Tock (warning, contains scenes of a graphic nature!)

So, when I left you last, I was doing what I definitely don't do best; running! I had picked up my Thomas Pack (25kg) and my patient monitor, and was jogging round a rather obstructive fire appliance to the incident on SmallRoad. I had already been informed that there was one patient, with a severe leg injury. In fact, the actual information was a partial amputation of the foot.

I arrive, only slightly breathless, to see a young girl, already out of the wreck of a car, lying on her left side, screaming in pain. Not a nice sight, but screaming is always better than silence, when you are on the road. She's not all that far from the car. Well, actually, she is lying right next to the car, with a foot that is hanging on by not much, and in a very unanatomical position. Purple isn't a good colour, either.

So, in true ATLS (Advanced Trauma Life Support, the way in which one manages serious trauma) fashion, I ignored the obvious, and went through my ABCD's:

Airway - well, screaming usually means that you haven't got a problem with your airway, so I move on to:

Breathing - again, you need to be able to breathe in to be able to breathe out enough to scream. There is no point in listening to the chest, as there is so much noise around, so on to:

Circulation - a bit of blood on the ground under her head, but no gushing from the foot. No need for my nonexistent tourniquet, then! Phew!! Pulse - 130!! Eeek! Pelvic trauma?? Abdomen?? Let's get a blood pressure while I move on to:

Disability - she's talking, in between screams, even being able to tell me her name, Samantha, and her address. But she is slurring her words, and not terribly coherent. There is a vague smell of alcohol. "Been drinking tonight?" I enquire. "Not much," is her reply. The car accident seems to refute that. She is able to wiggle her toes in the uninjured foot, and is moving her legs, so I am not too worried about a spinal injury, but we would still like to keep things as still as possible - not easy, as she pulls off her cervical collar. Her blood pressure comes back as very high, so I feel that her pulse is due to pain rather than blood loss.

Decision time. She has a severe injury, and is in agony. I have strong painkillers available to me, but they will alter her conscious state. She has drunk a lot of alcohol, despite what she has told me, and so may vomit. Do I intubate her (pass a tube into her windpipe) after giving her anaesthetic agents, or do I give her the pain killers? If I give her the anaesthetic agents and then fail to intubate her, or if she has an as-yet unidentified injury, she may die at the roadside, as a result of my interventions. Also, she is right up close to the car, and on her side; to move her into an easier location will be excruciatingly painful for her. I think about the distance from FarAwayTown to hospital; probably around 20 minutes. Oh, hell, I'm prevaricating, the clock is ticking, and I need action!

I get the painkiller out my pocket, look at it, look at her, and put it away again. "Alright folks, it's a tube and ventilate jobbie." I'll need all hands on deck for this one. Quickly, I draw up the necessary drugs, one to paralyse her so that I will be able to pass the tube easily between her vocal cords into her windpipe, and one to put her to sleep. I gather my equipment, including a long introducer that I keep in the car - bum! another run, back round the fire engine to get it out of my messy boot, and then back to the patient.

I organise the troops. One will need to assist me with the intubation, one will need to be holding the head still, to ensure that the neck is protected, and one will need to press on the front of the neck; to close of the oesophagus to prevent any regurgitation of stomach contents and stop them going into the lungs before I pass the tube. Oh, wait a sec; this one's on her side. I will need to give the drugs and then she will need to be turned on to her back, AND be moved away from the car so that we ll have room to move. And all this needs to happen, and the tube passed, before the patient's oxygen level drops to a dangerous point. Oh well, all in a day's work for the fire and ambulance crews I have around me.

Drugs in, patient rolled, tube passed and secured. Tick! We scoop the patient onto the ambulance trolley and load her in.

Right, monitoring on. Tick! We are almost ready to roll.

One more thing to do before we go. Anyone?? Yep, just the small matter of the foot. We can't wander into a hospital with it looking like that, now can we. So, I look to one of the paramedics. "Want to give that a tug?" I ask. "Me?" I guide her through the very satisfying job of relocating a nasty, open, fracture dislocation of the ankle. Minutes later, the foot is pink, and there are pulses in the foot. Tock! We're off!