Sixteen years old, just round the corner from these clowns a month ago. I shivered when the name of the district came up on my screen - working alone in a Rapid Response Unit I’m supposed to think a little harder before storming into less desirable areas. No mate behind you to watch your back or second set of six senses letting you know that things have turned south.

I park up at a six-in-a-block, this corner of the estate small and clear enough for my back-up crew to see the vehicle from the passing road, no need to leave the roof lights and red strobes to guide them in. From the boot I swing the response bag over my shoulders, hopping in place as I tighten the straps to suck the weight into the small of my back. The defib comes next, lifted from its housing on the left hand side.

Working alone on the RRU you get the luxury of carrying lightweight O2 cylinders. Carbon-fibre over old steel, half the weight, same capacity and tiny. Small enough to snuggle into the bag itself, leaving a crucial one hand free for your approach to the scene.

You can tell a lot by the state of peoples’ front doors and these are clean, new (but not the-polis-raided-last-week new) and in good order. The stair’s shitty, but on a weekend, so’s mine.

A woman in her 40s answers the door and leads me into a sitting room.

“He’s in the toilet just now…”

Perfect. Unless things have gone horribly wrong in the past 30 seconds while he’s in there, I can at least log the patient as “Alert and ambulatory”.

He’s at my back before I’m in the living room, grey cotton trackie bottoms, the hems slack on the floor behind his feet, a football shirt, not this season’s (I assume, like I’d know) if its soft, frayed edges are anything to go by. No shoes and an asymmetric curtain of hair under a woolen beanie. He is, in short, the ultimate image of kid-from-a-bad-estate.

Except for his body language. There is no stuck out chin, no sneering eyes and mouth, his left hand lacks a bottle of cheap cider, his right shows no signs of being lodged permanently down the front of his pants.

Instead his shoulders are up, his head down, his hands curled in front of his chest in a like a foetal boxer, covering up. Shivering manically, when he looks up in answer to my greeting his eyes are red rimmed and exhausted. Pale and gaunt, cracked lips, his shoulders banging up and down as he pants like a well-run mutt.

“Appears unwell” is often recorded on medical records, but I’ve got a better phrase for him.

He looks like cold shit.

He tells me he’s felt unwell since the morning, but tonight he started throwing up and now he can’t keep anything down, not even sips of water. When I ask him if he’s sore he drops his hands, crushed , to either side of him.

“I hurt everywhere. My head, my chest, my belly, my arms, my legs. Everywhere. My head’s the worst. I go to pee and I can’t, but I have to. I’ve had nothing to eat all day…but my sugar’s high, it’s weird.”

Bing!

“You’re diabetic?”

He nods.

“Let me check on my machine? Not that I don’t trust yours, but…”

I jag him, drop blood onto a plastic strip and we wait dutifully while the monitor counts down from 20.

2…1….

It reads 27.8 and underneath warns me “Ketones?”

I sniff his breath, a dusty carpet of stale vomit and dehydration, cut through with just a shard of nail varnish remover.

Ketones.

-
Here comes the science bit…

I want you to imagine that insulin is a stern school teacher, keeping everything on an even keel in your body. It ensures that your liver, pancreas and blood all toe the line, playing together nicely.

Diabetics have either insufficient, or no insulin in their systems. With insufficient insulin managing his body, a number of things have started to happen.

The hormone glucagon has a vital role in your body, it bullies your liver into converting a chemical called glycogen (which it jealously hordes) into glucose and pours it out into the blood stream.

Think of glucagon as a meanie who torments the fat kid into sharing his sweeties.

Given the chance, glucagon would bully the liver all day long, producing an unending stream of humbugs, but it’s kept in check by insulin, the stern teacher, who moderates the number of sweets the liver has to give up, making sure that glucagon doesn’t spoil dinner by stuffing itself.

In a diabetic with insufficient insulin, however, glucagon can go hog-wild, beating shit out of that chocolate hording little hepatic pansy. And so it does, the liver having no choice but to empty its pockets of every precious ju-jube and eclair into the blood stream.

You know how rough you feel when you have too many sweeties?

Your metabolism feels the same way.

Across the other side of the playground, your fatty tissues are freaking out. They’re the obedient, but dumb kids in class, never doing anything too interesting but sitting still and trying to win gold stars by not falling over their own feet too many times in a single day.

But now there’s no-one to impress, no-one to put your hand up to, insulin is gone and nothing else will keep them under control.

The fatty tissues can’t handle this; sycophantic, but ultimately stupid, they’re likely to eat the glue sticks and piss themselves. And so they do, peeing out acids that the liver quickly turns into ketones.

See, your body’s not useless. It knows something’s horribly, horribly wrong and that you can’t maintain this insulin-less condition for too long. So it makes ketones. Your brain can run on them for a good wee while, they’re sort of like cerebral iron-rations. When times are tough, your brain can survive on acid.

Didn’t know that, did you?

Ok, ok. Now that we’re all congratulating ourselves on being X-Men who can run on acid…back to the point.

While ketones are terribly clever and amazing emergency brain fuel and all that business, they’re acidic and make your blood acidic too.

Your body runs brilliantly at pH 7.3/7.4, slightly alkaline. At that point the electricity that runs your nervous system works just great. You shuttle chemicals in and out of your cells at top efficiency. Everything inside you stays, pretty much as it’s meant to.

Step beyond normal blood pH, though and you’re fucked. Your nervous system gets thrown out of whack, your ability to absorb oxygen decreases, ultimately your organs fail in a big soupy mess. It’s really not very nice.

Your body’s good at dealing with acidosis, though. One of the ways it can fix it is by increasing your respiratory rate and gulping down extra oxygen.

But this adds to your problems further. Breathing excretes moisture from your body; not a huge amount but enough to worsen the situation if, say, you were massively dehydrated.

Did I mention the dehydration?

See, when your blood gets jam-packed with glucose, it reaches a point of exceeding saturation and the glucose molecules start to spill over into your urine. This would be fine, since it’s the excess glucose we’re trying to get rid of in this situation, but like a drowning man, glucose pulls extra bits and pieces into the urine with it. Bits and pieces like water, sodium and potassium. All the important things that make your metabolism, you know, work. Ketones do the same thing, being excreted in the urine but dragging water molecules down with them as they go.

I suffered a sodium/potassium drop in Abu-Dhabi last Autumn, I wrote about it here. I felt *hideous* and only had the slightest of slight cases.

I dread to think how grim our patient feels.

Anyway, science lesson over. Back to the story.

“So, Luke…here’s the plan…”

He barely raises his eyes and head at me.

“…we’re going to take you into the hospital and get this dealt with, in the meantime we’re going to give you some fluid to sort out your dehydration. Deal?”

“Sure.”

You can tell a lot by how someone reacts to getting an IV, some people complain and squirm, jerking their hand away when they feel the point of the needle against their skin. The average teenager is a fucking nightmare to cannulate.

This guy, though, is cool. He stretches his arm out straight when I ask and, though he grimaces and complains when I stick him, keeps it where I need it until the wide-bore cannula is in place.

The crew arrive to back him up, two technicians, so one of them takes my car while I stay with the patient on the way to hospital. We pass a standby to hospital and run lights and sirens to resus while I stand by the trolley squeezing litres of fluid into his veins.

We’re on the bypass when his Mum asks me a baffling question.

“What do you think’s wrong?”

“What do you mean?”

“What’s wrong with him? Why’s he ill?”

“Well…he’s in DKA.”

“Deekie what?”

“His blood sugar…?”

“Is he having a hypo?”

“No, he’s…how long has he been diabetic for?”

“About a month.”

Ah.

That explains a lot. I take some time to bring her up to speed on what’s going on and, after our short chat, I look back at the patient.

He’s curled in a loose ball on his side, the blanket pulled around his chin. The shakes have gone, his face is pink and relaxed.

“Luke?”

He opens his eyes.

“How you doing?”

A nod.

“Feeling a bit better?”

Another nod, this one more emphatic.

“Still sore?”

Shake, no.

“Cool.”

It’s nothing major, nothing special or Hollywood, no babies born or hearts shocked.

But there’s a massive thrill to be had from just making someone better.

“Fallen from window” should tingle my spidey-sense, but a second look at the location calms the hairs on my neck. A favoured night-spot in the centre of town, the Mecca for stag nights and hen parties, I imagine a sozzled backwards lean into a ground-floor window seat. Maybe even a drop from the first floor, God’s benevolent palm cradling idiots, drunks and bairns safely to the ground.

The falls from height I’ve attended before have snapped ankles, broken wrists, maybe even clattered their heads against the wall on the way down. A collar and board for show, really, until a radiologist can confirm their linguine like spines are intact and here’s-some-Ibuprofen-and-don’t-do-that-again.

The message ends with “conscious and breathing”, which stamps it firmly as originating from the police, so I’m bemused when we pull up at the pub and find ourselves the only emergency vehicle present. There is nobody on the pavement and, crucially, no body on the pavement. A door steward waves us over.

“He’s down there, boys, but the gate’s locked.”

Beside the bar is a narrow alleyway, a full length metal gate and entry system guarding against intruders from the pavement. I peer down the vennel with my torch, but see nobody.

“At the back…you can maybe get through the pub’s back door?” suggests the bouncer.

My partner, DezzyBell trots into the pub with him to assess the route, while I rudely press every flat’s button on the door panel.

Nobody answers, accustomed, I’m sure, to drunken wankers playing tap-door-run late at night. I walk back to the vehicle to get the tool roll. Bolt cutters, crowbar, hacksaw. Loaded for bear, I’m back at the gate, now joined by two cops and a sergeant, all squinting into the gloom.

With a “snick” the gate unlocks remotely, from somewhere. Dezzy returns to our happy band, the back door of the pub having come up devoid of solutions.

The alleyway cuts through the bottom floor of an ancient tenement, we’re deep under the shadow of the castle here, right in the guts of the city’s medieval centre. These are not buildings that were built with emergency access or egress in mind. To the right climbs an impossibly tight spiral stair, up into the middle of the flats above and at the far end sits another lockfast metal gate.

Great.

This one is less secure, held to its post by a dodgy bike-lock, plastic coated wire and one of those keyholes that can be forced with any cheap screwdriver.

A man in a coat and hat, the patient’s brother, it transpires, runs down the stairs with a set of keys.

None of which fits the chain.

He runs up the stairs again, shouting that he’ll be back in a minute, just wait.

Beyond the gate sits a wide courtyard, paving stones and wooden pallets are stacked against the walls and, to our right, I can just make out a large man in his sixties. He’s sitting up, sort of, resting back against a stack of smashed building materials, facing away from me.

“Sir? Can you hear me?”

He raises a hand in greeting, tries to turn.

“No, no! Sir, stay still, try not to move, we’ll be in with you in a minute. Are you hurt?”

“I don’t think so.”

“OK, where did you fall from?”

“Up there.”

He points towards the roof.

“Which floor?”

“The top one.”

Four storeys. Four high, lofty Edinburgh tenement storeys.

Sixty feet. Give or take.

Jesus.

“How did you fall, sir?”

He drops his voice, ashamed, embarrassed, euphemistic to the last.

“I was trying to…do away with myself.”

“Alright boss.”

One of the cops, impatient with waiting, gestures at the lock.

“Fuck it, just force that. It’s nothing, eh?”

Fair enough.

The bolt cutters chew through the flimsy cable in a satisfying chomp and I slip them into a belt loop and swing the response bag over my shoulder as I step into the courtyard. With just the dim light from the back windows of the bar I’m glad of the mini Maglite my brother bought me for Christmas. I screw its metal head tight against the housing and focus the beam into a tight, bright point.

His face is cut, a large laceration over his forehead that bleeds down into his eyes, dust and mud stuck in a thick layer over his features. His shirt is ripped open to the navel, but I see his chest rising and falling comfortably. He rests both his hands on the floor either side of him, steadying himself, so I assume they’re largely uninjured. Left leg is dressed, smart suit trousers, missing a shoe.

Right leg…

My stomach flips over, I lose my cool and inhale hard before babbling a litany

“Right…right…ok…”

It’s just words, but they stop me swearing out loud.

His right leg is interrupted halfway down his thigh by the smashed end of his femur. Fat as my wrist it pokes obscenely through the tattered remains of his thigh muscles, a wicked scarlet grin slashed across his skin, yellow fat bubbling at the corners.

The tissues across the front of his leg are ripped and torn, sliced by the sharp edges of his bone when it snapped across its width and forced its way out of his skin like some triumphant parasite. It glares at me, mannerless, pointing and laughing from the mush that used to be the space above his right knee.

The lower portion of his leg lolls uselessly on the floor, twisted and filthy, connected to his body only by his hamstrings and a fat, twitching bundle of blood vessels, drawn up hard and tight under himself.

Somewhere in there is the lower half of his thigh bone.

Muscles only work when they’re tethered at both ends, with his quadriceps severed they’re now useless fleshy ribbons, pulled up tightly at his hip. They contract and relax, shiver and shake, frantically trying to get up and run like a road-struck rabbit. Hot and wet, they suck and slobber at my fingers as I cut his trousers away from the wound.

When I pull the shoe and sock from his foot the squeamish kid inside me shudders. The bottom half of his leg is pale and cool, the foot is white, grey, blue, frozen and shocked, dead before its time, its circulation strangled somewhere in the mess that was once his thigh.

A number of things strike me as my brain spools desperately.

That leg injury alone could kill him.

If he’s hit the ground hard enough to snap his femur, he’s almost certainly damaged other things.

Like his neck. Jesus…I haven’t even LOOKED at his neck.

Or his abdomen, I’ll bet the inside of his belly is just soup by now, organs pulled from housing, tissues shearing. Everything’s going to be bleeding in there.

I want a collar on him.

And two IVs.

And fluids up.

I want to put this leg in traction.

Am I meant to put open femurs into traction?

I can’t remember.

Fuck.

I haven’t put a traction splint on anyone in years.

There’s too much for me to do.

Dezzie, God bless ‘im, is dutiful and will follow instructions to the letter, but he’s a probie and pretty green with it.

I need more hands and I need them now.

“Can you call for a second motor, please?” I ask one of the cops. He nods and dips his chin to his radio. Dezzie runs back and forth from the ambulance, bringing kit and equipment, while I lay the traction splint out alongside the patient’s leg.

For those of you who’ve never seen such a piece of gear, I want you to imagine two long, telescoping parallel metal rods connected between by six canvas and velcro straps. The idea being that you fix one end to the patient’s hip and the other to their ankle and then, using a ratchet winder, drag the leg into a full extension, just as an intact femur should do.

My description doesn’t do it justice - some of you reading this might be thinking that it sounds sort of like a torture instrument and I wish to set you right.

It is exactly like a torture instrument. It allows me to grab the two broken ends of your leg and haul them back into position. I’ve only seen it used twice before and both of those patients screamed from their boots when we started twisting the ratchet.

This guy has hardly said a word since we got here, not a moan or a murmur.

Dezzie returns with the last of the kit. Both he and one of the cops ask the same question.

“What can I do for you?”

“Dez, start him on a Hudson, please. Fifteen litres. Then hold his head. Officer….”

I cast around the scene for something for the cop to do. He can’t dress a wound, fix a collar or start an IV.

“Can you get us some more light? Do you have a Dragon in your car?”

He looks to his colleagues who both sadly shake their heads; with no flood lights available he instead commandeers every torch they’ve got, holding them in a bundle.

It’s still dark.

I start turning the little silver wheel at the bottom of the traction splint and watch as the slack is taken out of the straps, squeezing tighter and harder against the skin of his leg. The cog-wheel snick-snick-snicks against itself and protruding six inches of bone in the top half of his leg snick-snick-snicks along with it, inching back into his flesh.

There’s a massive infection risk, I’m almost certainly pulling gravel, soil, debris, oil and shit deep into the wound. The sepsis that will result will take hours of surgery to clean out, endless rounds of brutal antibiotics to reverse.

And chances are that at the end of everything, the whole thing will rot and have to be amputated anyway

But if I don’t straighten this? If I don’t pull it back into position now and restore the circulation to the injured part?

I might as well hack it off here and now with the lock knife in my pocket. Split bone from ligament, muscle from tendon; slice it away like a joint of beef and bury the whole bloody mess in the mud in this medieval courtyard.

We’ve one chance to save his leg and a slim one at that, but as the splint’s tension pulls muscles and bones into something that at least resembles normal alignment, I’m warmed inside by the pink and purple rush that hurtles down his shin as blood pours into his hypoxic foot.

That’ll do in the meantime.

The patient, his head firm between Dezzie’s hands, breaks his silence and mumbles at me.

“Sorry, Sandy?”

“I said….”Can they fix it?””

I suddenly realise that I’ve missed the picture from the patient’s view. Here we have a man who planned to die tonight, who stepped from the window of his living room into blissful oblivion, no worries, no fears, no stress…. and now is a failure. A failure and a cripple. A failure and a cripple and the-brother-who-tried-to-kill-himself.

My head still whirling with the injuries that he could have, my answer is relatively honest.

“We need to look after both you and your leg. Right now I’m more interested in keeping you safe than the leg and you’re doing just fine, ok? We’ll get you to the hospital and get the surgeons to see you straight away.”

From the end of the passageway come voices and The Sisters Of Mercy come in like green-suit wearing angels, Sister Kay has years of experience on me, while Sister Ess registered as a para just a few months after I did. They are both Officially Lovely. One of them makes muffins and cupcakes and leaves them lying in the mess-room.

When a great crew backs you up, they slip seamlessly amongst you and your partner, diluting the problem. Unfettered by considering what-ifs, they can get on with getting on, taking the next necessary step without getting bogged down in details.

Their arrival marks the corner of the job, in minutes Sandy is collared, boarded, immobilised and lifted onto the trolley. We roll him into the ambulance and lock the trolley in the centre of the floor so that Sister Ess and I can both attack an arm each with IVs, doubling our chances of getting access.

Needles in, fluids up and wheels rolling, Ess and I ride to resus with Sandy, a cop in the passenger seat, Dezzie driving. Having dropped him off with a mob of specialists, I book the patient in at reception and thank the Sisters, dropping a kiss on their heads as they stand beside me.

“Thankyou.”

“Anytime. Night.”

-

It’s hours later when I cross my legs in the cab and wrinkle my nose.

“I can still smell blood…”

There, lodged in the tread of my boot, is a dark red glob of…blood? Muscle?

Sandy.

I stamp him out in the snow at the roadside, leaving smeary red bootprints like a hunter.

Recent job despatched to my screen.

And for those of you who would try, that image is triple protected against you peeking under the blackness to find patient details. Nae chance.

Nothing to write home, or anywhere else, about. Just an old feller with some indistinct shoulder pain that might, or might not indicate some sort of cardiac origin.

Dezzie is running through the standard questions.

“Any medical problems in the past?”

“No, none.”

“And do you take any medication?”

Because they ALWAYS say that they’ve never had anything wrong with them and then they ALWAYS have a list of medications that you can reverse engineer a medical history from.

You don’t get taught about common medicines on your Technician course. You should do, it wouldn’t be a hard module to drop in, just an afternoon of “Here are a couple of dozen very common drugs that lots of people take, remember them.”

It comes with time.

Because we’re ignorant about medicines, most of our patients also are - they take the pills the doctor gives them. As such, you also learn to recognise the mangled pronunciations of names that people come out with.

Even if you can recognise them, there’s no guarantees the patients will be pleased about it.

Back to Dezzie and our patient.

“I take an Aspirin in the morning and Oprah-Zamma-Roll.”

“What d’you take that one for?”

“It’s a gastric pill, helps with my heartburn.”

Ah, jolly good. Omeprazole is ridiculously common, everyone’s on it.

The conversation continues for a little while, Dezzie continues to probe at possible sources of the patient’s chest pain. Mostly we’re suspect of this gastric history.
“So the Omeprazole you take….”

“The what?”

“The Omeprazole.”

He stares blankly at us.

“The tablet? For your stomach?”

“Oh!”

Light dawns, he catches my eye and rolls his before leaning close into Dezzie, speaking slowly and clearly, as if to a stupid child.

“Oprah…..Zamma…..Roll.”

Dezzie doesn’t bother to correct him and the patient sits back, happy to have set us right.

I thought he was sleeping -
‘Til we rolled him over.

The hole in his head.

Grey, curdled lumps on his shirt.

Maybe vomit.

Maybe brain.

His leg torn to nothing.

Obliterated.

Gone.

We wrapped the stump in wet dressings.

To stop the absent bleeding?

To protect from infection, though we all know they’ll cut it off anyway.

It seems…”right”.

And doing nothing feels like we’re failing him.

Last week’s Doc2Doc post focussed on recognising racial differences in medicine.

Go take a peek.

He lies to the police, claims it was a bar fight. They explain that they’re usually in plain clothes, detectives back in uniform for a busy Saturday night. Where’s the blood on the pavement? On the stair? If you’d walked back from the pub, there’d be blood on the stair.

She did it, didn’t she?

He sighs, shoulders forward, a crescent slash from his hairline to the top of his eyelid, another pound of force behind it and we’d be packing his ruptured eyeball back into his head and running for the hospital.

Instead he nods, apologises for lying, expains he doesn’t want his partner charged. The younger detective fumes and fizzes while the older gives him a gentle talking to about wasting police time. They shut the door and we nash him up to A&E, allowing him a fly fag outside the doors before taking him in to see the nurses.