Aircrew - Pilot: Captain Paul Longden, Paramedics: Peter Bennett, Justin Barry, Mark Woolcock, Phil Nelson, Dave Lawton & Roland Chesney.

The patient was a Caucasian male, 69yrs old and of extremely muscular/stocky build. It had been reported that he had fallen off a ladder onto concrete two houses from where off duty Paramedic Peter Bennett lived.His condition was believed to be serious. Clinically, he provided various management problems. From the time of the first response he became particularly combative, which was attributed to two factors at the scene-

i) a head injury substantial enough to produce an intra-cranial bleed (increasing ICP thus affecting MAP)

ii) a chest injury substantial enough to produce a severly reduced SaO2(oxygen saturation of the blood), both of which resulted in poor cerebral perfusion and thus severe hypoxial confusion.

It was decided that to manage the patient appropriately, it would prove advantageous to administer 10mg of Diazepam and by 15.06hrs this had been complimented by a further 10mg performed by Phil Nelson.

This treatment served to sedate the patient enough so as to facilitate easier and more productive in-line immobilisation but more importantly to allow adequate oxygenation. Oxygen was delivered through a mask with a 100% reservoir bag attached. It did not seem prudent to hyperventilate the patient due to his already high respiratory rate(RR).

During this time, Justin Barry had gained IV access via an 18g cannula in the dorsum of the right hand (again due to the combative nature of the patient, this was the only option).

It was extremely apparent that although the patient was being excellently oxygenated and was relatively stable, his RR was still outside our acceptible parameters. On auscultation, Mark Woolcock reported that there were no breath sounds on the right side, with diminishing breath sounds on the left side. Percussion of the chest walls produced a distinctive hyperresonance on the right side.

Authorisation was gained from RCH Treliske A/E Consultant Miss M Hocking who sanctioned the necessary intervention and consequently Justin Barry and Phil Nelson performed bilateral emergency needle thoracotomy, by inserting a 14g cannula into the left and right side of the patients chest.

This produced an immediate effect, with the RR decreasing to around 20 bpm, his SaO2 started to increase and most prolifically there was a definite reduction in the previous hyper-inflated chest.

Obviously the patients condition was now much more stable and thus manageable: he was being adequately oxygenated, he was haemodynamically stable and of course his tension pneumothorax had been decompressed. Attention now has to be directed towards the significant head injury.

The patient was placed onto a spinal board with immobilisation still maintained by Peter Bennett as he still proved to be restless. The decision was then made to leave the scene, and to load the patient onto the Air Ambulance which was located some 50m away. With the patient loaded, the aircraft took off for RCH Treliske.

The total time spent on scene, from landing, locating the patient, assessment, treatment, evacuation and then lift off was only 23 minutes.

Within 10 minutes the patients was in a definitive care centre.