Rope

I rush into the Department, pager in hand, and am swamped with people wanting to join me on another shout,  High Tower and New Boss are the chosen two, and we jog over to the car, the two of them jostling for the front seat.  There's a lot of joking around: with High Tower in the car I am not going to have the same acceleration as I would normally get.  New Boss is very excited at the chance of seeing some action on the streets.  I'm quiet; I know what we are going to, and I know the impact it will have on these two.

New Boss is in the front seat, holding on for dear life as I hit the road.  The two of them continue to joke about my driving skills, and about how different I am out here, compared to in the Department.

The rope hangs from the banisters: a mute reminder of what this man has done.  The screams from the back room echo around us as we determine what we already know: this man has managed to do what he wanted to.

We drive back to the Department, each lost in our own thoughts of what we have witnessed.

I have seen many hanging victims, and so have High Tower and New Boss.  But they had never been to the house before, and the sights and sounds at the scene of a violent death can never be explained, can never be shared with someone who has only ever dealt with the victims in the sterile, cold environment of a hospital resuscitation room.  And what they continue to see in their mind's eye will remain with them forever.

The rope.

Avoidance

I've been avoiding you, dear Constant Reader.  I look back, and see that the last time I ventured here was three months ago.  It's not that I haven't thought of you, nor that I haven't had anything to say, no jobs to post.  In fact, quite the contrary.  There are some that I want to tell you about, and some that I need to tell you about.  It's not even the dreaded writer's block.  Posts and stories rise unbidden into my mind, and ache to be transposed to the page.

But I can't.

My anonymity on this blog has always been paper-thin. Some comments have even refered to me by name, and I have rapidly removed them, or asked the commenter to edit them.   Those of you across the pond, or just in another part of the island, won't know me, and therefore won't know my patients.  But, let's be honest: anyone who works where I work knows who I am.  There aren't many of us around, and it only takes one or two jobs for the connection to be made.

I cannot have my patient's confidentiality breached.  That's an absolute.  There is no grey area.  Anyone who knows me (here we go again) will know how precious I value confidentiality.

If I tell you about the police officers who spun their car off the road, you will say, "ah yes, I remember them."  If I don't say they are police officers, the story is missing the part that makes the story worth telling.

If I tell you about the chap found hanging (and I will, but with anything patient-related taken out) you will remember reading about it in the local news, and that patient's confidentiality will have been breached.

So I sit here, musing over what I can, and what I cannot, say.  And I end up saying nothing.

But I still have the need.

So, dear CR, read on...

2.3 x 10!!

Oh my legs!! And other parts of my anatomy!!  I can barely stand, let alone walk up the stairs to my room.  But, as I lie here, a mass of knotted muscle, I can't help but smile at what I have achieved today.  And, I mustn't forget that MiniRRD was there too, struggling with the ups and downs, but mostly the ups, that today brought.  In fact, the downs were what we were both looking forward to, more than anything.

Brands Hatch Race Track is a killer.  I can say this with authority.  It is 2.3 miles of pain and effort.  How can most of it seem to be going up?  It felt like I was riding in a picture by M C. Escher.  You know, the one where the steps just keep going up and up, and yet still join in a circle.

Let me just take you through the first little bit of the circuit, just so you get a feel for what MiniRRD and I experienced today.

Come out of the pit lane and speed up, before a gentle incline slows you down as you go through the timing arch.  Turn sharply right and shoot down a VERY exhilarating hill (I reached a top speed of 39.6mph on this one), which finishes with such a steep climb that all your lovely momentum disappears in an instant, and you are back in the lowest gear and crawling up, in a fair amount of pain may I add.  Round the corner and a cheeky drop for a second or two before ... yes, you guessed it, a climb.  This time it's not at all steep; just a gentle climb that slowly but surely saps your strength, until you are gasping for breath, and barely able to turn the pedals (well, that's how I felt).  And so on.

But, and here's the bit that makes it all worthwhile, if you look at the title of this post you will see that I went round a total of 10 times!  Yes, I managed to conquer this gruesome course 10 times today.  And MiniRRD?  Well, he had to beat me, but only by one.

My main claim to fame for today?  My fastest time of 14 minutes was slower than anyone else's time on the track.  I did manage to pass one rider over the whole day.  My pleasure was short lived; just after I passed him, he wobbled and fell off!!

I'm off to have a hot bath, and a loooong sleep.  Oh no, wait.  I'm at work first thing in the morning.

Decisions

What a busy day I have had!!  On the shop floor all morning, meetings all afternoon, and now I am sitting in my office sorting out the multitude of emails that have built up over the week.  I decide that enough is enough - my family are all at home, and that is where I should be.  I power down my computer, get my coat and leave.  I need the loo, but decide that as it's only a short drive I would forgo the pleasure at work, and wait until I get home.

5 minutes from home my bluetooth phone rings.  Assuming it's MrsRRD, checking on my arrival ETA, I answer with a "Hi, Darling!!"  After all, who else would be ringing me?

Control are quite surprised at my friendliness, but it doesn't stop them from tasking me, to a pedestrian hit by a car, in MilesFromAnywhere Town.  They tell me that the crew are having difficulty with the airway.  I sheepishly begin to explain my forwardness, then give up and hit the blues and twos, and set off.

I find myself on the M25.  What on Earth am I doing here??  Fortunately, my faithful Sasha (the SatNav - don't you have a name for yours??) is just avoiding all the traffic on the small roads around MilesFromAnywhere Town, and I am grateful for the decision when I come off at the next junction, and see the tailbacks behind me, presumably from the accident I am now racing towards.  My bladder gently reminds me of the last decision I made before leaving work, and I shift uncomfortably in my seat.

I arrive on scene: well, the point at which Sasha tells me I am on scene.  Nothing.  Just queues of traffic.  I keep going, thinking that, if the patient has an airway problem, I cannot waste any time.  Fortunately, round the corner is a police roadblock, and I am swiftly directed around the police van to the waiting team of ambulance crews.

This girl is in a bad way.  She is lying on her back, blood around her mouth, a paramedic bagging her.  I rush over and assess the situation:

Airway: well, at this moment in time she doesn't seem to have one.  There is very little of the precious oxygen getting into her lungs, despite the efforts of the crew.

Breathing - wait a minute, you all know the drill now.  If there is a problem with airway, it needs sorting, and straight away.

I unzip my trusty Thomas Pack and reach for my intubation pouch, grab a laryngoscope and prepare to have a look.  I can't see much, as there is so much blood in the mouth.  I use the suction proffered me, without me even asking (good crew, know what I need before I do) and clear the view.  She coughs and gags as I do, and I breathe a small sigh of relief - at least there are still some signs of life.  I have a good view of the cords, and a tube in my hands.  Despite the fact that I have given her no drugs at all at this stage, I decide that she has been starved of oxygen long enough, and I am not going to delay any further.  The tube goes through the cords, and she coughs and gags plenty more.  That's not good for raised intracranial pressure, what you get when you have a serious head injury, but, then again, nor is not being able to breathe.  

I quickly grab some sedation and paralysing agent and do what I would normally have done prior to intubating the patient.  She is now still, and we are able to ventilate her with ease.  

Phew!!  On to the next stage.

Breathing:  Well, at least we are now doing that for her.  I think about my next decision - do I perform bilateral thoracostomies?  For those who don't know what I am talking about, a brief synopsis.  Those who do can skip to the next paragraph.  When there is chest trauma, the lining around the lung can be punctured, allowing the entry of air from the lung into the space between lung and ribcage - a pneumothorax.  If someone is pumping air into your lungs, as I am now doing with this lady, the air is also pumped out of the hole in the lung and its lining, and fill up the space between the chest wall and the lung, compressing first that lung, then the heart and other lung, leading to fairly rapid death - a tension pneumothorax.  By making a small (well I think it's small, you might disagree) hole in the chest wall with a scalpel, I can equalise the pressure, and stop the heart and lungs being compressed into inactivity.

So, back to the story. I have to decide about how this girl's breathing will be best managed.  She has a tube in place, and we are breathing for her.  Her chest rises symetrically on both sides, and she has normal breath sounds.  However, she did have a lot of blood in her airway, and her oxygen saturations are in the low 80's, instead of the 100% I would expect / like to see.  I have a careful feel - I cannot see any signs of chest injury, and there doesn't appear to be any broken ribs or surgical emphysema.  Surgical emphysema is the result of having air in the tissues of the chest wall, and feels like cornflakes under the skin (honest).  This would be a certain indication that she had a lung injury requiring a thoracostomy.  But, no corn flakes can be felt.  Also, her blood pressure is good, and, if she had a tension pneumothorax, her heart would be compressed so much that her blood pressure would be very low indeed.  And it's not.

So, decision made: I will not cut this girl's chest, and watch carefully for any signs of deterioration.  If she does deteriorate, I will make the incisions.

Next, circulation.  Well, her blood pressure is high, and her pulse rate is high.  A high pulse rate can be due to blood loss, or lack of oxygen.  But, then again, the high pulse rate and high blood pressure could equally be due to having a tube stuck down your throat without an anaesthetic.  I decide to give her more sedation, and the pulse rate and blood pressure stabilise to normal.

And now I have the big decision - where are we going.  I look around me.  We are really in the middle of nowhere.  She definitely needs a Major Trauma Centre, but how far is that?  Blank looks from the crews and the police when I ask them driving time to MTC.  One of the police runs off to plug the address into his version of Sasha, and returns a few minures later with the news:  we are an hour away.  On blue lights you might knock off 10 minutes or so.  50 minutes does not sit comfortably with me, especially with oxygen saturations like she has.

What about helicopter?  There is one available.  I ask them to lift, while we look at getting her packaged and in the ambulance.  I ask for an update of how long the flying time to us will be, and the answer comes back: 30 minutes.  Where the hell am I, that it will take half an hour to get here by helicopter??  Turns out that the only helicopter available is in Cambridge.  Fair enough.  I leave them running while I consider my options.

Closest hospital by road, my old stomping ground: 15 minutes
My own hospital by road : 15 - 20 minutes
Major Trauma Centre: by road: 50 - 60 minutes
Major Trauma Centre by air: 30 minutes for helicopter to arrive, 10 - 15 minutes to hand over and load, 20 - 25 minutes to fly back (they will go back to Cambridge)

I make my decision: we are going to my hospital, with the knowledge that we can stabilise and continue our journey to the Major Trauma, probably within an hour or so of arriving there.

I get into the ambulance, my full bladder reminding me that my first choice of the evening wasn't so hot.  I hope and pray that the rest of them turn out to be better ones.

What's in a Name?

I am angry!  No, not really angry.  More frustrated than angry, to be honest.  I've been shouting at the TV for the last 30 minutes.  Fortunately, I like my TV too much to throw anything at it.

So, what programme has insensed me so much?  Well, MrsRRD and I sat down to watch "Emergency" with Angela Griffin.  This is an excellent programme, where the star of Waterloo Road follows the ambulance crews of the West Midlands, and does a damn good job of portraying the highs and lows of the work the crews do.

This evening's programme, recorded a few weeks ago, had good old Angela shadowing the CARE team as they went about their business.  The CARE team are a group of volunteer doctors, nurses and paramedics, who are called by the ambulance service to provide more advanced medical care to the victims of serious accidents and assaults, and to patients with severe, life threatening illness, at the roadside or in their own homes.  Sound familiar?  Yep, CARE is the West Midlands arm of BASICS, just like BASICS-London are the London group.  It's just that our name leaves nothing to the imagination, as to who we really are.

So, what great publicity for BASICS.  You'd have thought, wouldn't you?  But, despite the BASICS logo, and the word BASICS being visible on all of the team's jackets, BASICS wasn't mentioned.  Not even once.  So, folks, according to this programme, the CARE team are unique.  No-one else like them in the country.  All that possible publicity for BASICS, all gone to waste.  Not a dickey-bird.

Well, dear Constant Reader, you know who the BASICS team are.  There's probably one in your neighbourhood.  They may be called CARE, or MAGPAS, perhaps LIVES or SAVES, maybe even BEARS or NARS. But, whatever they are called, they are all BASICS doctors, nurses and paramedics.  They are sitting at home right now, probably thinking about tucking themselves in for the night, all knowing that their sleep may be interupted tonight, at 3am, when someone goes off the road, or is stabbed, or falls off a roof.

Remember us, and please, spread the word!

Only Joking!

There's not a whole heap of blood around, considering he has a gaping wound in his neck.  Probably because he had crawled half a mile or so before anyone had spotted him, and lost what he was going to lose someplace else.  He's very, very drunk!!  He tells me he was having a lark with some youngsters in the town when one turned nasty at some comment he had made, some funny joke that went wrong.  The joke led to him having a bottle shoved in his neck, and a beating he will remember far longer than any of the punchlines he has stored up.

He is refusing treatment, and six burly policemen have cuffed his wrists behind him, and strapped his legs together to stop him lashing out.  He is struggling hard against his bindings, and the cuffs are digging in to his wrists, leaving angry marks.

I lean in close.  "Jimmy, do you want those cuffs taken off?"  He nods.  "Then stop p***ing around and let us look after you."  He calms for a moment and looks at me.  "You get one chance, and one chance only.  I'm not joking around here.  You muck about once, and these cuffs are going back on and staying on."

The cuffs come off, and the police crowd round nervously.  He thanks me for getting the cuffs off, and I start looking at his neck wound.  "I need a big torch!" I say.  "I've got one, in me pants!  Wanna see?" replies Jimmy. 

Anyone got another bottle?

For All The Wrong Reasons

It's a quiet day in A&E.  Not all that unusual; after all, a lot of people are on holiday in August, so the population has gone down.  The emergency 'phone rings in the Department.  It's for me! A call to the M1, where a car has rolled multiple times.  The occupants are not badly injured, Despatch tells me, but, as there is only one ambulance available, I may be able to help by triaging them away from hospital, thereby saving a vehicle or two.  This is an occasional use of my time, and I am always happy to oblige.

I call out to the staff that there is an opportunity to accompany me.  There is a scurry of activity, as Baldy and Newby fight for the right to join me.

"Steady on, lads!" I say.  "It's not that exciting a job!  No point getting all worked up."

"We know," replies Baldy.  "It's not the job, it's the possibility of being mentioned in your blog!"

*sighs*

Surreal

I lead a surreal existence, I think to myself at 04:45, lying next to MrsRRD, sleeping soundly.  Only an hour ago I was asleep too, after a long day at work, and a relaxing(!) evening with the family.  And yet, 45 minutes ago I was in a dingy alleyway, cutting across a man's sternum in a vain attempt to save his life after he had been stabbed in a robbery gone so fatally wrong. 5 minutes after that I was holding his heart in my hand, stitching up the wound in the left ventricle, knowing that no amount of surgery was going to save him.

And now, only 30 minutes after I have pronounced life extinct, I am back in bed, chasing sleep once again, knowing that, for now at least, it will be just beyond my reach. 

Watching

The car is on its roof, having collided with another vehicle and gone off the road, onto a tree. Three youngsters are lying on the ground around the car, one trapped by his legs, all shouting out, but it is the fourth that holds all our attention. He is quiet and almost still, perhaps a flicker of one arm, trapped by the wreckage and the tree.

We can't get to him. His left arm is accessible, and a paramedic has already cannulated him. His head is pressed against the door, and we can't get to his airway. The dashboard has come forward, and is tight against his chest. We watch his chest rise and fall, slower and slower. There is no way to get him out. We will need to roll the car over if we have any chance at all to extricate him, and we can't do that at the moment, because of the chap whose legs are still entwined in the wreckage.

There is nothing we can do, except watch.

His breathing slows.

Stops.

Challenge

I told one of my best friends that I was planning to do the Brands Hatch Cyclothon in September.  After he picked himself up off the floor, he explained the humour of the situation.  You see, Brands Hatch is not the flattest of race-tracks.  In fact, it's rather hilly.  My friend showed me a youtube video of the track.  It's very scary.

And now he's thrown me a challenge: get round the track once without getting off my bike, and he will donate £100 towards BASICS.  That seems worth it.  Not so bad, really.  I accepted the challenge, and went out on my bike to find some suitable hills to ride up.  I found one.  I couldn't get up it.  Hmmm.  Think I need some more practice.

Avoidance

It's late, as usual.  I am on my way back home, after having been called in for a paediatric trauma - the patient, a 13 year old boy, was bigger than me, and virtually unharmed.  I am driving along the motorway, looking forward to bed, when I see, right in front of me in the fast and middle lanes, two cars, both stationary, one pointing the wrong way.  Brakes, swerve, stop.  I can see one of the drivers, but the other car, the one with it's bonnet towards me, is empty.

I flick my blue lights on, park appropriately to warn other drivers, and get out.  I don my flight suit, so that I am safe, and approach the driver.  He is unharmed, somewhat shaken, and rather worried about his cargo of china that he has in his car.  I help him across the motorway, where the other driver is sitting on the hard shoulder, unharmed but somewhat shaken.

I call 999 and let the police know what has happened, and tell them that I am in a blue-light vehicle, and that I have parked appropriately, in order that other drivers can see.  The police officer I am speaking to tells me that is inappropriate, and that, as long as there are no injured parties, I should continue on my journey.  I think this is somewhat odd, but decide to do as I am told.

Making my way back across the motorway, I watch in horror as a car hurtles towards to the accident scene at breakneck speed, swerving all over the road and coming to a very unsteady stop, mere inches from the cars.  I think about what might have happened had my blue lights not been visible, and know that I would have been called back.

I'm staying.

It's A Long Way...

"You want me to go where??" I ask Control.  "But, that's miles away, through all the Sunday traffic. Where's the helicopter?"  They tell me, and I wince: not quite next door to me, but, with a prevailing wind I could probably spit on the rotors from where I was sitting, comfortably ensconced with the family and a good Disney film on the box.

Off to the car (now I'll never know what happens in the film) and off I go.  As I turn on the engine, my fuel guage gently reminds me that I meant to fill up the last time I was out, but thought I would wait until the next time.  Hmmm, may be a problem.  My car eats fuel the way I drive it.  Well, at least I have my wallet in the car, so that I won't be completely stranded.

The traffic isn't as bad as I thought it would be: it is far worse.  I spend most of the journey on the wrong side of the road, as cars come hurtling towards me, then swerve around me at the last moment.

Up ahead, I can see the lights of the ambulance, fire tender and police.  Nearly there.  The traffic has slowed to a crawl, not unsurprisingly, this close to the accident, and I drum my fingers impatiently on the steering wheel, changing the tone of my sirens every few moments, trying to persuade the drivers to give me just a few more inches.

My mobile rings: it's Ambulance Control, standing me down.  The patient was initially very agitated, but has settled down, and the crew are happy to transport him to hospital.  I suggest that they wait a few minutes, considering they have made me miss my film, and I roll on scene.

He is in the back of the ambulance, having been cut out of his car.  His daughter, sitting next to him, tells me he had gone all vacant, just before colliding with the car in front.  She is unharmed, just very shaky, and he is calm and coherent.  He remembers what happened with a clarity I don't often get from patients.  He remembers driving his daughter to a friend, when, all of a sudden, he couldn't speak.  Then, he remembers his right hand dropping to his lap, lifeless, and his right foot become heavy and glued to the accelerator.  He recalls pulling the steering wheel over to the left, hard, so that, when he struck the vehicle in front, it was with his side of the car, not his daughter's. 

I look at his drooping face, his lopsided attempt at a smile, and hear his slurred speech.  He asks me if he has had a stroke, and I nod.  He sighs.  It's going to be a very long journey for him...

Next Venture

When I wrote about the BUPA 10K run, I mentioned that there was something else on the horizon, and that I would let you know soon.  Well, here it is.  Those eagle-eyed Readers will already have noticed that I have been doing a lot of cycling recently.  Also, the panel on the right now says "Training for the Brands Hatch Cyclothon."  Yes, yours truly, along with MiniRRD and 2 others, will be cycling round Brands Hatch for 8 gruelling hours!!

I love cycling, far more than I like running.  I decided I needed a new bike, especially if I was going to be doing this Cyclothon.  I went to my local bike shop and bought one.  Bear in mind that I know precious little about bikes.  I wanted to ride home on it, so off I went.

1 minute later, the back tyre was flat.  I walked back to the shop, and they put in a valve.  The fact that it didn't have one originally did cross my mind, but hey, anyone can make a mistake!!  I decided to ride home again.

2 minutes later, the back tyre was flat.  I walked back to the shop, where they refunded my money.

I went to a proper shop, where they know what they are doing.  I test rode 3 or 4 bikes, and found the perfect bike for me.  It's a red one!!  I decided not to ride it home, as we live a good 10 miles away...

Later that evening, like an impatient schoolboy ("can I ride my bike now?  Oh please, oh please!!) I waited for the rain to stop, then went for a ride on my brand new (red) bike.

1 minute later I fell off.  I scraped my left elbow really bad, and my knuckles on my right hand.  Undeterred, I got back on and carried on my journey, blood dripping off my elbow and my hand.

20 minutes later I got a puncture.  And then it started raining.  And then my elbow started hurting.  I called MrsRRD, and she came and collected me.

I'm really looking forward to my Cyclothon...

Difficult

You may have noticed I haven't written for a while.  There is a good reason for this.  I have been to a job so difficult, one of the hardest I have done in my 10 years as a pre-hospital care doctor, and yet one so unique that to write about it in any way would breach the confidentiality that is so important to all.  The family, with whom I spent such a long time at the hospital, don't want anyone to know about what really happened at the house, and, to be honest, I don't blame them.

So, where do I go with this?  How do I move forward, writing about the "simple" jobs, those that don't touch my heart as this one has?  I'm not sure, to be honest.  I worry that the images of what I have seen will seep through into my posts about the "ordinary", as they have been seeping into my waking and sleeping thoughts.  MrsRRD, as always, has been a tower of strength; understanding what only she can.  And, holding my children, one at a time or all together, is a balm around my heart.

And, if this is how I feel, what must the family be feeling?  I cannot begin to comprehend how any family can rebuild after such an event as this.  And yet rebuild they must.  They have to go about their daily lives; school, work, shopping, living, even though their lives have been shattered.

I know this all seems so cryptic to you, dear Constant Reader.  Thank you for reading, thank you for letting me offload to you, in the only way I can.

Alice's Bucket List

Just go and have a look at this brave young lady's blog.  Make sure you have some tissues ready!!

Excuse me, but it has suddenly got very dusty in here...

Done It!!

Well, it's all over. Except, that is, for the pain, the tiredness, and the wonderful sense of achievement. There is something very special about crossing the finish line of a your first 10K. The whole day was very exciting. We woke up early, and had a light breakfast, then met up with the rest of the team at Green Park. I cannot begin to tell you how it feels to be standing in a sea of people, all waiting to set off.

Scissors was by my side the whole time. He has run 8 marathons, so this wasn't going to be a challenge for him. He kept shouting at the crowd, urging them all to cheer us on - very amusing!

MrsRRD is there, at the 2km mark, along with the rest of the support team. I probably looked quite fresh at that time! Not so later on, as I wind my way through the streets of London, onwards, ever onwards.

And then I reached the 8K mark - uncharted territory for me. The pain in the hips was slowing me down, and my leg felt like jelly. Scissors turned to me (running backwards as he did - show-off):

"Do you want to spend a whole year, until the next BUPA 10K, wishing you had got in under your target (1 hour 20 minutes), or do you wish to spend the next year being pleased you did?", he asked me. Hmmm, tough one. My brain told my legs to speed up. My legs told my brain to sod off, then grudgingly stepped up the pace.

I have a GPS watch. I bought it with money from my birthday (yes, I still get money for my birthday, what of it??) It tells me exactly how fast I am going, how far I have gone, what my pace is. I have been using it to plan my race, and to optimise my training. I charged it up, so that it would be ready for race day, so that I could keep to just under 8-minute kilometres.

I left it at home.

So, I was dependent on Scissors to keep me on pace. If he is telling me I need to pick it up, then pick it up I will. And I did. Somehow, I managed to find those extra few muscle fibres, the ones that hadn't given up the ghost, and put them to work. I pass MrsRRD again, pushing myself harder and harder.

And there it is in the distance - the finish line! I have 400m to go, and I start to sprint, with Scissors muttering, "There's no grey - it's either black or white." No idea what he meant by that, but the sight of the finish line getting closer and closer spurned me on, faster and faster.

And I'm through!! I turn to Scissors, gave him a big hug, then asked the question? Was I in or was I out? He looks at his watch, and tells me the news: 1 hour 16 minutes 1 second!

And then, in true form, we meet everyone else, and have a picnic in Green Park.

And what of Princess RRD and Ginger? Did I beat them? No. 1 hour 5 minutes. No training. Nothing. Big Neph? 57 minutes. No training. Ah the joys of being young.

What's next? Something very exciting, but I'll keep that for another day!

Thank you to all of you for all your support. Without you watching me, I would never have managed this.

Race Day!

Well, the day is finally upon us.  After almost 140km of training, tomorrow I am running for BASICS.  I feel quite proud, to be honest.  I have often seen on the television the runners as they cross the line, and tomorrow that will be us!

I'm supposed to have had an early night.  It's nearly midnight here, and I'm not quite ready for bed.  After all, life doesn't stop at Chez RRD, not even for a 10k run.  There are children to get to and from parties, wallets to find (mine), and hair to be trimmed (mine).

And, of course, the preparations for the race day itself.  Ginger, one of Princess RRD's friends who is also running tomorrow, is staying over tonight, and the girls had a very giggly time.  They spent the afternoon decorating the back of their running shorts with the BASICS logo.  Oh, and the Union Jack on the front!!  Mrs RRD has been making the food for the after-run picnic.  Lots of food!!  Camera batteries have been charged, so I will be posting the evidence here tomorrow evening...

Shrink will not be running tomorrow.  An over-exuberent dance session over the weekend has left him hobbling on an injured ankle, so he will have to watch from the sidelines.  Scissors, a veteran marathon runner, has elected to keep me company all the way.  So, his time won't be any good, either!!

I have set things up so that any of you can follow my progress, inch by painful inch.  If you go to www.sportstracklive.com, and search for me, rapidresponsedoc, you should be able to find a live, as it happens, track.  My aim is to keep my speed as close to 8 minutes per kilometre - see how well I do and cheer me on.  Start time will be about 11:20, UK time.

Right, I am off to bed.  See you at the starting post!!!

Death

I see death every day.  Not many people can say that.  Not many people understand what it is like to be confronted with the fact of one's own mortality so often.  It's part of what I do, it goes with the territory.  That's not to say I don't get affected.  I believe if you don't get affected, then you are in the wrong profession, and it is time to move on.  But that makes it hard.  Hard to sit and watch the widow, the son, the father, after you have given them the worst of all possible news.

Death comes in many forms.  There is the expected death, often a blessed relief for all, patient included, perhaps after a painful, drawn-out illness.  There is the unexpected death, home just two weeks following a successful heart bypass, then found lifeless in bed one morning.  There are the deaths from trauma, car accidents or stabbings.

And then there are those that deal the fateful blow themselves.  Those that I get called to are invariably the more violent: the blade, the rope, the train, the 5 storey fall.  These cases affect me more than anything.  They leave me numb.  That anyone could want to end their life is one thing - to end it in such an aggressive manner is another.  They drain me, both the the act itself and the intent behind the act.  They often leave me empty and low for days after.

I had two today.

Countdown

In two weeks time exactly, I will be in agony, having successfully completed the BUPA 10k.  my legs will be on fire, and I will be falling asleep on my feet.  My time?  Only time will tell.  Less than 1 hour 20 minutes will make me happy.  Getting all the way round before I collapse in a heap will make me happy!!

And what about the sponsorship?  Well, so far, with two weeks to go, I have managed to get just over £1000 of pledges!!  How much will it be before the end?  That's up to all of you...

Thank you to everyone who has sponsored me and supported me.  And thanks to all who are going to before the 30th May.

The Fallen - Take 2

My cat sleeps on our bedroom floor, in a bag.  We try to discourage him, mainly because being woken up at 4:30am is too much like having a new baby, and not at all conducive to happy living.  But he likes his bag, and he likes our floor.

04:30, and the gentle miaow wakes both of us from slumber.  It's MrsRRD's turn, and she disappears downstairs to open a pouch, the diminishing tinkling of the cat's bell signalling the fact he has chased after her.

04:35, and the insistent ringing of my phone drags me back from sleep once again.  Can I attend a man who has fallen out of a 4th storey window, and now has a Glasgow Coma Score of 3.  After falling out of a 4th floor window, I would be surprised if he was walking around uninjured!!  I take the details while I pull on some clothes (socks!!)

MrsRRD is a bit surprised to see me downstairs and dressed, but quickly kisses me goodbye, and I rush to my car.

Sasha, my Sat Nav, seems to be having trouble waking up this morning - when I look at the overall map of where I am going, it shows me going round 3 sides of a square.  I set off along what looks like the shortest distance.  The no right turn at the end of the road doesn't stop me, but does explain somewhat why Sasha was sulking.

The ambulance is moving!  They are off without me.  The police look surprised to see me, and hesitate before lifting the police tapes to let me through.  The Station Manager bangs on the side of the ambulance and they stop to let me on and see the patient.

He is around 50 years old.  The crew had been called to a person who was threatening to jump out of a window in a block of flats. They were forced to watch him as he fell, despite the efforts of the police negotiator.  It cannot be nice watching something like that - usually we get there after the incident has occurred.  He's in a bad way, with signs of a serious head injury.  There is no doubt that he needs tubing and ventilating, and I look for a vein to put a line in.  There is nothing.  There are marks of intravenous drug use, which has caused all of his veins to become damaged.  I look at the veins in his neck - even these are looking difficult to cannulate.  The paramedic suggests we go for a needle straight into the bone of the leg.  Sounds bad, doesn't it.  But, an intraosseous needle, as we like to call them, is a great way of getting drugs and fluids into a patient when there are no other veins available.  We have what is essentially a cordless electric screwdriver, which we use to drive the needle into the tibia, just below the knee joint. I ask the para how many he has done.  He tells me that he has so far inserted three.  I tell him to make it four.  The shaking is barely perceptible, as he drives the needle home.

Just as I am unzipping my intubation kit, the door of the ambulance opens, and there are two more men in orange jumpsuits.  Great!! The HEMS team have arrived.  We have a little chat about where we are and what has occurred, and I maintain my authority over the case (I got there first) as I tell the HEMS medic that I will be intubating the patient.  She suggests that we regroup, with patient, outside the ambulance, as there isn't enough room for everyone.  No, not now you are here!!

As we are wheeling the patient back outside, I hear the grumbles of the ambulance crew, suggesting that it might have been better to have just gone.  I hush them, and we get to work, setting up a formal kit dump with everything we do need, and everything we might need if there are any untoward circumstances.

I have written about this before: my way of just opening my bag, grabbing what I need and getting on with it contrasts starkly with the HEMS way, where everything is laid out neatly and ticked off a checklist before proceeding.  Which is the right way?  Well, my way works, but only for me.  I can grab what I need, whenever I need it.  I am aware of the dangers of what I am doing, and mentally prepare myself.  The HEMS team are a team:  there will be different doctors working with each paramedic.  Nothing can be left to chance.  Everything has to be prescriptive.

Anyway, back to this patient.  He is now being given an anaesthetic, to facilitate me inserting a tube into his windpipe.  He's a grade 1 intubation, which means I can see the windpipe through the vocal cords so easily that I could, if I really wanted to, drop the tube in from 100 metres away.  But I refrain - after all, there are a lot of people watching, and I don't want to show off too much.  My one consolation is I am able to refuse the bougie, a device to make intubation easier, despite the fact that the HEMS paramedic tries to insist - after all, it is standard procedure for the HEMS team to use one for every intubation.

The tube goes in easily, and we package the patient for transfer to the Major Trauma Centre.  The HEMS doc is more than happy to travel with the patient, so I formally hand him over to her, and leave her to it.  Before getting back into my car I have a quiet word with the paramedic, suggesting that, despite the delay, the patient will definitely be better off travelling tubed rather than untubed.  He reluctantly agrees.

When I get home, my cat is sitting on the doorstep, waiting for me.  All is forgiven!

The Fallen

I am sitting quietly in a cafe with MrsRRD, enjoying a few precious moments between dropping a MicroRRD off at a friend and picking another MicroRRD up (we have three of these, along with a MiniRRD and a Princess RRD, remember), when my phone rings, asking me to attend a call.  A 50 year old man has fallen down some stairs, and is unconscious and fitting.   With only one car between us, MrsRRD is forced to endure a heartstopping journey on blues to the patient (she LOVES it really) and then she drives off, after leaving me her oyster card, so that I can get back from the Major Trauma Centre that I am sure I will be going to, based on what I have been told.  Unusually, the story is as given, and I rapidly make an assessment:

The man is lying on his back, feet on the bottom step, head in the kitchen.  There is very little room to work, and I have to squeeze past the paramedics already in attendance.  They tell me he has been very agitated since they arrived, and that the son has told them that he watched his father miss the last few steps and fall into the kitchen, off the hallway, and then proceed to fit.

I take a look at Tom, kneeling on the kitchen floor in my jump suit.  His airway is maintained, despite him being on his back, and his breathing is good.  There is no sign of blood loss, and his pulse is regular and strong.  His Glasgow Coma Score at this moment is 11 out of 15, made up of eyes 4 out of 4 (they are open spontaneously), verbal 2 out of 5 (he is moaning incoherently) and motor 5 out of 6 (he is moving purposefully, but not obeying any commands).  That's not bad for someone who has hit his head, and is on the cusp of whether I intubate and ventilate on scene or not.

The crew are very keen for me to get on and intubate their patient.  They are worried about how they are going to get Tom out of the house.  He won't lie still, and they cannot control his head movements.  If he has sustained a spinal injury he is in danger of making it a lot worse.

I begin to get the kit ready for an intubation, hoping that Tom will begin to come round a bit more.  After all, he has had a fit, and after someone has fitted they are usually a bit confused and out of it, what is known as post-ictal.  I ask Tom's son if his father has ever had a fit before.  He tells me that this is his first.

There is something about Tom's son that doesn't seem to fit (sorry about the pun).  He seems a little too calm, considering the fact that his father is lying on the floor, semiconscious.  I think how I might be reacting if it were my dad, and he is just standing there, writing down his details for the paramedics to take with to the hospital.

I wonder for a few fleeting seconds whether he had pushed his dad down the stairs (far too many crime novels to be good for me!) and then it hits me.

"Does your dad drink much?" I ask him gently.  He nods, and tells me that his dad is an alcoholic, drinking about three bottles of wine a day.  He had been trying to cut down, and hadn't drunk any alcohol for 2 days.  This all made sense.  When someone comes off alcohol too quickly, especially if they are a long-term heavy drinker like Tom, they are very prone to fit.  I can picture Tom coming down the stairs, and having a fit just as he reaches the bottom step, falling forwards, unable to stop his fall.

I am directed back to Tom, who is trying to sit up.

"Where am I?" he asks, querulously.  We explain what has happened.  He does not appear to understand, but is far more awake than he was when we first arrived.  I look to the crew for confirmation that they are happy to take him awake to the nearest hospital.  They signal that they are.  We carefully get Tom on to the ambulance trolley, and in to the back of the waiting ambulance.

I look around, remembering: I have no car.  I jump in the back of the ambulance.  "We'll be fine without you," chirps one of the crew helpfully.  I suggest that, while they might be fine, I would rather be taken to the local hospital to be picked up, rather than wait outside Tom's house.

As we speed up to the doors of the A&E, I see my car drive sedately in behind us.  MrsRRD has my coffee.  Now, that's service!

Training Update

Well!!  It's all going swimmingly!  Those of you keeping track may have noticed that I am getting into my stride now.  I am starting to run and cycle every couple of days.  I have managed to run 5.5km non-stop in 40 minutes, and I'm really proud of how I am getting on.

Or, I was until I made the mistake of looking at some of last year's finish times - just to see, you understand.  You just enter a runner number, and their time is displayed.  There are thousands of numbers to choose from, so I will start with runner 1000.  Hmmm.  10km in 44 minutes.  That doesn't sound promising.  Must be a good runner.  Try another one... Runner 179.  Erm, 10km in 37 minutes.  How about runner 2659?  Nope, 48 minutes.

I'm going to be last, behind the granny on her Zimmer frame.

Tachycardia

He lies there on the ambulance trolley, waxy skin, pale, tachycardic.  His pulse rate way above normal, a sure sign of blood loss.  I don't need his tachycardia to tell me that: the pools of blood on the floor of the ambulance is sign enough.  I sit next to the trolley, my hand pressed firmly against the pad applied to his mangled limb, but it seems to do little to stem the flow of blood.

His eyes roll up, and Para-Girl calls to him.  His eyelids flutter, and he is with us once again.  But for how much longer?  His skin is drenched in sweat, and yet his body feels alabaster-cold. We are losing him, and we know it.  I tinker with the intravenous fluid, but know that what he needs is blood.  I have already called ahead to the hospital to tell them to have some ready for when we get there, but will he last the journey?

As we come off the motorway, and slow to a crawl behind the selfish drivers, who want their lane and will not even relinquish it for us, I want to jump out of the ambulance, run up to the drivers and thrust my blood-stained hands against their windows.  But I sit there, pressing harder, while Para-Girl, almost as pale as our patient, mouths something unintelligible to me.  I know what she is saying, that we are not going to make it.

G-Man, our driver tonight, hunts down the spaces like a heat-seeking missile, and we are moving once again.  As we approach the last few minutes I grasp our patient's wrist, feeling in vain for a pulse.  He is hanging on by a thread, as we storm up the ambulance ramp, to the waiting Trauma Team, to bags of blood, and to a life snatched from the jaws of death.

The Phone Call

What a lovely day! We are all very bubbly, despite the lateness of the hour, as we drive home. I've spent the day with Besty, Mad Dog, our wives and children. We have eaten too much, spent too long in the sun, even played some rugby with the kids, and now it's off to Chez RRD, and then to pack the kids off to bed.

My phone is ringing. We are in Mrs RRD's car, so the Bluetooth remains inoperable, and by the time I have wrested it out of my pocket, and passed it to Mrs RRD, it has stopped. We wait for a few seconds, and sure enough my other phone starts its insistent ringing. I am just parking up, so grab the phone and answer the call from Ambulance Control. A stabbing victim awaits me. I open the door to the house and usher the waiting hordes in. Mini RRD keeps asking me what the call is - I know that if Mrs RRD knows I am on the way to a stabbing she will worry, so I blank him, and rush out to my waiting car.

Damn! I have been out in the garden all day, and when I slip off my trainers to change into my boots, the sight of my naked feet is a reminder that I haven't got any socks on. Oh well, no time to waste. They'll just have to rub a bit.

I arrive at the address I have been given. It's all very dark. I can see a few police cars (phew!) and an ambulance, but there are no blue flashing lights, and, while there are quite a few people milling around, none of them are in uniform. Hmmm. It's not just Mrs RRD that is worried this time. I am the first to admit that I am a coward. I will avoid danger, and never walk into a difficult situation.

So, I could sit here, and wait for someone to come and get me. But that does seem a little silly. So, I put my blues on, and sit and wait for someone to pop their head out of the back of the ambulance, and beckon me in. It was only a few seconds, but I wasn't getting out of my car until I knew where I was going.

There are quite a few people in the ambulance. There are two ambulance crew, and a paramedic off of the car. There are two police officers. There is Dave - seeing as he is the one lying on the ambulance trolly, his clothes soaked in blood, I thought he might be my patient. It wasn't all that obvious, as he was on the phone! Not many people who need my attention at midnight are chatting away on the phone, you see. But Dave was.

"Hello, Dave! I'm RRD, a doctor."

"F*** off! I'm on the phone!" replied Dave.

"Yes, I can see that, but I can also see you are bleeding, and in need of medical attention" I countered, helpfully.

"When I have completed this conversation with my dear mother, then I will be happy for you to attend to my chest wound, kind Sir". Or words to that effect.

We all wait patiently, while Dave relates the evening's events to his mother, before dealing with the very well spoken patient.

I do love being appreciated!

Last Passage

They come out in their droves: the young and the old, in dressing gowns and slippers. They have their mobile phones and their cameras, all the better to record this moment.  Held back by the police tapes, they crane their necks, anxious to see all they can.

I kneel down gingerly by the bonnet of the lorry, and peer beneath. He is lying there, his head resting by the wheel that has run him over.  He is still, no signs of life.  I slide under the lorry, taking heed of the blocks that have been placed there by the fire team, raising it the few centimetres I need to be able to reach him.   My hand reaches out, and I feel his neck.  No pulse beats beneath his skin.  I place my stethoscope in my ears, and press the bell against his chest.  No heartbeat, no respiratory sounds.  I slide out, and shake my head at the paramedics, police and fire crew waiting for my verdict.

He needs to be moved, from under the lorry and into the waiting ambulance, for his last journey.  The crowds remind me of spectators in a Roman Colosseum, baying for blood.  I don't want to be the one to provide them their sport.  I don't want him to be the object of their scrutiny.  I direct the fire crews to grab some tarpaulins and hold them up as screens against prying eyes, as we gently, reverently draw him out from underneath the lorry, place him on the ambulance trolley, and wheel him into the back of the waiting ambulance.  Behind closed doors, we complete our paperwork, before arranging for him to be transferred away from here.

As I leave the ambulance, as I grab my bag from the ground and walk slowly back to my car beyond the police line, I am afforded no such privacy.  The crowds, denied what they have come for, call to me, begging for whatever scraps of information they can get.  I shut myself in the relative safety of my car, and drive home.

Excuses

Some of you eagle-eyed readers may have noticed that my training has dropped dramatically.  Here are my excuses, one of which may be true.  See if you can spot which one...

1.  My phone has stopped working, so I have been unable to upload any of my training episodes.

2.  I have been too busy at work.

3.  My trainers (sneakers, for you on the other side of the pond) don't fit any more, and I haven't had the time to get a new pair.

4.  I decided I would have an unfair advantage over the other runners, so I should stop and give them a chance.

5.  I have had man-flu.

6.  I broke my leg.

7.  I broke someone else's leg.

8.  I've been on Jury Service.

9.  It's been too cold / wet / hot / snowy to run.

Yes, you guessed it, number 5.  Seriously, it's no fun having man-flu.  Everyone takes the Mickey, and you still feel as sick as a dog!  So, not only are you suffering, you get no sympathy either.  And, being medical as I am, I know all about the dangers of exercising while you are ill.  You can get myocarditis and everything!!  Not pleasant.  So, I've been taking it easy for the past week or so.  I am sure it all started with my hepatitis jab.  There was definite blood, and a very big bruise, that's still there a week later.

But anyway, today I decided that enough was enough!  I decided to start off nice and easy, with a gentle bike ride in the park with Mrs RRD and one of my Micro's.  Checking my pulse every few hundred yards for any signs of irregularity, I soldiered on through the shortness of breath, and it felt good!!  So good that, when I returned home I decided to go for a run afterwards.

Big mistake!!  Even a very gentle run (overtaken by a little old lady and her Zimmer) left me gasping for breath, and aching all over.  Still, I'm back on track, if a little far behind everyone else.

Please make this worth my while, by pressing that tempting "Donate" button on the right of the screen.  Whatever you can afford, every little helps...

Thank You To JB

I have been told about a group of 15 people who have clubbed together to raise some money for BASICS-London.  They each changed their name by Deed Poll to a famous Formula 1 driver, then raced round a track for a few hours, all to help those in need of the services we provide.

So, a big thank you to Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button, Jenson Button and of course my good friend Jenson Button!!

Trapped!

It's 02:30. He's been trapped in the car now since 23:30 the day before. This man has spent the past three hours stuck in the wreckage of his brand new BMW, that hit a tree at high speed. I can't get him out. The fire crew can't get him out. He's cold and in pain. His right leg is embedded deep in the metalwork of the car, and, because the tree looks as though it has grown through the bonnet of his car, we are unable to do a dash roll to move the dash away and give us some more room.

I need my friend here, my mobile mechanic, to help decide what bit of the car is what. I peer at the leg, and pass my hand down slowly, to see where he is trapped, and by what. I cannot get my hand further than mid-calf - the rest of the leg and foot is completely buried. I have a chat to the fire crew, and suggest various bits of the car to cut off, knowing that this is going to take a long time. Fortunately for Timothy the foot injury seems to be the only problem he has. He is very chatty, telling me about his work as a Loss Adjuster for a local insurance firm.

Another half an hour goes by. I can now get my hand down to the top of his sock, but we are running out of options. The fire crew are cutting away down a deep hole, and it is proving increasingly harder for them to do anything without hurting Tim.

I regroup with the fire officer. I wonder whether we would be able to pull the car away from the tree. This is not something we would normally do because of the risk of injuring the patient, but in this case I can't see any alternative.

I decide to have one more look. Sometimes, if you clear some space behind the leg, this gives a small amount of manouevrebility, and the foot slips out. I run my hand down the back of the calf, and hit what I at first think is the leather seat cover. I look at the seats they are fabric. But this definitely feels more leathery. I ask for a torch, and peer down the hole, only to be greeted with the sight of his shoe. His shoe, toes pointing upwards, behind his leg. Pushing the shoe, prodding it with my gloved hand, I realise that his foot is still in the shoe, bent all the way back and up against the back of the leg. Furthermore, the sole of the shoe, and so the sole of the foot, is not the side of the foot that is resting against the back of the leg - it's the top of the foot. Try this yourself: take your shoe off. Now, keeping your shoe in the position it was when it was on your foot, bend it back all the way, until the sole of the shoe is against the back of your leg, with the toes pointing up towards the back of your knee. Now twist the shoe round, so that the laces are against the leg, rather than the sole, still with the toes pointing up to the back of your knee. Finally, imagine doing that with your foot still in the shoe! Well, that is the situation my patient is in...

Ok, so, although he has an obvious nasty fracture of his ankle, this will make extrication far easier, because the foot is not buried in the car - it is behind his leg. I decide to give Tim some STRONG pain-killers, and PULL him out. I am kneeling on the passenger seat (did I mention the roof and doors were removed ages ago?) and there are fire crews all around, to do the heavy lifting, while I pull the leg and foot out of the hole.

Nicely out of it on painkillers, Tim doesn't make a sound as I pull hard on the leg and foot. It still won't budge. I feel around again, confused, until I realise that his heel is getting stuck on the metalwork, and I cannot get it out. I call over my shoulder for a pair of scissors, and cut away at the shoe, until I can get his foot out of the shoe. It is very odd, seeing his toes right at the back of his leg, but at last he is beginning to move. It gets very dark, as the fire crew lean over and across me to grab a piece of the released passenger, and haul him up the waiting spinal board.

I glance at my watch - 04:30.

Don't Read His Blog!!!

No-one go to Insomniac Medic's blog, please!!  He just has to do better than me, doesn't he?  It's not my fault I can't run as far as he can.  Sponsor me anyway, even if it is only a measly 10K.

PS, good luck, IM.

The End? Almost, But Not Quite...

On Monday, I, along with a large number of BASICS doctors scattered across our nation, received a large, official-looking envelope. Upon opening it, we all found an identical letter, dated 16th December, 2010, along with a 100-or-so-pages form.

The letter was from CQC, the Care Quality Commission. They are the independent regulator of health and social care in England. What that means is that they ensure that anyone providing health care does so to an approved standard. All very laudable, I hear you say.

But now to the letter itself:

Dear RRD

As an immediate care doctor you and your organisation need to register yourselves with the Care Quality Commission. The enclosed form needs to be completed and back with us as soon as possible. If you have not sent in the form by April 1st 2011, you will need to cease all practice as an immediate care doctor, or risk facing prosecution under the Act, blah, blah, blah. Oh yes, and you need to pay us a whopping fee to cover our processing costs. Oh, and there's a yearly fee for being on the register.

Yours sincerely

The Care Quality Commission


I may have paraphrased some of the letter, but you get the basic drift:  fill in the form & pay us the money, or stop doing your work.

Ok, I hear you say, surely this is all right and proper.  Who else is going to make sure that you all are properly trained and acting in our best interests, if not the CQC?  Who is going to stop the cowboys, those just out for glory, rather than those who care?  Agreed and agreed.  And, I was expecting to have to register with the CQC at some stage.  The last we had all heard was that we needed to be on the register by April 2012.  2012, not the week after next.

So, let's have a look at this form:

Please provide evidence to show you take the views of your patients into consideration when providing your service. "Excuse me, Sir, but I need to ask a few questions for my Patient Satisfaction Survey, before I intubate you."  Or, "Pardon me, Madam, but could you please tell me if you are happy with the colour of the cannula I have stuck in your arm, before I am able to give you any pain relief?"

Please provide details of every location where you provide your service.  If you haven't got enough space on the form provided, photocopy the relevant pages and send them off with the form.  Provide evidence that, at each of these locations, health and safety is considered.  Right, pass me a local A-Z.  And I'll just go and have a look and make sure there are no dangers lurking on the M25, shall I?

You can see my predicament.  Not only did they spring this on us, but they dated the letter December 16th, then sent it out in the middle of March! To everyone working in BASICS!!  Why the change?  Well, according to the letter, the Department of Health have advised them that immediate care work is outside the normal practice of the GP's.  Sorry?  Ok, there are a significant number of BASICS doctors who are general practitioners, but the Department of Health are unaware that there are a significant number of BASICS doctors who are not GP's, and who work in hospitals.

So, is that it?  Does RRD have to hang up his jump suit and boots?  Can Mrs RRD get a full night's sleep?  Not quite.  Fortunately, I have been able to get in touch with the Medical Director of my ambulance trust, who has agreed to include me in their submission... for now.  Watch this space.

Mrs RRD To The Rescue!!

It was like something out of an orienteering test: "Go to the M25, Junction X. However, do not, I repeat, do not, travel along the M25." Oh. So, how do I get there, if I can't drive along my favourite motorway? I have all of the local junctions programmed into my Sat Nav, but this one isn't that local, and I haven't the first clue. The HEMS paramedic who has activated me for this mission, isn't able to guide me in at all - he doesn't know this area well enough. However, I know a special lady who does.

A quick call to Mrs RRD, and, with Google Maps loaded on her trusty MacBook Pro, she guides me along the 30 minute journey. She plots my position with pinpoint accuracy, giving me key sites along the way, so that I am able to concentrate on getting through the traffic.

And then I am there. I can see the accident, as I arrive at the roundabout over the motorway. The HEMS para has helpfully advised me that I will need to travel westbound, on the eastbound carriageway. Erm, that's the wrong way!! Isn't it?? I go round the roundabout twice more, just to be sure exactly what my plan of action is. Ok, I need to go down to the motorway on the sliproad that cars normally come OFF the motorway on. That's rather pants-wetting, especially when a fire engine is coming the other direction!!

Training Day 3 - 13.83Km in Total

Two big problems with training today.

Problem 1: my phone kept rebooting, meaning that my track didn't update properly. I had to spend a good couple of hours cleaning the track data, so that it was as real as possible. The total distance and time are right - the average speed may be a bit inaccurate, however.

Problem 2: now this one's a biggie, and I'm not sure what to do about it. Whle running today I was overtaken by Mrs RRD's mum and dad, out for a leisurely stroll... Hmmm, need to rethink the plans!!!

When Lewis Carroll Meets Richard Bachman

It's a Saturday morning. It's 2am. I get called to an assault, and blearily climb out of bed, don whatever is at hand (a t-shirt with the immortal words, "Ketamine, Just Say Neigh!", and go downstairs, trying hard not to trip over the cat, sleeping on the stairs.

I arrive to see lots of people milling around two ambulances, and, fortunately, a similar number of police. I still feel nervous, and breathe a sigh of relief when I am directed to the relative safety of the back of one of the ambulances.

Once inside, I am greeted by InsomniacMedic. We nod to each other, quietly, as if we do not in fact know the other's secret identity. It's odd, calling him by his real name. He has it easy, just calls me "Doc."

I am told by one of the other 6 ambulance crew that the patient, hidden from view by a sea of green, has been hit over the head by a road sign. "What sort of road sign?" I quip. "Hold on, I'll go and check," was not the response I expected, as one of the police officers also crammed into the sardine can scurries out to find out, only to return a few minutes later with the news that it was a Keep Left sign.

With that vital piece of information to hand IM and I are able to make our plans: the patient has a GCS of 8, but I think most of that is due to alcohol rather than his head injury. I decide that he should go to the Major Trauma Centre (MTC), because one can never be sure about what is alcohol and what is head injury until a CT scan is forthcoming. As he is lying quietly on the ambulance trolley I decide that I would try and get him there without resorting to intubating and ventilating him.

This is a bit odd for me. Those of you who read my blog regularly may have noticed a more conservative approach. Whereas anyone who closed their eyes for a short while would be tubed and ventilated, I now seem to be taking the opposite approach and holding off on doing so, unless the patient's airway was compromised. It has been a while since I have intubated a patient pre-hospitally, and I wonder to myself if I am losing it.

Still, we have a plan: as long as he behaves himself, he will be left alone. As I relate this to the others, and as IM raises an eyebrow in surprise, the patient makes the decision for me. Trying to get off the trolley, trying to remove his hard collar, and thrashing about in an altogether not-going-to-the-MTC-awake kind of way. So, it's a deep breath as IM gets intravenous access, and I draw up my drugs and prepare my equipment.

I wonder what on Earth is wrong with me - I have done this hundreds of times, in far more difficult situations than this one. And I don't always have someone like IM, whom I trust to help get me out of any sticky situations. I must be getting old, I muse, as the tube slides effortlessly into the patient's trachea.

Patient all settled in and comfy, I then turn to the thorny issue of my car. The last time I went to the MTC, it took over 2 hours to get me reunited with my vehicle, and I am in no mood to do that again. So I need someone to drive my car to the MTC for me. Guess who gets the job? Yep, my fellow blogger has the privilege of driving the RRD-mobile!!

An hour or so later, the patient off to CT scan, I have a quiet chat with IM, no-one else around, and the chance to speak openly about our "other" lives.

And, as I drive home, through the quiet streets of London, I reflect on the case, and on how it doesn't matter how many time you do something; it still has the potential to go horribly wrong. Maybe I am getting older. Maybe that's not such a bad thing.

Training Day 2 - 7.8 Km Total

Make the pain go away - sponsor me, please!!

Training - Day 1

Well, it's started. I am officially in training. On 31st May, in London, I and the rest of my team will be running 10 Km, to raise money for BASICS-London. Now, for those of you who don't know me, I'm not what you would call athletic. My idea of exercise is pressing the button on the electric recliner. I find I get short of breath walking too fast up the stairs (well, there are two flights in Chez RRD), and got a cat rather than a dog, to save on the walking.

And yet I have signed up as one of 8 runners, participating in the Bupa London 10K run, on May 31st. Princess RRD is running with me (well, far out in front of me), as are BigNeph, Scissors, Flasher, GasPasser and Shrink. Over the next couple of months I will need to get my fitness up to a level where I don't end up needing the services of my ambulance colleagues, who will be watching me from the side of the road. You will be able to see how I am doing, by looking at one of the panels to the right, which will be updated every time I do any training. Hopefully, by me knowing that you are all watching, I will be encouraged to keep up the effort.

What will also encourage me is if I start receiving some sponsorship for this run. After all, I'm not doing it for my own health!! In fact, at my age, the money I raise by doing this run may well have to go towards my knee replacement! But seriously, if any of you wish to sponsor me for this run, all proceeds going to support BASICS-London, and the doctors that volunteer, just click on the PayPal link to the right. Do post a message along with your donation - we always like to hear words of encouragement.

There will be regular postings, telling you just how far I have run in total during my training, as well as - hopefully - a live update on race day itself!!

Recognition

It's a scary thing, to be launched into an unfamiliar environment, and expected to function at a high level, to control the team in order to provide the best care for the patient. It's my first day as Trauma Team Leader at the new Major Trauma Centre. I get to come to an Emergency Department (ED) I have never worked in before, with staff who have never met me before, and when a trauma is brought in by the Ambulance Service I get to tell them what to do. All night.

And then the bleep goes off: the first call on my first shift. I have 20 minutes before they arrive, so I get up, get dressed and run down to the ED. The team are assembling, and I start introducing myself. When another member of the team arrives I introduce myself again. And again. And again. There are a LOT of members of this Trauma Team.

Five minutes to go, and my bleep goes off once more: another trauma call, this one in five minutes. So, that means I will have 2 at once. Hmmm.

OK, Plan B. Divide the team into 2 and run between them both. With a set of people who don't know me from Adam.

The first ambulance arrives. I look in delight at a friendly face. "Hello, Mr RRD!" calls out the paramedic. He's one of my locals, bringing a patient from my patch all the way to the Major Trauma Centre, and for my first call. The team looks on as we share pleasantries, along with a handover, of course.

The second crew are from down South, miles away from my home town. So, I was even more surprised to hear the "Hey there, Mr RRD!" from this crew. The para used to be from my patch, but moved about 3 years ago. The Team look on in awe; this new Trauma Team Leader knows EVERYONE!!

Putty in my hands...

We Got Rhythm!

I know this isn't pre-hospital, but I just feel I must share something with you:

We had an elderly lady into the hospital, in cardiac arrest. So, she has no pulse and isn't breathing. Unfortunately, there is a tendency for Nursing Homes to call 999 when one of their residents dies, and this leads to a sequence of events, culminating in them arriving at the hospital, only to be certified a few minutes later.

Anyway, we start off as usual, continuing the cardiac massage. We need to compress the chest at a rate of 100 beats per minute, 30 beats followed by 2 breaths. It just so happens that the nursery rhyme "Nellie The Elephant" has just the right rate, and 2 verses makes exactly 30 beats. So, it is not uncommon to see the person providing the cardiac massage mouthing the words to "Nellie" while doing the compressions.

Today, one of my junior doctors demonstrated another song that fits the bill, of 100 beats per minute, 30 beats to a verse. However, while some of you may not think it is entirely appropriate to be mouthing "Nellie the Elephant" while attempting resuscitation, even I balked at the sound of my junior singing, fairly loudly, "Another One Bites The Dust", as she vainly tried to keep this lady alive.

Blood!!

As I lie there, awake, listening to the gentle breathing of MrsRRD sleeping next to me, I marvel at how precious is the time between first and second alarms. I have a whole 10 minutes, just to savour the quiet in the house.

Phil Collins shouldn't be here!! "In The Air Tonight" resounding around the room pulls me from my stupor, as I answer my phone from Control.

I am called to an RTC on the motorway, possibly fatal. I throw on my work clothes (thank goodness I am a slob, and I don't have to go into my cupboard for anything), kiss MrsRRD goodbye ("Did your phone ring?". "Go back to sleep.") and run down the stairs, thinking, Oh well, there goes my morning shower and ablutions.

The journey is easy today - kids off school, roads quiet, but I am stood down just as I approach. I decide that there is no time to return home, and I continue on to the hospital.

I stumble in to the Department, to various comments about the local bum turning up for work. This prompts me to a caffeine fix (well, NHS tea) and a decision to use the "value" razor I have in the office for just such an occasion.

There is no mirror in the loo, and I run the blade over my lathered face by feel, rather than sight. Ouch!! That's a small nick under the left nostril. Must remember to utilise the well-known haemostatic agent close at hand to that area when I'm done - wouldn't want to get any blood on my shirt before work!

I leave the makeshift bathroom, and go to my office for a 5-minute break. I have a mirror on the outside of my door (don't ask - it was there before I joined) and I look in horror at my ravaged face and my blood-spattered shirt. The blade has done a very nice job of removing all the stubble from my neck, along with most of the surface skin!! I look like a victim of the Barber of Seville!!!

Ok, regroup!! The blood on my shirt is only a few minutes old, and I know that washing in cold water will remove it. So, it's back to the loo, and, shirt off, I start the painstaking job of soaking and scrubbing the collar.

5 minutes later, and the shirt is clean, the flow of blood is (virtually) stemmed, and I am ready for work.

One problem - soaking wet shirt.

Another problem - meeting in 5 minutes.

Solution - wear shirt, put electric heater on, and make self-depreciatory comment about surgeons and blades!!!

Mornings

I've decided. I'm not a morning person. Especially 3am. That's not really morning, is it? That's still night time, isn't it? Ok, then, I'm definitely not a night-time person.

This is an unusual comment to hear from a chap who regularly jumps out of bed at 3am, drives at ridiculous speeds, and makes life-altering (hopefully -saving) decisions. I do all of those things, and, I hope, do them rather well.

What I find difficult is biting my tongue. When well-meaning, worried family members ask me questions in the middle of the day, I try hard to alleviate their fears, empathise with their need to know, and help them deal with the difficult decisions that are being made around them.

At 3am, when I am asked if a drug I am considering using to sedate a man to help get him down a steep set of stairs has any side effects, I answer "Yes, but they're better than just leaving him here all night." Not the most empathetic comment I have made in my life.

But it could have been worse. When same family member asks me if the neurosurgical centre I have chosen for their beloved is the best choice, I don't say, "no, I just chose it because it is near to where I live, and I'll be able to get back to bed quicker." I simply say, "yes."

Maybe I can cope with 3am's after all!

Nothing to do all day!

I've had nothing to do all day today. My nothing started at 5am, with a call to an agitated man, collapsed as he got out of his bed. The team were unable to get him down the stairs, because he was thrashing about too much. By the time I arrived, he was quiet, and easily transported down the stairs. I didn't help the crew this time... I decided to follow behind the ambulance to Local Neuro Hospital, just in case. Nothing happened

About 6 this evening I was just getting ready to go home, when I am called to a stabbing near by. He had been stabbed in the chest, and was in the back of the ambulance before I arrived. The crew were happy to wait, and I travelled in the back with them on the way to Major Trauma Centre, just in case. Nothing happened

I got home about 8.30. My new cat was waiting for me (more about him in another post), and so was my family and my dinner. About 8.35 I get a pager for an RTA not all that far away. I couldn't not go. After all, that's what I do. He had been thrown from the car at high speed, but seemed reasonably ok. I decided that, since we were only 5 minutes away from Local Hospital, I would travel in the back, just in case. Nothing happened.

I'm home now. Please let me have my supper!

I Hate You

You make me sick!! You think it's ok to go to the pub, have "a few" drinks, and then get into your car. You think it's ok to then drive like a lunatic, so hard into a parked car that you shunt it 20 feet.

THAT COULD HAVE BEEN A CHILD!!!! That could have been MY child!!!

And then you stand there, saying that you got unlucky, because you got caught.

Unlucky would be running someone over, or hitting a car with people in it. Unlucky would be driving into a bus shelter, with a queue of waiting people.

So you are going to lose your licence. Big deal! You should lose more than that, and, if I had my way, I'd be at you with a scalpel blade to your rather needed parts.

But instead I have to be polite, treat you like a human being, rather than the animal you are. At least I get to hand you over to the waiting police.

Phew!! That feels better - back to work.

Confidentiality Revisited

It's tough, you know. However hard I try, whatever I do to maintain confidentiality, events continue to conspire against me. People know people. My community is small, and my patients have family. Family have friends. And the friends read my blog. No matter what I do to try and change the facts, the facts are still there, in some form or other. And that means I am taking a risk, every time I write. For every one of you who lives so far away that the stories are just stories, there is another of you for whom these stories are ever so real.

And what does it matter? Well, I try so hard to include only enough reality to make the stories real to you, Constant Reader. I ensure that any medical information is couched in such terms as to negate the breach of confidentiality that these tales perform.

But, what if it were your kith or kin that were written about? What if you knew that what was written was at best inaccurate, and at worst a fabrication, would that matter to you? I am, on occasions, a little irreverent. How might it feel to you, reading that, at least I had gained a pair of scissors while attending to your loved one, injured so badly in a car accident that he lies between life and death on a hospital bed?

I don't know the answers to these questions. Maybe soon I will. Maybe the family of the lady I wrote about in "Scissors" will tell me. And, maybe, their words will bring this blog to an end.

You see, I write how I feel. And I cannot change the way I feel. Without the humour, the irreverence, I would not be able to cope with the endless sea of nameless faces.

To all of you out there, to all the families of those I have saved and those I haven't; please forgive my breaches, my fabrications and my irreverence. The patient is always first and uppermost in my mind, both at the roadside and at the keyboard. If you cannot forgive, then please try to understand.

Odd

I've just come back from a job on the M25, and seen I'm wearing odd boots. One's a Caterpillar, and the other's a Magnum. Funny thing is, I've got another pair, just the same, in my car!!

Goodnight!!!

Plants

My back hurts. Specifically, my left shoulder, up into my neck. We have about 50 people descending on Chez RRD this afternoon, to celebrate Princess RRD and Mini RRD's birthdays. No, they're not twins, just have their birthdays quite close in the year. Mrs RRD has resigned herself to sorting the house out herself, as a result of my incapacitation. She is doing it with her usual good grace - after all, it's not my fault that my back hurts so much...

Yesterday I get a call to assist a crew with an analgesia problem. This is not all that unusual, and, if I am not too far away I will try and attend. I carry more potent pain killers than the paramedics, but often I just support and supervise the crew to use what they are familiar with, only in much higher doses. If something goes wrong, if the patient's breathing slows too much, I can always take over their breathing in the time-honoured fashion of sticking a tube down their windpipe and ventilating them.

But I digress. This call was for a man who had fallen out of bed, and landed awkwardly between bed and wardrobe. So awkwardly, in fact, that he had broken his leg. He had managed, somehow, to drag himself to the top of the stairs, but was then in too much pain (surprise, surprise) to go any further. The crew have given large doses of morphine, and he was still in so much pain that they couldn't do anything with him.

By the time I arrive, the morphine has kicked in, and he is feeling much more comfortable. I assist the paramedics with getting a splint on his leg, and rolling him onto a scoop stretcher, and strapping him down in preparation for the journey down the stairs.

The stairs have a lovely bend in them, just the right place to have a window ledge, complete with pots of plants. Lots of pots. I spend a few minutes carrying the plants downstairs, so that we have a clear way down. The crew suggest we get another ambulance, so that we have enough pairs of hands - Jim is no lightweight. I realise that this will be a wait of another 30 to 40 minutes, and suggest that we three can manage.

For some reason, I find myself going down the stairs first, with all of Jim's weight in my hands, as I manhandle the stretcher. The tight curve means that the stretcher, with Jim firmly strapped in it, has to be almost vertical. Oh, and did I mention Jim is coming down head first?

So, Mrs RRD, it wasn't just one of those things that meant you had to do all of the schlepping today - it was my fault.

Next time, I'll stick to the pot plants.

Swimming Run; Running Call

It's Tuesday. Princess RRD has swimming on a Tuesday evening. It's my job to take her the 20 minutes to swimming, come back, wait about half an hour at home, and then go and collect her. I enjoy the time we spend together on those journeys. I just wish that the Blackberry had never been invented, so that we could have more time to chat. Still, it's good she has such an active social life.

On my way back, the traffic near home is a little busier than usual. I see some blue lights behind me - the other side of the road is clear, so I know he will have no problems getting past, even though some idiots are trying to overtake everyone sitting in the traffic jam, just because they are turning right in half a mile!

It's one of the local First Response Units. How I don't envy them their job. The thought of turning up first anywhere, then knowing that, once you are there the clock has stopped for the Ambulance Service and you might be there on your own for an hour or so fills me with dread.

I see a bus up ahead. The FRU drives past, then stops. Oh ok, I can guess the scenario: unwell woman on bus. As I approach, I can see that the paramedic is still kneeling on the road in front of bus. Change of scenario: woman hit by bus. I pull over, hit the rear blues, and jump out, rushing to the boot to don the tango suit.

It's Mabel. All the local crews know Mabel. Even I've met Mabel at my hospital, some miles up the road. She's, not to put too fine a point on it, the local drunk. Well, one of them, to be precise. The FRU who is here today tells me he usually gets called out to Mabel at least once a week, suffering with collapse. There's never much wrong with her, and she usually gets on her way as soon as the team arrive. Not today, though.

The pool of blood around her head where she lies corroborates the information provided by the shattered windscreen: today, Mabel has been hit by the bus, and has a head injury. How much of a head injury is yet to be seen.

Mabel opens her eyes when I call her name. She tells me, in a slurred voice, that she is just having a rest, and why don't we all F*** Off! Mabel is renowned for her careful choice of words, le mot juste. I lean in to take a look at her pupils, and sense the heady aroma of Mabel's favourite perfume: Eau de Pub.

I look around: we are on a main shopping street. The world and his wife, their children, the Au Pair and the next door neighbour have all gathered to watch. One woman, complete with shopping bags, nudges me a little, to move me out of her way, so that she can get a better view. I remind people that if they want some street theatre, Covent Garden is a short train ride away, but they remain glued to the scene. I ask a couple of police officers to prevent me from committing a criminal act on the closest individuals, and they hastily set up a cordon around us, to give Mabel some privacy. The only two who are left are the two who kindly stopped and helped her before we arrived. One was holding her head, the other was, well, I'm not sure, really. She was giving some very helpful suggestions, suggesting that we get an ambulance, advising us not to move her, except, perhaps, the recovery position?

The ambulance arrived a few minutes later (or, in my case, a phew! minutes later). We quickly get a scoop stretcher under her, to the accompaniment of the passer by suggesting that we don't move her! I wondered if she thought we should help Mabel set up home in the middle of the high street, but bit my tongue, much to the amusement of my colleagues.

By this time Mabel was as awake as she ever was, and the crew were happy to take her to the local - hospital, not off-licence!

I popped back to my car, just in time to turn round and drive back to the swimming pool.

As I am driving Princess RRD home, I told her all about my running call. For this journey, at least, her Blackberry was left in her pocket.

Scissors

She's 65. She's in a bad way. She's lying on the floor, moaning incoherently, with blood from her left ear, and her left eye swollen shut. Her arm is bent at a funny angle as well, but that's not bothering me now. What's more concerning is her head injury. I look at the car: the windscreen has been hit hard from the outside, and is now mostly in the car, on the passenger side. Thank goodness there was only the driver in the car, when it hit the lady as she crossed the road, iPod headphones bought for her by her granddaughter for christmas drowning out any extraneous noises.

The HEMS crew arrive shortly after me. They are in the car, it being night-time (oh, and it's raining - again!!!). I confer briefly with the HEMS doc, who is happy for me to run this one, and happy to take the patient for me to St Mary's Hospital. I am on call for my own hospital tonight, so can't be going on any road trips...

I call for assistance to stabilise the patient: scissors to cut up each trouser leg and across each sleeve, a cannula in the uninjured arm, blood pressure and other vital signs.

She's a bit more awake now, calling out, and asking for her mother. She's very confused and agitated, so will still need tubing before transfer.

The HEMS team do things a bit differently from me. They set everything out very neatly and ordered, whereas I have a tendency to unzip my bag and turn it upside down. And then there's the checklist. Before I tube a patient, I have a look around and make sure I can see the bits I might need. The HEMS crew have a laminated sheet, with a list of equipment, drugs and personnel, which is called out, much like the checklist before flying an airplane.

Please don't get me wrong: I agree in principle with the idea of a checklist, but it's just not me.

I call out the items on the list, and receive a "Check!" from the paramedic assisting me. I take a breath in, inject the drugs and insert the laryngoscope. Easy view! The tube goes in, we secure the tube, and the patient is wheeled into the back of the ambulance. 5 minutes later, the ambulance is off, with the HEMS doctor inside.

I look around at the mess that is left: discarded packets, gauze, blood from her head wound, and the tuff-cut scissors I used to cut the patient's trousers. I look around - no more ambulance crew here. I feel strangely deflated, giving over the patient to the HEMS crew and not being able to complete the job through to the hospital.

But at least I've gained a pair of scissors.

The Last Journey

Oh how I hate these kinds of jobs. Hangings never go well. The patient usually is in a very bad way and they are often at home, found by family members, which adds to the intense emotion of an already tense situation. So, I am very wary of this job. Also, the fact that I haven't been out on a call for many weeks doesn't diminish my concerns. I mentally run through the contents of my bag. Did I replenish the drugs after my last call? Do I have enough syringes? Are the batteries in my laryngoscopes still live? There is nothing I can do about these things now, as I drive into the car park to a block of flats near to where I live. This is not a particularly selubrious area, and I am comforted by the number of blue lights and police vehicles I can see parked up. I jump out and grab my gear.

Ok, number 63. Where is number 63? It's dark, and despite the presence of what looks like most of the emergency services in London, I can't see a living soul. Oh,a nd surprise, surprise: it's raining.

Erm, what now? I tried a tentative "Hello?", but got nowhere. Then, from a balcony above, I hear some murmuring. This sounds promising. I move towards the stairs leading up, and see, in very small type, the words "15-63". I start making my way up the stairs.

Now, for those of you who don't know me, I don't really do stairs. Lifts are good, escalators I can cope with. But not stairs. And not this many. And not with a 25kg bag on my back and a 5kg monitor in my hand. But, this building doesn't look like there is going to be a lift. Or escalators.

I stumble on to the 4th floor, and call out again, rather breathlessly. This time, I am answered, and ushered into a tiny hallway, and my first glimpse of Jake.

Jake is lying on the floor underneath a loft hatch. He is being held down by two policemen, whuile the boys in green tend to him. He is agitated, and has the marks of a noose around his neck. He has, according to his flatmate, fallen from the loft, with a rope around his neck. The rope held him for mere seconds, before he fell the last remaining feet, to land in this tight space between front door and the bedroom.

I think quickly: he is currently maintaining his airway, but is very agitated. He has clearly suffered some hypoxia (lack of oxygen) making his brain not function properly. He needs intubating and ventilating, and getting to a trauma centre.

We are 4 floors up. If I tube him now, it will be incredibly difficult to keep ventilating him all the way down the stairs. The likelihood is that any brain injury from his hypoxia will only be made worse by the journey down the stairs, not better.

So, we need to get him down awake. But he's not the most cooperative of gentlemen. Not at the moment, anyway. He's moving all his limbs, the lower ones quite agressively, so he hasn't broken his neck. But we still need to be very careful in how we move him.

I decide that he needs to come down awake, and we strap him to a scoop stretcher, before making the precarious journey down with him. Well, when I say "we", I mean the ambulance crew. I go on ahead to set up my equipment and drugs for the inevitable intubation when they bring him down.

It's a good 15 minute journey down the stairs, and I am completely set up by the time they bring Jake down to me. I need to reassess him, just so that I have a baseline set of observations. Pulse, 96. Blood pressure, 130/75. Oxygen saturations, 98%. Glasgow Coma Score, 15. Sorry? Let's just check that. Yep, he is fully conscious. Hmm. I decide that tubing this one may be a little more than he needs. I'm not sure how he could have improved so dramatically in such a short space of time, but I'm not arguing.

He still has had a major insult, and needs to go to a Major Trauma Centre. It would be inappropriate to ignore the low GCS initially, nor the mechanism of injury. I look at my watch: 22:30, T-1. T being the day that my local Major Trauma Centre opens its doors 24 hours a day. Yes, tomorrow at 8am, I can go to my local at any time of the day or night with my patients. Not tonight, tomorrow. Tonight I'm off to the Royal London. That's a looooong way. Over 45 minutes. Still, I have no choice.

What I do have a choice in is how I get there. The patient is going in the back of the ambulance. I'm not happy to have the crew take him there all on their own, not on a 45 minute journey with a man who, 15 minutes ago, had a GCS of 6. But, if I travel in the back with them, then someone will have to somehow get me back to my car. However, if I follow in my car, I can still jump out and help if they run into trouble en route, yet I will have my car available to drive back immediately.

Decision made, we package the patient securely, and I start on my last journey to the Royal London.