Ok, so I've just got back from a job, and I am so angry with what has just occurred:
He is 43. He has been out for a drink in a pub. Not something to get hit over the head for. He did ask another drinker to apologise for knocking his drink over. Not something that should lead to him lying on the ground with a gaping wound in the back of his head. But it did.
And so, here is James, a rather pleasant chap, according to his mates. He's not being very nice now. He is swearing and snapping at all of us. And when I say snapping, I mean he is trying to use his teeth on us. He can't, but only because there are 4 very strong police officers, holding him down. He needs cuffing, for our safety as well as his. He doesn't like this, and is pulling so hard at his cuffs that his wrists are red raw. Language I am hearing tonight is bluer than on Saturday Night Live. OK, you know the drill by now: the Primary Survey:-
Airway: perfectly maintained, as evidenced by the expletives that emanate from his mouth
Breathing: there's no point trying to listen to his breathing, but he has not received a blow to his chest, so I am happy
Circulation: we can't get a blood pressure, because he won't keep still, but his pulse is regular and strong
Disability: he scores 3 out of 4 for his eyes, as they open if I shout at him. I'll give him 4 out of 5 for voice - I wouldn't say he is orientated, but he certainly knows what he is saying! And he can have 5 out of 6 for motor, because, while he won't obey commands, he is trying his best to do a Houdini with the cuffs.
I do my usual at this stage. I get down close to him and reason with him: "Keep still and we'll take the cuffs off," I tell him, much to the consternation of the rather battered officers. He does quieten, but I don't think getting him out of the cuffs is going to be a winning decision with anyone else.
I know that we are only 3-4 minutes away from NeuroHospital, and, I reason, it's far safer to just go, as opposed to giving him a Rapid Sequence Induction (drugs to put him to sleep so that I can pass a tube into his windpipe and breathe for him.) So, as we are already in the back of the ambulance, I let the team know my plans, and we set off. As we start, one of the team passes the information to NeuroHospital, so that they are ready for us when we arrive: Male, 43, severe open head wound, GCS 12/15, combatative, DA (that's me!) on board.
We arrive, and wheel him in to Resus. We are met by... A nurse and an FY2! A junior doctor, 1 1/2 years post qualification!! At least we have an experienced nurse, but still!! I look around pointedly, and ask, "Where's the Trauma Team? Did you not get our call?" He replied, "Yes, but we didn't think it warranted a Trauma Call." What?? I only didn't tube this chap because I knew we were on the doorstep, and now there's just no-one here to look after my patient. I ask the nurse to put out a call; she just shrugs and goes out the door. Great!! Now we haven't even got a nurse in here!!!
A minute or so later, she returns and tells me the Consultant is in the Department, and will be coming in. Phew!! But no. He wanders in, looks down at me, and talks over me while I am trying to explain what has been occuring. Not interested in the pre-hospital situation, he goes over to the 'phone and tells the radiologist that the scan can be performed with the patient awake. I storm out, muttering under my breath.
The point here is that, despite the fact that the patient is now much calmer, he has had a very significant injury, with very significant pre-hospital features, and the hospital staff are ignoring all we are saying. This has made me angry. My ambulance colleagues are angry. We sit by the vehicle, drinking NHS tea, and bemoaning the difficulties associated with the interface between pre-hospital and in-hospital. As a Consultant, they expect that at least I will be taken seriously, even if they aren't. It's an eye opener for them too.
I have just rung NeuroHospital - he has cerebral contusions and is being intubated as we speak. I'm not a happy RRD.
Behind Closed Doors
3 hours ago