Memoirs of an Emergency Nurse (2 page)

My first major trauma as a new emergency nurse began by receiving a standby call from the paramedics. They indicated that a road traffic accident (RTA) had occurred on a bridge not far away from the hospital; one victim had chest injuries and one victim was unconscious.  The fast response vehicle from emergency was needed at the scene. The fast response vehicle, with its Peugeot 2.6 engine, was used to take a doctor and two nurses out to a patient in need in the community. There is a supply of essential drugs and equipment to keep the patient alive for a sustained period of time if the patient was trapped or cannot be moved from the scene. The doctor can administer drugs that the paramedics did not have and had the authority to refer the patient to hospitals outside the catchment area the paramedics worked within, if the patient need specific trauma centre treatment.

The trauma team were called over the hospital paging system and given an estimated arrival time of 30 minutes.

Two nurses raced to the major incident cupboard and began pulling on their fast response uniforms and grabbing the incident bags. The fast response uniform consisted of tough overalls with fluorescent nurse name tag along the back and steel toed capped boots to walk over the glass and debris that usually accompanies a major car accident. The incident bags were large orange backpacks which contained essential equipment like fluid bags, IV access equipment, drugs, dressings and scissors.

It is never a good sign when the fast response car is required. It often means that it’s a pretty bad incident and that a doctor and nurse are needed at the scene because the patient is critically ill beyond the capability of the paramedics or the fire officers cannot remove the patient from the scene within the golden hour, without further help from a doctor.

I was allocated to be the resuscitation nurse for when the patient was brought back to emergency and once the team had left, I assisted clearing the department of non-priority patients, such as performing minor dressings that hadn’t been attended to yet and preparing some rooms for patients while we were short staffed. I then moved to the resuscitation room and began to prepare. I had butterflies in my stomach as I wrapped a long green protective splash-proof apron around myself, put protective goggles over my eyes and pulled on some gloves. I turned on the oxygen, ready for the patient’s arrival, and made necessary equipment accessible quickly. Having only the information of road traffic accident, chest injuries and one patient unconscious, it was hard to prepare. I ensured that I had everything ready that I could, including standard IV fluid bags and unlocking all the drug cabinets. Because two emergency nurses were attending at the scene, there were only three nurses left in the accident and emergency department. We tried to prepare for the unexpected and also carry on treating patients in the main department.

After 20 minutes, I went to the ambulance doors, turned the key so they were fully open and waited patiently for the ambulance in my gown and gloves. One by one, the doctors and anaesthetists from the hospital trauma team had made their way down to resuscitation and were asking what we were expecting.  I couldn’t give them much information, but reassured them that our doctor had been asked to go out to the patient at the scene, so treatment will have already taken place.

Just as time seemed to be taking forever, we could see the ambulance hurtling down the main road past the hospital, its lights flashing and its siren blaring. I thought to myself that ambulances don’t normally go that fast down the main street so they must have been in a hurry to get extra assistance. At that point, we all took in a deep breath and didn’t really want to be there; we were there though and we had a job to do for these patients. Nerves needed to be pushed aside.

I was the first outside to greet the paramedics and gain first sight of the patient and a short verbal history as they were getting the patient out of the ambulance and into emergency. I couldn’t wait any longer. I needed to know what we had to do to help the patient and get prepared in my mind.

I jumped aboard the ambulance to assist with wheeling the trolley out and took a good look at the patient. The paramedic had sweat dripping from his forehead and looked worried.  The patient was female and had been screaming ever since the accident. She was incoherent and oblivious to what was happening to her. Her face was swollen beyond recognition and her lower lip had torn to reveal a flap of skin showing her lower teeth and jaw when she breathed. She was spitting blood bubbles which ran down her face. Amazingly my first thought was positive; at least she was breathing on her own and skin would heal.

The young woman was unable to give any information to the paramedics and we were going in blind, so we knew nothing about the events leading up to the accident or previous medical history.

We had visual confirmation from the paramedics that she had been ejected from the back seat through the front window and was found five meters from the vehicle on the tarmac on the central reservation of the motorway. Thinking logically about this
and calculating the impact speed,
speed of travel on a motorway is
usually
70mph, she was ejected five meters away from the car so she wasn’t wearing a seatbelt and she
had taken major impact on her
head. This girl was seriously lucky
to be alive and despite appearing to be relatively stable,
there was
a huge
potential to be hiding serious injuries.

I tried to talk to her as we unloaded her from the ambulance. I tried to reassure her but it was a worry that she never heard any of my pleasant words and remained screaming and spitting blood.

We got her inside the resuscitation room
s
he was on a spinal board and had both cervical spine collar and head blocks on. The head blocks are padded foam blocks that are placed by either ear while the patient is lying flat and they keep the spine in a straight alignment to minimise risk of further damage. The patient’s forehead is taped to the bed with tape over forehead and chin. This is essential for a patient who isn’t aware of their surrounding and at risk of further damaging their neck. The girl’s head was taped to the bed securely to protect her cervical spine from movement. She continued to scream and spit blood, her breath smelt of alcohol. The first to assess the patient was the anaesthetist, who suctioned her bleeding mouth and pronounced that her airway was patent due to all her screaming and that she was breathing on her own. She was still clearly audible, giving out a distressed wailing scream and ignoring our reassuring information. He attached a non-rebreather oxygen mask to her face, which covered most of her bleeding facial flap and suctioned when necessary.

Her blonde hair was matted with blood and her nose had been bleeding. Sharp shards of glass were stuck in the creases of her clothes and around her C spine collar. Another nurse, Matt, and I began swiftly cutting her clothes off while the doctors looked frantically for any veins they could give analgesia through.

Too late. The patient was already in shock and her veins had hidden away deep in her skin. It was 11pm on a winter’s night and it seemed, from the evidence of the alcohol on her breath
that she had been out drinking for a while. We needed venous access now, no time to mess around.
             

Matt got out a femoral artery kit. As we couldn’t find any venous access in her peripheral veins, we would have to access a main artery near the groin area so we could give the girl pain relief and sedatives. The girl continued to scream and writhe on the trolley with no change in her response to pain or verbal commands. The doctor punctured her femoral artery pushing a catheter into the artery and carefully stitched it tightly to her skin. By this time, the woman had been wriggling uncontrollably on the spinal board and was half off it, with her head still taped to the top. She was approximately 100kg in size and not in a fit mental state to cooperate.

The primary survey indicated little as the patient was so distressed she responded to neither verbal or painful stimuli but continued screaming and writhing about on the spinal board. I went to the top of the bed and tried to reassure her by talking close to her head, which was when I noticed that she had blood coming from her right ear.

I informed the doctors and we determined it wasn’t from her bloody face but indeed from inside her ear. Alarm bells rang in everyone’s head as we all thought the same thing.  Blood in her ear could indicate two things; base of skull fracture, which was highly likely after the force of her impact, or she may be haemorrhaging from her brain. If she had been wearing a seatbelt, she would have remained inside the car; but, unfortunately, her head may have received a massive impact and we suspected a basal skull fracture. If she kept moving around, she risked injuring her spine more.  She could not understand our instructions through either being intoxicated or the head injury.

The paramedic doors sounded their familiar bell and the resuscitation room doors were opened by paramedics with the next patient from the same car accident. The first patient was in the hands of the doctors and as we were short staffed, I moved to meet the second team of paramedics and patient and asked for the history while I was changing gloves. This was the driver f
rom
the same vehicle. He had been travelling approximately 70mph; lost control of the vehicle and hit the central reservation on the motorway.  This patient was also immobilised on a spinal board and a C spine collar was in place. The primary survey process began again. Airway, C spine, Breathing, Circulation. This young man was able to speak to me although he was shaken up and asking about his friends. This was a good sign but I was on edge, looking for hidden signs of injury, any discolouration of his skin, obvious wounds and bone deformities. This was the driver and his major impact was with the steering wheel. He had pain in his chest, but looked a good colour and was more distressed by his friend’s screams from the next cubicle. I cut away just his top, enabling access to veins and getting a good look for signs of injury. I attached ECG leads
to his chest
and took the vital signs while a doctor took over and assessed his condition.

The resuscitation room was now a hub of people; the police were outside, there were nurses in and out of the doors and doctors of different specialities waiting their turn to assess the patients. Radiographers patiently waited for doctors to finish vital medical care before venturing in to X-ray the patient. X-ray trauma series were carried out on the girl while in resuscitation and the white boards were filled with spinal views of her neck. Boxes were opened, drug cupboard doors were easily accessible and the sound of crunching glass came from the floor. Oxygen could be heard whistling at a high volume and there was a constant hum of voices discussing the patients. Three doctors and two radiographers stood to the side of the drug cupboard, trying to keep out of the way until it was their turn to assess the patients. The three-bed resuscitation room felt very crowded.

I tried to gain information from the new patient about the girl’s name, her phone number, how old she was and where she lived but the young man didn’t know. He just knew her boyfriend who hadn’t arrived yet. He kept asking how they were and, to his annoyance, I kept saying ‘We need to look after you first, concentrate on you first then we’ll find out how they are later.’  In reality, I knew the girl was critically ill and I didn’t want to give out false information to an already shaken patient.

In front of me, I had a lucky patient. He had slight chest pain from where the seatbelt had been and the impact from the steering wheel. He was talking, his vital signs were stable and there was not a scratch on his skin, whereas the girl was critical. The fact of the matter is, despite not having an airbag in the car, the driver appeared unscathed thanks to his seatbelt. There were no apparent internal
or external
injuries .

I completed initial interventions on this patient and then returned to the girl to continue observations and assist the anaesthetist. The decision was made to sedate and ventilate the girl so a CT scan could be carried out to assess the damage to her brain. We began the process of sedating and paralysing the girl. The anaesthetist was ready to insert an endotracheal tube into the patient’s airway and he would then connect her to the ventilator. I would continue to monitor her vital signs for any indication of shock or intracranial pressure; ensuring fluids were running through the femoral line to replace her blood loss. I got the appropriate drugs out of the cupboard and drew them up for the anaesthetist. The anaesthetist suctioned the girl’s mouth and asked if I could perform cricoid pressure.

Cricoid pressure is applying gentle pressure to skin on the throat in an area called the cricoids to essentially close off the oesophagus so that the patient cannot vomit while being intubated. As it was unknown when she had last eaten, she could easily vomit and inhale or aspirate stomach contents while she was being intubated, so this is a common procedure. Once the drugs were administered, the girl gave a little shake as the paralytic drugs commenced working, then her body relaxed and her screams stopped. A swift uncomplicated intubation followed, despite the facial trauma.

Once she was sedated, we were then able to perform the secondary survey, which reviews the progress of the patient and a more in-depth assessment. Airway, C spine, Breathing, Circulation, Disability, Exposure. It indicated no obvious fractures or deformities and her abdomen was still soft, so it was established that the head injury was the primary complaint. It was a relief when she was finally anaesthetised. The screaming stopped, as did the ringing through our ears, and we could examine the patient without distraction. We moved the girl off the spinal board onto the trolley and cleaned the glass away from her skin and clothes.