Make the call

I find it incredibly challenging to cope with the ultimatum that nothing can be done for someone. Sometimes people are just so broken that no amount of healing or the right place at the right time will save them. I think about these cases more than others because the calculation that must be done at the time is often not a simple one. Where is the line drawn? At what point do we say that to attempt resuscitation on this person is to directly impact the wellbeing of another.

A motorcyclist in his fifties is riding down an arterial freight road in the early hours of the morning. He has done some riding in his life, more than most actually. His family would joke that if it were not for his small stature as a toddler, his palms likely would have seen the hardened metallic grips of a motorcycle long before they ever saw the flimsy plastic grips of a push bicycle. Cumulatively he has been at the handles of motorcycles for tens, probably hundreds of thousands of hours over his life, with an overall distance travelled enough to circumnavigate the globe many times over. Riding is part of his identity.


At the grips of his Triumph Rocket 3, he makes his way down this road that he has travelled down thousands of times previously. Entering from a side street on a Ducati Monster 1200, another rider accelerates hard and pulls up next to him. Wearing protective gear it’s difficult to tell from body shape alone how old this second rider is. His Nike footwear and Dragonball Z helmet decals probably put him in his late twenties.


The guy turns his head toward the veteran motorcyclist and eyes his bike up and down, then drops two gears. Against the better judgement that his years of riding experience have empowered him with, the veteran rider takes this impromptu challenge as a direct assault to his identity, to his sense of self. He drops a gear himself and feels his bike begin to pull him forward harder. The younger man, with a partial turn of his wrist unleashes the full power of his bike. Head to head they race down the empty road, illuminated only by the first light of dawn. For two minutes they race, trading the forward position as the road winds back and forth, Stopping only at the sparsely distributed red-lights to reset. Then, in the third minute of racing, they round a corner; the last corner the veteran will ever ride.


He takes the wider line, tending toward the middle of the road. As he leans into the turn his handlebars make an unexpected adjustment in the opposite direction bringing one of his foot pedals in connection with the corner of a no U-turn sign on the median strip curb. At one hundred and fifty two kilometers an hour the connection rocks his bike violently, throwing the man in the opposite direction. He is airborne for two seconds, but at this speed that is ample time for him to fly eighty four meters and do a half turn inverting himself. His head hits the ground first and in this fraction of a moment, the huge force of the impact then follows his spine downward looking for a pivot point somewhat sturdy enough to impart the opposite reactionary force. It settles on somewhere around t2 or t3 where the ribcage offers some stability throwing his pelvis and legs violently into the ground. The frictional force of the ground slows his body as it skids across the final parts of the asphalt and down a shouldering, bushy embankment. His bike miraculously remains upright and continues forward, following a softer angle off the road, but making its way down the same embankment nonetheless, eventually stalling as it stops upright in a bush some two hundreds metres away from the man.


The other rider continues on, oblivious to what has happened until he reaches the next set of traffic lights. By chance, a man in his thirties on his way to work was driving his car down the other side of the road at the exact instance the veteran rider lost control and was flung off the bike. His angle of viewing relation to the median strip sign, the distance the man was thrown and the speed by which the bike continued on he fears he has been the only unlikely witness to the event. Having just completed a first aid course, he begins the call to 000 requesting an ambulance. Whilst waiting to be connected, he does a U-turn near the same street sign and parks his car near where he saw the rider leave the road and skid down the embankment.


With the gravity of the situation beginning to set in, he exits his car and begins to navigate the tenuous sandy path the older man’s now lifeless body has taken through the bushes down the sloped embankment. With his phone still in hand he confirms to the call taker that the man now isn’t breathing who instructs him to begin performing cpr.


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Three suburbs away I am lying on the couch at the ambulance depot trying to use the first chance I’ve had all night for some rest. After barely managing to take my boots off the job alarm rings and rattles off muffled details of a priority one. With disappointment I slide my feet back into my boots and shuffle out of the station and into the garage. My junior colleague follows just behind, looking as broken as I imagine myself to look. All I can put together from the information on the screen in the ambulance is that someone has been thrown from a motorcycle. We head on our way, only four minutes from the location of the accident. Dawn is upon us and thankfully so, because it makes jobs like this far easier when you don’t have to rely on the artificial light from the ambulance to illuminate the roadside. My mind is so foggy from lack of sleep that I barely have the cognitive energy to get nervous or worry about what might be happening at this scene. The radio chatters again and we’re updated that cpr has been commenced at the scene.

We approach from the same direction the witness to the accident did and see a second bystander hailing us from the side of the road. I perform the same U-turn and park the ambulance on a forty five degree angle to the road, blocking the outside lane. I attempt to navigate the sandy, waist high shrub covered embankment towards the person who I assume made the call and see the all too recognisable rhythmic bobbing of cpr. As I move around to the rider’s head, I cut his chin strap and begin removing the fractured, battered helmet. As I am doing this my colleague instructs the caller to stop cpr and confirms the man is not breathing. With great difficulty the helmet comes off revealing an already bloating, deep red/purple head with an open boggy mass at the crown of the parietal scalp. It is here that the future can forks into two.


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I instruct my junior colleague to push the oxygen and treatment bags down the hill and prepare the stretcher and extrication equipment. With my knees gently keeping his head aligned, I open his mouth and am met with a pool of blood. I insert the tip of the suction device into his mouth and remove about a cups worth. I then insert an iGel supraglottic airway device and attach the circuit to the oxygen. I squeeze the bag and am met with no chest rise and more bubbling from his mouth. Leaving the device in situ, I suction once more then use the trauma shears to open up his riding leathers. Looking down his body toward his hips the evidence of major, systemic trauma is becoming apparent. His chest is caved inwards toward his abdomen and it is now very apparent that his legs are splayed open, contorting his femurs in an unnatural way. I locate his second intercostal spaces left and right of his sternum and swab the spaces with a surgical wipe. With workable, ergonomic real estate on the embankment quickly becoming a commodity with equipment and open packaging covering the area, and being all too careful not to rock the rider’s head left or right I perform a needle thoracocentesis on each side of his chest.


Another ambulance arrives, I didn’t even hear it get dispatched. One of the paramedics from this vehicle comes down the embankment just as I finish performing the second thoracocentesis. She quickly evaluates where in the resuscitation algorithm I am at and without asking begins to locate a site on the riders left shoulder for placement of an intraosseous catheter. I squeeze the bag of the airway circuit and see a marginal improvement in the rise and fall of his chest.


In just three minutes from me arriving on scene the rider has been secured on a scoop stretcher and ready to be removed from the embankment. This is the most dangerous part for all four of us. In a precarious, synchronised motion, the four of us slowly carry the rider up the hill and place his body onto the stretcher on the side of the road. We remove the scoop stretcher and then tighten a pelvic binder around his hips that someone had the foresight to place on the stretcher prior to his body. Another minute later we are in the vehicle and moving rapidly toward the nearest hospital, just as the first police car arrives at the scene.


The hospital is twelve minutes away, and to be quite honest there is not much more we can really do for this man. En route to the hospital placement of the defibrillation pads shows wide complex pulseless electrical activity. A bag of fluid is run, some adrenaline prepared and finally a return to cpr. I call the hospital and advise them we are nine minutes away with a middle aged man with catastrophic injuries from a motorcycle accident in cardiac arrest. No details on identity.


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The emergency department has been busy all night. Not anymore busy for a Friday night than usual, but the drastically higher than normal number of patients that presented during the day caused significant issues with patient flow resulting in a bedblock. The wards are full, the intensive care unit is almost full and stuck right in the middle of it is the senior registrar in the department feeling the burden of a full emergency department.


As she looks at the overview screen she is met with a wall of names and medical problems. All fifteen resuscitation bays are full with none of the patients being suitable for discharge. Half of them are pending results from various investigations, and the other half have a provisional diagnosis, but are unable to be admitted into the hospital and moved into the wards because there is no space for them. She switches the screen to view the waiting room list. Twenty five people are still waiting to be seen with four ambulances also still taking care of patients they have brought into the hospital over three hours ago. The healthcare system has been stretched to its limits.


Then the ambulance patch phone rings. An audible sigh echoes amongst the staff around the resuscitation bays. She stands up and walks over to the phone, two of her junior registrars tailing as well as one of the nursing managers. Middle aged man with catastrophic injuries from a motorcycle accident in cardiac arrest. No details on patient identity. ETA nine minutes. Another exhausted, defeated sigh escapes her. Pointing at the same list of names on a different computer screen she coordinates with the nursing manager the required bed movements to make room for this new patient. The man with diabetic ketoacidosis is moved from bay six into bay three. The man with the chest infection to be admitted to the wards in bay three can go into the corridor. The emphysema exacerbation in bay fourteen on cpap can move into bay six where we can keep him monitored and the trauma code can come into fourteen. Like magic the fifteen resuscitation bays have become sixteen.


But they haven't really. By chance a man in one of the assessment sign beds had his formal scribed results from his x-ray come back and was able to be discharged just moments before the ambulance patch phone rang and the computer could be updated. The man with the chest infection is moved from the corridor into this bay. He is a dementia patient and his diagnosis is provisionally set at delirium secondary to community acquired pneumonia. He was sleeping before he was moved from bay three into the corridor but the movement of the loud locking mechanism from on the bed has brought him back to his violent disoriented self. He doesn’t understand why he is here and what is happening to his breathing so he begins to shout for help and tries to get out of his bed. Two of the nurses in the assessment area attempt to calm him, but in this state he is unable to be reasoned with. The outburst requires immediate attention for the safety of the patient and the other caregivers in the department and a different registrar stops his assessment of another patient and moves to help the nurses. The ordeal pushes back the waiting time for people in the waiting room by another fifteen minutes.


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In the waiting room a young boy with a stomach ache that would end up being acute appendicitis asks his mother how much longer they need to wait. Before she can respond he turns and points out the window toward the ambulance with its beacons flashing arriving at the hospital, she turns too and is met with the glare from the first light of the Saturday morning sun.


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I look down at the broken man before me. On the way to the hospital the deep gash on his scalp started haemorrhaging uncontrollably. The iGel and its circuit into the bag are now tinged red with blood that had entered his lungs and plural space. He required three additional needle thoracocentesis’ along the way with the last two bubbling only blood out of the end of the catheter. As the ambulance stops the back doors are opened from the outside. A nurse and porter connect their oxygen and the stretcher is removed from the ambulance. Resuscitation bay fourteen is full of people, full of people that were caring for others but had to be relocated to assist in the care of this man. The team consists of the senior emergency registrar, an anaesthetist, three junior doctors and five nurses all with a role to play in attempting to revive this man. As he is pulled across to the hospital bed, I offer a brief summary of treatment given and disclose what little other history we have. I don’t even have a name or a date of birth. They thank me and begin their efforts.


Thirty two minutes later his chest had been cut open, nine units of blood products and medications delivered and his injuries ultimately deemed too significant to warrant continued resuscitation efforts. Resuscitation bay fourteen was exhausted of most of its stock and would take over an hour to clear and prepare for the next patient. The waiting time for people in the waiting was pushed back another hour.


I spend forty five minutes writing up the details of the care I delivered and what the outcome was knowing that the police’s major crash team will likely be among the first to view the case sheet. My partner and I then spend another hour after scheduled knock off time cleaning the blood from the back of the ambulance and restocking all the equipment that we used.


I go home and stand in the shower wondering if I should have even taken him to the emergency department in the first place given the outcome.


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I’m back on the sandy embankment, I take a closer look at the rider’s head wound before instructing my more junior colleague to prepare the extrication equipment. I manipulate the loose skin around his head wound and see what I think is brain matter. I tell my colleague that these injuries are likely incompatible with life. We leave the rider laying down the embankment and cover him with a sheet. The police arrive shortly after and close the road in preparation for the police’s major crash team to investigate. I write the case sheet up in ten minutes and finish on time.


I go home and stand in the shower wondering if I could have done more for the rider.