Thursday, 3 June 2010


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!!


  1. Loved this story, and loved that I knew what you were talking about! Looks like I did learn something in paramedic school :-) Good writing

  2. Ah you tease RRD, every time I think it's finally going to be that time that you have to perform it the surgical airway but you're always saved at the last minute! You master of suspense you. In my layman's vagueness I always thought it was called a tracheo(s)tomy? I wonder where I got that one from.

    No thoracotomy on a tension pneumothorax this time then. I've just happily read the entirety of your blog and it seems to be something of an RRD signature procedure! And an incredibly useful one at that. Keep up the vital work.

  3. Thank you, both of you. A tracheostomy is a surgical procedure, done in an operating theatre, and is indeed one in which the trachea is cut and a tube inserted. So, what's the difference between that and a cricothyroidotomy (i just love the name)? Well, in an emergency, one doesn't cut into the trachea itself, but above the trachea, between the thyroid cartilage and the cricoid ring, which is where the trachea is attached to.

    In your comment, Convectuoso, you mention my penchant for performing thoracostomies on most of my patients. Yep, too true! Mainly because, once I have intubated a critically injured patient, any positive pressure will turn a simple pneumothorax into a tension. And that can be very difficult to diagnose in the back of a fast moving ambulance. Therefore, intubation + significant trauma to the chest = thoracostomy.

    Glad you enjoy reading - I hope I continue to live up to your expectations.

  4. You're more than welcome Doc. Aye, it's certainly a catchy one isn't it? Cricothyroidotomy... no doubt it's even harder to perform than it is to spell!

    It does seem like tensions are rife with the majority of the incidents you attend (pun intended, haha!), so it seems like one of the main reason you guys (by which I mean BASICS doctors) are so indispensable. It still sickens me that the government would funnel £10,000 into a leadership questionnaire featuring Hitler for the Ambulance Service, but none whatsoever to something so essential to patients' safety as BASICS.

    Considering how busy it must already be as a consultant in A&E, I certainly salute your dedication to give up yet more of your time just to help people. You're a real life Batman! Albeit without the rubber costume (I hope!).

  5. Personally, I like to think of him more as Superman rather than Batman. This is possibly because I feel Batman has an edge of darkness about him and Superman is just plain good! So far I have managed to ensure he never goes out with his underwear over his jumpsuit though!

  6. LOL! Mrs RRD, If he ever does please post pics! LMAO!

  7. Mrs RRD - having (as you probably know) met RRD on several occasions in the line of duty, I'd like to tell you that as soon as he gets on scene, the first thing he takes out the boot is his Superman underwear and cape - gets all dressed up - and then goes to work. :D
    Doc - I've just done my first ever Needle-Chest-Decompression - and even that was enough to get the adrenaline going. You just never know when you'll meet that elusive "first time"! If it ever does happen, I'd like to be the one there to assist!
    Keep up the good work!

  8. Hi, Chris. This WAS an RSI (rapid sequence induction, for non medics.) The issue here wasn't that I hadn't paralysed the patient; it was that fact that,despite paralysis, the jaw wouldn't open. I presume it was locked shut because of the trauma to the jaw when he fell face first onto the road.

  9. Very exciting, thanks for the continued writing!