Continued from yesterday's post

All I can see is the back of her head, some blood and the shattered windscreen. All I can feel is her head, neck and shoulders and yet something tells me that she is slipping into unconsciousness.

Cramped up in the back of the low roof van a firefighter appears beside me, he's trying to remove the metal plate that separates the two sections of the van and I have to wriggle to the side to let him see how securely it is fixed. He tells me it's going to take some time before the roof can come off.

I shout through to the FRU and ask him if my patient is still conscious.

"It don't look it", comes back the reply, he's busy getting some venous access while stretched across the passenger seat.

This means it's decision time - do we wait until the roof is cut off in order to fully protect the neck and spine, or do we just manhandle her out as smoothly as possible because of the real risk of her losing her airway and choking to death. Also, if there is a serious head injury then they may need their skull drilled and waiting for the roof to come off may take longer than this patient has.

It's all about potentials - potential neck injury (that if we aggravate could stop her breathing) versus a potential airway problem versus the potential need to be in hospital for neurosurgery before her brain squeezes, like toothpaste from a tube, out the bottom of her skull.

Then that familiar flash of imagination - me standing before the Coroner, explaining my actions and my reasoning.

"Sod it!", I say to the FRU, "We need to get her out now, we can't wait for the roof".

The spinal board is squeezed under her buttocks, then as carefully as possible we rotate her out and lay her flat on the board and then onto the trolley-bed. Securing her we move her to the ambulance.

She's now deeply unconscious.

Cutting off her clothes we make a quick check of the basics - the airway is still open, so we can manage that using the tools we have on the ambulance, she's still breathing - which is always handy, the slightly worrying thing is that her pulse is starting to drop although the blood pressure is remaining stable. A dropping pulse can mean a serious head injury.

The next question leaps to my mind, do we wait for the HEMS doctors to turn up, or do we make a run for the hospital.

"HEMS are eight or nine minutes away", my crewmate tells me, radio mike in hand. It would seem that she is reading my mind.

"OK, we'll go", I say, I know my mates driving - in nine minutes we'll be at the hospital. I go to secure the back doors of the ambulance and see the HEMS car pull up.

Stay and play a bit then.

The doctor jumps on board - as always polite and professional and starts to assess the patient. The doctor thinks that they should sedate the patient and intubate in order to protect the airway and I don't disagree - she'd need to be intubated before surgery anyway and this way the airway is definitely secure for the transport to hospital.

As they always do, they take the patient off the back of the ambulance so that they have more room. I know it's not the same thing but I feel pride for my crewmate who manages to intubate both in the back of the vehicle and when the patient is stuck under a wardrobe.

The doctor first wants to wrap the patient in bubble wrap to keep them warm - I bite my tongue at the thought that the back of my ambulance is perfectly warm, and besides what happened to therapeutic hypothermia? But HEMS are fully informed on the latest trauma research so I am more than happy to let them do what they want. The responsibility isn't on me anymore, it's on the HEMS doctor and I'm sure that they have also got the same 'Coroner's court' vision in the back of their mind that I have.

But I really should ask them about it the next chance I get.

Just as the doctor is about to intubate the patient she starts to come around. Suddenly she is no longer unconscious, but awake, alert and orientated.

That's good, but again, this can be the sign of a serious head injury.

"OK", says the doctor, "let's go without sedating them".

We load the patient back up onto my ambulance, change over the monitoring machinery (for the third time) and make our run to the hospital, the doctor in the back of the truck making notes while I make sure that our patient doesn't move around too much on the trolley-bed. Our patient's consciousness drops and rises during the trip.

The trip takes eight minutes - I swear that my crewmate channels Stirling Moss and I trust her driving completely (except for her reversing, but that's another matter).

Into the resuscitation room and the HEMS doctor hands over to the staff there, our patient is awake again and so the hospital doctors can get a better history from the patient. I go out to the ambulance and start the long process of documenting everything while my crewmate cleans up the back.

-----

There is no closure to this story.

I'd love to be able to tell you how the patient got on but I never knew her name, so I can't ask the reception staff to pull their A&E notes so I can have a look at what the CT scan showed. I don't see HEMS often enough to ask them about the progress of our patient, when I next see them they will have seen countless other seriously ill patients. The police probably won't ask me for a statement on the accident in question. I'll likely never know if my decision to move the patient before the roof was off was the right one, or if I did more harm to them. I'll not get a thank you letter and I don't expect one. The only way I think I'll know about my patient is if they die and it goes to the Coroner's court.

In which case I'm happy to remain ignorant.

So I'll probably never know what happened to my patient and that is the usual course of events. Just clean the ambulance and move to the next person.