Survival Seconds

"He's been stabbed!  He's been stabbed!"

"Where is he?"

"Quick, now, get through there, now, please, quick, it's my boy, oh Jesus..."

This is the welcome to the Ambulance Service crew when they arrived at a scene of domestic dispute.  They are one floor up in a tenement building in Edinburgh, and are trying to work out what is going on.  There is panic, blood, noise, and no short amount of conflicting information.

They find the patient streaked and lying in his own blood.  He looks deathly pale, is barely responsive, and despite all the distracting fracas that surrounds them, they remain professionally focussed on assessing the young man in front of them.  Most notably, they find a wound to the front of the man's left chest, and a long-bladed kitchen knife lying discarded in incriminating proximity. 

The natural tendency with these 3 factors present - very unwell patient, wound to chest, and weapon capable of reaching life-preserving structures - is to try and improve the patient to enable to allow a safer transfer to a hospital.  However, this is a fatal strategy to follow, and our Ambulance Service colleagues know this.

There is a very good chance that this man will have injuries to his lungs, causing them to collapse and potentially obstruct blood flowing back to his heart.  There is also a good chance that he may be bleeding to death from a tear to a major blood vessel in his chest.  Equally concerning is the possibility that he could have suffered a cut through his heart muscle.  This can cause the heart to leak blood into its surrounding capsule, which in turn compresses the heart with every heart beat so that in a matter of minutes the heart is unable to pump any blood at all.  All of these situations can bring death very rapidly.

Time is marching on, and the Ambulance crew are battling to get him out of the flat, past understandably hysterical family members.  With extraordinary powers of negotiation and focus, they manage to move the patient within a few minutes down into their ambulance vehicle.

On the way down the stairs, however, our patient has become less responsive, and his pulse is barely felt.  His breathing is shallow and irregular, and he looks ghostly white.  We are losing him.

 They are less than 10 minutes from the Royal Infirmary, and the best therapy for this man's condition is liberal use of diesel fuel.  They step on it, whilst somehow getting an intravenous drip in his arm, giving him some IV fluid to support his circulation, and ensuring the pressure in the left side of his chest cavity is not dangerously high by decompressing his chest with a cannula through his chest wall.

Just as importantly, they are able to radio ahead to pre-alert the team standing by in the Emergency Department as to the exact situation.  This enables the team to prepare equipment, as well as mentally and emotionally, for what is likely to be a rapid simultaneous deployment of interventions to try and save this man's life.

By the time he arrives in the Emergency Department, he is in cardiac arrest.  His heart is trying to beat, but there is no pulse being produced.  This is one of those very rare situations where chest compressions may be less helpful than in any other situation where patients collapse into cardiac arrest.  This is not a problem with the blood flow through the coronary arteries, but a lack of blood at all, or a compression of the heart so that it is unable to pump.

Now we are fighting against the tide, and every second is counting against this man's chances. 

The Ambulance team and the Emergency Department team join forces: the paramedics are deployed to ensure our patient is breathing via a tube inserted into his windpipe, whilst one of my Emergency Department consultant colleagues makes a large incision round and across the chest to access the heart. 

Within a couple of minutes of arrival, the heart is in plain view in the resuscitation room.  The team can see the dark red and purple appearance of blood through the capsule of the heart, which is compressing and obstructing its normal ability to pump.  They rapidly open the capsule and squeeze out all the jelly-like blood.  At the same time, other members of the team are infusing blood rapidly through the cannula in the patient's vein, treatments to slow down severe bleeding are being given, as well as adrenaline to try and support the circulation.

The heart is massaged to attempt to stimulate its own natural pumping action, and at this point, the degree of heart muscle damage from the knife becomes evident.  The front surface of the heart looks very badly torn and blood is oozing and leaking from multiple sites.

We continue to compress the heart to attempt to restart it, but now we and our patient are at the mercy of the state of the heart and the brain having had these dreadful injuries, and having been starved of oxygen and blood for way longer than nature intended.

Ultimately, it did prove too much.  Our young man died from his injuries, a (fortunately uncommon) fatality from violent acts.  These events are tragic on so many levels, and prevention remains one of the most effective means of reducing them.  With this in mind, we have recently welcomed our colleagues from Police Scotland's Violence Reduction Unit, our Navigators, who act as extremely skilled providers of support for victims and perpetrators of violence in the ED at the Royal Infirmary of Edinburgh (following on from their great work in the Glasgow Royal Infirmary).  We are striving to continually improve our ability to treat these injuries, but we would rather see fewer and fewer of them.  So look out for our "guys in pink" - they are here to help.