Smoke

As I drive home, my car is filled with the smell of smoke; I can't get rid of it, despite the windows being open all the way. My jumpsuit smells of smoke, my clothes smell of smoke, even my hair smells of smoke. And the smell evokes visual flashes that I don't want, don't need:

The burnt out hulk of the car in the field;

The lifeless face staring up at me, a mute appeal for help that I cannot provide;

The child, her physical injuries so minor, yet her emotional scars already evident in her glazed look, her cries, her questions about her mother;

The passers by, who have tried so hard to help the dying woman and her child, who sit by the side of the road, stunned by how fast their everyday journeys home have been transformed into a nightmare of screams, sirens and CPR. And smoke.

Don't Jump!

19:40. A job in ResidentialStreet, SmallTown; an unusual call, this one. A chap is threatening to jump out of a window. So, I turn up, to see a lot of police, and a man, quite naked, standing at the first floor window of a house. He had kicked out the glass, and was screaming obscenities at all of us below him. He is covered in blood.

So, what am I to do? The ambulance crew are sitting in their vehicle, waiting for instructions. The police are milling around. I am informed that there are a number of units within the house, but they cannot get close to the man. He is holding a razor blade, and has already cut himself multiple times.

I look below the window: a low garden wall and a small, gravelled garden. Great! If he jumps he is going to cause himself quite considerable injury. I am very worried. I have seen the effects on jumpers. but have never had to witness the fall itself.

I hear that the fire service are on the way, but I don't think we can wait too long. I suggest to the police that it might be sensible to place a mattress under the window, so that if he did decide to jump it may cushion his fall, at least a bit. They are not sure whether they can get hold of a mattress

Suddenly, there is a large amount of noise coming from the room in which the chap is in, and he comes charging towards the window, carrying the double bed! Wow! He is really strong!! He heaves the bed through the window, taking a large portion of the window frame with it. The bed lands across the wall – one mattress, just as the doctor ordered!

So, the mattress is in place, but now there is no window frame. Are we better off or not? The patient is now sitting in the window opening, holding the razor to his neck. He moves the blade to his left arm and slashes repeatedly: blood sprays across his face and chest. We have to do something soon. He sways visibly, as he stands and moves away from the window once more.

I turn to the senior officer, and ask him what plans he has to bring this to a conclusion. He shrugs. I half-jokingly suggest they could shoot him, and a look of realisation dawns on his face. “Of course! Why didn’t I think of that earlier?” as he runs off, babbling into his radio about various squads that he wanted on scene NOW!

Oh bum! What have I started this time? Suddenly, a nondescript van pulls up, and two very scary-looking police officers climb out, dressed in military uniform, carrying some sort of weapon. “They’ve gone crazy!!” I say, but quietly – I don’t want anyone to notice me, not after my suggestion.

They enter the house.

About 2 minutes later there is a bang, and I see the man fall to the floor, half in and half out the window.

I run upstairs, with the ambulance crew.

We are shown into an upstairs bedroom, blood all over the floor and walls. I look down to see a young man, probably in his early thirties. There are multiple slashes across his arms, chest and legs. But, wait a minute, why are there wires coming out of his body? What the heck is going on here? And then it dawned on me. They had shot him with a taser gun. This sends out two darts, attached to wires, which in turn are attached to a small, hand-held generator. The patient is then “electrocuted” with a current that induces neuromuscular incapacitation. In layman’s terms, when you have been shot by one of these, you cannot control any of your skeletal muscles, and you are unable to move or strike out.

So, here I am, confronted with a patient, completely paralysed, staring up at me. “Ok, Doc, he’s all yours.” Thanks! I have never dealt with this sort of patient before. I didn’t have time to Google "tasers" on line, to find out the effects. And yet all eyes were on me to know exactly what to do. “Can I touch him?” came my rather wimpy reply. “Course you can – he’s not live now,” chortles one of the officers. So, I’ve now shown myself up in front of most of London’s finest.

The man looks up at me, the power slowly coming back into his body. “What happened?” he asked. I explained that he had gotten a little out of hand, and had tried to hurt himself; hence the reason he was now handcuffed. He tells me he was a refugee from Afghanistan, and had repeated episodes of flashbacks to when he had been tortured. I tell the police to remove the handcuffs. The crew and I clean his wounds, all fortunately superficial, we find him a dressing gown, and he walks slowly down to the waiting ambulance, past the watching uniformed crowds.

Two Years Ago - The Story Of Kay

Two years ago I went to help a lady called Kay. Today, she has written to me to tell me she would be happy for me to tell her story on my blog. Kay, this one's for you. You are a brave lady indeed.

It is 2pm, and I am just about to go into a Coroner's Court, about a patient who died in the hospital. As I go to turn off my phone, prior to walking in to Court, it rings. I deliberate for a second or two - the Coroner does not like to be kept waiting - and then answer the call. It is from Control. There has been a microlight plane crash in St Albans, can I attend? I know I am only a few minutes away, being at Hatfield Coroner's Court, but I also know that rushing away from Court will not go down well. And I can understand that. The family of the deceased have prepared themselves for this most difficult day, and it will need to be put off if I cannot attend. But, I have been called, and it doesn't sound like a simple trapped RTA. So I push through the line of people waiting at the desk, and tell the clerk I am off. The look of horror on her face says it all - it will be her that has to tell the Coroner!

No time for regrets - my decision is made, and I rush to my car, change, and drive to the scene.
It is an odd scene for me. I am parked at the edge of a field. Way over in the distance I see a tree, and at the base of the tree a hive of activity. I sigh, not being a good runner, grab my kit and set off.

I arrive at the tree. There is a pile of wreckage that I am reliably informed was once a microlight plane. It certainly wouldn't be flying again. I turn my attention to the two casualties. There is a man. He is being resuscitated by two ambulance staff. I know them both well, and they have worked with me often enough to know my thoughts at this time. If someone is being resuscitated, and has no heart function, after major trauma, their chances of survival are zero. And yet we have another victim to look after. I go across to her. "Help me! I can't breathe!" she calls out to me, her voice thin and wavery. "What's your name?" I ask, as much to find out her name as to find out about her airway, breathing and circulation. "Kay," she replies, "It hurts so very much!"

As I check her over, my colleagues come over - they have abandoned the futile resuscitation attempt on the man, and are awaiting instructions. I can see that Kay is very badly hurt, with severe chest and pelvic injuries. Her respiratory rate is around 40 breaths a minute, instead of the usual 12, and her pulse is barely palpable. I have only a couple of minutes before she will succumb. I turn to the paramedic. "We need to do an RSI," I tell him. RSI stands for rapid sequence induction, and is the standard way to give a general anaesthetic in an emergency. "I need your help getting the kit ready. We have NO time," I add pointedly. He gets the message, and we quickly get the equipment and drugs ready.

I have only been on scene for a couple of minutes, and already Kay has deteriorated rapidly. Her pulse is now completely impalpable, and she is rapidly sinking into unconsciousness. One of the paramedics has already found a vein, and passed a cannula into it, so I give her the drugs that will paralyse her and put her to sleep, and pass the tube into her windpipe, easily and uneventfully.

That was the easy bit. Now it was going to get tricky. I knew why her pulse was fading, and why her breathing was so rapid: Kay had a tension pneumothorax. This is a life-threatening condition, where one has a collapsed lung (a pneumothorax), but one in which air is able to escape a hole in the lung, and enter the space between the lung and the chest wall, but is unable to escape. Imagine 3 balloons in a sealed box. If the pressure in the box increases the balloons get squashed. Two of those balloons are the lungs, and one is the heart. If the heart gets squashed enough it no longer pumps blood around the body. That was bad enough, but now that I was forcing air into her lungs, I was also forcing more air into the tension pneumothorax, and making matters far worse. I had to equalise the pressure in her chest, and immediately.

I had prepared for this, knew what I was going to do before I had started giving Kay the drugs. I picked up a scalpel blade and made a 2cm incision in her chest below her armpit on the left hand side. I cut through the skin easily. I then used my gloved finger to push between her ribs, and make a hole into the chest cavity. A large hiss of air accompanied this, and I swiftly moved across to the other side and repeated the procedure. This time, not only was I greeted with a large hiss of air, but a torrent of blood as well. Damn! She had bleeding into her chest. I can do nothing about this on scene, and need to get her to a hospital quickly.

So, I've sorted Airway and Breathing. I reassess her. Her pulse is still weak, but at least I can feel a pulse, whereas before the thoracostomies (the cuts I have made) I could feel nothing. Now on to Circulation. I have already decided she has a fractured pelvis, so I need to splint that. I get a sheet and pass it under her hips, then, together with one of the crew, I tie it in a big knot across the front of her pelvis. There! That should hold it until we get her to hospital.

And, talking of hospital, where are we to go? Just as I am about to discuss this with the crew, there is the whir of helicopter blades. I look over, and there on the field is a blue helicopter. It's an air ambulance. I think fast: if we are to save Kay she needs to get somewhere fast, and an ambulance journey is not going to be particularly prompt, especially as it might take us 15 minutes to get out of the field and into the ambulance. So, I call over the pilot and ask him if he can help. "That's why we're here," he replies. "Want to go to Milton Keynes?" That's miles away!! I wonder why he suggests MK, and he tells me it is the closest unit with Neurosurgery, Cardiothoracics and a helipad. Smart thinking!!

We get Kay on to the special stretcher, load her on to the helicopter and I strap myself in. I can see the monitors, and can just get to one of the cannulae she has in her arm, but not much else. I settle myself in for a difficult, tense ride. I know that, if Kay deteriorates en route I will be able to do nothing. I check the equipment one last time, before signalling to the pilot that I am ready.

I get a flash back to my time with the London HEMS as the helicopter lifts off, and I watch carefully for any signs of the pressure in her chest cavity changing as a result of the change in altitude. Not that there will be much I will be able to do.

The journey is uneventful. As we set down, I unstrap myself and feel for Kay's pulse - it is present, strong and regular. For the first time since I arrived on scene I begin to think that she might survive. We rush her in to the Trauma Room, I hand her over to the waiting team, and walk off. She's no longer my responsibility. There is nothing more for me to do, except wait for three hours while a member of the ambulance service drives to MK to collect me and bring me back.

A couple of weeks later, Kay comes to see me in my A&E Department. We look at each other, saying nothing. She shakes my hand, then apologises for what she is about to do. She flings her arms around me and hugs me. "Thank you," she whispers.

Kay's partner was flying the microlight, and died in the crash.

Don't Get Comfy

I don't know what brought this to mind today, but I thought it was important to share, and to ensure others can learn from my mistake and laziness.

I was called, unusually, to a cardiac arrest in a flat. I ran upstairs, and was greeted by a First Responder EMT and a hysterical young lady, no more than about 20. The patient was a man of about 45, who had arrested during sexual intercourse. We quickly got him on to the floor (there is no point trying to do cardiac massage on a bed) and began the resuscitation. It was soon apparent that this was not going to work - he was asystolic (no electrical activity at all) from the start, but we carried on. The ambulance crew arrived, and I let them continue. I sat on the bed while I sorted out the drugs I was about to give.

As the spreading wetness seaped from the mattress through my trousers, I wondered what I ever enjoyed about pre-hospital medicine.

Another One!!

I don't believe it! It's like buses - none for ages, then 3 come along all at once. I've already been to 2 callouts in the past 24 hours, and I am being called yet again. And, again, I am getting woken up at 5am. I really need a holiday. Oh, wait, that was last week, and I didn't get much sleep then, either. So, up, dress, run to the car, etc, etc, etc. I'm on my way to an RTC, apparently a bad one, with an unconscious driver, after he has ploughed into a van.

I enter an industrial estate, and my SatNav tells me I have arrived. Great! Erm, except, no RTC. Panic! As I am racing down narrow, one-way roads, with no signs of blue lights or accident, I am rung by Control. "What's your ETA?" he asks. "Well, that all depends...on WHERE THEY B.....Y ARE!!!!!!" Swiftly he talks me through the landmarks I can see, and guides me to the RTC.

I glance at the scene. There is a lot of information that one can get from looking at the vehicles. Here I can see a car, with damage to all sides, but mainly to the driver's door, which has caved in. I am directed to the ambulance, where the patient was awaiting my attention.

I open the door of the ambulance and peer in. I know there is a patient, but I cannot see him because of the number of people in there with him. I can hear him, though, moaning and groaning. I can see the effects of him, too, as those holding him down are thrown from side to side.

Ok, first things first. "Can I come in, please?" I remove 2 police officers, to give me a bit of space. I am greeted with, "Hi, RR. Good to see you!" It's great when ambulance crew recognise you; it makes working together as a team that much easier. What doesn't make things easier is the temperature in the ambulance: they have had the heater on, and, what with all the people in
there, it was a bit steamy. Anyway, time to get to work.

Primary Assessment:
Airway - he is groaning and moaning, so ok at the moment, but may not stay that way.
Breathing - he has a broken collar bone on the right, but everything else looks ok. He has oxygen saturations of 100%, which means that the lungs are working well. But.... Remember the state of the car? Remember what I said about the door? Well, there was a huge impact to the right side of the chest. He will have a serious injury to his chest, despite what I can see on examination. I'll come back to that in a moment. Circulation - he has a good pulse, but we don't seem to be able to get a blood pressure on the right arm. We switch the cuff to the left - 180/96. He his quite hypertensive, so I am not too worried that he is bleeding out, but we will keep an eye on it.

Disability - his is agitated, hence the need for the ambulance crew to be holding him down. I do a formal assessment of the Glasgow Coma Score - he scores 8 out of 15. 3 is the lowest, so, although his score is low, he is still exhibiting some higher function. He has a chance of survival. Even more reason to optimise his care en route to hospital.

First decision: he needs me to take over his breathing, pass a tube into his windpipe and make sure that his oxygenation is as good as it can be. I let the team know my plans, and draw up my drugs, one to paralyse his muscles and one to put him to sleep. I get my equipment ready, the tube, the laryngoscope, the bougie.

In position at the head, with the members of my team assigned their roles, I inject the drugs into his vein. Within seconds he is asleep and has stopped breathing. All as planned, so far.

I pick up the laryngoscope, an instrument designed to allow visualisation of the vocal cords and the passage of a tube between them. It lifts the tongue and soft tissues out the way, and has a light at its tip. I insert it into the mouth and sweep the tongue to the left.

A digression: I am a singer. I'm not suggesting in any that I am a good singer; it's just that, when I am working, I sing, softly to myself. "Breathe", by Pink Floyd, when I am intubating, "Bad Medicine", by Bon Jovi - you get the idea.

As I look in the mouth, I can see - nothing! Well, obviously not nothing, but just a tongue, with no sight of any vocal cords, or even epiglottis, when you are about to intubate someone, isn't a good view. I stop singing. Beads of sweat form on my forehead, as I struggle to adjust the position of the 'scope and give myself a better view. My mind rushes forward in time:
can't tube, will I need to resort to my first ever surgical airway - cutting a hole in the front of the neck into the windpipe? I take a deep breath , something my patient cannot do, and force myself to stay calm. Bougie," I snap, and one is slapped into my hand. This is a thin, stiff length of
plastic that can be passed into the windpipe, and then the tube is passed over this, thus guiding it into the right place. I thread the bougie where I imagine the windpipe should be, and railroad the tube over it. It slides in easily.

I hold my breath as the tube is connected to the breathing circuit, and exhale only when I see the chest rise and fall as the bag is squeezed. I'm in!! "Shall I tie that in for you?" The paramedic asks sweetly. "Er, no," I reply. "I think I'll do that one myself.". I am not having THIS tube falling out.

Usually, when there is a patient with severe chest injury, and one starts breathing for them, the pressure inside the chest can become so high as to block off circulation of blood out of the heart, and the patient dies. This is called a tension pneumothorax, and if it is suspected then some form of hole is made in the chest, to decompress it. I had decided this was indicated in this case, based on the collarbone fracture and the damage to the side of the car. Now is the time to get on with it. I reassess the patient: his chest is moving well and his blood pressure and oxygen
saturations are stable. With the idea of "less is more," I decide to wait it out, observe him all the way in to the hospital, and decompress his chest if he deteriorates en route.

We set off for the Neuro Centre, a journey of around 15 minutes. And here was the next problem: I may have mentioned before that I don't travel well. And it's hot and stuffy. And I am going to have to travel backwards, so that I can monitor the patient all the way. And I have just had a massive adrenaline rush, that tends to leave one feeling rather sick, even under normal circumstances. And we were in an industrial estate, with about 20 speed humps on the way out. Is this going to be the first time I actually end up hurling in the back of an ambulance? I desperately hope not. I start to breathe faster, and my stomach churns. My head starts to spin. Here we go! Fortunately, although I am completely unable to move, one of the paras takes pity on me and opens the skylight. Cool air rushes into the vehicle, along with pouring rain, and I drink in the sweetness, through my lungs and my skin. My head clears, and I am able to concentrate on the patient for the remainder of the journey.

UPDATE
I ring NeuroHosp a few hours later. The patient has severe injuries, but minimal bleeding into his brain on his ct scan. He does, however, have a severe chest injury, with a chest full of blood. Had I decompressed his chest then it is highly likely that he would have bled to death en route. Another close shave.

The Anatomy of a Car

I had 2 jobs today - that's on top of my 'day job' - and I'm knackered. I will write fully about the earlier job; this evening's one was just a little too intense to write down anything - maybe another time.

05:10 - 'phone rings, can I go to an RTA with person trapped, unconscious. Not a close job, in fact I am driving past GasPasser's house en route. I wonder fleetingly if he is away, and carry on. There is a water main leak, and for a moment I am aquaplaning, but the Quattro soon catches, and I am safely through.

05:19 - I arrive to see a solitary car, on its wheels (phew!), driven into a tree. The arbags have deployed. There is a man, sitting upright in the car, clearly not unconscious. An EMT is in the rear of the car, stabilising his neck. I approach, and am told that the crews are waiting for me for instruction. The issue: he cannot move his left arm or leg. This suggests a spinal injury, although it would be very unusual to have the effects confined solely to one side. Still, not a big deal; we will be taking the roof off and taking him out the rear of the vehicle on a spinal board, protecting his spine all the way. A quick chat with the fire officer with the white helmet, and I step back to let the fire crew do their thing.

They attack the "C" post. If you look at a standard 4 / 5 door car from the side, there are three posts; the "A" post between front door and windscreen, the "B" post between the front and rear doors, and the "C" post behind the rear door. Cut all six posts, remove the windscreen and the roof comes off. Or, cut "B" and "C" posts on both sides, make a small cut in the roof, and you can fold the roof forward. Nice and easy... ususally!

This was a nice, new car. Probably a year old, no more. The "C" post was cut with the Jaws of Life - no go. There are airbags in all sorts of places in new cars. Cut one of the cylinders feeding the airbag, and a small explosion is the result.

Ok, leave the "C" post and go for the "A". This was marginally more successful, but still took 20 minutes to get both of them done. This car was resisting the efforts of the fire crews big time.



"B" posts were next - after a VERY careul check for the ubiquitous airbag. Now 35 minutes in.

Small cuts to the rear of the roof, and the roof peel is completed - in reverse!


I look at the result - this is not going to be easy. Because the roof is at the rear of the wreckage, rather than in front, and because that is the way in which I want to bring the patient out, we are going to have to come out at an angle. And the doors are in the way. "Can you take the doors off, please?" I ask. A grunt is the reply from the fire officer. Another 6 or 7 minutes later the doors are added to the pile.

Right, let's get the board in behind the patient, and wind the seat flat. Oh. Electric seats. "Erm, can you cut the seat back, so that we can lie the patient flat?" I plead. Another grunt.

The lads attack the seat with a knife, and find - another airbag. What on Earth would this one do? An ejector seat, maybe? The crew cut the restraining bolts, and the seat reclines beautifully.

It's my turn!! I instruct members of the crew to take hold of various bits of clothing, so that they can slide him up the board. The one holding the head gives the count: "On three. Three, two, one!!" Huh?? Well, it worked, I suppose. We slide him out, smoothly, and lift him on to the ambulance trolley. I check him over - it looks like simple, but severe, bruising to the shoulder and hip. Better than a fractured spine!

I look at my watch. It's 6:45, and I am due in at 8 for a Ward Round. I look at my clothes: a pair of jeans and a Tigger t-shirt. Not going to go down well on the ward. So, I bade farewell to the patient and drive home. A quick cuddle, a change to more appropriate clothes, and I am out. On my way in to the Ward, I stop in to A&E and check up on my patient. He greets me with, "I recognise you. Where do I know you from?" Oh well.

Seatbelts are a Good Thing

This one was a nasty one. You have been warned.

It is one of those rare nights where Mrs RRD and I are alone in the house, with all of our kids elsewhere. At 2am the batphone rings (it's just my normal phone, but, after midnight, well, I'm sure you get the picture.). It's a call to an RTA in NearbyTown, 4 trapped. "Want to join me?" I ask Mrs RRD. "Why not?" Why not, indeed! Mrs RRD is more of a speed and car junkie
than I am, she just doesn't have the same ability in her job to be driving around on Blues - quick, I need an emergency photograph of my wedding!!

So, we BOTH get up and dressed, and both run out to the car. It's not the first time I have had observers, but for Mrs RRD it was a new experience, as we shoot through red lights and rush to the scene.

And, what a scene!! Let me try and describe what we were confronted with. We are on a dual carriageway. There is a great gouge cut out of the pavement to our left, running for about 100 metres. At the end of this trench is a tree. And, resting against said tree is a pile of twisted metal. It is unrecognisable as a car, although I am convinced that it once was. It looks as though it has been through a car masher, before being dropped from a great height. Oh, and it's screaming!!

I tell Mrs RRD to stay in, or at least near, our car, as I approach the wreckage. On closer inspection, the car was on its side, driver's side down. it had spun, so the front of the car was pointing back along the road. To be fair, there was no front of car: that was another 10 metres away. What was left at the front was the engine block.

Time to stop sightseeing and get to work. Time to find the victims and do what I am (not) paid to do.

Here's where it started to get complicated. Front seat passenger, still with seatbelt attached, at what is now the top of the car (remember, it's on its side.) A rear seat passenger, clearly without seatbelt, head and torso still in rear compartment, but legs and pelvis gone between front seats, and not actually visible. Another rear seat passenger, again no seatbelt, gone head first between seats, legs visible in rear compartment, head and one arm resting on engine block, unable to see rest of patient. Driver - no idea!!

Oh Lord, what are we to do here? All those visible are screaming in pain, so clearly have intact airway / breathing, but for how long? I go through the options; B-post rip, roof-fold, rear extrication; none will work here. I am stumped as to where to even begin. The fire crew are no closer to a solution, and we start, slowly, to dismantle the car. Meanwhile, I ask Control to find out if GasPasser, a very senior, experienced Basics doctor, (anaesthetist) is available to join me at the scene. He lives about 45 minutes away, but I don't think I will be done that quickly.

Meanwhile, I need to get started, and I begin with the rear seat passenger, whose legs have disappeared into the front of the car. We have peeled the rear of the roof forwards, allowing access to him. An IV line in his right elbow lets me give him some painkiller, but we are still unable to move him, because his legs are completely trapped. And I don't know where they are, because of the other occupants. Oh bum, bum, bum!!!

Ok, back to the front. We have one hanging from her seatbelt, but we can't see her legs. We have a head and right arm, from the other rear seat passenger. There are two legs somewhere, but we can't see them. And, not yet seen at all, is the driver. We are now almost an hour in, and I haven't made any significant progress.

Next step, try and peel the roof down. Only problem is that the front seat passenger seatbelt is attached to the roof, and if we bring the roof down, she will fall, but we don't have her legs free yet. So, we get a fire officer to hold her up while the roof is peeled down. She's now screaming even more, and in danger of falling. but at least things are beginning to be freed up - a bit. Suddenly the rear passenger's legs are freed, and he is able to be pulled out through the back of the car. He has two fractured femurs, and needs splinting of his legs, but is otherwise ok. The first ambulance departs the scene, nearly two hours after the accident.

Now, GasPasser arrives, and I breathe a small sigh of relief. He comes over and surveys the scene. "So, what are you going to do now?" he asks. I look at him, and see the twinkle in his eye - he's such a joker, is GasPasser.

Rapidly, he ascertains that the rear passenger who still remains in the car is lying under the lady still being held up by the fireman, and that the only way to extricate her is to get the fireman to lift the front seat girl up higher, and pull her out, over the engine block. A few screams later and she pops out like a cork from a bottle. That's 2 out of 4.

Oh dear!!! Revealed when she comes out is the driver. He is still sitting in his seat, seatbelt still on, and no obvoius injuries. Only problem, he is very, very dead. He has been smothered by the others lying on top of him, especially the rear seat passenger who we have just removed.

The girl glances down, and a look of horror and sadness comes over her face. She reaches down and brushes his face with her free hand. I quickly get a blanket, and cover him, but the damage is already done.

Two hours and forty-five minutes later, all the patients had been cleared, and Mrs RRD and I make our slow way home.

One Under

20:05 - I am called to a "One Under". This is the terminology for someone who has fallen or jumped under a train. These are, as you can imagine, quite nasty calls, or "Shouts", with usually devastating injuries. The other issues are of safety - more on that in a moment.

So, off I go, to CountryStation, to meet up with the crew. I say that because one can never be certain exactly where the patient is going to be. Think about it: when there has been an RTC, you can usually see a lot of wreckage, and that's a fairly good clue as to where the patient is going to be. Sure, they may have been ejected from the car, but you've still got a reasonable chance of seeing them.

When someone is hit by a train, there are two main differences. Firstly, there is generally no damage to the front of the train. The train may carry on for some time before coming to a stop. Also, the victim may be thrown many hundreds of yards from the track. Add to that the fact that, as this is an overground train, the victim might have been anywhere, between stations, at the time of impact. Oh, and it's dark.

I was always warned against playing on railway tracks. Two main dangers; the trains and the electricity. So, my first port of call, find someone in a uniform, and not a green one. I need to find a Station Manager or a member of London Transport Police. Plenty of them around. I ask if the power is off. They tell me, "We think so." Huh? You think so?? So, I gesture to the Station Manager, "After you!" He's not best pleased, and hurries off, presumably to find someone more expendable than him to go onto the tracks.

The second danger is that of the trains themselves. A train that has the power shut off to it can carry on moving for up to 4 miles. Plenty far enough if you 3 1/2 miles in front of it. Also, London Transport, and other rail companies, are keen to keep the service going, so they will often only turn off one line, and keep the other trains going in the other direction. Uh, uh, not for me.

So, I and my ambulance colleagues, along with the LT Police, who clearly feel the same way as I do, are left peering through the railings by the road, trying desperately to see if we can spot anyone. I have my head torch on - makes me look like a knob, but what the hell!

Suddenly, we spot something, way away in the bushes next to the line. It looked like a pile of rags - that's what one unders look like, I'm afraid. So, we have a patient. Alive or dead? We've got to go look.

About this time I hear the sound of a blue light vehicle approaching - HEMS is here. At night they drive a car, just like the rest of us, and they have been tasked on the job along with me. The protocol is simple; whoever gets there first is in control. Yippee, it's me!!

So, power off, trains in BOTH directions halted, and we're off to check on our patient, probably 30 minutes after it all happened. Not quite the Tick Tock of my previous post...

We clamber down, off the platform. Anyone who knows me will snigger at the image this brings to mind. I am not the fittest of doctors. I am also clumsy when I am walking on the straight, so the sight of me clambering is not one that would win me any agility awards. Still, I managed, with the help of a friendly fireman. Traipsing down the tracks, in the dark, is something I will never get used to.

We reach the body. The body that is still breathing! When I say breathing, there were a few, very shallow breaths, but where there's breath there's life. I remember that I am in charge, and kneel down to get a closer look: severe head injury, multiple limb fractures, no chance of survival.

If I would have been there without HEMS, that would have been it: I would have called it soon after. However, with two doctors on scene, things were different. We rapidly turned her onto her back. I intubated and ventilated - no drugs required. That is always a very poor sign. Multiple lines were inserted to give her fluid. About 40 minutes later, she was ready to be transported to the ambulance, a slow journey of another 15 to 20 minutes. The HEMS team decided they were going to take her back to a London Hospital, a journey of about 45 minutes. I was happy to let them take this one.

And then we are left, the ambulance crew and I. We look at each other, tired, cold, wet (it rained). Was that worth it? Was there any chance of survival. We all knew what I would have done, and knew that the outcome, while delayed for a few hours, was not going to be any different.

And then it's the clean-up. We had left a fair amount of kit at the scene, and it needed bagging up and removing. I offered to go down with one of the crew to give him a hand.

Oh bum! The trains are running! We were going to be escorted by two linesmen, across two sets of live tracks, to hunt around in bushes for the odd laryngoscope. Great! I thought it was bad before, now for some real fun! The linesmen instruct us to walk swiftly but carefully, always keeping between them. I do so, looking down all the time, so as not to trip. The trains rush past. The linesmen tell us we have a window of 1 minute before the next one to cross. I am not at all happy, but have offered my assistance; I can hardly back out now.

We cross safely, and approach the scene. It looks weird, without the patient. Quiet, somehow. Where before there was a mass of people, activity, lights and noise, now there are just 4 of us, and the wind blowing the rubbish about. We set about picking everything up, the silence punctuated by the occasional train rushing past us. At last it is done; one final sweep of the torch to make sure we haven't left anything behind. The return journey was no better - we had witnessed what happens when a train hits you.

Safely on the platform, we both glance back, then look at each other. "Just make it a basic RTC next time," I suggest. He just nods, obviously as shaken as I am.

I ring the next day - the patient died as they pulled up at the hospital.

Some Holiday!!!

This is getting silly! I am sitting in Pizzas 'R Us with Mrs RRD and the little ones tonight. I'm just tucking into my pizza with goat's cheese and caramelised onions, when I see a man being supported on both sides. He doesn't look great, shuffling along beside my chair. As his eyes roll up and his knees start to buckle, I decide pizza would have to wait. I jump up, grab the chap under his arms and get him into my chair. Then I get one of the waiters to help me carry the chair and, by now moribund, patient to the door of the restaurant. I make sure the chair is tipped back as much as possible, but by the time we go a few steps he is completely unresponsive and we lower him to the floor. I open his airway - almost no resps, and very difficult to feel a pulse. Fortunately, within a few seconds his pulse returns and he makes a few gasping breaths. I get the manager to call for an ambulance, then speak to Control, to give them some more information. 5 minutes later the FRV arrives, and the man is already much better, sitting in a chair. I hand over to him, and sit back down with my family. My pizza is retrieved from the oven, where it had been kept warm, and I finish my meal.

Busy, busy, busy!!

What a busy day I had yesterday. It all started off at 12:50 am, with a call to NearbyTown for a gunshot wound to the chest. Hmm, seems rather futile, but, apparently, according to the HEMS desk that tasked me, he was still breathing and had a slightly reduced conscious state. So, out of bed, clothes on - you know the score by now. A couple of minutes in to the journey, the desk calls me and tells me that the HEMS crew are also on their way, in the car. I know that I will get there before them; the only question is whether or not the crew will wait for me. That is answered as I approach the scene, with an ambulance blue-lighting it in the opposite direction, closely followed by a paramedic fast response vehicle and 2 police cars. So, I turn around and start making my way back home, still well within sight of the blue lights of the departing vehicles. I call the desk - they tell me that the plan is for the ambulance to meet up with the HEMS crew about 5 miles away. Er, hello??!! I'm here!! No, says the desk, it's all sorted... BUT, can you follow, just in case they run into trouble, or the HEMS crew get stuck somewhere. So, I'm driving along on blues, behind 2 police cars, a paramedic and an ambulance, feeling like a chocolate teapot! I consider ringing direct to Ambulance Control, but am concerned that I will upset the desk, and that will just adversely affect future calls. So I carry on, until I can see the HEMS crew arriving in the other direction. Lights off and I wander off home and back to bed.

07:00 and I am called by my work. I am on annual leave, so this comes as some surprise. I am told that a patient from a very serious RTC has been brought in, and is about to be operated on - IN MY A&E DEPARTMENT!! For those of you across the pond, this may be common in your neck of the woods, but almost unheard of in the UK. And blunt trauma is not an indication to open someone's belly in the A&E. So, I chat to the team, but essentially it is too late - they have already started. And, unsurprisingly, they call it 10 minutes later.

The reason I mention this in this blog about BASICS is that the man had apparently been trapped for over an hour. Why wasn't I called to the scene? I phone through to Ambulance Control, only to be told that they have no record of this accident. And then it dawns on me: it's just outside "my" area. I border 2 Ambulance Services, and get called regularly by both. However, a third is not all that far away, and it was on this border that the accident happened. So, now I will need to contact a third Service, and make sure they call me if there is anything at the border... More work! So far I have not been able to find anyone in authority who will agree to me being called by their Control Room - I may well just run up there and have a chat.

12:00, and I am sent on a job near the hospital I AM ON ANNUAL LEAVE FROM, only to be stood down about 5 minutes later, as the trapped, unconscious patient I was going to had got himself out of the car and was enjoying a nice hot cup of tea!

And then, at about 5pm, while I am walking back from the park with about 15 children - remember, I am on annual leave - I get a call to a motorcyclist on the M25. Probably fatal, is the call. So, that means it is, when it's a motorcyclist. I do the necessary (ringing Mrs RRD to take over creche duties) and take off.

The journey was uneventful, apart from being smoked by a passing police car (the hard shoulder was so full of rubbish that it was flying up behind him, and I couldn't see a thing!) As I approach the tailback towards the incident, I get a call, telling me that the paramedics have stopped resuscitation, and therefore I am not needed. I look ahead, at the queues of cars in front, and imagining the next 4 or more hours that I will be stuck here. "I'm not all that far - are you sure they don't want me to attend, just to lend a hand with the paperwork?" Please, please, please... "Ok," comes back the reply. Phew!! I know it may sound callous, but I desperately wanted to get back home for Friday night supper. So, I was able to continue to the front and deal with the formalities at the scene. And then, off home? No, unfortunately not. I then had to wait for "Crash" to arrive and assess the scene, so that when the ambulance, the FRV and I all left we wouldn't destroy any evidence. Oh well, won't take too long, I'm sure. No, only an hour-and-a-half of standing around, shouting at drivers who were slowing down to look at the scene, and at a body that we covered with a couple of sheets, but was still unmistakably a body. And then "Crash" turn up, take a lot of details, and let us go. For me, it was to go home to my family, for the others, to continue their shift.

Phone Rage

About 2 years ago I was called to a job in GentleTown, where I live. An old man, well-known in our community, was struck down by a car while he was crossing the road. He had severe injuries, and survived about 3 months, before finally succumbing to his injuries. The inquest heard that the chap driving was in all probability on his mobile 'phone at the time. Ever since then I have had a real "thing" about people driving while on the 'phone. With the ubiquitous nature of hands free kits and Bluetooth headsets there really is no excuse.

My car is a fully marked up Audi, with a fixed blue light bar on the roof. When I come up behind or beside someone, unless they are very observant, it just looks like a blue-light vehicle. Who knows, it could look a bit like a police car. I make it my business, if I see someone driving on the 'phone, to hoot them, often while I am riding in the lane next to them. I see it as service to the community. They may be the next one I have to scrape up off the road. Them, or the one they hit.

Today, I was driving to collect the kids from school, along a dual carriageway. The woman in the car in front was using a 'phone. I saw her steering with her elbows. My hackles well and truly raised, I pulled up beside her, and hooted. She looked at me. The phone was thrown to the seat next to her. Job done, I slowed and pulled in behind her, then indicated to go left at the next junction. She slowed, and stopped, obviously thinking I was pulling her over! I pulled out and went around her, leaving her clearly quite shaken and rather bemused.

I feel good about this. I'm not sure I should. I doubt she will use a 'phone while driving for a while now. I didn't impersonate a police officer. I just showed her the error of her ways. I'm sure this is a good thing. At least, I think it is...

RTC Car VS Ped

I am just on my way home from taking my daughter and some of her friends (they LOVE being driven around in my car) to a party, when I get a call to an old lady who has been knocked down by a car and is unconscious. On with the Blues and Twos, and off to PoshTown. I'm not all that far away, and I arrive moments after the ambulance crew. My thoughts en route are rather negative - old people are not always very robust, and being unconscious after being hit by a car usually suggests significant head injury. But, as always, I focus on getting there safely.

I park up and jump out. I go to the boot to get my kit, and realise that I am wearing no PPE (personal protective equipment.) I would normally get into my jumpsuit at home before setting off for a job, but this time I was already driving when I got the call.

I may have mentioned in previous posts that I am rather clumsy. I look particularly ungainly when trying to get into my suit. I look at the scene - there is a lady lying on the ground, the road is blocked off, I should be alright with just a reflective jacket. I carry one of these in the boot as well, usually for observers who ride out with me. So I pull it out and put my arm in to the sleeve. It won't go in!! What I haven't yet mentioned is that I am not as slim as I would like. This jacket is not for me, not my size, and definitely not going to fit!

Ok, enough mucking about. It's civvies for this one, and let's hope there's no pools of blood on the floor for me to kneel in.

I go over to the patient with my kit. She is calling out, "John, John!" I talk to her; she is fairly coherent, and tells me John is her husband. She is able to tell me that she remembers walking out of the church and crossing the road, when she was hit by a car. Not unconscious, then! There is a lady, also in civvies, putting a venflon in the patient. I introduce myself, and she tells me she is an off-duty A&E doc. Fair enough, the more the merrier. I leave her to the intravenous access, and carry on with my assessment:

Airway - talking, so that's ok

Breathing - same as airway. But, she is complaining of severe right shoulder pain - that might indicate an injury to her chest on that side. Have to have a closer look in a bit.

Circulation - she has a good, steady, strong pulse. But, she is complaining of severe pain in her left hip, so she might have a fractured pelvis. You can bleed all of your blood volume into one of those, so better be careful there. She's having her iv line sited, so, again, need to have a closer look shortly.

Disability - she is fully conscious, but a bit drowsy, and quite repetitive. She has some blood from a head wound (another pair of trousers ruined...) but is moving all four limbs. She will need a CT scan when she gets to hospital.

One can get a lot of information from looking at the scene. I quickly check out the car. There is a dent in the front passenger side bumper, and a large starring of the windscreen - what is known in the trade as a bullseye. So, I now know how she was hit. She impacted with her left hip on the bumper, and the right side of her head / shoulder on the windscreen. The bonnet is unmarked - there was little or no impact of her body on this part of the car. Oh, and then she was thrown to the ground.

She is scooped on to a stretcher, me doing an equal part in the lifting, and taken in to the ambulance. A second look reveals a definite pelvis fracture, a fracture of her shoulder and a probable femoral fracture. We shouldn't muck about with this one. The elderly do not tolerate blood loss as well as younger patients, and she is at risk of decompensating if we don't get her to definitive care. I won't be doing anything more with her - we are only minutes away from GoodHospital, and I can follow in my car, ready to jump out if there is a problem.

We arrive at GH, and I hand over her care.