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.


  1. "BP is now 10/60" Am hoping you mean 100/60!! Not a healthy BP otherwise lol!

  2. I was about to share the same ;) Great posts, keep them coming. I really like reading about your thought process as you go through your situation. It's helpful to see different perspectives as an inexperienced EMT.

  3. Interesting job. Have you considered using Ketamine with these patients. Good results without all the bad effects of Opiods/ Benzo's. I've worked with other Pre-Hospital Docs who swear by it. I give it to specific patients routinely. Just an idea. Pete.

  4. Thanks for the comments. Pete, I do use ketamine for analgesia if I am not going to anaesthetise the patient, but have not had much experience in using it as an alternative to the benzo / opioid combo for keeping the patient asleep post intubation. I will have a think / read, and possibly try it out next time - watch this space...

  5. This is a great post, the car accident at the beginning really had me gripped and I found it interesting and informative. I wish I had the skills that people in your profession do.

  6. Excellent site you have here. I also have a nursing blog and was wondering if you would like to exchange links with me. My blog url is http://NurseReview.Org. If you are interested please add my link and them leave me a comment so that I can add also a link back to your site. It will improve our google pagerank since we have the same niche.

    Hope to hear from you soon.

    Retrogression Update

  7. Doc> It's these sort of jobs where an pre-hospital doctor really comes into their own. Sticking a 14g (we use 12g dwell-caths) into a chest, often won't do the job. An advanced provider can give you the window to get the patient to definitive surgical care. It always amazes me at peoples ability to seriously injure themselves.
    Just on the Ketamine. I've had good results with multi-system trauma patients. Especially those who are hypovolaemic or have chest trauma. Analgesia, amnesia, a rise in bloodpressure and broncho dilation, what more could you ask for in an analgesic agent. Take care, Pete.

  8. I'm hoping that you mean Stephen King...

    Another great read, I've never commented but I really enjoy your blog, thank you.

  9. Yes, Vikki, I do, and thanks for your comment, it's always good to hear from readers...

  10. He's my favourite author too :)