Yes, sir, we are back with another episode of Best Case Ever, the mini podcast series

as part of emergency medicine cases.

I am your host, Dr. Rajiv Thavenathan, and on today's show, we have a very special guest.

It's Dr. Joel Lockwood.

He's an emergent

physician and TTL right downtown in Toronto, Ontario, Canada at St. Michael's Hospital. And he also

happens to be a transport medical physician with Orange, which is our critical care paramedic

service. And he's here today to tell us about his best case ever. So Joel, you take it away,

hit me with something good. Hey, thanks for having me. So I guess a bit of background about my best case. So Joel, you take it away. Hit me with something good. Hey, thanks for having me.

So I guess a bit of background about my best case. So I worked doing trauma, working for

ambulance, which is a trauma team where a doctor and a physician are dispatched pre-hospital

of trauma, arrive there either by car or by helicopter, and really work on the first 10 or 15 minutes of trauma

resuscitation before taking the patient to a hospital. And so I was called to dispatch to a

female that was struck by a bus. We arrived by car shortly afterwards. I was with a paramedic.

We arrived. There was a bus. We could see the scene. The bus was stopped. There was a lot of police and fire crews around. The bus had stopped sort of just beside a kind of concrete wall. And you could just see people working on a patient. So we made our way to the scene. And it was a pretty grisly scene, actually. The bus was partially on the patient's pelvis. The head was out on the side, and the patient's

legs were wrapped around the wheel well a bit. It seems like the paramedics had just got there a few

minutes before. The vitals were just getting in. The heart rate was about 130, and the blood pressure

was about 80 systolic. And around that time, we found the patient had a few other medical problems

as well. So we knew that there was a heart condition with an ICD, and that was kind of how things

started. So, I mean, that's a lot to deal with right off the bat. You have already used the word

grizzly. What was the primary survey like? Well, the first thing I think was identifying

that the patient was pretty sick. So the primary survey showed that there was bilateral open femur fractures. There was a lot of tissue lost in the legs as well. So there was a lot of fat and muscle kind of splayed open. I was worried there was an open pelvic fracture as well. There was certainly a big de-gloving of the skin and soft tissues on the flank, on the right flank, which was facing up and was sort of under the bus. There was a lot of devitalized tissue. And with a bit of further examination, I could tell the patient wasn't actually physically trapped on her pelvis by the wheel. But part of her flank, the skin and fat, was underneath the wheel. And there was a fair bit that was devitalized. The patient... Soft tissue, you mean? Yeah, exactly. It was probably about two or three inches thick, but just soft tissue. But I could put my hand between the pelvis and the wheel. So we knew that the wheel wasn't actually on the patient's pelvis. So she's pinned, you don't have even any IV access yet. You're worried about all these injuries. What do you do next? The decision we had to make was whether we were going to lift the bus up or whether we were going to try to take the patient out without lifting the bus up. And unfortunately, I was going to have to require cutting of some of that tissue that was under the bus. So I was pretty happy that it was very devitalized. Like, it was definitely crushed. And there was probably only three inches of it that was under the wheel. So I thought that we'd be able to efficiently move the patient quite a bit better if we didn't lift the bus. We were given an estimate that was going to take 10 minutes. Oftentimes, in my experience, it takes more than that. But I knew if we cut it, it would be probably about 30 seconds. That is an aggressive move, and necessarily so. Had you even done one of these before? Well, so that was the first time I've done in real life. We've simulated it a few times. And when I was working in London, there was a lot of, like, there was daily practice on different types of scenarios for things like this to sort of help decision making. And I think the principle is, is that you really want to avoid cutting anything unless you think it's a life and death situation. And in this case, I think we all kind of agree that she didn't look, you know, her color wasn't very good. She didn't look like she was profusing very well. And I don't think we had the time.

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