Wheely dangerous

Spent yesterday (I think, even our RTC victim was better orientated to day/date than I currently am) with the local LIVES volunteer doc (who is also an ST1 Anaesthetist and previous A&E Nurse & Army Paramedic), trawling the county for car crashes and cardiac arrests.

It must have been the quietest day in ambulance history. We had 8 1/2 hours without a single call. And even that was only a tiny piece of scone gone down the wrong way. We drove 30 miles on blues to get to it, as it came through as a cardiac arrest. I never even saw the patient, since there was a crew already on scene.

Instead, we spent the day on what amounts to an 'Intro to Pre-Hospital Care' course :)
Toured our local A&E (and left shocked at finding anaes units with halothane in them - even I recalled that my notes say it's no longer used! To be fair to them, there was a note on the halothane section recommending use of another agent).
Went to the local Fire station and checked out their search and rescue vehicles - they are literally massive store cupboards on wheels! Scissors the size of my body for cars, ropes thicker than my arms, huge lights for nighttime accident scenes, blocks to stabillise RTC cars... Plus everything you could ask for to completely destroy a car in a matter of minutes, from chains, glass cutters, scissors, separators, and 'ram's - hydraulic cylinders that are wedged under dashboards and extended to pull the entire dash forwards and up, away from anybody's legs! Strangely enough, they also had everything you could need to pull a cow out of a ditch...
Headed out to the smaller ambu-station that sits mid-way between us and the coast, where we found a single crew with their feet up watching morning telly :)
In that same town is our LIVES headquarters, so we went up there too. Had a lovely chat with two of the guys there, about how LIVES works, how it's funded, what it's capacity is, success rates, job variability, growth of local responder groups, AED access in public places, etc. Also checked out the recording from an AED brought in after an unsuccessful resus on a cardiac arrest. The guy had been down for 20 minutes before the responder got there, with security staff doing CPR until then. The trace was coarse VF, so he got 2 shocks. It was so easy to see where the CPR was occuring and when the responder stopped to do rescue breaths, and the timings of everything. After 2 shocks, he went down to asystole, but CPR continued for 26 mins total. The ambu crew took 33 minutes to arrive. Sounds shocking, but it was in a pretty remote area, and the responder was actually on scene just 4 minutes after the call was made.
After visiting HQ, we travelled on, out to the coast. The station out here is pretty tiny too, with 3 ambu's. Gorgeous weather, so we had a wander along the sands with a portion of chips each! Town was packed to the gills with chavs and oldies. We thought we'd check out the hospital too, and boy were we in for a shock! Residential street, with a (very) large house on one end. Yup, that house is the hospital. The original 'cottage hospital' sign was still above the door! Inside, we were almost on the set of The Royal. The house had been marginally converted and added onto over the years, but the A&E dept. was a corridor with the original rooms stripped and a hospital trolley added in each. Resus was a curtained off wider room at the end. Forget the horror of halothane gas machines, there were no gas machines! The radiographer went home at five, so no scans after-hours. Any trauma was taken straight out of town, 20-30 miles down the coast. We exited in complete hysterical giggles. I honestly didn't believe places like that existed. It was genuinely like being in The Royal!
The station was still dead, couple of Cat C's at lunchtime but nothing for us, so we headed north to another seaside down. It was so depressing that we drove straight through. Now was when we got our 'cardiac arrest' call! Quick satnav instructions, lights and sirens on, and we were off!
Horrendous roads, horrific corners, at horrible speeds. I think we did a minimum of 50, and that was in the corners. [Disclaimer: at no point did we exceed the emergency driving regulations of being more than 20mph above the speed limit.] Arrive at the nursing home. Para wanders out, looks a little surprised to see us, and explains it was a momentary choke-vomit-back to normal. Quick break to let the adrenaline of the drive wear off, and we were back on the roads, heading back towards HQ town. Well-deserved cup of coffee, an episode of eggheads, and we got our big shout. Entrapment/RTC!

We drove 40 miles in increasingly heavy downpour, down tiny bendy back roads that our rural county is well known for (and contribute greatly to our road carnage!) as fast as we could safely go. More info comes in as we travel: the main casualty is pregnant, and there are several other casualties. The entrapment remains.

10 miles out, I check the map for the exact road we're after, as Control can't put coordinates through to our Satnav like they can on their own vehicles. I get my fluoro coat on, and try and work out how to get the helmet on, so there's less time faffing around when we arrive.

1 mile out. I have no saliva left, my heart is about to implode, and I'm shaking like a leaf. Quite how Matt manages to drive, and think about all the eventualities on scene, while every drop of adrenaline surges through, I have absolutely no idea. The helmet goes on.

At the end of the road is the Police - Accident cordon. Oh shit. This is not a minor.

Around a corner, and there it is. All I can see is blue lights. As we slow, and a policeman moves the second cordon to let us on scene, I can identify a fire truck, an ambulance, a police car, and a paramedic team leader car. But no mashed car... yet.

As we pull round the ambulance to move to the far end of the scene (our car is less visible than a massive red fire truck, and it gives us time to assess the scene while parking), I spot the underside of a car. Off the road, in a field. In a ditch, to be precise.

We jump out, and I grab our trauma bag while Matt gets his helmet & extrication gloves on. As I deposit our stuff at the equipment dump site (a big tarpaulin the fire service lay out for all of us to put our gear on, so it's central to the scene and in no-one's way), I can see that we're not here for our extrication skills any more. The fire service are carrying a long board (occupied!) away from the ditch.

[I'm dumping our stuff off, and a copper nearby greets me. My immense nerves immediately blurt out "I'm just a medical student! I'm with the doctor (point at Matt)!". Gibbering wreck indeed. I think I was incredibly scared he was gonna assume I had some degree of medical competence and get me to do something! I'd never looked at my helmet before this call (it's carried in it's own fluoro bag) and I was expecting it to say 'OBSERVER' all over it. It doesn't. It says 'AMBULANCE'. Shit]

Matt runs back to the car to check out the damage while the paramedics deal with the patient. A quick glance at the wreckage patterns and physical damage to the car, and we're headed to the ambulance.

Our patient is loaded as we don our gloves (the medical examination ones, not the extrications and I try and overhear everything everyone is saying. We have a lone female patient (other casualties were very minor injuries and are with the police, giving details), 8 months pregnant, driving the vehicle when it flipped.

She's got a fair amount of dried blood in her hair and all over her face and hands, plus one foot (shoeless). First things first; she's talking, so we have an airway. And if you can talk, you're breathing alright. We do a formal assessment as well, cutting through her bra (hope it wasn't her favourite!) to examine her chest for open wounds and have a good listen for equal air entry. Her pulse is fine (turns out she's only 8 weeks, not months, pregnant, so all those physiological differences we discussed on the way in are irrelevant here), BP is normal, and she's satting at 99%, so all good.

The paras/fire service have her firmly tied on a long board, with a collar and head blocks. We get her out of those (with either the para or Matt holding her head straight at all times, checking that the other has full control before letting go) and start poking. She's tender over 3 cervical vertebrae, so that collar is going back on in a second.

Tenderness is also found over the zygoma, temple, and around the back of the head. No open lac is found for all the blood, but her hair is pretty clotted up already. She's quite capable of telling us where it hurts, and can identify the day and date better than I can (I could have sworn it were Monday, and as for the date.... ), so that along with the lack of other neurological symptoms (pupils, etc) is a reassurance.

[While Matt is doing his poking and prodding, the para grabs me to the feet. "I think her ankle's dislocated - it just looks wrong. What do you think?" Erm.... I think I'm supremely underqualified for this! However, my bedtime reading of Essential Ortho came in handy. She had pretty pudgy ankles (due to obesity, not pregnancy) that obscured any tuberosities or prominences, and a very curved foot. I had a quick press along the front of the tibia, and there were no depressions, abnormal movements or points of weakness (and no sudden screams from the head end!) and the same along the dorsum of the foot. We took the other shoe off to compare, and it seems she just had really tiny curved feet! I couldn't find any evidence of either fracture or dislocation, and Matt had a check of both ankles/feet on his secondary survey and found nothing either (he had the advantage of being able to ask her to flex/extend her ankles and wiggle her toes, which I couldn't do because she was busy answering his questions about head injuries!), so I was pretty pleased with myself on that count. I will add that I did explain that I was only a student before I did anything/said anything else.]

Matt's pretty sure we won't travel, given her stable condition and fairly minor injuries (given the mechanism of injury), so we cannulate. 1 grey stops at a valve, so he leaves that dangling while he gets another one in further up the dorsum of her hand. Some choice words from the patient to fill the back of the truck with blue air, but given that I can pass out at a tiny 22g needle, I don't blame her with two 14g's in her hand! I use my new ambulance skills to anticipate the alco-swab, saline flush, tegaderm, and dressing pad (for the failed cannulation attempt) - ok, small contribution, but it makes me feel useful. I get to hang the saline, too, if only because the para is about four inches shorter than me!

We negotiate an A&E destination, recommend a trauma call to the receiving team to be ready in case of any deterioration en route, and leave them to it. The fire truck and all but one police car have gone by now, having done their bit. The fire truck in particular hightailed it out of there as soon as the patient was out! The ambulance pulls away as we strip off gloves and gather ourselves together.

Time for a longer look at the scene, now the casualties are sorted. The skid marks on the road are obvious from the corner (opposite to the direction in which we arrived), swerving across the wet road. There's a gouge out of the tarmac with some scrapes of car paint that show exactly where it flipped (I never realised it could cut holes in the road!), and the flattened long grass at the roadside shows where it slid across, to land pretty squarely on it's roof, wedged in the ditch.

We head down into the ditch to have a closer look. The roof is squished in, down to about head-rest height I reckon (couldn't estimate properly as the seats had been fully reclined to get the patient out through the boot. She'd been suspended via seatbelt, but unclipped herself and tried to self-extricate, but not got far.), and quite crumpled. The back end is relatively unharmed, suggesting a front flip, rather than side. The back windscreen is way back towards the road and the front is attached round the edges, but fully splintered from ground contact. The side windows have all been shoved out too. Inside the vehicle, the dashboard is completely intact and appears undamaged. Blood patterns on the roof inner show dripping and dragging rather than any spurting (how CSI?!). Shoes and umbrellas are scattered underneath the car. Round the side, we find speaker casings, windscreen wipers, and the front grille (still with logo attached) scattered across the field for around 10 yards. The front of the car is tricky to see, with the bonnet and the ground keeping each other company. I have tons of photos of the wreckage (plus impromptu ones of Matt (also taking photos) and of the copper who came to put his 'Authorities Aware' sticker on the wreckage) - tis entirely legal to take photo's, so long as anything involving patients is fully consented first.

So, get the bags (completely unused, but soggy) back into the boot, get helmets packed away, and dry off with the in-car heating :) Then we headed up to the A&E where our patient had disappeared to. Rang R on the way to organise my lift home from the station, and that's when the shock hit. Partly cos he flipped his car a couple of years ago. I didn't even know him them, let along have seen the wreckage, but looking at that car in the ditch, I could only imagine how terrifying it must have been to flip over at speed... He came away with a fragment of windscreen in his knuckle, and a torn earlobe. Lucky sod :) I do believe I told him (on this phonecall) that he was never ever driving again. I calmed down over a cup of tea in a pub en-route (to give A&E time to assess our patient and get some scans/treatment organised) though.

Turned up at A&E (about 2100hrs by this point) and wandered round to resus, only to be accosted by a nurse and doctor. Ahem, is the entire fluoro jump suit (marked in huge letters with the words 'ANAESTHETIST', 'DOCTOR', 'BASICS', and 'LIVES') not clear enough? Plus, we knew the patients name, injuries, and location/type of accident. We'd hardly just wandered in off the streets.

Turns out they'd only just assessed her. We popped in to say hello anyway, and she was sufficiently compus mentis to recognise Matt ('that nasty doctor' - who was perfectly nice until he wanted to put big needles in!).

Got back to the main ambu station about forty minutes later and called up to check on her progress. Still not scanned, but at least the CT had been ordered by now.

I got a text at just gone midnight to confirm that she only had scalp lacs, and no skull fractures! All good news! A&E staff were suspecting a depressed skull fracture cos her head was pretty 'boggy' at the back, but turns out it can feel like that with scalp lacs because of the looseness of the aponeurosis and the way blood can fill that gap, outside of the skull. So she'll be in til today for observation, and possibly for O&G input to check on her baby, but at 8 weeks, with that amount of padding, I'm pretty sure s/he's just fine :)

All in all, I'm incredibly grateful for the day I spent with Matt. Even with only one call, I learnt a hell of a lot, and I haven't even seen him do anything outside of a paramedic remit yet!

The adrenaline rush of turning up on scene not knowing exactly what awaits you, while knowing that it must be serious seeing as we haven't been stood down en-route, is just.... immense.

I've already started putting out feelers for what I can do in pre-hospital care, even at this stage of my career. I can't wait to see what the future holds....