Saving lives within the 'Golden Hour'

A Bloodbath.

That’s what it’s like in the resuscitation room of the emergency department whenever a slash victim is brought in.

And time is of the essence. 

Often, doctors and nurses need to stabilise and optimise the victim “in as short a time as possible, usually between 1 and 1½ hours after arrival at the hospital” before sending him either to the operating theatre or the intensive care unit (ICU).

Window period

This window period after a traumatic injury is sometimes referred to as the “golden hour,” the periodin which a victim is thought to have the greatestchance of survival if given medical attention. 

Doctors here have had to deal with more such cases with the recent slashing incidents. 

Earlier this month, a 26-year-old man underwent a six-hour operation after he was slashed in the left arm and both legs following a dispute in Ang Mo Kio. 

After another slashing attack, which happened last month in the Orchard area, a full-time national serviceman reportedly underwent a three-hour operation to fix his hand because a finger had almost been hacked off. 

Senior consultant at the Emergency Medicine Department of the National University Hospital (NUH) Victor Ong told The New Paper that the emergency room personnel have to first ensure the victim brought in is still breathing. 

“Sometimes we introduce a breathing tube into his windpipe and use manual or mechanical means of ventilation to ensure that he gets the needed oxygen. 

“This also ensures that any bleeding from the facial region, including the mouth, does not enter the windpipe and the lungs,” he said. 

It is only after this is done that they work to stop the bleeding, usually with external compression on visible wounds, and immobilising the injured limbs by splinting or sometimes stitching wounds together.

“We usually need to replace the blood loss so as to ensure (there is) good circulating blood volume and that oxygen is carried to the rest of the body.
Replacing the blood products also plays a major role in trauma resuscitation as it stops the bleeding from internal wounds,” Dr Ong said. 

There may also be defensive wounds, especially on the arms, sustained when the victim tries to protects himself against the knife or parang attack and this often results in bleeding wounds, fractures and nerve injuries. 

Dr Ong said that they sometimes make use of what is known as the Massive Blood Transfusion Protocol to replace the significant blood loss in such patients. 

“Such victims can rapidly become cold internally due to continual loss of blood and also exposure to the elements for some time before they are rescued. 

“We need to replace the blood and fluid at a warm temperature. We also use external warmers such as a blanket that is filled with constantly circulating warm air,” he said. 

At the same time, the doctors need to establish if there are any injuries to the internal organs, “especially in areas not immediately visible to the eyes, with the help of a variety of imaging technology”. 

Working hand-in-hand

“We work hand-in-hand with the trauma surgeons very often, and the best way to stop internal bleeding is to undergo immediate... surgery. 

“The surgery done may be initially limited to just gaining control of the bleeding and then resuscitation is continued at the ICU. Once the patient is stable, he is returned to the operating theatre for definitive surgery,” Dr Ong explained. 

“But should the source of the bleeding clearly require surgical intervention from the start, then the patient is optimised as best as the emergency doctors (are able to), then transferred immediately for further resuscitation at the operating theatre while undergoing surgery.

“That decision is usually taken jointly by the emergency medicine specialist, the trauma surgeon and the anaesthetist or ICU specialist,” he said. 

Slashing, if done randomly, may affect numerous areas of the body, including the head and neck region and cause a large amount of bleeding. 

Dr Alphonsus Chong, who heads the Hand and Reconstructive Microsurgery Centre at NUH, said the damage done depends on the type and size of the knife and how it is used. 

For example, a parang, one of the more common instruments used, typically inflicts slash wounds on the arms, head and torso. 

“But knives like daggers or switchblades may be used to stab someone and can cause penetrating injuries to the abdomen and thorax,” he said. 

“In the limbs, the muscles, nerves, vessels, bones and joints can be injured, but in the thoracic and abdominal cavity, important organs can be damaged.”