Monday, 12 July 2010

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

Sunday, 4 July 2010

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.