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In emergency medicine we hardly ever see people at their best. Accident victims are often brought to us wearing ragged and torn clothes, covered in blood, vomit, dirt and incontinence; eye make-up washed in tear streams and hair in a mess.
Emotional turmoil prevails where patients are conscious enough to communicate their distress and pain; where relatives are in attendance they too will add to the cacophony and our team will make it even worse. Armed with large pairs of scissors they will cut to ribbons any remaining clothes to expose the bits that need to be examined.
If this sounds like bedlam it’s much worse for paramedics at the roadside. Recently, for a variety of reasons and in the absence of anyone else, I was called on to attend the scene of a head-on collision between a large truck and a small hatchback. The car had crumpled into the engine compartment of the truck and, despite a large team of fire-service personnel, with every conceivable item of cutting equipment, the hatchback driver could not be disentangled from the wreckage.
Clambering into the car from the rear was entering a scene of chaos, with broken glass, blood, engine fluids and an unconscious, heavily soiled driver compressed between the remains of the driver’s seat and the undersurface of the dashboard and lorry grill, which were merged into one.
The route backwards out of the vehicle for the victim was blocked by his lower-limb injuries and entanglement in the pedals. Added to the difficulties were darkness and rain, with dismal wetness permeating the scene, despite the tarpaulins and lights erected by first responders.
Finding and securing an airway had been the problem the paramedic had called for assistance with, and, unlike the situation in our resus room where there is ample light, a wide array of equipment designed for this scenario and the support of expert anaesthetists, at the roadside it’s very different.
With insufficient access for intubation, a laryngeal mask seemed the best option and achieved the desired effect permitting ventilation, although this was only after the airway had been heavily soiled with blood and vomit. Obtaining intravenous access proved easier and permitted much-needed IV fluids – although it was clear that this resuscitation attempt was compromised from the start and unlikely to succeed.
Eventually, when most of the rear of the hatchback had been cut away along with the roof and doors, it became possible to remove the seat-squab supports to create a backward route for the driver to be extracted along with pieces of impaling metal from the car’s pedal box.
By the time we returned to the emergency department following a traumatic high-speed dash, and after handing over my victim to the in-house team, I visited the decontamination shower suite and found a familiar sight in the mirror – a ragged and soaking-wet individual, with torn clothes covered in blood, vomit and dirt clearly not looking his best.
Charles Lamb is an emergency medicine consultant. He writes under a pseudonym
Welcome to the world of Immediate Care; I had many such experiences in my 25 year career as a BASICS GP providing roadside care.
the motor car - what a marvel
I sincerely hope ( but somehow doubt ) that all those who are brave enough and skilled enough to work under such conditions are offered the support they might need ; thanks to you all.
This type of experience accelerated my switch from surgery and trauma to radiology.
Once again, as with my own patients, I find myself wondering what happened to this patient. Did he survive?
There was a time when I revelled in doing this sort of thing, though happily not too often. Then one day it was me being rescued, and things took on a different perspective, ever after. It was, in retrospect, interesting to see my colleagues, mostly friends, trying to work with the detached compassion necessary for optimal performance; even trying it myself and offering helpful hints about my treatment. But afterwards, even when fit to work again, I found the memory of pain and terror made me identify too closely with the injured patient to be able to perform adequately well, and I changed my career. I applaud Charles Lamb and those like him, who so obviously care enough to work in such conditions.
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