Double - Not Quite

"He's up here," calls one young police officer to me, as I enter the house. The night sky is bright with blue flashing lights, my own amongst them. "Mind the glass as you go."

I gingerly ascend the stairs of the tiny house, wondering just what I will find. The window on the landing is broken; glass is strewn across the stairs. Just because it's in a house doesn't mean I shouldn't wear my steel-soled shoes. Oh well, I'll just have to be extra careful this time.

Three ploice officers point me wordlessly towards a closed door. I push against it, only to hear a grunt from the man behind the door. It's a paramedic, who swiftly moves out of my way to let me enter. I wish he hadn't.

It's a bedroom. There are pictures on the wall; family in various poses, holidays around the world; memories of better times. It's not a big room, and the double bed, dresser and large oak chest of drawers seem out of place.

He is lying on the floor. Blood is everywhere. The bed is soaked in it, and large clots lie on the bedspread and the pillows. The carpet is saturated with it. He, on the other hand, is pale, almost translucent. There are multiple lacerations and stab wounds, on his face, his head, his neck and torso. It is difficult to get into the bedroom because he is lying across the entrance.

I slide around the partially opened door, trying hard not to tread on the body. Yes, body. This man is clearly no longer alive. And yet, until we, the medically trained personnel in the room say so, he is legally. Until I check the monitor, see the straight line, confirm that there is no life present (passing a tube into his windpipe while all this is going on), until I utter the words, "Let's call it. Time of death...", he is still alive.

All of this has happened in the few minutes I have been on scene, and yet I am exhausted, mentally shattered. What started off as a pleasant evening at the in-laws, turns into a frantic, futile effort, while kneeling in the life-blood that should still be running through his veins.

I make my slow, careful way down the stairs, carrying my bag and monitor, and I wonder what had happened.

Outside the house, I am chatting to a police seargeant. He wants my shoes, as evidence. Fine; I'll wear the boots I should have donned before going in to the house. He wants my bag and monitor as evidence, too. I argue with him. Without them I am off-line, and I know it will be weeks, if not months, before they are returned.

As we talk, I am aware of another man being questioned by another officer. The cuffs go on, and I look a little more closely at him, wondering what might have led him to commit the act, the results of which I had witnessed upstairs.

Suddenly, there is a flurry of activity: two police officers run to their car and drive off in a flash of blue lights. Moments later, their sirens pierce the night. The seargeant's radio crackles into life, and he excuses himself for a moment - life goes on.

He rushes back to me. "We've got another one, and she's alive!" I find out where it is, and rush to my car. I turn, and ask, "Is the ambulance crew coming with?" He shakes his head, and explains that, if the same crew attended both scenes, it would definitely muck up the evidence. Oh, great!! Now I have no idea when I will get backup.

As I am driving the very short distance to where my next patient lay, I contacted the Ambulance Service, just to be sure that they knew where I was going - they didn't. A good phone call to make.

The second scene is as awash with police as the first. I am directed to behind a restaurant, where there is a small, walled off area for preparing meat. She had been stabbed multiple times, and struck on the head with what looks like a baseball bat, left lying in the corner of the room, matted with blood and hair.

She is lying in another corner, on her side, facing away from me. Only the faintest rise and fall of her chest suggests that she was still alive. There was blood everywhere: I was standing in pools of it, there were splashes up the walls, and on every surface of the "kitchen".

I move carefully towards her, trying not to slip, nor to gag on the stench of blood. This is unlike anything I had seen before. How could she still be alive, having lost so much blood?

I reach her, and put my gloved hand on her skin - it is icy cold, deathly. I realise that the cold is what has probably saved her life, and I am determined that my actions will continue that trend. With the help of some very green-faced police, we move her in to the centre of the room, and I begin to assess her. She is, surprisingly, conscious, but only just, and has good air entry on both sides of her chest. I cannot feel a pulse.

She has multiple stab wounds, but none of them are bleeding. I am unsurprised at this: she has no blood pressure to pump any more out. Perversely, I don't want to raise her blood pressure at all out here - if I do, she will start bleeding again, and probably die at my feet. She needs a hospital, and now!! I get the police to radio through to Control, and tell them we need transport immediately. I keep looking for a vein while I wait - there is nothing, not even in her groin, where the usually drainpipe-sized femoral vein has collapsed to nothing.

The ambulance arrives, we load and go. This is a journey I won't forget!!! The speed of the driver made me look up in surprise, expecting, perhaps, Jenson Button to have taken up a new career after getting his MBE. But no, it's just Tim, as anxious to get this lady to hospital as me.

As we drive, and the temperature in the back rises, she begins to bleed, and I get Tim to turn off the heating and open all the windows. We might just make it!!

A very short time later, we arrive, and hand over to the waiting team.

My drive back to my family is a sober one, with visions of blood-splattered walls, and of the evil that men do.

Flowers

As I drive past the accident scene, I see fresh flowers adorning the trees along the side of the road and down in the ditch where the car came to rest. I wonder who it was who didn't survive: the passenger? The driver? My patient, or the one managed by the HEMS crew? Both? In a blink of an eye, I am transported back to that fateful night:

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The scene is not an easy one: the car has slid down a steep bank, and is now jammed against a tree. There is noise; lots of shouting from the crews, the rumble of the generator and the engine of the fire truck. There is little light, and I quickly get out my headlamp and strap it on.

"Where do you want me?" I call to one of the ambulance crew. He shrugs his shoulders, and I stop in my tracks: how many people are involved in this accident?

I run over to someone being attended to, lying some feet from the wreckage, the car that I haven't yet been able to get close to. He looks up at me, and the crew tell me that he is ok; there are worse cases to deal with.

Ok, time to get to the car. It's not easy; the slope is very steep and very slippery. I grab hold of a passing fire officer, and he assists me down. What awaits me is very shocking:

I am approaching the car from the passenger side. The car has clearly rolled, as the roof has collapsed down on to the passenger. There is a sheet of metal across his chest, yet, somehow, his head is exposed, presumably through the side door window. He has his eyes closed, and is making some respiratory effort. I reach over to his neck to feel for a pulse, expecting none, or perhaps something weak and thready. But no, his pulse is strong and bounding. His colour is ok, and, despite him being so severely pinned, he certainly is someone who might have a chance, albeit very slim. I turn to the fire crew, and ask what their thoughts are. I explain that this man is time-critical, and that we need him out immediately. He shakes his head: "It'll be at least 20 minutes, minimum." It is my turn to shrug - if that is what it takes, then so be it.

I hear a shout from the other side of the car, and hurry round to see what's what. There is another ambulance crew, dealing with a third victim; the driver. He is already out of the car, lying some feet away from the vehicle. He has obvious head injuries, with a Glasgow Coma Score of 6. He is breathing and has a good pulse.

This is really bad. I am not going to be able to do this on my own. There are two patients who need intubating and ventilating. If I am alone I will only be treating one, and it will be the one already out of the car. But the one still in the car might have a chance. What to do?

I get on the phone to GasPasser, another BASICS doctor, not too many miles away from where we are. No answer. Bum!! Looks like I am on my own after all.

Just then, I hear another set of sirens. I look up to see a very familiar car coming to a standstill next to mine. It's the HEMS car!! Phew.

I rush up, and before they have even got out of the car I have begun to appraise them of the situation. As I am first on scene, I am in charge, and I let the HEMS team know what it is I want from them: they will need to look after the one already out, and I go back to the passenger, still in the car.

Just as I am sliding down, I hear a call from the crew down below, shouting for suction. Not good! I rush over, to see that the patient is now making gurgling noises, and is not breathing well. I quickly take over from the paramedic, and push his jaw forward with one hand, and insert the suction device into his mouth, to clear the blood from his airway. This seems to make a difference, and he settles once again.

That's a sorted for the moment; now to get some IV access. There is one arm free, and I put a tourniquet round his elbow. Sliding a cannula into the vein, he jerks his arm away! He is responding to pain, something he wasn't doing before. Things, while still looking pretty poor, are not as bad as I first thought when I first came across the accident.

The fire crew have done sterling work, and his upper body is now free. This lends itself to more problems, as the car is at a good 30 degree angle, and he is tending to slide towards the driver's side. That's not good, as we need to ensure that he moves as little as possible, in case he has a spinal injury. I have his head at this time, because his airway has once again become a problem. I am at such an awkward angle that my upper arms begin to cramp up, but I mustn't let go, or even shift position. I ask the crew how much longer, and they tell me it will be another 10 minutes or so. This is looking badd again.

Just then, the HEMS doc taps me on the shoulder to update me on the situation: his patient has an isolated head injury, and they are going to intubate and transport to the Royal London Hospital. I think quickly: my patient is far more seriously injured, and definitely would benefit from going to the major trauma centre. However, I am supposed to be on call for my own Department (remember, this is my voluntary "work", and I have a job in a local hospital), so there is no way I can go all that way with this one. However, there is a more local neurosurgical centre, and I could definitely go there with the other chap. This is well against protocol - it's not best practice to swap patients in mid-treat, but I can see no other way around it. So, I hand over the passenger, scrabble up the hill to the driver, who is with the HEMS paramedic. Together, with the assistance of the ambulance paramedics, we swiftly anaesthetise the driver, pass a tube into his windpipe, and connect him up to the ventilator.

By this time, the passenger has been extricated, and a bid a fond farewell to the HEMS para, as he goes off to assist with the driver.

Packaged in the ambulance, we make the uneventful journey to the neurosurgical centre, and I hand over.

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I shake my head, clearing the visions, and continue home, where my family awaits, hugs at the ready, still wonderng what the final outcome had been.

Curry

Our friends arrive for a night at Chez RRD, takeaway curry. The phone doesn't ring! We decide what to order (that takes a while) - the phone remains silent. Mr A drives off to get the curry (the restaurant's car has broken down, so sorry, no delivery tonight). No calls. We start the repast, a fine spread!! Still we are not disturbed. Then, just as I breathe a sigh pf relief, as the last of the CTM is mopped up with the final piece of peshwari naan, my phone goes off. A job about 20 minutes away. A car has hit a tree, and the driver is unconscious.

I learn something this evening: it's not easy to bend down to tie the shoelaces of your brand new, free(!) Magnum boots with a gut full of curry! It's even harder sliding down a ditch to help get a now fully conscious, if rather inebriated, driver out of a Peugeot. And, don't get me started on the journey to the hospital...

Tomorrow - Chinese!!!

Eyes

He lies there, hardly a mark on him. Just a small graze on his forehead. Not much at all. And yet...

And yet, the car windscreen is shattered

And yet, he has a GCS of 4; eyes closed, no verbal response, limbs extending

And yet, when I lift up his eylids, his eyes tell all.

Pupils widely dilated, eyes diverging.

His eyes, windows to the soul, fortellers of death

A Tale of Two Bloggers

All I can see in the distance is a set of hazard lights, emitting an intermittent orange glow against the dark background of the night. Maybe this RTC won't be quite as given - trapped and unconscious - but as I approach at a rapid pace I can see that the hazard is not the car with the lights flashing, but a car facing the wrong way, lying on its side, perched up against a street light.

At four o'clock in the morning there's very little traffic, very little life about. The world sleeps as I do my small bit to keep it safe and well. The call rate to the ambulance service drops, but so do the number of available ambulances. I know I may be on my own for a while. I stop by the car, take one look at it and its unfortunate occupant, and call for help. I need everyone. Fire Brigade, police, at least one ambulance and a Basics doctor. This patient could need a lot of help, and quickly.

I’m fast asleep, having just finished a late shift in the A&E. How weird, then, that I can hear the drum solo from “In The Air Tonight!” Wait a minute, that’s my ‘phone, Ambulance Control. I blearily answer it, and accept a job nearby – car overturned, entrapment and unconscious.

I climb into the car through the boot, hoping that my assessment of its safety was correct and that the kerb would hold the car from tipping further. The patient was clearly unrestrained, lying with his head on the passenger window against the road, and his legs wrapped around the steering wheel. His breathing is a little slow, which concerns me but just putting an oxygen mask on him is a struggle. He tries to fight me off, making me think that this could be anything from a diabetic coma, to alcohol, to a serious head injury.

The journey is uneventful, and I pass the police barricade a few minutes after leaving home. It usually takes a little while for me to wake up fully, but the sight of the car on its side, facing the wrong way, and the lamp post knocked down, is like a splash of cold water. This doesn’t look good. I jump out of the car and grab my pack – anything else I will come back for. I jog round to the car, and am directed to the rear.

The Fire crews turn up first, and I ask about taking out the windscreen, but that would apparently take some time. I need him out quicker, but have no way to move him and no where to move him to. As I'm still fighting to get a primary set of observations done, three pairs of legs appear at the back of the car, two of them green belonging to the crew, and one of the pairs of legs orange. I recognise the voices and thank everyone who needed thanking for them turning up in a hurry. The orange pair of legs belongs to RRD, and I was fairly certain that when I'd asked for a Basics doctor, it would be him that I woke from his slumbers as I knew I was on his patch. At least now I could share my thoughts and decisions.

I peer in through the hatchback of the car, and see a familiar face – Ben! Excellent! This is going to be entertaining, if nothing else. He quickly appraises me of the situation – an unrestrained driver, was deeply unconscious, now is combatative. Difficult to get access to the patient, no obs done. We discuss what options we have; peel the roof down or bring out through the back. I want this man out here, so I suggest to Ben that he tries to wind the seat back down, so that we can bodily drag him out. I wander over to the Fire Chief, and let him know what we are doing. He doesn’t look best pleased – I guess he was looking forward to some cutting, but offers all assistance with lifting etc that we might need. I go back to the boot of the car, to see Ben struggling vainly with the seat controls. “Got a problem?” I ask. He just grimaces, reaches under the patient, and the seat magically drifts back, giving the crew room to get him out. I leave them to it, and go and set up for the inevitable intubation.

We extricated the patient out the car the same way I'd climbed in, through the boot, and onto a rescue board. He was still trying to fight back. By now I could smell the alcohol, but still couldn't rule out that his behaviour was due to a head injury, and we treated as such. RRD knocked him out, intubated him, and made sure that our transfer to the hospital would be as event free as possible.

I watch as, first Ben and then the patient, are born(e) from the back of the car, the patient on a spine board. The crew wheeled him into position, near my kit dump, and we start to cut through all his clothes, so that I can make a formal assessment of his injuries. Ben is set the task of getting iv access. I check him over, head to toe, and find little else wrong with him, apart from the obvious – he is eyes closed, occasional groans and localising to pain. Glasgow Coma Score is therefore… anyone?? 8. of course!! I’ve got the kit ready, the team are ready, Ben gives the drugs, and the tube is in. We get him on to the vehicle, and I ask Ben to travel with us.

I travelled with them, abandoning my car at the scene and remaining in charge of the patient's ventilations as we did the breathing for him.

The journey is uneventful, and the three of us in the rear chat about stuff – other jobs we have done, BASICS, the state of the country, that sort of thing. All the while, we are closely monitoring the patient for signs of deterioration, of which there are none. We get to LocalNeuro, and hand over the patient, with some playful banter about whose IV access is better, Ben’s or mine (mine, of course)

All that remained was the tidy-up, paperwork, NHS tea in paper cups, and to get back to my car and return to base for the end of my shift. Maybe, if I asked really, really nicely, RRD would take me back in his cool car...

And then it’s all done. It’s early in the morning, and there’s a bit of paperwork and a lot of clearing up to do. We stand around, drinking our tea, before I offer Ben a lift back to his car.

Confession

Ok, so my Dad comes in to the hospital today, and needs iv access in a hurry. So, I get the kit, and go for the right wrist. Damn!! I missed!!! My own father, veins like drainpipes, and I missed.

I am sure some would say, that is why you don't treat your own family. I know, but, when your father is in front of you, and he needs a line, and you are the most experienced person there, you just do it (or, in my case, botch it!)

He's fine now, just been discharged.

Speed!

Saturday:
Post for me! Excellent. Looks official. I open it to find a Notice of Intended Prosecution. Excess speed of 40MPH on a 30MPH restricted road. I check the date, and let out a sigh of relief as I see it is on a date I went out on a job - a double stabbing, one survived, one died. Ok, no problem, just knock off my usual standard letter, giving CAD number and whoosh! All sorted.

Thursday:
More post. Looks official. Another letter from those friendly souls at Traffic Criminal Operations Unit. This time, it is an offer. I can agree to pay the fine and get 3 points on my licence. Or I can go to Court and contest it. Oh dear! I have another, closer look at the letter. Ah, I see the issue. The time of the speeding was a good hour after the incident. So, I wasn't on my way to the incident. I must have been on my way back home. Still, surely that is mitigating circumstances; having attended such a disturbing scene. Ok, no problem, just knock off a rather more in-depth letter, explaining what had been going on, and hope that will all be sorted.

Friday:
I am driving towards the hospital, when I see the drated camera that got me. Wait a minute! The camera is pointing TOWARDS the hospital. So, that means... wait another minute! I was in the back of the ambulance with this patient. So, someone else was driving my car. I rack my brains. It was definitely not one of the ambulance crew - they were too busy with me and the patient. It must have been one of the police officers. Oh, well, too late now to do anything about it.

Monday:
I try to find a number for the Traffic Criminal Justice Operational Command Unit, but there is no way of getting hold of it. I ring the local station, and am advised that I need to send the original form, with the name of the police officer who was driving. Not so easy, on two counts. I haven't got the form, and I haven't got the name. I ask for someone in Homicide to call, to get some advice.

Friday:
The Homicide Officer calls, and I explain once again what has happened. She promises to deal with it for me. Phew!!

Normal vs Para-Normal

NORMAL:

It is 7pm, and you are sitting at home. Your rest is disturbed by the sound of your mobile phone ringing: "The Boys Are Back In Town", by Thin Lizzy. It's your mate Ben, wondering if you might like to meet up for a drink later, as you haven't seen each other for a while. You go out to a quiet pub, with a roaring fire, have a few drinks, and reminisce about the old days, and complain how no-one seems to do their job properly. You get back home around midnight, and go to sleep.

PARA-NORMAL:

It is 4am, and you are in bed. Your sleep is disturbed by the sound of your mobile phone ringing: the drum solo from "In The Air Tonight" by Phil Collins. It's Ambulance Control, wondering if you are available for a job, as your mate Ben has called in a serious RTA. You jump out of bed, go out immediately, into the pouring rain, to help Ben get an unconscious chap out of an overturned car. You travel in the back of the ambulance with him, then. once you have handed over your patient, you stand around in the freezing cold, drinking NHS tea out of paper cups, and reminisce about the old days, and complain how no-one seems to do their job properly. You get back home around 6am, and lie awake.

Nice to see you this morning, Ben.

Great to Be Recognised and Remembered

So, I'm in the back of an ambulance at 2am this morning, and the paramedic says to me: "You'd better sit here, facing front. I remember you, you puke if you face back, don't you?" Ah, fame!!

My Worst Fear

It's about 7pm; it's cold and wet (what's new?), and I am just dropping off a friend near home, when I get a call. Am I near to SuburbanTown? Yep, I'm in SuburbanTown. Can I attend an RTC at SmallRoad, ST? I think quickly - SmallRoad is a turning off the street I am currently on, probably about 30 second's walk from where I am parked up. I enquire hopefully whether this is a crew request, and get the heartsink answer: no, they are on their way.

Hey, this can't be all that bad, after all, it is SmallRoad, so there won't be much speed involved.

I turn up, clad in orange, to see a car, driven into a garden wall. There are lots of people around, none of them wearing anything remotely reflective or green. I'm on my own - my worst fear.

As a hospital doctor, one is never alone with a critically ill patient for more than a few seconds. A quick shout out of the door and you are very quickly overrun with doctors and nurses, all with their own tasks to perform. One quick phone call and I can have a full trauma team, a cardiac arrest team, a paediatric team, all there to help with the patient. Those of you reading this who are EMS spend your life being first on scene, and especially you first responders, spend your life being the only one there: I don't, and I don't like it. It brings to mind an awesome film with Patrick McGann, Paper Mask, in which a porter takes on the identity of a junior doctor, and gets a job in a busy A&E Department. In the turning point of the film, he is giving an anaesthetic to a patient all on his own; it goes wrong and the patient has a cardiac arrest. The terror of him working on his own, trying to save the lady's life, is so brilliantly portrayed by McGann - get the film and watch it!!

But I digress, big time!

So, here i am, standing outside this car, looking in at a chap, slumped over the wheel, not moving. Hmm, worse that I thought. Ok, back to basics:

Safe approach? The engine is still running, so there is a chance the car will explode. No friendly fire crew, complete with hose. Oh well, at least the road is quiet.

Airway? Lying slumped against a steering wheel isn't going to be the best position for anyone, especially one who is unconscious. I need to act fast, and position him better. Still no fire crew, with cutting equipment, to get an easy access. How am I going to get to him? Break the glass? Never a good idea. Thinking quickly, I try the passenger door - it opens easily. I slip into the car and lift his head in to a better position, putting my thumbs behind the angle of the jaw and pulling forwards, to get the tongue out of the way of the airway. He takes a big gasp, starved of oxygen for a few minutes. Phew!

Breathing? Well, now he is. Can I have some oxygen? No. I don't carry any, and I am on my own. Listen to the chest? No. I have my hands full, supporting the neck and opening his airway, so I can't do much else.

Circulation? Usually, when I am opening an airway, I can manoeuvre my fingers to feel a carotid pulse in the neck, or, failing that, get a facial artery under my thumbs, so that I can assess. However, that's far easier if the patient is lying down, and this one's not! I am lucky in this case, as I can feel a very slight pulse in his neck, weak and thready.

I start to hear the sweet, sweet sound of sirens. Moments later, I am greeted with the sight of a First Responder. One becomes two!

I rapidy apraise her of the situation: this man needs a rapid extrication from a car that doesn't appear to be all that damaged. We both wonder aloud whether this may be a medical collapse, precipitating the crash. There doesn't appear to be any signs of external injury, and we agree that if we get him out we will have a much better chance of dealing with him.

Turn to the crowd, grab two of them and get help to bodily lift patient out of car. This isn't protocol, and I'm not sure if the first responder would have done this if I hadn't been there (comments, anyone?) We lie him down, and proceed with a more formal assessment.

By now, the fire crew have arrived, and are happy to assist with movement, holding bags of saline, shining torches in our direction, as we continue to work on the elderly gentleman. He is tubed quickly, and fluid is given to him, in order to get a pulse at the radial artery. We still have no blood pressure recorded on the machine, nor can we get a manual BP. I begin to wonder what else we can do with him here when the ambulance crew arrive. We bundle him on to the stretcher, and I travel with him to the local A&E.

They are expecting him. I don't mean as a result of the trauma call we put out. No, his GP had phoned them, to tell them that he was on his way, with a suspected leaking aortic aneurysm. He decided he wouldn't waste ambulance time, and would drive himself.

Unbelievably, he survived his emergency surgery.

For The Want Of A Shoe...

I lost a shoe this evening. It's the sort of thing the kids do; come home from school with only one shoe. Apparently they change for P.E., and don't pick up their belongings, coming home with no trousers, or just one shoe. How ridiculous. I keep telling them: be more responsible of your stuff, what do you expect me to do, just go out and buy you a new pair? Money doesn't grow on trees, you know.

Well, this afternoon I am sitting in a meeting with my Chief Exec, when my phone starts vibrating. It is HEMS, asking me to attend a horse rider, who has been squished by her horse. Gets me out of the meeting!! I rush to my car, open the boot and decide, in an instant, that a muddy field will be the ideal place to test my new, waterproof Magnum boots. So, off with my brand new shoes, chuck them in the back of the car, and slide on the Magnums. Smoooooth!

A simple journey later, I park up in a small, unlit alley, and jump out of my car. Boots working well! I open the trunk of my car and pull out my trauma pack. I am vaguely aware of the sound of something falling out of the car, but when I look, I cannot see anything - must be imagining. I rush over to the ambulance, where the patient is (damn! no muddy field) and enter. She is fine, a mild concussion, and I decide to follow the ambulance in my car, so that I am available if she becomes ill en route. She doesn't, and, after a quick drink with the crew (tea, honest!!) I am off home.

When I get home I get out of my boots (very comfortable, even on an hour's drive), and reach in to my trunk for my shoes. Oh dear. One foot too many.

It's confession time to my family. Mrs RRD is very understanding, but Mini RRD is in hysterics, as he kept picturing me throwing open my trunk, dragging out my trauma bag, and, in the process my left shoe flying out and hitting a cow!! Very odd child.

Magnum Boots - A Review

Just like Medic Triple Nine, I have been asked to review a pair of Magnum Elite boots. Obviously, a disclaimer is needed first - the opinions in this blog entry are, as always, completely my own, and not necessarily those of Basics. I have a conflict of interest, and that is that, as a result of agreeing to review the boots, I get to keep them! As a Basics Doctor, and especially as a bloke, I love the opportunity to try out new gadgets. All right, that's that out of the way; now on to what I thought of the boots.

These are a new style of boots, known as Elite. The main selling point of them is what is known as Ion-Guard. It is a special waterproof coating that actively repels moisture, which is designed to keep your feet dry, even when submerged. It will also repel other fluids, such as blood and urine, which I didn't try.

Let's get the bad out of the way immediately. These boots do not have steel toe protection. This essentially means that they are unsuitable for most pre-hospital practitioners. I contacted the the manufacturers, and they assured me that there is a new boot coming out, known as Shield, which will be much more suitable for us.

But, apart from that, how did the boots fair? I have certain key factors that I consider when considering which boot is right for me.

The obvious one is comfort. These boots get a resounding thumbs up for this. I wore them for a day while at work in the hospital, and I had no problems. There are no uncomfortable seams, and they did not rub at all.

Second obvious is looks. These boots do look the business, as can be seen here:

Now for an unusual one. I don't as a rule, walk around in my boots all the time. As a Basics Doc, I need to be able to jump into my personal protective equipment quickly, at a moment's notice. And, when I looked at how high up the ankle these boots come, I was expecting problems. I was, therefore, very pleasantly surprised when I saw that the boots do not have the usual eyelets for the laces. Instead, there is a very clever arrangement, that means that the boots can be opened wide very easily, and subsequently tightened remarkably quickly:

And finally, the water repellent coating. I and Mini RRD did the water test this evening, and as you can see from the photos, there was a very definite running off of water, and my foot was completely dry, despite his best efforts to soak me.

I would be very interested to know what happens when the boots get scuffed, as they inevitably will. Also, especially considering a recent job I was on, I am interested to find out how they fare with diesel...

So, in summary, as a stout pair of walking boots, a resounding YES. As a work boot for pre-hospital care, definitely not, certainly until the new ones come out, with the steel toe-protectors.

Now, anyone out there want me to review a new car, I'd be happy to oblige - as long as I can keep it!!

Bingo!

She doesn't look too badly injured, lying there in the back of the ambulance. It's just after 3am, and she's had a skinful, before having a row with her boyfriend and running out of the house, into the path of a fast-moving car. The driver of the vehicle is not without blame - he has also been drinking.

The main issue with her is that her conscious state is low. She has a Glasgow Coma Score of 7. The GCS is made up of 3 parts: eye opening, verbal response and movement. She isn't opening her eyes to painful stimuli - score 1 out of 4. She is making incomprehensible sounds - score another 2 out of 5. She is withdrawing from painful stimuli - score 4 out of 6. This is an indication for intubation and ventilation, as someone with a GCS less than 9 cannot maintain their airway, and is at a risk of either aspirating or stopping breathing. But I'm really not sure if she has a true head injury or if this is the effect of too much alcohol. I have to decide.

I draw up the drugs, and prepare my kit. It's always a worry - here you have a fit teenager. They are breathing on their own and don't appear to have any significant injury. Yet, if you don't act they could die en route to the hospital. However, if you do act, they might die as a result of your intervention. This is not the first time I have had to make this difficult choice. I reflect on how much easier this can be, if they are either obviously badly injured, or completely awake. Oh well, I may not be paid for it, but this is what I do!

So, usual procedure, get all the kit within easy reach, including the stuff for a surgical airway (if I have it ready, I'll never have to use it, right?" and I slowly give the paralysing drug, followed by the anaesthetic. Laryngoscope in left hand, lift up the tongue, sweep over to the left, visualise the cords and in. A textbook, grade 1, intubation. Blow up the cuff on the tube, connect up the CO2 monitor and give a few puffs with the bag. A good trace. Phew!! Another one under my belt.

"Pulse of 140," says Mick, my para, helpfully. "190." "210." What?? "215." Ok, Mick, now you're just freaking me out! Stop with the numbers, already!! I look up at the monitor: sure enough, the pulse is way up. This is not what I need right now. I was planning a nice, leisurely trip to NeuroCentre, about 20 minutes away, and she's playing bingo with her pulse! Her blood pressure is almost unrecordable.

Calm and centre.

Causes of tachycardia and hypotension, from the top:

1. Hypoxia. This is when there is not enough oxygen in the blood stream, and the heart tries to compensate. Usual cause in an intubated patient is wrongly placed tube. But, I have seen the tube pass through the cords, and I have a good trace on the CO2 monitor. CO2, carbon dioxide, is only produced in the lungs, so if I have a trace, going up and down with every squeeze of the bag, then I'm in. Oxygen is attached to the bag, so hypoxia is not the problem here.

2. Tension pneumothorax. The dreaded tension, happens when there is chest trauma, and I can see none. I listen and can hear good breath sounds. I decide that this is not the time or the place to be making holes in her chest wall. I move on:

3. Hypovolaemia. Fluid loss, specifically blood, can lead to a rapid rise in the pulse rate and a drop in blood pressure. So, is that it? Is there some, as yet unidentified, injury? Is she bleeding somewhere? While I am looking I get Mick, my bingo caller, to squeeze her fluid bag, and try and get as much as he can in to her. I don't like fluid in the pre-hospital arena - it makes people bleed more. But in circumstances where they have almost no palpable pulse and a blood pressure of... 50/20!!!... it might just enable us to get her to a hospital alive.

I check her over, remembering the mantra: one on the floor and four more. There is no external blood loss, and her chest, abdomen, pelvis and long bones all seem intact. Still, I can't think of anything else to do, apart from giving fluid.

4. Cardiogenic. This is where there is direct trauma to the heart. Again, I have no reason to believe this is the case, as there is no sign of chest trauma.

It is now 5 minutes since I have tubed her, and her heart rate is unchanged. I have given her 500ml of fluid, and I can feel a pulse, at least. I look at the monitor; the rhythm is very fast and it's irregular. Irregular? That's atrial fibrillation!! What's a 19 year old doing, having AF, that we normally see in much older people, often with heart disease? I have no idea. I wonder if she has had an adverse reaction to the anaesthetic agents I have given her. I've never heard of this before, but I'm not an anaesthetist, and anything's possible.

Right, I'm totally out of my depth. She needs a hospital, and fast. NeuroCentre is 20 minutes away, but LocalDGH is 5. It's a no-brainer - she might not get to NeuroCentre alive. I let Mick know what we need, and he puts pedal to the metal. 3 minutes later we pull up outside, with a girl with a barely palpable pulse, no recordable blood pressure and a heart rate of 220. What a gift!

I hang around, while the team don't exactly fill me with confidence. She may not be in my care now, but I did work hard to get her here, and I would like to see the hospital staff work a little faster. I look at the anaesthetist, and he shrugs. "Maybe next time you'll decide to go somewhere else." I don't disagree with him.

5 minutes later, we look at the monitor, as she flips out of AF and into a normal sinus rhythm. Pulse rate: 84, blood pressure a very healthy 135/75. We chat about what may have caused the AF. I am secretly relieved that he has no idea either.

The next morning I ring up and find out that she is on a general ward, awake, with a headache. CT scan was normal.

Helping Hand

So I'm driving home, after looking after a drunk, who decided that tonight would be a good night to run out in front of a car. Fortunately for him, tonight was also the night for the car under which he threw himself was being driven by a very good driver, and his injuries are more likely to be due to the fall, rather than the car. After checking him over, I leave him to the capable hands of the paras, and start my journey back home.

I'm about 5 minutes away from home, when I see a car fly out of a side turning in front of me, straight into the side of another vehicle, before swerving into the side turning opposite, and coming to a less than graceful stop.

I'm remarkably calm, considering what I have just witnessed. My biggest fear is arriving on scene before the ambulance staff, as that always leaves me very vulnerable and unsure of what to do next. I know that sounds very wimpy, but I depend very much on the experience and assistance of the paras and emts out there.

Anyway, I calmly flick my blue lights on, and park up on the side of the road, next to the wreckage. I am already in my jumpsuit, as I generally don't change out of it at the roadside - too dangerous. I then assess the scene:

There is a car in the middle of the road - it looks on fire, as there is smoke coming out of the side window. The car that has done all the damage is in the side road, and is relatively intact. I can see the driver, an elderly gentleman, sitting in the car, looking somewhat dazed, but otherwise ok. I therefore make the other vehicle my initial priority.

I look into the car - I can see smoke, but no fire. The airbag has deployed, and I realise that the smoke is from there, rather than anything else. There is a single occupant, and she looks alright. She is fully conscious and has no pain anywhere. I leave her and make my way to the other car. En route I call up to Control, and let them know that I have come across the accident, requesting an ambulance.

As I get to the other car and peer in, I am bodily pulled away. I turn, to find a chap, tugging at my jumpsuit. "It's ok," he tells me. "I've seen Casualty, and I can look after him" Good, thank you, now why do you think I am wearing a bright orange jumpsuit with the word "Doctor" emblazoned on my back? I gently, but firmly pull him away from the car, and explain that I would probably be able to cope. He looks at me, and asks what he can do to help. I suggest that he could make sure that no traffic comes down the side road. He eagerly ran off to do so.

A few minutes later, once I had ascertained that the gentleman was relatively unharmed, I became aware of the sounds of car horns blaring behind me, on the main road. I look up, and see my helpful chap, in the middle of the main road, cars all around him. Somehow, he has managed to get the cars to all drive on the right hand side of the road, in both directions. I rush over, and ask him what has happened. He shrugs, and tells me that he was trying to keep the cars out of my way, but that they didn't quite understand his intentions.

"Sir," I say, "Where do you live?" He points to a house across the road. "Now, I need you to do something very important for me." He looks up at me eagerly. "Go across to your house and call someone."

"Who?" he asks.

"Anyone!" I reply.

Children Should Be Seen And Not Hurt

For the Handover Carnival, hosted by my friend and colleague, Ben Yatzbaz, at http://insomniacmedic.blogspot.com/. Well worth a visit...

He's 13, and waiting for a bus to school. It's cold. He's running late. How fab, then, when he sees his sister's boyfriend drive up to the bus stop. Who wouldn't accept an offer like that?

5 minutes later, he is deeply unconscious, lying in the unrecognisable wreckage of the car.

10 minutes later, I am in the ambulance, vainly struggling to get IV access, to pass a tube into his windpipe, essentially to save his life. IV line in, tube is passed with difficulty. He makes no response, despite the fact that I have given him no anaesthetic drugs. This is bad news. His pulse slows, down to 30. There is no pupillary response to light. He has a severe head wound, and his neck feels as if it broken.

The monitor shows a heart rate of 20; wide, very abberant waves. I can feel no pulse in his neck or groin. I open up the giving set, and push through another 500mls of saline. None of us are talking much in the ambulance; we all know where this is going.

Asystole: flat line. I consider making a cut in his chest, to decompress any tension pneumothorax, but I know it will be to no avail. One of the paras begins CPR, and I tap her on the shoulder, and silently shake my head.

I ring the local hospital - it's not mine, but I know the team well there, having worked there a number of years before. I let them know the situation: that we are bringing in a young lad, injured in a serious RTA, and who I have pronounced on scene. It is not usual practice to take someone to hospital after you have pronounced life extinct, but I can't leave him here, and I know the family have been informed. For their sake, he needs to go to the hospital.

I travel with him, a silent journey, no sirens, no blue lights.

At the hospital, we are met by a paediatric trauma team - my message clearly did not get through properly. I tell them what has happened, and they disperse, until I am left, alone with the paramedics and the A&E nurse and .. Oh no! I don't even know this child's name.

"The aunt has arrived, will you talk to her?" I look around. The receptionist stares back at me, tears glistening in her eyes. "I know him," she whispers, as she leaves the room, without a backward glance. I remember how difficult it is, working so close to where you live, when any one of the thousands of patients you see could be a friend or a relative.

The aunt had been on scene, had seen the car, knew her worst fears had been realised the moment I walked in to the relatives room. We sit there quietly for a few moments, she just telling me isolated snippets of his lfe; things he got up to, what he was like.

And then, it is time for me to leave, to drive to my own place of work. All day long I am not my usual self, thinking about how every single decision can have such far-reaching effects.

A month or so later, I am sitting in my office, dreading the arrival of his mother, a lady I haven't yet met, but who wants to talk to me. She enters, and I rise to greet her. She looks around my office, at the many photgraphs of my five children, and a wistful smile flickers on and off her face.

She wants to know what happened at the scene, and I tell her, sparing her no detail. It is my impression that what is imagined is always worse than reality. She asks me if he said anything to me, and I shake my head, and tell her that, based on what I had seen, he had been deeply unconscious from the moment of impact. She frowns. "But I was told he was talking initially," she tells me. I probe a little deeper. It turns out that her sister, the aunt whom I met on the day, had 'phoned her and told her that her son was talking, possibly so as not to unduly distress her initially, before the worst was known. The mother had never discussed that with anyone since, yet had lived with the thought that her son must have suffered terribly before he died. I assure her that that was definitely not the case. She clings to this information, making me promise. I do so, and tears roll down her face. What had been imagined was far, far worse than reality.

She leaves my office, and I sit there, staring at my photographs, my own tears starting to flow.

EDIT: Now, this is really spooky. I have just come back from a job, and, while in the back of the ambulance, the para told me that the last time we had worked together was about 3 years ago, when a kid died after getting a lift from his sister's boyfriend! Three years ago!! I still have goosebumps, thinking about the strange coincidence, that I should write about this case this morning, and meet up with the same crew this afternoon...

A Kodak Moment

There are times in this job when a camera is essential:



When a child has been the victim of non-accidental injury, we need to be able to document accurately the injuries, the bruises and the marks. A photograph will ensure that this is done perfectly.



When someone has an open fracture we need to photograph the wound, before soaking the area in Betadine and covering the wound. The photograph will stop the doctors from needing to take off all the bandages, so reducing the risk of bone infection.



When we have a really interesting rash, or deformity, or other unusual clinical sign, we want to be able to show our junior staff, our medical students and our colleagues, to educate and inform.



However, when you get called to a man knocked down by an ambulance, and when you get there and he's still half under the vehicle, the temptation is almost overwhelming!



NOTE: Before anyone thinks how callous and awful I and the others at this scene are, the chap was fine. He had been lying in the road, after a little too much to drink, and the vehicle came to a stop before actually hitting him. It just looked SOOOO incongruous. Also, no-one actually took a photo, honest!!

Ponderings

As I peel of my blood-stained jumpsuit and carefully put it into a plastic bag, for cleaning later, I wonder why a murder scene such as the one I have just left affects me so very much.

True, there was an awful lot of blood, but I see blood a lot, both in my job in the hospital and in pre-hospital care. And the gore associated with some of the motorbike accidents can be far worse; mangled limbs and the like.

Maybe it's the fact that it's one human being against another. But no, the assaults are often far worse, with people laying into each other like crazy, with knives, with champagne bottles, with baseball bats. And that's just par for the course, what we deal with in A&E and on the streets on a daily basis. It doesn't really affect us like this one does.

But there are two things that are different today.

Number 1: this man is clearly past any help whatsoever. He's dead, and there is nothing, nothing at all, that we can do. And yet we are duty-bound to go through the motions of getting a tube in place, etc, etc, etc. For those who spend their time trying to save life, that is difficult.

Number 2: this isn't an act of violence bourne of aggression, of alcohol, of cross words; not a fight gone wrong. This is an intentional act; someone has deliberately taken another's life. And, for those whose raison d'etre is to preserve life, that is an abomination.

Bumpity, bumpity, BUMP (and the rudest patient ever!!!)

2:30am, and I find myself driving to GreenTown, to an RTC, persons trapped and unconscious. This is the sort where I can possibly be of most use - the patient is clearly very unwell, and the chance of a rapid trip to hospital is hindered by them not being easily accessible.

So, Sat Nav Sasha is telling me, in a nice loud voice, where I am to go. The indicated time of arrival is 2:55, but I know that, at this time of night, and at the speed I am travelling, I should be able to half the journey time, and get there in les than 15 minutes.

I pass rapidly through MyHospitalTown, and move into as yet unchartered pastures. "Turn left in 100 yards," suggests Sasha. Not one to argue with a woman, I indicate right, only to find a narrow track, bordered by high hedges. I glance at the on-screen map - sure enough, this looks like the road. Off I go, down this path. As it narrows further, and as my headlights reveal larger and larger potholes, just before I am jolted out of my seat, I slow my speed right down, and give thanks once again to Mrs RRD, this time for encouraging me to get the 4-wheel drive version.

Up ahead I can see the road widening, as I reach the end of the track. Phew!! Thanks, Sasha, I never doubted you...

Now on a tarmac'd road again, I let my speed increase, and as I race past houses to my left, my mind, as it so often does at times like these, wonders if anyone is lying awake, seeing the flash of blue reflected on their bedroom ceiling.

The road is a dead end.

Not totally - I can just about make out a tiny, path in front of me, one that makes the previous dirt track look as wide as the M25. I reluctantly call Ambulance Control, and utter those dreaded words: "I'm lost."

The despatcher is very understanding. She checks on her map, and tells me I need to continue Nrth, along the path, for another 1/2 mile or so, after which I will be almost there. She stays on the line with me (bluetooth!) as I endure another back-wrenching journey, bushes scraping both sides of my car at the same time. At one stage, I think I am going to get stuck, as a hole the diameter of a large dinner plate, and a depth you could have buried a large dog in (sorry, but that is how I am thinking) has to be navigated through.

I can now see blue lights ahead - I am there. I say goodbye to LovelyDespatcher and arrow towards the lights.

A line of police beacons and traffic cones block my way. No police, just the cones and beacons. I have to admit, I curse loudly, then get out of my car and, not very gently, rearrange the obstructions to allow my car through. about a 10 yards further on, I arrive. I glance at my clock: 02:55.

And the rude patient? Well, she is deeply "unconscious" on scene, not responding to painful stimulus at all, yet her eyelids twitch as I brush her lashes - drunk as a skunkm, to use the technical term. We fully expose her, as she has clearly had a significant injury, and rush her to MyHospital for further care. The next day I am told by the staff that when she woke up she was more abusive than anyone else they had had there (and for an A&E Department, that is saying something.) She threatened to sue the Trust, because we had cut her brassiere! There's thanks for you.

To The Girls On The Bridge

Dear Girls

I hope you enjoyed watching us today, as we battled to save the life of the poor chap who had collided with two lorries, before being thrown from his van.

I hope you got a real thrill from seeing the blood.

I hope that when you look at the photographs you took from the bridge they bring you real pleasure.

I hope that you have fun retelling the tale to all your friends.


But, most of all, I hope that the young child who was watching with you doesn't grow up to be like you.

Fun in the Back of an Ambulance!

His name is Chris, and he is 12 years old. He's been out for a bike ride today, wearing appropriate protective gear. He has a helmet on, and elbow and knee protectors. Unfortunately, these will only do so much when you ride straight out of an alleyway into a busy road. He's been clipped by a car, and on my arrival is lying in the road. According to his mum, who is with him before the ambulance arrived, he was out cold for a few minutes, but seems to be ok now.

I have a look at him: he's awake and talking, his pulse is strong and regular, but he does have a bump on the back of his head. He has a few abrasions, but seems to have got off lightly, considering.

I have a chat to the crew: we are about 15 minutes away from the local A&E, and I feel it's probably best to ride in the back with Chris and his mum, just in case. After all, he was "out cold" after the accident.

As we are travelling to the hospital, I am chatting to mum about BASICS, and what we do. She used to be a nurse, so she is quite interested in what I do. I keep a close eye on Chris all the time: he is quiet, but responding appropriately to questions, and his observations are fine.

About 10 minutes away from the hospital: I notice that Chris is a lot quieter. He is still responding, but just monosyllabic. Hmm. I'm getting a bit worried about this, and I let mum know that I will be asking the hospital to get a Trauma Team ready, "just routine precautions, nothing to worry about." Phone call made, I am also less communicative, watching Chris carefully.

About 5 minutes away from the hospital: Chris is hardly talking at all now. My heartrate is higher than his, as I quietly, calmly, start drawing up some drugs, "just in case, nothing to worry about, Mum." My call to the front of "are we nearly there yet?" is meant seriously.

About 3 minutes away from the hospital: Chris is looking over to his right. This is baaad. We're not going to make it. I will him to keep in there, just for another couple of minutes, but I realise that time is running out. I quietly unzip my intubation bag, "just to be safe, nothing to worry about, Mum."

About 2 minutes away from the hospital: I turn to mum, just to reassure her. I see the look of horror on her face, and know that time is out!! "He's fitting!" she screams at me. I turn back to my patient, to see a full-blown, tonic-clonic seizure. His body arches and strains against the straps, and his face takes on the blue shade of cyanosis.

"Stop the vehicle," I call, and ask Mum to step outside while I sort out Chris, "Just to get him a bit stable, nothing to worry about!" I'm not very convincing at this point.

Withing 30 seconds of his fit beginning we have anaesthetised him, and secured his airway. With no other injuries, we are able to carry on the journey to the hospital, far more uneventfully than before. Mum is sitting next to me again, and I am reminding her about extradural and subdural haemorrhage, as well as intracranial contusion. I remind her that, as Chris was fully conscious before we left, and that as we had terminated his fit and maintained good oxygenation for all but half a minute or so, his prognosis is excellent.

Arriving at the hospital, I hand over to the team, then wait with mum for the CT results - a small contusion, no need for surgery.

2 days later, Chris is woken up and extubated. 2 weeks later he is back at school.

Plane Crash on M25

Just thought I'd share my morning's experience with you all. I got a call about 11am, telling me to proceed to one of our local M25 junctions, because a call had come in reporting a 'plane crash on to the M25. I duly rush off, leaving my guests behind (sorry, Lady Penelope and Joe 90).

Mrs RRD, LP and J90 were scanning all the news channels, calling their parents, and searching desperately for some information or photos of the carnage, when I called them up to let them know that, just as I arrived at the RVP (rendezvous point) I was informed that the 'plane was a remote controlled toy, and my services were no longer required!

My Dream Last Night

I am in my car dressed in my orange jump suit. It is night. Where I am going and where I have been is a mystery. A call comes through from the HEMS desk to attend a call all the way over in Essex. I start on my way, then get sidetracked, and stop off at a friend's house for a drink. An irate call from HEMS sends me scurrying out to my vehicle. As I start the engine, the passenger door opens, and a very drunk women gets in. I scream at her to get out - she does so, with a bit of a shove from me. I turn to reverse out of my parking space, and my gaze is met by the lifeless stares of the two girls I have failed to save, sitting in the passenger seats behind me.

My screams waken Mrs RRD, and she calms me down, but it is a long time before sleep finds me again..

The Hazards of Parking on a Hill

16:00. I am standing in the Department, when my telephone rings. A call to an RTA about 5 minutes away. I start to sidle out of the Department, only to be spotted by Beardy and Baldy. The hundred metres dash to the car was a dead heat, so both bundle into the car, only to have a fisty-fight over who gets the yellow jacket when we get on scene, and who has to just hope that any other drivers will spot a chap in a dark shirt.

We arrive to find an interesting scenario. A lady has parked her 4x4, and walked down the hill. As she was walking, she heard a vehicle coming down the hill towards her. She, quite sensibly, moved as far to the side as she could (there was no pavement as such on this stretch of road). Unfortunately, the vehicle veered to the right and hit her, pinning her against a wall. The driver of the vehicle was obviously to blame. When I say driver (have you worked it out yet), I am not being totally accurate. You see, the driver was the woman under the 4x4, whose parking brake had not been correctly applied.

So, here she is, lying on her right side, rolled almost completely on to her front, the car having rolled a few feet further down the road. She is hard up against a small wall. The immediate assessment is of a lady, in her early 30's, conscious, breathing fast, with a very bent left leg. But, I must ignore the obvious, and start at the beginning. Come on, Constant Reader*, you know the drill:

Airway: Well, she's breathing, but very fast. She is able to tell me her name (Katherine), so the airway is intact, at the moment.

Breathing: How would your breathing be if you had just been run down by your own 4x4? Her's wasn't all that great. I could see her left side quite easily, as she was rolled almost completely on to her front, and there were lots of abrasions to the skin. The chest wasn't moving in the way it should - as she took a breath in, part of her chest wall was being sucked in, and, on feeling her chest with my hand, there was a crunchiness normally associated with corn flakes. She had what is known as a flail chest. Two or more ribs, broken in two or more places. Not good news for the lung underneath, as there will have been a lot of trauma to the lung, and lung tissue is a lot like blancmange in consistency. The cornflakes are due to air in the soft tissues, and is called surgical emphysema, for those who want to know. OK, something to deal with shortly.

Circulation: Surprisingly good. A good blood pressure, and a nice, strong pulse, if a little fast. She does, however, have a nasty broken femur (thigh bone), which can bleed out 2 litres into the muscle. So, needs dealing with too.

Disability: She's talking, she can wiggle her toes - good stuff.

So, we have a lady with a severe chest injury and a long bone fracture. She can be looked after at the local hospital. I know that - it's mine! However, we have to get her there safely. So, decision time. Awake or asleep? As she has quite severe chest trauma, I decide it is far safer to put her to sleep here, rather than waiting until she gets to the hospital. I prepare all the kit, and start to make use of my two colleagues. Beardy is an experienced A&E doctor, so he gets the job of drawing up my drugs. Baldy, an experienced Health Care Assistant, is given the fun job of straightening out the leg, and applying traction. This will both reduce the pain (after hurting like mad as you start to pull, of course) and reduce the bleeding.

Now, remember her position? She's lying almost prone, and we need her on her back. She's also up against a wall (why is nothing ever simple?), so the paras and I muck in to move her away from the wall and then, while Baldy is still hanging on to the foot for dear life, turn her on to her back. That done, we get her on to an ambulance trolley for the intubation.

Drugs in, and an easy tube.

Now, with the airway secured and the monitoring all on, it's time to sort out the chest. Think of the lungs as two balloons inside two expandable, but airtight, wicker baskets. As the baskets are pulled open, they pull air in to the balloons. That's how we normally breathe. However, when you are artificially ventilated, it's different. Now the balloons are inflated by someone blowing in to them. Imagine one of them has a very small hole. When you blow in to them you also blow air through the hole, into the space between the balloon and the wicker basket. The more air in the basket, the less room for air in the balloon, until such time as the balloon is fully deflated, and all the air goes straight in to the surrounding basket. That is what happens in chest trauma when you ventilate someone. Only, inside your chest is also your heart, which also gets compressed. Nasty things, tension pneumothoraxes. I need to stop all this happening, by making a surgical incision over the space between the 5th and 6th ribs, and then pushing my finger through all the muscle layers, between the ribs and into the space between the ribcage and the lung. Fun!!

So, off I go, scalpel in hand, and perform yet another thoracostomy (we have to call it something clever). Not a huge amount of air is released, nor is there much blood. That's odd. And then it dawned on me. We've turned this lady over, so it's the other side that is of concern. Never mind, I always decompress both side anyway, so I decompress the left chest, and am greated with a hiss of air and a puddle of blood. Good, that's the chest sorted.

Leg splinted, sedation and pain killer given for the journey. I feel ready to get going. A quick check of the blood pressure before we go: 60/40 (for those of you not in the know, 120/80 is considered "normal".) Nah, must be the monitor. Recheck: 55/30. Now my sphincters are working overtime. I'm about to lose this lady, and I'm not having that. My normally jovial, laid-back attitude disappears, as I snap out orders to all present: Push in a litre of fluid, stat, splint the pelvis, check the tube position, put a finger in each thoracostomy and make sure the lungs are still inflated, recheck the BP, palpate the abdomen to check for occult bleeding. Everything is in order, the blood pressure slowly creeps up. I decide we cannot stay here any longer - she needs to be off this hill and in my resus room.

It's not often I fear for my life, but that journey in the back of the ambulance was a doozy! I guess the para realised I was a tad worried about our patient, and wanted her in quick. Suffice to say, records were broken.

By the time we drive up to the hospital the BP is now 100/60, and I am beginning to relax. I realise that the drop in blood pressure is most likely a response to the morphine; a much exaggerated response because of the excessive blood loss, from her leg and her chest.

I get in to the Resus Room, only to find that the most senior doctor is an SHO. Oh well, I won't be going home for a while...

*Constant Reader - I have stolen this phrase unashamedly from my favourite author.

I'm sorry to moan, but...

I'm not the sort to moan, as regular readers are well aware, I hope. But, this morning, I just need to.

It's six am. I'm pretty much asleep, having only got in from work at 1am. "Ring, ring!" Am I available, crew request to a man who has electrocuted himself with a circular saw while up a ladder, has fallen and sustained a nasty leg injury.

Bleary eyed, I get up and kiss Mrs RRD goodbye, and find myself sitting in my car, dressed in my jump suit, address programmed in to the sat nav.

The journey was complicated by me driving past an important turning en route (must remember to activate the sound on the sat nav), which added a couple of minutes to the travel time. In cases of electrocution, like many other injuries, time is of the essence, and I mentally kick myself for my error.

I arrive to find two ambulances (never a good omen), and a patient lying motionless (another bad 'un) on the ground. I grab my kit from the boot and rush over, calling the HEMS desk to let them know I have arrived safe and sound (they do worry so).

He's about 30, looking up at me with a big grin on his face. Eh? I don't usually get grins, especially from my pre-hospital patients. And I notice, in his left hand, the mouthpiece of an Entanox (laughing gas) cylinder.

"What's occuring?" I ask the waiting crowd of ambulance paras and techs (remember, two ambulances.)

The story is as follows: Chap is cutting branches of a tree, comes down ladder with saw still running(!) and slips on last step. Saw falls from hand, striking left knee.

So, he has a deep laceration to his left knee. He is fully conscious, if a little happy from the laughing gas and morphine he has been given. He has a good pulse and blood pressure, and is not bleeding significantly. So, dear readers, what am I doing here?

"So, folks," I ask, "What do you need from me?" Blank looks. "We didn't think you were available." Hmmm. I ascertain that they had indeed requested HEMS or a BASICS doctor, but cannot find out why. No-one seems to know.

Oh well, let's just get on with it. I help log roll the patient on to a spinal board, and help lift the man on to the ambulance stretcher. Job done, I slip back in to the car, and look with dismay at the sat nav traffic display. Not good news, considering I need to be in work in an hour, and haven't had a shower yet...

Now, I've never had a problem with being tasked by Ambulance Control to a job based on history, only to find that the job is not as given. I also have no problem with crews requesting my attendance to assist with a patient, even if there's not much I need to do, apart from provide reassurance that they are doing everything the patient needs. But I do get miffed when a crew requests, and then hasn't got a clue why they did.

Let the flaming begin...

Why?

Why didn't she drive slower?

Why did she hit the lampost?

Why didn't her seatbelt save her?

Why did these three young girls have to die?

My First Emergency

This month's Handover Carnival is entitled 'My First Emergency', and here is my submission.
The date: August 1996. The place: Knebworth. The band: Oasis. 125,000 fans have come to Stevenage to pay homage to two brothers for a weekend 125,000 each day! My job at the time: Registrar in A&E at The Lister Hospital, Stevenage.

The weekend starts off as most do, fairly quiet. A few drunks left over from the night before, the early morning jogger who is hit in the chest by the sledgehammer of a heart attack. I and my team listen to the radio reports, sending out information about the hoards of fans streaming up and down the A1 towards our normally peaceful town. The ambulances slowly roll in, each one finding it harder than the last to get through the traffic.

And then it happens - the blue 'phone rings. This is the 'phone that is a direct line from Ambulance Control, and is used to let the Department know of the impending arrival of a critical patient, either a cardiac arrest or a major trauma. But not this time.

This time, Ambulance Control has another problem. An ambulance has been dispatched to a serious RTA, with a barely conscious driver, and the traffic is so bad they don't think they will be able to get her to us in time. Could we send a mobile team to the scene.

Many a time I have found myself outside the Department, in full Personal Protective Equipment, fully laden with kit, waiting to be collected and taken to the scene of a major accident, only to realise, some 10 minutes later, that it was, once again, a wind up by my "friends." Not this time. Within minutes a police car arrives at the door, and me and Newbie are being rushed across town to a car that has driven into a railway bridge.

I must remind you that this is 1996, 4 years before I start my job as a HEMS registrar, 6 years before I become a BASICS doctor. I have NO experience of pre-hospital care.

We turn up at the job. There is a car, mercifully on all four wheels, but buried bonnet-first in the upright of a railway bridge. The driver is still in the car, and the fire crew have begun the job of dismantling the vehicle. The roof is off, and she is very nearly out.

No seatbelt means that she has hit face first into the windscreen. She has nasty lacerations across her chin and on to her right cheek. Her face is oddly flattened and elongated, a sign I have read about but never seen. She has a severe facial fracture (a Le Fort 3, for those of you in the biz) and is going to have a tough airway to manage.

Out she comes, and on to her back. Airway: virtually gone! I go to open her mouth, only to find it won't open! She has a severely fractured lower jaw, and it is not going to move for me. Oh BUM!! I grab a endotracheal tube, and slowly and carefully pass it into her left nostril, and feel the tube as it goes down past her tongue. Blind nasal intubation is a very difficult procedure, and I had only done a couple, under very controlled circumstances in Theatre, but I had very little else to offer this girl. She coughs as the cord passes her cords (I hope). Newbie listens to her chest. "Nope, no breath sounds," he reports. BUM, BUM, BUM!! I take out the tube, not being sure it was in, and reach for a needle to stick through the skin of her neck and in to her trachea, so that I can breath for her that way. If Blind nasal intubation is difficult, needle cricothyroidotomy (a posh name for sticking a needle into someone's throat) is no better. I have had no experience of this one at all. Still, I have a go. "Nope, no breath sounds." Newbie, I don't like you any more!! Still, if there are no breath sounds, then something else has to be done.

There was no way I was going to go to the next stage, of cutting her neck and introducing a tube under direct vision into her trachea. That was well out of my league. I carefully insert the blade of my laryngoscope between her teeth and twist. A splintering sound heralds the end of her incisors, and a pulling up on the laryngoscope certainly doesn't assist the shape of her jaw. But, I can now see the cords, and I quickly pass the tube between them, into the dark safety of the trachea. "Nope, no breath sounds," comments Newbie. Do you actually know how to use your stethoscope??? I listen myself - not a sound. Bum, tit and other bits of anatomy!!!!!
Suddenly it dawned on me. I grab a scalpel blade and perform my first two pre-hospital thoracostomies, with a very satisfying hiss coming from both sides. Bilateral tension pneumothoraces is uncommon, but will certainly give the physical sign of absent breath sounds on both sides.

She now has an airway, she has a pulse, and she is ready to go. I have saved this one. So far. But we need to get to hospital quick. And there is no way through the traffic.

I am told that there is a police helicopter, and we can use that to fly her to the hospital. But I will have to fly with her. I don't do flying, and have never been in a helicopter. I steel myself, don my flight helmet and say to Newbie, "I hope I don't throw up en route." Advice to the unwary: Flight helmets are fitted with radio mikes. Everyone in the police service heard my comment. It takes a long time to live that one down.

-----------------------------------------------------------------------------------

This may have happened 13 years ago almost to the day, but I can still see the driver, can still sense the metallic taste of fear in my mouth as I battled to save my very first pre-hospital patient.

I've Got A Hat!

I come to a halt on the motorway, the accident clearly visible. A car is on its side, resting aginst the barrier of the central reservation. Already, cars are slowing on the other carriageway, people craning to get a look at the unfortunates. I jump out my car with the junior doctor who has come along for the ride, and we race round to the boot to collect my bag and monitor. We can hear the high pitched screams of an obviously conscious victim: good!

As we get nearer, I see a group of people kneeling down. I see the victim, and my heart sinks. I rush back to the car to get my paediatric bag, as my head screams at me, "A child! It's a child!"

Fortunately the majority of trauma victims I have to deal with are adult. The few occasions I have been called to children, they have already been past my, or anyone else's, care. Children are not just small adults. Their whole anatomy and physiology is different enough to make dealing with kids a separate speciality in Medicine. And it's not mine! I have a paediatric bag, filled with pouches, colour-coded for different ages. But that's like being asked why you think you could be a lion-tamer, and answering, "I've got a hat. It's got the words Lion-Tamer on it." I'm not a Paediatrician, despite the bag.

I run back to the scene and assess.

The child is a 4 year old girl. She has apparently been ejected from the car as it rolled. Airway and breathing are most definitely intact, as she is screaming loudly. Similarly, circulation is not immediately a problem. She is able to talk, when she is calmed down a little, and is able to recognise her father, who was driving the car at the time. I then turn to a secondary assessment, looking at injuries not immediately life thratening.

She has a large gash on her forehead. She has a severely broken left arm. More obvious, and very distressing, she has a massive degloving injury of her left leg. A degloving is where the skin (and sometimes muscle) of a limb is sheared off, much like removing a glove. Usually, and in this case, the skin is still attached, just pulled out of position. Ouch!

My assessment finished, I consider my options. She clearly has no life threatening injuries as far as I can see now, but there may be internal injuries that will only become apparent as time progresses. However, the injuries I can see means she needs very strong pain relief, and that means giving her a general anaesthetic and intubating her. That's where I don't want to be going. But I don't see I am going to have a choice. My mind begins to shut down. I can't begin to calculate doses for a 4 year old!

She has no venous access. I have to do that. Her left arm is a no go. Her right is being attended to by one of the paras, so I move down to her right foot. These needles are tiny, and so are the veins, but at least this is a skill I have mastered! My hand steadies, and the needle slides into the vein. Secured.

Suddenl, I can hear the sound of a helicopter. Not just any helicopter. This one I have flown in many, many times. The distinctive roar of the Explorer gets louder.

"Who called HEMS?" asks one of the paras. "We've already got RRD here, stand them down."
"No!" I shout, "Let them land!"

HEMS is London's Helicopter Emergency Medical Service. I have written about them before, and my usual thought is "Oh no, they're going to take over, aagain." The rule in BASICS / HEMS is smple: whoever gets there first has overall charge of the scene / patient. But that is not always adhered to by the flight crew. Today however, as they come running up, I immediately relinquish all care of the child to them. I am given tasks to do, such as support the neck, set up iv's and talk to the father, jobs I am more than happy to do.

As I sit at home later,Mrs RRD can sense that there is something wrong. She knows the job went well: the child was tubed and ventilated and flown to the local Trauma Centre. I find it difficult, but slowly I open up to her, tell her how incapable I felt, how unprepared I was to manage a patient of mine. She understands. She always does.

Holiday

Hi Folks

Just wanted to let you know that I'm off on holiday with Mrs RRD and the 5 kids. A nice, leisurely drive down to the South of France. I must be mad!!! I packed an emergency bag, then found myself working out the doses of anaesthetic agents and tubes sizes for each one of my family, at which point I gave up. I'm taking a pack of steristrips and some glue, and that's it! Mrs RRD however has taken the contents of the local pharmacy with her. See you soon!

RRD

A Public Apology

This goes out to all the paramedics and EMT's out there. Today I received a blog rating from a paramedic. While he gave my blog a very respectable 8 out of 10, he also raised a very serious concern he had with what I write. I will quote him verbatim: "Several times I noticed the author mentions having to give advice to paramedics re. gaining IV access and providing fluids etc. Seemed at times like he was implying paramedics just wait around for the Dr, not knowing what to do and needing their advice."

I would like to state very publicly that this is not at all how I feel. I work on a daily basis with paras and EMT's, and have nothing but the greatest respect for them and for the work they do. I am there to provide assistance, where needed, and to work together with the crews. Clearly this has not come out in my writing, and for that I apologise.

Fire!!!

"Explosion in NearTown, persons reported." I grab my watch and stare, bleary-eyed at the time: 03.30. I'm in the car in minutes, and I shake my head, trying to clear the last vestiges of sleep from my mind.

It's an easy journey, and my thoughts go to the management of severe burns. The priorities are still the same; airway, breathing and circulation; but in this case they take on a whole new meaning. Very often with a severe burn there is swelling of the soft tissues of the neck and throat, making the airway close up alarmingly quickly. I will need to look for evidence of inhalational injury, and act accordingly, rather than waiting for something to develop. Similarly, the lungs can be badly damaged by the smoke and the heat, and the patient can deteriorate very rapidly. As far as circulation is concerned, burn victims lose a large amount of fluid, both from the initial burn and from the exposed flesh, leading to severe dehydration and low blood pressure. They need lots of fluid replaced. However, those damaged lungs will not tolerate much fluid given to a patient, and will leak plasma into the air spaces if too much is infused. It's a very fine line to be tread.

And that's not including the management of the burn itself. Learning which dressings to use when is a whole career in itself.

I arrive on scene. I know I am there because of the vast number of fire tenders, all parked across the road, in the road, on the pavement. Oh well, it's on foot from here.

As I make my way slowly through the emergency vehicles, managing, on 3 separate occasions, not to trip over a fire hose, I am greeted with an increasing amount of debris. A chair. A filing cabinet, strangely mishapen. Half a table, its corners burnt. And then, as I approach the building, there is just a space. A gap between two other buildings, filled with rubble. The roof tiles are strewn across a huge area. I wonder why I have been called. Surely, no-one could have survived this.

I am directed to an ambulance. I open the door and enter, heavy hearted. My one fear, bordering on phobia, is that of being involved in a house fire. So many times I have been presented with men and women, occasionally children too, who had no chance of survival.

This man is talking. He apparently had come home, to his flat above a newsagents, and switched on the light. At which point, he tells me, his world exploded. When the fire crews arrived, he was sitting on what was left of the stairs, headin his hands, wondering what had happened.

He's not unharmed, far from it. I make a rapid assessment: He is talking, but his voice is hoarse and he has singed nasal hairs. He's going to need intubating some time soon. His chest is clear, with only a few wheezes. He has a good pulse and blood pressure. His burns are quite extensive - about 30% estimated. He will need to go to a specialist unit to have them properly treated. My mind shifts to an email I received from our regional burns centre, stating that they would no longer accept any direct referrals from the roadside, and that these cases need to go to the local hospital first to be stabilised. Good, that's one decision out of my hands...

So, do I tube him here, or get him to the nearest local, about 15 minutes away. I think back to my last post, when I took an unintubated patient to the very same hospital, expecting an immediate response, only to get ticked off when they did nothing. So, that's another decision made: he's being tubed here.

I am always very worried when I tube a burns victim. I have no idea until I have a look with the laryngoscope how much swelling has already occurred. There is always the possibility that the windpipe is so narrowed that it will be nigh on impossible to get a tube in place. I prepare the standard drug cocktail, and open my emergency airways pack. This is a set of instruments designed for me to make a hole in the patient's neck, and pass a tube directly into the windpipe. Never done one yet, but I'm not going to be caught out.

I give the drugs, take a deep breath, and pass the laryngoscope in to his mouth, sweeping the tongue over to the left, to give me a view of .... the cords!!! Yippeee! I can't describe the relief I get when I see the glistening white of the vocal cords, with the windpipe visible as a dark tunnel. These cords are not so glistening: there is a fine coating of soot, and this tells me that, had I not tubed him there and then, the journey to the hospital would have been a whole different ball game...

Tubed, ventilated, packaged. We call in the job, and drive to the local A&E Department.

After we finish the necessary paparwork, tea and debrief, the crew drive me back to the scene. It is daylight now, and we stand there, wondering how anyone could have survived such a devastating blast.

Fall From Height

He lies there, at my feet: a broken man. He had jumped from the car park on top of the local shopping centre. I look up at the dizzying height of the roof above. How many times had I looked over the edge of Level 6 of the car park? I imagine the fall, can see his flight to death. The rain now falls on to his back, his head twisted at an angle incompatible with life, eyes sightlessly looking up at where he has jumped from.

For he is dead, of that I have no doubt. But, there are formalities to complete, before I can stand up, stretch out my back from kneeling awkwardly at his head, and say the words that will signify the end of this poor man's life: "Ok folks, I'm calling this one at... 16:43."

I gently roll him on to his back, and proceed to pass a tube in to his windpipe - the view is initially obscured by blood, and I use the suction to clear my way. Tube in place, I then make two cuts, one on each side of his chest, and push my finger through muscle and fascia, then between the ribs, into the chest cavity, in order to decompress any tension caused by a collapsed lung. That done, and still with no response, I stand, stretch out my back, and call it.

Oh, The Power!!

As a counter to my last post, I just thought I would relate what happened to me this morning:

I arrived at work, and parked up just outside the ambulance parking bay. As I was chatting to one of my friendly paramedics about a job he was on at the weekend, another ambulance pulled up alongside. The EMT got out, and took out the new fold-up chairs that they have been issued with. After a few minutes of watching him struggle with this strange contraption, the para and I wandered over. Deftly, and within a few seconds, the para had assembled the chair.

"Thanks, Doc!" said the EMT.

I'm Angry!

Ok, so I've just got back from a job, and I am so angry with what has just occurred:

He is 43. He has been out for a drink in a pub. Not something to get hit over the head for. He did ask another drinker to apologise for knocking his drink over. Not something that should lead to him lying on the ground with a gaping wound in the back of his head. But it did.

And so, here is James, a rather pleasant chap, according to his mates. He's not being very nice now. He is swearing and snapping at all of us. And when I say snapping, I mean he is trying to use his teeth on us. He can't, but only because there are 4 very strong police officers, holding him down. He needs cuffing, for our safety as well as his. He doesn't like this, and is pulling so hard at his cuffs that his wrists are red raw. Language I am hearing tonight is bluer than on Saturday Night Live. OK, you know the drill by now: the Primary Survey:-

Airway: perfectly maintained, as evidenced by the expletives that emanate from his mouth
Breathing: there's no point trying to listen to his breathing, but he has not received a blow to his chest, so I am happy
Circulation: we can't get a blood pressure, because he won't keep still, but his pulse is regular and strong
Disability: he scores 3 out of 4 for his eyes, as they open if I shout at him. I'll give him 4 out of 5 for voice - I wouldn't say he is orientated, but he certainly knows what he is saying! And he can have 5 out of 6 for motor, because, while he won't obey commands, he is trying his best to do a Houdini with the cuffs.

I do my usual at this stage. I get down close to him and reason with him: "Keep still and we'll take the cuffs off," I tell him, much to the consternation of the rather battered officers. He does quieten, but I don't think getting him out of the cuffs is going to be a winning decision with anyone else.

I know that we are only 3-4 minutes away from NeuroHospital, and, I reason, it's far safer to just go, as opposed to giving him a Rapid Sequence Induction (drugs to put him to sleep so that I can pass a tube into his windpipe and breathe for him.) So, as we are already in the back of the ambulance, I let the team know my plans, and we set off. As we start, one of the team passes the information to NeuroHospital, so that they are ready for us when we arrive: Male, 43, severe open head wound, GCS 12/15, combatative, DA (that's me!) on board.

We arrive, and wheel him in to Resus. We are met by... A nurse and an FY2! A junior doctor, 1 1/2 years post qualification!! At least we have an experienced nurse, but still!! I look around pointedly, and ask, "Where's the Trauma Team? Did you not get our call?" He replied, "Yes, but we didn't think it warranted a Trauma Call." What?? I only didn't tube this chap because I knew we were on the doorstep, and now there's just no-one here to look after my patient. I ask the nurse to put out a call; she just shrugs and goes out the door. Great!! Now we haven't even got a nurse in here!!!

A minute or so later, she returns and tells me the Consultant is in the Department, and will be coming in. Phew!! But no. He wanders in, looks down at me, and talks over me while I am trying to explain what has been occuring. Not interested in the pre-hospital situation, he goes over to the 'phone and tells the radiologist that the scan can be performed with the patient awake. I storm out, muttering under my breath.

The point here is that, despite the fact that the patient is now much calmer, he has had a very significant injury, with very significant pre-hospital features, and the hospital staff are ignoring all we are saying. This has made me angry. My ambulance colleagues are angry. We sit by the vehicle, drinking NHS tea, and bemoaning the difficulties associated with the interface between pre-hospital and in-hospital. As a Consultant, they expect that at least I will be taken seriously, even if they aren't. It's an eye opener for them too.

I have just rung NeuroHospital - he has cerebral contusions and is being intubated as we speak. I'm not a happy RRD.

The Handover Carnival

Well, at long last, here is June's edition of the Carnival. Communication is so important to all of us that I wanted this to be the subject of my edition.

And I am happy to start with a submission from the editor of last month's Carnival, about communication bourne of many years, demonstrating the love between family members:
http://rescuing-providence.blogspot.com/2009/01/communication.html

Peter wants to try and persuade us of the benefits of smoking in his entry:
http://medicscribe.blogspot.com/2006/02/cigarette.html

Our insomniac colleague has some thoughts on 21st Century Britain, that made me sit back and think:
http://insomniacmedic.blogspot.com/2009/04/21st-century-britain.html

A great post from Medic 3, about how sometimes there can be too many words, and no communication:
http://www.medicthree.com/2009/05/here-at-little-ambulance-that-could-we.html

Dani provides us with an insight into how the body can communicate volumes to us, and help us medics do our job properly:
http://medicdani.blogspot.com/2009/05/body-never-lies-how-we-communicate.html

Lumo has something to say, to every patient who has walked into the A&E Department - maybe we should have a biiiiig poster made for the Waiting Room:
http://lumo-wafflings.blogspot.com/2009/05/dear-patient.html

Our HappyMedic has a wonderful post, filled with memories from 1968, and how the communication worked way back when, before mobile phones and pages - possibly better than it does now...:
http://yourhappymedic.blogspot.com/2009/03/pegging-board.html

"It's wern me!" What does this mean? In New Orleans it means something, and to the patient it is important that Sean knows, so that he can help. Read this well-written tale of difficulties with "English" in another language:
http://newburningtiger.blogspot.com/2007/02/ramp-rants-communication.html

Our very own MedigBlog999 has submitted this entry, about Michael, who has is own way of communicating, hopefully not what any of us would subscribe to:
http://medicblog999.wordpress.com/2009/06/08/its-all-about-how-you-say-it/

Here are some tips from Steve about using communication to make a connection with your patient - well worth noting:
http://theemtspot.com/2009/06/09/connections/#more-920

And my final entry, from Kristan:
http://newparamedic.blogspot.com/2009/06/communication.html

This has been a real experience for me, hosting this Carnival. I am looking forward to next month, which is to be hosted by our very own TraumaQueen, whose blog I have followed with interest ever since I started my own. Head on over to his website to see what I mean.

Next month's Carnival is entitled "Pivotal Moment". Entries to kal@traumaqueen.net, by 27th July.

RRD