The story behind the casualty | Jonathan Joslin

Starting on a positive note Jonathan Joslin tells of the teamwork and dedication of the doctors and nurses working at the accident and emergency department at Mater Dei Hospital. He says this is the only department in the whole health care system where everyone really does work as a team.

“The end objective of everyone working there is always the same – to save lives. There are no hidden agendas and everyone uses their own expertise towards a common goal.”

A team leader dealing with a patient suffering from cardiac arrest relies on other team members’ expertise. One person is responsible for clearing the airway, another for cardiac massage, another for setting up lines and taking blood. An anesthetist is also present. Everyone knows what is expected of them and they work together to save lives.

The same team approach is prevalent in the emergency ward whether treating severe trauma patients or minor injuries.

Joslin is head of pre-hospital emergency care which is much more demanding than actually working in the hospital itself.

“You don’t have access to an anesthetist who is two minutes down the hall you just have to deal with whatever is thrown at you.”

The highest mortality rate seen by accident and emergency are the result of car accidents and work related accidents – construction injuries and falling from heights. This is true of European countries and most Arab States, Malta being no different.

Car accidents have always been a major cause for concern and these seem to be on the increase. The usual culprits are always to blame. Driving under the influence of alcohol or drugs make up the usual Friday or Saturday night accidents, but Joslin has identified some other less publicised causes.

He blames the increase in traumas – which has already reached 53 this year – on the fast lifestyle we are leading today. Especially youngsters are trying to make the most of the 24 hours in the day. Working all day, then fitting in some sort of exercise routine followed by social activities in the evening. Others just have to work another job in the evening because they need the money, leaving very little time for rest. These exhausted people then get into the car and often fall asleep at the wheel.

Aside from the exhaustion, everyone is so busy they cannot take a moment to answer the phone and will do so while driving.

“How many people actually make use of a hands free set?”

He talks about his pet-hate texting while driving.

“Nobody ever admits to texting being the cause of their accidents but this is becoming a frightening reality.

“People are spending more time looking down while they are driving than they do looking at the road. They hit the curb and roll over.”

Importation of faster ‘boys’ cars are on the increase and this is leading to an increase in the severity of car accidents the youngsters are getting into. In a car accident severe enough to cause entrapment of the driver or passengers the forces necessary to crumple the steel machine are also exerted on the people inside the car resulting in critical injuries to bones and internal organs as well as the unsightly external wounds.

Entrapment from a car accident can be very frightening for the victim and doctors alike. As they can’t be removed from the car, the doctor tries to recreate a hospital scenario in the car until the Civil Protection Unit is able to get the patient out.

“We can’t take the patient to the hospital so we have to take the hospital to the patient.”

An emergency response team has been set up to respond to any major incident happening in Malta. This is made up of the Civil Protection Unit and doctors who are trained in pre-hospital treatment and care.

Joslin talks about the ‘Golden Hour’ which is the first hour following an accident. Studies have shown that if definitive care is given to a victim within this period chances of survival are greatly increased. This is such a short time. Fifteen minutes have usually already passed by the time the accident has happened and someone else has arrived at the scene and notified the rescue services and they get there. They work on getting to the scene in the shortest possible time.

Pre-hospital care is a relatively new area of study with only three doctors being specialized in the subject. Joslin hopes that in time more young doctors will take this up as an area of study help make the response teams better.

Increasing awareness is imperative to reducing the amount of accidents caused. Some awareness groups do exist that lobby for greater awareness of various issues. A group of parents have come together to try to campaign against driving under the influence of alcohol or drugs. However there is little awareness of the dangers of exhaustion and the use of the mobile phone.

Safety at work needs to be emphasized. “Why does it have to be a law for workers to wear safety boots and helmets? If you have a family relying on you to support them you should want to take every precaution possible to ensure you can always look after them.”

The second major killer Joslin and his team see, are cardiac arrests. Although people suffering from heart disease are referred to specialists they are left in the hands of the emergency team at the most critical moments – when their heart is failing.

Joslin talks about the changes in cardiac arrests over the last 20 years. He says that 20 years ago the average age of patients coming in with cardiac problems was 65 – 70, nowadays, as a result of obesity, less exercise and stress patients are as young as in their forties.

In the case of an emergency, although the ambulance gets there fast, this can often be too late as cardiac tissue starts to die within four minutes of the heart ceasing to beat. The Malta Resuscitation Council has been training people both inside the hospital and in the community at large basic resuscitation techniques and how to use a defibrillator.

“The lay person is the first link in the chain of survival. If that link is weak then overall chances of survival for that patient are greatly diminished.”

Joslin believes that defibrillator machines should be available at all places where many people congregate, like at theatres and football stadiums and people be trained to use them.

“Why not begin training in these life saving techniques as part of the school curriculum. I have taught children as young as nine to perform these techniques and they are very receptive.”

To conclude Joslin spoke about the resources available to people requiring emergency treatment.

He said “The accident and emergency unit at the hospital has to be treated as such to ensure best use of the resources we’ve got.

Anyone who has had some sort of pain for a few days can go to other health care centres for treatment.”

All doctors practicing at polyclinics have been through a three to six month training stint in the emergency ward so they have the correct training to deal with minor injuries. New X-ray machines have been installed in some clinics that through a PACS system can be uploaded to the hospital and a diagnosis can be given from there without having to go to the hospital.

Emergencies are treated at the hospital in order of gravity, so a person suffering from a sprain may be kept waiting to ensure the survival of a patient suffering an acute asthma attack.

“There are a finite number of doctors and nurses available at the hospital and we have to put our resources where they can be utilised best.”

Joslin thinks that working at the emergency ward is an exciting yet stressful job. One accident may leave a number of people critically injured taking up all their resources but other days may be quiet. “You never know what you are going to be doing in the next ten minutes.”

He says, on the whole, the stress makes you calmer as a person. The job also gives him a better perspective on life, looking at situations with more realism.

Having an excellent team also makes the job more manageable. “We meet up outside of work and help each other manage the stress of the horrors we see at work everyday.

“Watching a child die through a tragic accident makes you associate it with your own family and you wonder what life would be like if that was your own child.”

Music, sports, exercise, the sun and the sea all help Joslin de-stress after a tough day at the ‘office’, but overall the job is rewarding and the team works hard to provide the best service in health care that can mean life or death for many of the people they come into contact with.