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.
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.