Great to Be Recognised and Remembered

So, I'm in the back of an ambulance at 2am this morning, and the paramedic says to me: "You'd better sit here, facing front. I remember you, you puke if you face back, don't you?" Ah, fame!!

My Worst Fear

It's about 7pm; it's cold and wet (what's new?), and I am just dropping off a friend near home, when I get a call. Am I near to SuburbanTown? Yep, I'm in SuburbanTown. Can I attend an RTC at SmallRoad, ST? I think quickly - SmallRoad is a turning off the street I am currently on, probably about 30 second's walk from where I am parked up. I enquire hopefully whether this is a crew request, and get the heartsink answer: no, they are on their way.

Hey, this can't be all that bad, after all, it is SmallRoad, so there won't be much speed involved.

I turn up, clad in orange, to see a car, driven into a garden wall. There are lots of people around, none of them wearing anything remotely reflective or green. I'm on my own - my worst fear.

As a hospital doctor, one is never alone with a critically ill patient for more than a few seconds. A quick shout out of the door and you are very quickly overrun with doctors and nurses, all with their own tasks to perform. One quick phone call and I can have a full trauma team, a cardiac arrest team, a paediatric team, all there to help with the patient. Those of you reading this who are EMS spend your life being first on scene, and especially you first responders, spend your life being the only one there: I don't, and I don't like it. It brings to mind an awesome film with Patrick McGann, Paper Mask, in which a porter takes on the identity of a junior doctor, and gets a job in a busy A&E Department. In the turning point of the film, he is giving an anaesthetic to a patient all on his own; it goes wrong and the patient has a cardiac arrest. The terror of him working on his own, trying to save the lady's life, is so brilliantly portrayed by McGann - get the film and watch it!!

But I digress, big time!

So, here i am, standing outside this car, looking in at a chap, slumped over the wheel, not moving. Hmm, worse that I thought. Ok, back to basics:

Safe approach? The engine is still running, so there is a chance the car will explode. No friendly fire crew, complete with hose. Oh well, at least the road is quiet.

Airway? Lying slumped against a steering wheel isn't going to be the best position for anyone, especially one who is unconscious. I need to act fast, and position him better. Still no fire crew, with cutting equipment, to get an easy access. How am I going to get to him? Break the glass? Never a good idea. Thinking quickly, I try the passenger door - it opens easily. I slip into the car and lift his head in to a better position, putting my thumbs behind the angle of the jaw and pulling forwards, to get the tongue out of the way of the airway. He takes a big gasp, starved of oxygen for a few minutes. Phew!

Breathing? Well, now he is. Can I have some oxygen? No. I don't carry any, and I am on my own. Listen to the chest? No. I have my hands full, supporting the neck and opening his airway, so I can't do much else.

Circulation? Usually, when I am opening an airway, I can manoeuvre my fingers to feel a carotid pulse in the neck, or, failing that, get a facial artery under my thumbs, so that I can assess. However, that's far easier if the patient is lying down, and this one's not! I am lucky in this case, as I can feel a very slight pulse in his neck, weak and thready.

I start to hear the sweet, sweet sound of sirens. Moments later, I am greeted with the sight of a First Responder. One becomes two!

I rapidy apraise her of the situation: this man needs a rapid extrication from a car that doesn't appear to be all that damaged. We both wonder aloud whether this may be a medical collapse, precipitating the crash. There doesn't appear to be any signs of external injury, and we agree that if we get him out we will have a much better chance of dealing with him.

Turn to the crowd, grab two of them and get help to bodily lift patient out of car. This isn't protocol, and I'm not sure if the first responder would have done this if I hadn't been there (comments, anyone?) We lie him down, and proceed with a more formal assessment.

By now, the fire crew have arrived, and are happy to assist with movement, holding bags of saline, shining torches in our direction, as we continue to work on the elderly gentleman. He is tubed quickly, and fluid is given to him, in order to get a pulse at the radial artery. We still have no blood pressure recorded on the machine, nor can we get a manual BP. I begin to wonder what else we can do with him here when the ambulance crew arrive. We bundle him on to the stretcher, and I travel with him to the local A&E.

They are expecting him. I don't mean as a result of the trauma call we put out. No, his GP had phoned them, to tell them that he was on his way, with a suspected leaking aortic aneurysm. He decided he wouldn't waste ambulance time, and would drive himself.

Unbelievably, he survived his emergency surgery.

For The Want Of A Shoe...

I lost a shoe this evening. It's the sort of thing the kids do; come home from school with only one shoe. Apparently they change for P.E., and don't pick up their belongings, coming home with no trousers, or just one shoe. How ridiculous. I keep telling them: be more responsible of your stuff, what do you expect me to do, just go out and buy you a new pair? Money doesn't grow on trees, you know.

Well, this afternoon I am sitting in a meeting with my Chief Exec, when my phone starts vibrating. It is HEMS, asking me to attend a horse rider, who has been squished by her horse. Gets me out of the meeting!! I rush to my car, open the boot and decide, in an instant, that a muddy field will be the ideal place to test my new, waterproof Magnum boots. So, off with my brand new shoes, chuck them in the back of the car, and slide on the Magnums. Smoooooth!

A simple journey later, I park up in a small, unlit alley, and jump out of my car. Boots working well! I open the trunk of my car and pull out my trauma pack. I am vaguely aware of the sound of something falling out of the car, but when I look, I cannot see anything - must be imagining. I rush over to the ambulance, where the patient is (damn! no muddy field) and enter. She is fine, a mild concussion, and I decide to follow the ambulance in my car, so that I am available if she becomes ill en route. She doesn't, and, after a quick drink with the crew (tea, honest!!) I am off home.

When I get home I get out of my boots (very comfortable, even on an hour's drive), and reach in to my trunk for my shoes. Oh dear. One foot too many.

It's confession time to my family. Mrs RRD is very understanding, but Mini RRD is in hysterics, as he kept picturing me throwing open my trunk, dragging out my trauma bag, and, in the process my left shoe flying out and hitting a cow!! Very odd child.

Magnum Boots - A Review

Just like Medic Triple Nine, I have been asked to review a pair of Magnum Elite boots. Obviously, a disclaimer is needed first - the opinions in this blog entry are, as always, completely my own, and not necessarily those of Basics. I have a conflict of interest, and that is that, as a result of agreeing to review the boots, I get to keep them! As a Basics Doctor, and especially as a bloke, I love the opportunity to try out new gadgets. All right, that's that out of the way; now on to what I thought of the boots.

These are a new style of boots, known as Elite. The main selling point of them is what is known as Ion-Guard. It is a special waterproof coating that actively repels moisture, which is designed to keep your feet dry, even when submerged. It will also repel other fluids, such as blood and urine, which I didn't try.

Let's get the bad out of the way immediately. These boots do not have steel toe protection. This essentially means that they are unsuitable for most pre-hospital practitioners. I contacted the the manufacturers, and they assured me that there is a new boot coming out, known as Shield, which will be much more suitable for us.

But, apart from that, how did the boots fair? I have certain key factors that I consider when considering which boot is right for me.

The obvious one is comfort. These boots get a resounding thumbs up for this. I wore them for a day while at work in the hospital, and I had no problems. There are no uncomfortable seams, and they did not rub at all.

Second obvious is looks. These boots do look the business, as can be seen here:

Now for an unusual one. I don't as a rule, walk around in my boots all the time. As a Basics Doc, I need to be able to jump into my personal protective equipment quickly, at a moment's notice. And, when I looked at how high up the ankle these boots come, I was expecting problems. I was, therefore, very pleasantly surprised when I saw that the boots do not have the usual eyelets for the laces. Instead, there is a very clever arrangement, that means that the boots can be opened wide very easily, and subsequently tightened remarkably quickly:

And finally, the water repellent coating. I and Mini RRD did the water test this evening, and as you can see from the photos, there was a very definite running off of water, and my foot was completely dry, despite his best efforts to soak me.

I would be very interested to know what happens when the boots get scuffed, as they inevitably will. Also, especially considering a recent job I was on, I am interested to find out how they fare with diesel...

So, in summary, as a stout pair of walking boots, a resounding YES. As a work boot for pre-hospital care, definitely not, certainly until the new ones come out, with the steel toe-protectors.

Now, anyone out there want me to review a new car, I'd be happy to oblige - as long as I can keep it!!

Bingo!

She doesn't look too badly injured, lying there in the back of the ambulance. It's just after 3am, and she's had a skinful, before having a row with her boyfriend and running out of the house, into the path of a fast-moving car. The driver of the vehicle is not without blame - he has also been drinking.

The main issue with her is that her conscious state is low. She has a Glasgow Coma Score of 7. The GCS is made up of 3 parts: eye opening, verbal response and movement. She isn't opening her eyes to painful stimuli - score 1 out of 4. She is making incomprehensible sounds - score another 2 out of 5. She is withdrawing from painful stimuli - score 4 out of 6. This is an indication for intubation and ventilation, as someone with a GCS less than 9 cannot maintain their airway, and is at a risk of either aspirating or stopping breathing. But I'm really not sure if she has a true head injury or if this is the effect of too much alcohol. I have to decide.

I draw up the drugs, and prepare my kit. It's always a worry - here you have a fit teenager. They are breathing on their own and don't appear to have any significant injury. Yet, if you don't act they could die en route to the hospital. However, if you do act, they might die as a result of your intervention. This is not the first time I have had to make this difficult choice. I reflect on how much easier this can be, if they are either obviously badly injured, or completely awake. Oh well, I may not be paid for it, but this is what I do!

So, usual procedure, get all the kit within easy reach, including the stuff for a surgical airway (if I have it ready, I'll never have to use it, right?" and I slowly give the paralysing drug, followed by the anaesthetic. Laryngoscope in left hand, lift up the tongue, sweep over to the left, visualise the cords and in. A textbook, grade 1, intubation. Blow up the cuff on the tube, connect up the CO2 monitor and give a few puffs with the bag. A good trace. Phew!! Another one under my belt.

"Pulse of 140," says Mick, my para, helpfully. "190." "210." What?? "215." Ok, Mick, now you're just freaking me out! Stop with the numbers, already!! I look up at the monitor: sure enough, the pulse is way up. This is not what I need right now. I was planning a nice, leisurely trip to NeuroCentre, about 20 minutes away, and she's playing bingo with her pulse! Her blood pressure is almost unrecordable.

Calm and centre.

Causes of tachycardia and hypotension, from the top:

1. Hypoxia. This is when there is not enough oxygen in the blood stream, and the heart tries to compensate. Usual cause in an intubated patient is wrongly placed tube. But, I have seen the tube pass through the cords, and I have a good trace on the CO2 monitor. CO2, carbon dioxide, is only produced in the lungs, so if I have a trace, going up and down with every squeeze of the bag, then I'm in. Oxygen is attached to the bag, so hypoxia is not the problem here.

2. Tension pneumothorax. The dreaded tension, happens when there is chest trauma, and I can see none. I listen and can hear good breath sounds. I decide that this is not the time or the place to be making holes in her chest wall. I move on:

3. Hypovolaemia. Fluid loss, specifically blood, can lead to a rapid rise in the pulse rate and a drop in blood pressure. So, is that it? Is there some, as yet unidentified, injury? Is she bleeding somewhere? While I am looking I get Mick, my bingo caller, to squeeze her fluid bag, and try and get as much as he can in to her. I don't like fluid in the pre-hospital arena - it makes people bleed more. But in circumstances where they have almost no palpable pulse and a blood pressure of... 50/20!!!... it might just enable us to get her to a hospital alive.

I check her over, remembering the mantra: one on the floor and four more. There is no external blood loss, and her chest, abdomen, pelvis and long bones all seem intact. Still, I can't think of anything else to do, apart from giving fluid.

4. Cardiogenic. This is where there is direct trauma to the heart. Again, I have no reason to believe this is the case, as there is no sign of chest trauma.

It is now 5 minutes since I have tubed her, and her heart rate is unchanged. I have given her 500ml of fluid, and I can feel a pulse, at least. I look at the monitor; the rhythm is very fast and it's irregular. Irregular? That's atrial fibrillation!! What's a 19 year old doing, having AF, that we normally see in much older people, often with heart disease? I have no idea. I wonder if she has had an adverse reaction to the anaesthetic agents I have given her. I've never heard of this before, but I'm not an anaesthetist, and anything's possible.

Right, I'm totally out of my depth. She needs a hospital, and fast. NeuroCentre is 20 minutes away, but LocalDGH is 5. It's a no-brainer - she might not get to NeuroCentre alive. I let Mick know what we need, and he puts pedal to the metal. 3 minutes later we pull up outside, with a girl with a barely palpable pulse, no recordable blood pressure and a heart rate of 220. What a gift!

I hang around, while the team don't exactly fill me with confidence. She may not be in my care now, but I did work hard to get her here, and I would like to see the hospital staff work a little faster. I look at the anaesthetist, and he shrugs. "Maybe next time you'll decide to go somewhere else." I don't disagree with him.

5 minutes later, we look at the monitor, as she flips out of AF and into a normal sinus rhythm. Pulse rate: 84, blood pressure a very healthy 135/75. We chat about what may have caused the AF. I am secretly relieved that he has no idea either.

The next morning I ring up and find out that she is on a general ward, awake, with a headache. CT scan was normal.

Helping Hand

So I'm driving home, after looking after a drunk, who decided that tonight would be a good night to run out in front of a car. Fortunately for him, tonight was also the night for the car under which he threw himself was being driven by a very good driver, and his injuries are more likely to be due to the fall, rather than the car. After checking him over, I leave him to the capable hands of the paras, and start my journey back home.

I'm about 5 minutes away from home, when I see a car fly out of a side turning in front of me, straight into the side of another vehicle, before swerving into the side turning opposite, and coming to a less than graceful stop.

I'm remarkably calm, considering what I have just witnessed. My biggest fear is arriving on scene before the ambulance staff, as that always leaves me very vulnerable and unsure of what to do next. I know that sounds very wimpy, but I depend very much on the experience and assistance of the paras and emts out there.

Anyway, I calmly flick my blue lights on, and park up on the side of the road, next to the wreckage. I am already in my jumpsuit, as I generally don't change out of it at the roadside - too dangerous. I then assess the scene:

There is a car in the middle of the road - it looks on fire, as there is smoke coming out of the side window. The car that has done all the damage is in the side road, and is relatively intact. I can see the driver, an elderly gentleman, sitting in the car, looking somewhat dazed, but otherwise ok. I therefore make the other vehicle my initial priority.

I look into the car - I can see smoke, but no fire. The airbag has deployed, and I realise that the smoke is from there, rather than anything else. There is a single occupant, and she looks alright. She is fully conscious and has no pain anywhere. I leave her and make my way to the other car. En route I call up to Control, and let them know that I have come across the accident, requesting an ambulance.

As I get to the other car and peer in, I am bodily pulled away. I turn, to find a chap, tugging at my jumpsuit. "It's ok," he tells me. "I've seen Casualty, and I can look after him" Good, thank you, now why do you think I am wearing a bright orange jumpsuit with the word "Doctor" emblazoned on my back? I gently, but firmly pull him away from the car, and explain that I would probably be able to cope. He looks at me, and asks what he can do to help. I suggest that he could make sure that no traffic comes down the side road. He eagerly ran off to do so.

A few minutes later, once I had ascertained that the gentleman was relatively unharmed, I became aware of the sounds of car horns blaring behind me, on the main road. I look up, and see my helpful chap, in the middle of the main road, cars all around him. Somehow, he has managed to get the cars to all drive on the right hand side of the road, in both directions. I rush over, and ask him what has happened. He shrugs, and tells me that he was trying to keep the cars out of my way, but that they didn't quite understand his intentions.

"Sir," I say, "Where do you live?" He points to a house across the road. "Now, I need you to do something very important for me." He looks up at me eagerly. "Go across to your house and call someone."

"Who?" he asks.

"Anyone!" I reply.

Children Should Be Seen And Not Hurt

For the Handover Carnival, hosted by my friend and colleague, Ben Yatzbaz, at http://insomniacmedic.blogspot.com/. Well worth a visit...

He's 13, and waiting for a bus to school. It's cold. He's running late. How fab, then, when he sees his sister's boyfriend drive up to the bus stop. Who wouldn't accept an offer like that?

5 minutes later, he is deeply unconscious, lying in the unrecognisable wreckage of the car.

10 minutes later, I am in the ambulance, vainly struggling to get IV access, to pass a tube into his windpipe, essentially to save his life. IV line in, tube is passed with difficulty. He makes no response, despite the fact that I have given him no anaesthetic drugs. This is bad news. His pulse slows, down to 30. There is no pupillary response to light. He has a severe head wound, and his neck feels as if it broken.

The monitor shows a heart rate of 20; wide, very abberant waves. I can feel no pulse in his neck or groin. I open up the giving set, and push through another 500mls of saline. None of us are talking much in the ambulance; we all know where this is going.

Asystole: flat line. I consider making a cut in his chest, to decompress any tension pneumothorax, but I know it will be to no avail. One of the paras begins CPR, and I tap her on the shoulder, and silently shake my head.

I ring the local hospital - it's not mine, but I know the team well there, having worked there a number of years before. I let them know the situation: that we are bringing in a young lad, injured in a serious RTA, and who I have pronounced on scene. It is not usual practice to take someone to hospital after you have pronounced life extinct, but I can't leave him here, and I know the family have been informed. For their sake, he needs to go to the hospital.

I travel with him, a silent journey, no sirens, no blue lights.

At the hospital, we are met by a paediatric trauma team - my message clearly did not get through properly. I tell them what has happened, and they disperse, until I am left, alone with the paramedics and the A&E nurse and .. Oh no! I don't even know this child's name.

"The aunt has arrived, will you talk to her?" I look around. The receptionist stares back at me, tears glistening in her eyes. "I know him," she whispers, as she leaves the room, without a backward glance. I remember how difficult it is, working so close to where you live, when any one of the thousands of patients you see could be a friend or a relative.

The aunt had been on scene, had seen the car, knew her worst fears had been realised the moment I walked in to the relatives room. We sit there quietly for a few moments, she just telling me isolated snippets of his lfe; things he got up to, what he was like.

And then, it is time for me to leave, to drive to my own place of work. All day long I am not my usual self, thinking about how every single decision can have such far-reaching effects.

A month or so later, I am sitting in my office, dreading the arrival of his mother, a lady I haven't yet met, but who wants to talk to me. She enters, and I rise to greet her. She looks around my office, at the many photgraphs of my five children, and a wistful smile flickers on and off her face.

She wants to know what happened at the scene, and I tell her, sparing her no detail. It is my impression that what is imagined is always worse than reality. She asks me if he said anything to me, and I shake my head, and tell her that, based on what I had seen, he had been deeply unconscious from the moment of impact. She frowns. "But I was told he was talking initially," she tells me. I probe a little deeper. It turns out that her sister, the aunt whom I met on the day, had 'phoned her and told her that her son was talking, possibly so as not to unduly distress her initially, before the worst was known. The mother had never discussed that with anyone since, yet had lived with the thought that her son must have suffered terribly before he died. I assure her that that was definitely not the case. She clings to this information, making me promise. I do so, and tears roll down her face. What had been imagined was far, far worse than reality.

She leaves my office, and I sit there, staring at my photographs, my own tears starting to flow.

EDIT: Now, this is really spooky. I have just come back from a job, and, while in the back of the ambulance, the para told me that the last time we had worked together was about 3 years ago, when a kid died after getting a lift from his sister's boyfriend! Three years ago!! I still have goosebumps, thinking about the strange coincidence, that I should write about this case this morning, and meet up with the same crew this afternoon...