by Stuart Gray
So I stood at the bottom of the stairs with two coppers and the neighbour who’d called us. No ambulance was yet free and the dog handler was a good 30 minutes away.
As we waited, we discussed the tenant’s habits and medical conditions with the neighbour, trying to build up a picture of what might have happened to him. He had a long history of heart problems and he never, ever left the house without his dog, she said. The back door had been left unlocked. Things were looking dire.
After a while, and with still no sight of the dog handler, I decided to use the mirror to have another go at establishing if there was a body in the room.
The first thing I saw (and I can tell you my breathing rate was a lot faster than normal) was a huge Alsatian on the bed. He was looking straight into the mirror at me, with angry eyes and a mouth-full of nasty-looking teeth. I didn’t have much of a horizon to view, and I couldn’t see the man. But he could easily have been elsewhere. It did occur to me that the dog might have eaten him - stranger things have happened - but I dismissed the thought and put it down to nerves.
I craned my neck, trying to see further into the bedroom. Every second or two, my eyes flicked back to the dog; my horror-movie fear was that I’d be scanning the floor as he crept nearer to me, fangs bared. All I’d see were two rows of teeth and a dribble of saliva, followed by a messy end (mine, not his). I still saw nothing of his master.
I came back down the stairs and waited with the other nervous people below. The dog was still snarling and growling menacingly upstairs. Suddenly, and very nonchalantly, a man opened the back door and strode in. A look of shock flashed across his face at the sight of two policemen and a paramedic standing in his hallway. Then he recovered himself.
‘Can I help you at all?’ he asked.
‘Are you the tenant of this property, sir?’ said one of the police officers.
‘Yes, what’s going on - why are you all here?’
Meanwhile, the neighbour is trying to curl up into the smallest ball in the known universe.
‘We were called because your dog was howling and barking and the neighbour thought you were in trouble,’ said the cop.
‘I’m OK. I just went out for the night to visit my sister.’
‘Do you always go out without locking your doors, sir?’
‘Yes.’
I could hear the siren of the police dog van approaching. The dog handler would get out of his vehicle, get his equipment prepared and be told to stand down. He would be so disappointed. I had to smile.
The man went up to see his dog and brought it down to say hello to us. Everyone took a step or two back, but it just walked by, wagging its tail and licking the owner’s hand, and didn’t even look at us.
TRAFFIC
IT’S GETTING WORSE everywhere, isn’t it? In London, it’s beyond bad these days. Despite the higher charges and ludicrous taxes, despite the congestion charging and speed camera rip-offs, our traffic problems are greater now than ever before. Expensive and unreliable public transport systems don’t encourage people out of their cars, and driving to work is still often cheaper and easier than travelling by any other method.
For a paramedic, this increase in traffic means more accidents than ever. Though we’re supposed to call them ‘collisions’ now.
Despite that, the chances of you dying in an RTC are still low, and the number of road deaths has remained fairly constant over the last ten years. Around half of those who do wind up dead on the road are car drivers, around a fifth are on motorbikes and the rest are spread around cyclists, bus drivers and hauliers. Oh, and pedestrians.
Early one cold, foggy Friday morning last December, I was sent to a fatal RTC, called in by an off-duty policeman who’d seen a car swerve in front of him and had then seen a body lying in the road.
It had happened outside a tube station; I raced there hoping, as I always do, that there’d been a mistake and the word ‘fatal’ had been used by accident.
When I arrived there was a queue of traffic blocking my way and vehicles were being reversed out. There was a flurry of activity up ahead and I could see flashing blue lights. I drove down the wrong side of the road to get to the scene and an ambulance followed behind me.
I swung my car around - I was on the FRU at the time - and my headlights lit up a body in the middle of the road, completely uncovered and obviously dead. It was a man and half his head had disappeared. I got out of the car and walked over.
The nearby pubs and clubs were chucking out and loose groups of people were standing around the railings at the side of the pavement; knots of young men and women staring at the mangled body a few yards away. Some, shockingly, disgustingly, were taking photos with their mobile phones.
I crouched down and examined his injuries. He was in his twenties, dressed for a night out drinking and clubbing. His skull had been crushed, leaving a large pool of blood on the road, and his intestines had burst from his abdomen and were lying on the road just in front of him. He wasn’t long dead: an eerie plume of steam was rising into the cold air from his exposed organs. His limbs were all horribly out of shape and place.
RTC. Road Traffic Collision. We used to say RTA (Road Traffic Accident) but someone, somewhere, decided the word ‘accident’ meant that nobody was to blame and potentially posed a legal nightmare. Now, no matter what hits what (eg bike vs. pedestrian, bus vs. car, cyclist vs. manhole cover), someone can be held accountable, although I'd like to see what a manhole cover has to say for itself in court.
I went back to the car and got a blanket. I had used it half an hour earlier to keep a drunken 18-year-old warm; now it was going to cover this young man’s body before anyone else decided to take pictures of it. Although there were lots of people knocking around, no-one seemed to know what had happened to him - even his mate, who was now with the police, had no idea how he’d come to be lying dead in the middle of the road.
As I covered the body up, I noticed there was a club’s wrist tag lying nearby. His trainers had been forced off his feet and were lying at different locations near his body; body parts, which had been forced out by whatever had hit him (and it must have been something big and heavy), were on the Tarmac. I got some yellow clinical waste bags and covered everything on the road that had belonged to him or been him.
Another ambulance had now arrived. Sadly, there was nothing we could do, but we couldn’t move the body, either: this was a crime scene and we had to wait for forensics. So I sat near the body, in the damp, early morning air, listening to the sounds of London around me, pondering. It looked like a straightforward hit-and-run, where the guy had left a club and simply been run over as he walked across the road. But the more I thought about it, the less likely that seemed. His position and injuries didn’t equate to a straightforward stand-up collision with a couple of tons of vehicle. No, he’d been lying down when he’d been struck. I think he’d climbed the pavement barrier and lain down in the middle of the road to sleep. He was probably very drunk, and, for some reason, drunks sometimes do this. I think he was right there, on this busy road, covered in a shroud of rolling fog, when a vehicle came round the corner and ran over him. He was a small man and his clothing was dark; it wouldn’t have been easy to see him. The vehicle had destroyed his head and mid-torso instantly, rolling the body a few times. The driver had then carried on, either because he hadn’t realised what he’d just done - I’ve heard of a similar incident, where the driver thought he’d gone over a bin bag when he’d actually just killed someone - or because he was so shocked and terrified that he didn’t know what else to do. Alternatively - and this is a possibility, these days - he just didn’t care.
Whatever happened, it was all over very quickly. It makes you think: the lad had probably had a shower, splashed on his favourite after-shave, got dressed up and gone out. On any other night, he might have met the woman he’d marry, or had a kebab and gone home. But on this night, when he’d shut his front door, he had six hours to live.
Some RTCs involv
e horrific injuries that are still survivable if the right action is taken. Rapid Sequence Induction (RSI) is carried out in emergencies where there is a need to quickly intubate a patient in order to preserve the airway and lungs. I took a night-time call to a ‘Car vs. Pedestrian’ in a distant part of town. I didn’t think I’d get to it - it was in an area that I normally get cancelled down on before I arrive. In fact, when I got on scene there was a crew already in attendance - a paramedic and an EMT. They were working around a large male who looked either unconscious or dead in the road. The paramedic broke away for a second or two to tell me that the guy had been unconscious since being hit by a car at an unknown speed a few minutes earlier. A Delta Alpha - our term for a rapid response doctor - had been called.
RSI: Rapid Sequence Induction involves putting the patient to sleep using an anaesthetic; this relaxes the muscles so that they cannot breathe for themselves and have no gag reflex, so we then intubate them. This means inserting an endotracheal (ET) tube into the trachea (windpipe); this is sealed so that only the air being pushed through it will enter the lungs. Fluids and other obstructions from the mouth and the contents of the stomach will not be able to get down the trachea – this guarantees a secure airway for the patient. The tube feeds into a cylindrical plastic bag, which is in turn fed by an oxygen bottle. We squeeze this cylinder in a rhythm which mimics breathing, forcing oxygen down the tube and into the lungs, artificially inflating them and oxygenating the blood. Only Delta Alphas – emergency doctors – can perform RSI, and, in the ambulance service, only paramedics can intubate.
I crouched down alongside my colleagues. I could see that the man had sustained a serious head injury but we could find no other significant or obvious trauma to the rest of his body. His neck was stabilised and an oropharyngeal airway (OP) had been inserted to keep his tongue from obstructing his airway. He was breathing and he had a strong pulse, but when I lifted his eyelids to check his pupils his eyeballs were rolling from side to side, a sign of possible brain injury. He also had blood coming from his left ear, so a basal skull fracture was likely. The guy was in serious trouble.
We got him into the ambulance and began to gather all the information we needed for our baseline obs. His breathing was unpredictable (shallow, then deep), and he needed assistance with a bag-valve-mask while I got on with cannulating him so I could run fluids through his veins if necessary.
CANNULATION: A cannula is a plastic tube designed for insertion into a body cavity. We use a cannula for the nasal-delivery of oxygen, and paramedics also use venous cannulae, incorporating a sheathed needle which is inserted into a vein (cannulation) so that fluids and drugs may be delivered. Paramedics will decide on an appropriate size (IV cannula sizing is all about bore width – how wide the hollow part of the needle is) depending on: the age and size of the patient, the size and condition of their veins and the amount of fluid or drugs that are to be given. Larger bore cannulae are chosen for trauma and cardiac arrest, simply because fluids will almost always be given. It is common for paramedics to choose a middle-sized cannula (18g) for most patients requiring IV access because this will enable a choice of drugs and fluids if required. Paramedics may also decide to cannulate a patient so that a vein is made ‘patent’, in case his condition deteriorates and finding an appropriate vein becomes difficult later on. This technique is known as 'Keep Vein Open' (KVO).
The Delta Alpha arrived. As he did so, the man began to stir, probably awoken by the oxygen. The doctor quickly RSI-d him, feeding a sedative in through the tubes I’d inserted.
As the drug went in, the man started thrashing around. We call this being ‘combative’. People with massive head injuries can become very combative, and it’s amazing and frightening to see. Essentially, the higher brain has ‘shut down’ and the person is operating at an instinctive level, with the pre-modern brain stem in charge - it summons up huge amounts of adrenaline, which in turn summons up a huge amount of strength. (It’s for this reason that soldiers in battle report that they are unaware of physical exertion, and how terrified people manage to perform amazing feats of strength - a mother lifting a car off her child, for instance.) Injured people can become almost superhuman and it can take three or four of you just to hold them down; I have seen people hurled - in fact, I’ve been hurled - around ambulances by tiny folks who you wouldn’t look twice at. Obviously, this is dangerous: as they flail about they can easily injure themselves - or us - and break equipment. Blood and tissue is flying around.
Luckily, in this case, almost as soon as he became combative he was out again, thanks to the RSI. He was already bagged, and now we gave him fluids to replace his lost blood; his condition stabilised and he was ready to go to hospital.
I got in my car and led the ambulance there as rapidly as possible, using my vehicle to clear a path, helping to ensure a smooth ride for the patient and those in the back with him.
We got him into Resus and he was quickly taken for a CT scan. His chances of survival should be good, but if the initial crew on scene, or me, had been delayed by a matter of minutes - maybe by one of those hoax callers - he’d have been dead or very seriously impaired. He was a married man with a couple of young kids; we did a good job that day.
OBS: Short for ‘observations’. Initial clinical obs are carried out for every patient, and they include the vital signs; respiration rate, pulse rate, blood pressure and temperature. Other clinical obs include oxygen saturation level, capillary refill duration, BM (blood glucose) measurement, pupil responses and possibly an ECG (an electrocardiogram measures electrical activity in the heart). Generally speaking, an EMT or paramedic will decide which of the non-vital signs require further investigation, although our guidelines direct us to carry out many of them routinely. Two full sets of obs are required if a patient is to be left at home or in the care of another person.
Of course, as you stand over a bleeding, semi-conscious bloke lying in the middle of the road, you can’t concern yourself with his family. You have to keep your emotions in check, however hard that can be. I went to another RTC where a group of teenagers crammed into a small car had sped down a hill and smashed straight into a big, brick wall. No brakes had been applied - there were no skid marks - and they must have hit it at 50 or 60mph. The wall hadn’t yielded, so the car and the people inside had taken most of the force from the impact.
The scene was one of devastation and the LFB (London Fire Brigade - they cut people out of cars for us, hold up fluid bags and give everyone oxygen, and they also rescue cats and do stuff with fires) were already on scene with another ambulance when I arrived. Two of the four youngsters in the vehicle had already been taken to hospital with serious injuries, another was in the ambulance that had arrived ahead of us and we were to extricate and convey the last casualty - a young girl of fifteen who was trapped inside on the passenger’s side.
It took us more than 15 minutes to get her out of the car. She screamed and cried throughout the entire process, and thrashed around, making it impossible to give her morphine. She was yelling about the pain in her legs, and it was thought she may have broken both femurs. This was a life-threatening injury.
We get her out, a pretty young kid with her whole life in front of her, and into the ambulance as quick as we can. Hold her down. Talk to her. She’s not listening. In fact, she’s wailing and kicking those broken legs about. The restraints can hardly hold her. She’s in agony. Her pelvis may be broken, too. Not a moment too soon, the Delta Alpha arrives. She is RSI-d.
So now she’s asleep, which is good, but we have to keep her alive. This is an awesome responsibility.
She was breathing on her own 60 seconds ago. Albeit in a lot of pain, but she was breathing. Now I’m breathing for her, with the bag.
If she dies, it will be my fault. No-one else to blame.
Intubating sounds easy - stick a tube down the throat, how hard can that be? Well, imagine it’s dark, you’ve got seconds to work with, there might be blood in the mouth… if I don
’t get the tube directly into her lungs, via her trachea, the chances are that 80% of this air will instead go directly into her stomach. If it goes into her stomach, it’s not going into her lungs. It will also inflate her stomach, which will cause her to vomit. And then she’ll be screwed, because her already starved airway is now blocked with puke. Vomit is the biggest complication in resuscitation and can indirectly kill people.
I get the tube in correctly, and she doesn’t vomit.
We blue her in and I bag her until she arrives at hospital, where the trauma team take over her life support and work out their treatment strategy.
Her weeping parents arrive and stand at her side as the medics begin their work. Quite distressing, the whole thing, and you can’t help putting your own kids in that position and seeing yourself in the parents’ place.
I learned a few months later that she had survived - it was touch and go - and was well on her way to recovery. She remembered nothing of the accident, or of the chaos that had ensued.
BLUED-IN: Taken to hospital on blue lights and sirens. Time-critical and life-threatening injuries and illnesses are conveyed like this. It’s a clinical judgment call sometimes and it can be embarrassing if it’s incorrectly judged. EOC – our Emergency Operations Centre, from where every ambulance in London is monitored, directed and supported – will call the receiving hospital on their ‘red phone’ and the Resus department will be made ready for the patient (and lots of medical students will turn up out of thin air).
