Why didn't she drive slower?
Why did she hit the lampost?
Why didn't her seatbelt save her?
Why did these three young girls have to die?
How To Get Affordable PVC Paste Resin
4 years ago
Thursday, 27 August 2009
Thursday, 20 August 2009
My First Emergency
This month's Handover Carnival is entitled 'My First Emergency', and here is my submission.
The date: August 1996. The place: Knebworth. The band: Oasis. 125,000 fans have come to Stevenage to pay homage to two brothers for a weekend 125,000 each day! My job at the time: Registrar in A&E at The Lister Hospital, Stevenage.
The weekend starts off as most do, fairly quiet. A few drunks left over from the night before, the early morning jogger who is hit in the chest by the sledgehammer of a heart attack. I and my team listen to the radio reports, sending out information about the hoards of fans streaming up and down the A1 towards our normally peaceful town. The ambulances slowly roll in, each one finding it harder than the last to get through the traffic.
And then it happens - the blue 'phone rings. This is the 'phone that is a direct line from Ambulance Control, and is used to let the Department know of the impending arrival of a critical patient, either a cardiac arrest or a major trauma. But not this time.
This time, Ambulance Control has another problem. An ambulance has been dispatched to a serious RTA, with a barely conscious driver, and the traffic is so bad they don't think they will be able to get her to us in time. Could we send a mobile team to the scene.
Many a time I have found myself outside the Department, in full Personal Protective Equipment, fully laden with kit, waiting to be collected and taken to the scene of a major accident, only to realise, some 10 minutes later, that it was, once again, a wind up by my "friends." Not this time. Within minutes a police car arrives at the door, and me and Newbie are being rushed across town to a car that has driven into a railway bridge.
I must remind you that this is 1996, 4 years before I start my job as a HEMS registrar, 6 years before I become a BASICS doctor. I have NO experience of pre-hospital care.
We turn up at the job. There is a car, mercifully on all four wheels, but buried bonnet-first in the upright of a railway bridge. The driver is still in the car, and the fire crew have begun the job of dismantling the vehicle. The roof is off, and she is very nearly out.
No seatbelt means that she has hit face first into the windscreen. She has nasty lacerations across her chin and on to her right cheek. Her face is oddly flattened and elongated, a sign I have read about but never seen. She has a severe facial fracture (a Le Fort 3, for those of you in the biz) and is going to have a tough airway to manage.
Out she comes, and on to her back. Airway: virtually gone! I go to open her mouth, only to find it won't open! She has a severely fractured lower jaw, and it is not going to move for me. Oh BUM!! I grab a endotracheal tube, and slowly and carefully pass it into her left nostril, and feel the tube as it goes down past her tongue. Blind nasal intubation is a very difficult procedure, and I had only done a couple, under very controlled circumstances in Theatre, but I had very little else to offer this girl. She coughs as the cord passes her cords (I hope). Newbie listens to her chest. "Nope, no breath sounds," he reports. BUM, BUM, BUM!! I take out the tube, not being sure it was in, and reach for a needle to stick through the skin of her neck and in to her trachea, so that I can breath for her that way. If Blind nasal intubation is difficult, needle cricothyroidotomy (a posh name for sticking a needle into someone's throat) is no better. I have had no experience of this one at all. Still, I have a go. "Nope, no breath sounds." Newbie, I don't like you any more!! Still, if there are no breath sounds, then something else has to be done.
There was no way I was going to go to the next stage, of cutting her neck and introducing a tube under direct vision into her trachea. That was well out of my league. I carefully insert the blade of my laryngoscope between her teeth and twist. A splintering sound heralds the end of her incisors, and a pulling up on the laryngoscope certainly doesn't assist the shape of her jaw. But, I can now see the cords, and I quickly pass the tube between them, into the dark safety of the trachea. "Nope, no breath sounds," comments Newbie. Do you actually know how to use your stethoscope??? I listen myself - not a sound. Bum, tit and other bits of anatomy!!!!!
Suddenly it dawned on me. I grab a scalpel blade and perform my first two pre-hospital thoracostomies, with a very satisfying hiss coming from both sides. Bilateral tension pneumothoraces is uncommon, but will certainly give the physical sign of absent breath sounds on both sides.
She now has an airway, she has a pulse, and she is ready to go. I have saved this one. So far. But we need to get to hospital quick. And there is no way through the traffic.
I am told that there is a police helicopter, and we can use that to fly her to the hospital. But I will have to fly with her. I don't do flying, and have never been in a helicopter. I steel myself, don my flight helmet and say to Newbie, "I hope I don't throw up en route." Advice to the unwary: Flight helmets are fitted with radio mikes. Everyone in the police service heard my comment. It takes a long time to live that one down.
-----------------------------------------------------------------------------------
This may have happened 13 years ago almost to the day, but I can still see the driver, can still sense the metallic taste of fear in my mouth as I battled to save my very first pre-hospital patient.
The date: August 1996. The place: Knebworth. The band: Oasis. 125,000 fans have come to Stevenage to pay homage to two brothers for a weekend 125,000 each day! My job at the time: Registrar in A&E at The Lister Hospital, Stevenage.
The weekend starts off as most do, fairly quiet. A few drunks left over from the night before, the early morning jogger who is hit in the chest by the sledgehammer of a heart attack. I and my team listen to the radio reports, sending out information about the hoards of fans streaming up and down the A1 towards our normally peaceful town. The ambulances slowly roll in, each one finding it harder than the last to get through the traffic.
And then it happens - the blue 'phone rings. This is the 'phone that is a direct line from Ambulance Control, and is used to let the Department know of the impending arrival of a critical patient, either a cardiac arrest or a major trauma. But not this time.
This time, Ambulance Control has another problem. An ambulance has been dispatched to a serious RTA, with a barely conscious driver, and the traffic is so bad they don't think they will be able to get her to us in time. Could we send a mobile team to the scene.
Many a time I have found myself outside the Department, in full Personal Protective Equipment, fully laden with kit, waiting to be collected and taken to the scene of a major accident, only to realise, some 10 minutes later, that it was, once again, a wind up by my "friends." Not this time. Within minutes a police car arrives at the door, and me and Newbie are being rushed across town to a car that has driven into a railway bridge.
I must remind you that this is 1996, 4 years before I start my job as a HEMS registrar, 6 years before I become a BASICS doctor. I have NO experience of pre-hospital care.
We turn up at the job. There is a car, mercifully on all four wheels, but buried bonnet-first in the upright of a railway bridge. The driver is still in the car, and the fire crew have begun the job of dismantling the vehicle. The roof is off, and she is very nearly out.
No seatbelt means that she has hit face first into the windscreen. She has nasty lacerations across her chin and on to her right cheek. Her face is oddly flattened and elongated, a sign I have read about but never seen. She has a severe facial fracture (a Le Fort 3, for those of you in the biz) and is going to have a tough airway to manage.
Out she comes, and on to her back. Airway: virtually gone! I go to open her mouth, only to find it won't open! She has a severely fractured lower jaw, and it is not going to move for me. Oh BUM!! I grab a endotracheal tube, and slowly and carefully pass it into her left nostril, and feel the tube as it goes down past her tongue. Blind nasal intubation is a very difficult procedure, and I had only done a couple, under very controlled circumstances in Theatre, but I had very little else to offer this girl. She coughs as the cord passes her cords (I hope). Newbie listens to her chest. "Nope, no breath sounds," he reports. BUM, BUM, BUM!! I take out the tube, not being sure it was in, and reach for a needle to stick through the skin of her neck and in to her trachea, so that I can breath for her that way. If Blind nasal intubation is difficult, needle cricothyroidotomy (a posh name for sticking a needle into someone's throat) is no better. I have had no experience of this one at all. Still, I have a go. "Nope, no breath sounds." Newbie, I don't like you any more!! Still, if there are no breath sounds, then something else has to be done.
There was no way I was going to go to the next stage, of cutting her neck and introducing a tube under direct vision into her trachea. That was well out of my league. I carefully insert the blade of my laryngoscope between her teeth and twist. A splintering sound heralds the end of her incisors, and a pulling up on the laryngoscope certainly doesn't assist the shape of her jaw. But, I can now see the cords, and I quickly pass the tube between them, into the dark safety of the trachea. "Nope, no breath sounds," comments Newbie. Do you actually know how to use your stethoscope??? I listen myself - not a sound. Bum, tit and other bits of anatomy!!!!!
Suddenly it dawned on me. I grab a scalpel blade and perform my first two pre-hospital thoracostomies, with a very satisfying hiss coming from both sides. Bilateral tension pneumothoraces is uncommon, but will certainly give the physical sign of absent breath sounds on both sides.
She now has an airway, she has a pulse, and she is ready to go. I have saved this one. So far. But we need to get to hospital quick. And there is no way through the traffic.
I am told that there is a police helicopter, and we can use that to fly her to the hospital. But I will have to fly with her. I don't do flying, and have never been in a helicopter. I steel myself, don my flight helmet and say to Newbie, "I hope I don't throw up en route." Advice to the unwary: Flight helmets are fitted with radio mikes. Everyone in the police service heard my comment. It takes a long time to live that one down.
-----------------------------------------------------------------------------------
This may have happened 13 years ago almost to the day, but I can still see the driver, can still sense the metallic taste of fear in my mouth as I battled to save my very first pre-hospital patient.
Saturday, 25 July 2009
I've Got A Hat!
I come to a halt on the motorway, the accident clearly visible. A car is on its side, resting aginst the barrier of the central reservation. Already, cars are slowing on the other carriageway, people craning to get a look at the unfortunates. I jump out my car with the junior doctor who has come along for the ride, and we race round to the boot to collect my bag and monitor. We can hear the high pitched screams of an obviously conscious victim: good!
As we get nearer, I see a group of people kneeling down. I see the victim, and my heart sinks. I rush back to the car to get my paediatric bag, as my head screams at me, "A child! It's a child!"
Fortunately the majority of trauma victims I have to deal with are adult. The few occasions I have been called to children, they have already been past my, or anyone else's, care. Children are not just small adults. Their whole anatomy and physiology is different enough to make dealing with kids a separate speciality in Medicine. And it's not mine! I have a paediatric bag, filled with pouches, colour-coded for different ages. But that's like being asked why you think you could be a lion-tamer, and answering, "I've got a hat. It's got the words Lion-Tamer on it." I'm not a Paediatrician, despite the bag.
I run back to the scene and assess.
The child is a 4 year old girl. She has apparently been ejected from the car as it rolled. Airway and breathing are most definitely intact, as she is screaming loudly. Similarly, circulation is not immediately a problem. She is able to talk, when she is calmed down a little, and is able to recognise her father, who was driving the car at the time. I then turn to a secondary assessment, looking at injuries not immediately life thratening.
She has a large gash on her forehead. She has a severely broken left arm. More obvious, and very distressing, she has a massive degloving injury of her left leg. A degloving is where the skin (and sometimes muscle) of a limb is sheared off, much like removing a glove. Usually, and in this case, the skin is still attached, just pulled out of position. Ouch!
My assessment finished, I consider my options. She clearly has no life threatening injuries as far as I can see now, but there may be internal injuries that will only become apparent as time progresses. However, the injuries I can see means she needs very strong pain relief, and that means giving her a general anaesthetic and intubating her. That's where I don't want to be going. But I don't see I am going to have a choice. My mind begins to shut down. I can't begin to calculate doses for a 4 year old!
She has no venous access. I have to do that. Her left arm is a no go. Her right is being attended to by one of the paras, so I move down to her right foot. These needles are tiny, and so are the veins, but at least this is a skill I have mastered! My hand steadies, and the needle slides into the vein. Secured.
Suddenl, I can hear the sound of a helicopter. Not just any helicopter. This one I have flown in many, many times. The distinctive roar of the Explorer gets louder.
"Who called HEMS?" asks one of the paras. "We've already got RRD here, stand them down."
"No!" I shout, "Let them land!"
HEMS is London's Helicopter Emergency Medical Service. I have written about them before, and my usual thought is "Oh no, they're going to take over, aagain." The rule in BASICS / HEMS is smple: whoever gets there first has overall charge of the scene / patient. But that is not always adhered to by the flight crew. Today however, as they come running up, I immediately relinquish all care of the child to them. I am given tasks to do, such as support the neck, set up iv's and talk to the father, jobs I am more than happy to do.
As I sit at home later,Mrs RRD can sense that there is something wrong. She knows the job went well: the child was tubed and ventilated and flown to the local Trauma Centre. I find it difficult, but slowly I open up to her, tell her how incapable I felt, how unprepared I was to manage a patient of mine. She understands. She always does.
As we get nearer, I see a group of people kneeling down. I see the victim, and my heart sinks. I rush back to the car to get my paediatric bag, as my head screams at me, "A child! It's a child!"
Fortunately the majority of trauma victims I have to deal with are adult. The few occasions I have been called to children, they have already been past my, or anyone else's, care. Children are not just small adults. Their whole anatomy and physiology is different enough to make dealing with kids a separate speciality in Medicine. And it's not mine! I have a paediatric bag, filled with pouches, colour-coded for different ages. But that's like being asked why you think you could be a lion-tamer, and answering, "I've got a hat. It's got the words Lion-Tamer on it." I'm not a Paediatrician, despite the bag.
I run back to the scene and assess.
The child is a 4 year old girl. She has apparently been ejected from the car as it rolled. Airway and breathing are most definitely intact, as she is screaming loudly. Similarly, circulation is not immediately a problem. She is able to talk, when she is calmed down a little, and is able to recognise her father, who was driving the car at the time. I then turn to a secondary assessment, looking at injuries not immediately life thratening.
She has a large gash on her forehead. She has a severely broken left arm. More obvious, and very distressing, she has a massive degloving injury of her left leg. A degloving is where the skin (and sometimes muscle) of a limb is sheared off, much like removing a glove. Usually, and in this case, the skin is still attached, just pulled out of position. Ouch!
My assessment finished, I consider my options. She clearly has no life threatening injuries as far as I can see now, but there may be internal injuries that will only become apparent as time progresses. However, the injuries I can see means she needs very strong pain relief, and that means giving her a general anaesthetic and intubating her. That's where I don't want to be going. But I don't see I am going to have a choice. My mind begins to shut down. I can't begin to calculate doses for a 4 year old!
She has no venous access. I have to do that. Her left arm is a no go. Her right is being attended to by one of the paras, so I move down to her right foot. These needles are tiny, and so are the veins, but at least this is a skill I have mastered! My hand steadies, and the needle slides into the vein. Secured.
Suddenl, I can hear the sound of a helicopter. Not just any helicopter. This one I have flown in many, many times. The distinctive roar of the Explorer gets louder.
"Who called HEMS?" asks one of the paras. "We've already got RRD here, stand them down."
"No!" I shout, "Let them land!"
HEMS is London's Helicopter Emergency Medical Service. I have written about them before, and my usual thought is "Oh no, they're going to take over, aagain." The rule in BASICS / HEMS is smple: whoever gets there first has overall charge of the scene / patient. But that is not always adhered to by the flight crew. Today however, as they come running up, I immediately relinquish all care of the child to them. I am given tasks to do, such as support the neck, set up iv's and talk to the father, jobs I am more than happy to do.
As I sit at home later,Mrs RRD can sense that there is something wrong. She knows the job went well: the child was tubed and ventilated and flown to the local Trauma Centre. I find it difficult, but slowly I open up to her, tell her how incapable I felt, how unprepared I was to manage a patient of mine. She understands. She always does.
Thursday, 23 July 2009
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
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
Wednesday, 22 July 2009
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.
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.
Tuesday, 21 July 2009
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.
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...
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.
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.
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.
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