Extreme Medicine (12 page)

I sat clutching my trauma pack next to an A&E registrar and opposite Christine, one of the nurses. The rest of the team was in the other ambulance. Christine leaned in and raised her voice above the noise of the sirens: “This is a major incident,” she said. “You are wearing your personal protection equipment. In your jacket pockets and pack are the following items . . .” She started reeling off the list.

I just stared at her. She was looking me right in the eye and talking to me—nearly shouting, in fact, to get above the din of the engines and sirens—but it felt as though she were addressing someone else. She paused, waiting for me to carry out my checks. I pulled the pockets open. It was all there, just as she'd said it would be. How could she know what was in my pockets? And then I realized that she, unlike me, was trained for this event. She, at least, knew what she was doing.

The ambulance went up and down through its gears, hurtling toward the scene with us in the back. The journey couldn't have taken more than five minutes. When it drew to a halt, I didn't really know where we had arrived. Then the rear doors opened.

It took more than a few moments to orientate ourselves. We were at the junction of Old Compton Street and Dean Street, part of London's theater district. The streets there usually thronged with tourists and clubbers. But as the doors opened, it was unrecognizable. Glass carpeted the street, ambulances crowded all of the access roads; the place was awash with casualties.

When we arrived, the scene was barely under control. The bomb had gone off less than thirty minutes earlier. The pub was still smoking; the fire brigade had just finished hosing bits of it down. A registrar from the Helicopter Emergency Medical Service (HEMS) had arrived ahead of us and had taken charge of the medical decision making. He, along with the ambulance officers, had separated the walking wounded from those most severely injured.

When we arrived, we were pointed at a litter of bodies in the middle of Old Compton Street being attended by paramedics and firemen. They were the most severely injured people I had ever seen. They remain so to this day. There were perhaps a dozen people on the ground in front of us. They were exposed; most of their clothing had been incinerated in the flash fire that followed the detonation. Their bodies had suffered burns; some of their limbs had fractured or been amputated by the blast.

In the worst situations, the trick is not to think too hard. It's best to stay focused on the one task at a time and to make that task as simple as possible. For fast-moving situations, there are protocols that can be unpacked and delivered almost reflexively. While these achieve many things, one of their most important functions is to stop you—struggling in the midst of events that words could never adequately describe—from grinding to a halt.

The alphabet of survival comes to the rescue, the Advanced Trauma Life Support. Those simple ABCs get you moving and stop you from thinking. You don't much care about where the system came from or how it was designed. You are just grateful that it exists, and you wonder how anyone could be expected to cope without it.

—

B
ACK IN 1976,
D
R.
J
AMES
K
.
S
TYNER
was flying his family from Los Angeles to his home town of Lincoln, Nebraska, after attending a wedding. The family had traveled some considerable distance: east across Southern California and Arizona, landing briefly in New Mexico to refuel.

They took off and continued their journey home, eventually turning north over Texas and up through Oklahoma and Kansas. As they crossed over into the airspace of their home state, Nebraska, they ran into thin, low-lying clouds. The day was coming to an end, and, not being rated to fly on instruments alone, Styner chose to stay below the cloud base. By the time they reached Lincoln, the sun had already set, but they were almost home. Then—flying low with the skies nearly dark—Dr. Styner became suddenly disoriented. He steered his plane low across a pond and realized too late that he was below the treetops.

There was a deafening roar as the aircraft hit the trees and plowed into and then across the ground, ripping through the underbrush, disintegrating as it went. In those brief seconds, James Styner waited for his life to end. The wings were torn off almost immediately and the remaining fuselage slid for over two hundred feet, spinning so that it finally faced backward. The plane somehow came to rest upright, its fuel tanks ruptured and spilled, a huge hole gouged in its right-hand side.

James opened his eyes, amazed that he had survived the impact. The lower ribs on the left side of his chest were fractured, and his forehead and face, which had smashed into the dashboard, were deeply cut. Charlene, his wife, was nowhere to be seen.

The world fell silent around him. Dazed, he pulled himself out of the aircraft. Once outside, his head cleared a little, and his priority became the children still trapped in the wreckage.

Chris, ten years old and the eldest of the four, was least injured—his arm was broken, and his hand was bleeding, but he was still awake, alert, and oriented. Kim, sitting on his lap with the same belt around her waist, was unconscious, her head having collided with a fire extinguisher. She was three years old. The other children, Rick and Randy, were in even worse shape. Eight-year-old Rick's head was deeply lacerated, and he too was unconscious. Randy's leg was partly impaled on the jagged fuselage and trapped beneath the plane.

Dr. Styner got Kim and Rick out first. He knew that Randy was pinned and injured but feared that the aircraft might yet burst into flames. If that happened none of them would survive and so, as hard as it was, he had to stage and prioritize the rescue of his own children. He carried Rick and Kim a safe distance from the wreckage and set them down on the ground. Then he returned to the plane and dug into the ground around Randy's trapped leg, excavating and freeing it from its impalement. He expected it to bleed profusely, but mercifully it didn't. Chris, with his broken arm, managed to find his own way out.

They gathered some clothes from the scattered luggage and piled them like blankets over the younger children. It was winter in Nebraska, and that night temperatures fell below freezing. They waited in the near darkness—illuminated only by the light of the moon—for help that never came. Finally, realizing that they were on their own, James went out in search of his wife, Charlene. He ventured out twice without success, returning to the children each time. On the third occasion, he found her. She had been thrown more than three hundred feet from the plane and had suffered a catastrophic head injury. Charlene was dead. With temperatures still dropping outside, James now had to focus his attention on his children.

Worried about the injuries they had suffered, Dr. Styner decided to go in search of help. From the crash site, they could see a road in the distance. He was aware of pain in the ribs overlying his spleen and wondered if it too might be injured and bleeding or in danger of rupture. If that were true, then the long march in search of help would only make things worse. But with no idea when, or indeed if, rescuers would arrive, he decided that he should take the risk and go anyway.

James talked frankly with his ten-year-old son, Chris. He told the boy that he was concerned about the state of his own spleen but more worried about the children's injuries. He explained his plans to go get help and said that if he didn't return, Chris shouldn't go looking for him but instead stay with his brothers and sister. His voice was calm and remarkably free of emotion. James said good-bye and then shortly after two
A.M
., he set out for the road.

After what seemed an eternity, he finally reached the road and flagged down a car. His face was caked with blood, and initially the occupants were hesitant to leave their vehicle. But he managed to explain his situation, and together they returned to the crash site. They gathered up the children, and James said a final good-bye to his wife. Then, somehow, the five of them crammed into the back of the car and drove a few miles south to Hebron hospital.

Hebron was a small community hospital, and when they arrived in the early hours of the morning, the door to its Emergency Room was locked. A lone night nurse stood at the door and asked them to wait for the doctors to arrive. Somehow they forced their way in, but things didn't improve much when the hospital's medical team finally arrived. Their approach lacked structure and seemed to ignore key injuries. It became obvious to James that they were unprepared for the nature and extent of the family's traumatic injuries. Sliding off his trolley, he stopped the local doctors from treating his children and took over their care. He had come too far for things to fail here.

Next he contacted colleagues in Lincoln and organized transport by air back to his own hospital. They landed at Lincoln Airport and traveled by road to Lincoln General Hospital's Emergency Room, arriving at eight
A.M
.—more than fourteen hours after their crash. There James Styner could finally resign the role of doctor to a team of his friends and colleagues and once more become a patient and parent.

Dr. Styner was incensed by how long it had taken to get his children the trauma care they needed. He didn't blame the physicians and nurses at Hebron, but he felt that he'd been able to deliver better care as a trauma victim at the scene of the accident than he'd received at the local hospital. If that was the case, the system was broken, and things would have to change.

In the years that followed the accident, James K. Styner invested all of his efforts in designing a straightforward protocol for the management of cases of trauma; one that could, if necessary, be delivered by even the smallest of hospitals. He based it on existing models for the delivery of cardiac resuscitation, adopting that powerful ABC approach and extending it. Just four years after his plane crash, Dr. James K. Styner's Advanced Trauma Life Support (ATLS) course was adopted by the American College of Surgeons. He trained people to deliver lifesaving trauma care whatever their situation, and then he trained them to train others. Courses sprang up all over the United States and then all over the world. In the years that followed, ATLS went viral. To date, more than a million people have learned to follow it. In a 2006 lecture, Styner told the remarkable story of its origins and finished by joking that it had spread around the world and would soon be taught on the Moon and Mars. He wasn't far wrong.

—

O
N THE CHAOTIC
S
OHO STREET,
I checked the first of the casualties I reached. He was lying on the ground, his clothes in tatters, his skin scorched. There were nails embedded in the skin of his chest and abdomen, but his hands were warm and he could still talk to me clearly. I pushed an intravenous drip into a vein on his arm. I tried to stick a dressing over the top of it but it wouldn't hold; the layers of burned skin just sloughed off underneath. I'd never seen anything like it. Grabbing a crepe bandage from my pack, I wound it around the line and tied it in place. And then, having done the little I could, I realized I had to leave him with the paramedics and move on to someone else. I turned to discover a much more seriously injured man with Christine already at his side.

There was bleeding; at least that's what I remember most of all. One of his legs was missing and his face and chest were burned. Bits of shrapnel protruded from his remaining limbs. He was awake but only just. I started at the top, at A, checking his mouth for injury or obstruction. Then on to B: I got my stethoscope out and went through the motions of placing its bell on his chest. But above the chaos of the scene neither the gentle rush of air nor the drum of his beating heart was audible. I put my cheek close to his mouth and turned my head to look at his chest, watching for its rhythmic rise and fall and the rush of warm air against my face. At this point one of the firemen pointed out the amputated leg, worried perhaps that I was ignoring the obvious injury.

He was right, of course. When it comes to trauma the alphabet arguably should start at C for Circulation. Major hemorrhage has to be dealt with first. The adult heart circulates around five liters of blood a minute, more if you've just been injured and there's a lot of adrenaline around driving it harder and faster. For a man of average height and build, the whole circulation holds perhaps only five liters and so a significant bleed will kill in minutes—at least as fast as an obstructed airway or injured chest. I looked at the leg. There was plenty of blood on the floor, and it appeared to be oozing steadily. I felt down for the femoral artery in the front of his right thigh. The pulse there was still good and reasonably strong. I grabbed one of the firemen and pulled his hand down onto the spot where I could feel the pulse, asking him to push down hard over the artery with his thumb, hoping that this would close it off and slow the rate of blood loss. Then I carried on with my survey, working again from head to toe.

I sited a line into his arm, too, and started some fluids. He was sick and getting sicker. There in the middle of the street, there was nothing else I could offer, nothing else I knew how to do. Just at the point at which the protocol I was following ended and I might have started to flounder, one of the HEMS paramedics walking by put a hand on my shoulder and said: “Does he need to stay or go?”

“He needs to go,” I said.

—

I
T IS TEMPTING TO THINK
of that moment as the end of the story for trauma: the point at which the ambulance doors shut and the victim is sped along to the nearest hospital. In truth, rapid access to treatment and the ATLS protocol have transformed the survival rate of seriously injured casualties. But the fight doesn't finish there.

For Dominique-Jean Larrey on the battlefields of the Napoleonic Wars, trauma surgery relied largely upon getting casualties into a field hospital as fast as possible and then stitching wounds and performing amputations promptly to arrest bleeding. There were no anesthetics or antibiotics, and survival depended upon addressing the primary injury before it became truly life threatening.