Aquo’s Golden Hour…

Since my accident my friends circle has changed dramatically! It went from being friends with the wild ones, the bad asses because let’s face it, they are the fun ones, to being friends with doctors, ambo bearers, firies, solicitors, accountants, financial advisors, business people – you name it.
I’ve become friends with the doctor in charge on the morning of my accident, I asked him if he would write me a piece about what he was confronted with on that morning, he obliged and this is his story – Mum, do not read this! You will be an absolute mess and I don’t want to do that to you!
It’s 5am and the phone rings.
“Hello, doctor? There’s been an accident, a patient is coming in after an accident with a head injury, they’re GCS 3, and the other doctor wants you to come in.”
“Yes, of course, I’ll be there as soon as I can.”
I am, of course, not ‘on call’ for the night, but this sort of event needs anyone available to help.
My wife and I have been living in Ingham for 9 months. I’m not popular at the hospital with the other staff because I tend to tell it like it is, which in the healthcare setting can cause friction.
Whenever we get a call like this, the mind starts racing. Do we know the patient, particularly likely in a small town? What injuries could they have? How are we going to manage them? What are we going to walk into? Will they even make it to hospital? Often we get the call, race in only to find that the person has died before arrival.
The physical act of getting dressed into a pair of scrubs and driving allows the fog of sleepiness clear. I think of a line from a medical book, ‘Cautionary Tales’ which reminds us to slow down, drive properly to a call out so as not to cause another accident. I slow down, just as well! Some idiot has thought that 5am is a great time to wheel their bloody motorbike out onto the middle of the road, when it’s as foggy as all hell and visibility is shot to shit. I narrowly avoid them.
Wouldn’t that have been great… one severe injury becomes two, and takes out the doctor going to help the first one…
I arrive at the hospital, not five minutes later, right in front of the ambulance, the adrenaline already pumping.
The paramedics bring the patient in. Their condition is as said over the phone, GCS 3, with a probable head injury, having come off a quad bike.
The GCS is the Glasgow Coma Score, which is an assessment used to guide how severe a head injury is. 15 is a normal person, and 3 is the lowest you can get, meaning the person is completely unresponsive with no external signs of any brain activity; common medical knowledge and medical research gives such persons almost no chance of surviving such injuries.
Yet, the way people in this situation present, they often appear remarkably intact from the end of the bed, with almost no external sign of injury. That is the case here, a young girl, quite pretty actually.
“What’s the situation?” I ask.
“We’ve been called out to the scene, quad bike injury, we think there’s been alcohol involved. Head injury, GCS 3 on arrival. We think her name is Amy Aquilini.”
They say this because having someone’s name and date of birth becomes important for us to arrange retrieval to a larger hospital, and so that we can give a name to the person. Also, if the worst should happen the police will need to attend the hospital and this information can help them get an identity and make the dreaded trip to the family to inform them.
We’ve put this information onto the whiteboard. I am the most senior doctor on the ground and so this is my scenario to run.
The management of someone in this situation is driven very much by a system and protocol to run through, and follows an ABCDE format.
A is for Airway. Airway compromise, meaning that the person cannot move air into and out of their lungs, is very common in this situation, but right now Amy has a clear airway.
B is for Breathing, the action of moving air into and out of their lungs. This is currently being controlled by the paramedic, who is using a device called a Bag Valve Mask over the face, to provide ventilation. I listen to both sides of the chest, and hear air moving in and out equally. This is important, because what we call a ‘tension pneumothorax’ can occur, where the lung space becomes occupied with so much air that nothing can move in or out, and it can kill within minutes.
C is for Circulation, the beat of the heart pumping blood to the body. We check this by measuring heart rate and blood pressure and by looking at the person. These are often well maintained in young, fit and healthy people which proves to be the case here. The heart rate is high, which is to be expected in this situation.
D is for Disability – given the story of a head injury, some form of compromise to the brain function seems entirely likely, and this assessment refers to the person’s conscious state among other things. It reminds us to be wary for an injury to someone’s neck. The GCS is 3, move on.
E is for exposure. When someone has a serious head injury it is not uncommon for other injuries to be present. Amy’s clothes are removed completely. This is no time for dignity. There are some bruises to her right shoulder and arm, but no signs of injury to her chest, abdomen or pelvis. By the time the night is through I will have done things like check for nerve injury to the rectum, and to help the nurse insert a catheter into Amy’s bladder. This was not in the brochure…
I’m then on the phone to retrieval services to arrange a helicopter to retrieve Amy from Ingham to Townsville, where she will get the care she needs. They’re on their way.
It’s about this point where a difficult situation becomes much worse – where everything turns to shit.
The paramedic, who until now has been admirably managing to provide ventilation through the bag-valve mask, tells us that they are starting to struggle to move air in and out.
This can be due to any number of things. Sometimes it is because there is swelling in the mouth or voicebox because of injury, or bleeding. Sometimes it’s because the stomach contents are regurgitating up, which can also be life-threatening – this is literally someone ‘choking on their vomit’ and it’s how Bon Scott from AC/DC died. Whilst I am sure that someone like Amy would consider that fact somewhat cool, it’s not really what we’re aiming for.
I must take over. There’s me, the other doctor, and a couple of nurses. In the big smoke there would be a team of probably at least 15 people to look after this situation. Oh, well!
We need to secure the airway, which means inserting a breathing tube. This is called a Rapid Sequence Intubation and it is one of those things that raises the hair of even the most experienced emergency doctor.
I ask the nurses to get things ready, as I’m busy trying to ventilate Amy. We need the tubes themselves; a laryngoscope (this is a device that pushes the tongue back and allows us to insert the tube), other pieces of equipment that help guide the tube directly into the voicebox, and drugs that will allow us to insert the tube by inducing complete anaesthesia (no pain or awareness) and paralysis, so that the muscles and reflexes don’t prevent the tube going in.
This team is very much unpracticed in this sort of procedure. I am by far the most senior person on the ground with the most experience here, but I’m only three years out of medical school.
The KISS principle applies here – Keep It Simple, Stupid! There is a simple trick to this procedure called the 3/2/1 rule, to simplify the drugs used, based on body weight. 3micrograms per kilogram of Fentanyl, a potent painkiller. 2milligrams per kilogram of Ketamine, a potent agent that induces anaesthesia. Finally, 1milligram per kilogram of Suxamethonium, an agent which blocks a chemical that causes muscle contraction, therefore paralysing her. Similar agents are used in poison darts, another useless fact.
Amy is now completely paralysed and her life is in my hands. If we have made the wrong decision, or if this procedure doesn’t work, she will die right here.
I insert the laryngoscope, which has a video camera attached to improve visibility – we need every little bit of help we can get. I can see her vocal chords. I ask for the tube, but it’s too big. I specifically asked for the smaller size! OK. “Hand me a bougie.”
“What’s that, doctor?”
Fuck. Me. Dead.
Now I have a paralysed patient, who cannot breathe for herself, and I cannot breathe for her without a breathing tube, and this is not the time to tell me that you don’t know what a standard piece of equipment is.
“OK, on the trolley, 20 metres away, to the left of the defibrillator, is a long piece of blue plastic. Please bring that to me right now.”
This direct instruction works better than assuming people know what things are and how to set up for this procedure, as they really should in this situation. I recognise that by far the most important thing to do is to remain calm, and even. Shouting like they do on TV is guaranteed to kill someone, literally, from lack of oxygen.
Amy is blue at this point, from lack of oxygen. Keep in mind that her oxygen levels were low and her breathing was in peril before we started. In the big smoke and in an operating theatre this would have been done in a carefully controlled environment, with a perfectly well patient, with doctors and nurses who do this every day. The odds are stacked up against us.
The bougie arrives. I put the laryngoscope in again. I put the bougie in, which thank Christ sails right through the vocal chords. I ‘railroad’ the tube in over the top of the bougie, and straight through the vocal chords. We attach the breathing bag and I start pumping furiously – we need to get her oxygen now! Amy’s chest starts to rise, and fall, and within a minute her oxygen levels have returned to normal. She is lovely and pink again.
We can hook her up to the breathing machine, finally.
We have fixed the immediately life-threatening problem. It’s funny how the mind works. I remember every single bit of the intubation itself as if it was yesterday, but only patches of what we did before and afterward.
At this point, the retrieval team of expert doctors and paramedics arrive. They’re surprised in a good way at what we’ve managed to achieve. They transfer Amy to their ventilator. The sun is up now. I remember the sunrise. A new day, new hope?
I remember the retrieval doctor barking instructions after a line had become kinked and it appeared as if Amy had no recordable blood pressure.
I remember Amy’s family, particularly the moment Allen – or Amy’s dad, as we knew him then – leant forward to give Amy a gentle kiss on her forehead. That moment stuck out, and to be honest I thought that would be their last kiss goodbye, so sick Amy was.
Did I talk to the family? I can’t remember. I remember going home for a rest, then heading into work that afternoon. Naturally, we debrief. “Back then” the best way to keep up with what had happened to our patients sent to Townsville Hospital was to ‘stalk’ the blood test results. Amy’s treating doctor was a general surgeon and often this means that the person is likely to be a candidate for organ donation. This, at that time, was not unexpected and is what happens to the vast majority of people who have this injury. One medical journal I read even said there was no chance of survival!
I heard that when Amy had to be re-intubated in the Intensive Care Unit a few days later, the team there struggled – with many multiples of doctors and nurses over and above what we had in Ingham, more resources, and in a much more controlled environment – my boss at the time said that was a testament to the job we had done for Amy in our ED.
Then, the news articles. The vigils in Ingham. The recovery, over months and months, that happened, was nothing short of miraculous. The role we had played paled in comparison to the work done by the massive team at Townsville Hospital – but by the same token she probably wouldn’t have made it there if we hadn’t stabilised her. We talk about a ‘golden hour’ in trauma where if injuries and complications are assessed and treated the person has a fighting chance. We caught Amy’s ‘golden hour’.
I followed from afar, not wanting to intrude further on what was an extraordinarily difficult time for the family. Then, some months later, Allen came in to see me for an unrelated matter and we got to talking about Amy. I mentioned that I was there that night.
Then Amy came in to see me, and seeing her alive, well, and chatting to her in person was one of the most amazing experiences of my life, and certainly the most rewarding of my medical career.
Since then, I have thankfully transitioned out of being one of Amy’s medical practitioners to being able to see her and her family socially – never often enough!
Her wedding day remains one of the best of my life. Seeing this amazing young woman, radiant and beautiful on her special day, and knowing that if not for what I’d done she may not have been there, is something that I will carry with me forever.
Medicine can be a tough gig, a demanding marriage partner. It separates us from our family, and takes the best years of our lives, our weekends, our sleep, and sometimes our sanity. At times I wonder whether it has been worth the sacrifice, as I am sure most doctors do at some stage. Then I think of Amy, and I know that it’s all been worth it.
I believe in you.
This was written by Stephen Dick, Doctor in charge.
We had quite a small wedding on the Tablelands, North Queensland but I wasn’t going to stand for Stephen and his wife not being part of the guest list! We don’t catch up half as much as any of us would like to, life is just crazy at the moment! But that doesn’t mean their not always in my thoughts. Hats off to Chrissy for being a doctor’s wife – I couldn’t do it! But then I think I married a farmer so that’s pretty much the same thing, just with a massive reduction in wages! Haha, I make myself laugh at the places my thoughts take me.
I’ve decided to post this as there are a lot of rumours going around about that morning, but that’s what comes with living in a small town, people can be real assholes! I want to make people understand that my accident was a major life changing event for me, my family and really, the Ingham community. I believe it will open a lot of people’s eyes to how bad I actually was, and to Aquo’s golden hour!
Aquo Xx