Thursday, 29 October 2009

My Worst Fear

It's about 7pm; it's cold and wet (what's new?), and I am just dropping off a friend near home, when I get a call. Am I near to SuburbanTown? Yep, I'm in SuburbanTown. Can I attend an RTC at SmallRoad, ST? I think quickly - SmallRoad is a turning off the street I am currently on, probably about 30 second's walk from where I am parked up. I enquire hopefully whether this is a crew request, and get the heartsink answer: no, they are on their way.

Hey, this can't be all that bad, after all, it is SmallRoad, so there won't be much speed involved.

I turn up, clad in orange, to see a car, driven into a garden wall. There are lots of people around, none of them wearing anything remotely reflective or green. I'm on my own - my worst fear.

As a hospital doctor, one is never alone with a critically ill patient for more than a few seconds. A quick shout out of the door and you are very quickly overrun with doctors and nurses, all with their own tasks to perform. One quick phone call and I can have a full trauma team, a cardiac arrest team, a paediatric team, all there to help with the patient. Those of you reading this who are EMS spend your life being first on scene, and especially you first responders, spend your life being the only one there: I don't, and I don't like it. It brings to mind an awesome film with Patrick McGann, Paper Mask, in which a porter takes on the identity of a junior doctor, and gets a job in a busy A&E Department. In the turning point of the film, he is giving an anaesthetic to a patient all on his own; it goes wrong and the patient has a cardiac arrest. The terror of him working on his own, trying to save the lady's life, is so brilliantly portrayed by McGann - get the film and watch it!!

But I digress, big time!

So, here i am, standing outside this car, looking in at a chap, slumped over the wheel, not moving. Hmm, worse that I thought. Ok, back to basics:

Safe approach? The engine is still running, so there is a chance the car will explode. No friendly fire crew, complete with hose. Oh well, at least the road is quiet.

Airway? Lying slumped against a steering wheel isn't going to be the best position for anyone, especially one who is unconscious. I need to act fast, and position him better. Still no fire crew, with cutting equipment, to get an easy access. How am I going to get to him? Break the glass? Never a good idea. Thinking quickly, I try the passenger door - it opens easily. I slip into the car and lift his head in to a better position, putting my thumbs behind the angle of the jaw and pulling forwards, to get the tongue out of the way of the airway. He takes a big gasp, starved of oxygen for a few minutes. Phew!

Breathing? Well, now he is. Can I have some oxygen? No. I don't carry any, and I am on my own. Listen to the chest? No. I have my hands full, supporting the neck and opening his airway, so I can't do much else.

Circulation? Usually, when I am opening an airway, I can manoeuvre my fingers to feel a carotid pulse in the neck, or, failing that, get a facial artery under my thumbs, so that I can assess. However, that's far easier if the patient is lying down, and this one's not! I am lucky in this case, as I can feel a very slight pulse in his neck, weak and thready.

I start to hear the sweet, sweet sound of sirens. Moments later, I am greeted with the sight of a First Responder. One becomes two!

I rapidy apraise her of the situation: this man needs a rapid extrication from a car that doesn't appear to be all that damaged. We both wonder aloud whether this may be a medical collapse, precipitating the crash. There doesn't appear to be any signs of external injury, and we agree that if we get him out we will have a much better chance of dealing with him.

Turn to the crowd, grab two of them and get help to bodily lift patient out of car. This isn't protocol, and I'm not sure if the first responder would have done this if I hadn't been there (comments, anyone?) We lie him down, and proceed with a more formal assessment.

By now, the fire crew have arrived, and are happy to assist with movement, holding bags of saline, shining torches in our direction, as we continue to work on the elderly gentleman. He is tubed quickly, and fluid is given to him, in order to get a pulse at the radial artery. We still have no blood pressure recorded on the machine, nor can we get a manual BP. I begin to wonder what else we can do with him here when the ambulance crew arrive. We bundle him on to the stretcher, and I travel with him to the local A&E.

They are expecting him. I don't mean as a result of the trauma call we put out. No, his GP had phoned them, to tell them that he was on his way, with a suspected leaking aortic aneurysm. He decided he wouldn't waste ambulance time, and would drive himself.

Unbelievably, he survived his emergency surgery.


  1. Oh wow, bit of a twist at the end there. Amazing he survived!

    Why oh why is it that the people that really need an ambulance are the ones that don't?!

  2. I may be being a bit judgemental but wasn't it careless of his GP to let him drive in that condition? It's one of those situations that turned out OK but leaves you thinking "what if..."

  3. I'm not sure that his GP had suggested to him to drive. He had requested an ambulance, but the patient had cancelled it...

  4. Yikes, the fellow was lucky to survive.

    Your link to Paper Mask has a syntax error, an extra "http//" before "" than needs to be edited out.

  5. Thank you for pointing this out to me - all sorted.

  6. He might want to buy a lottery ticket this weekend... that is one lucky guy...xx

  7. My god, they made them tougher back in the "good old days" ... I'm glad he came through.

  8. Groan - leaking AAA and he let him leave the surgery? And drive home? That is a brave GP.

    (For certain values of 'brave' - imagine the coroner's questions if he had died/killed someone...)

    As for your question about first on scene pulling people out of cars - like most folks in ambulancing, when it comes to life threatening stuff I'll take what I can see (crappy breathing and circulation) over what is only possible (in this case a c-spine injury).

    In other words I'll sort out what'll kill you *definitely* rather than panic too much over things that *might* kill you.

    (The joke, of course, is that every dead person is a paralysed patient).

  9. There have been a number of comments about what I have said regarding rapid extrication of a time-critical casualty. I was not suggesting that it was only the remit of a doctor to get a patient out immediately. Rather, that it is often my role to facilitate this sort of decision making, and to be the one to take the risk because I am there.

  10. Good result. It's irrelevant our feelings or fears. The important thing is doing right for the patient, given the circumstances.

  11. Interesting blog - came here from hydrantgirl. My thought when you asked assistance from bystanders - I believe in the states one can accept help, but may not legally request help. (I could be wrong...)
    I agree about his daftness in not taking the ambulance - luckily he didn't take anyone with him when he lost control.

  12. Welcome, S. When I say I asked the bystanders for assistance, they were clamouring to help, but didn't know what to do.

    As far as the man not calling the ambulance, from what I can tell, the GP had asked for an ambulance, but the chap decided to just go. That's the issue with telephone consults, I guess