As I drive past the accident scene, I see fresh flowers adorning the trees along the side of the road and down in the ditch where the car came to rest. I wonder who it was who didn't survive: the passenger? The driver? My patient, or the one managed by the HEMS crew? Both? In a blink of an eye, I am transported back to that fateful night:
The scene is not an easy one: the car has slid down a steep bank, and is now jammed against a tree. There is noise; lots of shouting from the crews, the rumble of the generator and the engine of the fire truck. There is little light, and I quickly get out my headlamp and strap it on.
"Where do you want me?" I call to one of the ambulance crew. He shrugs his shoulders, and I stop in my tracks: how many people are involved in this accident?
I run over to someone being attended to, lying some feet from the wreckage, the car that I haven't yet been able to get close to. He looks up at me, and the crew tell me that he is ok; there are worse cases to deal with.
Ok, time to get to the car. It's not easy; the slope is very steep and very slippery. I grab hold of a passing fire officer, and he assists me down. What awaits me is very shocking:
I am approaching the car from the passenger side. The car has clearly rolled, as the roof has collapsed down on to the passenger. There is a sheet of metal across his chest, yet, somehow, his head is exposed, presumably through the side door window. He has his eyes closed, and is making some respiratory effort. I reach over to his neck to feel for a pulse, expecting none, or perhaps something weak and thready. But no, his pulse is strong and bounding. His colour is ok, and, despite him being so severely pinned, he certainly is someone who might have a chance, albeit very slim. I turn to the fire crew, and ask what their thoughts are. I explain that this man is time-critical, and that we need him out immediately. He shakes his head: "It'll be at least 20 minutes, minimum." It is my turn to shrug - if that is what it takes, then so be it.
I hear a shout from the other side of the car, and hurry round to see what's what. There is another ambulance crew, dealing with a third victim; the driver. He is already out of the car, lying some feet away from the vehicle. He has obvious head injuries, with a Glasgow Coma Score of 6. He is breathing and has a good pulse.
This is really bad. I am not going to be able to do this on my own. There are two patients who need intubating and ventilating. If I am alone I will only be treating one, and it will be the one already out of the car. But the one still in the car might have a chance. What to do?
I get on the phone to GasPasser, another BASICS doctor, not too many miles away from where we are. No answer. Bum!! Looks like I am on my own after all.
Just then, I hear another set of sirens. I look up to see a very familiar car coming to a standstill next to mine. It's the HEMS car!! Phew.
I rush up, and before they have even got out of the car I have begun to appraise them of the situation. As I am first on scene, I am in charge, and I let the HEMS team know what it is I want from them: they will need to look after the one already out, and I go back to the passenger, still in the car.
Just as I am sliding down, I hear a call from the crew down below, shouting for suction. Not good! I rush over, to see that the patient is now making gurgling noises, and is not breathing well. I quickly take over from the paramedic, and push his jaw forward with one hand, and insert the suction device into his mouth, to clear the blood from his airway. This seems to make a difference, and he settles once again.
That's a sorted for the moment; now to get some IV access. There is one arm free, and I put a tourniquet round his elbow. Sliding a cannula into the vein, he jerks his arm away! He is responding to pain, something he wasn't doing before. Things, while still looking pretty poor, are not as bad as I first thought when I first came across the accident.
The fire crew have done sterling work, and his upper body is now free. This lends itself to more problems, as the car is at a good 30 degree angle, and he is tending to slide towards the driver's side. That's not good, as we need to ensure that he moves as little as possible, in case he has a spinal injury. I have his head at this time, because his airway has once again become a problem. I am at such an awkward angle that my upper arms begin to cramp up, but I mustn't let go, or even shift position. I ask the crew how much longer, and they tell me it will be another 10 minutes or so. This is looking badd again.
Just then, the HEMS doc taps me on the shoulder to update me on the situation: his patient has an isolated head injury, and they are going to intubate and transport to the Royal London Hospital. I think quickly: my patient is far more seriously injured, and definitely would benefit from going to the major trauma centre. However, I am supposed to be on call for my own Department (remember, this is my voluntary "work", and I have a job in a local hospital), so there is no way I can go all that way with this one. However, there is a more local neurosurgical centre, and I could definitely go there with the other chap. This is well against protocol - it's not best practice to swap patients in mid-treat, but I can see no other way around it. So, I hand over the passenger, scrabble up the hill to the driver, who is with the HEMS paramedic. Together, with the assistance of the ambulance paramedics, we swiftly anaesthetise the driver, pass a tube into his windpipe, and connect him up to the ventilator.
By this time, the passenger has been extricated, and a bid a fond farewell to the HEMS para, as he goes off to assist with the driver.
Packaged in the ambulance, we make the uneventful journey to the neurosurgical centre, and I hand over.
I shake my head, clearing the visions, and continue home, where my family awaits, hugs at the ready, still wonderng what the final outcome had been.