Feb 17

That’s not meant to be there…

“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.

30 Responses to “That’s not meant to be there…”

  1. Special K says:

    Whoa. I don’t consider myself a squeamish sort but I was wincing through most of that. Your writing is, as ever, probably my favourite in THE WHOLE INTERNET.

    You must have an incredible sense of smell.

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  2. Sarah says:

    Wow, the returning rush of blood down his leg must have been quite something to see.

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  3. Dungeon Rob says:

    Not only am i always in awe of the work you do, but the writing in this piece is fantastic. You paint such a vivid picture that i almost feel like i was there with you. You should seriously be writing novels. Outstanding work on all counts Kal!

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  4. Carrie says:

    Bloody hell Kal. I’m not squeamish at all normally but I got the watery-mouth-queasy-feeling reading that. Bleurgh!

    Xxx

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  5. Lucy says:

    Ewwww. Hope all your hard work paid off for the poor guy.

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  6. Charl says:

    Kal I don’t often comment but I feel I have to.

    That is simply the best written blog post I think I have ever read.

    I can’t say more than that.

    Thankyou for sharing.

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  7. Clare in Leeds says:

    Jeez, Kal. That was absolutely amazing writing, Totally compelling and in the moment.

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  8. Loth says:

    Astonishing writing Kal, really astonishing. Thanks.

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  9. Croila says:

    But did he live?? Did he survive?? Yep, the writing was good because I really, really, really want to know the outcome here…

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  10. Morpheus says:

    I haven’t told you recently how much I appreciate the fact that you write. Keep it up, please.

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  11. Helen says:

    Kind of reassuring to know that even with experience Big Sick Trauma as it were still makes you go oo-er mentally before getting on with it. Random question; what sort of traction splint is it? From the description it’s not at all the one we use, which is a Sager (looks like an idiots machine gun according to a colleague). Yet to use any sort of one in anger though, happily for my patients.

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  12. Donna says:

    Yowza. I’ve never used one “in practice” (being a mere “trained only” medical responder who’s switching to nursing) but … man, all the times I put a sager on someone (or had one put on me) for training, I remember thinking “gah, uncomfortable.” I can’t even fathom what it would be like on a real person.

    Curious, though — open femur fracture is a contraindication for a sager ’round these parts (although fucked if I know what else you’re supposed to do then… pray, perhaps? apologize when his leg falls off?) — what kind do you use?

    Also: Thank you for writing this. :)

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  13. Lynne says:

    Wow. You’re good!

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  14. Cath says:

    Do you often get to hear the end of the story, Kal?

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  15. heron says:

    Ouch! On all accounts. Sounds like he got “lucky,” all things considering, though you really got to it when you mentioned the disparity between the patient’s view and the crap-gotta-stabilize-this-open-femur-fracture-and-god-knows-what-else medic view. Let us know if you hear a follow-up, will ya? And yes, thanks for writing this.

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  16. heron says:

    Reading over that again — says he doesn’t think he’s hurt, barely murmurs despite unilateral femur fx, laceration to the head, etc. Crap, he came out with half his spine shattered (though apparently below the neck) from the massive compressing force, didn’t he? How were his other sensorimotor functions?

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  17. Christy says:

    That is so sad, poor man. I’ve been thinking about him all night. Well done you guys.
    Fourth floor of Edinburgh flats- that’s too unbelievably horrible.

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  18. Yorkie says:

    Yikes. Nice work fella. 60 feet i woul say is a significant fall from height then!
    Tricky situation, although i would have went with the splint as well. As per usual, all the ‘genuine’ jobs seem to be in the most inhospitible, inaccessible and inconvenient of environments.

    Donna and Helen.. Kal is in the same trust as me (although works in the second most important city in Scotland ;-) )and we use the Trac3 traction splint….although we dont have shiny bolt cutters and hacksaws on our waggon..

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  19. Fee says:

    Holy god. He’s surely lucky to have survived the initial fall? Maybe lucky’s not the right word, but 60 feet is a long way down.

    Gruesome description. Glad I wasn’t eating at the time.

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  20. MacMarsha says:

    amazing job, amazing writing.

    unfortunately for me I was half way through a jammy doughnut (krispy kreme too) while reading.

    Best Diet Tip Ever

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  21. Stonehead says:

    The rural ambulance services in Victoria, Australia, used to have pneumatic traction splints. I saw them used a couple of times at the scenes of RTCs and once for a climber. The splints worked like a trombone—attach the splint at foot and hip, slowly pump air in to make the splint extend, tighten the retaining screws, and depressurise the splint. They were quite an ingenious bit of kit that didn’t seem to need much movement of the patient to fit and were very smooth in operation.

    Anyway, Kal, a excellent piece of writing.

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  22. Clare says:

    First off- your tool roll has tools in it? Where did you get the funding for that?? You brought your own, didn`t you?
    Second this reminds me of a call i had a long time ago. Boy feel, again, about 60 feet into a dead space which we could only access through a vent. He landed onto about 60 years of pigeon crap which probably saved his life. No apparent injuries though we clobbered his head trying to get him back through that vent on a spinal borad. Two inch cut above the forehead strap. Probably the worst thing he got was from us trying to save him… Couldn`t get that pigeon crap smell out of my nose for days…
    Highly impressed you managed that splint. I still have vague recollections of sitting with one in my hands at barony just praying I`d never need to take it out the bag again…

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  23. HeatherTheVet says:

    Note to self – if ever decide to jump, go headfirst.

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  24. kirikate says:

    Kal, could you please but a pre-post warning on the posts that will make me feel like throwing up. “this post may report disturbing events that may be unsuitable for people with a weak stomach”. Something like that. I have a tummy bug.
    Love you anyway!
    Kiri

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  25. Alice says:

    Hi Kal,

    I do not know how you and your colleagues do your job but I am glad you do. Meanwhile is there a good website you can direct me to which has diagrams because I just cant see how that splint works. So far my mental image is of a a metal pole with an anchorage at hip and foot covered by a big plastic bag that is vacuum packing a lump of meat at the hip, another at the foot and a bit of straightened bone and gore at the middle. However that means its all pressurised so how do you maintain the blood flow…which means im imagining it wrong. Help!

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  26. Stonehead says:

    Alice,

    This might help—from the book Emergency Care: A textbook for Paramedics (and no, not gruesome).

    http://tiny.cc/cBYUS

    (Links to Google books.)

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  27. Chris says:

    Like many other commenters, I didn’t think I was squeamish but read most of this through screwed up fingers over my eyes. Just like I used to watch Dr Who when a kid. Great writing!

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  28. Metamor4sis says:

    Who needs photos when we’ve got Kal…. gasp…

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  29. Bobbi says:

    Hell. Poor guy. Almost would’ve been better not to survive the fall. Did he live? I know you’re not supposed to know what happens to a casualty after you chuck them at the hospital, patient confidentiality etc, but just a hint? Or do you know anything at all about what happened to him afterwards?

    I’m stunned he survived a 60-ft fall. Assuming onto pavement here, too. At least there were still some intact blood vessels to his foot. Better chance of saving the leg? I dunno. Poor man.

    Brilliantly written, as always. Thanks….I think…

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  30. Patch says:

    Great writing. Great patient care as ever. Will add a long piece of rope to the kit for the desert. You’ll need to make your own traction splint….

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