Continued from yesterday's post
All I can see is the back of her head, some blood and the shattered windscreen. All I can feel is her head, neck and shoulders and yet something tells me that she is slipping into unconsciousness.
Cramped up in the back of the low roof van a firefighter appears beside me, he's trying to remove the metal plate that separates the two sections of the van and I have to wriggle to the side to let him see how securely it is fixed. He tells me it's going to take some time before the roof can come off.
I shout through to the FRU and ask him if my patient is still conscious.
“It don't look it”, comes back the reply, he's busy getting some venous access while stretched across the passenger seat.
This means it's decision time – do we wait until the roof is cut off in order to fully protect the neck and spine, or do we just manhandle her out as smoothly as possible because of the real risk of her losing her airway and choking to death. Also, if there is a serious head injury then they may need their skull drilled and waiting for the roof to come off may take longer than this patient has.
It's all about potentials – potential neck injury (that if we aggravate could stop her breathing) versus a potential airway problem versus the potential need to be in hospital for neurosurgery before her brain squeezes, like toothpaste from a tube, out the bottom of her skull.
Then that familiar flash of imagination – me standing before the Coroner, explaining my actions and my reasoning.
“Sod it!”, I say to the FRU, “We need to get her out now, we can't wait for the roof”.
The spinal board is squeezed under her buttocks, then as carefully as possible we rotate her out and lay her flat on the board and then onto the trolley-bed. Securing her we move her to the ambulance.
She's now deeply unconscious.
Cutting off her clothes we make a quick check of the basics – the airway is still open, so we can manage that using the tools we have on the ambulance, she's still breathing – which is always handy, the slightly worrying thing is that her pulse is starting to drop although the blood pressure is remaining stable. A dropping pulse can mean a serious head injury.
The next question leaps to my mind, do we wait for the HEMS doctors to turn up, or do we make a run for the hospital.
“HEMS are eight or nine minutes away”, my crewmate tells me, radio mike in hand. It would seem that she is reading my mind.
“OK, we'll go”, I say, I know my mates driving – in nine minutes we'll be at the hospital. I go to secure the back doors of the ambulance and see the HEMS car pull up.
Stay and play a bit then.
The doctor jumps on board – as always polite and professional and starts to assess the patient. The doctor thinks that they should sedate the patient and intubate in order to protect the airway and I don't disagree – she'd need to be intubated before surgery anyway and this way the airway is definitely secure for the transport to hospital.
As they always do, they take the patient off the back of the ambulance so that they have more room. I know it's not the same thing but I feel pride for my crewmate who manages to intubate both in the back of the vehicle and when the patient is stuck under a wardrobe.
The doctor first wants to wrap the patient in bubble wrap to keep them warm – I bite my tongue at the thought that the back of my ambulance is perfectly warm, and besides what happened to therapeutic hypothermia? But HEMS are fully informed on the latest trauma research so I am more than happy to let them do what they want. The responsibility isn't on me anymore, it's on the HEMS doctor and I'm sure that they have also got the same 'Coroner's court' vision in the back of their mind that I have.
But I really should ask them about it the next chance I get.
Just as the doctor is about to intubate the patient she starts to come around. Suddenly she is no longer unconscious, but awake, alert and orientated.
That's good, but again, this can be the sign of a serious head injury.
“OK”, says the doctor, “let's go without sedating them”.
We load the patient back up onto my ambulance, change over the monitoring machinery (for the third time) and make our run to the hospital, the doctor in the back of the truck making notes while I make sure that our patient doesn't move around too much on the trolley-bed. Our patient's consciousness drops and rises during the trip.
The trip takes eight minutes – I swear that my crewmate channels Stirling Moss and I trust her driving completely (except for her reversing, but that's another matter).
Into the resuscitation room and the HEMS doctor hands over to the staff there, our patient is awake again and so the hospital doctors can get a better history from the patient. I go out to the ambulance and start the long process of documenting everything while my crewmate cleans up the back.
—–
There is no closure to this story.
I'd love to be able to tell you how the patient got on but I never knew her name, so I can't ask the reception staff to pull their A&E notes so I can have a look at what the CT scan showed. I don't see HEMS often enough to ask them about the progress of our patient, when I next see them they will have seen countless other seriously ill patients. The police probably won't ask me for a statement on the accident in question. I'll likely never know if my decision to move the patient before the roof was off was the right one, or if I did more harm to them. I'll not get a thank you letter and I don't expect one. The only way I think I'll know about my patient is if they die and it goes to the Coroner's court.
In which case I'm happy to remain ignorant.
So I'll probably never know what happened to my patient and that is the usual course of events. Just clean the ambulance and move to the next person.
I take my hat off to you.
I hate not knowing what happened to the patient. To make it harder, the worse the job is, the less likely you are to be able to follow up, as you won't be concentrating on remembering names and details. I can't imagine how difficult it'll be trying to hunt out details somewhere this size of London! š
Do you feel it would help inform your practice if there was a method of following up patients?I get frustrated not knowing if what I did was the right thing for any particular patient, the only way I see patients again unless they are unlucky enough to be admitted is usually if the doctor sends them back for more films. Which does not always mean that what we did was wrong, some times it means we demonstrated things the medical staff didn't anticipate initially.
If you knew that a particular course of action worked out well for a patient do you feel that it would help you to make similar decisions in the future?
Tough call, but I'd say a good one!!! We often make instant decisions and then think about them afterwards. I tend to find that gut instinct is one of the best emergency decision makers…
I would have thought that apart from just being nice to know, it would be valuable to get some feedback on how you did.
I too hate not knowing what happens to patients. It's surprising (to me) that a lot of people just don't understand this. On occasion I've asked nurses in the units to which we've transferred patients, how they got on; but usually just get a blank stare.Feedback is valuable, IMHO.
Another well-written and thought provoking post – the reason why I visit this blog almost every day. Thank you.I'm suprised with all the databases and paperwork in the NHS, the patient cannot be linked back to you – or at least your ambulance?
Answering a few of the comment.1) Yes feedback would be very helpful, especially because we are all supposed to be reflective practitioners now – sadly part of the problem is that we don't have the time to chase up patients at the hospital – we need to turn our jobs around in 28 minutes otherwise certain high ranking management types start to get upset about ORCON going out the window.2) Tracking patients also has implications for patient confidentiality – they may have told hospital staff things that they didn't want us to know, there is a chance of ethical problems there.3) Of-times A&E send patients up to the wards not knowing the full out-come. And it's sometimes hard to find out what ward a patient has ended up on, couple that with us not having the same 'relationship' with ward nurses as we do with A&E nurses.4) Most of our jobs are so run of the mill we seldom worry about our treatment of our patient.5) I'm yet to receive anything other than the most cursory feedback on anything from *within* the LAS, expecting other trusts to give us feedback is a bit of a stretch.6) Sometimes we can find out – an interesting example of which will be blogged about in the near future, maybe even tomorrow…
Great story and great writing, I'll be back for sure!HM
Isn't not knowing hard? Doesn't it play on your mind? I came across something on a tube while I was in my St John Ambulance uniform the other day. As soon as the emergency services got there they did their thing and I stood out of the way in the outskirts. I wasn't doing anything but I wanted to see it through, find out what happened to the casualty in the end…
Not knowing what happens to patients is a problem, I think. You will never know if you did the right thing. Ours is a fairly small hospital, but because of electronic patient files, no-one can check for us because they have to give their name and they are not allowed to look at files of patients not directly under their care. So patient confidentiality prevents us from learning. Even if you happen to find the doctor who treated the patient, they are not likely to remember, or even want to talk about it for the same reason. I've even had midwives who wouldn't tell me if the patient gave birth to a boy or a girl ten minutes after we arrived at the hospital.Visitors in hospitals and care homes are even encouraged not to tell anybody what they see or hear as “staff may be accused of breaking patient confidentiality”. All this while the one person (the patient) who doesn't have to worry about this, tells every lovely detail to every person he knows the very moment it happens.
Tom,Ring the HEMS desk. Let them know what call it was (time and place if you don't still have the CAD) and they speak to the Doc. HEMS follow up all their patients (except the assist onlys) so they'll get back to you quite quickly.
Maybe we need an internal email account for this sort of thing?
DSO
Positive feedback is most essential, 'tis how we improve and grow, If one gets only negative feedback then that is counter productive and creates a nervous wreck for those cases that be border line.Most people are Not that egoistical that whatever they do is always absolutely perfect and can never be wrong.Awaiting a coroners inquiry is not the best form of feedback.I know mushrooms grow in the dark and only fed muck, but ye be no mushroom or spore.
Quick question to the health care people out there. I know HEMS do best practice research, but is there any NICE guidelines/current research for best practice for “regular” ambulance drivers. (I'm not trying to be insulting here, just couldn't think of a more appropriate term). IE If the patient is displaying symptoms A, B and C then treatment D is most appropriate, but if patient is showing symptoms A, B and E, then treatment F is best, etc.
I think it's down to JRCALC guidelines (tempered of course by your trust's own protocols).At least that's what I've always been led to believe…
If you go to the HEMS forum you should get some feedback.