Monday, 16 May 2011

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!

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