Sunday, 27 September 2009

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!!

Saturday, 26 September 2009


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.

Friday, 25 September 2009

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.

Saturday, 19 September 2009

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.

Tuesday, 15 September 2009

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.

Saturday, 12 September 2009

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..

Wednesday, 9 September 2009

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.

Tuesday, 8 September 2009

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...