X-ray of a foot showing Lisfranc fracture

Tom was brought in by a friend who wore a distinctly sheepish expression as he manoeuvred the wheel chair along the corridor. The patient had a particularly swollen and painful right foot; even I didn’t need an x-ray to tell me that something was amiss.

“This chap ran over my foot” he said by way of an explanation when I asked him what had happened. In fact, what he said differed slightly from that but as I am a lady I find I am unable to repeat the colloquial and somewhat colourful words that he actually used.

Tom had managed to bag a lift home after a hard day on the building site. He jumped out of the 4×4 while his mate was stopped at a red light but leant back in the car to retrieve his rucksack just as matey was beginning to pull away. The back wheel drove right over his steel toe capped boot that housed the afore mentioned right foot. Having witnessed Tom’s potty-mouth first-hand I can only imagine what delights must have been emitted as the vehicle lolloped over it – the thought made me blush!

His x-ray was quite spectacular (see below). You can see below that many of the bones in the mid-foot had been pushed outwards to the right (dislocated) and a couple of them were also fractured, the bone leading up to his big toe was also dislocated to the left, this type of fracture called a Lisfranc after Jacques Lisfranc, Napolean’s military surgeon in the early 1800′s. Surgery would be required to return the bones to their natural position and fix them there. I have put two radiographs here to show you how his foot looked and how it should look.

X-ray of a foot showing Lisfranc fracture

X-ray of a foot with no acute injury

Image courtesy megadem on Flickr

I was telling my friends and family about a call I went to recently. It involved a toddler hit by a car with possible life changing or life threatening injuries. My colleagues and I were busy – we had a child screaming with a head injury and the pain of numerous broken bones needing our urgent medical attention, not to mention a traumatised mother and older brother to consider. In the middle of all of this organised chaos I went to retrieve some equipment from my car and as I looked up I noticed that a number of bystanders were holding their phones out in front of them, focussed on the child, filming the incident.

I have to say that I feel considerable disgust at this new social propensity for members of the public to reach for their mobile phone to capture every detail of the suffering of another human being.

When it comes to the media, this is their bread and butter; even the police have no absolute right to stop them from filming. In their guidance it states they have ‘no legal power or moral responsibility to prevent or restrict what they record’. Some matters, arguably, are in the public interest; after all the media are responsible for capturing everyday situations and dramas to inform and record both for contemporaneous and future consumption and that is, perhaps, how it should be. For example, the amateur footage of the tsunami gave an almighty boost to the relief effort; court cases of police brutality have been won and lost on the basis of recorded material – often provided by the public.

However, it surprised me to discover that even if the mother of the child had asked the police to stop people filming him that guidance states ‘If someone distressed or bereaved asks the police to stop the media recording them, the request can be passed on to the media, but not enforced’ – Really? Should that be so?

Am I being a hypocrite? Undeniably.  I too have been ‘guilty’ of watching this stuff on numerous occasions, as has anyone who watches the News at Ten. Perhaps though, there are degrees of hypocrisy. This however, is about the lack of ability in each of us to regulate the setting of our own moral barometer. Have we really become so desensitized to the suffering of others because of the graphic images we are regularly bombarded with in the media that we actually delight in the pain and suffering of a small child to the point where we welcome its presence because it gives us something to share and talk with the family when there’s nothing good on the telly?

What will these non-media people do with their booty?

A) Share it with their children over dinner

B) Commit it to DVD format

C) Send it in to Harry Hill’s TV Burp because one of the paramedics rather hysterically tripped up on some equipment?

A big red helicopter landing on an urban lawn the size of a postage stamp is interesting material, and you can film me doing my job should you wish – I’m doing nothing wrong. Film the blue lights on the brightly coloured ambulance if that’s what you like; but please draw the line at filming a little child lying in the road clearly terrified and suffering during what could be his last moments of life – because next time it could be your child.

White toy teddy bear with bow, by Horia Varlan, on Flickr

Some people just seem to have the worst luck. I was given a call to a road traffic collision (RTC) and the control room asked me to provide a report for HEMS. The initial calls to 999 must have made it sound very serious if they were considering sending the helicopter out. As I pulled up on scene it appeared that the cars had taken the worst of it, but the passengers were all up and walking about – It didn’t look like there was going to be any need for that helicopter thankfully, and so we gave a report to that effect!

Another fast response paramedic (FRU) arrived at the same time as me and he took charge the occupants of one car while I took the other. My patients were a fairly young married couple, they said they had no pain or injuries and adamantly declined to go to hospital from the outset. It was then that I noticed that the woman was clutching a children’s teddy-bear tightly in her arms and her eyes appeared swollen from crying.

“Is there a child in the car?” I asked, becoming suddenly alarmed at the thought.

“No, our son died this morning, we were on our way home from the hospital, the car is full of his things” she replied – Oh my word, suddenly I had to shift my priorities. We were standing on the grassy bank of a central reservation on a busy road with passers-by literally slowing down and gawping at them. How do you begin to comfort a couple that have been living through the greatest nightmare of their lives, in these circumstances?

I threw one of our large red blankets over the metal railings to form a sort of curtain and put my coat on the floor so they could sit down and be partially shielded from the nosey ‘rubber-neckers’.

The fire-brigade and police arrived and I let them know the situation so they could be sensitive to the distressed couple while they questioned them about the accident, dealt with the damaged car (which their son had loved) and their son’s possessions. At times like these there are sometimes practical things that we can do instead of offering the usual blithered platitudes, which are not only likely to be completely inappropriate and  insulting, but are quiet simply not enough under the circumstances. Between us we managed to coordinate a lift for their onward journey (which was a considerable distance), phone calls to loved ones were made on our mobile phones and contact details supplied for the Child Bereavement Charity.

The sight of the back-seat of their car stuffed with many of their son’s possessions broke my heart, but they held it together, I can’t tell you how impressed I was by their quiet dignity.

Deciding to challenge my Italian language skills beyond their limits and seeing the opportunity for a little jaunt to my favourite country in with the deal, I signed up to attend a presentation on safety on the road in Italy.

Those who have passed a holiday in a city in Italy will recall the chaos of the busy cobbled roads. The cacophony of car horns, the hot-headed drivers appearing to flaunt the common courtesy of road manners and the plucky teenagers whipping around the traffic on their mopeds without fear or foresight. And anyone who has lived to tell the tale will recall with a pounding heart, the ‘run for your life’ dashes to cross roads even while on the relative safety of a zebra crossing. “Keep moving, they expect to drive around you, if you stop they’re more likely to hit you” I was warned by one wise friend! Bill Bryson tells us that when traversing a road in Italy, we should attempt to take the hand of a passing nun, as no Italian would ever hit a nun, therefore your safe passage would be guaranteed!

Italy has one of the highest densities of car ownership in the world and unfortunately road accident statistics bear out its image as a country of spirited drivers with little regard for the law or the rights of pedestrians. The number of road fatalities per capita is double that of the UK and nearly four times that of the Netherlands, according to figures from the World Health Organisation. In 2009 there were 4,050 road deaths in Italy (DfT). This equates to 6.7 road deaths per 100,000 of population compared to the UK average of 3.8 road deaths per 100,000 of population.

The ‘Educazione Stradale’ type events have been taking shape for the last couple of decades but since 2001 they have taken a more collaborative approach with the traffic police, fire-brigade and ambulance service delivering the lectures together predominantly to young people in schools. The evening event that I attended was hosted by two road traffic police officers Andrea Scamperle & Antonio Benedetti, and my good friend Massimiliano Maculan, an ambulance nurse who works for the S.U.E.M 118 Croce Verde in Verona (see previous post).

There was a good turn out from the people of the small lakeside town of Lazise on Lago di Garda; at a guess I would have said that there were approximately 100 or so who came along. The presentations consist of a series of videos, depicting both real and reconstructed collisions as well as testimonies from the police and ambulance staff. By far the most powerful of the testimonies came from the families of those who have lost loved ones in a Road Traffic Collision (RTC). Although I struggled at times to understand the detail of what was being said, it didn’t stop me feeling the raw emotions of the mother who spoke about her pain at the tragic loss of her teenage child in a RTC. Various videos were used to demonstrate the dangers of poor driving. During one of the videos in particular, a fatal crash caused by texting on a mobile phone while driving was played out, I could see that some of the family members became emotional. It was very graphic and must have taken considerable courage for them to watch it.

Having attended a similar presentation here in London, Safe Drive Stay Alive, it came as no surprise to note that the key messages delivered are the universal ones – all occupants should use a seatbelt, use no drugs or drink alcohol before driving, never use mobile phones to call or text while driving and of course, always drive at a sensible speed.

With each new generation of young drivers bringing up the rear, the need to repeat these events ad infinitum will remain. Sadly it seems that we human beings never have been very good at learning from other peoples mistakes.

Here is a UK video warning of the dangers of texting while driving.  A little warning here if you have any children in the room with you – it’s a graphic reconstruction.

Smashed windscreen, by wheany, on flickr

I was working on a car with my colleague Richard when we were called to a RTC (Road Traffic Collision). It was the rush hour, already dark and it had just started to rain. The traffic was dreadful as we neared the scene and even though the drivers were trying their best to move their cars out of the way for us, it was gridlock and we were struggling to pass through them. Eventually, after realising we were going nowhere fast, I decided to get out, grab as much kit as I could carry and run the last part of the journey.

The police and fire brigade were already on scene and I found our patient, an elderly man, being tended to by one of our first responders. At this time the responder was only able to hold on to the man’s head and neck to stop him moving, and potentially risking further damage, until further help arrived to assist him.

Our patient had been walking along when a car mounted the pavement and he was thrown in to the air. His face struck the windscreen (bulls-eyed) and he was flipped over, coming to land flat on his back on a raised wall area of ground that was part of the garden of a public building. He was in a very awkward place and the car was jammed up tightly against the wall.

Incredibly he was still conscious and able to talk to us. Although he was bleeding heavily from a nose bleed and a head wound, he appeared to have no obvious serious injuries elsewhere. His breathing was fine and all his physical observations were stable. We gave him oxygen and began to cut off his clothes to enable us to assess him further for any possible injuries. We placed a cannula in his arm in case he should need any medicines from us, and of course we covered him with a blanket to protect his modesty and keep him warm.

The HEMS team had been activated and they arrived by car a few minutes after us along with an ambulance. We put a stiff neck collar on him and lifted him on to a spinal board before moving him in to the ambulance.

Thankfully his condition remained stable, but because of the significant mechanism of injury we blue’d him in to hospital to give the hospital time to prepare the trauma team and make some space in the resuscitation room to receive him.

I popped back to see him a little later and he was waiting for a head scan, and thankfully I have since heard that he is still doing OK.

My last shift before my holiday was comprised of a diverse bunch of calls and here are some of them;

Firstly there was the 45 yr old lady found dead on her kitchen floor. Not seen for days; found by a neighbour who held a key. The police were on scene too and we suspect that she had fallen as she was lying in a pool of dried blood from a head injury with an over-turned step ladder nearby. When her family arrived they were extremely distressed and beside themselves with grief.

The young man with stomach ache; just one minute after the pain started his wife called 999. I arrived some 3 minutes later with an ambulance in my wake. No sooner had I introduced myself when he informed me that the pain had resolved and he had completely recovered. A total of 4-5 minutes of pain resulting in an emergency ambulance and car attending for what was most likely no more than a nasty case of trapped wind!

A 14 year old lad fell from a ramp while skate-boarding. He had sustained a really nasty injury of his forearm. I didn’t need an x-ray to tell me that the two bones were fractured as his wrist was very deformed (dinner fork deformity).  I cannulated him and gave him morphine in the middle of the skate park surrounded by at least 70 young people whizzing about me on bikes and boards.  The young people were brilliant; they helped carry my bags and made themselves generally useful. The mixture of entonox (laughing gas) and morphine made the lad very emotional and he was declaring love for those around him and literally crying and laughing at the same time which made us giggle.

A young girl with Down’s Syndrome accidentally had her finger shut in a door. It was bleeding and obviously fractured. She resisted most of my efforts to assess her, but eventually I managed to wrestle a dressing on to it to stop it flapping around and she and her family went to hospital for further treatment.

Then there was the road traffic collision. Luckily the couple were uninjured following the accident on their way to a wedding. The lovely police officer on scene kindly agreed to drop them off at the wedding. I imagined their friend’s faces as they clambered out of the back of the police van outside the church dressed in all their finery!

A toddler, newly diagnosed with epilepsy who had suffered another fit. Bless him; he was still dressed up in his fireman’s uniform when we arrived!

Last but not least was the alcoholic gentleman who had become very unwell due to his years of excessive drinking. What made me sad here though was his daughter. Rather than being able to simply enjoy herself with the trials and tribulations of being a teenager, she was instead, clearly well out of her depth dealing with the business of trying to ‘fix’ her father. She was grown-up beyond her years and told me all about her dreams to study and become a doctor – I suspect that she will be a very fine doctor indeed.

So now, I’m off on holiday – See you next week!

Image by Dplanet on Flickr

On my way to work one day I approached a busy junction. I could see that the lights weren’t working so I stopped and pulled on the handbrake. I noticed with horror that a motorcyclist and car approaching the junction from different roads were on a course for collision. As the vehicles impacted, suddenly the body of the motorcyclist was catapulted through the air like a rag doll and landed hard on the road in front of my car.

Forgetting I was in my own car I instinctively I reached for the radio to call the control room, then remembering myself I switched off the car engine and pulled my Hi-Viz coat from the passenger seat. I grabbed my paramedic bag from the boot and made my way to where the body lay. In my mind I was convinced that I had just seen someone killed – so I was very surprised to see the ’body’ start to move. I was grateful that at least she was conscious and breathing. I told her to lay still and knelt at her head and held it still to keep her from moving and possibly damaging her neck further.

At this time I remember someone approaching me. They told me that they had called an ambulance; and so I waited for it to arrive and in the meantime I tried to comfort my patient – it felt like an eternity.

The next thing that happened was a milkman parked up his float and marched over to me. He then started to yell and swear at me, blaming me for the fact that the lights hadn’t been working for two days. He shouted in my face telling me to get ‘her ‘out of the road and out of the way. I asked him, fairly politely, to go about his business and crossed my fingers that help would soon arrive. Things were getting rapidly out of hand!

Luckily, a couple of off-duty police officers passed by and stopped to help with the traffic  – little did they know at the time that my patient was in fact one of their colleagues on her way home from work. Their presence at least had the beneficial effect of making the horrible shouting milkman leave us in peace!

Next an off-duty paramedic stopped and together we safely removed her helmet (the removal of a crash helmet in this situation requires two people and special training so as not to cause any further damage to the spine). We then checked her over to determine her injuries.

When the ambulance arrived we all worked together. We placed a stiff neck collar on her and moved her on to the back of the ambulance using a spinal board, then gave her pain-killers to help her cope with her injuries.

Amazingly despite her flight through the air, it transpired that she had only sustained a very severe fracture of one of her lower legs (I found out afterwards that she went to theatre for pins and plates to be fixed to the broken bones while they healed).

This experience brought home to me how very different actually witnessing an accident is compared to arriving in an ambulance some minutes after the event; and while the actions of the milkman saddened me it was reassuring to see that even when off-duty you can always rely on the emergency service to stop and help when they can!

Signpost vs Sports Car

Someone had a really lucky escape when they walked away unscathed from this wreck! Incidentally, on my way to this call I was surprised to see Spiderman running along the pavement, closely followed by four Teenage Mutant Hero Turtles and three grown men in tu-tus; at this point I remembered that there was a fun run taking place and thankfully I wasn’t hallucinating.

When I arrived I found the driver talking to the police, who had arrived just before me. He told me that his car had spun out of control after hitting rubbish that had been dumped or fallen from another vehicle on this fast road. After spinning a number of times on the wet road – he lost count of how many times – the car eventually came to rest when it struck a sign-post backwards. The sign-post, warning of a narrowing road ahead, can be seen poking out from the rear of the car. Thankfully the driver didn’t sustain any injuries and no other vehicles were involved.

What sort of forces were involved here?

Cast your mind back a little… do you remember what you learned in physics in school about kinetic energy? This referred to energy forces from “things in motion” and “impact”? We learned that the weight of an object and its speed have a direct impact on the outcome. Realistically if you double the weight of the object you double the energy; but if you double the speed of the object, you quadruple the energy. As paramedics we apply this principle daily when we consider the seriousness of the injuries any patient may have sustained because we know that it is proportional to the amount of energy transferred and the ability of the body to resist that energy.

When this principle is applied in the context of road traffic collisions clearly speed is the greatest determinant of the forces involved. Other factors such as any pre-existing medical conditions and age should also be considered as they can make a person more vulnerable to these forces. When you arrive on scene, even if your patient ‘looks well’ it is still crucial to find out exactly what happened and the mechanism of injury before you accept this at face value. Don’t be fooled just because they initially appear to be all in one piece.  For example, if the history given to you is of a person who while standing next to a stationary bus fell over, banging their head, the transfer of energy could be assumed to be fairly minimal even though they have  ‘struck a bus’. If however, reports suggest that the bus was moving at 30 miles per hour when it struck your patient, clearly the energy transference is far greater and it is very probable that they will have sustained a significant injury such as tearing of muscles, blood vessels, broken bones or damage to internal organs.

Every object continues in a state of rest, or of uniform motion in a straight line, unless it is compelled to change that state by forces acting upon it.”

Sir Isaac Newton (1643-1727)

When I was called to a man hit by a bus recently the thought occurred to me that if I had arrived from the top of the road and not seen the damage to the front of the bus I may have been fooled into thinking that my patient’s injuries were likely to be very minor. He was lying in the road, not only fully conscious but very chatty and apart from a laceration to his head seemed to be all in one piece.  However, I had arrived from the bottom of the road and when I first saw the damage to the bus I initially wondered if a car had taken off and launched itself in to the front of it! Unbelievably this damage was all done by the patients head and body.

So even though the patient was stable, the HEMS team were activated. We immobilised him on scene and managed his pain; he was then transferred to a trauma unit for further assessment of the extent of his injuries. I am waiting to hear about the outcome for this patient and will update this post when I find out.

Image by Jon Yates, on flickr

It was a cold and dark evening when the call came in – ‘RTC car vs pedestrian’; luckily I was only a minute away and arrived while the caller was still on the telephone giving details to the ambulance service. At first glance, there was the usual array of bystanders milling about the scene; The car was sitting awkwardly in the centre of the road and lying in front of it, the unfortunate pedestrian. Reassuringly I could immediately see that he was conscious and talking.

The rain started to drizzle (again) as I pulled various bags from the car and walked towards the crowd. Bystanders had piled coats on top of the patient to keep out the bitter cold and one was directing traffic in the now–single lane street; another was kindly supporting the distressed driver of the car. They were a particularly organised group of bystanders – it seemed to me as if they had just come from a course on the subject as they appeared so coordinated; although seemingly none knew the other before the accident.

My young patient, whom I shall call Michael, was leaning up on one elbow. He looked about twenty years of age. As I approached, he begged me to look at his leg. I made a rapid assessment of his head, neck and chest, and as he had no other pain or priority symptoms I moved down to have a look at his leg.  A small puddle of blood was already forming around his foot. I cut his track suit trouser up to the thigh to see clearly what injury he had, and immediately it was obvious that he had sustained a particularly nasty fracture. The two bones of his lower leg (tibia and fibula) were sticking right out through the skin – their whiteness glistened blue intermittently as the flashing lights from my car reflected on them; the lower half of his calf was bent off at an impossible angle. At that moment Michael looked me in the eyes and pleaded:

“It’s not broken is it? – I am an athlete and I’m joining the army soon.”

My heart went out to him as I knew realistically that it was unlikely he would be doing that anytime soon. I think I said something vaguely reassuring about how, yes, it was broken but nothing that couldn’t be sorted, as I started to prepare the pain-killers he needed. It would definitely too painful to move him before they were in his system. At that point an ambulance turned up and we worked together giving him intravenous painkillers as well as gas and air (Entonox); when we straightened his leg and put it in the splint he barely seemed to notice thanks to the analgesia! We placed him on an orthopaedic stretcher and warned the hospital that we were on our way, so they could prepare for his arrival and treat his injuries promptly.

I popped in to A&E to see how Michael was doing a little later, thankfully he was comfortable and very drowsy; his leg had been placed in a temporary plaster cast while he waited for the operation to fix it. I will probably never know the final outcome for Michael, which is a frustrating situation but it is something we get used to with our job.

Ever got involved when you’ve witnessed an incident in a public place?  Did your instincts take over or did you feel very helpless?  Leave me a comment below.