Another One!!

I don't believe it! It's like buses - none for ages, then 3 come along all at once. I've already been to 2 callouts in the past 24 hours, and I am being called yet again. And, again, I am getting woken up at 5am. I really need a holiday. Oh, wait, that was last week, and I didn't get much sleep then, either. So, up, dress, run to the car, etc, etc, etc. I'm on my way to an RTC, apparently a bad one, with an unconscious driver, after he has ploughed into a van.

I enter an industrial estate, and my SatNav tells me I have arrived. Great! Erm, except, no RTC. Panic! As I am racing down narrow, one-way roads, with no signs of blue lights or accident, I am rung by Control. "What's your ETA?" he asks. "Well, that all depends...on WHERE THEY B.....Y ARE!!!!!!" Swiftly he talks me through the landmarks I can see, and guides me to the RTC.

I glance at the scene. There is a lot of information that one can get from looking at the vehicles. Here I can see a car, with damage to all sides, but mainly to the driver's door, which has caved in. I am directed to the ambulance, where the patient was awaiting my attention.

I open the door of the ambulance and peer in. I know there is a patient, but I cannot see him because of the number of people in there with him. I can hear him, though, moaning and groaning. I can see the effects of him, too, as those holding him down are thrown from side to side.

Ok, first things first. "Can I come in, please?" I remove 2 police officers, to give me a bit of space. I am greeted with, "Hi, RR. Good to see you!" It's great when ambulance crew recognise you; it makes working together as a team that much easier. What doesn't make things easier is the temperature in the ambulance: they have had the heater on, and, what with all the people in
there, it was a bit steamy. Anyway, time to get to work.

Primary Assessment:
Airway - he is groaning and moaning, so ok at the moment, but may not stay that way.
Breathing - he has a broken collar bone on the right, but everything else looks ok. He has oxygen saturations of 100%, which means that the lungs are working well. But.... Remember the state of the car? Remember what I said about the door? Well, there was a huge impact to the right side of the chest. He will have a serious injury to his chest, despite what I can see on examination. I'll come back to that in a moment. Circulation - he has a good pulse, but we don't seem to be able to get a blood pressure on the right arm. We switch the cuff to the left - 180/96. He his quite hypertensive, so I am not too worried that he is bleeding out, but we will keep an eye on it.

Disability - his is agitated, hence the need for the ambulance crew to be holding him down. I do a formal assessment of the Glasgow Coma Score - he scores 8 out of 15. 3 is the lowest, so, although his score is low, he is still exhibiting some higher function. He has a chance of survival. Even more reason to optimise his care en route to hospital.

First decision: he needs me to take over his breathing, pass a tube into his windpipe and make sure that his oxygenation is as good as it can be. I let the team know my plans, and draw up my drugs, one to paralyse his muscles and one to put him to sleep. I get my equipment ready, the tube, the laryngoscope, the bougie.

In position at the head, with the members of my team assigned their roles, I inject the drugs into his vein. Within seconds he is asleep and has stopped breathing. All as planned, so far.

I pick up the laryngoscope, an instrument designed to allow visualisation of the vocal cords and the passage of a tube between them. It lifts the tongue and soft tissues out the way, and has a light at its tip. I insert it into the mouth and sweep the tongue to the left.

A digression: I am a singer. I'm not suggesting in any that I am a good singer; it's just that, when I am working, I sing, softly to myself. "Breathe", by Pink Floyd, when I am intubating, "Bad Medicine", by Bon Jovi - you get the idea.

As I look in the mouth, I can see - nothing! Well, obviously not nothing, but just a tongue, with no sight of any vocal cords, or even epiglottis, when you are about to intubate someone, isn't a good view. I stop singing. Beads of sweat form on my forehead, as I struggle to adjust the position of the 'scope and give myself a better view. My mind rushes forward in time:
can't tube, will I need to resort to my first ever surgical airway - cutting a hole in the front of the neck into the windpipe? I take a deep breath , something my patient cannot do, and force myself to stay calm. Bougie," I snap, and one is slapped into my hand. This is a thin, stiff length of
plastic that can be passed into the windpipe, and then the tube is passed over this, thus guiding it into the right place. I thread the bougie where I imagine the windpipe should be, and railroad the tube over it. It slides in easily.

I hold my breath as the tube is connected to the breathing circuit, and exhale only when I see the chest rise and fall as the bag is squeezed. I'm in!! "Shall I tie that in for you?" The paramedic asks sweetly. "Er, no," I reply. "I think I'll do that one myself.". I am not having THIS tube falling out.

Usually, when there is a patient with severe chest injury, and one starts breathing for them, the pressure inside the chest can become so high as to block off circulation of blood out of the heart, and the patient dies. This is called a tension pneumothorax, and if it is suspected then some form of hole is made in the chest, to decompress it. I had decided this was indicated in this case, based on the collarbone fracture and the damage to the side of the car. Now is the time to get on with it. I reassess the patient: his chest is moving well and his blood pressure and oxygen
saturations are stable. With the idea of "less is more," I decide to wait it out, observe him all the way in to the hospital, and decompress his chest if he deteriorates en route.

We set off for the Neuro Centre, a journey of around 15 minutes. And here was the next problem: I may have mentioned before that I don't travel well. And it's hot and stuffy. And I am going to have to travel backwards, so that I can monitor the patient all the way. And I have just had a massive adrenaline rush, that tends to leave one feeling rather sick, even under normal circumstances. And we were in an industrial estate, with about 20 speed humps on the way out. Is this going to be the first time I actually end up hurling in the back of an ambulance? I desperately hope not. I start to breathe faster, and my stomach churns. My head starts to spin. Here we go! Fortunately, although I am completely unable to move, one of the paras takes pity on me and opens the skylight. Cool air rushes into the vehicle, along with pouring rain, and I drink in the sweetness, through my lungs and my skin. My head clears, and I am able to concentrate on the patient for the remainder of the journey.

UPDATE
I ring NeuroHosp a few hours later. The patient has severe injuries, but minimal bleeding into his brain on his ct scan. He does, however, have a severe chest injury, with a chest full of blood. Had I decompressed his chest then it is highly likely that he would have bled to death en route. Another close shave.