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.

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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.