Sunday, 28 February 2010

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.


  1. RRD - just came here after reading 999Medic's blog, about the difference between "treating" a patient, and "caring for" a patient. Your post brought tears to my eyes (you frequently do, that's why I read) and I thought, you are clearly a carer. Bless you.

  2. Can I ask...if it's a stabbing wound that has injured the heart, why hasn't the sac already been torn in the process, thereby stopping it from filling with blood?

  3. I would guess at it being something to do with either the relative pressures, or the fact that blood can clot!

  4. Yes, Matt, it is about the relative pressures. Inside the heart there is a pressure of over 130mmHg, which will pump blood out of even a small hole in the heart. The heart fills at a pressure of around 30mmHg, so, if the pressure around the heart is greater than 30mmHg, then it won't fill. The blood in the pericardial sac won't leave the sac until its pressure rises, because the hole may be small.

    Hope that makes some sense