The Times Magazine 13so they know where to go hunting for injuries.
It’s very important for me to debrief the
ambulance crew and check they’re OK. They
were very, very stressed. Then we cleaned
our kit so we were ready to be activated again
as soon as possible. There’s only one trauma
team on overnight in London and we got
another job straight away. I haven’t seen the
patient since. I find it very emotional seeing
my patients; I would only do it if they wanted
me to. I’m very good at keeping my game face
professional on a job, but even hearing about
them pulls at my heartstrings.Bella Stretton, 29, staff nurse in A&E
at St Mary’swas working in Resus that night, which
is the part of A&E for critically unwell
patients. It was quite busy; we had three
trauma calls close together, but Danilo was
our first and most serious. When you’ve got
someone like him coming in, a code red, it’s
all about being able to hit the ground running.
We book scans and blood tests straight away
under a fake name, because we don’t know
their real names, so there are no delays when
they arrive. If you wait, you could be looking
at a delay of maybe 10 or 15 minutes before
anything is done and that affects outcomes
later on.
The nurse who picked up the phone at the
nurses’ station put out the call for the rest of
the team to gather, so all the doctors and nurses
were there when he arrived. With Danilo
there were around ten doctors, one from each
speciality – anaesthetic, orthopaedic, trauma,
plus the radiologist. We knew that he’d come
off his motorbike, but not much more. As
nurses, our main priority is to get him from
the paramedics’ trolley onto the A&E trolley
and get the monitoring on, because whoever
brought him in – London Ambulance Service
or HEMS [Helicopter Emergency Medical
Service] – will obviously take their monitoring
equipment away with them.
As soon as the patient hits the A&E trolley,
they’re getting blood and oxygen. We find out
from the HEMS team what medication they’ve
already given him and if they’ve already given
him any blood, because that’s important if
we need to give him more. We have our own
fridge in the emergency department with
type O, the universal blood, so I make sure the
label matches the unit of blood and that we’re
giving the right blood for the age and gender
of the patient. We get the blood up to body
temperature, because if we’d given him cold
blood – which it is, because obviously it’s been
in a fridge – he could have gone into shock.The team calculates if the patient will
survive if he goes to the CT scanner or
whether we should take him straight to
theatre and do exploratory surgery to find out
where he’s bleeding from. My main job is to
make sure we’re keeping an eye on the blood
pressure and oxygen and alerting people.
There’s so much going on with someone like
him that sometimes people forget to look at
the monitors. It’s my job to say, “His blood
pressure has dropped – do we want to give
him more blood or take him to theatre?” It’s
about keeping an eye on the bigger picture.
We wanted to get wide-bore cannulas
into his veins, because they give fluids and
medication more quickly. His blood pressure
was dropping because he was bleeding, but we
stabilised him enough for him to have a scan.
That means that when he gets to theatre, they
know exactly what they’re doing instead of
just opening him up and exploring. We aim
to get patients in the CT scanner within
30 minutes, but he was with us a bit longer
because he was more unwell.
The team leader usually speaks to the
relatives after the scan, so we can give them
a more realistic view of what the next couple
of hours will be like. Generally, after a patient
has left us we don’t see them again. We don’t
usually even know their name. Our team
leader wasn’t sure what quality of life Danilo
would have at the end. We’d done everything
quite quickly, but it depends how everything
else goes along the way. While another nurse
handed Danilo over to the theatre staff, I was
already dealing with the next patient.SATURDAY NIGHT/
SUNDAY MORNING
Colin Bicknell, 48, the on-call consultant
vascular surgeongot a call late at night to say a young guy
had come in as a code red with a high-
impact injury. When I got to the ER, the
trauma team showed me the CT scan.
I said he needs to have that treated now. He
had torn his aorta and bled outside the aorta,
but the blood was contained within the tissues
around it. That’s a good thing, in that it meant
Danilo made it to surgery. Overall, though,
it’s a bad thing. Of the four types of aortic
disruption, this is the most severe.
What went through my mind is that this
man is stable for maybe one minute, or ten
minutes, or an hour, we don’t know how
long. The biggest tragedy would be delayingtreatment any more than necessary. All
we’ve got to do is reline the aorta and this
potentially life-threatening injury is cured.
Sounds easy! No one in the UK has extensive
knowledge of this particular injury, first
because it’s not that common, thankfully,
but second because 90 per cent of patients
with these injuries die at the scene.
At this stage, if we can get him to theatre
and deliver our stent to reline the aorta, he’ll
have a really good chance of not dying from
this injury. But his pelvis was in bits and his
leg was starved of blood and we didn’t really
know what had happened to his brain.
The surgery isn’t our top tier of complexity.
But it needs to be done efficiently and
effectively. We go into the artery in the
groin, usually a simple task, but his artery
was misplaced because of the pelvic fracture.
We put a wire all around the aorta up to the
heart and then over that wire we put a stent
in a delivery device. I pushed the stent up
from the groin, guided by X-ray, working in
conjunction with Professor Mo Hamady, an
interventional radiologist.
You get the stent half above and half below
the tear, and deploy the stent so that it seals
above and below the tear. You inject dye
into the aorta to check that the blood flows
through the middle of the tube, not out of the
hole, and you’re done. The whole procedure
probably takes 45 minutes to an hour, if you’re
really slick. From our point of view, if the stent
is in a good position, I would hope it’s going to
stay there for the rest of his life and not cause
him any problems. He’s very lucky to be alive.
He had a life and limb-threatening pelvic
injury and a torn aorta.MONDAY MORNING
Chris Jordan, 41, trauma orthopaedic surgeon
with a special interest in pelvic reconstructionanilo came in over the weekend and
I was operating on the Monday. By the
time I saw him, his aortic injury had
been stabilised. That was top of the list
of things that potentially would cause him
to die. The pelvic injury was next on the
list. The vascular team had done the really
hard bit so we had to hold up our end of the
bargain. I knew he’d been in a road traffic
accident and I knew he’d been pretty unstable.
He could easily have died at the scene or
had a catastrophic brain injury.
I knew he had a significant pelvic injury. I’d
reviewed the scans on my laptop on Sunday
night so I knew it was a big deal, probablyI D
I
‘I PUSHED A STENT UP FROM THE GROIN, GUIDED BY X-RAY’