Holiday

Hi Folks

Just wanted to let you know that I'm off on holiday with Mrs RRD and the 5 kids. A nice, leisurely drive down to the South of France. I must be mad!!! I packed an emergency bag, then found myself working out the doses of anaesthetic agents and tubes sizes for each one of my family, at which point I gave up. I'm taking a pack of steristrips and some glue, and that's it! Mrs RRD however has taken the contents of the local pharmacy with her. See you soon!

RRD

A Public Apology

This goes out to all the paramedics and EMT's out there. Today I received a blog rating from a paramedic. While he gave my blog a very respectable 8 out of 10, he also raised a very serious concern he had with what I write. I will quote him verbatim: "Several times I noticed the author mentions having to give advice to paramedics re. gaining IV access and providing fluids etc. Seemed at times like he was implying paramedics just wait around for the Dr, not knowing what to do and needing their advice."

I would like to state very publicly that this is not at all how I feel. I work on a daily basis with paras and EMT's, and have nothing but the greatest respect for them and for the work they do. I am there to provide assistance, where needed, and to work together with the crews. Clearly this has not come out in my writing, and for that I apologise.

Fire!!!

"Explosion in NearTown, persons reported." I grab my watch and stare, bleary-eyed at the time: 03.30. I'm in the car in minutes, and I shake my head, trying to clear the last vestiges of sleep from my mind.

It's an easy journey, and my thoughts go to the management of severe burns. The priorities are still the same; airway, breathing and circulation; but in this case they take on a whole new meaning. Very often with a severe burn there is swelling of the soft tissues of the neck and throat, making the airway close up alarmingly quickly. I will need to look for evidence of inhalational injury, and act accordingly, rather than waiting for something to develop. Similarly, the lungs can be badly damaged by the smoke and the heat, and the patient can deteriorate very rapidly. As far as circulation is concerned, burn victims lose a large amount of fluid, both from the initial burn and from the exposed flesh, leading to severe dehydration and low blood pressure. They need lots of fluid replaced. However, those damaged lungs will not tolerate much fluid given to a patient, and will leak plasma into the air spaces if too much is infused. It's a very fine line to be tread.

And that's not including the management of the burn itself. Learning which dressings to use when is a whole career in itself.

I arrive on scene. I know I am there because of the vast number of fire tenders, all parked across the road, in the road, on the pavement. Oh well, it's on foot from here.

As I make my way slowly through the emergency vehicles, managing, on 3 separate occasions, not to trip over a fire hose, I am greeted with an increasing amount of debris. A chair. A filing cabinet, strangely mishapen. Half a table, its corners burnt. And then, as I approach the building, there is just a space. A gap between two other buildings, filled with rubble. The roof tiles are strewn across a huge area. I wonder why I have been called. Surely, no-one could have survived this.

I am directed to an ambulance. I open the door and enter, heavy hearted. My one fear, bordering on phobia, is that of being involved in a house fire. So many times I have been presented with men and women, occasionally children too, who had no chance of survival.

This man is talking. He apparently had come home, to his flat above a newsagents, and switched on the light. At which point, he tells me, his world exploded. When the fire crews arrived, he was sitting on what was left of the stairs, headin his hands, wondering what had happened.

He's not unharmed, far from it. I make a rapid assessment: He is talking, but his voice is hoarse and he has singed nasal hairs. He's going to need intubating some time soon. His chest is clear, with only a few wheezes. He has a good pulse and blood pressure. His burns are quite extensive - about 30% estimated. He will need to go to a specialist unit to have them properly treated. My mind shifts to an email I received from our regional burns centre, stating that they would no longer accept any direct referrals from the roadside, and that these cases need to go to the local hospital first to be stabilised. Good, that's one decision out of my hands...

So, do I tube him here, or get him to the nearest local, about 15 minutes away. I think back to my last post, when I took an unintubated patient to the very same hospital, expecting an immediate response, only to get ticked off when they did nothing. So, that's another decision made: he's being tubed here.

I am always very worried when I tube a burns victim. I have no idea until I have a look with the laryngoscope how much swelling has already occurred. There is always the possibility that the windpipe is so narrowed that it will be nigh on impossible to get a tube in place. I prepare the standard drug cocktail, and open my emergency airways pack. This is a set of instruments designed for me to make a hole in the patient's neck, and pass a tube directly into the windpipe. Never done one yet, but I'm not going to be caught out.

I give the drugs, take a deep breath, and pass the laryngoscope in to his mouth, sweeping the tongue over to the left, to give me a view of .... the cords!!! Yippeee! I can't describe the relief I get when I see the glistening white of the vocal cords, with the windpipe visible as a dark tunnel. These cords are not so glistening: there is a fine coating of soot, and this tells me that, had I not tubed him there and then, the journey to the hospital would have been a whole different ball game...

Tubed, ventilated, packaged. We call in the job, and drive to the local A&E Department.

After we finish the necessary paparwork, tea and debrief, the crew drive me back to the scene. It is daylight now, and we stand there, wondering how anyone could have survived such a devastating blast.

Fall From Height

He lies there, at my feet: a broken man. He had jumped from the car park on top of the local shopping centre. I look up at the dizzying height of the roof above. How many times had I looked over the edge of Level 6 of the car park? I imagine the fall, can see his flight to death. The rain now falls on to his back, his head twisted at an angle incompatible with life, eyes sightlessly looking up at where he has jumped from.

For he is dead, of that I have no doubt. But, there are formalities to complete, before I can stand up, stretch out my back from kneeling awkwardly at his head, and say the words that will signify the end of this poor man's life: "Ok folks, I'm calling this one at... 16:43."

I gently roll him on to his back, and proceed to pass a tube in to his windpipe - the view is initially obscured by blood, and I use the suction to clear my way. Tube in place, I then make two cuts, one on each side of his chest, and push my finger through muscle and fascia, then between the ribs, into the chest cavity, in order to decompress any tension caused by a collapsed lung. That done, and still with no response, I stand, stretch out my back, and call it.

Oh, The Power!!

As a counter to my last post, I just thought I would relate what happened to me this morning:

I arrived at work, and parked up just outside the ambulance parking bay. As I was chatting to one of my friendly paramedics about a job he was on at the weekend, another ambulance pulled up alongside. The EMT got out, and took out the new fold-up chairs that they have been issued with. After a few minutes of watching him struggle with this strange contraption, the para and I wandered over. Deftly, and within a few seconds, the para had assembled the chair.

"Thanks, Doc!" said the EMT.

I'm Angry!

Ok, so I've just got back from a job, and I am so angry with what has just occurred:

He is 43. He has been out for a drink in a pub. Not something to get hit over the head for. He did ask another drinker to apologise for knocking his drink over. Not something that should lead to him lying on the ground with a gaping wound in the back of his head. But it did.

And so, here is James, a rather pleasant chap, according to his mates. He's not being very nice now. He is swearing and snapping at all of us. And when I say snapping, I mean he is trying to use his teeth on us. He can't, but only because there are 4 very strong police officers, holding him down. He needs cuffing, for our safety as well as his. He doesn't like this, and is pulling so hard at his cuffs that his wrists are red raw. Language I am hearing tonight is bluer than on Saturday Night Live. OK, you know the drill by now: the Primary Survey:-

Airway: perfectly maintained, as evidenced by the expletives that emanate from his mouth
Breathing: there's no point trying to listen to his breathing, but he has not received a blow to his chest, so I am happy
Circulation: we can't get a blood pressure, because he won't keep still, but his pulse is regular and strong
Disability: he scores 3 out of 4 for his eyes, as they open if I shout at him. I'll give him 4 out of 5 for voice - I wouldn't say he is orientated, but he certainly knows what he is saying! And he can have 5 out of 6 for motor, because, while he won't obey commands, he is trying his best to do a Houdini with the cuffs.

I do my usual at this stage. I get down close to him and reason with him: "Keep still and we'll take the cuffs off," I tell him, much to the consternation of the rather battered officers. He does quieten, but I don't think getting him out of the cuffs is going to be a winning decision with anyone else.

I know that we are only 3-4 minutes away from NeuroHospital, and, I reason, it's far safer to just go, as opposed to giving him a Rapid Sequence Induction (drugs to put him to sleep so that I can pass a tube into his windpipe and breathe for him.) So, as we are already in the back of the ambulance, I let the team know my plans, and we set off. As we start, one of the team passes the information to NeuroHospital, so that they are ready for us when we arrive: Male, 43, severe open head wound, GCS 12/15, combatative, DA (that's me!) on board.

We arrive, and wheel him in to Resus. We are met by... A nurse and an FY2! A junior doctor, 1 1/2 years post qualification!! At least we have an experienced nurse, but still!! I look around pointedly, and ask, "Where's the Trauma Team? Did you not get our call?" He replied, "Yes, but we didn't think it warranted a Trauma Call." What?? I only didn't tube this chap because I knew we were on the doorstep, and now there's just no-one here to look after my patient. I ask the nurse to put out a call; she just shrugs and goes out the door. Great!! Now we haven't even got a nurse in here!!!

A minute or so later, she returns and tells me the Consultant is in the Department, and will be coming in. Phew!! But no. He wanders in, looks down at me, and talks over me while I am trying to explain what has been occuring. Not interested in the pre-hospital situation, he goes over to the 'phone and tells the radiologist that the scan can be performed with the patient awake. I storm out, muttering under my breath.

The point here is that, despite the fact that the patient is now much calmer, he has had a very significant injury, with very significant pre-hospital features, and the hospital staff are ignoring all we are saying. This has made me angry. My ambulance colleagues are angry. We sit by the vehicle, drinking NHS tea, and bemoaning the difficulties associated with the interface between pre-hospital and in-hospital. As a Consultant, they expect that at least I will be taken seriously, even if they aren't. It's an eye opener for them too.

I have just rung NeuroHospital - he has cerebral contusions and is being intubated as we speak. I'm not a happy RRD.

The Handover Carnival

Well, at long last, here is June's edition of the Carnival. Communication is so important to all of us that I wanted this to be the subject of my edition.

And I am happy to start with a submission from the editor of last month's Carnival, about communication bourne of many years, demonstrating the love between family members:
http://rescuing-providence.blogspot.com/2009/01/communication.html

Peter wants to try and persuade us of the benefits of smoking in his entry:
http://medicscribe.blogspot.com/2006/02/cigarette.html

Our insomniac colleague has some thoughts on 21st Century Britain, that made me sit back and think:
http://insomniacmedic.blogspot.com/2009/04/21st-century-britain.html

A great post from Medic 3, about how sometimes there can be too many words, and no communication:
http://www.medicthree.com/2009/05/here-at-little-ambulance-that-could-we.html

Dani provides us with an insight into how the body can communicate volumes to us, and help us medics do our job properly:
http://medicdani.blogspot.com/2009/05/body-never-lies-how-we-communicate.html

Lumo has something to say, to every patient who has walked into the A&E Department - maybe we should have a biiiiig poster made for the Waiting Room:
http://lumo-wafflings.blogspot.com/2009/05/dear-patient.html

Our HappyMedic has a wonderful post, filled with memories from 1968, and how the communication worked way back when, before mobile phones and pages - possibly better than it does now...:
http://yourhappymedic.blogspot.com/2009/03/pegging-board.html

"It's wern me!" What does this mean? In New Orleans it means something, and to the patient it is important that Sean knows, so that he can help. Read this well-written tale of difficulties with "English" in another language:
http://newburningtiger.blogspot.com/2007/02/ramp-rants-communication.html

Our very own MedigBlog999 has submitted this entry, about Michael, who has is own way of communicating, hopefully not what any of us would subscribe to:
http://medicblog999.wordpress.com/2009/06/08/its-all-about-how-you-say-it/

Here are some tips from Steve about using communication to make a connection with your patient - well worth noting:
http://theemtspot.com/2009/06/09/connections/#more-920

And my final entry, from Kristan:
http://newparamedic.blogspot.com/2009/06/communication.html

This has been a real experience for me, hosting this Carnival. I am looking forward to next month, which is to be hosted by our very own TraumaQueen, whose blog I have followed with interest ever since I started my own. Head on over to his website to see what I mean.

Next month's Carnival is entitled "Pivotal Moment". Entries to kal@traumaqueen.net, by 27th July.

RRD