In safe hands: the people who respond to critical injuries in extraordinary circumstances

A 112 call comes in. A person has been seriously injured. Aware every second counts in the critical first hour, emergency agencies mobilise immediately

Note: Some readers may find the contents of this article upsetting

The call came in just as Dr Jason van der Velde was heading to bed in his Clonakilty home. A man had fallen into a blowhole in Garretstown.

It was well after 10pm, the last Saturday in April this year, and the call came from the National Ambulance Service’s (NAS) National Emergency Operations Centre in Tallaght.

Dr van der Velde, a pre-hospital emergency medicine and critical care retrieval physician attached to CUH, knows the Garretstown area well: “I swim there and I go there recreationally with my family.” He left in the response car and on his way picked up Eamonn Barry, a coast guard diver and part of the committee of West Cork Rapid Response. “Just before we arrived we were alerted by ambulance control that another person had swum into the blowhole to get to the first.

“I know from experience that someone falling into that blowhole is going to be dead. No question. It was a very stormy night, the sea was extraordinarily rough – we feared we’d have two people dead in there.”

By the time the two colleagues arrived on the cliff – a place of multiple ravines and deep crevices – where the blowhole is located and where a group of friends had been camping, the coast guard’s cliff rescue team was already there, as were other elements of the emergency services.

They could see into the blowhole and it was immediately apparent one of the men had died, while the other was alive, keeping afloat in what Dr van der Velde says were “extremely rough conditions”.

With the water rushing in and out of the blowhole – “it’s a massive turbulent cave in there,” says Dr van der Velde – the coastguard set up a specialised lowering-and-hoisting rope system. “Eamonn and I got permission to climb and we went down in our dry suits to secure the deceased and also his friend who was getting hypothermia. With hypothermia you become cognitively impaired. He was in imminent danger of dying.

“One of the coast guard climbers came down with a strop, secured him and hoisted him up. The paramedics looked after him, got him into an active warming system and transported him to CUH. Meanwhile, Eamonn and I held onto the deceased, and all the time the water was coming into the cave, into that blowhole, like a gigantic washing machine.”

Critical golden hour

Dr van der Velde has been involved in emergency medicine since 1992. Picture: Denis Minihane.

Dr van der Velde, who has been involved in ambulance work, rescue and pre-hospital emergency medicine since 1992, says the rescue and retrieval effort, from point of first descent to securing both friends and bringing them up, took “a good hour”.

Dr Adrian Murphy, consultant in emergency medicine at CUH and – along with Dr van der Velde – one of four pre-hospital critical care doctors attached to CUH, says there’s a concept in emergency medicine called the golden hour. “It refers to the first 60 minutes after the patient has sustained serious injury. For someone who’s sustained life-threatening injury, the treatment received in the first 60 minutes can often significantly influence the outcome.”

Given that Ireland’s a broadly rural and dispersed country, Dr Murphy says the golden hour is largely a pre-hospital event. As soon as the life-threatening injury occurs – whether from an industrial or agricultural accident, a road traffic accident or a fall from a cliff – the dying process starts.

“There are things we can do that slow down that dying process.” It’s about stopping further injury from the initial insult [the accident], says Dr van der Velde. “The sooner you reverse the lack of oxygen, turn around the derangement in the blood, give the antibiotic for infection, the sooner you halt the dying process, the sooner you make a massive difference in terms of mortality or consequences. To achieve this in rural Ireland we have to get to the patient soon.

“That’s why we break down the barriers of the walls of the resuscitation room, why we reach out to our colleagues in the coast guard, the defence forces, to all the emergency agencies, why we go to the point of injury – to the farmyard, street, cliff-side.”

This vital link-up of services so that the life of the imperilled and the at-risk can be preserved very often begins with a bystander witnessing an incident unfold. The passing motorist comes across a car crash. The walker on a beach or headland sees someone lose their footing on a loose rock atop a cliff and come tumbling down.

“We’ve some of the most beautiful coastline in the world. People seek to enjoy that, but at the same time there are hazards,” warns Dr Murphy.

When an accident’s reported, all the inter-agency elements of the emergency services immediately swing into action. In the case of the person injured after stumbling off a cliff, for example, the coast guard’s invariably the primary agency activated, says Dr Murphy. 

“The coast guard might task a helicopter to the scene, they’ll invariably task a lifeboat and at some point they’ll contact the Gardaí and the NAS. And if somebody’s critically ill or injured, the Emergency Operations Centre at the NAS will generally contact a pre-hospital emergency medicine or critical care doctor and task us to the scene. The whole idea’s to bring the emergency department, the resuscitation to the roadside, the cliff-side – it Gobecomes the resuscitation room.”

After that, explains Dr Murphy, the patient will be transferred to the hospital most appropriate to their needs. CUH, for example, has been designated one of two major trauma centres in Ireland. “It has all the key specialists to cater for the vast majority of severely injured patients’ needs.”

Direct access to medical advice

When emergency medicine is delivered in a “resuscitation room without walls”, it often starts with the critical care doctor going out from the hospital – or from his/her home, often at the weekend or late evening. But it also starts telephonically and over the radio, says Dr van der Velde, who heads up Medico Cork, the HSE’s national 24-hour emergency telemedical support unit, which is managed by CUH emergency department.

Medico Cork guarantees direct access to specialist medical advice to anybody in Irish territorial waters and the Irish Coast Guard, Defence Forces, NAS, Dublin Fire Brigade, Beach Lifeguard Services and Mountain Rescue Ireland.

“Not a week goes by that we don’t have some collaboration with Medico,” says Gerard O’Flynn, deputy director and head of operations with the Irish Coast Guard. The service is hugely important, he says, for the coastal and maritime communities – it provides medical advice and support to ships at sea in Irish waters. which extend out 200 nautical miles, and Irish-registered boats worldwide.

“It could be a fishing vessel, sailing ship, a cruise liner – someone at sea has an urgent medical condition. They might have a serious heart condition, suspected appendicitis or suffered a major injury,” says O’Flynn.

(Dr Murphy points out that fishing vessels in particular present a hazardous remote working environment – there are lots of mechanical parts on board trawlers – and injuries are not uncommon).

Critical care equipment on the go. Picture: Denis Minihane.

O’Flynn explains that the ship-to-Medico calls arise out of scenarios at sea where ordinarily you’d go to A&E. “The master of the vessel contacts the Coast Guard, who determines what assistance is appropriate. The Coast Guard will either relay messages to Medico or put the master of the vessel in touch with Medico, which is staffed by doctors qualified in conducting remote consultations.”

A decision is then made as to how to stabilise the patient. Two requirements inform this decision – care of the patient and risk-reduction. “It’s not a case of dial a number and call a helicopter,” says O’Flynn. “Maybe the ship has a chance to come back into port. Maybe certain drugs can be given. Or perhaps the medical advice is to get the casualty to hospital immediately.”

But medical evacuation can be extremely hazardous to both patient and helicopter due to austere environments and weather conditions. “Putting a casualty into a stretcher on a relatively small vessel, where there’s lots of movement, there’s high risk of making a bad situation worse. So it’s not always a simple ‘go, collect, deliver’. In the middle of the night, in a storm or gale, it could be decided to wait until first light,” says O’Flynn, adding that while medical advice is critical as to whether a helicopter should be tasked, it is at the end very much a team effort and everybody deals within their own area of expertise.

“The final decision as to whether to undertake a mission is vested in the commander of the flight – the ultimate decision-maker.”

It’s what we do every day

Dr Murphy says CUH emergency department has a long-established history of sending medical teams and doctors to the scene of accidents and disasters. “It’s pretty unique compared to every other hospital in Ireland. Over about six years in the 1970s and ’80s – when it was Cork Regional Hospital – it responded in a pretty extraordinary way to a number of tragedies,” he says, citing the 1978 Glounthaune bus crash, the 1979 Whiddy Island disaster, the 1980 Buttevant rail accident and the 1985 Air India disaster.

“It’s easy to understand, based on all these tragedies that staff have dealt with over the years, how emergency services would have had to evolve and mature,” says Dr Murphy.

For the individual at the centre of the emergency, it’s the most traumatic day of their lives. It was that for 37-year-old Killarney man Shane Breen one Tuesday evening last summer. He was driving home from his job in Cork when he was involved in a collision with another car. “I remember the pain, the guards, the ambulance, the fire brigade, a load of people around me, someone trying to keep me calm.”

He doesn’t know how he got out of the car, doesn’t remember the journey to CUH, where he was operated on for internal bleeding – but he knows he owes his life to all those emergency agencies and to the doctors. 

“It doesn’t matter what the job is that we’re called out to do,” says Dr van der Velde. “There is that balance: that for the patient it’s the worst day in their life, the most distressing moment – and for us, it’s what our job is, what we do every day, what we’re trained to do, what we pride ourselves on, excellence in pre-hospital emergency care.”

• If you have been affected by any of the issues raised in this article you can contact the Samaritans: freephone 116 123 or samaritans.org

Essential support from Medico 

Laura O' Callaghan is an advanced paramedic with the National Ambulance Service. Picture: Jim Coughlan.

As advanced paramedic with the National Ambulance Service, Laura O’Callaghan knew she’d exhausted all she was authorised to do for the man lying in front of her.

His daughter had called the ambulance having found it difficult to wake the mid 70-year-old shortly after lunch.

“He had low heart rate. He was critically unwell,” says O'Callaghan, recalling that afternoon last winter. “We operate under clinical practice guidelines to provide treatments. I gave him medicine and IV fluids so I’d exhausted all measures I’m authorised to do, yet he wasn’t responding.” 

O'Callaghan is training to be a critical care paramedic with MICAS (Mobile Intensive Care Ambulance Service) and is attached to CUH as part of the MICAS medical team. She recognised the man needed additional care that she was unable to give.

She also knew moving him posed a problem – not because they were 45 minutes away from CUH in a fairly inaccessible rural location, but because the man’s condition wouldn’t survive being moved. “I knew what I wanted to do for him but it wasn’t in my scope of practice.” 

On a team that afternoon with three paramedics, a grade below hers, and aware her colleagues weren’t familiar with what she wanted to do, O'Callaghan did the only thing open to her. She contacted Medico Cork, the HSE’s national 24-hour emergency telemedical support unit, based at CUH emergency department.

“I wanted to pace him – set the defibrillator to a rate that’d ensure delivery of an electrical impulse to maintain sufficiently normal heart rate.” 

O'Callaghan had a “clinical conversation” with Medico and got confirmation the course of action she was considering was correct. Once authorised, she carried out the procedure.  "It was successful – he was able to wake up and talk to us on the way to CUH, where we brought him to the resuscitation room.” 

O'Callaghan found Medico’s support invaluable. “When there’s a lot happening and you’re in the middle of it, it’s easy to initially get skewed in a decision. I got to talk through what I was thinking with someone separate to the situation who understood my reasoning – that was reassuring.”

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