Memoirs of an Emergency Nurse (5 page)

On one particular day
,
the emergency
department
had a standby phone call from paramedics, to let us know to expect a 31 year old man
was
being airlifted from
a
road traffic accident
.
The patient was a male motorcyclist with leg injuries and
falling
blood pressure, estimated arrival time was ten
minutes;
the
pillion passenger
was
currently being transferred
to us
by ambulance
.
In short
,
the accident was motorcycle versus tractor!

So there it was,
with
the limited information that I was given, I
prepared
the resuscitation
room
and had my scissors ready
to cut
through leather
biking clothes
.

I always feel horrible when cutting off biker’s leathers as my family and I ride motorbikes and I know how expensive they are to replace, but thank god people wear them
.
T
hey are absolute lifesavers
.
I always feel a bit calmer when I see that the biker has worn the proper equipment, but I know
it’s
probably going to have been a high speed impact and the person can easily deteriorate in front of my eyes
.

I know the rush biking gives a person, the feel of the cool air racing past your body and the adrenalin of being on a
fast machine
and being in control, so I hate it when I hear a fellow biker has come in
.
  I understand that if they come to us
,
they are in pretty bad shape and usually
with
multiple injuries
.
T
he fact is motorcyclists aren’t bad drivers and they don’t drive like lunatics,
it’s
just car drivers don’t see them
.
I
t’s
inevitable that the biker always comes off worse.

I heard the familiar
sound
of the paramedic doors opening and saw the helicopter paramedics in their bright orange flight suits
wheel the patient into the resuscitation room
.
I went to the patient and greeted him with
‘
hello
’;
he said
‘
hello
’
back and
this
indicated that his airway was clear and that he was breathing.

The paramedics lifted the patient over onto the
bed, he was
on a spinal board
and had
a C-spine collar and head blocks on
.
I listened to the paramedic handover.
I
apologised to the biker but explained that I needed to cut o
f
f his leathers to see what damage he’d done
.
He was in so much pain that he didn’t care, he just wanted pain relief.
Once
he was
adequately exposed
,
I was able to
measure
blood pressure and pulse and ensure a second cannula was inserted into his vein in his o
pposite
arm so that I could give more fluids
.
His blood pressure was indeed low
and he
had already been given some
pain relief in the helicopter
by the
air paramedics
.
The biker has been airlifted as
the
paramedics suspected internal bleeding. His body was sweaty and pale and he stated that
despite
having 5mg of morphine in the helicopter
,
he was in 8 out of 10
in
pain. We gave
him
another 5mg of morphine
as we wanted to
  move him
so we could
assess the damage
.
We also gave him
an anti
-
sickness drug as
the
morphine can make people vomit.

W
hile the helicopter crew were still around
,
the doctor assessed the
patient’s
spinal tenderness by log
-
rolling him onto his side and feeling down his spine
,
asking the patient to indicate where it hurt,
reminding him to
mak
e
sure that he didn’t move his head or neck and only spoke yes or no to make sure his answers were clear
.
Despite the pain
relief
,
he was still in agony and complained of leg pain being the major discomfort.
We took away the hard spinal board and lay him flat on his back on the trauma bed
.
Being the smallest person
,
I
held
the patient
’
s head
to keep it still
while
we rolled him as a tea
m
making sure that he kept his head and neck still while I held his head when we rolled him simultaneously.

The paramedics took away their spinal board and s
traps
and said they would come back later for their other equipment
.
W
e started giving intravenous fluids immediately as his blood pressure was low
.
T
he biker looked dangerously pale
.
I asked him what he remembered had happened and he recalled the incident while the doctor was
taking
blood and calling for x-ray
.
             

He
had been
on
a ride with his mates
.
T
hey had turned
i
nto
a scenic
route
for a change of pace and were travelling
along the narrow country roads without
a
problem
.
The biker
recalled that
he was overtaking a tractor when it started turning into an open field without indication
.
The tractor
hadn’t seen the group of bikers travelling behind and ended up colliding with my patient
,
running over his lower body and throwing his
passenger
girlfriend off the bike into a hedge.

The biker hurt everywhere
.
N
ot surprisingly
.
H
e was so lucky to be alive after
colliding
with
a tonne and a half of
tractor
.
We
had
a basic trauma series of x-rays done while he was in resuscitation and luckily he had no cervical spine fractures
so
the doctor removed his collar
.
His blood pressure remained low and
despite
the collar being removed,
I
could only sit him up a little without him feeling dizzy and his blood pressure dropping.
W
e
then
moved him into radiology to get
a full pelvis
x-ray
, left arm, right thigh and ankle. The
radiographers must
have spent over half an hour in there x-raying his bones
.
The diagnosis was not good.
H
e had a smashed pelvis and had lost so much blood from that
injury
,
that
we commenced a three unit blood transfusion in emergency
before transferring him to the ward
.
His blood pressure remained low and he could only tolerate sitting up a little without turning grey and hav
ing
to
lie
down again
.

His
girlfriend
had been brought into emergency by ambulance and the nurse caring for her told me she
would bring her around in a wheelchair after plastering her arm and
leg.
Men and women bikers waited patiently outside for news of his condition but we were all too busy and worried about him to leave him alone or bring his friends in to see him
.
His left leg was relatively unscathed but for a puncture hole behind his knee
;
his right leg was broken in several places and had cuts and grazes all over it
;
he had broken bones in his hand and bits of leather in open wounds
.

After the first unit of blood
,
his condition
stabilised and I was able to bring his friends in
. They
were all over thirty and wearing the appropriate leathers and boots
.
I stayed while they told him how his girlfriend was
.
She had sustained a
C
olles
’
fracture of her wrist, both radial and ulna bones
were broken
and
her left leg
was broken.
S
he was
also
shaken
.
The nursing staff in the main area had managed to get her into a
wheel
chair and wheeled her around to be by the biker’s side
.
The biker kept asking for more pain relief and we kept topping him up until he went to the ward
.
H
e still looked ghastly pale and his friends
,
lacking in medical knowledge
,
didn’t seem to understand the full severity of his injuries.
             

A
nurse came in and asked if it was alright if the
biker’s
parents came in
.
D
espite being over thirty
,
he didn’t want to have to face telling hi
s
mum and dad that he had had a crash
and
he
was more worried about them telling him off than anything else
.
Once they came in
,
sure enough
,
they were worried about him
and relieved their son was alive,
not
concerned about
his crash or his bike
.
People worry about the silliest things that
even
don’t matter
.
S
eeing critically ill people every day
definitely puts things into perspective. When I
go home
, I
know what really matters in life.
             

The biker went to the trauma orthopaedic ward and later went to theatre to get an external fixater on his pelvis
. These are
metal pins to hold the bones tog
ether
and help them heal in the correct position
.
H
e had wiring and plating to his leg that was broken, but continued to be unwell for the next week
.
H
is girlfriend was also an in-patient
and
we managed to get her on the same ward as him.

Paramedics brought a patient into the resuscitation room one day accompanied by the police
.
H
e was formally
under arrest
but he was quite unwell so the officers stood to one side and let us
provide medical treatment
.

The
paramedics handed over that the
patient
had been
involved in a road traffic accident, consisting of a
driver’s
side collision at approximately seventy mph
.
The patient had
low
blood pressure and
suspected
multiple injur
i
es
.
The
patient’s
mechanism of injury was the initial reason for assessing the patient in the resuscitation
room
, where all equipment was at hand if the
patient’s
condition deteriorated
.
D
espite the patient breathing on his own and
being
able to tell me how he was feeling, there was no colour in his face, he looked as if he was bleeding internally and the paramedics measurements of blood pressure showed a related drop in circulating blood volume
.
H
is skin was cool and clammy and he had several open wounds
under
his ripped clothes
.
The patient indicated that his right arm and leg hurt like crazy and he "felt like crap
.
"

G
loved and armed with trauma scissors,
we transferred the patient to the emergency trolley.  A
ll of his clothes were removed,
an
ECG
was
performed and vital signs measured and interpreted
.
The doctor suspected internal bleeding and possible compound fractures where the open wounds bled
.
The man was covered in glass scratches and had bloody abrasions over most of his uncovered
skin. His
jeans had ripped and he had imbedded material in his wounds on his legs
.
Despite the patient being conscious and fully aware of his surroundings, his vitals showed tachycardia and hypotension
,
meaning that his blood pressure was very low
and his heart was racing
.
These signs we interpreted as
the
first stages of shock and fluid resuscitation was commenced
.
IV
access
had been
gained by the paramedics at the scene and the doctor ordered
one
litre of
Hartman’s
fluid to try to increase his circulating blood volume
which would
increase his blood pressure.
After 15 minutes
,
the fluid did little for his sheet white colour and lethargy. Due to the patient's lack of normal vital signs
,
the trauma team was called to review the patient for potential surgery to correct the suspected internal bleeding.
T
he potential fractures and open wounds could wait.

The police
then
took me to one side to give me some information about the patient. The
y
were first on
the
scene
and stated that the patient
had been
found by the
driver’s
side of a car
just
after
the
collision.
All of t
he damage to the car was down the
driver’s
side
.
 
T
he patient swore blind that his friend had been driving and crashed the car before absconding from the scene. However, the damage done to the patient was mainly on his right hand side, which is the position of   impact.
There was also
white powder sprayed inside the
car;
quite 
a lot, according to
  the officer and white residue was found around the
patient’s
lips. He was also currently banned from driving. Taking this into account
,
the doctors were informed that the patient may be under the influence of cocaine or speed and
that
would cause more masking of injuries.

A t
en-minute observation indicated that the litre bags of
Hartman’s
w
ere
not helping to push his blood pressure up as quickly as we all would have liked and his skin colour remained pa
le
despite
the fact that we were
keeping him warm and comfortable under blankets.

The surgeon assessed his abdomen
.
T
he
patient
said that his abdomen did hurt but his right arm hurt more
.
His arm had a slight bend to it and an old scar amongst many tattoos
.
With
his
d
ropping blood pressure
,
the trauma team w
ere
unwilling to give the man any pain relief, as
one side effect of
morphine
was
lowering blood pressure.

I kept asking him to score his pain on a scale of one to ten
;
ten is the worst pain you can imagine and zero is no pain
.
H
is score was eight
.
I was not happy that this patient was without analgesia and was glad when a consultant anaesthetist arrived
.
I had told
the anaesthetist
that his pain score was 8/10 and asked could he have
some morphine, which he agreed to. I drew up the morphine and
2.5mg was given to
the
patient to ease his pain
.
T
he
man’s
blood pressure remained low and by this time we had given about three litres of fluid
.
W
e needed to give him fluid resuscitation because he needed fluids
to ensure
that there was enough volume of blood to pump around his body.

The surgeons continued to be concerned about his possible internal bleeding and
an
urgent portable ultrasound was requested
.
T
he consultant radiologist came to do it
himself
and couldn’t find anything obvious
.
The patient’s
condition was stable enough
for us to be able
to
take
him to x-ray to determine any broken bones
,
and
from x-ray we moved straight to CT scan for a more accurate view of
his
abdomen.
I accompanied the patient to all his
x-rays
and CT and unhooked
the
portable observation machine so
I
could monitor his vital signs throughout
the
radiological
procedures.

Once
back in
the emergency
department
,
I
reported back to the doctor. The
patient’s
blood pressure remained low and we were waiting for blood to be cross-matched for the patient
to be transfused
.
T
he consultant anaesthetist had organised a bed in the intensive care unit for the patient and we were waiting for them to call back when they were ready
.
The police had followed
the
patient throughout his
treatment
as he remained under
arrest;
they stood by
his
side
but
allowed me to provide the medical treatment
that
he needed.

The police surgeon had arrived to take samples of blood to test for illegal drugs
.
This is usual procedure for people suspected of being under the influence while driving
.
Two samples of blood are taken, one remains with the patient and another with the police for testing.
T
he officer had told me that
as
the patient
was
going to
ICU
he would leave
;
h
owever
,
h
e remained under arrest and instructed staff to call the station if he had any positive or negative condition changes
.

Amazingly the x-rays showed no fractures
.
T
here were pins in his right arm where
there had been
previous surgery and the
re was a
clear deformity in his arm
.
His limbs were fine and I'd dressed his wounds while I was waiting for the bed in
ICU
.
His abdomen was normal and no internal bleeding was found
.
T
his man
,
who
we were so worried about
,
had no
injuries
.
H
is blood results came back normal, he remained conscious and talking
.
T
he blood transfusion was cancelled and
the blood
stored in the fridge
,
just in case
. T
his man
, who we had all thought was near death’s door,
had
had
an amazing escape
.
The drugs he had taken prior to the crash were the root cause of his dropping blood pressure and racing heart rate rather than the car crash.
I had asked him had he taken any drugs at all and he denied it,
but
after what the police had told me and his state of shock
,
it was hard for me to believe
him.
I told him we need
ed
to know for medical purposes
and
it d
id
n’t matter about the police, but he still denied it.

The
ICU
bed became available
so I gathered my equipment and
,
with a porter
,
moved him
to
ICU
and handed
him
over to the
ICU
nurse. His condition remained serious and needed regular monitoring
;
if he
had
take
n
speed or cocaine
,
he was at risk of having a heart attack, but I guess I will never know if it was sherbet powder or something stronger
.