Category Archives: Military

Blood and bloody idiot

There are a couple of terms used to define bleeding in the medical field;

Capillary – this is when the surface of the skin is scratched, but not deeply, and small spots of blood ooze from the damaged capillaries.

Venous – when a vein is nicked and blood will slowly weep from the wound.

Arterial – Blood will spurt out with every beat of the heart, sometimes spraying large distances depending on the size of the artery.

 

That final one, the arterial bleed, is considered to be a catastrophic haemorrhage. That is, if the bleeding is not quickly stemmed, a person will die within minutes.

 

Today, while working from a different station to normal, we were sent to a 25 year old who had punched through a window in a fit of rage, cutting his forearm. We were told the call had come from Police and they would also be attending.

We arrived after the Police and followed the significant trial of blood to a male laying on the floor, with his girlfriend tightly holding a towel around his arm, blood pouring down through her fingers. Thankfully, we had brought our critical haemorrhage kit in with us, so prepared to uncover, assess and re-dress the wound.

My crew mate wrapped his hands tightly around the arm to slow any bleeding while I prepared some gauze, a trauma dressing (more on that later) and a tourniquet.

*This next section is not for the squeamish!*

I slowly removed the towels to find a large would which was deep enough to nearly see bone through muscle and tendons. He had two large skin flaps where he had effectively de-gloved his arm, he had some blood clots within the wound from a venous bleed, and a quite noticeable spurting bleed from his Ulnar artery (one of two which run down the forearm). He had lost around 500ml of blood. The quick actions of his partner prevented him losing any more than that, which would have lead to shock.

We quickly ‘eyeballed’ the wound for any pieces of glass – there was none – and wrapped our trauma dressing around it. The trauma dressing we used has been developed by the military. It is specially designed to apply pressure directly over a section of injury on a limb, without using a tourniquet, which is always the last line of defence in a catastrophic bleed, as the limb may not survive.

While all this was going on, we obtained a quick history of what had happened. An argument with his ‘missus’ caused a fit of rage and he’d punched a window. He was also intoxicated and had been taking cocaine. He was also a bit of a knob head.

He immediately took a dislike to my crew mate (the person applying pressure to his wound to stop him bleeding to death) because he had “one of them faces innit”, calling him a c*nt and saying he would smash his face in. Delightful. Thankfully, I’ve got a knack of getting on with people like that, a trick I learned from an old crew mate of mine. As such, I quickly built up a rapport with him and persuaded him to come to hospital with us. Yes, I had to actually persuade him!

During this, he continued to be verbally aggressive to all of us and stood unaided to show us how strong he was. Now, he clearly worked out, but also clearly used steroids. We advised he shouldn’t eat or drink in case he needed surgery, so he drank a pint of water. We recommended a wheelchair due to the blood loss, so he walked upstairs to find his phone, all the while, using the C-bomb like it was punctuation and swearing at us all and being generally aggressive and intimidating. The Police said they would travel with us and called for backup from the PC they had dubbed the ‘man-mountain’. And with good reason. At 6’2″ and 18 stone of muscle, he would certainly be able to contain our almost equally sized patient – owing to the advantage of a working arm. And pepper spray. And a taser.

He eventually walked to the ambulance and sat in a chair because we’d suggested he lay on the stretcher (am I building up a picture of what this bloke is like?). I inserted a cannula into his vein to give some pain relief through a drip. All the while he told me how shit I was at my job. We swiftly left the scene on blue lights heading for A&E. After around 6 minutes of travelling, he decided he had become board of wearing a seatbelt and sitting in a chair while in an ambulance travelling at speed through a town centre, so he undid it – against mine and the PC’s insistence – just as my crew mate had to reduce his speed for traffic ahead. As such, the unrestrained man now hurtled towards the bulkhead, stopping himself on a work surface, pulling his IV line out as he did so. This angered him greatly, and clearly it was my fault so he began swearing at me and saying how I wasn’t fit to do the job etc etc. We had to stop the ambulance, causing traffic chaos, to re-restrain him on the stretcher.There was no way I was going back near him with a needle, so I offered him some gas and air for the pain, which he accepted….

 

…for 3 minutes before throwing the mouthpiece at me and calling me a smug c*nt. The Police officer all the while provided suitable dissuasion from him trying anything. I was glad of the PC’s presence!

This pattern of threatening violence, kicking equipment and behaving like a general tit continued for the long 20 minute drive to A&E. It was one of the most stressful journeys I’ve ever had while attending a patient in an ambulance, and I’ve dealt with some stuff in my time! During the whole trip, I had to keep an eye on the wound to make sure it didn’t start bleeding through the dressing, I had to check that it wasn’t so tight it was cutting circulation off to his hand and somehow get some vital signs. He declined any vital signs and wouldn’t let me near him. All I could do was document it and make sure the built-in CCTV was functioning.

We handed him over to the A&E nurse with an apology, as they’d have to deal with his very unpleasant manner. I feel I should add that he hadn’t lost enough blood to cause severe agitation like that, he was just drunk, high and angry.

Afterwards, I was washed out and a bit teary. It’s very hard to provide life saving treatment to someone, only for them to call you a c*nt 27 times and throw things at you. I can scarcely believe there are people like that out there. But there are, and I’m sure I’ll meet many more during my career.

 

So, I guess….don’t do drugs. Or punch windows. Or be a prick to people who save your life 🙂

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Green cross code

The morning had been a busy one.

We’d attended a lady who’d fallen out of bed, was uninjured so we helped her up, checked her over and left her to her breakfast, we’d taken a 57 year old man with chest pain to hospital with a possible heart attack, and rushed a 60 year old man to hospital who was having a bleed on the brain – what we like to call ‘big sick’! 

We were almost back to our station for a much needed restock and cup of tea when we received another call. 

It came through as a road name in the next city. No house number, just a road name. Usually that means someone has fallen in the street, or there’s been a car crash. 

We received a message which said: “14 year old hit by car – unconscious, massive head injury”

Shit! Pedal to the floor and off we go. My colleague driving as I don my hi-vis jacket and think about how I might treat the patient depending on what we’re presented with. 

We receive another message:

“Ambulanc officer is on scene, he states the patient is GCS5 (which means barely conscious!) and has requested priority 1 backup and the air ambulance as a priority.”

Double shit!

We arrive shortly after to exactly the sort of thing you’d expect to see at an incident like this. An ambulance officer’s car straddling the road, a pickup truck parked awkwardly at the curb, a man sat beside it in tears while members of the public console him, a police car screeching to a halt to block traffic and a lifeless child led in the road with a stream of blood trickling down the Tarmac, our officer colleague at her side rapidly assessing her. 

The clinical handover was brief, it didn’t need to be complicated, we could all see what had happened and all knew what we needed to do. 

Her level of consciousness raised after some oxygen. She was in pain and distressed. 

“Quick ABC; airway clear. Breathing adequately and chest clear on auscultation, radial pulses present, she’s tachycardic (fast heart rate) and pale. Let’s get some IV access and get her off the floor.” 

Another paramedic arrives in a car to assist. I look up and see several more police cars now on scene interviewing witnesses. The patient’s mum arrives in a frenzy! Now we have 2 to look after, the paramedic who’d just arrived set to reassuring mum that we were working hard to save her daughter.

With some volunteers holding up a blanket to make a screen for some dignity, we cut her clothes off to assess her fully. She had a large head wound that we had pressure on, a presumed neck injury, large abrasions on her back and shoulders where she’d rolled down the road like a rag doll. She had wounds to her lower legs but as far as we could tell, no broken bones. We gave her some pain relief, a drip, some anti-sickness medicine as she’d vomited profusely (another concerning sign of head/brain injury). She was a little more ‘with it’ now. The helicopter had landed at a nearby school as the road was too narrow for them to safely land. A police car sped off to collect them. A HEMS paramedic and critical care paramedic arrived just as a critical care doctor arrived by road from another base. We told the story and it was agreed we would take her by road to the nearest children’s major trauma centre under blue lights with the doctor on board. 

We scooped her off the floor and onto our stretcher ready to load onto the ambulance. Another quick ABC check and we were ready to leave. The helicopter left having offered their opinions and assistance and we prepared to leave he scene. 

It was around 40 minutes to the trauma unit, with my crew mate driving and me in the back with the doctor and patient. She was fully immobilised and calmed by the pain killers we’d given via the IV. She vomited twice en-route meaning we had to roll her on the spinal stretcher she was on. Not easy with just two of you while doing 70mph through city streets, but this is the career I chose! 

We arrived to a resus room full of doctors, nurses, surgeons, orthopods, paediatric specialists and porters, around 18 people who would now take over her care. 

There was silence as the critical care doctor gave his handover. As soon as he’d finished, the trauma lead set everyone to work. 

Each was allocated a task from airway and breathing to assessing neurological function of her feet. Every inch rapidly assessed for defecit before whisking her away for a CT scan to see what was happening under the skin level.
Absolutely exhausting and emotionally draining, as dealing with children often can be. The police had driven mum to hospital, leaving us space to work in the back of our cramped ambulance. 

Hoping for a good outcome for her thanks to our interventions, we’ll probably never find out though. 

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Critical Haemorrhage

I’ve mentioned before that our ‘Primary Survey’ (i.e your initial assessment of a patient to decide if there’s anything immediately life threatening that needs correcting) differs from that of a first aider, who’s primary survey will be:

D – Danger

R – Response

A- Airway

B – Breathing

and maybe C – Circulation

Our primary survey is:

D – Danger

C – Catastrophic Haemorrhage

R – Response

A – Airway

c (deliberately small) – Cervical Spine injury

B – Breathing

C – Circulation

D – Disability or Neurological signs

E – Everything else

F – Family/Friends for history taking

G – Glucose levels.

So, as you’d expect, it’s a bit different.

When it comes to managing Catastrophic/Critical Haemorrhage (by which I mean an arterial bleed which will bleed a patient dry in mere moments), we don’t piss around. As you can see, we control Catastrophic Bleeding before we even try to get a response from our patient, let alone try managing an airway etc etc.

Most if not all of our critical haemorrhage kits have been developed by the Military. Their ‘bread & butter’ work is dealing with traumatic amputations and massive trauma to the abdomen and chest.

They’ve developed very efficient tourniquets and dressings known as ‘blast dressings’, or to give them their proper name, ‘haemostatic dressings’. These have a chemical in them which promotes clotting to stop bleeding quickly. These dressings are idiot proof, very large and very expensive. They save lives.

I’ve never been unfortunate enough to have to apply a tourniquet, though my regular crew mate was – he was sent to a lady who was trapped under the wheel of a bus!

I have, however, applied a blast dressing to a lady with a catastrophic bleed from the chest. It works very well indeed.

We have a special bag which is a cool, special op’s style black bag with red writing which says ‘Critical Haemorrhage Kit, Trained Personnel Only”. In there we carry tourniquets, various sized blast dressings and haemostatatic gauze.

On my last day shift, we answered a 999 call for a man who’d cut himself shaving, so the bag was left on the Ambulance that day……*sigh*.

Needless to say, we recommended some basic first aid and left him to it. Another life saved 🙂

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