Words by Darren Hodge
Here at The Shift Extension, we exist to assist paramedics write, publish and share their experiences. From first time writers to published authors. Today we feel both fortunate and grateful to have MICA Darren Hodge share a full chapter from his published book. Our careers shape our experiences, and the more we can share, the more we can learn. With much appreciation to Darren, please enjoy, this chapter.
In 2012 I was working with two of my favourite crewmates, pilot Pete Elliott and crewman Bill Smits, when we were sent to a country road east of Melbourne where a truck had left the road and bumped down an embankment into a big tree. This type of accident is common, but the information coming to us from the paramedics at the scene suggested uncommon problems. The truck was on a steep incline and had almost rolled. The paramedics felt the truck was at risk of rolling over, and thus it was unsafe to work in, on or around it. They suggested we bring our harnesses. I had never had to wear my harness to access a patient before.
We landed in a farm some distance from the scene, and were picked up by MICA paramedic Duncan Rooney, who had assumed the scene commander role. That too was unusual: why would the most senior clinician leave the scene? Duncan briefed us on the drive there. The only thing holding the truck was the big gum tree embedded in the cabin where the sole occupant was well and truly trapped. And it could roll.
At the scene, the gradient of the slope was a big problem. Walking back up the hill to higher ground and the road was almost impossible. Multiple emergency services were there, and they had laid ladders on the ground with rope lines for access. One member of a particular emergency service, despite repeated requests to him and his superior officers to cease, was placing himself at risk around the truck. I’ll call the elderly emergency service worker ‘Joe’. To secure the vehicle, a heavy-duty tow truck had been summoned and was then about 20 minutes away. The accident scene was disjointed. Each emergency service’s contingent stood in their own group. There was no obvious interaction going on, as you would expect. We picked our way down the embankment. The truck was beyond 45° to the slope. Aside from the dangers, just standing around the vehicle was difficult. The driver’s upper body was partially hanging out his side window, trapped by both his lower legs. He was conscious, described his pain as ‘tolerable’ and, despite his predicament, was in good spirits.
To access the patient meant staff would have to be downhill of the truck, in its path if the tree gave way. I agreed with Duncan’s appraisal of the scene: deadset dangerous. I voiced my agreement: ‘We should wait for the tow truck.’ Joe, standing under the precarious truck again, said, ‘Bullshit. The truck won’t move, it’s safe as a church. Why don’t you just get on with your bloody jobs? Look, what you need to do is get two large cranes here, lift the bloody truck back up to the road and get the bugger out.’
His raw aggression left me speechless, something that doesn’t often happen. There are times when you know you can have a reasonable discussion with someone, and there are times when you know you cannot. Joe was in the latter category. I went back up to the road to talk with the emergency service commander and form rescue plans. I introduced myself, aired my concerns, told him what Duncan and I thought, and asked him to get Joe to pull his head in. The commander agreed with our view, but Joe would not listen to him or anyone else. We elected to move on and plan our rescue. The plan was to secure the vehicle with the tow truck and access the patient through the front window and breach the rear cabin one. To get into the front window area I would need an extension ladder and access the driver in harness with a rope attached to it. But the tow truck, which had not arrived though more than 20 minutes had elapsed, took a lot longer than expected. Meantime, Joe was chatting to the patient and was becoming distressed by our lack of action.
When the tow truck did arrive, we went about securing the patient’s vehicle. By the time we were ready to access the patient, Joe was more than a little grumpy. He gave me a blast as I made my way to the front of the cabin, including how his immeasurable experience meant we should have cranes etcetera. This time we exchanged harsh words. His peers growled at him to behave. I threatened to have him removed, and I should have simply done it, but he promised to pipe down.
I made my way into the cabin and met our patient. Despite his predicament, the young man was quick to make jokes about his imminent demise. The patient was alert and complained of moderate pain to his left arm, which was obviously fractured. His legs were spread apart and both legs were independently trapped in the wreckage. Momentum on impact had propelled him out the driver’s side window — he would have been ejected from the cabin if his legs had not trapped him. Half his torso was out the side window. The position of the vehicle was such that he would have fallen 6 or 7 metres should his legs be freed. The left leg appeared the most challenging. It disappeared into the floor of the truck just below the knee. Examination by sense of touch where the leg disappeared into the void suggested it was fractured below the knee, twisted to a 90° angle and partially amputated. The leg was wrapped around the gum tree, a trunk as thick as a man is tall, that had invaded the front of the flat nose truck cabin by over a metre. His right leg had fallen down beside the seat and was trapped by the heavily damaged driver’s door. This, I knew then, was going to be tricky.
In an attempt to provide some support to our patient, we fitted our winching strop around his torso and ran a line through the cabin, out the passenger window and secured it to another tree.
I passed on my observations to the team of rescuers, then handed over my pager and phone to Duncan who would be the communication conduit to ambulance and air ambulance. As we briefed the team on our action plan, emergency service personnel focussed on breaching the rear of the cabin while I focused on treating our patient. A monitor was applied, a collar fitted and a small dose of narcotics given. His obs — blood pressure, pulse, oxygen levels, breathing, temperature — were stable and
his injuries, with the exception of his broken arm, seemed to be restricted to his legs. The patient was a lovely young man. He repeatedly took full responsibility for the accident. ‘Don’t cut my legs off,’ he said with a grin.
‘Tiger, I have never cut someone’s legs off before, so I am
not planning on that today.’
While treating our patient I twice had to stop emergency service workers in a very short space of time from using dangerous tools without advising us. Despite my pleas we were not working together. I looked up to see the huge jaws of a cutting shear inches from our patient’s head. I called a stop and asked to speak to the relevant emergency services commander. Duncan and I explained our concerns and asked for the crew’s best rescue operator. We were presented with a man who took responsibility to oversee the rescue. I appointed a paramedic to the role of safety officer. I handed patient management responsibilities to a MICA paramedic. After an assessment by our new rescue supervisor, we identified the need for a coordinated approach to try to free the left leg.
The space in which we were working was tight. Various rescue tools often had to operate dangerously close to the patient. I was fortunate enough to have untaken urban search and rescue training, and I am comfortable with the use of hydraulic rescue tools similar to that being used in this setting. The man appointed by his superior was an absolute superstar: he guided his workers on various tasks while he and I tackled freeing the patient’s left leg. To access the area where the leg was trapped meant I had to straddle the patient, put one foot either side of him on the window’s sill and lean my torso on the deformed steering wheel. The work area was so compressed that, for hours, the two of us guided the jaws of the various tools to within millimetres of the patient’s flesh. Our emergency services expert operated the hydraulics through the rear truck window while he stood on the truck’s flatbed which sat at an angle of 50°. Quite a challenge for all.
Hours passed. Our lack of progress became alarming. I discussed this with Duncan and my emergency services co-worker. We asked the rescuers to see if they could access the cabin from below or from the front, find some room to manoeuvre. More intense cutting, spreading and ramming followed. But we were no closer to freeing the leg than we were when we started. We stopped for a moment to reassess.
Duncan and I for the first time discussed the notion of a getting a surgical team to remove the leg. This has never happened before in Ambulance Victoria’s history. I felt that we would be far better to have had the discussion earlier, as it would take time to arrange a suitable team and get them over. But, then, I was still of the belief that we could free the leg ourselves. If we needed to cancel the surgeons, no great loss. What we could not do was wait another three hours and then make the request. I asked Duncan to contact the doctor retrieval service that is managed by the ambulance service and have them send a surgical team.
We continued to attack the truck floor without success. As the minutes passed, my patient began to sense the dire nature of our pitiful progress. Leaning on the steering wheel, straddling him, I kept reassuring him we were doing our best. The guy was big hearted: he began to reassure me! He said it was all his own fault and raised the notion Duncan and I had talked about, of removing his leg. A difficult conversation followed. I said that we had a surgeon coming, on the way here as we spoke, ‘just in case’. I promised we would keep working to free the leg. He looked me in the eye. ‘If it needs to be removed, then just do it.’ As he said it, the noise of the machines went quiet. We stared at each other.
I was driven to try harder. We rallied, all of us. Every possible solution was discussed, investigated and evaluated. Some were implemented, but nothing worked. After all the effort we had put in, it had made no impact on what was trapping the patient’s leg. I was still able to squeeze my fingers into the void below the floor, repeating my assessment of the lower leg, half hoping I had got it wrong before. The leg was definitely bent at an unnatural angle, the bones in the leg were definitely, clearly fractured and I could feel where it was partially amputated. At the back of my mind was the potential complication that develops when a patient’s body parts are compressed for long periods. The tissues build up a toxin and, when the compressive force is released, those toxins are released and can kill.
My fatigue grew. It was warm. Physical work without result took its toll. Hours of leaning on the steering wheel straddling the patient meant my legs shook and cramped up. I was soaked in sweat.
Our model patient till that point had little analgesia until I stood on his fractured arm. ‘Ouch!’
‘I am so sorry.’
As the clock ticked by, the floor that we had tried to cut, spread, shear and ram looked no different to when we started. Our patient told me, ‘Cut off the leg.’ He held my gaze.
‘It’s OK, mate.’
As I heard the roar of an inbound helicopter, I stopped working, we all did.
I exchanged glances with all the emergency services workers in the immediate area. They had worked their backsides off for many hours without a break. My emergency services counterpart did not leave that truck for a second. His guidance and support were exemplary.
I looked our patient in the eye: ‘Look, we have tried to come in under the truck, through the engine bay, through the cabin, and we haven’t been able to free your leg. That helicopter that’s just landed has a surgeon on board.’ He looked at me. He looked at my emergency services counterpart. He looked at all of us who could see. ‘Just do it.’
The first person out of the helicopter I saw was a police observer. That was odd. Where was the MICA Flight Paramedic? What I really wanted was a colleague who would put an eye over the scene, feel the void perhaps, and take over. The helicopter’s crewman approached the truck and said he had a surgeon from the Alfred Hospital and a junior doctor from the ambulance retrieval service with him. No MFP meant I would not get any relief. I felt let down.
The surgeon, a widely respected trauma specialist, arrived in surgical scrubs and crocs, not ideal given the situation. She was quickly kitted out in SES overalls and boots. Both doctors were given a brief, site inspection and an introduction to the patient. We decided to anaesthetise the patient in the truck and amputate at the point where the leg was fractured. Anaesthetising people in vehicles is not an uncommon practice for paramedics, but it is for doctors.
To gain access to the patient’s head we needed to approach him from the lower side of the embankment. Large extension ladders were secured to the truck cabin and all the hardware required for the procedure was cable tied to the truck. I made the event a teaching opportunity for the junior retrieval doctor, and she hung on every word.
We climbed the ladders and had a final word with the patient who was resigned to his fate. ‘Hurry up and put me to sleep.’ The patient went to sleep, his airway was secured, the registrar doctor performed well and assumed responsibility for the patient’s breathing. The surgeon was brought into the cabin and the leg prepared, which took a relatively long time. The physical separation of the lower limb took only seconds, as the incision was in line with the fractured bones and the partial amputation from the accident. The stump was packaged. Then we moved to the right leg. It of course remained trapped by the driver’s door and was all that was holding the patient in place now. I expected this part of the rescue to go quickly. It did not.
We focused on the driver’s door, prised it open. I was shocked to learn that the right lower leg curled in to the cabin floor. Not again. Joe, who I had forgotten about, once again told everyone that we should ‘get cranes and lift the truck up to the road’. This time I never had the chance to say a word; his colleagues put him in his place. It took us about 20 nervous minutes to free the right leg. The patient, precariously positioned 10 metres in the air, was very carefully loaded on a spine board and we began the delicate removal just as the rain began to pour. As we loaded the patient to a nearby ambulance for the short trip to the helicopter, my pilot, Pete, informed us that as the weather had deteriorated, we might not be able to fly to Melbourne. I felt like crying. What else, really, what else!
Nevertheless, we loaded into the helicopter. I sat in the aircraft’s chair, overwhelmed by exhaustion. The case had been running for more than eight hours. I had not eaten or passed urine in that time. The physical and mental demands seemed to hit me all at once. But, fortunately, we made it to Melbourne’s Alfred Hospital.
Entering the emergency department, we were met by a senior doctor from the hospital, one who also had a senior role with the ambulance retrieval service. He asked, ‘Why were you in such a hurry to cut off the leg?’ I was bewildered. A fact that seemed lost on some people is, they weren’t there.
The surgeon elected to stay at the scene to see if the lower limb could be retrieved. That, and because she was not a fan of flying. Multiple tow trucks were required to winch the truck back up the embankment. This move took hours and the cabin was half mashed in the process. My question to Joe and any other critic who wanted to crane or winch the truck up the hill is: can you absolutely guarantee me that the patient would not be further injured in the process? No, was the answer to that question every time it was raised. Duncan was on the scene during the truck recovery, and it was his view that to have left the patient in the truck move would have killed him.
My torso was extensively bruised by leaning on the steering wheel. In my 30-year ambulance career I have not been exposed to a more physically demanding case. This represented an extraordinary case in Ambulance Victoria: never before had we amputated a limb in such circumstances. My support network of colleagues and friends rallied around me. I was — and remain — grateful for their support. I heard nothing from my organization until the day I received a call from a manager. I was advised that they had received a call from the same senior doctor that met us at the Alfred. He has said the lower leg, which had arrived at the hospital later that day, was pristine: we had amputated a perfectly sound limb. I was devastated. How could this be? I had assessed the limb in the limited access I had, and I knew it was severely damaged. I was advised that I would need to meet with ambulance service legal representatives to prepare for possible litigation. That was one of the darkest days of my life. The following day I received another call. The same doctor had again called ambulance: the leg was in fact severely damaged. He had been confused by a different leg. This type of politics is a day-to-day proposition in my industry. I find it hard to comprehend that two amputated legs were transported to the same hospital on the same day, so to understand how or why this happened is baffling to me. One day, when I feel I can discuss this without bursting into tears, when I can remain professional, I would like to discuss this with that doctor.
Fallout continued. Duncan and I received criticism internally for not following the chain of command. We should have requested the surgical team through the appropriate department, not direct. I felt bad for Duncan because it was my request. I had a conversation in passing with a senior ambulance manager, and was once again left disappointed. He informed me that he felt he would have freed the limb, a comment he repeated during a formal internal debrief. I remain very disappointed by such comments. A multi-agency debrief was conducted, but I was not invited to participate. Perhaps the reason why was that Joe had written to the heads of several ambulance departments, and, I understand, to our CEO, and there was also a suggestion that his displeasure was expressed to other bodies. Among Joe’s many criticisms, one was that we did not support him and the patient when we waited for the tow truck. I accept that we should have had paramedics close by the patient at a safe distance providing reassurance as best possible, I accept that he felt abandoned by ambulance during this time. As for his other concerns, we will agree to disagree.
My pilot, Pete, went to the barber. As he waited for a chair he listened intently when a disgruntled man aired his concerns about the ambulance management of this case. It was not until he made a comment about the flight path of the outbound helicopter that Pete spoke and corrected the man.
‘How would you know?’ he was asked.
‘I was the pilot.’
I believe there was some further discussion about some of his earlier comments. Pete is a loyal friend. Pete lives in Joe’s part of the world. A few years later, Ambulance Victoria was involved in another infield surgical amputation. A young man struck by a train lost limbs and was critically injured. Paramedics found the patient at Death’s door. One of his legs was trapped under a train wheel. There was no way of lifting the train and there was not enough time available to get a surgical team there, so the paramedics consulted with senior medical personal, got permission, amputated the already partially amputated leg, and got the patient to hospital alive. Unfortunately, but not unexpectedly, he succumbed to his injuries. A large-scale debrief was arranged to discuss the case. At the time I was totally unaware of this second amputation or the debrief until an attendee, who I barely knew, called me to say another attendee had made reference to my case in historical terms. The caller had been a part of some review over that case’s management too. The attendee who raised the subject of my case had said the only question was if the amputation was in fact necessary. This comment left me lost for words, like I had been kicked in the guts.
I had lived in fear over intervening years that one of the people making uninformed comments about my case may cross paths with the patient. The thought that my patient may think that all avenues were not exhausted before the decision to amputate was made was devastating to me.
After the phone call I could not put this job out of my mind. That day I drove to work, the two-hour trip a blur, feeling physically ill. I simply could not stop thinking about the job. I ran through every element, every decision. During my nightshift I was tasked on an inter-hospital transfer, and I welcomed the distraction. The transfer was relatively straightforward thankfully, as my performance was similar to a person on their first shift. I could not sleep. I was unravelling. For the first time in 30 years I felt mentally unable to perform my job, a frightening feeling and an upsetting prospect in itself. I took some time off, but struggled to find anything positive to do. Things that I normally enjoyed were unpalatable.
I was frightened where this was taking me. There was a period when I felt I had worked my last shift in ambulance. I was terrified when I wondered if I was following a well-worn path to a severe psychological injury, which compounded my distress. Family and colleagues supported me. Ambulance Victoria provided counsellors, who provided tools for healing, making me a strong advocate for counsellors to anyone who finds themselves in a place like I was in then.
In the entire washup since the truck driver was hospitalised, I had never been asked to present my case in its entirety, to anyone. The only debrief that I participated in discussed the failure of our communication with an internal part of ambulance, an error to which I accept responsibility, but as far as patient care, the main event, the above error was irrelevant.
Whether I asked one department or another department for a surgeon is not important; what was important is that we had a surgeon attend. To know that this case created much discussion among various bodies within ambulance is understandable. Amputation is rare. I am happy for people to have a view on this case that differs from mine. I am an advocate for review. However, it is completely unacceptable for people to verbalise their opinions in the absence of the facts. I was fortunate. I only needed a few weeks to get myself sorted. The most interesting lesson from the counselling sessions was that the key source of trauma was not the actual case, or its management, but the sense of abandonment I felt from the ambulance service.
Now, I feel differently. My defences to some of the demands a paramedic faces have been reduced. I am more vulnerable, but I know it. Six months later a phone call came out of the blue: I had been nominated for a commendation over the clinical management of the case. Because I had not participated in any clinical review, I informed the caller that I did not wish to receive any commendation.
The most positive action I took was to go back and discuss the case with Duncan and some of my most respected mentors. If I should ever cross paths with the patient, I can look him in the eye and tell him hand on heart there was nothing more that we could have done, despite anything he might have heard. That’s the Big Thing.
This chapter has been published with permission.