Warning: contains material some might find distressing. No happy ending.
It was a cold and rainy early morning in winter. Tony and I were looking forward to the end of our night shift. The shift had been busy with the usual routine type of emergencies – nothing too taxing for us. We were on our way to the last job of the shift, a category 2 emergency – an 83 year old male who had fallen while making an early morning visit to the bathroom. With a bleep on the data pad our plans were changed. We were passed a category 1 emergency – immediately life threatening.
It was a report of a male lying in the road outside a bar; the caller didn’t want to get too close but was unsure if the male was alive. It was about 6am, most bars in this area had closed hours ago so it was unlikely to be a drunk sleeping it off. We were only a few minutes away so we would know soon. We arrived at the bar and stopped. We looked around but could find no trace of any male lying in the road. Two police cars arrived shortly after us and started to look around the immediate area as Tony contacted our control room (EOC) to ask for any further details about the location. We were both thinking that this was after all a case of a drunk male who had miraculously come back to life and wandered off before we arrived. The message came back from EOC that the man was a few hundred yards further along the road, hidden from our view by a hill. We jumped back in the ambulance and set off. As we got to the crest of the hill we saw our patient. He was lying on his back in the road with just his feet on the pavement.
We didn’t know his name, I still don’t know what his name is as I write this but I’m going to call him Jack. This is to make the account personal and to honour the human being. In the medical reports and police statements I referred to him as ‘the patient’ or ‘the male’. This feels horribly impersonal and makes us forget that this is a person with a life history who has family and friends who love him. This is for Jack.
We parked near Jack, using the headlights to provide as much light as possible on this dark rainy morning. The police had already blocked the road in front of and behind us so at least we didn’t have to look out for cars speeding past inches from us.
I grabbed the first response bag and walked to Jack. We rarely run, that’s when you miss things and risk having an accident yourself or further hurting the patient. As I approached I was taking in the scene, trying to get an idea of what had happened. It was hard to see in the dark but I could see a quite large amount of blood on the downhill side of Jack’s head – obviously a head injury which was bleeding profusely. He was fully clothed against the winter weather so it was hard to assess any other injuries. He looked about 45 years old. I knelt by his head to quickly assess. Jack’s mouth was open and was full of blood so his airway was totally blocked, he was obviously not breathing and I couldn’t feel a pulse in his neck. He was in cardiac arrest (No heartbeat and not breathing). As I was assessing him I noticed that Jack was still quite warm. Since he was lying on the road in the rain I knew he hadn’t been down very long.
This was decision time.
We don’t automatically try to resuscitate every cardiac arrest we attend. Some are beyond all hope of help. Medical cardiac arrests (caused by medical emergencies such as heart attack, stroke etc) have a slightly better chance of survival. Studies indicate that recovery rates range from approximately 36% to 3% depending on the presenting heart rhythm, assuming immediate resuscitation attempts are made at the time of collapse. This was a Trauma cardiac arrest (caused by trauma = physical injury). Studies show that survival rates from traumatic cardiac arrests are 6% at best. Certain injuries are deemed to be unsurvivable and if a patient has an unsurvivable injury we don’t attempt to resuscitate. If we decide resuscitation is viable and we start, trauma resuscitation guidelines advise that the resuscitation attempts should continue as the patient is transported to a specialist trauma centre.
The decision we had to make was: did Jack have a survivable or unsurvivable injury? We couldn’t take long over this decision – if, after a prolonged examination we decided his injuries were survivable we would have killed him by delaying resuscitation attempts.
I decided we couldn’t say his injuries were unsurvivable here in the dark and rain on the floor so I decided to start working on Jack while we moved him into the ambulance for a closer look. A police officer was ‘volunteered’ to do chest compressions then my next priority was to clear his airway. Tony had brought the suction unit so I could use a tube to suck the blood from his mouth. As soon as I cleared his airway it refilled with blood. I decided to intubate as soon as possible. I do this by kneeling above his head and use a laryngoscope. This has a blunt blade at right angles to a handle with a bulb on it. By using it to lift the tongue and lower jaw gently up I can then see the vocal chords – the structure at the top of the trachea – the windpipe. After a last attempt to suction the blood out of the way I inserted an endotracheal tube (ET) through the vocal chords and into the top part of the trachea. The ET is about 10 inches long and the end of the ET which sits in the trachea has a balloon on the outside, I inflate this and this seals the trachea, blood in the mouth can no longer block the airway. The other end of the ET is projecting out of Jack’s mouth and by connecting to a ventilator we can breathe for Jack.
By this time a second ambulance, an off-duty paramedic on his way to work and a senior paramedic in a response car had arrived. Tony was organising them to get the equipment we needed to immobilise Jack and move him to the ambulance. Under Tony’s supervision as I concentrated on protecting the airway and neck, a police officer continued chest compressions we immobilised and moved Jack into the ambulance.
In the ambulance where it was brightly lit (and warm and dry) we could fully assess Jack. While still carrying on the resuscitation attempt, we cut all Jacks clothes off. It was obvious that Jack’s injuries were severe; this wasn’t just a case of falling over and banging his head on the kerb. Multiple fractures were now obvious throughout Jack’s body and his head injury was substantial. As a team we sadly decided that continued resuscitation would be unsuccessful so we stopped.
This was a breach of our guideline. If we decide not to attempt or to terminate resuscitation we’re not supposed to put the patient on the ambulance. Legally speaking, the site of a traumatic death is a crime scene until the police have ruled out foul play. By moving the patient to the ambulance the ambulance becomes the crime scene. Our managers frown on this. In the debrief, the senior staff agreed that this was an exceptional case and I couldn’t have done anything else. I couldn’t have said that Jack’s injuries were unsurvivable without a proper examination and I couldn’t do that in the dark on the road. They all reluctantly agreed that they would have done the same.
I still don’t know what happened to Jack that morning. His injuries suggested high energy impact, not just falling over. One possibility was a hit and run RTC – the injuries weren’t typical of impact with a vehicle though. The road where Jack died passes through a cutting in the hill with steep embankments about 60 feet high on both sides. The most likely explanation was that he fell or jumped from the top of one of the embankment walls.
It was a sad, late and wet finish to our night shift.