The Essentials

Ah, Monday mornings!! How I love my Monday mornings! You see, I don't go to work until 4pm on a Monday, so for me it's a continuation of my weekend, just without the noise of 5 smaller people.

It's a dressing gown morning for me. Mrs RRD has been up at the crack of dawn to take Princess and Micro2 to the bus stop, and I am enjoying a hot cup of tea and some 'us' time, while we work out what to do with our day together.

The ringing of my 'phone sends a small shiver of anticipation through my bones: yes, the screen reads "Unknown." Control seem to have got the message that I am still alive, and this is a call to a trapped RTC nearby.

"Want to come with?" I enquire of Mrs RRD. She acknowledges that this might be fun, and I rush upstairs to get dressed.

As I run down the stairs she is passing in the opposite direction! "Get into your suit and program the SatNav," she suggests, "while I get my essentials."

Thirty seconds later, the engine running, the SatNav all ready and the lights flashing, Mrs RRD jumps in beside me; flask of tea, book and make-up bag at the ready.

As I ease out of the drive, the 'phone rings again. I answer on BlueTooth (before anyone says anything!!): "Can we cancel you down on that job: no-one trapped or injured." We climb out and continue our day.

Jaded??

Some of you eagle-eyed readers may have noticed that I haven't posted for a while. Why? Well, mainly because I haven't had anything to write about. I haven't been on holiday (apart from a weekend in Holland - more about that in a moment), just haven't been called out to anything. Nothing. Sure, there have been some serious incidents in my area; someone falling out of a tree and landing on his head, a couple of fatal accidents on my stretch of the motorway. But no calls.

You may be wondering why. Well, so am I. I call the Desk regularly, they thank me very much for letting them know that they can call, day or night, and get me running. But they don't. I ring and ask them about the call the night before, and no-one can tell me why I didn't get a call. So, I begin to wonder: have I upset someone? Nope, I'm just out of the radar.

Cut to this weekend: a great break in Holland with the whole family, visiting more family. Let me tell you something; 8 children between the ages of 16 months and 17 years in one house isn't conducive to sleep!! We get back at just before midnight from the airport. The kids are tired. The adults are tired. The phone rings as I open the door to the house. Yep, nothing for almost 2 months, and then a call at midnight on the day I get back from holiday.

It's a call for assistance to a man who has rolled his car and is now deeply unconscious. Sounds reasonable. And yet I am looking for excuses not to go. This is so unlike me. How far away is it? Oh, that would take me at least 30 minutes to get there - they shouldn't wait for me, just scoop and run.

This isn't like me at all!! Whatever the distance, wherever the call, I would normally be out of the door like a rat out of an aqueduct!! But not this time. I know I have just got back from holiday, but it was only a weekend, and I'm not that tired. And I have been complaining bitterly about not being called. I get off the 'phone wondering what has happened to me, why I am feeling so jaded for the first time about driving out at all times of the day and night.


And then the 'phone rings again. Control tells me that the crew are running to the local with the patient, and I breathe a sigh of relief. But they continue: can I run to an alcoholic who has fallen and hit his head? It's a close one this time, so I shrug my shoulders, jump into my suit and drive off to pick up the pieces of an overindulgence at the pub.

A Night Out

Why is MrsRRD nudging me? Surely it can't be time to get up already? No, it's my 'phone. I'm so sleepy that even the dulcet tones of the drum solo from "In The Air Tonight" have failed to penetrate my dreams. No wonder: I had already had one call tonight, and only been asleep for a couple of hours. Fortunately, MrsRRD is awake enough to remind me that my jump suit and boots are in a pile on the floor of the bedroom, or I would have had a bit of a shock when I got down to my car and found them absent.

A few minutes later, SatNav programmed, I shake my head repeatedly to get rid of the last vestiges of sleep, and start my journey.

The car is on 4 wheels. That's always a good start. I see the airbags have deployed. That's not bad. The windscreen has a spiderweb pattern of cracks on the driver's side, the centre of which is pushed out alarmingly. You and I both know what made that mark - yes, Constant Reader, the classic sign of a bullseye, made when the driver's head impacts at speed with the windscreen. Not so good. Not good at all.

I survey the scene for patients. There's a woman, looking ok, with a piece of gauze on her chin. She's walking around, so she can wait. There's a young chap, looking very much the worse for wear, but from an alcohol point of view, rather than injury - at least that what it seems at the moment. He is jawing away in his phone, and the police seem very interested in him.

Ok, to the car. There is a young man being extricated on a spine board through the passenger door. He has a deep gash on his head, and looks as though he has a broken femur. I presume that this is the driver, who is being brought out this way because it was easier, but, when I question the ambulance crew, it turns out this is the passenger. The driver is the rather drunk chap, who is wandering around in the company of the boys in blue! Hmmm.

I check the passenger out - he is in a lot of pain, and will need stitches galore to repair the scalping he has had, but will be ok.

Wait a minute! This is the passenger! Not the driver. But it was the driver's side that had the bullseye in the windscreen. I rush over to the car to check the position of steering wheel, just in case I have got this wrong. Nope, wheel on right, with pedals underneath. So, man who has bullseyed the windscreen is - somewhere.

I have a chat with one of the officers. Apparently, the police have taken him away into custody. (Crazily, my mind repeats a sleep deprived litany, "Rhubarb and custardy, rhubarb and custardy!"). I try to get my mind round this one. Has anyone medical seen this chap? Nope. Well, you'll just have to bring him back, then. Boys in blue not too pleased about this turn of events, but agree that they were probably a little hasty in dragging him off to the cells.

I hang around scene as he is returned. It doesn't take me long to examine him and find he is completely uninjured, save for a probable fractured toe. I relay this information to the waiting police.

"What??" he exclaims. "I've broken my toe?????!!!! Will they have to operate??".

It took all my restraint not to drag him over to his friend, lying in the ambulance, a laceration you could keep a bottle of WKD in, and show him what he had done.

I go home, and eventually fall into a troubled sleep, with dreams of car crashes and damaged teenagers.

Filling the Coffers

Once again, MrsRRD helps our Charity to gain much-needed funds. She wrote to Waitrose in Mill Hill and nominated BASICS-London for their Community Matters scheme. Each month, three charities are chosen at each branch, and £1000 is split between them, based on the number of tokens each charity gets. The tokens are handed out to all the shoppers, and they chose which of three boxes to place their token. So, for the month of September, if you live anywhere near Mill Hill in London, do pop in and support your favourite charity. Who knows, you may meet someone special there...

Kids!!

My 7 year old niece told my sister-in-law that drinking too much coca-cola would kill you. She knew this was true because she had seen it on the television. She hadn't been paying too much attention, because she was playing with her brother at the time, but the man reading the news definitely said that drinking too much coca-cola would kill you. A repeat of the news show later revealed an interesting story about the dangers of alcohol. Close, so close!!

Sudden Death x2

He lies there, the driving rain beating down on his upturned face. I look at him and know, without a doubt, the eventual outcome. The tube in his windpipe lets the paramedic inflate his lungs, but there is no movement of their own. His body shows me all too clearly the trauma that he has suffered, when the cars collided, when he was ejected through the windscreen. I pierce his chest, deflate the tension pneumothorax, and again on the other side. But still, the monitor attached to him shows a straight line, asystole, death.

His family watch in horror, as I stand, my job done, and the paramedics draw the blanket over his head.

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He lies there, unable to stay still, unable to catch his breath. He calls out, pleading for me to help him. I look at him, and know, without a doubt, the eventual outcome. I have nurses, monitors, a whole hospital at my disposal this time. I listen to his chest, fight to find a vein to give life-saving drugs, and watch as his eyes glaze over and he takes his last breath in front of me. I pass a tube into his windpipe, breathe for him, and give him clot-busting drugs, in an effort to dissolve the clot that is blocking his pulmonary vessels.

His family are brought in as we continue the resuscitation attempt, and watch in horror, as I switch off the monitors, and the nurses draw the sheet over his head.

Leather

Well, Constant Reader, I would like to share with you something about me. Three years ago tomorrow, I stood beside a beautiful lady, slipped a ring onto her finger, and turned her into MrsRRD. Yes, tomorrow is our 3rd wedding anniversary, traditionally celebrated with a gift made of leather.

And, very publicly, I want to say thank you, MrsRRD, for standing by my side three years ago, and for continuing to stand beside me. You are the one who makes everything possible, who supports me in what I do, and who always helps me make the right decision. Without you, I wouldn't be RRD. I wouldn't be anyone.

Dreams, Rain and Driving

Sitting down with friends, talking about dreams. We've just come out of the cinema, having seen Inception. Princess RRD isn't sure, not totally, what had been going on. Mrs RRD isn't sure, not totally, whether she liked the film or not. Break Dancer wants to know what her dream about chasing a labrador around the garden in her nightie means. Break Dancer's husband is checking it out on www.whatsmydreammean.com. And I am just sitting there, enjoying the company of true friends.

Buzz!! Buzz!! I glance at my pager, set on silent during the movie. I must remember to bring my reading glasses out with me. Squinting, and holding the pager at arms length, I can just make out the characters: 29D02, local motorway junction. My pager is linked to the Ambulance Service coding computer. AMPDS, for those who care, is the way in which the computer translates the information the call taker gets from the caller into coded information for the crews, including the priority of the job. 29 is the code for an RTC (road traffic collision - don't call it an accident, oh no!) and D02 is high speed. Well, it is a motorway, after all. I sigh, theatrically. My family and friends know the score - I might be off. A lot of these are simple shunts, and don't amount to anything. I generally wait for at least 2 calls before calling in my availability. And anyway, I still haven't heard about the labrador and the nightie!! The sound of rain on the conservatory roof is a comforting backdrop to our conversation.

Buzz!! Buzz!! I sigh theatrically again, and squint at the characters: 29D05. Suddenly, all thoughts of dogs, dreams and gardens are swept away. D05 - all services required. I call it in, and hear that there has been a 3-car pileup, with one man unconscious.

As I enter the motorway, the rain starts in earnest. I can barely see out of the windscreen; my wipers are ineffectual in this weather. And it just gets worse. Cars are stopping on the hard shoulder, but I grimly carry on, my speed dropping lower and lower, my hands gripping the steering wheel knuckle-white. I am leaning so far forward that my nose feels as if it is pressed against the window; like I used to in my old house, watching the rain from my bedroom.

I can see blue lights ahead, but know that my journey is not yet over - they are on the other carriageway, and I have to go up to the next exit and back down again.

My eyes flick across to the scene as I am about to pass it, then flick back ahead again.

What the ....!!!! Twisted metal appears in my windscreen through the driving rain. A lamppost is down, and the lantern arm is across my lane. I swerve to the left (we're in the UK, remember) and slide past it with inches to spare. Fortunately, my 4x4 is able to cope with the maneouvre, and I regain control of my beating heart.

A few minutes later I am jumping out the car and running through the rain towards the waiting casualities; I know that getting there is only the beginning.

Half Price, Special Offer

"Oh, he's gorgeous!" exclaims MrsRRD. "You must buy him, especially as he's on special offer."
"Half price," I said. We buy him, and I put him in the back of my car, staring out of the window. He looks so funny, and so appropriate to what I do.

Later that evening, as I am stashing my gear into my boot, the pouring rain against my hood, his lopsided grin seems so wrong, so out of place. His blue body and bandaged head mirrors the body lying behind me, my lights reflecting off his skin.

And there he sits, my special offer, half price, Mr Bump.

An Image From Vancouver

So, there we were, about to get on our rented bikes, when I see a young kid with a bike helmet. It must be the first time this mother has been asked for a photo of the back of her son's head, but I just couldn't resist!!

Another One Bites The Dust

First Medic999, now NeeNaw. There seems to be a trend appearing here. No-one comes out and says why. Not in so many words. We all know why we write. I can guess why some of us stop. Pressure. Pressure from above, to stop giving away our sectrets. To stop giving away the secrets of those we serve - our patients. Confidentiality is one of the cornerstones our our professions - without it, no-one would ever trust a doctor or health care professional again.

I believe strongly in confidentiality. Mrs RRD could tell you a thing or two about being the wife of someone who holds as a sacred secret anything they find out in the course of their work. It wasn't easy for her at first; the cryptic phone calls from friends and family, asking for advice, or occasionally for a visit. And she hears nothing! Our friends don't always get it either. "Didn't your husband tell you I was really ill?" they ask, expecting her to know all about their ailments, expecting her to be party to their secrets.

And why do you, Constant Reader, come back for more? Isn't it the same need to know, need to see, that makes people slow down to gawp at accident victims? Do you think I don't slow, even if I know that I can do nothing? Even while on holiday these past few weeks, I would casually wander past a parked ambulance, "just in case they needed some assistance." Some assistance, my foot!! I just want to know what's happening. I'm nosey, just like everyone!!

I think I do quite well in my blog. I don't breach patient confidentiality. Some bloggers retain anonymity, and so have little problem with confidentiality. That was how I started out, but it soon became apparent to many out there just who I was. So I had to change tactic, and modify the stories, so that they became just that - stories. Sure, someone who was there may think they recognise a patient or an event. But they don't. I change enough so that it is not possible to discern which patient I am describing. Some are recent; others far less so. And remember, I have been a BASICS Doctor for nearly 10 years, and a HEMS Doctor before that. So I have a lot of cases to call upon.

But it is still a risk. If someone thinks they recognise a case, that might be enough to cause trouble from one's seniors. And, I guess, that is where I have an advantage over my ambulance colleagues. Up until now, I haven't really had a boss, when it comes to my prehospital work. I am tasked by the Ambulance Service, but I am not employed by them. That is, I wasn't. There is a change afoot in London. We will all have contracts with the London Ambulance Service, a contract which, I have no doubt, will have a clause somewhere about keeping confidentiality. And, at that point, I will be in exactly the same situation others have found themselves. And I will need to have a long, hard think...

When Words Just Won't Come

I have tried, so many times, to write this post. Words can't express the emotions that this job evoked in me; I don't know how to write it and still keep patient anonymity. And yet, it needs to be written. It has been a number of months, but it is still as fresh today as if it was yesterday:

The call comes through: can I attend a 4 year old girl who has fallen into a pond at the local park, and is now in cardiac arrest. My heart sinks - every call this month has been to a child, and all very serious. This one sounds bad. I tell Control to let the crew know I am about 10 minutes away, and that they shouldn't wait for me, if they are ready to go before I arrive.

As I am driving to the scene, I am hoping that they leave before I get there. I don't want to be involved in this case. I know I can't refuse, but this is my nemesis, this is what I fear more than anything (it used to be the "one-under" - someone hit by a train, but desperately sick kids took over from that some time ago.)

I arrive to a scene of horror: a child, lifeless, blue, distended abdomen, vomit around her face; two paramedics working on her, another getting a monitor attached; the monitor showing a straight line, no electrical activity at all; the family, screaming and wailing. My heart, already in my boots, sinks even lower.

I rush over, my paediatric bag banging against my hip, my monitor slung over my shoulder. As I kneel by her head, I look into her eyes: the glassy stare of an arrested child. The deep blue skin and vomit over the face tell me all too clearly what I don't want to know: this child has been without oxygen for a long time, perhaps too long. I need to get a tube into her windpipe and breathe for her. It's all very well using mouth-to-mouth or a bag and mask, but most of the air goes into the stomach - the distended abdomen is the result.

Age over 4 plus 4. Age over 4 plus 4. My mind shouts the formula for calculating the size of an endotracheal tube in a child, yet I cannot work it out. I reach, blindly, for a size 5, and take a breath in before inserting the laryngoscope blade that has been handed to me by the paramedic. This isn't like an adult intubation. It's not just the size: in an adult we use a curved blade, the tip of which fits into the space between the tongue and the epiglottis, whereas in a child, because the epiglottis is usually much floppier, we use a straight blade that is designed to pick up the epiglottis as well as the tongue. In with the blade and lift. There are the cords, there goes the tube.

A few puffs with the bag attached, and the chest rises and falls. But that's not good enough; I need to be able to hear breath sounds on both sides, but, with the noise of the crowd, I cannot be certain. I need, instead, to get my monitor attached, and see if there is any carbon dioxide coming out of the tube. But, there are only us three, and we have lots to do. So, in between bagging the child, continuing chest compressions, finding intravenous access and giving adrenaline, we manage to get the monitor attached, and I see the reassuring rise and fall on the carbon dioxide tracing.

We move her on to the ambulance gurney, and wheel her into the ambulance, still giving chest compressions and ventilating her. I tell the crew that I don't want the family in the back with me; I need to keep my wits about me for the short journey; but, in reality, I cannot bear the thought of the questions, the hope, the need to know that she is going to survive this awful turn of fate.

Back home; I am quiet, sullen even. I talk, but I am not able to express just how I feel. The fear of not doing it right, of not doing all I should be doing. The anger at a death so unnecessary, so preventable. And the fear, that one day it will be someone I know. Later, after tears, Mrs RRD holds me, as I fall into a troubled sleep

More Thoughts on The Tree

You may recall that my last post was about how I had to think very hard about where to take a young child after his fall from a window. While the resultant comments were very interesting, and demonstrate very clearly that, on occasions, these blog entries develop a life of their own, I wanted to be able to write a bit more about the new directions that trauma care in London are heading, and how it affects me and my colleagues.

There are now three Major Trauma Units in London, The Royal London, Kings and St Georges, with St Mary's Hospital coming on line some time soon. Now, for those of you who don't know, this leaves my patch quite isolated. My jouney time to the 'local' Major Trauma Unit could be as long as 45 minutes. That's a long time to have an unwell patient in the back of the ambulance. And yet, for a discussion about the pros and cons, read a little 'story.'

"He had fallen out of a window, onto the driveway. Another child, this one only 9 years old. This one was accidental - the boy had been trying to open the window because he was hot, and had fallen out when he succeeded. When I arrive on scene he is stable, but not responding appropriately. He is very agitated, and, despite his eyes being open, they are not fixating on anything or anyone. The back of his head reveals a large swelling. He needs urgent care, but where from? We are outside of the LAS (London Ambulance Service) territory, and this crew will go where I want them to. I'm a few minutes away from my own hospital, and yet we don't have neurosurgery on site. The nearest neurosurgical unit that deals with paediatrics is one of the Major Trauma Units, 45 minutes away. I am not happy to travel all that way with a child that I will have to intubate if we are going that far.

And another point to consider: I am currently on call for my A&E Department. I have a contractual duty to be available if I get called. If I commit to a 45 minute journey on Blues in the back of the ambulance, I will probably be unavailable for the job I am paid to do for 3 hours or so. I decide; we are going to my own hospital, 5 minutes away, with the child awake.

The journey is easy and uneventful. He is intubated soon after arrival, and we get him up to scan. Damn! He has a depressed skull fracture and some bleeding in his brain. Now he needs to be transferred. 2 hours after arriving at the A&E Department, he leaves for the neurosurgical centre, and arrives there almost 4 hours after his accident. If I had taken him, he would have arrived there an hour after his accident. 3 hours wasted."

This really has set me thinking about my role, and about how it interacts with my work in a very busy department. If I attend a job while I am on call, and take a patient to a Major Trauma Centre, then I run the risk of a disciplinary which could result in me losing my job. If I attend a job while I am on call, and take a patient to a hospital that is not a Major Trauma Centre, the patient is not going to get the best possible care.

It's more complicated: if it is an LAS crew, they will, if I am not there, take the patient to the Major Trauma Centre. Therefore, the patient will potentially be disadvantaged if I attend. If it's not an LAS crew, then they will go to the local hospital, even if I am not there. So, if I attend those, I can provide immediate care and take them to the local hospital, knowing that they have not been disadvantaged by my attending!!

So, I am now prepared. I won't go out on ANY jobs for LAS when I am on call, but will go to other calls. I am ready for the long haul: if I go to a job when I am not on call, I will make sure that I can get the patient all the way to the Royal London, and that's a long and scary way! Watch this space.

The Tree

He's only 10, and he's jumped out of the window. Only 10 years old, and he's jumped. This litany keeps running around in my head, as I kneel down to assess the young lad at my feet. I can't remember the last time I had to look after someone so young, someone who, even at that tender age, had decided to try and end his life. His parents stand by anxiously, as I take a look.

He doesn't look all that bad. He is lying on his right side, and his eyes are open. He tells me his name when I ask him, and he tells me that his right wrist hurts. I'm not surprised; he has clearly broken it. He says his back hurts a bit, but he can wiggle his toes without any problem.

The main issue we have is that he is in the front garden, and there isn't a whole lot of room for us to work in. Still, we manage to get a scoop stretcher next to his back, and then roll him on to it, with only a modicum of difficulty. And then it's a simple matter of lifting him over the wall and on to the waiting ambulance trolley.

I find out that he has been treated at the local hospital by the psychiatry team fora while. As he doesn't seem too bad, I decide that the local hospital is the best place for him; once the A&E has sorted out his wrist they can get the psychiatrists to look after him, and that's what he needs more than anything else.

I suggest this to the crew, and a look of horror comes over their faces. "But, what about the tree?" they ask. I panic, and look up in confusion, wondering if one is toppling over towards us.

But no. The crew are talking about the new Trauma Tree. Now, when you go to a trauma case, you call up a clinical coordinator in Central Ambulance Control, and they will tell you where to take the patient, based on a tree-like decision tool. And oh the trouble you get into if you don't do as suggested.

I tell the crew that I don't want to go anywhere else, and that I will make the decision, as the senior clinician on scene. They relent, but ask me to make the call, so that they don't get into trouble. Now I'm worried. Will I get into trouble? The crew tell me that all calls that are blue-lighted into hospital are scrutinised. I think quickly: the local hospital is only 3 minutes down the road, and he's not all that badly injured. We can just drive him to the local A&E without blue lights. They agree, sort of, with the proviso that I come with them, so that I can explain why they are bringing a 10 year old who has fallen two stories, without calling it in as a Trauma Call first.

Now, I am all for assistance to the crews when they need it, and wholeheartedly support the idea of a clinical coordinator desk, where crews can call in if the are having difficulties. But the idea of a clinical decision tool that is inflexible, and which has to be used on all trauma patients regardless of what the crews at scene feel, makes me worried. As this was a child, and as paediatric trauma is not well resourced in London, I can only imagine that we would have been directed to the closest hospital in London with paediatrics and trauma, and that would have been a journey of over 15 miles, and about 30 minutes or more. Worse than that, he would have been far away from his family and the support mechanisms he needed most.

Naming the Dead

I sit there, in front of them all; the coroner, the jury, the press, the families. The latter stare at me, no signs of emotion, as I am walked through my evidence. And then, the pain begins to show on their faces, as I am asked to name them, one by one; Austin, Jonas, Lin, Wu, Emma. Each time a name is mentioned, images return to me from the past, memories that have no business here in 2010, 8 years on, yet I need to remember every detail, for the families, and for those that died on that fateful day.

May they rest in peace, and may this finally mark the beginning of peace for their families and friends.

No Rhyme Or Reason

She swerves all over the motorway, crying and calling out. Her daughter sits quietly beside her. She knows not to argue or cry, not when her mother has been drinking so much, not when she's in this state.

And now she sits by the wreckage of the car, the car that has flipped over and landed on its roof, not a scratch on her.

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He carefully checks his young daughter's crash helmet, and adjusts the straps, before they get on to his motorbike. She loves riding behind her dad, does it every day to school.

But now she lies unconscious on the road, blood from both ears.

Drive-By Triage

Just dropping Micro-RRD3 (our youngest - must think of a name for him soon) off at school, when I received a pager for another RTA, motorcyclist vs car. Control tell me that the road has been blocked off, and I decide that, based on past experience (see my previous entry) it is worthwhile me running on this one.

I arrive, and pull up alongside the scene in my car and wind down my window. I can see a chap, lying on a spinal board, shuffling himself into a more comfortable position. His hands are behind his head, and he doesn't look particularly unwell. Darren / Steve (see earlier post of mine) looks up. "We're fine here, see you at the hospital."

I wind up my window and drive on.

Underwear

Another standard job: motorcyclist vs car. No further details available. I have 'phoned this one in, because I have received a number of messages on my pager about the job, and just wanted to check whether I am needed. As there are no other details, I book myself on to the job, and get on the road.

I test out my new sirens: I had an "issue" a couple of weeks ago, when my sirens just suddenly stopped working - I was left with hooting and sticking my head out of the window, shouting "nee naw, nee naw!!! They work beautifully - thanks, Tone!

As I am driving, I wait for the call to stand me down; none is forthcoming, and I sigh to myself as I reach the small road. This won't be anything, and I will be able to wend my weary way home and go to bed (it's been a bit of a stressful week.)

Just as I park up, I see one of the paramedics, Blondie, running from her vehicle with a monitor in her hand. Ok, clearly not nothing.

I can hear her long before I see her: the noisy breathing of a partially obstructed airway is VERY distinctive. She is lying in the road, face up, with a LOT of blood around her, and over her face. Now, face up is not a good position to be in when you are unconscious and bleeding from the mouth and nose. Essentially, you drown. And that's what she is doing. In front of my eyes.

So, we have an unconscious female, who has come off her bike and hit her face on the road. So, you eagle-eyed readers, why is she lying on her back? Enter the helpful passer-by...

I could turn her on her side again, but that would potentially cause more problems to her neck, and she's already been moved once. So, I need to get on and intubate her, and quickly.

First step is to get intravenous access. I'm on the right and Blondie is on the left. I miss the first attempt; so does Blondie. The race is on for number 2. Damn: she beats me by a second or so, but it was definitely a photo finish!

Now, those of you who have read this blog regularly should be able to do this next bit yourselves - drugs in, laryngoscope in, sweep tongue over to left, visualise cords, pass tube between cords, etc., etc.. I know, I keep writing about the same technique. Ok then, here we go:

Drugs in, laryngoscope in... hold on, I can't open her mouth. Erm, hello. How am I supposed to do all of the rest of those steps if I can't open your mouth, young lady. She starts to go blue. Erm, hello?? Saturation probe starts to bleep at me. I start to get a little nervous, here. If I can't get her mouth open, I can't intubate her, and I can't oxygenate her. I will have to make an incision in her neck and place the tube directly into her trachea. Sounds nasty, doesn't it? Well, despite the fact I have been doing this for A LONG time, I have never performed a cricothyroidotomy (don't you just love the name?) Ever!! And I don't want this to be the first.

Why on Earth is her jaw stuck closed. I presume it is as a result of the severe trauma to her face and chin that has done this. Well, I have to get on with whatever it is that I am going to do. I force my fingers between her top and bottom teeth and FORCE her jaws apart. There is just enough room for the laryngoscope blade - I cannot see much more than her tongue, but it's enough for me. I grab my trusty bougie (a long piece of sturdy plastic, goes between the cords and then the tube goes over the plastic, like a guide) and just blindly push it where I know the cords are. I feel the clicking of the bougie tip as it passes over the rings of the trachea, and then railroad the tube over it. Feels good!!

Next time I go out on a job, I'm taking a change of underwear!!

Goodbye, Uncle

It has been a very emotional weekend for me, leaving Mrs RRD and the kds and flying off to be with my cousins, as they said their final farewell to their father. Meeting family that I haven't seen for many years, seeing the children I have never seen before, reminiscing, laughing, crying.

And seeing one of my family, his life changed forever about two and a half years ago, the motorbike he loved and cherished turning against him for one, fateful moment, a moment that echoes through time, and through the generations. I sit with him, talk with him, not expecting a reply. He is gone: what remains is a husk of the man I once knew.

And then back to the house of mourning; pictures, memories evoked by a chair, by a sound, by my sadness.

Goodbye Uncle.

Confessions Part 2

I need to get Princess RRD to the train station - she's meeting all her friends and going to Thorpe Park. But it is REALLY early, and I'm feeling rather grouchy. In an effort to give the impression that I am happy to be getting into my car at 7 in the morning, when I could have had a nice long lie-in (to 7:30), I graciously move my car away from the bush that is blocking her passenger door. I reverse out of the space, and hear the sickening crunch of metal against metal. Bugger!!!

I jump out of my car and hurry round to the rear, spitting expletives as I go. Can anyone guess who's car I have hit?? Yep, Mini-RRD's!!!!! I cannot believe it!! How on Earth am I going to own up to this one? Here am I, rapid response driver, constantly correcting his driving, telling him to check his mirrors, ete, etc., and I'VE HIT HIS CAR!!!

Ok, regroup. Check damage: My car - big dent in bumper, could fit my head it in (or someone else's.) His car - tiny scratch. That's it? How ridiculous! I am now going to drive around with a car that looks like it came off worse in a Demolition Derby, and he gets away with nothing?? Unfair!!

Ok, regroup. I hit him. Not the other way round. Maybe I can get away with this - after all, he might not notice. Then I look up at the house. His face, staring at me, through his open window, tells me that I need a Plan B.

What's The Point?

She lies there, between life and death.  Sure, she breathes, she eats what is placed in her mouth.  When her father comes to visit, as he does every day, is there a glimmer of recognition?  Does her face light up, just the tiniest bit?  He'd like to think so.  He tells me, with a tremulous voice, that she squeezed his hand today.  Six months ago, she was wrested from the jaws of death, dragged from the wreckage of her car, and FORCED to stay alive, with drugs and tubes.  But, what is this life she now leads; what is the life her family now leads?

I walk down the stairs, heavy hearted, doubting myself, my purpose.  

And then I see her: Kate.  She's 19 this week.  She smiles so sweetly at me as she walks towards me, a little awkwardly, as she often is with me.  She kisses my cheek, that gentle act of tenderness.  She tells me how she has been accepted to college, and we talk about her new life, always skirting around the events of two years ago, when she, too, was dragged from a wrecked car, and from death's cold embrace.  And I know: as long as I can, I will always try.

Fight!!!

He slams his fist into the other's face repeatedly.  His opponent falls to the floor.  I glance up at them, then turn a page, slowly.  The big man picks up a chair, and brings it down towards the smaller guy's head.  Quick as a flash, he rolls away, and sweeps the big man's feet out from under him.  He comes crashing down, and lies there, still.

Suddenly, there is an explosion, and another man enters the scene.  He hurls expletives at the little guy, and runs at him, murder in his eye.  I turn another page.  The two of then are nose to nose, shouting and screaming at each other.  The crowd of people watching are in a frenzy, urging them to more violence.  One elbows the other in the face, and he falls to the ground.

Unnoticed, the big man rises to his feet, walks calmly over to the scrapping pair, and jumps onto both of them.

"One.... Two.... Three!!!"  The bell rings, signifying the end of another bout, as I continue to read my book.  Oh how I love being the medic for World Wrestling Entertainment.

Hmmm

So, call this evening to the M25, multiple car RTC, bodies strewn across the carriageway.  Driving through the rain, I get a call to update me: not required, 1 car, minor injuries only!  Hmmm

CFR x2 Part 2

CFR 2

She sits in the car, her boyfriend driving. They are off for a celebratory meal - she has just been promoted at work. Suddenly, the traffic slows, and a flash of blue lights up ahead tells her that something is amiss. As they crawl past the wreckage of the car, she notices that there is no ambulance - a lone Paramedic struggles in the rain. Just past the accident, she instructs her boyfriend to pull over. She jumps out of the car and rushes to the boot, from which she pulls out her Community First Responder jacket and Response Bag. She has only been a CFR for a few months, and has never dealt with trauma before, but the sight of the single yellow-jacketted soul brings back so many memories of wishing there was someone else there with her.

She runs over to the para. He looks up with a smile of such relief that the cold and wet become insignificant. She looks down. The driver of the car is already out. How he has crawled from the tangled metal she has no idea. She gasps in horror as she sees the swelling on the left side of his chest, which rises and falls with every breath; in as he breathed in, out as he exhaled. Her mind jumps crazily to her childhood, of sailing with her father. His ribcage looked ... billowy, like a sail flapping in the wind!

"What on Earth is that!?" she exclaimed.

"It's called a flail chest, and it's going to kill him," her new partner tells her, between gritted teeth.

A flail chest, where two or more ribs are broken in two or more places. Yes, she remembers reading about them. But this doesn't look like two broken ribs. More like 10!!

She does as instructed: she places her hand FIRMLY against the flail segment, pushing it in, so that the expansion of the ribcage can at least get some air into the rest of the lung, the area that hasn't been crushed to a pulp as his car flipped end over end over end. He doesn't like that one bit, and tells her so, in language that, under any other circumstance would have earned him a slap round the face. Not here, not now. Now, he hears the gentle voice, calming him, telling him he is going to be ok, telling him she won't leave him.

Double sirens in the distance herald the arrival of an ambulance and a BASICS doctor. She starts to move out of the way, only to be told, quite firmly, to stay just where she is, as she is undoubtably keeping him alive. She is asked to take her hand away very gently, so that the BASICS doc can have a little look. He pales and his jolly demeanour is suddenly replaced with a flurry of activity. His voice is filled with tension, as he quietly tells the ambulance crew, who have by now packaged the patient, that we are leaving NOW.

"What about me?" she asks. He looks at her: "Can you stay - we need you." She gets one of the police to tell her boyfriend, and the doors close.

In the ambulance, she sits by the patient, chatting to him as she presses the flail segment, now with her fist, as her hand has cramped up. The BASICS doctor has a laryngoscope and tube in one hand, and a scalpel blade in the other. He tells her it's "just in case." She begins to pray.

Moments later, they arrive at the hospital, and she rushes, bent double, next to the ambulance trolley, as the patient is wheeled into the resus room.

"Don't leave me now," he whispers. "You said you wouldn't leave. I'm scared I'm going to die."

She stays with him, still with her hand pressed against his chest. She can't feel her fingers, but nothing else matters. She is draped with a lead apron as x-rays are taken; she listens as anxious conversations ensue between the BASICS doctor and the anaesthetists: do we intubate and then put the drain in, or put the drain in while he is awake.

Finally, a decision is made. The drugs are given, and, at a word from the BASICS doc, she releases his chest. A slash of metal, and the chest drain is in. His eyes close, as he is anaesthetised.

She sits down, job done, and waits for her boyfriend to take her to dinner. "Double celebration", she thinks.



Thank you to all the CFR's out there. You do a fabulous job. These two cases happened within 24 hours of each other. This man survived, and all thanks to the CFR.

CFR x2

CFR 1

He was just on his way to work, this Community First Responder. He couldn't keep going, not when he can see the cyclist lying there, his bike a tangled wreck beside him. Sure, this isn't what he would normally deal with; cardiac arrests are his usual callout. But he'll be able to do something, before the ambulance arrives.

He stops his car and jumps out. His car is protecting him and the casualty, so that's sorted. He bends down to assess the chap, and realises that this one is a bad one. He is not moving, has no pulse and is not breathing. He quickly checks to make sure that an ambulance is on the way, and then proceeds to make use of the bystanders who have also stopped, getting a team together to turn him carefully onto his back, still keeping the spine immobilised, before starting chest compressions and breathing for him.

A few minutes later, the ambulance arrives, and he stands, to make way for the experts. They know a useful resource when they see one, however, and he continues with CPR, while the crew get their lines and monitors attached.

A few minutes after that, the BASICS doctor arrives. Once again, the CFR feels the need to move out of the way, and, once again, is encouraged to continue helping. He works around the "experts" as the patient is intubated, as the chest wall is incised, to ensure that there is no collapsed lung. And all the while, the patient receives expert CPR.

"Hello, I'm a Consultant Anaesthetist, can I help?" A curt "No thanks" sends him away, as the team of five men and women struggle in vain to save the young man's life.

A little later, and the team debrief at the side of the road, the shrouded body of the cyclist a silent reminder of what, this time, had been the result of their endeavours. Once again, the CFR tries to walk away, to leave the experts to their debrief, and, once agin, he is pulled back. The team is incomplete without him.

Debrief over, handshakes all round, he gets into his car and drives to work.

...to be continued...

The Handover Carnival

Well, folks, another month and another Handover Carnival. Head on over to Life Under The Lights, and see if you can find my guest appearance - co-written with InsomniacMedic. Lots of really good stuff, here. Enjoy!!

This Time, Please!

This time, please let this time be different. Let this 18 year old survive. Altered consciousness, breathing noisy, Control have told me, as I rush to the scene of yet another RTC. As I negotiate the roundabout, and I see a motorcyclist swerve out of my way, my mind, inevitably turns to three hours earlier:

He was 17, only 17. Why he had come off his motorbike, no-one knew. There were no other vehicles involved, he just clipped a kerb and lost control. I wasn't called - it probably wouldn't have made a difference anyway. He might have been conscious on scene, but he wasn't right, according to the crew. He was very combatative, and very VERY pale. And then he had a cardiac arrest in the ambulance, six minutes away from the hospital. As I gathered the Trauma Team, I was in no doubt that this man would not survive, had in fact already died, even before he arrived in the hospital. But we worked on him anyway - he was only 17, after all. Into automatic mode, we tubed him, decompressed both sides of his chest, and poured in as much fluid as we could. Six minutes later, I called it, the inevitable end result. And then, I get the inevitable backlash, from all the staff: how could we have stopped so soon? He was only 17; we should have tried more, done more, spent more time. Doing what? Doing anything, comes back the answer. And this is from the nurses and from the doctors. Despite the fact that they all agree that the resuscitation attempt was futile, that he was dead before he arrived in the Department, they all still wanted to carry on, to throw all the resources, all the magic of resuscitation, to try to achieve the impossible. I leave the hospital with a heavy heart.

And, now, here I am, 3 hours later, hoping that, this time, there will be something, anything, that I can do.

100,000 Visits - Now It's Your Turn

Dear Constant Reader,

Today, just over a year since this Blog went live, I have reached the 100,000 mark! 100,000 visits to my blog. I accept that most of the hits are from Mrs RRD, but still, that's a whole heap of people who now know about BASICS, who previously had never heard of us. I look at the map of where visits have come from, and I am astounded at the interest from so many different countries.

My life has changed so much, as a result of this blog. I have found an outlet, a way of expressing myself, that I never had before. I have joined and become part of a community, the blogging world, and been accepted by it. I have "met" and made new friends. I have a new name, and so have my wife and children.

There was always a purpose in writing this blog - to raise the profile of BASICS-London, and try and get as many people as possible to be aware of who we are and what we do. But now we move into Stage Two, and this is where you come in.

BASICS-London is a charity. It costs a lot of money to put a doctor on the street, and every penny comes from donations. The doctors themselves get no payment for the work they do, and pay for the extra fuel, insurance and wear-and-tear on the vehicle out of their own pockets.
Each doctor needs blue light driver training (£1000), modifications to their car (£1500), personal protective equipment for themselves (£1200) and the necessary medical equipment to save lives (over £10,000). All of the doctors currently on the road have the first 2, most cadge some form of protective equipment, and few have all the necessary equipment needed. There are currently 15 active doctors in London and the surrounding regions. Many more are standing in the wings, waiting to be trained and equipped.

You may have noticed a new button on the top right of this Website, entitled "Donate". Press it. Give something, anything. There are about 250 visits per day. If every one of those visits paid £2, then, in 2 days we would be able to get another doctor trained on blue lights. In a week, I could have him equipped and ready to go. If you pay more, it will happen sooner.

This is a legitimate request. We are a Registered Charity (look us up on the Charities Commission website - http://www.charity-commission.gov.uk/, Number 1002819). Your payment is securely sent direct to the Charity's bank - I will have no individual access to any funds coming in. I will keep you informed of how much is being raised.

For my part, please watch this space, as I will be telling you about some exciting ways in which I will be trying to raise some more money for BASICS-London.

Thank you

RapidResponseDoc

Annual Leave

Another week off this week, so that I can use up all the remaining holiday before March 31st. So, what do I have planned? A trip to Costco, paint the toilet (the bathroom, for my trans-atlantic readers), daily visits to the gym. Not going to the hospital, not worrying about the Department, is a holiday all on its own.

So, just getting ready for my first trip to the gym this week, having spent FAR too much at Costco, and having looked at the walls and deciding that the preparation will, as usual, be far worse that the painting; guess what? "Can you attend an elderly lady, who has fallen off a ladder?"...

He sits there, on the front step, pulling his dog to him, in an embrace that is born from fear. She lies on the ground in front of him, not moving. The three of us work silently, securing her cervical spine, getting intravenous access, assessing for injury, and moving her from the ground where she lies to the back of the ambulance. He watches every move, his gaze a mute plea to save his wife of 49 years, his wife who was well enough to climb a ladder to clean the upstairs windows, yet not lucky enough for the ladder to not slip on the wet grass. Her stillness, her silence, tells him more than I do, later, after I have seen her CT scan.

Back at home, forgoing the gym for today (tomorrow, definitely tomorrow!), I look once again at the toilet walls, and start the grim task of stripping the old wallpaper.

The Book Sale

They come knocking on our door, in ones and twos, laden with bags or boxes of books to add to the growing pile. Mrs RRD bustles around them, proffering tea and biscuits, as they search for a literary gem, for a much loved author. The questions: "Who brought this fab book?" "How much for this one?" The chat, about the kids, about school, about ailments, about BASICS. And then they leave, carrying with them treasures for an evening soaking in the bath, for a train or plane journey, or to shade their eyes from the sun on the beach this Summer.

All of them are here to support our charity. All of them give generously, both of books they no longer want, and for books that they have found.

Thank you to all of you, but especially, and as always, to Mrs RRD, for caring so much.

Good News!!

I feel good tonight! I just wanted to share something with you all:

About a month ago I went out to a man hit by a taxi cab. Unsurprisingly, he wasn't in a good way. I tubed and ventilated him and transported him to my hospital. A little later that evening he was transferred to a cardiothoracic centre for major aortic surgery. I didn't expect he would survive, and indeed, I didn't hear anything positive from the hospital, just that he needed more surgery.

Fade to this evening:

I am standing in A&E, coat on, just about to leave to go home. BlarneyNurse walks up to me. He stops, and points his pen at me. I wait, patiently. "Someone's looking for you," he mutters. I wait, patiently. "Cubicle 2," he eventually says, and wanders off.

I pop off my coat and go and see who wants me. A family member? A barely recognised friend, who wants to jump the queue? No, not this time.

Lying there in Cubicle 2, smiling up at me, is the man from the taxi. (Well, from under the taxi, but you get my drift.) He looks well, considering. He and his wife have been asking after me. They are in because one of his stitches needs removing.

We chat, the three of us. She tells me about the agonising wait outside Theatre, repeated only a few days later. He tells me about waking up in ITU, 2 weeks of his life just ... gone.

Then they both tell me about their family; how their 8-year old and 10-year old want to thank me for making sure they still had a Daddy.

I take out his stitch, wish them both well, and float home.

Musings

I could have got there in less than 25 minutes. Maybe 20. Less than that, if there wasn't too much traffic.

Mrs RRD and the Micro RRDs could have got themselves home from the restaurant. I know it was cold, but they could have got a taxi - we were only a few minutes from home. It wouldn't have cost much.

I had eaten well at lunch, and had had the starters tonight, before the call came in. I wouldn't have suffered unduly, had I skipped out of the main course that was on its way from the kitchen.

True, it might have been difficult getting Mini RRD and Princess RRD back from their party, but I'm sure I would have been back well before then.

The caller said the patient was unconscious - he could have benefitted from my presence.

But I still said no.

I have a right to a life, to some 'time out' with my family. What I do is voluntary, and I need to be able to choose. My family also have a right to be with me. The Micro RRDs need me, need to spend time with me. Mrs RRD is always so long-suffering, always understands when I rush off. Yet, she'd much rather me stay, and she, too, deserves some time off from coping with the difficulties that my BASICS volunteering causes. And, there are plenty of times when I rush off, only to find that the call was not as given, and I wasn't needed after all.

But I still feel guilty.

Hello Down There!!

Something a bit different today:

I am on my Rounds in the hospital when my 'phone buzzes in my pocket, I excuse myself from the patient and his family, and answer the "Unknown Caller". Surprise, surprise, it is Control. Can I attend a chap who is trapped in a hole? I decide that Rounds will have to go on without me, and I rush into A&E to see if anyone wants to join me on my trip.

Beardy jumps up, as usual, then looks around in dismay at the department devoid of junior docs - they have all gone to teaching, and he is one of the few docs left to man the Shop Floor. Sadly, he gives up the opportunity, and Ginger chases after me, hotly pursued by two nurses - that's a first for him!!

We all bundle into the car and I program the Sat Nav. Ginger, a new Medical Student, is looking rather bemused - he's not quite sure what's going on yet!! Fasten your seatbelt, Ginger, we're going for a ride!

We turn up at the address -it's 2 doors away from Princess RRD's friend, so I know I'm going to be quizzed big-time by her when I get home. I jump out and hand bits of equipment to my rather green- looking passengers.

The scene is a simple one; builders putting up extension, man digging deep hole for foundation, walls of hole collapse while he is in it, man trapped by clay up to mid-thigh.

First difficulty - none of my passengers have ppe (personal protective equipment), so none of them are going to be coming anywhere near this hole. They don't look happy about this, and go and sulk in the back of a fire truck to keep warm.

Second difficulty - there is very little access to Johnny, the man in the hole. There is a large piece of hardboard that he has been using to shore up the sides - rather unsuccessfully, as it happens - in front of him, and a fence behind him. He is well and truly stuck. Fortunately, he is standing upright, and is fully conscious. Unfortunately, the clay is beginning to set.

You may at this stage be wondering why I had been called. Well, to be honest, so am I. I know that there are dangers associated with crush injury, especially when the blood supply to a limb is cut off. Toxins build up in the affected limb, then, when the pressure is released and the blood is able to flow again the toxins rush around the body, and can cause circulatory collapse. It might happen, but I am unconvinced. Still, if I complain about not being called when I am needed (which I do on a regular basis) I can hardly complain when I am called.

So, I stand around for an hour or so while Johnny digs himself out. Yes, you heard that correctly. There was no room for anyone else down the hole, so the fire crew lower empty buckets down to johnny, who fills the buckets up with lumps of clay that he has dug out with his bare hands. There really is no other way we can help him, despite the three hundred and fifty seven different suggestions offered by the attending fire crew.

Eventually, he has removed enough clay from around his legs to be free. He is lifted out of the hole, placed on a spinal board, and carried out of the area, to the waiting ambulance. I remember my three passengers, and they join me on the back of the rig, as I cut up his trouser legs, and find cold legs, with no injuries.

"You've got away without any injury," I tell Johnny. He asks me about his shoulder, and I see a hugely deformed fractured collar bone. "This hurts a bit," he says. I think about how he has been able to dig himself out of a hole with a fractured collar bone, and decide that he's a braver man than I will ever be.

RVP Part 2

To recap, I have just arrived at an RVP for a 17 year old who has been stabbed multiple times. Why an RVP? Well, the police go in to the scene first, ensuring that it is safe for the ambulance crews to enter and treat the patient. It may take a few minutes to clear the way, but ambulance and prehospital docs need to keep ourselves as safe as possible.

So, this RVP is mighty close to the scene itself. I can see about 5 or 6 police cars, two police vans, and both an ambulance and a rapid response car. There also appears to be a small riot! A large crowd of civilians are being held back by the police, including 2 very menacing-looking dogs. The bottles being thrown at the police look equally menacing, and the shouts from both sides do nothing to inspire confidence in my safety. Apparently, the crowd are angry because we, the health care professionals won't go in, and the police have entered first. Go figure!! A scenario, where I walk calmly up to the henchman, pull him close by the collar of his jacket, and ask him if he wants to quit fannying around so that we can attend his friend, flashes through my mind. Then I remember - I'm a coward, and I wait patiently to be escorted quickly through to the front door of a small house.

Here's another break from my run-of-the-mill road traffic accidents (collisions - we aren't supposed to use the 'A' word any more) which always unnerves me. I enter someone's house, and there, alongside their possessions, their items of daily life, is blood, pain and chaos. This strange juxtaposition always puts me off-kilter for a few moments, while I do my best to re-focus.

I can't get near him - he is surrounded by his friends. They hold him close, and I can't yet tell if he is even alive. They part for me, without a word, and he turns towards me. Alive, then.

Stabbings, penetrating trauma, are a very special type of injury, with their own rules for management on scene. The phrase 'scoop and run' was made for stab wounds. There is little to do on scene. The longer you 'stay and play', the more likely, if there is any serious internal injury, for the patient to suddenly lose blood pressure and die. There is only one possible intervention that might be required on scene, and that is a thoracotomy.

If someone is stabbed in the chest, there is a possibility that the blade has penetrated the heart. If that happens, the heart itself will bleed. The heart is enclosed in a sac, rather like a plastic bag. If the sac fills with blood, then the heart is compressed and cannot pump blood around the body, and the poor unfortunate will die. Unless, that is, there is someone brave enough to take a pair of scissors, cut through the chest wall between the ribs, from one side of the chest to the other, cutting through the breastbone as he goes, thus opening the chest - a thoracotomy. From there, with heart and lungs exposed, he can cut open the sac, thereby releasing the pressure on the heart. That's why I've been called.

At this moment in time, Jamie is very much alive, but he does have three stab wounds to the left side of his chest, right about where his heart is. If one of those has nicked his heart he could be bleeding into the sac right now, and any moment might stop breathing and collapse. Now you can see why we don't hang around. I have done 2 pre-hospital thoracotomies in the past, and they are not pleasant experiences.

Right, a quick needle into a vein, just in case, and we lift Jamie on to a carry chair and take him out into the early morning air. On the back of the ambulance, we lie him down and I make a quick assessment. He has slightly reduced breath sounds on the left, so his lung is probably damaged, but he is still getting normal amounts of oxygen into his bloodstream. We need to go, and now!!

I decide that we need to go to a cardiothoracic centre. The nearest is 25 minutes away - not a nice thought for me. I get ready my scalpel and scissors, just in case.

We then have an agonising 10 minute wait while the police move enough of their vehicles out of our way, so that we can start our journey. I see the seconds ticking away, and urge them to hurry.

Jamie looks up at me. "I'm scared," he whispers, the fear so evident on his pale face. And then it hits me. He's 17 years old. This kid, lying in the doorway between life and death, is the same age as MiniRRD. My own son could be lying here! Suddenly, I am overwhelmed with the knowledge of just how young my patient was, so young, and yet old enough to have been in a situation where he could be stabbed three times in the chest!

I know that there is nothing more I can do for him, that whether he lives or dies depends solely on the path of the knives that penetrated him. No, that isn't quite true. I sit close to him, and place my hand on his shoulder. "You are going to be fine," I tell him, and we stay like that, as the ambulance races through the streets of London to his future.

RVP

"The RVP for the job is at the corner of ... and ...," Control tell me, at 3am this morning. Oh, how I hate these jobs. Mrs RRD murmurs sleepily for me to be careful as I go. I don't tell her what I am off to - I know how much she worries, just about me travelling to an RTA. If she knew I was on my way to an RVP (rendezvous point, the place the ambulance service meet while police clear the scene of the evil-doers), she wouldn't get back to sleep at all.

Being shot in the chest isn't a recipe for a long and happy life. Three times with a shotgun, and you are probably rolling fate's loaded dice. That's what Control have woken me with. These are the jobs I dread.

As I am getting in my car, there is an update: a 16 year old, stabbed in the chest three times: the RVP has moved a little closer to the scene, and I am asked for my ETA. I know this place well. I am only about 3 minutes away.

I can hear the RVP long before I can see it. Sirens blare, and yet, even above that noise, I can hear the sounds of shouts, of voices raised in anger, of dogs barking. Oh, how I hate RVP's

...to be continued...

Donation

Someone has just given a whopping donation to BASICS-London!! And I mean whopping!! Apparently, they were involved in an accident, and the insurance has just paid up. All I can say is, "Thank you." You know who you are, and I and my BASICS-London team are so very grateful to you. Love Ya!!

Stalker

Ok, this is getting ridiculous!! I'm driving to an RTC on the M25, getting totally stuck between the fast and middle lane, trying to get the cars to part, a la Moses and the Red Sea. Im thinking to myself that I need to get over to the hard shoulder, but finding the traffic too tight to get there. I hear sirens behind me, and look over to my left to see GassPasser2 passing me on the hard shoulder! What!!! Where the heck did he come from?? Is he following me? Listening in to my 'phone calls??

3 minutes later and I arrive at the scene of the RTC, and assist GP2 to get a fairly well man out of his car, after he had lost control and hit the central reservation. No intubation needed, just an extra pair of hands (x2!!)

GP2 and I chat about the increased call rate that we have both noticed over the past few weeks, and wonder if has anything to do with the fact that we have both got very shirty on the phone to Control when they have not called us for jobs we were needed at. Then we notice that a) it is night time, b) it's freezing cold and c) it's pouring with rain, and we get into our respective cars and drive home. See you soon, no doubt!!

MrsRRD Speaks

I've never done this before. Tonight, Constant Reader, I hand my blog over to a guest writer. It is my pleasure to bring you my greatest fan, as she tells you about my second encounter today with GasPasser2. So, without further ado, I give you, Mrs RRD:

Today I had a rare treat; in fact to be honest it was a privilege. I was on my way home with RRD after a rare trip out together, without the RRDettes! His phone rang, not unusual in itself, but it is a colleague BASICS Doc, en route to a call, in far away town. A couple of trapped and unconscious patients, too many for him to deal with alone, can RRD assist? RRD calls into ambulance control, tells them he will run on the call & finds out more details. Car versus lorry, 2 people trapped & unconscious plus one other patient, Air Ambulance on scene, but no Doctor onboard.

We head for the motorway; heavy traffic greets us early on & I witness first hand the difficulties in getting through: the drivers who seem oblivious to the ‘heat seeking missile’ fast approaching in their rear view mirrors, lights & sirens blazing. The lorries, that move swiftly out the way, despite their size. As the cars part, I think of Moses parting the Red Sea! RRD heads for the hard shoulder and we cruise down steadily, through the dirt & rubbish on the road. Our passage blocked by stationary cars, we weave out into the clogged lanes. Finally we get through to our junction. We leave the motorway & speed up, soon we’re approaching a Police road block. We, unlike the other vehicles, get waved through. The roads are eerily quiet now; we approach another junction, another roadblock, another wave. Suddenly the road is filled with flashing lights, blue & red, there is a stillness I don’t expect.

RRD slows to a stop, a little way behind the helicopter, and we get out. I am handed the camera, for the BASICS–London website; to capture the scenes, the faces, to tell the story. He gets into the obligatory orange jumpsuit, grabs his heavy bag, his monitor and his helmet. He leaves my side and strides quickly forward, approaching the scene.

What lies ahead of him is a line of 2 fire tenders, two “ambos” and a crowd of uniformed personnel. Beyond, a car, the roof already pealed back, like a tin can, full of people, working together to extricate a victim.

I am suddenly struck by the collaboration of these professionals. So calm, so organised, no shouting, no running about, they all work as one. The teams don’t all know each other, nor do they usually all work together, but here they are, striving for one purpose. There are clearly those in lead roles, taking quiet control, guiding and overseeing, but everyone else is an integral part of an efficient team.

Suddenly the patient is removed from the car, clearly the most seriously injured of the three. She is smoothly & quickly transferred to a trolley where a cluster of emergency medics, paramedics, EMT’s, the helicopter crew & our two BASICS Docs all gather around, taking their part in saving this woman’s life.

We are so fortunate that we have such amazing emergency services; they are such an incredible group of dedicated and hard working people. So committed to supporting us all at our worst and most vulnerable.

I felt truly privileged to witness this today, so grateful to them all and those like them and so appreciative of their care.

Thank you all.

So, We Meet At Last!!

I'm on annual leave at the moment. It's really quite enjoyable, not having to go in to work. Today is my second day, and I spent the greater part of yesterday on the 'phone to the Department, sorting out this and that. So, today is a day to spend with the family, but not until much later in the morning, after a proper night's sleep.

So, why is it that I am awoken in the early hours by a strange yet insistant buzzing sound? Ah yes, forgot to turn my 'phone off vibrate last night. Oops! Good job it still woke me. Ambulance Control are at it again, sending me to a job near my own hospital. A motorcycle has been in collision with a bus, and the rider is in a serious way. My immediate thought, apart from "there goes my lie-in", is that, unless the rider has gone underneath the bus, he is unlikely to be trapped, and I suggest that the crew might want to consider scooping and running to the hospital, rather than delaying waiting for me. I ask Control to advise me if the crew are not going to wait, and I get dressed and hurry down to the car.

As I am getting in to my car, Control ring again. Am I stood down? Well, not exactly. As I made the comment about the crew running with the patient, they have called upon another BASICS doctor, who lives the other side of town, and asked him to attend. My arch nemesis, GasPasser2! There have been a number of occasions when he has wrested jobs from me, arrived before me and taken charge. But this one's mine!! I'm not relinquishing control to him today!!! I let Control know that I will go as well, jump into the car, and the race is on!

I don't want anyone to think I drove any faster than I normally would, just to get there before him. That would be highly irresponsible and dangerous. But, as I come off the motorway, and see his flashing lights in my rear-view mirror, I must admit to a feeling of satisfaction, knowing that, this time, he would be aswering to ME!

As we weave through the early morning traffic, sirens blaring in harmony, I think back to how rare it is for me to work with another BASICS doctor.

We arrive and jump out of our cars. I feel like I'm in a Bond movie: "So, Dr GasPasser2, we meet at last!!"

Despite the fact we so rarely work together, this makes no difference, as we squeeze into an already very full ambulance, and assess our (my!!!!) patient:

He is a big chap, well over 120kg, and is being less than cooperative. He is trying to sit up, and is being restrained by a police officer who outweighs him by at least 10kg. Told you it was a tight squeeze! It's not easy to assess someone while they are being sat on, but I do my best. "What's your name?" He tells me. So, airway and breathing are ok. I lean in close. "Now, listen to me. If you want this policeman to stop sitting on you, you need to cooperate with us. Are you prepared to lie quietly?" He nods, and I gesture to the police officer to relax his grip on the unfortunate. In an instant he is sitting bolt upright, struggling with all of the crew in the ambulance. Bad call. With Mr Bobby replaced on his chest, we quickly go to work, securing intravenous access, and the decision is made - he cannot be transported to hospital in this agitated state, and will need to be intubated and ventilated.

For those of you who might be wondering, agitation such as this is commonly seen in trauma cases. There are a number of causes, the most important being poor oxygenation, blood loss and head injury. Only when all of these have been excluded can one conclude that the agitation is due to alcohol, drugs or just bloody-mindedness. If it is any of the former it is important to gain control, by intubating and ventilating the patient after the administration of a general anaesthetic.

Because I got there first, GasPasser2 has to defer to me, and I get the opportunity to intubate this one. It's not that there's any competitive nature to this BASICS lark, honest. But, he is an anaesthetist (hence the name) so he gets to do this every day...

The drugs are given, the tube slides in easily, and he is finally quiet and still. Mr Bobby is released from his duties as human paperweight, and we get ready to leave scene. I say my farewells to GasPasser2, little knowing that, in less than 5 hours, we would be once again racing to the scene of another accident, and that this time he would beat me!!

Danger in the Classroom

This is just awful. I stand there, wondering how I had got myself into this situation. Only days before I had been dealing with Danny, a 5-year-old, crushed by a car in his own playground, and now I have to deal with 60 five-year-old's, all at once. I look around at them all, sitting there in front of me. I feel so uncomfortable, my jump-suit seems so tight, and I find it hard to draw a breath.

Dammit! This is what I do. I have to focus!

"Hello, children," I start. "My name is David, and I'm a doctor. I've come to your classroom today to tell you about what it's like to be a doctor." Hey, this is going ok, I can do this.

One little boy puts his hand up. "I've seen a dead person. My granny died at home and I saw her. Have you seen a dead person?" Ah, didn't take long to get on to dead people, then. I quickly skirt the subject, and show them my stethoscope. I get a few up to listen to my heartbeat, thinking that might be fun. Another hand shoots up. "Do you make dead people better, too?" Now what? I look across at MrsRRD for some guidance, but for once she is not any help at all - she is trying hard not to laugh, and the effort is bringing tears to her eyes.

I plug gamely on: "No, once someone is dead, I cannot help them, but I can stop some people from being dead." Shaky ground, this. Why, oh why, did I agree to come here? Surely a policeman is more fun for 5 year olds. And suddenly it hits me. "Who wants to come and turn the sirens on in my car?" I ask. I am quickly surrounded, and we march off into the rain (hats and coats first) and they each press the buttons for the lights and sirens, using up the last of my 20 minutes, allowing me to escape with no more tales of dead grannies.

Back in the car, I turn to MrsRRD. "Never again!" I exclaim. "No," she says softly. "Not after the next three schools I've booked you in for."

Danger in the Playground

"5! He's only 5!" my mind screams at me, as I drive to my latest call - a young child pinned between a wall and the bumper of a car. For those of you not regular readers of this blog, children are my one fear in pre-hospital care. They are remarkably difficult to assess, wherever you are, and this becomes even worse without all the usual diagnostic equipment found in an A&E Department. Also, injured children decompensate very rapidly. One minute they may look fine, the next they may have no blood pressure or pulse. Add to that the emotional aspect of dealing with a young child, and you have a recipe for severe anxiety.

I arrive at the school, and rush into the playground with my kit, my paediatric bag as well as my monitor. I have to keep focused, despite the urge to run back to my car and hide somewhere.

He's lying on the ground. The car has been moved back a little, and there is just enough room for me to crouch down beside his tiny frame. He looks up at me. "It hurts," he cries. Well, that's a good start!

A quick check, and it is clear that he has a fractured thigh bone, but is, fortunately, conscious and talking. But I am well aware that a little one such as Danny here can bleed out into his thigh, and, as I said at the beginning of the post, their condition can deteriorate at an alarming rate. First things first, I need to cannulate him, so that I can get some fluid into his veins. If I wait much longer, the veins will all shut down and be harder to see than they are now. He's shivering - not just from the cold but also as a sign of blood loss. Come on, RRD, calm it!!

I let Danny and his mother know what I am planning - he is crying, but I don't think he noticed as the needle went into his arm. Damn!! Whilst I am able to get the needle to puncture the vein, it won't thread through. The vein is just too small. I know what needs to happen, and I am less than happy.

In a child, if a vein is not immediately accessible and fluid or intravenous drugs are needed in an emergency, the quickest way to the circulation is via a needle inserted into the shin bone. Yes folks, you read that right. It is called an intra-osseous needle, and it is as nasty as it sounds. I have put lots of them in in my time, but all on unconscious or arrested kids. And it is looking like I am going to have to do my first one on an awake child in the next couple of minutes. My mind goes back many, many years, to when I was a junior doctor, fresh out of Medical School. Her name was Fiona, and she was 2 years old. She looked alright when I first saw her, but, only 45 minutes later, I was helping to resuscitate her. And all because the doctors looking after her wouldn't admit defeat when they were looking for a vein, and wouldn't put an intraosseous needle in early enough. Not this time...

I know the score; 2 attempts at cannulation, then intraosseous. I have one more to go. I take a deep breath, turn to the other arm. Nothing at the elbow. One tiny thread on the back of the hand. I reach for a yellow venflon - tiny and short. My hand steadies. I look at Danny's little face, then back to the task in hand. The venflon slides effortlessly through the skin. I feel a barely perceptible pop as it pierces the vein. A tiny bead of blood appears in the venflon. I slide the assembly forward, so that the plastic tubing over the needle is in the vein. Pulling back the needle, I watch as the blood flows gently through the venflon. Success!!

I've only been on scene for a few minutes. I secure the venflon to Danny's hand (certainly don't want this one falling out) and attach a bag of saline to it. Next, we turn to splinting his leg and carefully we get him on to the ambulance trolley.

Double damn!! I watch in horror as Danny's skin goes deathly pale, as he fades out of consciousness. I reach up and squeeze the saline bag, forcing the fluid in as fast as I can. There's more than just a fractured thigh bone here. I suspect that his pelvis may have been injured, so we cut away his clothing from his abdomen and legs. Oh 5h1t!! He has a 5cm wound on his lower left abdomen, deep and bleeding. He now looks as though he has multiple injuries, and we haven't a moment to lose. We pass a sheet under his buttocks, and tie it across the front of his pelvis, tight, to splint a possible pelvic fracture, and stop any further bleeding. Straight on to the ambulance, and we are off to hospital. En route, I somehow manage to get another line in, despite the fact that we are bumping along a motorway - can't do it while we are stationary, but able to at 65 miles an hour!

By the time we arrive at the hospital, Danny is talking to us again. He has had half a litre of fluid, and this seems to have perked him up. He's out of the woods for the moment, but he's got a way to go before he's going to be on his feet again.

A few hours later I give the hospital a call. He's in Theatre, having his spleen removed and the wound to his abdomen debrided (cleaned up). I say a silent prayer for him, and get ready to go home for the inevitable kid-hugging session.

Please

Tomorrow, MiniRRD turns 17. Tomorrow he becomes another one of those legally able to get behind the wheel of a car. He is desperate (BOY is he desperate!!) to start driving. Mrs RRD and I have heard little else from him in the past few weeks. He's not starting just yet; he needs some cash first, but this is, even so, a special milestone in his life.

Understandably, my thoughts turn to the youngsters who thought they could drive, who drove fast to impress their friends, who couldn't say no to just one more drink before we go home, to the 17 and 18 year olds whose families now spend each and every birthday grieving for their son or daughter, and so I send a plea to you, MiniRRD:

Remember, Son, that nothing is more precious than life, and no-one is more precious to me than you, your brothers, your sister and Mrs RRD.

Remember that you are not invincible.

Remember that it only takes a second, so take a minute, just to be safe.

Remember that it might not be you who can't drive, but that there are many out there who shouldn't be on the road - watch out for them, because they won't be watching out for you.

And remember, we all love you, and want you to stay safe, always.

Have a fab birthday tomorrow.

Help!

Why is it always between 2 and 4am? Why is it always raining? Why didn't MrsRRD and I go to bed early, rather than staying up to watch ANOTHER episode of "Modern Family?" These three questions run through my head as I jump out my car and rush towards the car wreck. At least the rain is waking me up, clearing my head, and making everything crystal clear in my mind.

The car has come off the road and struck a railway siding. There is just one occupant, and she looks at me as I squeeze my way between the burly fire crew, all intent on cutting away the metal that is trapping her. She is conscious, complaining of pain in her right shoulder. At least that means we have some time - her airway is intact, and her breathing and circulation, at least for now. I am, however, concerned that the shoulder is not all that far from the chest, and so there could easily be associated lung injury, that may make itself apparent only if we watch carefully for it. The saturation probe, placed on a finger and used to measure the amount of oxygen getting into the bloodstream, is pretty useless in a cold patient, where the arteries in the peripheries are closed down. So, we'll just have to use our eyes instead. We'll watch her conscious state, her respiratory rate and her colour. Much more preferable (but it is nice to hear the reassuring "beep beep" as well.) I ask her some questions, mainly to assess her conscious level, rather than for the answers. She tells me her name is Sam, and that she doesn't remember the accident. "Where were you going?" I ask. She replies, "Just out for a drive." Hmm, a bit late for a drive, but, there's nowt queer as folk.

She remains stable, as we prepare to lift her out of the car, along a spinal board placed behind her back. I am very careful as I hold her right arm to her side, to minimise any movement of her shoulder, but she still cries out in pain.

Out of the car, and on the ambulance trolley, she shivers from the cold, and we quickly roll her into the back of the ambulance, so that I can assess her better. I need to see her chest wall, to check for rib injuries and to ensure the movements on both sides are equal. I reach for the shears, asking half-jokingly if the jumper she is wearing is one of her favourites. Fortunately for her it isn't. I begin to cut the jumper, starting at the bottom.

Oh.

A criss-cross patchwork of scars is revealed as I expose her abdomen. All old, and none of them surgical. I glance at her left forearm - the pattern is repeated here, some newer than others. I look at Sam's face, and her eyes stare back at me, the fear and the guilt so evident. And, suddenly, it all makes sense.

I know

I know what happens to you. I've seen it. I know what you look like when you drive too fast and hit another car, or spin out of control into the central reservation. I know what happens when you get hit by a bottle, or get stabbed in the chest. I've cut you out of car wrecks, watched you fall from a second floor window. I've cannulated you, I've tubed you, I've even opened your chest and held your barely-beating heart in my hand. I've saved your life, and I've watched you die. You are my patients, and while you owe your life to me, I owe mine to you.

Circle

They stand there, the three of them, holding hands, a family circle so much smaller today, because of the one who lies only a few yards away, and yet who is unreachable. They call out, beg, plead for her life to be saved, but I know, as I walk out of the resuscitation room towards them, that this is one prayer that will not be answered.

No!

3am, I am woken from troubled sleep by Control. Can I attend FarAwayPark, where a man has been sledging (at 3 am!!!???) and has hit a tree. Massive head injury, CPR in progress? My muggy brain starts doing the Math - 2-3 minutes to get up and dressed, 5 minutes to dig my car out of the ice, 3 minutes to get to the end of my icerink of a street, another 20 - 25 minutes to get to the entrance of FarAwayPark (maybe longer in this weather), and a final 3-4 minutes to get from my car to the patient, without going a over t in the snow. That all adds up to - No!

Weather Report

I'm at work in the hospital. Nice and cosy, not too much in the box. I am suturing up a thumb when my 'phone rings. Not much I can do at this stage, but I am on the last stitch, so I cut the thread and, stripping off my gloves, reach for the 'phone when it starts its insistant ringing for the second time. Can I attend a call on the M25? No probs, I leave the cleaning up to my junior and head on out to the car.

The wind hits me as I leave the relative comfort of the A&E. Blinking heck, but it's cold!! I throw on jumpsuit and boots (steel toe caps an essential for M25) and start the engine. As I speed out I depress the lever to spray windscreen wash over my front windscreen. Big mistake. I now have a thin sheet of ice barring all but the tiniest view of the road ahead. I glance at my outside thermometer gauge - -2.5 degrees centigrade! I hit the wipers and they quickly clear enough of a hole in the ice for me to start rolling.

The journey is uneventful, and I reach the scene in record time.

The car is on its side, the driver buried beneath a mound of groceries. He had clearly been shopping, and the bags had had as much of a tumble as the car rolled over and over as he had.

We are all standing around as the fire crew dig him out of loaves of bread, milk cartons and bags of pasta. He isn't badly injured, so the fire crew are taking things steady.

Only one problem - it's blinking cold out here!! We are all shuffling around, trying to keep warm, and yet he is stuck, immobilised both by the fireman at his head and the tins of peaches, the crumpets (oh how good they would be right now, toasted, with a smidge of strawberry jam!) and the root vegetables that surround him.

Eventually he is freed, and we slip him gracefully out on to a spinal board.

"Where to?" I ask the crew. The hospital isn't mine and the patient is only suffering from the cold, so I leave them to it, jump into my car and turn the heater on full blast.

Back at my A&E Department, I decide that my boots are staying on - far to cold to change in the car park.