She doesn't look too badly injured, lying there in the back of the ambulance. It's just after 3am, and she's had a skinful, before having a row with her boyfriend and running out of the house, into the path of a fast-moving car. The driver of the vehicle is not without blame - he has also been drinking.
The main issue with her is that her conscious state is low. She has a Glasgow Coma Score of 7. The GCS is made up of 3 parts: eye opening, verbal response and movement. She isn't opening her eyes to painful stimuli - score 1 out of 4. She is making incomprehensible sounds - score another 2 out of 5. She is withdrawing from painful stimuli - score 4 out of 6. This is an indication for intubation and ventilation, as someone with a GCS less than 9 cannot maintain their airway, and is at a risk of either aspirating or stopping breathing. But I'm really not sure if she has a true head injury or if this is the effect of too much alcohol. I have to decide.
I draw up the drugs, and prepare my kit. It's always a worry - here you have a fit teenager. They are breathing on their own and don't appear to have any significant injury. Yet, if you don't act they could die en route to the hospital. However, if you do act, they might die as a result of your intervention. This is not the first time I have had to make this difficult choice. I reflect on how much easier this can be, if they are either obviously badly injured, or completely awake. Oh well, I may not be paid for it, but this is what I do!
So, usual procedure, get all the kit within easy reach, including the stuff for a surgical airway (if I have it ready, I'll never have to use it, right?" and I slowly give the paralysing drug, followed by the anaesthetic. Laryngoscope in left hand, lift up the tongue, sweep over to the left, visualise the cords and in. A textbook, grade 1, intubation. Blow up the cuff on the tube, connect up the CO2 monitor and give a few puffs with the bag. A good trace. Phew!! Another one under my belt.
"Pulse of 140," says Mick, my para, helpfully. "190." "210." What?? "215." Ok, Mick, now you're just freaking me out! Stop with the numbers, already!! I look up at the monitor: sure enough, the pulse is way up. This is not what I need right now. I was planning a nice, leisurely trip to NeuroCentre, about 20 minutes away, and she's playing bingo with her pulse! Her blood pressure is almost unrecordable.
Calm and centre.
Causes of tachycardia and hypotension, from the top:
1. Hypoxia. This is when there is not enough oxygen in the blood stream, and the heart tries to compensate. Usual cause in an intubated patient is wrongly placed tube. But, I have seen the tube pass through the cords, and I have a good trace on the CO2 monitor. CO2, carbon dioxide, is only produced in the lungs, so if I have a trace, going up and down with every squeeze of the bag, then I'm in. Oxygen is attached to the bag, so hypoxia is not the problem here.
2. Tension pneumothorax. The dreaded tension, happens when there is chest trauma, and I can see none. I listen and can hear good breath sounds. I decide that this is not the time or the place to be making holes in her chest wall. I move on:
3. Hypovolaemia. Fluid loss, specifically blood, can lead to a rapid rise in the pulse rate and a drop in blood pressure. So, is that it? Is there some, as yet unidentified, injury? Is she bleeding somewhere? While I am looking I get Mick, my bingo caller, to squeeze her fluid bag, and try and get as much as he can in to her. I don't like fluid in the pre-hospital arena - it makes people bleed more. But in circumstances where they have almost no palpable pulse and a blood pressure of... 50/20!!!... it might just enable us to get her to a hospital alive.
I check her over, remembering the mantra: one on the floor and four more. There is no external blood loss, and her chest, abdomen, pelvis and long bones all seem intact. Still, I can't think of anything else to do, apart from giving fluid.
4. Cardiogenic. This is where there is direct trauma to the heart. Again, I have no reason to believe this is the case, as there is no sign of chest trauma.
It is now 5 minutes since I have tubed her, and her heart rate is unchanged. I have given her 500ml of fluid, and I can feel a pulse, at least. I look at the monitor; the rhythm is very fast and it's irregular. Irregular? That's atrial fibrillation!! What's a 19 year old doing, having AF, that we normally see in much older people, often with heart disease? I have no idea. I wonder if she has had an adverse reaction to the anaesthetic agents I have given her. I've never heard of this before, but I'm not an anaesthetist, and anything's possible.
Right, I'm totally out of my depth. She needs a hospital, and fast. NeuroCentre is 20 minutes away, but LocalDGH is 5. It's a no-brainer - she might not get to NeuroCentre alive. I let Mick know what we need, and he puts pedal to the metal. 3 minutes later we pull up outside, with a girl with a barely palpable pulse, no recordable blood pressure and a heart rate of 220. What a gift!
I hang around, while the team don't exactly fill me with confidence. She may not be in my care now, but I did work hard to get her here, and I would like to see the hospital staff work a little faster. I look at the anaesthetist, and he shrugs. "Maybe next time you'll decide to go somewhere else." I don't disagree with him.
5 minutes later, we look at the monitor, as she flips out of AF and into a normal sinus rhythm. Pulse rate: 84, blood pressure a very healthy 135/75. We chat about what may have caused the AF. I am secretly relieved that he has no idea either.
The next morning I ring up and find out that she is on a general ward, awake, with a headache. CT scan was normal.
2 years ago