A Medic's Tale, page 16
Not long after my arrival, I was in the department one afternoon when a patient arrived with a dislocated shoulder. As many people are aware, there are proposed several methods to reduce such an injury. On this occasion, I decided to use the process where the patient is laid flat on the trolley and a weight applied to the injured limb. After a period of traction, you apply the appropriate manoeuvres and the shoulder is easily and successfully reduced. This had not been performed before in the unit and there was, I assessed, by the body language of the assembled nursing staff, a degree of scepticism with regards the possible outcome of this treatment. I reviewed the patient a few minutes later to assess how it was going. Only to discover that the weight was not providing the necessary pull to the limb but resting on the floor. With a little adjustment to apply the necessary traction and further positive mutterings from me, we proceeded. In due course, I returned and nonchalantly (in truth, a degree of trepidation and a repeated prayer, “Oh please let this work,” muttered under one’s breath), gratefully and easily reduced the offending joint. This was what most would consider a miniscule point, and a minor procedure, in the context of the various ailments that present to the casualty department. But in my case, it certainly raised the profile of the new boy in the department and, I can say, made other, possibly more radical, ideas, more likely to be accepted or at least considered by the staff in the future days and years.
Slowly and, to a degree, surely, new concepts were devised and implemented. I remember in those early days having a meeting with the chief executive and conveying my thoughts on the necessity of the hospital having a trauma team. This, as you could envisage, required me to liaise and, to a certain extent, coerce my surgical and orthopaedic colleagues regarding the necessity of such an innovation. After some delicate negotiations this came to fruition. The various members were provided with specific emergency pagers, allowing them to respond quickly in trauma cases. Our team initially consisted, apart from the staff in the department, of personnel from anaesthetics, surgery and orthopaedics. We could, as necessarily, request other specialties to attend. I would like to think that this helped, even in a small way, the better and more rapid treatment of such cases.
We eventually managed to develop a helicopter landing site next to the department, thus allowing quicker transfer of injured patients. We had initially surveyed the hospital to find a suitable landing area. To facilitate a landing of helicopters, especially on an existing building, is a rather complicated process. It goes without saying that the roof on which it is anticipated to land is adequate in size and structure. The whole adventure would be extremely embarrassing for the edifice to crumble under the weight of the aircraft. After finding such a site, it requires quick and easy access from there to the accident department. This would reasonably need the input of a lift, providing rapid transfer. None being possible within the confines of the actual hospital site, we looked in the surrounding environs. Fortunately, not far from the department there was a local park with a large flat grass area. This was the start of various rather protracted negotiations. There were other interested parties, including residents living beside the park, the people and organisations that frequently used the facilities and the local council, who would be most instrumental in listening to and discussing the various proposals both for and against the siting of a landing zone within the park confines. It would need acceptance and authorisation from the Civil Aviation Authority to deem it safe and adequate for the intended purpose. As you can understand, this is literally a minefield to wade through. As part of the procedures, this required attendance to the council meetings with written submissions to explain and plead our case for the usefulness of such a project. There were objections from members of the public and the situation was not looking promising. At this specific meeting, we had been seated for a couple of hours and were beginning to fear for our cause. Rather unusually, I was permitted to put our proposal forward, as usually members of the public could attend these council meetings but not be directly involved with discussion. This was not ‘the norm’ but it was an opportunity to gather support. I am glad to report that the committee, having graciously listened to my deliberations on the matter, decided to accept our submission. Consequently, the hospital proceeded with implementing the necessary developments to allow the helicopter to land. It included having the (CAA) Civil Aviation Authority scrutinising the layout and the feasibility, particularly the most important factor – that of safety to one and all. In the vicinity of the park there were numerous large trees and the pilots would have to be sure it was not going to cause a problem when landing. After their review, we were able to start the landing of the helicopter in daylight hours, allowing the transport of patients to our A & E.
Other additions included a special trolley to improve comfort and safe transport of the injured patient for those last few yards into the department. This was purchased and our porters were given the role of clearing the site pad in advance of the helicopter landing. By and large, we had an incredibly positive response subsequently from the local populace, as they understood the importance of such a process. It certainly was much in evidence approaching the hospital, as we were near the centre of the town and everyone could hear the distinctive noise of the rotor blades flying overhead.
Quite a substantial number of traumas that presented to us were related to riders who had managed to part company from their trusty steed and injured themselves in one way or another. This may sound ungracious but I was always concerned as to the actual condition of the horse. Another similar group who made regular appearances were the jockeys, having been part of the field traversing the various jumps at the well-renowned Cheltenham Racecourse, often occurring at the equally famous Cheltenham Festival. By and large, no major catastrophes but now and again a famous rider from the world of horse racing would visit our doors. Their stay was often fleeting as they appear to have been spirited away, more often than not, by one of the orthopaedic team.
Many of us will have the usual anecdotal tales of the horrendous injuries that we have seen. Compared with the multiple, mind-blowing, extravagant scenes we see daily on our televisions, they may even be considered rather small fare. We had a couple of what are referred to as ‘major incidents’. This usually implies the department may be overwhelmed by the sheer number of casualties, the severity of the injuries, or both. As with most hospitals, we had a protocol for implementing and basically it is all hands on deck. I believe it would be described as ‘organised chaos’. Looking after a seriously injured patient requires a dedicated team and numerous others as back-up. If possible, the person is stabilised and then referred to the next appropriate destination. Sometimes this is not feasible and they require being taken directly to theatre to have surgery, often to stem internal bleeding.
We had an interesting chap attend the department who bore a remarkable resemblance to the renowned Black Sabbath lead singer Ozzy Osborne. He presented with chest pain and an ECG demonstrated a STEMI and, as at that time per protocol, he was given thrombolysis with no antecedent or apparent contraindications. Soon after initiating his treatment, he most ungraciously decided to arrest and we promptly defibrillated him. He kindly quickly responded to our ministering and reverted to normal rhythm. His rather quaint response to this was that we should decorate the ceiling as it was rather bland visually. Maybe it was Ozzy Osborne!
Another late call one Friday evening involved an unusual case. I walked into the resus room and the first thing that caught my eye was the fishnet tights, so I naturally assumed that this was a woman. On further inspection and a closer look and armed with my years of medical training, it was evident that I had mistaken the gender of the patient. The story unfolded that the person concerned had been a member of the audience during a performance of The Rocky Horror Show and to be more involved in the play, he dressed up as one of the characters. This chap, having come out of one of the local theatres, was set upon by a group of inebriated thugs for some pathetic reason only known to them. He sustained severe head injuries and required intubation and admission to the ITU. Mercifully, he did recover, but not to his former state. It is a sad reflection of our so-called modern society and fuelled with the excesses of alcohol that many similar incidents occur.
12
Teaching and Training
Before becoming a consultant, I had managed to participate and be successful in attaining the status of an instructor in both ALS and ATLS. At this time, there were no such courses being held locally. I decided that it would be beneficial to implement these courses at the hospital. As you can appreciate, this was mingled with enthusiasm and the usual lack of total comprehension of the task ahead. Surely it would be quite straightforward to put together all the necessary paraphernalia required of such an undertaking – a mere trivial matter. It was simple. It had been done elsewhere and it was, as we say, a piece of cake. All I had to do was find a suitable space or building to hold these spectacular events, assemble a knowledgeable faculty and the doctors from near and far to become the unwitting candidates – what could be easier?
I had visited our postgraduate centre on a couple of occasions for meetings and lectures. It seemed a splendid place to initiate our courses. My poor, unsuspecting secretary did not fathom the depths and complexity that she would soon become embroiled with in all facets of this new venture. I am indebted to Jeanne and her subsequent incumbent Mair (a lady of infinite support, patience and loyalty) for all their fantastic efforts, hard work and forbearance with me to bring this concept to fruition. Jeanne left to pastures new after the initial course. I trust that the experience of the course was not the reason for her departure. It would be hard to put into words and enumerate the huge contribution she made to the courses, without which they would never have passed the embryonic stage. They are both owed an enormous debt of gratitude from teachers and taught alike. The beginning required almost clandestine recces to the post-grad building which were necessary to assess its suitability and designate the numerous rooms for lectures, faculty and the skill stations. This was not too troublesome but the arduous factor would be the three floors that had to be negotiated on numerous trips up and down the stairs. This involved ferrying the cumbersome pieces of equipment from one room to another. It certainly was an educating exercise, at least in the first instance.
Our initial ALS course was an interesting affair. There was the frisson of beginning something entirely new mixed with excitement, expectation and a certain degree of nervousness hoping that all would go well. It started with the usual introductions and the candidates were each allocated their mentors to support and assist them throughout the course. Soon after, in the initial skill stations, I was approached by a lady who introduced herself and informed me she was from the Resuscitation Council and was there to overview the course to ensure it was of the acceptable standard. This remit included a close inspection of the facilities, equipment and, more ominously, me, as course director. I was to be scrutinised and assessed as to my credentials as director. Of course, I should have known this was obligatory, especially in a new centre, as a certain standard must be adhered to for all concerned. I suppose I had anticipated some form of advanced warning of her presence but to have her just appear in front of me was rather unsettling. This was complicated by a certain candidate who had voiced his opinion, after just one of the lectures, that they were useless and poorly presented. The situation did not improve as he walked out of a skill station which had been given by an experienced instructor, stating, “That girlie is useless, she should not be teaching.” As the director, it fell to me to have a discussion with him and address his obvious concerns. I had to carry out his BLS (Basic Life Support) station as it had not been completed. (Nowadays this is a prerequisite before the course.) I decided, professionally, to have no preconceived thoughts on the person but to carry out the skill station in the normal manner. He was informed of the scenario and invited to continue as appropriate. Without any cursory assessment, he informed, nay, told me, all was safe and blithely continued with what could only be described as an attenuated version of BLS and initial resuscitation. Despite my restrained, even I would state, calm, efforts to guide and direct him, he demonstrated no desire to listen. This was an awkward situation and provided me with a dilemma. I deliberated and deemed it was necessary to assemble the faculty and we decided we would have to advise him of our concerns. We could try further remedial training and if unsuccessful he would have to leave. The meeting was to take place after the next lecture. As it transpired, fate lent a hand and, in the interval, the same chap left the premises. Initially we assumed for a quiet smoke and maybe contemplation on his circumstances but on resuming the course he was nowhere to be found. He never reappeared; the somewhat disconcerting point was that he had stated he was an anaesthetist! The rest of the programme carried on without any major hiccups and we completed the course with everyone intact. Our inquisitor was very complimentary and said she would be sending a positive report to the Council. It was a most satisfying conclusion to our first course. Rather interestingly, in due time I was regional adviser to the ALS course and carried out the duties of visiting various centres and assessing how they were progressing. This too had its moments, on one occasion having literally just arrived to meet with the course director and faculty to be informed that there was a problem. As regional adviser, they required my input and consideration on a rather delicate matter involving a member of faculty and concerns that had arisen. It resulted in having to request that person to leave the course; not the most memorable or enjoyable of duties but a necessary evil and had to be done. (Not the same chap, I have to say.)
So, after the elation and euphoria had settled, you would expect a modified degree of stability to resume and to return to normal duties. At this precise moment in time, I had another inspirational cerebral moment. Surely the ALS course has not really been that difficult an obstacle to surmount, so we will tarry forth and introduce the first ATLS (Advanced Trauma Life Support) course. After having accomplished the ALS, this would be a walk in the park. At this instance, in time no-one of sane mind was present at the moment of my splendid idea and so with no negative feedback, it was ever onward.
The ATLS course had originated in the good old USA. It was initiated by a surgeon who, having been involved in a serious flying accident, resulted in him, despite his injuries, treating his own family at the local county hospital. He deemed this an utterly unsatisfactory state of affairs and vowed to invest in a better system to improve trauma care. So, it started and has now spread across the globe as a universal approach to the initial phase of trauma resuscitation. I realise there are variations in different countries often due to local considerations.
In respect of the ATLS, this was originally a regional course and was held literally in the middle of nowhere at a place called Batch Farm. An interesting hideaway somewhere near, well, somewhere. I remember the chest drain station held outside in surprisingly warm weather. It began well but the afternoon session started to become complicated by the arrival of flies, which appeared interested in the sheep’s thorax and were accompanied by a distinctly unfavourable aroma.
The faculty dinner was a minor expedition to a local hotel or restaurant. It was good fun and rather a carefree time meeting up with new people, who, in turn, over these courses became friendly faces that you recognised and considered kindred spirits. We initially congregated in a sitting room-cum-lecture theatre and on the final afternoon it facilitated as the testing station, or moulages as we prefer to name them. The space was at a premium and the patients who had been realistically made up by the Casualty Union were separated by blankets or sheets. All totally impervious to noise so that no-one could know what lay in wait in the adjoining cubicle! It was here, sad to say, that I had the unenviable task of failing a candidate for the first time. It is neither a habit nor something I relish or care to repeat and thankfully rarely have had to do despite numerous courses over the years. The poor chap had been tested and was found wanting in crucial areas, despite extra tuition and input from his mentor and various members of the faculty. As a faculty we had a good appreciation of those who will perform adequately, those that may be destined to be shining stars and those for whom there is concern. But a standard must be reached and maintained by all the candidates so the faculty can be assured that the course is keeping true to its goals and ethos.
Returning to our local course, there were obstacles to its inception. I had politely requested that Cheltenham should be given initial and due consideration for any new courses outside the original regional centre. As it happened, it did not quite evolve in the desired manner. Suddenly, out of the blue, another course was manufactured and started at St Elsewhere. A place of good standing and well able to provide the necessary personnel and equipment as it was a large general hospital. Our case was viewed with a degree of circumspection as we were small in size and few in numbers of local instructors. This irked me as I did not consider my request as capricious. I firmly reiterated my desire to commence a local course. This involved cajoling various regional officials and went so far as to contact the national ATLS medical director about our worthy cause.
