Traumas

The security guards had lost control of the situation, a truck had pulled into the courtyard and a man was standing in the back shouting at everyone and no-one in particular, his stance seemed both threatening and desperate at the same time.  A crowd had gathered around the vehicle and the situation felt tense.  There was a cacophony of sounds and it was impossible to establish what was happening; approaching the truck felt like a bad idea though.   I maneuvered gently through the gathered throng and made my way into the triage room to find a scene of devastation.

A woman lay motionless on the stretcher in the centre of the room, two more victims sat either side; one crying out in pain clutching his ribs and one sat quietly with a deep wound across his forehead.  There was another patient still in the back of the truck who had apparently died on the way to hospital.  The triage nurse explained that a lorry had collided with a mini-bus on the outskirts of town and several people had perished at the scene.  The small, brightly coloured mini-buses or poda-podas as they are known here, are a ubiquitous, cheap form of transport seen throughout the city and will squeeze as many as twenty people or more onto cramped, wooden seats that would comfortably fit half that number in what is essentially a large painted, tin can on wheels.  I shuddered at the thought of what the accident site must have looked like. 

It was rapidly evident that nothing could be done for the lady on the stretcher and as I stood beside her, I noticed another body curled quietly in the corner of the room; a boy in his late teens.  A pool of crimson had congealed on the trolley next to his head, the source seemed to be his ear indicating a significant head injury and at first glance I feared that this was another tragedy about to be discovered.  My initial feelings of overwhelming anxiety were suppressed by my determination to gain control over the situation and prevent further harm whilst also attempting to preserve the dignity of those that were beyond help.

The man sitting with the wound across his forehead was talking, lucid and had no neck pain so I was happy for him to stay where he was for the time being.  The triage staff swiftly carried the unconscious young man into the resus room and as they placed him on the bed, he began to vomit what looked distressingly like fresh blood.  The medical officer was also in attendance at this point and he assessed the man with the chest injury in the other available resus bed.  His vital signs were reassuringly normal and after analgesia, he was beginning to calm so I felt less worried; attention focussed back on the young man that was in danger of compromising his airway.  The nurses were doing a fantastic job supporting his neck, suctioning his stomach contents to prevent them entering his lungs and beginning fluid resuscitation.

At one point there were six staff around the bed, efficiently tending to him and after several attempts to get past them to assess the patient, I gave up and stood back.  The patient was now connected to the newly installed monitors, his oxygen levels were improving and the heart rate and blood pressure were stable so it seemed reasonable to get out of their way for the sake of a few minutes.  Fortunately, the family had arrived by this stage and were able to afford the cost of a CT scan and some x-rays.  After a rapid assessment which identified the head injury as the main cause for concern, we were able to transport him to radiology.  A brief review of the scan revealed air within the skull indicating a fracture and some swelling of the brain but to my great relief, no significant bleeding.  There is no neurosurgery capability in the country and a sizeable bleed would almost certainly have been fatal.

There was no point waiting for a radiology report as this would not be available until the following day so the patient was transferred to intensive care, by which time the oxygen and fluid were taking effect and he was a little more responsive.  I returned to A&E just an hour after I had first arrived, the courtyard was an oasis of calm, the crowd had dispersed and the resus was being cleaned.  A medical patient that had collapsed on his return from the bathroom in the middle of the trauma was now safely back in bed and appeared comfortable.

The new A&E department had only been open a week at this stage and I felt proud of the way that the team, nurses especially, had dealt with such a major incident.  The nurses staffing resus are medical nurses and not trained in severe injury management, but they demonstrated that using basic life-saving principles can make a real difference to patient outcome.  I added relatively little to the proceedings and felt confident that the staff would have performed just as well with a similar outcome had I not been present.  This is the aim of what we are trying to achieve and it has taken a lot of hard work by many people to get to this point.  It may be harder still to maintain.

Triage Nurse Samuel

I felt a mixture of emotions; satisfaction that the systems work with tangible results but a profound sorrow for those families that have unexpectedly lost loved ones today.  Trauma is a preventable disease, it is responsible for too much death and disability here and I feel strongly about trying to improve this situation, even if this contribution is on a small scale.  The next phase in the A&E redevelopment is to re-open the trauma ward and begin trauma training, working with the surgical consultants and senior nurses at the hospital.  Having a trauma receiving unit is only one part of the system; emergency surgery capability, blood availability, rehab, data collection and a functional pre-hospital service are just a few other aspects that spring immediately to mind that will need strengthening over time.  Changes at a population level will require funding, political will, legislation change and enforcement of regulations.  From my experiences, ensuring that motorbike riders start wearing helmets again would be a reasonable place to start.



An accident waiting to happen?