It's A Long Way To The Trauma Centre, It's A Long Way To Go

Ah, peace at last!! My gentle drive home from the hospital is in stark contrast to the week I have had.  Busy doesn't cover it.  But, at least I am free all weekend.  I have great plans for tomorrow morning - I won't be surfacing until at least noon.

Before that, however, I have an evening at home with the family.  A nice quiet, relaxing evening, that I have been looking forward to all week.

Arriving home, I am assaulted by the wonderful aromas of my dinner, simmering in the oven! Can it get any better?  RRD-Dad rings, and we have a chat about who's been busier than who.

My other phone rings.

My heart sinks as I realise that, at least for me, dinner will just have to wait.

As I ride the motorway to my destination, I muse on how long it has been since I have been called to a job.  Sure, I have been woken; on one occasion I even got to the car and started driving.  But, an actual job - well, many weeks. And then I start to wonder quite how I will manage this one.  Will this job be the one where I find myself unable to make the right decision, where someone's life depends on me, and I get it wrong?

Uneasy now, I arrive at the police roadblock, and am waved through.  The road is eerily quiet now, so unusual for a Friday night.  The mass of blue flashing lights up ahead signify I have arrived.  I get out of my car, then leave the road and scramble down an embankment to the waiting crew.

She's been thrown from the car.  That's bad.  Ejection equals serious trauma.  It also suggests a lack of a seatbelt.  The car has definitely rolled over - dents and damage to the roof make that a cetainty.

She's not moving.  Her left leg is at a very unusual angle.  But I have to ignore the obvious injuries, and search out the immediately life-threatening ones.

She is breathing spontaneously, and her chest is rising and falling symmetrically.  Her tummy feels ok, and her pelvis is intact.  But, she is not conscious.

I decide that, as she is out of the vehicle already, the best thing to do is to scoop her onto the stretcher and carry her back on to the road, where it will be much easier to assess her.  A couple of minutes later we are by the ambulance; lots of space and lots of light.  Also, being on the stretcher means she is at a much better height for me to examine her.

She is still breathing normally, and there are no sounds of snoring, suggestive of an obstructed airway.  This is unusual in someone who is unconscious from a head injury.  I file that titbit away, and carry on looking.  Her chest is clear, and the movements are still symmetrical.

Into the ambulance and some further observations:  pulse rate 130, blood pressure 170/110, oxygen saturations 98%, respiratory rate 18.  For those not in the know, she has a very high pulse rate, a very high blood pressure and a moderately fast respiratory rate.  This could all be due to the pain from her obviously broken leg.

I ask about distances to hospitals.  My own hospital is a mere 15 minutes away, with the Major Trauma Centre about 45 minutes.  I know what the right thing to do is: we need to go to the Trauma Centre.  I don't like these long journeys, but I know it is better to spend a longer time in the primary transfer from the scene to a specialist centre.  The decision is made, and the crew get ready to depart.  I think for a moment about intubating her, but decide that, as her breathing does not seem at all like that of someone with a significant head injury, we would wait and see how she goes.

We set off.  She's very cold, and the saturation probe finds it difficult to get a consistent reading.  The blood pressure is a lot better now: 110/ 60.  She starts to moan and open her eyes, and ParaGirl and I smile, knowing that this is a good sign.

She starts to vomit.  Not a good sign at all.  As she is strapped to a spinal board, if she is not conscious enough she will be unable to clear the vomit from her mouth and will inhale it.  Aspiration is a leading cause of death in trauma patients.  But not this one.  She lifts her hand to her mouth and coughs.  Good.  That means she has an intact gag reflex, that will protect her airway.  She spits out the vomit.  Good for her, not so good for us in the back of the ambulance.

She vomits again.  And again.  And again.  We have the sucker ready, but this is ridiculous.  What on Earth has she been eating?  And so much of it??

We have by now stopped on the hard shoulder while we try and sort her out, stopping her from drowning in her own vomit.  We manage, but ParaGirl is gagging.  "I don't do vomit", she gasps between hiccups.  Well, you are in this job, and in the back of an ambulance swimming in it, so you just have to.

She's now stopped vomiting, and has settled back into her previous unresponsive state.  I check the observations as we set off again:  pulse 145, blood pressure 69/50, saturations 95%.  Hmmm, her pulse rate is climbing, and her blood pressure, while initially high, has fallen dramatically.  I open up her drip, and give her more fluids, willing the ambulance faster.

It's a Friday night, and the roads get busier.  We are getting slower and slower as we approach the Trauma Centre.  The blood pressure now reads 47/20, and I am sure we are going to lose her before we get there. I squeeze the bag of fluid harder, pushing another bag into her.  ParaGirl asks if I want another blood pressure.  I shake my head, knowing that, as long as she is still breathing, there is precious little else I can do, and seeing another blood pressure will only add to my anxiety.  Her lips are pale, and I know that she is bleeding somewhere; presumably into her abdominal cavity.  I alert the Trauma Centre of our impending arrival.

We arrive.  She still has a pulse.  She begins to moan again as we wheel her in to the resuscitation room.  I wonder again whether we should have gone to the closer hospital.  But, when, 5 minutes later, she is being rushed to Theatre, a surgical team ready to save her life, I know I have done the best thing for her.

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?