was back to normal after the mayhem of the morning, thanks to the cleaners and the nurses who’d restocked the supplies. Thinking of the facial injuries and the effect they might have on the patient’s airway, she checked their stock of all the different sorts of airway the anaesthetist might need, and then went out to meet the ambulance, just as Nick emerged from his cubicle and headed towards the door.
‘Perfect timing,’ she said as the ambulance backed up and the doors opened. As the trolley was lifted out, she winced inwardly. Their casualty was a mess—she was on a spinal board, her face was trashed and her colour was lousy despite the oxygen mask held lightly in place.
The paramedic gave them a quick rundown as they wheeled her rapidly into Resus.
‘Twenty-five-year-old female, name of Jodie Farmer, neighbour saw her jump off her third-floor balcony. She landed on the concrete path outside. GCS 15 at the scene. She needs a tube down really but I thought I’d leave that to you guys as she’s still able to breathe and we were only round the corner—watch her jaw, it’s shattered and her tongue’s bleeding. She’d got umpteen teeth missing, too. It’s a mess in there.’
It certainly was, Sally thought, listening to the list of drugs she’d had on the way in and mentally assessing her. Her left cheekbone was depressed, her eye seemed twisted slightly, her upper lip was huge and torn to ribbons and her lower jaw was grossly misshapen.
In fact, her face was so severely injured Sally was amazed that she hadn’t had a lower score on the Glasgow coma scale, which measured the level of consciousness. She would have expected some degree of concussion, but maybe that would show itself later. She’d have to keep an eye on it and rescore her frequently.
In the meantime, her whole face was swelling before Sally’s eyes, and she was getting restless, moving her head and fluttering her hands, fighting for breath.
It was a fair bet that the inside of her mouth was swelling too, cutting off her air supply. Protecting that had to be the first priority, and the moment she was on the trolley in Resus Sally was ready. ‘Are you going to try and get an airway in?’ she asked doubtfully, but Nick shook his head, confirming her suspicions.
‘Not a chance, and we can’t wait for the anaesthetist, she’s distressed now. I’ll do a laryngostomy. I don’t want to poke about in there. OK, Jodie, just relax, you’re in good hands. I’m just going to get you some air.’
Within seconds he’d located the cricothyroid membrane, made a neat little slit in it and slipped in a tube. Instantly the patient stopped struggling, and her colour started to improve in moments. ‘Right, let’s get some oxygen into her and assess her injuries. I want X-rays of head, chest, total spine and pelvis to start with, and we’ll work from there. Is there a maxillofacial team here?’
‘Yes—I’ve alerted them.’
‘I want them here now. This needs urgent attention. Her eye socket’s compressed and her tongue’s bleeding badly. The orthopaedic reg could do with seeing her when we’ve got the plates, too, because this pelvis needs sorting out.’
They stood back as the radiographer slid the plates into the trolley, took the required shots and disappeared to develop them.
ABCDE, Sally thought. They’d sorted out her airway, made sure she was breathing, they were running in fluids to protect her circulation, Nick had done a brief neurological check to assess any obvious disability, and the last thing on the list was exposure—seeing the whole patient naked to check for anything else they might have missed. Before the door swung shut behind the radiographer, Sally was busy cutting clothes off, and it was immediately obvious that Jodie’s pelvic injuries were very severe.
The skin over her hipbones was stained dark purple with bruises, and there were sharp spikes of bone pushing up against the skin in places.
‘Nasty,’ Nick said softly. The probability of internal injuries is very high, I think. Circulation to both legs seems good, though, amazingly. Watch her pressure—what is it?’
‘A hundred over fifty.’
‘She’s young, but it’s still very low. Watch it like a hawk, please. I don’t want to miss anything. Pulse?’
‘One-twenty and erratic.’
‘She’s breathing all right for herself still, so hopefully her spine’s intact. Let’s check her reflexes.’
He ran a quick neurological check to see if there was any likelihood of spinal damage, and incredibly she seemed to have been lucky. ‘Looks OK. Wonders will never cease,’ he murmured under his breath.
He gave her a little more pain relief, then bent over her, speaking clearly. ‘OK, Jodie, I’m just going to have a look at your mouth and see what you’ve done,’ he told her, then carefully removed the tape from the neck brace and opened her lower jaw a fraction to make sure there was nothing life-threatening that they’d yet to find. He was gentle, but of necessity thorough, and she moaned softly.
‘Sorry, sweetheart,’ he soothed. ‘I won’t be long.’ He sucked out her mouth, his hands gentle as he probed the shattered jaw, and he shook his head.
‘We need to tape this up to support it but there’s nothing much to tape it to. She’ll need it fixing a.s.a.p., and her tongue needs stitching fairly soon, it’s still oozing. Where’s the faciomaxillary surgeon, for heaven’s sake?’
‘Here.’ The door slapped shut behind him, and he moved up beside Nick and assessed the patient rapidly. ‘OK, I can see why you called me,’ he said under his breath. ‘Has she got a name?’
‘Jodie Farmer.’
‘Hello, Jodie, I’m Tom Kievenaar. Don’t worry, we’ll soon have you much more comfortable.’ He turned back to Nick. ‘Got any plates of this yet?’
‘Right here,’ the radiographer said, snapping them up onto the light box.
The evidence was incontrovertible. ‘Ouch,’ Nick said softly, and Tom gave a short, humourless laugh.
‘Oh, yes, this one’s a lulu. Lower jaw, upper jaw, cheekbone, nose, all the top front teeth—there’s enough material here for a whole symposium. The rest of her skull looks all right, though, by a miracle. What’s her GCS?’
‘Fifteen at the scene, but she might have been KO’d. No deterioration since admission.’
‘OK. No obvious neurological signs?’
Nick shook his head. ‘Nothing so far.’
‘Good—let’s hope it stays like that. OK, let’s get cracking. Anything else you’ve found out?’
‘She’s bitten her tongue—it’s still bleeding slightly and it needs stitches, but it’s not a priority. I haven’t checked the spinal X-rays yet, though, so we need to do that before she’s moved.’
They went over them together while Sally continued to monitor their patient and stabilise her. Her pressure was dropping slightly, probably due to the huge blood loss from her many fractures, and Sally opened up the flow on the plasma expander to maximum and reported the pressure drop to the two men.
‘Is she cross-matched?’ Tom asked, and Sally nodded.
‘Six
