Bang!!! Part 2

So, here I am, at a school many miles from my home, with a dented boot, Sonny Jim having ridden his motorbike into my rear en route. My patient is a 5 year old boy who was hit by a Land Rover. When I say hit, what really happened is that the lad, Tim, had been leaning against a wall when the child sitting in the front seat of the Land Rover had taken the hand-brake off, and the rather large vehicle had pinned Tim against the wall.

I need to act fast here. Children don't act the same as adults: when they get injured they display very few signs of shock until the very end. So, I will have to keep my wits about me. The mechanism of injury tells me a lot - the potential for chest and abdominal trauma is high. I will need all my kit out of the boot.

Oh bum, bum and tripple bum!! I can't get my boot open! The impact with the bike has damaged the locking mechanism. Having an Estate car would be good at this stage - I would have just pulled down the rear seats and grabbed the stuff from there. But I haven't. So I can't.

Quickly, I run over to the ambulance, no kit in hand, and call to one of the fire crew, to appraise them of the boot situation. He calls to his colleagues, and my vision, as I enter the back of the ambulance to deal with a sick 5 year old boy is of 3 burly fire officers attacking my beloved car with some heavy equipment. Oh well, concentrate on the job at hand:

Tim is awake, whimpering in pain. He looks very pale, and is quite drowsy. He has an obviously deformed right thigh. There is bruising across the right side of his chest. Ok, need to get some order into this:

Airway - maintained. He is speaking, and so I can move on to:-
Breathing - looks fast, and the right side isn't moving as well as the left. A count of breaths per minute gives me 30. What's normal for a 5 year old? Can't be more than 25, can it? The EMT agrees with me. Listening to his chest with a stethoscope demonstrates very little air entry in his right side. A pneumothorax? Blood in the chest? I tap on his chest, but cannot decide whether it is dull (blood) or resonant (air). Damn! It's really not as easy when it is a child, nor when we are in the back of an ambulance... Oh well, park that for a moment, and move on to:-
Circulation - pale, weak, thready pulse, blood pressure unrecordable, obvious fracture right femur, probable pelvis fracture. This is not looking good.
Disability - he is conscious, and responsive, with a Glasgow Coma Score of 14/15. He is moving all 4 limbs.

Just then, there is a knock on the ambulance door, and the fire officer hands me my bags from my boot. I'm not even going to think about it...

I start making some decisions: time to any A&E Department is over 20 minutes. Tim is in a bad way, losing blood from a probable pelvis fracture, as well as a femur fracture. He also has a chest injury. If he were 20 not 5 there wouldn't be a choice - he would be put to sleep, and I would decompress his chest. But he's 5 years old!! Giving him a general anaesthetic will be hard enough, what with choosing the correct doses of drugs. And then decompressing his chest! I can't remember the last time I did that in such a small child! No, this one will have to travel awake. In a way this makes the journey much harder, as I will have to be prepared for the worst. I give Tim some ketamine, a sedative used for anaesthetising horses. A much smaller dose for Tim, though, and he is sleeping nicely. Very slow fluids, just to keep his blood pressure stable. Not too much, or he will start to bleed more. Equipment ready to intubate him if he deteriorates en route.

I signal to the ambulance crew, and we make our steady way to hospital. I watch Tim's vitals like a hawk, listening constantly to his chest, my fingers on his pulse all the way. I breathe a sigh of relief when we drive up to the A&E, and I hand him over.

A couple of days later I call to find out how he is: he is still fighting, having had operations to pelvis, femur, chest and abdomen.

Handover Carnival

I have been asked to host the June edition of Handover Carnival. For those of you who have not heard of the Carnival, it is an opportunity for bloggers to send in their favourite offering: a post related to EMS, to A&E; to anything emergency. Last month's Carnival was hosted by Rescuing Providence, and was entitled "Partners". Head on over to a great blog, and an excellent selection of posts.

My interest, apart from the obvious, is in communication. We in the emergency world spend our lives communicating; with patients, with family, and with each other. And what is blogging, if not communication. So, for June I am looking for posts that have communication as their basis. Please send your links to: rapidresponsedoc@yahoo.co.uk. The deadline is June 21st, so that I have time to get them all straight and out there in time for month end. I look forward to seeing what you all can come up with.

Signing Out

Tonight, for the first time in I can't remember how long, I signed myself off duty from both Ambulance Controls. It didn't feel good, but a lot better than the thought of being on scene and unable to do anything because of my blasted ribs!

Interlude - Physician, Heal Thyself

It's 4am. Most of my posts are written in the present tense; a method of drawing in the reader. This time it's for real. I am lying here in bed, my laptop under the covers, waiting for dawn. I am unable to sleep, despite being exhausted. I am not even afforded the pleasure of being able to toss and turn, as every movement, every breath, is painful. I check my pulse - tachy? Probably not. I cast my mind back to yesterday afternoon, a warm, sunny end to a lovely day. I had been riding in the local park with Mrs RRD, our daughter LittleMuffin, and SonThree. I was thinking how much fitter I was, having recently started going to the gym twice a week. Suddenly, I felt my front wheel lock up, and I went flying over the handlebars, the right one jamming into my chest!

I lay on the ground, flopping around, like a fish that has been hooked, netted and flung onto the river bank. I can't breathe! Searing pain in my ribs, low down on my right. The family rushing over, I proceeded to do my own Primary Survey:

Airway - definitely ok, despite the fact that I can't talk
Breathing - bloody painful!! There's no surgical emphysema (air in the tissues of the chest wall, signifying a collapsed lung.) Wait a moment, how long does it take for that to develop? Oh well, come back to B in a minute.
Circulation - no dizziness, pulse up a bit, but that's to be expected, no blood on the floor. pelvis intact, but right hip hurts a lot. I can move it, so clearly it's not broken.
Disability - I can't check my own pupils for reaction to light, but my Glasgow Coma Scale is 15 out of 15, and I am moving all 4 limbs. Thank goodness I was wearing my helmet.
Exposure - No way am I exposing myself in my local park! That's not the sort of publicity I or BASICS needs. Still, I am wearing shorts and a T-shirt (oh Gawd! It's my Trauma Junkie shirt - how mortifying!), so most of me is available for inspection. LittleMuffin offers, but it is Mrs RRD who checks over all my various grazes, and pronounces me battered but intact.

Mrs RRD looked on anxiously as I slowly dusted myself off and try to get up. Ow, my ribs!! Together, the three of them hauled me up (not quite enough gym, after all), and we made our slow way home.

As the evening wore on, so the pain increased. A veritable cocktail of drugs before bedtime, and yet still I lie here, listening to the soft sussuration of Mrs RRD's breathing, and now to the sound of birdsong outside my window.

Bang!!

I look ahead with a sinking heart; the traffic on the motorway is stationary. I'm used to this when the incident is on the motorway, but I have many miles to go before I get to the 5 year old boy pinned to a wall by a Range Rover in CountrySchool. As a result of the road works there is no hard shoulder for me to race down, so I don my "Moses" beard and staff, sit on the line between middle and fast lane, and watch as a new lane is formed, just for me.

It's slow going, as cars in the two lanes next to mine work out what it is I need them to do. My wing mirrors are retracted to give me extra manoeuvring ability. I spot in my rear mirror a motorcyclist, taking full advantage of my passage, trailing me in my wake.

Good, my junction. I indicate left and slow, searching for a way through. Suddenly; Bang!!! What have I hit?? I look around me, and see the motorcycle, attached to my rear bumper. I jump out, spitting tacks, and rush round to the rear of my beloved vehicle. The cylist is still sitting on his bike, looking rather sheepish. "You braked a bit fast, didn't you?" Wrong move, matey. I make it quite clear to said biker that I didn't really have time for discussion about the finer points of slipstreaming emergency vehicles. I also explain to him that he is very lucky that my vehicle is still driveable, as I have to get going. I whip out a piece of paper and a pen, and get his details, photograph his bike (and him - not getting caught this time) and prepare to leave.

"What about me? What about my bike?" I look closely; he's breathing. Good enough for me.


to be continued...

Futile

I look across at MikePara, and in his eyes are reflected the same thoughts as in mine. The scars on his tiny body tell us that this boy has spent his short life suffering, and that the cardiac arrest we are called to is just the final chapter in his story. As I pass a tiny tube into his trachea, as I thread a miniscule needle into a vein, I think how futile this is. And then I look across at the mother, sitting in the ambulance with us, watching our every move, silent tears running down her face, I realise who we are treating.

So we continue our last, futile battle to save this poor boy's life, a life that has only just begun, yet has seen him go through far more than any of us. We we give him drugs, we give him fluids, we massage his heart and ventilate his lungs, for his mother.

This battle is lost, the war is over.

It's Early In The Morning

04:10: "Hi there, it's John in Control. Are you available to go to a trapped RTA in TinyTown?" I get up, get dressed in the dark, kiss Mrs RRD goodbye, and set off down the stairs. I suggest to myself, as I make my bleary-eyed way to the car, that in future I will pay much more attention to which way round I put my pants on, as I now have an industrial-sized wedgie!

I put my jumpsuit on and sit in the car, squirming uncomfortably, as I punch in the details to my Sat Nav.

04:14: "Hi there, it's John in Control. The trapped RTA is now out and walking around, with no injuries. I can stand you down. Sleep well." I take the key out of the ignition, take my jumpsuit off, stumble upstairs and climb back into bed, wondering how long it will be before sleep finds me again.

The Best Birthday Present

Mrs RRD has just given me the best birthday present! A Trauma Junkie T-Shirt. I am so chuffed, thank you so much. The words emblazoned on it epitomise just how I feel about my BASICS work.

Watch Out!

14:03. I am at work, plowing through emails. My pager bleeps - again! All day long, my pager, linked to the Ambulance Service, has been notifying me about calls in the area - chest pain, abdo pain, asthma attack, more chest pain. I sometimes wonder why I agreed to have it programmed in for every damn call. None of these are what I would be called out to. Oh well, let's have a look. The code 29D04 flashes repeatedly on the tiny screen. I squint, just making sure, through all the dust that has collected from my trouser pocket under the screen. 29D04. 29 denotes a road traffic collision. D04 tells me the patient is trapped. Now, that's what I am (not) paid for! A quick check on the address - I could walk there from the hospital in under 5 minutes. I decide the car would be far better, and rush through the Department, pager in hand.

My colleagues are well aware of what that signifies - a chance to get out the hospital with me to a job. At the worst it will mean riding the streets of HomeTown at speed, blue lights blazing and sirens blaring; at best it will mean they get to experience first hand the joys of pre hospital emergency care. And they get to hear me jabber on about scene safety while we are on the way...

BabyDoc, one of the paediatric specialists, wins the arm wrestle contest over BeardDoc, and she rushes with me to the car parked conveniently at the entrance to the A&E. Seatbelts on, and I barely get past "Always look before you walk out into the road, even if the police have closed it off," before we arrive.

What I see is a car, right up against a lamp post, and a garden wall that has been knocked down by the car. I jump out, give instructions to BabyDoc to grab my kit (well, she wanted to come with), and I start hurrying towards the car, and the obviously injured driver, slumped against the wheel, his head being held by an EMT.

"Hi, RRD," calls a friendly fireman. "Can you smell gas?" I stop short, and turn to him. "Sorry?" "You know, gas!" he replies. Fortunately, he continues: "The car has hit the domestic gas main, and it seems to be leaking. A bit," he adds. I sniff. I don't know why I sniff, because the lining of my nose has been destroyed by 19 years of vomit, smelly feet, smelly wounds, faeces, and other unmentionables, and I can't smell a thing. Still, it seems the right thing to do at the time.

I have to start making a risk assessment. On the one hand, I have a seriously injured patient, just about to be released from the car. And on the other, I have leaking gas from a domestic gas main. A bit. I decide that gas is only a big problem if it is in an enclosed space, and this is, well, outside. So, I suggest to the police that they move the rubberneckers back 100yds, and proceed in with BabyDoc (fully laden) to the car.

The chap is breathing, but he really should have worn his seatbelt. His teeth were never again going to grace a Colgate advert, and his face looks like it had hit the indside of a windscreen - basically what had happened. He isn't talking, his eyes aren't open, but he is moving fairly purposefully. His Glasgow Coma Score, a measure of how awake he is, is 7 out of a possible 15. So, he is going to need to be put to sleep, and I will need to intubate him. I think about how much harder this will be with his facial injury, and mentally prepare myself for a surgical airway, where I will make a hole in his neck and put the tube directly into his windpipe. Not something I have ever done in real life, I am once again very conscious of how precarious life is out here on the roadside. Still, I have practised enough times on sheep larynxes - how much harder could it be on a real live patient, whose life will depend on doing it right. Anyway, I am getting myself stressed for nothing - this tube will go as well as all the others (I'll just put this scapel blade here, just in case, you understand...)

A quick check of the rest of him, while BabyDoc draws up the drugs for me: Airway - a little bubbly, due to the blood. Breathing - equal on both sides. Circulation - a good, strong, steady pulse. Disability - Glasgow Coma Score now 6. Ok, looks like an isolated head injury, let's optimise this baby by ventilating him properly, and ship him out.

Drugs in, laryngoscope in left hand, passed into the right hand side of the mouth, sweeping the tongue to the left and lifting the soft tissues out of the way to see ... the vocal cords! A straightforward intubation (I told you I wouldn't need that scalpel blade...) Tube in, tied in place, position checked, it's all going like clockwork.

"Holy F***!!!" screams one of the bystanders (I thought I had asked that nice policeman to move them all back!) "Get the hell out of there - it's going to go!!!!"

Bum, bum, bum, tits and bum!!!!!!! My assessment of the scene was screwed, and now so am I, BabyDoc, my paramedic and the patient. That gas main is going to blow!! I can see in my periphery BabyDoc and the paramedic fleeing, so that's two of us out the way. I decide that I am not staying behind, and stagger to my feet, dizzy from fear. As I turn to run, there is a horrible groaning sound from the ground beneath my feet, and the road gives a little shake. I picture the inferno, that is going to engulf this street, and like Lot's wife, I turn and look:

I see three very burly firemen grab the lamp post that is falling towards the car and the spot where I had been only moments before, and stop it just before it hits the patient. They pull hard, and bring it to rest inches away from his head.
Well, that wasn't expected!! I am shaking from release of adrenaline, but I realise my patient might need a few puffs of oxygen, as I have left him fully asleep, with no-one to breathe for him except me. I scurry back, and carry on, with a few, very sincere, words of thanks to the fire crew.