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.