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.