Emergency: Christmas

The noise level in the trauma room rose as equipment was manoeuvred and the team focused on gathering the observations and information they required immediately.

Penelope moved swiftly back to her position at the drugs trolley. Extra drugs that might be required needed drawing up and labelling. Despite the level of concentration the task entailed, Penelope was still able to assimilate most of what was happening around her.

‘The patient’s name is Richard Milne. He’s nineteen years old.’ Information previously relayed by radio needed repetition and clarification by the ambulance staff. ‘He got blown off course while paragliding and landed in a tree.’

‘BP’s 140 over 80.’ Belinda was able to keep an eye on the monitor screens from her position at the head of the bed.

‘What gauge IV access do we have?’ Emergency Department registrar Mark Wallace was checking the patency of the cannulation done by the paramedics.

‘Fourteen.’

‘Let’s get another line in.’

Penelope watched the circulation nurse collect and deliver the supplies Mark would need. Chrissy was also watching carefully as another bag of IV fluid was set up and the giving set attached and primed with no hint of any tangles in the tubing.

‘He tried to get himself out of his harness to climb down, slipped and was caught around the neck by the harness as he fell.’ A paramedic was speaking to the consultant leading the medical team, Jack Hennessey. ‘He hung long enough to lose consciousness, then the branch broke and he fell approximately six metres. The fall was broken to some extent by lower branches and he landed on a grassed area.’

‘Was he wearing a helmet?’

The helmet was in the hands of a second ambulance officer. ‘It’s damaged at the back,’ he reported. ‘Witnesses didn’t think he was KO’d.’

‘He was conscious on our arrival,’ the paramedic continued. ‘Glasgow Coma Score 14. No neurological deficit. Fractured mid-shaft femur on the left side and a fractured right wrist. GCS dropped en route to 10 with increasing respiratory distress.’

Penelope glanced towards the patient’s head. The level of consciousness was still well down. The teenager’s eyes remained closed and his verbal responses were limited to an occasional moan. The neck collar had now been removed and Belinda Scott was providing manual stabilisation while Jeremy assessed the injury to the neck and the patency of the patient’s airway. Air movement was not good. Penelope could hear the girl’s harsh inhalations clearly through the general noise level. She could also hear Jeremy Lane speaking to the consultant.

‘We’ve got some major oedema here. Trachea’s still midline and there’s no subcutaneous emphysema on the neck but I can’t rule out a tracheal rupture.’

‘Oxygen saturation is down to 85 per cent.’

Jack Hennessey turned to Mark Wallace. ‘See if you can get an arterial blood gas off after you’ve secured that IV line.’ He looked back at Jeremy. ‘Are you going to intubate?’

‘I’ll have a go. Could do with fibreoptic endoscopy, judging by the oedema present, but it won’t be the first time I’ve done it blind.’ Jeremy sounded confident. ‘Could I have someone ready for cricoid pressure? Thanks.’

Penelope looked at the registrar standing beside her at the drugs trolley. Labelled syringes were spread out in front of them, including sedation and paralysis agents and cardiac drugs in case prolonged laryngoscopy led to a deterioration in heart function. Duplicate ampoules were readily available. The registrar acknowledged their readiness with a nod.

‘You do it, Penny. I’m all set.’

Belinda was still holding the patient’s head in a position to protect his neck. A cervical spine injury had not yet been ruled out. Jeremy was hyperventilating their patient with rapid squeezes on the bag mask unit. A neuromuscular blocking agent was administered and then Penelope positioned her fingers on the young man’s neck to press on the cricoid cartilage. With the amount of soft tissue swelling this wasn’t as easy as Penelope would have liked but she was confident she had located the correct spot. She knew that pressure on this part of the Adam’s apple reduced the risk of vomiting and aspiration during the procedure. It also displaced the larynx and aided visualisation for Jeremy.

In this instance it wasn’t enough of an aid. Jeremy had two attempts to pass the intubation tube into the trachea.

‘This is hopeless,’ he pronounced. ‘Bag him, will you, Penny? The suxamethonium won’t wear off for a while yet. We might have to go for a tracheostomy here.’

Penelope fitted the face mask securely and squeezed the bag to provide oxygen to the now paralysed teenager.

‘What about a needle cricothyroidotomy?’ Jack Hennessey suggested. ‘The injury seems to be above the level of the larynx.’

‘That would only give us thirty to forty minutes’ effective ventilation. This lad’s going to need CT scanning to rule out a skull fracture and C-spine injury before he even gets near the operating theatre.’

‘Heart rate’s dropping. Down to 90,’ a nurse warned.

‘And pulse pressure’s widening. One-fifty over 95.’

Tension in the trauma room went up a notch. The signs could be a warning of rising intracranial pressure from an as yet undiagnosed injury. Airway control and adequate ventilation had to be instigated as quickly as possible.

‘Surgical cricothyroidotomy should be enough.’ Mark joined the discussion between Jack and Jeremy. ‘Fewer complications than a tracheostomy, which could be done later in Theatre if it’s needed.’

‘Are you happy to do it?’

Mark nodded. He glanced at Jeremy. ‘Unless you want to?’

Jeremy shrugged. ‘Go for it, mate. I’ll look after the bag mask and Penny can assist you.’

Penelope relinquished the ventilation equipment, taking a quick glance at Jeremy as she did so. Was he bothered by his unusual failure to intubate a patient? Less than happy to hand over the imminent procedure to a newcomer? If so, he didn’t show it. Jeremy smiled at Penelope.

‘Seen one of these done before, Penny?’

‘No, but I know where the kit is. I’ll find it.’

She opened the roll of sterile drape on top of a fresh trolley to reveal the sterilised equipment that would be needed.

‘Clean the whole area over the cricoid and thyroid cartilage,’ Mark directed her. ‘Then we’ll infiltrate with one per cent plain lignocaine.’

Penelope swabbed the young man’s neck.

‘I’m going to stabilise the thyroid cartilage here,’ Mark told the onlookers. ‘Then I make a horizontal incision over the cricothyroid membrane. Scalpel, please.’

Everyone in the trauma room was crowding in for a closer look. This wasn’t an everyday occurrence. Mark appeared confident as he cut carefully into their patient’s throat. He reversed his hold on the scalpel and inserted the handle.

‘It’s helpful to rotate it through ninety degrees to open the airway,’ he explained. ‘Can I have a size 9 endotracheal tube, now, please?’

The tube that Penelope handed him was carefully inserted and the cuff inflated. Penelope had the sutures ready to hand over next. She watched as Mark stitched the tube into place.

‘I’ll get us hooked up.’ Jeremy was adjusting controls on the ventilator. ‘Let’s see if we can get some better-looking oxygen saturation figures.’ He nodded at Mark. ‘Well done.’

‘Thanks.’ With the airway and breathing for their patient now under control, Mark’s attention was diverted. He was examining Richard’s chest for injuries and had his stethoscope in his ears to recheck breathing.

‘Let’s have another neurological check,’ Jack requested. ‘What are the pupils like?’

‘Equal and reactive. Bit more sluggish than they were.’

‘Let’s run off a C-spine, chest and pelvic set of films,’ Jack directed. ‘Then we’ll send him for a CT scan of his head and neck.’ He was watching Mark as the registrar took a moment to re-examine their patient’s abdomen. He glanced at Penelope. ‘Give Neurology a call and get someone down for a consult, will you, please? Don’t worry about Orthopaedics just yet. That femur and wrist can wait.’

The doctors moved back as the radiographers positioned equipment.

‘Chest and abdomen look OK,’ Mark informed Jack. ‘I’d say he’s pretty stable for the moment.’

‘Now that we’ve got that airway sorted out, he is. Nice job, there, Mark.’