Pulse(4)

‘Coming,’ I said, without taking my eyes off the monitor screen above my patient’s head. The second dose of adenosine had just been administered.

‘Now,’ Jeremy insisted, tugging gently at my sleeve.

‘OK,’ I said, turning towards him. There was a look of apprehension in his eyes.

‘It’s a really bad one,’ he said. ‘A motorcyclist lost control on London Road and hit a lamppost when doing nearly sixty. And he had a passenger. Both will be here in two minutes with multiple life-threatening injuries.’

‘OK,’ I said again. ‘I’m coming.’

An incoming trauma casualty with life-threatening injuries demanded the undivided attention of an emergency senior consultant and Jeremy and I were the only two currently on duty. I handed the comatose man over to the junior doctor.

‘Keep me informed,’ I shouted over my shoulder at him as I hurried away.

The emergency department at Cheltenham General was known universally as A&E, which stood for Accident and Emergency even though it was nicknamed Anything and Everyone by the doctors and nurses who worked there, and Arse and Elbow by some idiots who thought we didn’t know the difference.

By the time the two motorcyclists arrived by ambulance we were ready for them with two separate trauma teams, each of six staff. In addition, I’d already paged the on-call orthopaedic surgeon in the sure knowledge that he would be needed.

We would also likely require a neurologist. Even with modern full-face safety helmets, the forces acting on the head in such high-speed incidents nearly always resulted in some form of brain injury, often severe and debilitating, not to mention the likelihood of life-changing spinal cord damage.

But our job as emergency staff was to assess the patients, to ensure they were stable and not about to die. Only after that could the specialists deal with the further fallout from the accident.

The two patients were wheeled in on trolleys, each with a couple of paramedics in attendance together with a first-response doctor who had attended the scene. I took the female pillion passenger while Jeremy looked after the male driver. Both of them were in a bad way and close to death.

For the next hour or so my team and I worked feverishly to stabilise the young woman’s condition.

She had arrived in a coma, medically induced by the doctor at the roadside, so there was no chance of asking her where it hurt. But it really didn’t take any great medical skill to determine the extent of some of her injuries.

From the unusual angle of her feet it was clear that both her legs were broken and she had numerous gashes in her leather suit that indicated severe lacerations beneath.

But, in emergency medicine, the same mantra applies as in first aid: ABC – airway, breathing and circulation. Without respiration and circulation a patient will rapidly die and intervention elsewhere would be fruitless.

So we initially concentrated on keeping her airway open, her lungs ventilated and her heart beating. Next we checked for signs of major bleeding, both external and internal, and in particular into the chest cavity. When we were confident that she wasn’t about to die on us in the scanner, we took her to CT for a full-body scan that revealed not only the multiple fractures to her lower legs but also several cracked vertebrae in her back, together with a bruise and small bleed into the brain.

If the bruising caused any swelling to her brain then the pressure in her skull would need to be relieved. She would need dedicated specialist neurological treatment, something that was not available here at Cheltenham. If we hadn’t been so close to the accident she probably wouldn’t have come here in the first place.

As soon as she was well enough, she would be transferred to the regional major trauma centre in Bristol, some forty miles away. A dedicated ambulance was already standing by.

With her breathing and pulse finally stabilised, I had to be sure that she had an adequate blood supply to her lower limbs before she was moved. If the broken bones had punctured the tibial arteries through her calves, then her feet would start to die even before she made it to Bristol.

I studied the CT scan closely. It showed that there was a little internal bleeding behind the knees but not as much as would be expected from an arterial tear. In addition, I could feel a slight but steady pulse on the top of each foot.

‘OK,’ I said. ‘She’s ready to go.’

A fresh team of paramedics connected her to their portable monitoring equipment and then wheeled her gently out to the waiting ambulance.

My whole team took a collective sigh.

‘Well done, everybody,’ I said. ‘Good job.’

The young woman had been on the brink of death when she’d arrived but now there was every chance she’d survive. Only time would tell if her brain injury would be life-changing.

So preoccupied had I been trying to save the patient in front of me that I had temporarily forgotten about the unconscious man I’d left in the other cubicle – that was until I saw the junior doctor, who was standing to one side waiting for a break in the action. I could tell from his expression that things were not good.

‘What is it?’ I asked.

‘He died,’ he said bluntly.

‘He what!’ I shrieked at him in anger. ‘How?’

‘Cardiac arrest,’ he said. ‘Just after you left. We’ve been trying to resuscitate him for most of the past hour.’ He looked up at the clock on the wall. ‘I declared him dead five minutes ago.’