Memoirs of an Emergency Nurse (4 page)

Classical foxhunts on horseback are few and far between in the UK due to the ongoing debate about them and the widespread protests.

This particular day, the paramedics brought in a horse rider with suspected neck injuries. The patient was carried into the department on a spinal board and with head blocks and C spine collar on. I recognised him immediately. He was the head of a foxhunt, a countryman dressed in full classical fox hunting attire. His bright red jacket stood out from his black riding jodhpurs and shiny black riding boots. I don’t recall his name but I do remember the looks on the paramedic’s faces when they brought him in. They were not happy that he was a foxhunter. Sometimes, personal feelings can’t help but get involved in situations. At the end of the day, we are only human but attempt to be non-judgemental regarding people’s beliefs and values.

I took handover from the paramedics and began my observations of the patient. The patient was stable and talking. He lay still and flat on the trauma trolley, fully clothed and damp from lying on the wet ground. A nurse was holding the patient’s head and neck to keep his spine in line; a hard collar was in place around his neck. He told me that he was head of the hunt and that he was following the family tradition by carrying on the country way. He had been leading the hunt on his horse up a hill; the horse had lost its footing and thrown him forwards over the horse. He had fallen head down onto the ground with a bent neck.  He knew immediately that something was wrong and he had stayed still until someone called for help and the paramedics arrived.

From the history alone, it was suspected that the patient had spinal injuries. The mechanism of the injury was a fall from a horse more than two meters high, at canter speed, full force of speed and patient’s weight directed at
his
head and bent positioned neck. All indicated a high risk of spinal damage. Immediate pain had been felt at the cervical spine area at the scene and although the patient could feel all his limbs, he had tingling in his right arm.

The routine in emergency for any trauma patients, once their airway is maintained, is to remove their clothing so the damage to the body can be assessed. The main priority in a spinally injured patient is to maintain the spine in a horizontal position, with the patient’s movement at a minimum. The easiest way to remove a patient’s clothing when in a neck collar with minimal movement is to cut the seams of the garments and then, with many hands assisting in rolling the patient, the cut clothes can be removed without assistance from the patient and without compromising spinal position.

I remember asking the patient if we could do this and was shocked at his reaction. Most people are so glad to be receiving medical treatment and scared of paralysing themselves by moving, they will do anything we suggest to help; after all, they can buy new clothes but they can’t buy a new body.

This patient shouted, “NO WAY! This jacket cost six hundred pounds. Do not cut the jacket.” Bear in mind that the patient had been lying in wet grass, he was cold and the jacket was made from thick wool which would have hindered the radiology process. We also needed to rule out back injuries and assess for open wounds not visible through a thick wool jacket. After several attempts to inform the patient of the reasoning behind cutting the clothes off and persuasion towards it, he remained firm in his decision and wouldn’t let us cut his clothes off.

The nurse holding the patient’s cervical spine in line did a wonderful job as one by one item of tight clothes were removed. Each riding boot was vacuumed to his skin from the wetness and I had to use my leg weight against the trolley to pull off the boots. The jacket just didn’t move when the material was pulled at the arms, as it was so thick and fitted; in the end, an inch was released from the left giving more room on the right and so on. I believe all the staff sighed with relief when a doctor, pulling on the arm material, finally released one
arm, with a nurse holding the patient’s shoulder flat to the trolley so he remained straight and supine, the other arm could then be freed and the patient was rolled onto his side and his back assessed while removing the rest of the jacket out of the way.  The patient had put the staff in a dangerous position and this posed an ethical dilemma - do what is best for the patient or do what the patient wished. It was not easy to remove his clothing and it was an essential part of providing treatment.

Once the patient was assessed for injuries, we replaced the head blocks against either ear and taped the patient’s head and blocks to the mattress so he wouldn’t move, and also to keep his spine in alignment. A blanket was placed over the patient to keep him warm as the wet clothes had cooled his body. A series of trauma x-rays were taken of his head, neck and chest. The patient remained conscious throughout and talked of his time riding horses and fox hunting. He continued to have sensation in his limbs and the tingling and pain in his neck reduced after having analgesia.

The radiology report showed a compression fracture of C2; the horse rider had broken his neck. No other injuries were found. The man was moved to an orthopaedic ward and had Halo traction fitted the next day.

Halo traction consists of a metal frame screwed into the patient’s skull, the frame is attached to shoulder pieces that sit on the patient’s shoulders and this essentially holds the head and neck in a straight line, with no possibility of head or neck movement. It is very heavy and sticks out from the person’s head noticeably. The Halo traction may be worn for up to eight weeks until the bones in the neck have stabilised and healed.

While working nights, we often saw the results of people fighting. Due to the binge drinking culture of the UK, people would often get really drunk and start fights. Patients with head injuries would attend emergency, needing us to suture their wounds, throughout the night from about midnight to four am.

The combination of alcohol and head injuries can mask many types of neurological injury and the normal procedure was that if a person had sustained a head injury, we would observe them for four hours, taking regular neurological observations to monitor any deterioration. This can be very difficult when the patient could not talk properly or walk in a straight line and reactions were all slowed by alcohol. Often, there were only one or two doctors working the evening shift and as they had to see all the patients, we often assisted them by suturing the patients so they could continue assessing more patients.

One night, all four cubicles on one side of the emergency department had some sort of suturing needed to be done, one after the other. Not just a small 1 cm laceration but full blown 3-inch wounds that would gape open and need deep tissue suturing. One conversation in the post x-ray waiting area between two patients, who had been the one fighting each other and had obviously sobered up a little, went like this:

“What happened there then, mate?”

“You were looking at my girlfriend.”

“Aw, mate, sorry about that. I didn’t mean anything by it.”

“Oh ok, well, sorry about all this.”

“Yeah,
no problem.”

I tended to both of their wounds and they left. I wondered if it was all worth it.

One patient came in with his girlfriend; he had been slashed with a broken bottle on the face. He was very drunk but very talkative.  He was accompanied by his girlfriend, whom he must have loved very much as he would not leave her side and kept showering her with kisses and leaning on her. The only trouble was that his lower lip was torn away from his face and flapped around whenever he opened his mouth. The young man was oblivious to losing all of his bottom lip and the skin tear was about 3 inches all the way down to his jaw bone. I guess his girlfriend was so drunk she didn’t mind passionately kissing a torn off piece of face as the two were really very passionate while in the waiting room. The injuries were so bad that we had to get out the on-call maxillofacial surgeon out to repair the tear and assess for any salivary gland involvement.

This meant that the patient waited for a few hours before being able to be sutured and, after advising the two to stop kissing and not wanting to leave the girl on her own in the waiting room, I put a makeshift cover over his flap so it didn’t spray blood around or flap when he tried to talk. Once the surgeon arrived in the emergency department, we took him into another room with better light to suture him up. I remember by this time it was 3am and I was due to finish at 4am, one of those horrible shifts that aren’t classed as a full night shift but still mess up my circadian rhythm. Well, we were in that room for the entire hour, suturing deep tissue and also suturing so that the scar wasn’t a large scar. The patient was still talking while the surgeon was trying to stitch him back together, even though he had a surgical drape over his face.

In his drunken state, he was trying to chat me up now that his girlfriend had gone. He seemed to remain unaware of the gaping hole in his face. The surgeon told him to shut up and keep still but he kept forgetting and started talking again. We discharged him once we had finished and told him to go to his GP’s to get the sutures removed. I wrote the date on a card and put it in his wallet so he would remember. Well, 10 days later he returned to emergency, wondering if we might be able to take the stitches out of his face, so I guess he didn’t
remember the instructions I had given him. I was happy to oblige as I had seen him when he first came in and was amazed at how well the wound was healing; it would be a really minor scar from such a big wound.

It’s
not very often that we get a patient
attending t
he emergency department
in the golden hour after
taking an
overdose
.
T
hey usually want to kill themselves and therefore wait
a good few hours before
coming to the department
to get help
s
urprisingly
,
in one week
,
we had four adults
and
three children
overdosing
.

One of the children who ha
d
overdosed was an adorable two year old who had managed to get hold of her mum
’
s
Voltarol
tablets and was found with pink stains around her mouth.

She had taken two tablets of
high strength
non-steroidal anti-inflammatory
medication
, but even one tablet at adult strength would seriously affect the child as
it
was highly
toxic.

The child looked well, happy and smiley
and was
not complaining of any ill effects
;
however
, there was no
time to be lost
. 
As
with all
parents, immediate guilt came over her
mother
and she was kicking herself for not putting the
tablets
somewhere else, she thought they were out of reach
.
I told her not to worry about that now
.
The quicker we treated this little girl
,
the less likely that she would get any permanent liver damage
.
I quickly took a history from the mum, including what time she had taken them and how much she weighed and
then
I phoned the
N
ational
D
rug
’
s
D
atabase
.

I remember the women’s words of concern on the other end of the phone
as
she took details from me and relayed the many side effects for these tablets over the phone
.
My piece of paper was barely large enough
;
tinnitus, nausea, convulsions, liver and renal abnormalities and diarrhoea
.
In a child this small the potential problems were large
.

The women told me that only
the previous
week an eight
-
year
-
old suffered convulsions and died from taking the same drug
and
my patient was only 10 kg in weight so the risks were higher
.
She advised me to give charcoal to the child to try to soak up the drug before it got into her system
.
I disturbed one of the senior doctors
,
told him about my patient and what the poison
’
s line ha
d
told me
.
H
e assessed the little girl and prescribed the charcoal for me to give her.

I mixed up the advised amount of 10-15grammes of the thick, gritty black liquid
,
poured some neat blackcurrant cordial into the cup and mixed
them
together
.
I put on gloves and an apron tied up to my neck to cover my uniform
.
I knew attempting to give this horrible black liquid to a two year old was going to be messy
.
I expected tempers to get high and black charcoal being spat everywhere
,
or better
,
projectile vomit
.
I decided against wearing a face mask, as I knew it would give me limited credibility and
a
lack of trust from the little girl if I tried to give her something horrible to drink while also looking like an alien.

I had pre-warned
the
mum that it
was
horrible stuff and no matter how we tr
ied,
we
c
ould
n’t
improve the taste of it but that the child needed to drink it
. I told her
that the risks of having convulsions from taking an adult dose of a highly toxic
drug
could be minimised by the charcoal binding with the
Voltarol
.
I offered her an apron.

The little girl sat on her mum’s knee and took a mouthful of the black liquid
.
S
he said
,
“N
o
,
I don’t like it,
”
but her mum said that she needed to drink it and
to
have another mouthful
.
To my absolute amazement
,
the little girl did what her mum said and despite pulling disgusted faces and wiping black all over her face
,
the girl sat on her mum
’
s knee and drank the charcoal
.

Her tiny new teeth were stained black and her lips
were painted black
with smudges around her cheeks
.
Slowly and surely the volume in the cup went down
.
T
he child began to tire and I went to get a cup of blackcurrant juice, her cunning mum said
,
“O
ne mouthful of blackcurrant and three of charcoal
.”
T
he child obliged and gradually the black charcoal disappeared from the cup
.
I was so glad
.
There are
so
many
faddy and disobedient
children,
it was a relief to have a child do as their mother asked without a fight
.

I offered both orange and blackcurrant
juice
to the child to take away the awful taste, I gave her
mum
baby wipes to clean her face with and
then
organised a bed on the children’s ward for eight-hour observation
.
I was so pleased the little girl had done what her mum had asked her
,
she was such a good girl
.
After a couple of final checks and assessments and calling the children’s ward, I went to photocopy her notes
.
 
S
he kept asking
“W
here’s the lady
?”
When I went to take her to the children’s ward, I offered
her
my hand and she held it all the way to the children’s ward, despite me being the one who made her drink that horrible gritty liquid.

Normally
,
I don’t panic with kids and I know the medical treatment needs to get done to help them in the long run
;
so when they are to
o
young to comprehend the necessity of treatment, I do my best to keep them informed and not to lie
about
it.
It
was
best
just get on with what I need to do with as limited fuss and drama as is possible.

I was so pleased for this little girl, she was so grown up and drinking all the charcoal had helped
decrease
medical problems later
.
S
he
would probably have no ailments due to
ingesting the Voltarol.
It made my day that I’d managed to get the essential medicine into her and that she didn’t get upset at all
.
Simple things make me smile.