relative—until I realized how
crucial a caring approach to relatives can be. Relatives look closely at how
we—the medical and nursing staff—behave: how we speak, how we react
to situations and questions—and it affects them. Whether we have the extra
few minutes or even ask how the relatives are doing themselves. Just how a
sentence like “Visiting hours are now over.” is formulated and pronounced
—matter-of-factly or regretfully—can make a difference as to whether a
relative grieves for a long time or leaves the ward with the feeling that a
close person is in good hands.
In acute situations, things often have to happen very quickly, relatives
have to be quickly removed from the room and sit stunned during a
resuscitation attempt nearby. This can usually not be avoided in the current
situation, but it is important what happens afterwards: That we take the time
to explain what happened, show empathy, possibly express sincere regret.
And in the event of a death, to give the relatives plenty of time to say
goodbye [5] is often quickly sidelined in the hospital. All the more it is
appreciated if attention is paid to it.
The case described above is extreme and I know that the relatives of the
affected patient were in psychological care to process the experience—such
an emergency measure can shake outsiders that much. We should therefore
never forget to always keep the perspective of the relatives in mind in our
work and—to the extent that resources permit—to take them into account
and show empathy. Because I can assure you from my own experience:
When working through painful processes, this can be relevant, decisive or
at least helpful.

References
1. Nunez ER, Schenker Y, Joel ID, Reynolds CF 3rd, Dew MA, Arnold RM, Barnato AE (2015)
Acutely bereaved surrogates’ stories about the decision to limit life support in the ICU. Crit Care
Med 43:2387–2393
[Crossref][PubMed][PubMedCentral]

2. Brooten D, Youngblut JM, Seagrave L, Caicedo C, Hawthorne D, Hidalgo I, Roche R (2013)

Parent’s perceptions of health care providers actions around child ICU death: what helped, what
did not. Am J Hosp Palliat Care 30:40–49
[Crossref][PubMed]

3. Haave RO, Bakke HH, Schröder A (2021) Family satisfaction in the intensive care unit, a cross-
sectional study from Norway. BMC Emerg Med 21:20
[Crossref][PubMed][PubMedCentral]

4. Garrouste-Orgeas M, Périer A, Mouricou P, Grégoire C, Bruel C, Brochon S, Philippart F, Max A,

Misset B (2014) Writing in and reading ICU diaries: qualitative study of families’ experience in
the ICU. PLoS One 9:e110146.

5. Böhler F, Kubsova J (Hrsg) (2020) I’m a nurse: Warum ich meinen Beruf als Krankenschwester
liebe- trotz allem. Heyne, München.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_50

50. 5000 m / 16400 feet

Bernd Fertig1
(1) Department of Paramedicine, University of San Marcos, Lima, Peru;
and Autonomous University Gabriel Renè Moreno, Santa Cruz,
Bolivia, Institute for Patient Safety and Quality in Emergency
Medicine, Waldbronn, Germany

Bernd Fertig
Email: [email protected]

In August, at noon, a call for help comes in to the EMS helicopter in Lima,
Peru, from the Swiss embassy regarding a mountaineer who, at a distance
of approximately 450 km / 280 miles and an altitude of approximately 4600
m / 15100 feet, is suffering from altitude sickness. Due to the great distance,
the Bell-212 helicopter is filled to capacity with fuel and three additional
barrels (each 200 l) of jet fuel A1 are loaded. We unload the gasoline
barrels at a distance of approximately 60 km (38 miles) from the site of
operation. The co-pilot also remains there because the site of operation
would be near the service peak altitude of approximately 5500 m / 18000
feet of the helicopter. Any, even seemingly minor, weight savings are
helpful because, due to the decreasing air density, both the performance of
the engines and the overall lift decrease and the helicopter must have power
reserves just above ground level in order to avoid being brought down by
strong winds in the mountains. After landing at the base camp, we learn that
it is not a case of altitude sickness, but of an injured person who is
approximately 5000 m / 16400 feet above sea level. At an outside
temperature of −15 °C (5 °F), we find there, in a tent, a young, somnolent
man (Glasgow Coma Scale 6) with regular, uncoordinated stretching and
bending reactions on the left side of his body. The right pupil is dilated. The
breathing is partly obstructed by the tongue with a breathing rate of 6/min;
heart rate is 135/min, oxygen saturation 84% and blood pressure
110/80 mmHg. At an altitude of 5000 m / 16400 feet, such an oxygen
saturation is normal, but it also only represents an arterial oxygen partial
pressure of approximately 50 instead of approximately 95 mmHg at sea
level [1], which is unfavorable in the case of a head injury. The injured
person was hit on the head and right arm by an ice avalanche at an altitude
of approximately 5900 m / 19350 feet while climbing to the summit in the
afternoon of the day before and, as a result, suffered a head injury and a
fracture of the forearm; subsequently, the increasingly disoriented
mountaineer managed to descend, first with his climbing partner and then
with the help of other climbers, to the base camp, which, however, took
approximately 9 h for 900 altitude meters or 2950 feet. Later that morning,
a high-altitude worker reaches the next village in 3 h instead of the usual
6 h, so that the first call for help comes in about 18 h after the accident. Due
to the time pressure caused by bad weather, we can only provide a short
initial treatment with oxygen inhalation, intravenous access and
immobilization. We then fly to the intermediate landing site at an altitude of
approximately 3000 m / 9800 feet, where our co-pilot and our gasoline
barrels are waiting for us. The pilots fill the 600 L (158 gallons) of jet fuel
A1 that has been prepared, we intubate the patient and can take off for the
90-minute flight to Lima about 24 h after the accident. This is followed by
another 90 min in the ambulance between the airport and the hospital in this
metropolis of 11 million inhabitants. After admission to the hospital, the
patient undergoes immediately a craniotomy, during which an epidural
hematoma is relieved. The patient is then quickly weaned and successfully
extubated. He recovers very well, so that he can return to his Swiss home
one week later by a normal airliner. After our return from Peru, we visit the
patient on his mountain farm in Switzerland. It is a very moving reunion,
because it has become clear to both our patient and the parents how much
luck and good will of all involved had worked together here. This visit is
also very special for us, because everything had a good ending- often the
efforts had been similar in other missions, but the outcome was fatal for the
patient. We sit for a long time with the whole family in front of the farm
and enjoy the magnificent view over the mountains of the Swiss Alps. We
are all aware that here it will hardly take 15 minutes for an EMS helicopter
to arrive, while in Peru it takes many hours or even days for such a mission
to clear the bureaucratic hurdles and for help to finally arrive.

Diskussion
The clinical development in this case is classic- after the trauma follows
a “free interval” in which the climber was initially even able to descend
independently, but then increasingly needed more help and showed the
usual symptoms of an intracranial pressure increase with headache,
vigilance disturbance, ipsilateral midriasis, and peripheral motor
phenomena at base camp. If left untreated, the rising intracranial
pressure causes a respiratory disturbance, which in turn, through hypoxia
and hypercapnia, sets in motion an untreated lethal intracranial pressure
vicious circle; in 1927, a mortality rate of 86% was described for this
mechanism without therapy. [2]. In a study from Berlin, patients with a
traumatic epidural hematoma and an initial Glasgow Coma Scale < 9 had
a mortality of 15%, but the prehospital time was usually < 1 h and not 24
h as in our case. [3] It is almost impossible to find literature on such
delayed urgent craniotomy because in industrialized countries, even if
there is a time delay, such a procedure is usually started no later than 2.5
h after hospital admission-including about 1 h of prehospital time, i.e.,
about 3.5 h after the accident. [4].
For European mountaineers, a professional (air) EMS service and
excellent hospital care are a matter of course. It always amazes me that
tourists or mountaineers travelling to the mountains of the world also
consider this to be self-evident in distant places. A foreign health
insurance policy in one’s pocket is a deceptive security, because the
insured benefits on site are often simply not available. In the Andes of
Peru, there is hardly any mobile phone network in most regions, so an
emergency call without a satellite phone, as in our case, has to be made
by a local “running messenger” who ran 20 km / 12 miles through
valleys and over two passes to alert the EMS. The rescuers are often on
foot themselves, which can take up to two weeks in some regions, and
they also have hardly any medical equipment that would be comparable
to a European mountain rescue service. The rescuers repeatedly
experience the tragic experience that accident victims die from the
consequences of long-term exposure to altitude, blood loss and shock, as
well as inevitable hypothermia, even before their rescue, because the
time interval between the accident and the arrival of the rescuers was
several days. The availability of the EMS helicopter and relatively good
weather in this case were also fortunate circumstances. Unfortunately, a
nationwide primary air rescue service for everyone was not a matter of
course in Peru at that time. The rule is a time-consuming organization of
cost-sharing declarations. Overall, our injured mountaineer therefore had
enormous luck—a single gap in the rescue chain, such as the lack of
numerous rescuers in the high mountains or too bad flying weather,
would probably have cost him his life.
In Peru, there are only one tenth of the cars in comparison to
Germany, but in 2018 in Peru 19 times as many children under 15 died
in road traffic accidents in relation to Germany. For adults, it is “only”
the approximately threefold higher number of fatal traffic victims [5]. In
Peru, there are about two accidents per year that are unimaginable in
Germany, such as the crash of a tourist bus over an 80 m / 262 feet high
cliff, in which 48 of the 57 bus passengers were immediately killed and
four more died in hospital [6]. In 2018 alone, there were 5966 accidents
involving buses in Peru, resulting in 38,323 injuries and 771 deaths [7].
There is a seat belt law, speed limits, a ban on alcohol at the wheel, a
helmet requirement for motorcycle riders and a ban on mobile phones
while driving in Peru, just as in Europe, but hardly anyone adheres to
them. And if offences are punished by the police, this is usually done by
a “tip” in the policeman’s pocket. In Peru, the EMS reaches the accident
site in 5% of cases in cities within 10 min and in 95% of cases within
20–30 min; in remote rural areas between 60 min and 4 h or even longer.
Since mainly young people die in traffic accidents, the economic damage
is enormous. A professional EMS could therefore save many lives with
little investment.
Due to the long distances, poor roads and terrestrial obstacles, a
supply of Peru with an exclusively ground-based EMS service is
probably not feasible or affordable, while an air rescue service with
extended aid deadlines of about 60 min in combination with some EMS
vehicles can cover an extremely large area with a radius of about 220 km
/ 137 miles [2], which would correspond to more than the area of the
state of Baden-Württemberg in Germany with 35751 km2 (13804 square
miles) area and 11.3 million population. This too may hardly be
imaginable in Germany, but Peru is about 3.5 times larger than Germany
 with comparatively very difficult traffic infrastructure and partly
sparsely populated regions in the mountains and the rainforest region. In
the final development stage, it is planned to supply Peru with 20 EMS
helicopters operated by the Peruvian Air Force. This would be a huge
development step for Peruvian emergency medicine, even if this would
also not be imaginable in comparison to Germany, since then Germany
as a whole would be supplied with only six EMS helicopters and not
with about 89 as is currently the case.
Until 2020 there was no air rescue system and no central EMS
control centre in Peru; we are currently building this up with the support
of the German federal government. The state-based ground EMS system
“SAMU” (Servicio de Atención Médica de Urgencia) is organised as a
rendezvous system after the German model. We have compiled this
vision in an expert opinion for the Peruvian Ministry of Health in 2019.
In 2021, in cooperation with Bolivia and Colombia, we will start a dual
bachelor’s degree programme at the Faculty of Medicine of the
University of San Marcos according to the German curriculum of the
emergency medical technician. Thus, our experience in the care of over
2600 emergency patients in the years 2000 to 2020 now leads to a re-
organisation of the EMS in Peru, which we have always considered to be
the basic health service for the entire population. The Peruvian policy
intends to offer the EMS free of charge.

50.1 Conclusion
Rescuing a mountaineer who has had an accident at an altitude of 5000 m /
16400 feet in the Andes is possible, but in addition to the usual components
of personal training, experience and technical aids, it takes insane luck to
have all of this available without gaps and ad hoc. To implement an air
rescue in Peru, we have invested almost 20 years of hard work to convince
all parties of the sense, affordability and feasibility.

References
1. Imray C, Wright A, Subudhi A, Roach R (2010) Acute mountain sickness: pathophysiology,
prevention, and treatment. Prog Cardiovasc Dis 52:467–484
[Crossref][PubMed]
2.
Maugeri R, Anderson DG, Graziano F, Meccio F, Visocchi M, Iacopino DG. 2015 Conservative
vs. surgical management of post-traumatic epidural hematoma: A case and review of literature.
Am J Case Rep 16:811–817

3. Gutowski P, Meier U, Rohde V, Lemcke J, von der Brelie C (2018) Clinical outcome of epidural
hematoma treated surgically in the era of modern resuscitation and trauma care world Neurosurg
118:e166–e174
[PubMed]

4. Marcoux J, Bracco D, Saluja RS (2016) Temporal delays in trauma craniotomies. J Neurosurg

125:642–647
[Crossref][PubMed]

5. https://www.who.int/publications/i/item/9789241565684

6. https://www.zeit.de/gesellschaft/zeitgeschehen/2018-01/peru-verkehrsunfall-bus-strand-tote?utm_
referrer=https%3A%2F%2F

7. https://andina.pe/agencia/noticia-accidentes-transito-dejan-771-muertos-el-pais-lo-va-del-2018-
731877.aspx
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_51

51. Hyperventilation
Björn Hossfeld1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine,
and Pain Therapy, Federal Armed Forces Hospital, Ulm, Germany

Björn Hossfeld
Email: [email protected]

We do our work in the emergency medical services with passion and

concern for the patients entrusted to us, but at the end of the day we would
rather report on the spectacular experiences. According to the slogan
“Triple-T” it is of course great if we have been able to provide a severely
injured patient with a tube and two thoracic drains in a time-critical manner
before hospitalization and have handed him over stable in the emergency
room. However, the less spectacular scene calls are not necessarily less
challenging, or less exciting.
With the alarm keyword “Hyperventilation” on the pager we were on
our way to a 14-year-old boy in a school and accordingly we joked on the
way: “Again a Triple-T: Talk-down (calm down verbally), Bag (in German:
“Tüte” for rebreathing in hyperventilation) and Tavor® (pharmacologically
calm; in this case with lorazepam)”. After all, acute hyperventilation
syndrome is a common disorder, especially in young people, which rarely
causes us diagnostic or therapeutic problems. Although in our perception
young women have to be (not) medically treated more often,
epidemiological studies show that the frequency is equally distributed
between the two genders.
Situations in which strong affects such as fear are suppressed (for
example, before difficult school tasks) are often the trigger for a
hyperventilation syndrome in school age, which is characterized by
paroxysmal, accelerated and deepened breathing. This in turn causes a
reduction of dissolved carbon dioxide in the blood and as a consequence an
increase in pH in the sense of a respiratory alkalosis. This pH increase in
turn leads to a reduction of free calcium in the blood with the typical tetanic
symptoms, such as paresthesia and paws position. These somatic symptoms
can intensify the patient’s fear, triggering a further deepening of breathing
and thus a circulus vitiosus. The rebreathing from a bag held in front of the
patient’s mouth and nose seems to be a logical consequence in order to
make the carbon dioxide in the blood rise again, but is controversial
because also cases of unnoticed hypoxia are described when employing this
method. In a case series from San Francisco with supposed hyperventilation
syndrome, a rebreathing therapy was applied but it was overlooked that the
main pathophysiology was hypoxia or myocardial ischemia; all three
patients died from this treatment error [1]. Therefore, monitoring of
peripheral oxygen saturation is essential and an additional monitoring of
end-tidal carbon dioxide can be extremely helpful.
I often find myself thinking that many ambulance calls could be handled
just as well by a good EMS team without an EMS physician, usually faster
and without any disadvantage for the patient. So on the way to this call, I
also doubted the usefulness of my alarm. But on site the following situation
presented itself. A 14-year-old male student was lying on a stretcher in the
school’s infirmary. The initial treatment was being carried out by the team
of an ambulance, which by chance happened to be nearby and was the first
vehicle to be alerted by the EMS control center. The patient had a clearly
increased respiratory rate of over 30/min, which was impressively visible in
the movements of a plastic bag held up. I was greeted with the words:
“Sorry Doc, we can’t do it without sedation.” At first glance, the patient
was unconscious. However, that this did not fit into the history of a classical
hyperventilation syndrome had escaped the young ambulance crew; here,
another cause for the tachypnoea had to be present. We established the
intravenous access prepared for sedation. The blood sugar test carried out
immediately from this showed a pronounced hyperglycaemia of
>600 mg/dl. The high respiratory rate of the patient was therefore not due to
a psychological stress reaction, but corresponded to the physiological
reaction of the body, which was caused by the hyperglycaemic metabolism
to compensate for ketoacidosis respiratorily. Accordingly, we infused
generous amounts of cristalloid fluids, replaced the bag with an oxygen
mask, and established end-tidal carbon dioxide measurement in addition to
pulse oximetry, for which the measuring line was simply placed next to the
mouth and nose under the oxygen mask thanks to the sidestream
technology. This showed a value of 7 mmHg instead of the usual about
40 mmHg. The history did not reveal any previously known diabetes
mellitus, so the patient was presented to the emergency room with suspicion
of the first manifestation of a Type I diabetes. This diagnosis was
confirmed.

Discussion
A fixation error is perhaps something deeply human because we usually
professionally as well as personally welcome it when we encounter
something familiar again and thus seemingly follow accustomed paths
during an initial examination of a matter, even though they may be
wrong or even are. A very nice example was described from Bonn: A
man with signs of self-injury sat naked on a chair for 9 h in a neglected
apartment, antipsychotic medications were lying on the dining table and
the concerned neighbors said that “the man was known in the psychiatric
facility” and had become increasingly conspicuous, e.g. by persecution
mania and boards nailed to the door [2]. The emergency physician tried
to get an overview but then ran out of time due to the request for a
follow-up scene call. So what could be more natural than to transport
this patient to the hospital in an ambulance and present him to a
psychiatrist? However, the patient then became cardiorespiratory
unstable, had to be intubated in the end and was finally operated on for a
gastric perforation and four-quadrant peritonitis. A coronary intervention
was also performed during the course. The initial symptomatology was
therefore most likely due to a septic encephalopathy.
The hyperventilation syndrome is a differential diagnosis: Before we
“impute” a mental diagnosis to a patient, we must clarify vital
threatening causes of tachypnea [3]. The respiratory compensation of a
metabolic acidosis is in the foreground, but other causes are also
conceivable for a tachypnea. I remember, for example, a spontaneous
pneumothorax in a young football player without trauma. In such cases,
in addition to a careful past medical history, the appropriate experience
and the clinical training of the emergency physician are extremely
helpful. It is not about blaming the young paramedics of the ambulance
being responsible. The pre-hospital conditions and the often time-critical
action offer a certain risk for so-called “fixation errors”. The fixation
refers to the unhelpful trust in experiences from already experienced
situations, which are similar to the current situation, but ultimately not
the same. So if we focus on an aspect that we recognize—in the
described case the tachypnea—and do not recognize the relevant
difference to previously made experiences—namely that the patient is
unconscious—then our experiences will lead us into a dead end. In the
case example, this perception is further reinforced by apparently typical
environmental conditions (young patient in a school), as in our memory
the last hyperventilation syndromes have just occurred in this context. If
we do not recognize the error in our assumption by mentally taking a
step to the side and questioning the situation, we will not develop an idea
for an alternative approach. Evie Fioratou and colleagues deal with this
problem in their really worth reading study [4].
Fixation errors should be kept as low as possible using so-called
Standard Operating Procedures (SOPs). While such SOPs can often be
well represented as flowcharts, they often start from a suspected
diagnosis or symptom. The case described shows that the clinical
experience of the emergency physician is an essential component for the
most likely suspected diagnosis. The colleagues in this case have fallen
for a fixation error that was triggered by the symptoms (tachypnea) and
the situation (typical environment and typical patient age for
hyperventilation). If they had not let themselves be influenced by the
situation and had not fixated on the obvious suspected diagnosis of
“hyperventilation tetany”, they would probably have noticed that the
unconsciousness does not fit the situation. An algorithm for
unconsciousness would have suggested a timely blood sugar test with a
high probability. This would have made the problem of hyperglycemia
noticeable earlier. However, the unconsciousness and not the tachypnea
must be recognized as the leading problem. Therefore, the repeated
critical re-evaluation is an important instrument to minimize such errors.
The medical industry often uses aviation as a model for error
management because the culture of error is better developed there, for
example through media-attracting accidents that generate corresponding
pressure to act. By no means does everything run smoothly in aviation,
 there are also fixation errors there. A nice example is the flight of an Air
Canada Boeing 767 that was supposed to fly from Montreal to Winnipeg
in 1983. The cockpit crew calculated a mass of 22,283 from 12,589 liters
in the tank and a weight of 1.77 pounds/liter—mathematically correct,
but because the plane was calibrated in kilograms, the onboard computer
assumed 22,283 kg of fuel. In fact, however, there were only 12,589 L ×
0.803 kg/liter = 9144 kg of fuel in the tank, somewhat less than the
imagined half. The cockpit crew recalculated several times, but did not
recognize the error in the unit. In the end, the pilot said: “That’s it, we’re
going”. About halfway there was an engine failure due to fuel shortage
and the plane was finally able to reach a retired military airfield in a
glide, where the landing was made without injuries [5]. Here, too, the
cockpit crew had fallen for a fixation error: Although the pilots felt that
they had not tanked enough, the mathematical control always gave the
same number despite several recalculations—that man and machine
started from different units, they did not notice.

51.1 Conclusion
All alarms must be taken seriously, even if they appear to be nonsensical,
implausible or bland, and we are unlikely to be able to tell great stories.
Suspected diagnoses of the rescue control center or the first responders
should always be critically questioned. You should also remain suspicious
over time until all findings and the medical history “fit together” and are
consistent. It is better to pay attention to findings that refute one’s own
thesis than to those that confirm this assumption.

References
1. Callaham M (1989) Hypoxic hazards of traditional paper bag rebreathing in hyperventilating
patients. Ann Emerg Med 18:622–628
[Crossref][PubMed]

2. Baehner T, Heister U, Boehm O, Hoeft A, Knuefermann P (2012) Fixation errors in emergency

medicine. Notfall Rettungsmedizin 15:606–611
[Crossref]

3. Herrmann JM (1999) Series: functional disorders-functional breathing disorders. The

hyperventilation syndrome. Dtsch Ärztebl Intl 96:694–697
4.
Fioratou E, Flin R, Glavin R (2010) No simple fix for fixation errors: cognitive processes and
their clinical applications. Anaesthesia 65:61–69
[Crossref][PubMed]

5. Richter JA (2008) Der Gimli Glider. Aerointernational 9:86–88

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_52

52. Hybrid-ECMO
Marc O. Maybauer1
(1) University of Florida College of Medicine, Department of
Anesthesiology, Gainesville, Florida, USA

Marc O. Maybauer
Email: [email protected]

A 31-year-old patient, four months post-partum with a history of asthma,

smoking and chronic back pain, was admitted to the emergency department
of an outside hospital with the diagnosis of anaphylactic reaction. The first
symptoms such as shortness of breath occurred after the initial
administration of baclofen (a gamma aminobutyric acid derivate), which
was prescribed to her for her lumbar pain syndrome. With a heart rate of
148/min, respiratory rate 38/min, blood pressure 127/101 mm Hg and an
oxygen saturation of 89% on room air, she was initially given an oxygen
mask at 4 l/min, epinephrine intramuscularly, as well as cortisone and an
H1 antihistamine intravenously. She was admitted to the intensive care unit
for monitoring. With increasing complaints, she was given a beta-2
sympathomimetic via nebulizer and BiPAP ventilation with light sedation
was initiated. With increasing oxygen requirements, confusion and carbon
dioxide retention, she was intubated and given nebulized epinephrine,
which, however, did not alleviate the increasing bronchospasm. Sedation
was then deepened with propofol. Over the next hours, despite ongoing
therapy, a status asthmaticus developed with severe hypoxemia and
hypercapnia. At this time, late in the evening of the day of admission, our
“Shock & ECMO Center” was called and asked for help. About 45 min
later, our ECMO team that had flown by helicopter, landed at the hospital,
about 120 km (75 miles) away. By this time, the patient’s condition, who
was now in extremis with invasive ventilation (PIP 45 cmH2O, PEEP
5 cmH2O, FiO2 1.0), had deteriorated significantly. The arterial blood gas
showed a pH of 6.9, PaO2 58 mmHg and a greatly increased, no longer
measurable paCO2 using a mobile blood gas analysis system. Clinically,
there was a pronounced subcutaneous emphysema of the right chest,
shoulder and neck region, which pointed to a pneumothorax. With this
suspected diagnosis, we changed the sedation to ketamine/midazolam and
paralyzed the patient with cis-atracurium, which unfortunately did not
“resolve” the status asthmaticus. The chest X-ray taken in the meantime
confirmed a tension pneumothorax; placement of a chest drain immediately
led to an improvement in hemodynamics and reduction in norepinephrine
infusion, but not to an improvement in oxygenation. Subsequently, a 25-Fr,
55 cm venous multistage ECMO cannula was inserted into the right femoral
vein and a 23-Fr, 23 cm venous return cannula was inserted into the right
internal jugular vein, and veno-venous extracorporeal membrane
oxygenation (V-V ECMO) and lung-protective ventilation were initiated.
The paCO2 was slowly lowered and by the time we arrived at our ECMO
center, the patient already had normalized blood gases and was
normotensive without the need for vasopressors. A transesophageal
echocardiogram (TEE) was performed to exclude pericardial tamponade
potentially due to ECMO cannulation and to document cardiac function,
which showed a left ventricular ejection fraction (LVEF) of 70%. Thirty-six
hours after ECMO cannulation the patient again developed hypotension and
required high-dose norepinephrine. In the follow up TEE, the apical left
ventricle was shown to be akinetic with an LVEF of about 20% and thus
raised the suspicion of a stress-induced Takotsubo syndrome, which was
confirmed by a relatively low troponin (1.29 ng/mL). With increasing lactic
acidosis and vasopressor requirements, the V-V-ECMO configuration was
extended to V-AV (veno-arteriovenous) in order to achieve respiratory and
circulatory support. For this purpose, a 15-Fr cannula was placed in the left
femoral artery, together with a 5 Fr antegrade distal perfusion cannula to
optimize blood flow in this extremity. The blood flow from ECMO to the
patient was now via a modified tubing system that distributed the return
blood flow through a Y-piece to the vein and artery. Since the blood flow
always follows the least resistance, only a blood flow of 1.5 l/min resulted
in the arterial cannula (15-Fr) and about 4 l/min in the venous (23-Fr). This
was unavoidable because the femoral artery of the rather delicate patient did
not allow placement of a larger cannula due to its diameter. To compensate
for this, we reduced the blood flow in the venous leg by partially clamping
the tubing system and were able to generate a blood flow of about 2.5–
3 l/min on both sides. This proved to be sufficient as the lactic acidosis
gradually subsided. The following day, the LVEF was already in the range
of 30%. However, the patient developed an MRSA-positive pneumonia,
whereupon the prophylactic antibiotic therapy was changed from cefepime
to vancomycin and ceftaroline. Due to the cardiogenic shock, the patient
developed acute renal failure. The creatinine, which was 0.99 mg/dL at
admission, rose to 3.1 mg/dL within four days, for which she received renal
replacement therapy (CRRT). The daily echocardiogram showed an
improvement in left ventricular function with an LVEF of 30–35%, 40–45%
and 55–60% over the third, fourth and fifth day on V-AV ECMO. Now the
arterial cannula, which was placed for circulatory support, could be
removed, and the patient remained on respiratory support by V-V ECMO
alone. On the right side, a complete collapse of the lung with a new tension
pneumothorax developed over time, which led to the placement of another
thoracic drainage. In repeated bronchoscopies, purulent secretions could be
suctioned from the lungs and a general improvement of the pulmonary
situation could be achieved. On days 11 and 13, the blood cultures were
negative for the first time. The collapsed lung could be recruited, and the
patient was weaned from CRRT. On day 20, ECMO was explanted and the
patient was transferred to the floor after 28 days in intensive care. After 40
days and rigorous physiotherapy, the patient was discharged home to her
child “walking”. This led to great joy of the entire team, which cared for
this young mother very emotionally and selflessly during her hospital stay.

Discussion
This patient initially had a status asthmaticus with pneumothorax, caused
by an anaphylactic reaction. Whether the pronounced hypoxemia and
hypercapnia was exacerbated or caused by the development of an MRSA
pneumonia and sepsis could not be demonstrated in the course of her
hospital stay. The resulting severe stress reaction led to a Takotsubo
syndrome with cardiogenic shock. The Takotsubo syndrome, which is
caused by stress, leads to left ventricular failure due to endogenous
catecholamine release, and is also described in association with
infectious diseases and sepsis [1]. The Takotsubo syndrome can be
treated with inotropic substances or V-A ECMO [2]. In our case, the
diagnoses of anaphylaxis, refractory status asthmaticus, tension
pneumothorax, MRSA pneumonia, sepsis and Takotsubo syndrome with
cardiogenic shock could already cause a high morbidity / mortality rate
by each comorbidity alone. The complex combination would have been
fatal for this patient without ECMO. A recent meta-analysis [3]
describes the technology change in the field of mechanical circulatory
support (MCS) systems over the last decade with a significant reduction
in the use of intra-aortic balloon pumps (IABP) compared to the Impella
system and V-A ECMO, with V-A ECMO being used most frequently
[3]. In our assessment, the IABP would have been of little use in this
case, as it can only increase the pumping performance of the heart by an
average of 10–15%. We were presented with the choice between Impella
and V-A ECMO in the form of the V-AV configuration for left
ventricular support, as V-V ECMO was already established. The
implantation of a left ventricular assist device (LVAD) was not
considered at this time, as the patient was hypoxemic and dependent on
V-V ECMO. In our assessment, this was a probably reversible and short-
term event for which V-A ECMO could be used as a temporary bridge to
recovery [4]. During arterial cannulation, only a 15-Fr cannula was
chosen due to the diameter of the femoral arteries. This is in contrast to
our usual practice of using a 17-Fr cannula whenever possible. This
unfortunately led to the above-mentioned problem of reduced blood
flow, but this could be compensated for by partial clamping of the
venous tubing system. A minimum of two l/min should flow through
each cannula to reduce the risk of thrombus formation. After initiation of
V-AV ECMO, the patient initially had borderline circulation and
hypoxemia. When the venous side of the tubing system was clamped to
increase the flow in the arterial leg, oxygenation worsened with
improvement in hemodynamics and vice versa. Here, the ideal balance
between oxygenation and circulatory support had to be found by
repeatedly adjusting the clamp with different flow rates. At this point, we
questioned our decision for V-A ECMO against Impella, as the Impella
5.0 or 5.5 could have generated higher flow rates. The Impella, which
pumps blood out of the left ventricle into the aorta by means of an
 Archimedes’ screw, shows good left ventricular unloading, especially
with the high-flow devices such as Impella 5.0 or 5.5, while the devices
(Impella 2.5 or CP) with flow rates of 2.5 to 3.5 l/min are less effective
and are often used only to support V-A ECMO for left ventricular
venting in case of insufficient contractility, as V-A ECMO results in a
significant increase in afterload. The main advantage of ECMO is the
possibility of oxygenation while providing circulatory support. The
Impella should therefore only be used in patients with sufficient
oxygenation in case of isolated cardiac pump failure. Since V-V ECMO
already provided the possibility of oxygenation, an Impella 5.0/5.5
would have been a good alternative. In addition, the question arose as to
central cannulation of the aorta, which, however, requires a sternotomy,
which can cause additional complications and is considered obsolete in
this case in the presence of peripheral MCS. At this point, we had found
a setting of approximately 3 l/min each, which ensured oxygenation and
slowly reduced the lactate level. Alternatively, the use of levosimendan,
a calcium channel sensitizer, would have been possible to achieve
inotropic support to reduce catecholamines. However, levosimendan is
not currently approved by the US Food and Drug Administration, which
is why we quickly dismissed this idea [5].

52.1 Conclusion
V-AV ECMO is a useful configuration for combined cardiorespiratory
support. Benefits and risks must be weighed individually for each patient.
The choice of cannula diameter and length should ideally be determined
before implantation, although it is almost impossible to predict whether a
patient will require a later change in configuration. The patient’s age and
optimal management by an experienced ECMO team, which treats
approximately 150 ECMO patients per year, favored the therapeutic
outcome. Patients with a similar pathology but higher Body Mass Index
(BMI) are probably benefiting from the use of the Impella 5.0/5.5 to
achieve sufficient blood flow and left ventricular unloading.

References
1. Li S, Koerner MM, El-Banayosy A, Soleimani B, Pae WE, Leuenberger UA (2014) Takotsubo’s
syndrome after mitral valve repair and rescue with extracorporeal membrane oxygenation. Ann
Thorac Surg 97(5):1777–1778
[Crossref][PubMed]

2. De Giorgi A, Fabbian F, Pala M et al. (2015) Takotsubo cardiomyopathy and acute infectious
diseases: a mini-review of case reports. Angiology 66(3):257–261
[Crossref][PubMed]

3. Mariani S, Richter J, Pappalardo F, et al. (2020) Mechanical circulatory support for Takotsubo
syndrome: a systematic review and meta-analysis. Int J Cardiol Oct 1; 316:31–39.

4. Maybauer MO, El Banayosy A, Hooker RL et al. (2019) Percutaneous venoarterial extracorporeal

membrane oxygenation as a bridge to double valve implantation in acute biventricular heart
failure with profound cardiogenic shock. J Card Surg 34(12):1664–1666
[Crossref][PubMed]

5. Karvouniaris M, Papanikolaou J, Makris D, Zakynthinos E (2012) Sepsis-associated takotsubo

cardiomyopathy can be reversed with levosimendan. Am J Emerg Med 30(5):832 e835–837.
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_53

53. Stop
Urs Pietsch1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Cantonal Hospital, St. Gallen, Switzerland

Urs Pietsch
Email: [email protected]

Just before the end of the day, we are called to a mountain biker who has
fallen. Quickly, we sit in the EMS helicopter on the way to the site of the
accident, which is about 15 min flight time away. We receive more detailed
information about the injury during the flight by radio. We learn that a biker
has overturned in a technically difficult descent and is now unconscious.
We can get out of the helicopter and quickly reach the patient with our
material while the helicopter can land a little lower. The patient presents
with impaired A (airway) and B (breathing), probably as part of a severe
head injury with a Glasgow Coma Scale of 6 points. The radial pulse is only
weakly palpable. In addition, a laceration on the head and multiple bruises
on the abdomen impress us at first glance. One of his friends reports that the
injured person fell head first over the handlebars and remained motionless.
While I am busy with the body check, my emergency medical technician
has in the meantime inserted a large-volume intravenous access. We discuss
the further treatment and its priorities as a team. The main problems are a
severe head injury and a tense abdomen as a possible sign of liver or spleen
laceration. We are in agreement: The patient must be intubated and quickly
transported to a hospital of maximum care.
Although not ideal like in an ambulance, we are still in a suitable place
for pre-hospital anesthesia induction and further treatment. We have access
to the patient from all sides, an experienced team with emergency medical
technician and emergency physician as well as additional help from the
pilot and the patient’s colleague, so we can treat the patient well. Drugs and
materials are directed as well as another 10 for 10 (focused team time out)
is carried out before laryngoscopy. Intubation is successful without
problems. Afterwards, the patient is quickly evaluated from head to toe in
the sense of a re-assessment. We quickly decide to inject 1 g of tranexamic
acid in case of questionable intra-abdominal hemorrhage. We are satisfied
with the condition of the patient, who is cardiopulmonally compensated by
our therapy, and make our way towards the helicopter with the patient.
Then I relax next to the patient and sort all cables and tubes in the
helicopter to get us ready for take-off. But what’s blinking on the monitor?
“Systole 60 mmHg”! Damn, what happened now? Do we now have a
tension pneumothorax after intubation? Or did we underestimate the
questionable intra-abdominal bleeding? Quickly the question is answered;
instead of tranexamic acid, we grabbed the ampoule of the same size and
color and injected it with the anitihypertensive drug Urapidil, an alpha-
adrenoreceptor antagonist! How could this happen to us?

Discussion
Approximately 30–50% of all treatment errors are medication errors.
Medication or dosage errors are among the most common errors in
hospitals and outpatient clinics. For the USA, the literature assumes that
5% of all hospitalized patients experience a medication error every year;
of these, 13% are serious. Professional societies and large hospital
providers have now recognized the need for action to improve patient
safety and have launched corresponding campaigns. A wide range of
measures for better and more uniform labeling, mutual control, and
standardized procedures for administration are intended to make the
risks aware to employees and lead to a reduction in medication errors.
Often, it is only after the injection of a medication that it is realized that
an error has occurred; but then it is unfortunately too late because the
medication is already in circulation. This is where one of the protection
concepts comes in: all employees should take a short STOP just before
injecting the medication (Stop-Inject Check!), then think about whether
an error could occur so that it can still be corrected (Check!). The
concept of the “Stop-Inject Check” only takes a few seconds, but can
potentially reduce the error rate significantly [1]. Another established
method for increasing safety and avoiding medication errors is the
application of the so-called 5-R rule. Here, five questions are asked
before each medication order and administration: Is it the right patient?
The right medication? The right dosage? The right administration route
and -location? The right time? The 4-eye principle—that is, showing the
drawn-up medication including the ampoule—also contributes to safety.
This re-check has nothing to do with mistrust of a given colleague. As in
our case, it can happen quickly that the wrong ampoule is accidentally
picked up. Very similar ampoule labels can quickly lead to unnoticed
mix-ups; ampoules with similar appearances but different active
ingredients should therefore under no circumstances be in the same
corner of the emergency kit or anesthesia trolley. It can quickly become
complicated if changing prices or delivery conditions lead to purchasing
decisions in the pharmacy that abruptly negate these efforts. The
statement “Said is not heard; heard is not understood and understood is
not implemented” is of course also central to safe medication
administration!
Standardized labels according to DIN ISO 26825 for drawn-up
syringes enable a quick assignment of the medication group due to a
color-coding and give the concentration in mg/ml again. If there are
different blood vessel accesses, attention should also be paid to a color-
coding in order to avoid accidental arterial drug injection. The labeling
of venous (blue) and arterial (red) accesses by means of differently
colored closure plugs and three-way stopcocks has established itself
here.
In the described case, the classical error-favoring factors came
together: the work environment with a high load directly after or during
pre-hospital rapid sequence intubation in a severely injured patient,
unclear responsibility in the team and individual factors, such as here the
optically (size and label) very similar ampoules of Urapidil and
Tranexamic acid [2]. In our described patient, hypotension caused by the
injection of 50 mg Urapidil instead of 1 g Tranexamic acid could be
quickly remedied by fractionated injection of noradrenaline. So it
temporarily a potential vital danger of the patient developed, but
fortunately no permanent damage occurred.
 Each of us has already experienced such situations in which he was
so sure that it is all but guaranteed not this. No, no, that’s fine … Some
things are so unimaginable that one does not believe it possible. But it
can happen. For example, that laughing gas (N2O) comes out of a
ventilator instead of oxygen. In one case, anesthesia was initiated in a
young man and a few minutes later he developed a cardiac arrest because
anesthesia was induced with 100% N2O and not 100% O2 [3]. A lapidary
ventilation with a self-inflating bag and room air would have solved the
problem, but it was just unimaginable that something like this could
happen. One was so fixated and so sure that it must be something else,
but definitely not a problem with the ventilator. But during the setup of
the workplace, the O2 and N2O lines were swapped and the device check
or inspiratory gas measurement was ignored; in the end, a family father
died unnecessarily. It was not the only case of accidental lethal N2O
ventilation—in a number of pregnant women with cardiac arrest in
Germany, a placental embolism was suspected until a policeman simply
locked the operating room because there was a death and an
investigation was required. Otherwise, there might have been the next
death because for health personnel a dead person on the operating table
is nothing completely unimaginable, but for a policeman it is. Only if
one discusses such a scenario of accidental swapped gas lines outside the
immediate workplace, one has the chance to prevent it later [4].
Such fixation errors meet us very often in clinical everyday life and
they represent one of the main reasons for incidents in the medical field.
In complex situations, we can, for example, get so involved in
administering a given activity that we do not even realize that much
more important things are being forgotten or misinterpreted in the
process [5]. This becomes quite drastic, for example, as in our case,
when we are so fixated on one thing and so sure that we have taken the
right ampoule that we totally lose sight of normal procedures (read the
label without stress, 5-R-rule and stop-check-inject again). This becomes
even more clear with manual and mentally demanding activities, such as
difficult intubation. Quickly, one no longer perceives anything around
oneself and is trapped in one’s tunnel vision. A good, but tragic example
of this is the case of Elaine Bromily in England [6]. The patient died
during routine surgery because the anesthesia nurses correctly assessed
 the “can not intubate can not ventilate” situation and handed over a
coniotomy set, which the experienced anesthetists did not want to use. In
clinical everyday life, we are most often exposed to the risk of such
fixation during diagnosis. Thoughts like; “This—and only this—it is”…
“Everything but not that one it is”… “It’s all right”… often lead to this
fixation dead end. A constant and honest re-evaluation in the team is
usually a successful strategy to avoid these fixation errors and to break
free from them again.

53.1 Conclusion
The work environment of emergency medicine is particularly error-prone
because composition of the teams and the work environment often change.
Often, pre-hospital care is provided under unfavorable conditions for
patients at risk of life, which automatically creates a high level of
expectation and action pressure on the treatment team, which in turn can
lead to errors. Simple thought supports such as the “stop-inject-check”, 5-
R-rule or uniform “labeling” can be helpful to prevent avoidable errors.

References
1. Koppenberg J, Henninger M, Gausmann P, Rall M (2011) Patient safety in emergency services:
what contribution can CRM and teamwork make? Der Notarzt 27:249–254. https://doi.org/10.
1055/s-0031-1276905
[Crossref]

2. Pierre St, Hofinger G (2020) Human Factors and Patient Safety in Acute Care, 3rd edition ISBN
978–3–642–55420–9

3. Herff H, Paal P, Lindner K et al (2008) Nitrous oxide related deaths. Anaesthesist 57:1006.
https://doi.org/10.1007/s00101-008-1434-7
[Crossref][PubMed]

4. Herff H, Paal P, von Goedecke A, Lindner KH, Keller C, Wenzel V (2007) Fatal errors in nitrous
oxide delivery. Anaesthesia 62(12):1202–1206. https://doi.org/10.1111/j.1365-2044.2007.05193.x
PMID: 17991254
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5. Singh JM, MacDonald RD, Bronskill SE, Schull MJ (2009) Incidence and predictors of critical
events during urgent air-medical transport. CMAJ 181(9):579–584. https://doi.org/10.1503/cmaj.
080886
[Crossref][PubMed][PubMedCentral]
6. https://www.youtube.com/watch?v=44tH98eLrkQ. Accessed 18 Feb 2021
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_54

54. Less is More

Urs Pietsch1
(1) Department of Anesthesiology, Intensive Care, Emergency Medicine
and Pain Therapy, Cantonal Hospital, St. Gallen, Switzerland

Urs Pietsch
Email: [email protected]

It is one of those beautiful autumn days in the mountains. We sit relaxed in

front of the hangar in the sun and enjoy the silence. In this time, between
the winter and the summer high season, it is often quiet here in the
mountains, while in the high season the scene calls follow one after the
other. Then a crashed hiker in a remote mountain valley pulls us out of the
midday break. Quickly we sit in the EMS helicopter and fly in the direction
of the reported accident site. Over the radio we learn that a hiker from a
group of five people has stumbled and fallen down a steep slope. The group
had called several times for the person, but had received no answer. I go
through possible scenarios: How severe is the trauma, is a landing possible,
how dangerous is the terrain, which target hospital could be suitable, how is
the weather … While I am thinking, we are already hovering above the
reported position. Quickly the group of hikers is spotted from the air. But
where is the patient? About 100 altitude meters or 330 feet below, a person
is located lifeless between the rocks. A landing here is impossible, so I will
be lowered to the patient with the rescue winch. My paramedic stays in the
helicopter as a winch operator. So I float alone with a physician’s bag and a
mountain bag (including a vacuum mattress for rescuing of the patient by
winch) to the patient. Once I arrive at the bottom, it quickly becomes clear
that the patient is seriously injured but still alive. An irregular, gurgling
respiration quickly points to a severe head injury together with an enlarged
pupil. “Everything is fine,” I think to myself, “A and B have to be secured,
so an intubation!” Quickly I put on a pulse oximeter, the oxygen saturation
is only 73% at a heart rate of 65/min. Confirmed by these values, I further
arrange the drugs, the laryngoscope and the tube for a rapid sequence
intubation and insert an intravenous access. To be honest, it really doesn’t
work quickly. Arranging material alone and without additional help and
looking after the patient at the same time, let alone storing it in the
mountain bag for transport, takes time. “When are you ready to be picked
up?” Sounds through the radio and pulls me out of my world. Is it really
clever and realistic what I am doing here? This cannot be done alone, let
alone safely cared for. “In five minutes you can pick me up, please prepare
everything for an intubation at the intermediate loading point!” I report
back. Quickly I pack all the arranged things into the doctor’s bag, store the
patient as best I can in the stable side position and with a Guedel tube to
keep the airways open in the mountain bag and get ready for the winch
action. A few minutes later, the patient and I float together on the winch
under the helicopter hanging over the valley towards the intermediate
landing point. Together, in a well-rehearsed team, the patient is intubated
and prepared for transport to the hospital.

Discussion
The case described here shows important aspects of alpine emergency
medicine. Often, missions are carried out as in tactical medicine and
“care under fire”, namely in a difficult environment. Wind, cold,
darkness or strong sunlight in the snow, in addition limited working
conditions or even dangerous terrain limit the possibilities of care and
force us to plan our actions deliberately and foreseeingly and to deviate
from guideline-conform algorithms. In the case described, it is clear to
all colleagues active in emergency medicine that airway management in
the event of a head injury and as a result of impaired protective reflexes
and insufficient respiration has high priority. Together in a well-
rehearsed team in an ambulance, this rarely poses a problem. In
mountain rescue, one often works alone, because the paramedic remains
as a winch operator in the EMS helicopter, or also in randomly
composed teams. These ad-hoc teams consist, for example, of mountain
rescue specialists or ski slope rescuers who have very different medical
skills [1–4]. In addition, they are often little or completely unknown to
us, with whom we have no routine in cooperation, including all the
resulting problems.
In principle, simple measures, such as drawing up drugs, setting up
an infusion, an endotracheal tube or the optimal positioning of a patient,
are partly significantly more difficult or even impossible in the alpine
environment and under adverse conditions. So at significant minus
degrees a syringe or infusion is quickly frozen and drugs can not be
applied at all. The downwash of the helicopter reliably blows away any
perfectly directed material. Intubation alone or before winch rescue is
also technically possible in alpine terrain, but requires a very critical
risk-benefit assessment. What use is a formally secured airway if I can
not ensure continuous ventilation, or if there is a tube dislocation during
the rescue mission or during the winch operation?
If you use an invasive measure, you can stabilize an unstable
situation or turn an unstable situation into a catastrophe. We have all
experienced it before, that, for example, a too young operating room
team initiates a too large surgical procedure on a too unstable patient too
late at night and afterwards nothing was as it was before. Although you
will hardly find descriptions of these cases in the literature, this is
probably the “negative publication bias”, that you simply omit
publishing certain unpleasant things. On the other hand, you don’t have
to look long in the literature to find reports of intubation errors. The
incidence of unrecognized pre-hospital intubation errors is better in
German-speaking countries than in the USA, but of course still
associated with high mortality [5]. The regular use of capnography to
control a correct endotracheal intubation has had a positive impact on
faster and safer control of correct intubation in recent years and also
offers the EMS team an objective parameter in hectic situations to
quickly recognize and correct a potential intubation error. In addition,
technical developments in recent years, such as the now widespread use
of video laryngoscopy, aim to increase the so-called First Pass Success
(intubation on the first attempt). In experienced hands, this has led to an
improvement in the First Pass Success. However, all these aids should
not lead to a false sense of security of the team on site and make the
respect for difficult airway situations disappear. Various publications
have shown that, for example, due to the problem of the partly good
 visualization of the vocal cord level by means of video laryngoscopy, but
an impossibility of the correct tracheal positioning of the tube, more
desaturations and relevant hypoxemia could be detected than by means
of classical laryngoscopy. This underlines how important training and
education for all colleagues working in emergency medicine is, despite
technology. Not only technical skills are essential, but also the handling
of human factors and human errors.
Anesthesiologists like to make fun of non-Anesthesiologists who
“cannot intubate”, but at the same time create pressure to intubate by
making casual comments in the emergency room like “Why doesn’t the
patient come to us intubated?” It is logical that in such a case a non-
Anesthesiologist initiates intubation pre-hospitally, but the situation is
more difficult than expected or his own experience and pharmacological
strategy is not as good as expected and the situation gets out of control.
In the emergency room I have almost never experienced that a non-
Anesthesiologist said: “The situation was too dangerous for me outside;
therefore I did not initiate any invasive airway management in order to
control it later in the emergency room with more personnel, experience
and better conditions.” This decision is the smartest of all—whoever
knows and communicates his own limits, his team and his material can
save lives by (almost) not doing anything (for example, Wendl/Guedel
tube in spontaneous respiration instead of anesthesia initiation with
subsequent “cannot intubate cannot ventilate” scenario) [6].

54.1 Conclusion
In mountain rescue, whether terrestrial or air-based, it often requires
deviating from established supply concepts. Environmental conditions
dictate the extent and sequence of measures that are useful on site and
which should follow at a later time. Ad-hoc teams assembled are an
additional challenge in this environment. This problem and the associated
problems are also transferable to the entire emergency medicine. Special
requirements must be trained beforehand to ensure a safe supply for both
the patient and the rescuer. Less can be more quickly, as the right
intervention in the wrong place or at the wrong time can go wrong quickly.
Knowing your own limits, those of the team and of the material and
communicating them openly is particularly important in emergency
medicine for a safe patient care.

References
1. Pietsch U, Knapp J, Kreuzer O, Ney L, Strapazzon G, Lischke V et al (2018) Advanced airway
management in hoist and longline operations in mountain HEMS – considerations in austere
environments: a narrative review this review is endorsed by the International Commission for
Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med.
26(1):23
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2. Lischke V, Berner A, Pietsch U, Schiffer J, Ney L (2014) Medical simulation training of

helicopter-supported mountain rescue situations (MedSim-BWZSA). Notfall Rettungsmed.
2012(17):46–52
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3. Pietsch U, Ney L, Kreuzer O, Berner A, Lischke V (2017) Helicopter emergency medical service
simulation training in the extreme: simulation-based training in a mountain weather chamber. Air
Med J 36(4):193–194
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4. Pietsch U, Strapazzon G, Ambühl D et al (2019) Challenges of helicopter mountain rescue

missions by human external cargo: need for physicians onsite and comprehensive training. Scand
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5. Timmermann A, Russo SG, Eich C, Roessler M, Braun U, Rosenblatt WH, Quintel M (2007) The
out-of-hospital esophageal and endobronchial intubations performed by emergency physicians.
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6. von Goedecke A, Keller C, Voelckel WG et al (2006) Maskenbeatmung als Rückzugsstrategie zur

endotrachealen Intubation. Anaesthesist 55:70–79. https://doi.org/10.1007/s00101-005-0927-x
[Crossref]
© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_55

55. Quiet Voice

Sylvi Thierbach1
(1) Federal Armed Forces Hospital, Department of Anesthesiology,
Intensive Care, Emergency Medicine and Pain Therapy, Ulm,
Germany

Sylvi Thierbach
Email: [email protected]

February 2015, Mazar-e-Sharif, Afghanistan. Our German field hospital is

set up like a small district hospital for the treatment of our own and allied
soldiers: surgery, anesthesia, internal medicine, radiology with a CT, six
intensive care beds, a small ward, emergency department, laboratory, two
operating rooms, sterilization, a dental unit and a general practitioner; a
total of 50 people. It’s a relatively quiet time. There are few attacks or
fighting probably due to the cold, unpleasant weather—in the field hospital
normal operation is running and there are no patients in the intensive care
unit. In the afternoon we receive the request to treat in our field hospital a
small Afghan girl with head and brain trauma after a collision with a car. At
the beginning of the mission in Afghanistan, the treatment of civilians
under the motto “winning hearts and minds” was favored and took place
regularly. During the course of the military operation, this changed and the
treatment of Afghan civilians required approval of the military leadership.
Fortunately, the decision to treat the girl was granted quickly. However, it
should be noted that the current calm situation could change quickly with
an immediate need for intensive care beds. But there is hardly any
alternative for the girl in this place. A land-based transfer to the nearest
children’s hospital in Kabul would take a day or more for the 430 km (267
miles) due to the bad road conditions over the Hindukush mountains and an
airlift would not be available. Although emergency equipment for children
is available, we do not have a stock of consumables for long-term
treatment, as this is not the primary task of the field hospital.
Four hours after the initial call, 4-year-old Farzana arrives at the field
hospital in an ambulance with a red crescent. At first glance, the prognosis
is not good—although Farzana is breathing spontaneously with a
nasogastric tube and is hemodynamically stable, her Glasgow Coma Scale
is only 6, her pupils react isocoric and only sluggish to light; she vomits
when turned. We intubate immediately and perform a CT, which shows a
covered head trauma with a small intracranial bleed, but thankfully no brain
edema. Neurosurgical colleagues in Germany confirm the diagnosis by
telemedicine; there is no indication for surgical intervention and we transfer
Farzana to the intensive care unit. In the coming days, pediatric intensivists
from our own circle of friends in Germany become our telephone jokers—
we discuss findings, sedation and nutrition regimes, and after a few days we
are able to extubate Farzana without problems. At first we are optimistic,
but neurologically she does not show any progress in the following days.
Although she has protective reflexes, she has synergistic flexion and does
not fixate, her Glasgow Coma Scale is borderline, so that we discuss re-
intubation on a daily basis. Many employees of the field hospital spend
hours at Farzana’s bedside, read to her and help her with physiotherapy and
occupational therapy. Almost every day, her father and her cousin Farzana
visit, but their efforts in familiar language do not change the condition of
our little patient. After another two weeks, our relief arrives. We are
allowed to go home. Actually a moment that you look forward to after
being two months abroad, but we travel home with a heavy heart and mixed
feelings. What will become of Farzana?
We stay in close contact with our successors and are pleased to hear that
Farzana is becoming more awake, starting to fixate and eat, that even bed
rails are needed, which have to be made specially by the employees of the
field hospital, and now prevent the increasingly mobile Farzana from
tumbling out of the big bed. One day we receive a voice message and with
tears in our eyes we hear Farzana’s soft voice trying to imitate the
colleagues. It was the “toughest” men who were moved the most. Farzana
can finally be discharged from the field hospital after a total of six weeks of
treatment. Three years later I am back in that field hospital in Mazar-e-
Sharif, and after long efforts by the special forces and their contacts, who
have to find the girl’s father with great difficulty, I see her again. She goes
to school, learns to read and write. She is shy, but an alert child and the
parents are overjoyed that their daughter has been given a chance at a good
life in a society in which women have hardly any rights and medical care is
only rudimentary in large parts of the country.

Discussion
Child emergencies are and remain situations for all those who work in
emergency medicine, which one approaches with great respect. In the
injured or seriously ill children one sees possibly one’s own child and is
automatically affected. The concern increases when we come across
child emergencies in an environment in which we cannot draw on full
medical resources and the lack of resources can impose a limitation of
therapy. In Afghanistan, according to data from the WHO [6, 7 and 8],
medical care of the civilian population is precarious due to the ongoing
war for over 40 years with only few interruptions. In 2015, there were
only three physicians and three nurses/midwives and four hospital beds
per 10,000 inhabitants in Kabul. In Germany, there are almost 12 times
as many doctors and 20 times as many hospital beds per inhabitant.
Many medical facilities in Afghanistan are poorly equipped, there is a
lack of specialist personnel and the security situation leads again and
again to destruction and closures. Although medical care is free of
charge in state hospitals in Afghanistan, the costs of hospitalization,
required medication, examinations and treatment must usually be paid
for by the family. The family also takes care of the patient in the hospital
[2]. Many Afghan families cannot afford such medical care or do not
have access to medical care facilities of a higher level in urban areas due
to a rural location. Rehabilitation facilities, such as those we know in
Germany, for example, for follow-up care in the event of a severe head
injury, and which are available in sufficient numbers, are completely
lacking.
In crisis areas, children make up a significant proportion of patients
requiring treatment [5]. Approximately 10% of patients receiving
medical intervention in military facilities in crisis areas such as Iraq or
Afghanistan were children with an average age of approximately
12 years [3, 4]. As military physicians, we regularly treat children in
 emergency medicine and in everyday operating room practice at home in
German Armed Forces hospitals, although not as frequently as our
civilian colleagues in children’s hospitals. However, German Armed
Forces hospitals are not designed for intensive care of children, so
routine care is lacking here. This makes the possibility of telemedicine
all the more important for us, which has not yet been established in
Germany due to many uncertainties, such as incompatible IT interfaces
and standards, lack of acceptance, data protection problems, and
unresolved legal framework conditions [1]. In our case, telemedicine in
radiological diagnostics with radiologists and neurosurgeons alike
represented a relevant and essential gain in information and professional
exchange, and in terms of intensive care for children, it offered better
patient safety through professional exchange. Admission and treatment
of the girl in a facility equipped with material and personnel according to
Western standards meant a real chance of survival, which would
otherwise have been very likely to be close to zero due to the medical
treatment situation described above in Afghanistan.

55.1 Conclusion
Thanks to the entire medical team of the field hospital and our friendly
colleagues in intensive care for children in Germany, we were able to make
a decisive difference for the child and her family in the case of Farzana.
Cases like this bring treatment teams together and will also continue to
provide special interdisciplinary cohesion in German Armed Forces
hospitals in the future, far beyond the deployment period. Those who have
worked together far beyond their comfort zone will function together in the
interests of the patient and the team at home even better. It is precisely these
experiences and the shared sense of success that make these deployments so
valuable to us, despite the recurrent absences from home, from family and
friends.

References
1. R Klar, E Pelikan (2009) State, possibilities and limitations of telemedicine in Germany.
Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz 52(3):263–269
2.
 Korzilius H (2008) The principle of hope, medical care in Afghanistan. Dtsch Arztebl 105:A-267

3. Mauer UM, Freude G, Schulz C, Kunz U, Mathieu R (2017) Pediatric Neurosurgical Care in a
German Field Hospital in Afghanistan. J Neurol Surg A Cent Eur Neurosurg 78(1):20–24
[PubMed]

4. Naylor JF, April MD, Roper JL, Hill GJ, Clark P, Schauer SG (2018) Emergency department
imaging of pediatric trauma patients during combat operations in Iraq and Afghanistan. Pediatr
Radiol 48(5):620–625
[Crossref][PubMed]

5. Pannell D, Poynter J, Wales P W, Tien H, Nathens A B, Shellington D (2015) Factors affecting

mortality of pediatric trauma patients encountered in Kandahar, Afghanistan; Can J Surg, 58:141–
145

6. http://www.emro.who.int/images/stories/afghanistan/who_at_a_glance_2019_feb.pdf?ua=1.
Accessed 2 Jan 2021

7. http://www.emro.who.int/images/stories/afghanistan/joint_country_programme_j_afghanistan_
2018_2019.pdf?ua=1. Accessed 2 Feb 2021

8. http://www.ippnw.de/commonFiles/pdfs/Frieden/Akt21_Afghanistan.pdf. Accessed 2 Jan 2021

© The Author(s), under exclusive license to Springer-Verlag GmbH, DE, part of Springer
Nature 2023
V. Wenzel (ed.), Case Studies in Emergency Medicine
https://doi.org/10.1007/978-3-662-67249-5_56

56. Quarantine
Petra Tietze-Schnur1
(1) Day Clinic at the Ocean, Bremerhaven, Germany

Petra Tietze-Schnur
Email: [email protected]

The Sunday before Christmas, a physician-manned ambulance is deployed

early in the morning with the message: “lifeless person”. When we arrived,
the patient’s husband greeted us and led us into the garden. There we find
the hanged wife of the man; she is not even 50 years old. She has lividity
and of course asystole; we stop the chest compressions started by the first
responder. The husband tells us that his wife had a positive Corona virus
test ten days ago, but no disease symptoms; she was therefore in home
quarantine. For a few days, according to the husband, she had increasingly
“strange” symptoms—she had delusions of her person and was of the
opinion that “our water, land and soil are contaminated”, “how can one ever
get that clean again”. The husband asked me: “Why did she do that?”, But I
had no answer. The husband reported that he had been worried and
contacted the family physician non-emergency service hotline the day
before. There he was told that the EMS was responsible. He then chose the
EMS emergency number, described his problem and received the statement
that “the EMS is not responsible for that”. Then there was a longer
conversation with a local chaplain in the evening, which is said to have
calmed the wife down a bit. In the morning the husband got up (they had
separate bedrooms because of the quarantine) and wondered that his wife
was not in the kitchen as usual. Since the door to the garden was open, he
looked and found his wife lifeless.
Discussion
The Spanish flu pandemic (1918–1920; worldwide about 30–50 million
deaths, including more than 400,000 in the then German Reich) caused
an increase in suicide rates, which was probably due to fears of the
pandemic and reduced social integration. In our time, the Corona
epidemic is an unimaginable social, economic, political and health crisis
for all of us, exposing each of us to an unimaginable stress. Scientists at
the University of Kentucky even describe the Corona circumstances as a
“perfect storm” that destabilizes vulnerable people and thus increases the
risk of suicide: an intensification of social isolation through lockdown
measures, economic difficulties due to short-time work, unemployment
or collapse of entire industries, difficult access to outpatient medical
care, unlimited sale of alcohol, ban on public leisure activities such as
swimming pool, gym, restaurants, libraries, etc., double burdens through
home office and home schooling as well as relationship problems in the
family and partnerships [1]. In the USA, the problem is compounded by
the fact that there are 396 million firearms in private hands for a
population of 326 million [2], which practically anyone can use to
commit suicide with a firearm at any time if all the fuses “blow”. Nine of
the ten weeks with the highest number of requests for a background
check for a gun purchase from the US federal police FBI since 1998
have been since the beginning of the pandemic 2020 [3]. One victim was
a 24-year-old man in Traverse City, Michigan with depression and
anxiety disorders; his therapist had to close his practice, his college too,
his father lost his job, his mother tried desperately to find a therapy place
for her son within a radius of 1500 km (932 miles) but always ended up
on answering machines. The mother finally found a note on his desk: “I
am sorry. I love you all”. Almost all shops were closed, but not the gun
shop, where he bought a gun for 560.67 US$ and shot himself in a park.
Before official national statistics are available on whether suicides have
become more frequent during the coronavirus pandemic, it will take one
to two years. Significant regional increases of around 25% have been
reported, for example, in Arizona, Oregon, Chicago and Japan. For
example, a father found notes from his son after his son’s suicide during
the coronavirus pandemic about how much he missed meeting his three
best friends, who had helped him through difficult phases of his
depression. Studies show that even simple personal care by concerned
friends or family members during such an apparently unstable phase can
significantly reduce the suicide rate or a carefully taking medical history
making paramedics or admitting physicians in the hospital who identify
suicidal thoughts and initiate the appropriate consultations or treatment
[4].
The personal despair caused by the coronavirus pandemic continues
in other cases worldwide with suicides. In Lockport, Illinois/USA, in
April 2020, a 54-year-old shot his 59-year-old girlfriend, who was
suffering from severe breathing problems; he then shot himself. He was
afraid that he had contracted the coronavirus from his girlfriend. Both
had taken a coronavirus test, but had not learned the result before their
death. The autopsy showed that neither of them was infected with the
coronavirus [5]. In Amritsar, India, in April 2020, a 65-year-old man and
his wife committed suicide with an oral poison. They left a farewell
letter in which they wrote: “We are ending our lives. No one is
responsible for this. There was great pressure because of Covid-19. We
were also sick.” [6]. In April 2020, a young couple committed suicide in
Uttarakand, India, a few months after their wedding. The man was in
quarantine without any Covid-19 symptoms outside his home village; his
wife was pressured by neighbors to leave the village because they
thought her husband was Covid-19 positive. She then visited her
husband and the couple saw the situation as so hopeless that they hanged
themselves from a tree; shortly before, they communicated this via
WhatsApp to their home village [7]. In May 2020, a couple in Bihar,
India, was unable to service a loan for a delivery van because they had
no work because of Covid-19. The woman burned herself and died in the
hospital; her husband then hanged himself. The couple left two children
(7 and 10 years old) [2]. At the end of March, a 49-year-old nurse had
agreed to work on the new Covid-19 in Jesolo, Italy. She got a fever,
took a coronavirus test, and was then alone at home; shortly afterwards,
she jumped from a bridge into a river and drowned. The test result
remained unknown. In London, England, at the end of March 2020, a
young nurse was found dead on the intensive care unit. Eight patients on
this intensive care unit had died shortly before, there was a shortage of
staff and personal protective equipment. Also at the end of March, a 34-
year-old nurse was tested positive for the coronavirus on an intensive
care unit in a suburb of Milan, Italy. She was stressed by the terrible
 events in this region, which was extremely hard hit by the Covid-19
pandemic, and committed suicide in her quarantine. In May 2020, a 32-
year-old nurse worked voluntarily on a Corona unit in Florida. He was
very worried about a shortage of personal protective equipment and
developed strong fears and trauma. He was supported by digital
meetings; the day before his suicide, the digital meeting was canceled
and he felt secretions on his face when intubating [8]. At the end of April
2020, the medical director of an emergency room in New York City told
her family about terrible impressions of Covid-19 patients. Later she
became infected with Corona at work, went into quarantine, returned to
work too early, was sent home again, and then visited her family in the
neighboring state, where she committed suicide [9]. Her father said:
“She tried to do her job, and it killed her.”
It is relatively easy to say that the risk of “corona suicides” can be
reduced by reducing stress, anxiety, and loneliness. People must be
encouraged to sleep enough, eat healthy, talk about their fears and
concerns, and not neglect physical activity on traditional ways and if this
is not possible digitally through family, friends, and media [10]. The
Corona crisis is likely to generate a breakthrough in telemedicine
because consultations are possible in a low-threshold and geographically
independent manner. Although this was already technically possible
before Covid-19, it was avoided for a variety of reasons. If help is
needed, this can be done at any time in a low-threshold manner via
telefonseelsorge.de in Germany, telefonseelsorge.at in Austria or the
Dargebotene Hand (143. ch) in Switzerland.

56.1 Conclusion
The risk of suicide during the coronavirus pandemic is probably increased
in people who already have mental health problems, for example, due to
social isolation, economic difficulties, and difficult access to therapists and
leisure activities. Detailed official statistics are not yet available.
Dispatchers in rescue control centers as well as EMS personnel and
emergency physicians at the scene should question any unclear situation in
patients with potential suicidal thoughts as long as necessary, research,
organize, and treat until a satisfactory solution or treatment has been found
for all involved.

References
1. Brown S, Schumann DL (2021) Suicide in the time of COVID-19: A perfect storm. J Rural
Health 37:211–214
[Crossref][PubMed]

2. https://www.washingtonpost.com/news/wonk/wp/2018/06/19/there-are-more-guns-than-people-
in-the-united-states-according-to-a-new-study-of-global-firearm-ownership/. Accessed
1 Jan 2021

3. https://www.fbi.gov/file-repository/nics_firearm_checks_top_10_highest_days_weeks.pdf/view.
Accessed 1 Jan 2021

4. https://www.washingtonpost.com/health/2020/11/23/covid-pandemic-rise-suicides/. Accessed
8 Feb 2021

5. https://www.bbc.com/news/world-us-canada-52192842. Accessed 31 Dec 2020

6. Griffiths MD, Mamun MA (2020) COVID-19 suicidal behavior among couples and suicide
pacts: case study evidence from press reports. Psychiatry Res 289:113105

7. https://www.telegraphindia.com/india/hounded-over-coronaviruscouple-%20%20kill-
themselves/cid/1765526. Accessed 31 Dec 2020

8. Rahman A, Plummer V (2020) COVID-19 related suicide among hospital nurses; case study
evidence from worldwide media reports. Psychiatry Res 291:113272

9. https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html.
Accessed 31 Dec 2020

10. Sher L (2020) The impact of COVID-19 on suicide rates. QJM 113:707–712
[Crossref][PubMed]