Compromise

We arrive at the scene carefully picking our way through the traffic to the lay by. There is a lot of activity going on.

2 lorries are sat in the lay by with a large trailer looking out of place in between the two. It looks like it belongs to the truck blocking the road.

The traffic officer in charge leads us to the cabin of one of the lorries. A female driver is sat looking pale and in pain.

"Hi there, whats happened?"

It seems she was sat in the lay by having a well earned rest on her drive down from Inverness when something hit her from behind. That something it turns out was the out of place trailer. It had become detached from the lorry at approximately 40 mph and had slammed into the trailer of the stationary wagon.

My mind wonders to the scene this would have been had the trailer not hit the lorry but taken out some cars on the carriageway.................... I decide it doesn't bear thinking about and should just be thankful for this outcome, although I'm not sure our patient would agree right now.

"Where are you sore?"
"I lurched forward as I'd taken my belt off and hit the bottom of my ribs and breastbone on the steering wheel. Its really sore to breath in too deep."

I can see this is biggest problem she has, wincing every time she tries to take a deep breath. I put some oxygen on her. I want to listen to her chest but there in no point in the cab as its too noisy. It'll have to wait.

"Do you have any pain in your neck or back?"
"A little in my neck, it feels stiff rather than painful"

I look down out the cab and it becomes apparent a manoeuvre to board her in the cab would be far to dangerous for everyone involved. The mechanism of injury and the fact she has neck stiffness dictates I need to immobilise her by the best means possible.

I get a collar on her in the cab, its a quick and simplistic solution for the mean time. The oxygen and collar are taking care of her chief complaints. My main concern is her difficulty breathing.

We manage to bring the ambulance closer to the truck's cabin, I ask SoItIs* to put the board onto the trolley bed. We planned to help the patient down from the cab while controlling any neck movement as much as possible. Its seems to work well, with a few more hands found in the traffic police.

We carefully start to help the patient lower on to the spinal board.

"I can't lay like this, it makes the breathing worse, I can't lay down it hurts too much" I can see its causin her an awful lot of discomfort even trying to lay flat.

Right.

We need to immobilise her painful neck, which she now informs us has pain shooting into her head, but we also need to protect her breathing. Hmmmmm.........?

I come to a decision and move the trolley bed so she is positioned for optimal breathing. ABC's right? Breathing is my priority, the other stuff we can work around. Rolled up blankets are placed either side of her head to keep it in position and taped into place. I ask the patient to try her best to keep looking out the back window to keep her head in line. Its the best compromise I can some up with.

I set about having a look and feel of her lower rib cage, a quick listen doesn't suggest a pneumothorax (punctured lung) but I take a full set of obs and keep a close eye on her condition. The ECG looks normal, if a little fast, but it looks like the strike to her sternum hasn't sent her heart into an odd pattern.

On arrival at Holy Hospital I wheel the patient through to triage delighted to see Smiler* behind the desk (seriously in all my time going there I have not seen her crack a smile once).

She looks up then stands up to look over the desk. The look she gives the immobilisation I've had to improvise says "What have these idiot paramedics done now?" a sigh and a role of the eyes completes the show of distaste for my ingenuity.

"Would you like a hand over to explain why the patient is immobilised in this way or do you just want to make up your own mind that we're stupid now?" I was not in the mood for this kind of attitude today. I'm not usually this cheeky preferring not to rock the boat but sometimes it just niggles at you a little too much.

A raise of the eyebrows and nod of the head tells me to go round to Majors where I hand over to a nurse who patiently listens to my handover and explanation of the patients problems. She gives us a smile and a thank you while busying herself with the patients obs. See its not difficult is it?



I truly think that A&E nurses and doctors should be required to come out on the road with ambulance crews to witness the decisions, compromises and difficult manoeuvres we have to make when dealing with a patient in a non-clinical environment.

Then maybe the minority wouldn't be so quick to dismiss us when we bring in something unusual and not wrapped and packaged for them in the standard way.