Male on the road – no sign of life.

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.

Typical day at the office

This is a timeline of a typical dayshift I worked last week.  It developed into a longer blog than normal for me.

06:40  

I arrived at work.  My mate, Tony arrived pretty much at the same time.  The station we are based at is in a pretty rough area.  We are allowed to put our cars in the garage as there is a high risk of them being vandalised while we are out and about on emergencies if left out on the street.  We walked into the mess room and I made straight for the kitchen to put my food in the fridge and more importantly make coffee!  The night shift had already arrived back on station and were pleased to see us.  They handed over the radios and Pat, the paramedic I was taking over from gave me the key to the safe in which the controlled drugs are stored.  We chatted about their night shift and they started to get their belongings together to get home to bed and a well earned sleep.  Tony and I drank our coffee while we contemplated the 12 hours ahead of us.

07:00

Time to sign on.  We carried our personal equipment onto the ambulance.  We take it in turns to drive – Tony and I usually swap half way through the shift.  This morning Tony was driving first.  I got into my side of the ambulance and put our staff numbers in the data pad in the cab.  When I pressed ‘send’ this told our dispatcher who we were and that we had signed on for the shift.   Our dispatcher called us up on the radio to say good morning and check we had all our equipment and were ready to go.  While I had a brief chat Tony had started the engine, put all the lights on and was walking around the vehicle making sure that they were all working and that the tyres all looked ok.  In an ideal world we would be given time to check equipment in the back of the ambulance, restock any consumable equipment we were running low on and check and sign for the drugs and the controlled drugs.  However….

07:04

The first job of the day was passed.  An 86 year old lady had fallen in her bedroom; her elderly husband had made the call because she was unable to get herself up.  It was fairly local so we were there in minutes.  I got the First Response Bag from the side door of the ambulance.  This is a (heavy!) rucksack which has all the equipment we need to assess and start treating just about any emergency.  Mr J was waiting at the door for us and he pointed up the stairs.  “She’s up there lads, don’t think she’s hurt, but I can’t lift her.”  We found Mrs J lying on the floor next to her bed; Mr J had covered her with the quilt to keep her warm while she was on the floor.  After checking her, there was no sign of injury and from her baseline observations no sign of illness.  She said that she had not fainted or felt unwell, just lost her balance while getting up from bed. We helped her up and she was able to walk down the stairs as normal.  There was no need to take Mrs J to hospital or arrange a doctor’s appointment.  I rang her son to let him know what had happened and then, with Mrs J’s permission I passed her details onto the local falls team, a multi-disciplinary team who would visit Mr and Mrs J with a view to giving advice to prevent further falls.

09:30   I cleared the job, making us available again for the next emergency.

09:30

We were passed details of a 13 year old boy who was unwell with stomach pains.  We arrived and were shown into the front room where Toby was curled up on the sofa hugging a bowl.  He had vomited twice while waiting for us.  From the history and his presentation the most likely diagnosis was appendicitis.  We needed to take him the hospital for assessment and possible operation.  Appendicitis is difficult to diagnose with absolute certainty.  Toby would be seen by the Emergency Department (ED) doctor and referred on to a surgical specialist.  Even the surgeon would not know for certain, they operate if the “index of suspicion” is high that it is appendicitis.  We dropped Toby and his mum off at the ED and took the chance to make a cheeky coffee to take out to the ambulance while we checked and signed the drugs check sheet.

10:30   I cleared the job.

10:30

The next job was passed, a 93 year old gent who had fallen in the night and his carer called us because he “wasn’t himself”.  We arrived to find Albert sitting in his chair.  His morning carer had visited and was about to leave as we arrived.  He was annoyed that his carer had called us, he didn’t like fuss.  There was no sign of injury from his fall and he was able to walk with no problem since his fall, which he said was just down to being half asleep when he got up in the night to go to the bathroom.  His baseline observations were all normal.  There was no need to go to the ED.  Once we told him this he brightened up and started to talk.  He was feeling low because he didn’t want to leave the house he had lived in for 50 years and was scared that we would take him away and that would be it.  I reassured him that we were all there to help him and to keep him well so he could carry on living in his own house.  He agreed that I could phone his grandson who he was close to and Tony made him a cup of tea while I did this.  His grandson agreed to call round with fish and chips after he had finished at work.  I suggested that Albert made an appointment with his GP (GP = General Practitioner: the doctor who looks after us in the community and co-ordinates our health care) for a general check up and review of his medication, which they agreed to do.  I also passed his details to the falls team – we were keeping them busy this morning!

11:58   I cleared the job.

11:58   We were told to Return to Base (RTB) for meal.

We set off back to station but two minutes later…

12:00

We were passed another job (dinner would just have to wait!).  This was in the next town, a 27 year old female who was 30 weeks pregnant and was passing blood with abdominal pain.  We arrived and the family met us at the door.  They had phoned the local maternity unit (MU) and they had said to come in.  We helped Safira onto the ambulance and her mum then after quickly assessing her baseline observations set off to the MU.  They were obviously subdued on the journey in and didn’t want to chat so after getting the essential details I needed I let them have peace.  We cleared at the MU and this time we would have to be allowed back for a break because we had been out more than 6 hours.  Sometimes ‘Health and Safety’ works in our favor.

13:20   RTB for meal.

13:35   Arrived on station and demolished our packed lunches.  Sometimes I pick up a take away but generally prefer to bring a packed meal.  Meal break is 30 minutes long and when we have been out longer than 6 hours cannot be disturbed by control.

14:05

Right on cue, the next job was passed to us.  It was my turn to drive.  We were given a 55 year old man who was in severe abdominal pain. We walked into his flat to meet Joe.  Joe admitted he was alcohol dependant (we guessed by the empty cider bottles next to the sofa).  He suffered with chronic pancreatitis as a result, and the pain had flared up this morning.  This is a long term condition where the pancreas is damaged, in Joe’s case by many years of daily drinking cider.  Joe had taken his usual amount of cider this morning (it can be dangerous for an alcohol dependant to suddenly stop drinking) but the pain was not subsiding.  We helped him onto the ambulance, checked his observations and I cannulated him and gave some morphine.  This dulled his pain and we took him to the local ED.  We raided the ED staffroom for a cheeky coffee and a few biscuits.

15:20   Tony cleared the job.

1520

The next job was waiting for us, the jobs were stacking up in control now and this had waited 50 minutes before an ambulance was available to allocate.  It was a 25 year old male who had cerebral palsy, development problems and epilepsy.  He lived in an adapted house with 24 hour care support to enable him to live as independently as possible.   Jamey had had a seizure.  The care staff were concerned that the seizure had been triggered because Jamie had an underlying chest infection and had contacted Jamie’s GP to arrange a check up.  The GP had insisted an ambulance was needed.  We checked Jamie’s observations.  We worked slowly and got the carer to help keep Jamie calm as we explained each test as we did it.  Jamie had fully recovered from his seizure by now and was back to his normal self.  There was no need to take Jamie from his secure, familiar house to a noisy, busy ED, so Tony convinced the GP service that Jamie was safe to stay home and wait for a doctor to start treatment for a chest infection.  (This sounds straightforward but actually is frustratingly time consuming: we make a phone call to one of the GP services we use and give the basic details to a call taker.  We then wait for A GP to ring us back to discuss the case.  This can be up to an hour later.  Then, during the daytime office hours the GP will often ring the patient’s own GP (we’re not supposed to do this directly ourselves – don’t ask!)  Then our GP will ring us back with a decision).

17:10   We cleared the job.  We were over due our second rest break of the shift, 20 minutes this time, but control asked if we would take a look at a child involved in an RTC they had no ambulances available to cover.

17:10

We were passed the job, a 14 year old girl who had been struck by a car.  The girl’s friends had made the call and were hysterical so our call taker had no idea of any injuries.  We arrived at the scene and were relieved to see everyone was on their feet – no one was lying on the road – a good start to the job!  Chelsea had been checking Facebook on her phone and had stepped out into the road. A car had managed to almost stop in time but had connected at low speed with Chelsea’s right leg, knocking her to the ground.  She had managed to avoid banging her head and jumped up immediately.  She was more upset that she had dropped her phone and the screen was smashed.   We got her onto the ambulance and checked her over.  We were happy from the mechanism and from the examination that there was no spinal injury.  She had some bruising to her right thigh and bruising and a cut to her left elbow where it had hit the road.  As we were checking Chelsea we heard raised, worried voices approaching – mum was here. Chelsea’s friends had rung her mum as well as phoning for the ambulance.  With a loud hammering on the ambulance door mum arrived.  I opened the door to let her in and calm her down as Tony was getting some details from Chelsea.  When mum saw that Chelsea was basically ok she burst into tears of relief then started shouting at her and threatened to kill her for the worry she had caused.  I asked her to wait until after 7 o’clock before she killed her because that was when we went off duty.  That lightened the mood.  We took Chelsea and her mum to the ED to get her elbow x-rayed and the cut closed.

18:35   We cleared the job and were RTB’d for our belated rest break.  At least it meant we would finish on time.

18:45   We arrived back on station, for the second time since we left at 07:04 this morning.  We took our gear off and I grabbed a mop to give the floor a clean as Tony got a few things from stores that needed restocking.

The night crew arrived and we handed the vehicle, radios and controlled drugs keys over to them.

1900    Time to go home.  Quite rare to finish on time, normally we are still on a job when finish time comes around and we obviously have to finish the job before we can go home.

Time now to relax until 07:00 tomorrow when we get to do it all again.

Why I wear a Remembrance Day poppy

This blog post has no ambulance anecdotes in it; this is what the symbolic meaning of the remembrance poppy is to me.

The poppy was first used in 1921 as a symbol to commemorate the fallen military in the First World War. It was inspired by the war poem ‘In Flanders Field” by Lt Col John McCrae.  Since then it has come to be a symbol of remembrance of military fallen in every conflict including and since the First World War.

Some see it as a political statement and a measure of patriotism, some as a glorification of war and others even as a racist slur.  To me it’s none of these.  I certainly don’t glorify war – I wish we as a species could at long last ‘grow up’ and accept differences, tolerate other viewpoints and all get on and love and help each other.  John Lennon summed it up for me in his masterpiece ‘imagine’.  End of rant.

I wear a poppy to remember and honour my great uncle Saville.

Saville was born in 1899 in a small Yorkshire town, Northowram.  He joined the army in 1915, joining the Royal Army Medical Corps as a stretcher bearer.  Some stories have been passed down through the family and one of my favourites is about how Saville and his colleagues dealt with wounds.  If a wound was bleeding and they were struggling to stop the bleeding one trick they found to increase the pressure was to place a dressing on the wound then place a small stone, or even once a potato on the wound then strap a bandage around it – the stone would increase the pressure to stop the bleeding.  Coming back to the 21st century, one type of trauma dressing we use has a plastic pressure bar insert (with a projection shaped like a small potato!) to be strapped over a wound to increase pressure and help stop bleeding.  It always makes me smile to myself because I think that my uncle and his friends invented this gadget!

Saville was awarded the Military Medal for bravery during a particularly fierce battle making several sorties out into no-man’s land to fetch wounded soldiers back to safety.  Tragically he was killed on the first of October 1918 – just weeks before the end of the war.  A shell exploded above him while he was on his way to pick up some wounded soldiers and a fragment of shell casing struck him in the chest, killing him instantly.  His mother, my great grandmother, never got over her grief at losing her son.

This is just one tragic story out of the hundreds of millions of casualties in the 20th century wars but it is very personal to me.  I obviously never met my great uncle but I would love to talk to him and hope that he would be pleased I’m a modern day stretcher bearer.

That’s what the poppy means to me and that’s why I wear it.

Child RTC – unknown if breathing

(SPOILER ALERT: To avoid undue distress this anecdote ends happily)

 

One Saturday afternoon Tony and I were passed details of a job: it was a reported child RTC (Road Traffic Collision – in other words the child had been hit by a vehicle).  Due to the panic of the caller and language differences, our call taker was unable to establish if the child was breathing, responding or conscious.  All we had was the street name and possible age, 7.  The street was not far away and we were there in minutes.  On the way we were both apprehensive and anxious.  There’s something about an unwell or injured child that that I dread. I think that every emergency worker feels the same – it’s just so heartbreaking when a child is harmed or killed and even after 20 years I feel very scared when a child’s well being and even life is in my hands.

I turned the ambulance onto the street, blue lights still flashing, and the sense of dread increased.  A large crowd of people were standing in the street and on the pavement.  As soon as we arrived members of the crowd started waving and shouting at us.  At this point we couldn’t see the child through the crowd.  We got out of the cab and the shouting got more frenzied as people tried to rush us.  Tony got the response bag (a large rucksack which contains most of the equipment needed to start treating almost every conceivable emergency) out of the side door and we started to walk toward the area of the crowd that we were being jostled towards.  People sometimes think that ambulance staff are too casual and slow when approaching an emergency, they expect us to run.  During training it is emphasized that you should never run – that’s when mistakes are made and injuries happen.  We are trained to take a calm, measured approach and observe as much of the scene as we approach to evaluate and minimise any dangers to us, the patient and any bystanders.

We pushed through the crowd and finally got to the young boy, Bilal, who was lying on the street on his side with his mum cradling his head and sobbing and praying.  A multi-person-vehicle (MPV) was parked a short distance away with a large, obvious dent in the front where it had collided with Bilal.  We had to gently get Bilal’s mum to let go of him so we could roll him onto his back so we could protect his neck and assess his breathing and circulation.  Tony gently held Bilal’s head in neutral alignment so his spine was in its natural position and to our relief we saw that he was breathing and had a pulse, both were in the normal range for his age and there was no obvious difficulty with breathing.  His blood pressure was normal for his age. A man came forward and introduced himself as Bilal’s uncle, Ash, who offered to interpret for us as Bilal’s parents spoke very little English.  Tony knelt on the floor holding Bilal’s head in neutral alignment, also protecting his airway and explained to Bilal’s parents, via Ash, what we were doing and what we needed to do.  I tried to clear some space around us by shepherding some of the crowd away onto the opposite pavement.  I went to the ambulance to get the equipment we needed: a rigid collar to help immobilise Bilal’s neck, scoop stretcher plus padding to fully immobilise and various straps and a blanket.  As soon as I started back to Tony and Bilal the crowd had resumed their position in a tight circle around them.  I forced my way in with the equipment and Tony and I began the delicate task of immobilising Bilal so we could safely move him from the floor to the ambulance and then on to the Emergency Department.

Bilal had a large swelling above his right eye from his collision with the MPV and a swelling to the back of his head which had a small laceration on it: as with all scalp wounds this had bled profusely.  His level of consciousness was reduced from normal and was constantly changing.  He would be restless and agitated crying in pain then lapse into a quiet phase then return to the restless phase. We tried to apply the rigid collar but he became very agitated, fighting us off.  We made the decision to compromise and leave the collar off.  Although this was reducing the immobilisation of his spine this was one of those cases where it’s better to leave the collar off and keep the patient calm than try to keep the collar on and have the patient agitated and restless – probably doing more damage to a potentially damaged spinal cord.  We managed to get Bilal on the scoop and place the padded head blocks and body straps on without disturbing him too much, and moved to the ambulance.

In the ambulance we settled Bilal’s mum and uncle Ash and closed the doors so we could work in relative quiet.  We rechecked all Bilal’s vital signs and checked him thoroughly from head to toe.  His main injuries were the swelling above his eye and the laceration to the back of his head.  There were several other superficial cuts and abrasions on his elbows and his back.   His pupils were equal size and both reacted when a light was shone into them.  If one or both pupils became dilated and stopped responding to light that would be a sign that there was internal swelling in the brain.

Before we left the scene we had a quick word with the driver of the MPV and some of the witnesses, they all said that he had been driving along the street at about 25 mph when Bilal had run out in front of him giving him no chance to stop.  Bilal had been knocked to the floor and had been completely unresponsive for a few minutes before recovering to the agitated state he was in now.

We set off to the ED of the local hospital with no further delay (this was before we had specialist trauma centres).  As we set off we asked the control centre to pre alert the hospital so they were waiting for us as we arrived.

The rest of the shift carried on as normal but both Tony and I kept dwelling on the job, analysing everything we did and wondering if we should have done things differently, if there was a better way to have handled the job.  As always, I had a vague sense of guilt that I had not done enough for Bilal, although I couldn’t put my finger on anything specific.

A few days later we checked and were relieved to hear that Bilal had made a full recovery and was discharged home.  A happy ending this time, hopefully in future he’ll be more careful on the roads!

Putting his foot in it.

One day we were called to a job in a local factory.  The factory produced, among other things, corrugated steel sheeting for roofing and other uses.  One particular machine corrugated the steel sheets.  A plain sheet of steel was fed into a slot on top of and the machine spat it out corrugated.  Apparently the machine was prone to jamming and required frequent maintenance.  This afternoon the machine had jammed and due to the pressure to get the current order out of the door, the operator had tried to help by climbing onto the machine and giving the stuck sheet a kick.  It worked and the sheet flowed into the machine to be corrugated.  Unfortunately the rollers also grabbed the lad’s boot and dragged his foot in too.

When we arrived the fire service had already arrived, the factory supervisor had rung them first since the lad, Rob, was trapped in the machine.  I climbed up a set of step ladders and joined Rob and two fire fighters on the top of the machine.  The fire fighters had dismantled part of the machine and just freed Rob’s foot.  He was fully alert and while his foot was trapped had not really been in much pain, just his left leg felt numb. Now the leg was free the pain started. I started him off with some pain relieving gas, entonox.  There was no sign of active bleeding so we carefully passed him down from the top of the machine to my mate Tony and a group of firemen at the base of the machine and they placed him on the ambulance stretcher Tony had prepared.  Once on the ambulance we could have a closer look.

The skin on Rob’s foot had been stripped from above the ankle and was all bunched up around his toes.  A single, thin and very stretched strand of skin joined this skin to the skin above the injury.  The tendons and bones of Rob’s foot were exposed and it reminded me of one of the model feet you see in anatomy class (and also in art schools life art classes!) to show the students the underlying structure of the foot. The term for this injury is ‘degloved’ and applies to hand and feet injuries where the skin is fully or partially removed as in taking off a glove.  The term applies to feet as well as hands, there’s no such term as far as I know as ‘desocked’.

The degloved tissue was very cold to touch, numb and pale which told us there was virtually no remaining blood supply – a time critical emergency as without quickly restoring the circulation Rob would lose the foot.  Rob’s pain was increasing now and the entonox was not really helping.  Tony checked his baseline observations and I quickly checked there were no other injuries.   I gained IV access and gave some IV pain relief to back up the entonox.  This was in the days before we were trusted with the controlled drug morphine, a very effective pain reliever and the best we had was called nubain – a synthetic opiate which was supposed to work in the same way but in my experience didn’t help people much, nowhere near as effective as the morphine we carry now.

This was also before we had trauma centres we could take serious injuries such as this one to where all the specialist staff are in one place, we had to take Rob to the local Emergency Department (ED) where he would be assessed by the ED doctors and then referred on to a specialist unit.

On the short ride to the local ED two things were worrying him: the first was that he played football for a pub team and was supposed to be playing the next weekend.  I said he probably wouldn’t make the match, he jokingly asked if he’d be OK to play in goal.  The second worry was that he was getting married in a few weeks.  The thought of all the surgery he was faced with scared him less than the thought of his future wife’s reaction.  I hope it went well for him!