Trapped in Darkness - Part 2

continued.....

"Male, U/K age, One Under"

Until now, I had been totally patient focused and hadn't noticed the commotion around me! There were about 6 Fire fighters under the train too with various member of underground staff trying to work out how to lift up the train. I'm guessing by the discussions that it isn't something that is done too often! In most One Unders they are either a) dead, in which case the train is driven off them or b) alive but trapped by a limb, in which case if a quick extraction is needed an amputation and dragging out will happen. Unfortunately, they couldn't drive off as it was his pelvis on the track and you can't amputate a pelvis for obvious reasons!

As minutes ticked by we got drugs flowing! In went morphine and ketamine and fluids. We cut of as much of his clothing as possible to examine what we could get to. There were minor cuts and abrasions but nothing major. All the while, the patient was getting more and more frantic so more and more drugs were given to numb the pain and relax him. Problem was there was no real access to his head. He couldn't see anything but  darkness and could only hear and feel what was going on, and for someone who is claustrophobic I imagine it was torture. I was starting to get very uncomfortable my self, the heat, the smell, the noise, the taste of air, it all made it a very uncomfortable atmosphere. Add to that the fact that realistically the patient could simply die and we would be powerless to do CPR, ventilate and remove quickly. It was a scary thought! 

"Sorry we're all talking about you. How are you doing?"

"Get me out of here"

"We are, it will just take a little while, I'm staying here right by you, if you feel any new pains or anything changes, please tell me."

"Get me out of here"

"We will, we will."

"Please, help me, I don't want to die" he cried.

Talking to someone who can't see you is bizarre. I could only imagine his facial expressions and the fear painted across his soot covered face. I felt totally helpless in all honesty. I tried to keep him positive but as the pain continued and the time went on and on he became more anxious. To be fair, so did I. 

Eventually, after about an hour they were ready to lift. I don't credit the fire service that often but credit where credit is due. They had been fantastic. The were working their nuts off, bringing us more oxygen, providing light and lifting 120 tons of train up! It wasn't a case of 1-2-3 lift! So, in a co-ordinated effort and a very detailed plan, the scoop was lowered down to the tracks and slid along, rope on 1 end. The pelvic splint was positioned and as many hands as could fit were placed on various parts of the patient. We are all told to stay away from the wheels as if the train drops we don't want to get trapped! 'Drops?' 'DROPS?' Encouraging! 

"OK, we are lifting......"

"He's free. Lower him down"

"We got him"

He let out a gut wrenching scream. Once on the scoop he vanished. Pulled the along the suicide pit and out onto the platform where the HEMS paramedic and my crew mate would take over while we crawled out. I shuffled backwards slowly, eventually making it to the platform where the light and underground breeze could be felt. The platform was full. Police everywhere, about 30 fireman, a few ambulance officers, a second crew and of course......HART team huddled together watching! The patient was being strapped up and wrapped in bubble wrap. Blood infusions were being prepared and he was being put to sleep by HEMS. I bet he wished he'd been asleep a long time ago. 

Within only 2-3 minutes we were ready to go. I took over the breathing for the patient and 8 fireman lifted him up and off we went through the maze of tunnels and escalators. FRESH AIR! Oh how I missed it. Behind us was the band of merry men and woman carrying all the kit. Everything was chucked on board, blue call placed and off we went. I was trying to take stock of everything that was going on. Suddenly, the doors swung open, we were at hospital, I hadn't even noticed we'd stopped. Into resus we went, a 30 strong team waiting for us. Luckily for me HEMS did the handover. I'd have probably starred blankly and said 'Hit by a train...erm...'!

We went back to the vehicle which  looked like a bomb had exploded inside. We tidied up and I started on the paperwork. Where the hell did that job come from! It really is true, EMS Rule number 10:

EMS is extended periods of boredom, interrupted by occasional moments of sheer terror.

Nothing can prepare you for things like this. It isn't for everyone. It is one of the few jobs that tests every part of you. The problem is you never find out if you passed the test. As all crews will say, he was alive when we got him to hospital so that's a win for us. It's a cover though. In reality, we are all desperate to know if he survived. We will probably never know. That's the reality of pre-hospital care....once you're at the hospital, your care is supposed to end. 

 My crew mate pointed at my face...

"You got a bit of dirt on your cheek!"

Trapped in Darkness

As far as shifts go, it hadn't been a bad one. I hadn't been spat at, sworn at, I hadn't had to carry anyone and no one had wound me up enough to change my mood! That's not to say that anyone actually needed an ambulance. The mere fact everyone had walked on and walked off meant that in reality, no one actually needed an ambulance but that's by the by! It was late in the evening, we reckoned that we had about two jobs left to do to see us off, so made ourselves available. We were a fair way away from station so we started heading in the right direction as fast as possible (within the legal speed limit of course!). We didn't get very far at all! Within about 5 seconds.....

"Male, U/K age, One Under"

Action stations. We were only 2 miles away so there was a good chance we'd be first there. While my crew mate drove like a bat out of hell I dived into the back to get the hi-vis on and safety helmets out the top locker. Back in the front and...

"UPDATE: Patient is screaming, injuries, unknown"

....we started to get a plan. Once we had confirmation power was of and track protectors were in place, I would get under the train and assess, crew mate pass staff and liaise with fire brigade and train staff. I began stuffing my pockets with stuff I might need; gloves, tape, torch, cannulas, bandages and a tourniquet.

"UPDATE: HEMS on way. Eta 8 minutes"

Right, that should give us just enough time foe me to get under before HEMS take over and we are sidelines! (Trust me, totally happens!). We pulled up at the station to see we'd been beaten by the Fire service and Police.

"UPDATE: HART team on way"

They can bugger right off! HART or Hazardous Area Response Team is by far the biggest waste of money the service has ever had. Always late to any incident in their fancy suits and equipment and they just sit and watch the fire service. They have lots of fancy kit that they never use and it's a classic old boys network full of wannabe firefighters. I predicted they will be stood on the platform on mass.....watching at some point during this job! 

We were indeed the first medical staff to arrive so we needed to carry everything! Luckily some 'water fairies' were on hand to help. We took paramedic bag, response bag, oxygen bag, Life pack, dressings pack. suction, scoop, head blocks, entonox, straps and blankets! The problem with underground stations is some are very very very deep and going back for kit isn't really an option if you need something quickly. We made our way down, and down, and down to the platform. The fire service were on the tracks and doing a good job of talking to the patient. I jumped down to have a look and there he was. In one piece, very much alive and trapped. What was bizarre was that he wasn't trapped or tangled by a limb, which is common. He was trapped by his pelvis between the train and one of the tracks, on his side!

Now, there are no text books telling you what to do, no algorithm, no guidelines, nothing. It was going to be a case of improvise, adapt and overcome. Under I went. Blimey! I forgot how hot it is under trains! And dirty! By the time I got to him my hands were black. He was very much conscious and there was no obvious blood! Always a good sign! He was however in a lot pain from his pelvis and was obviously very panicked. He hadn't jumped. He was drunk and had tripped and was hit trying to clamber out and by all accounts the train had nearly stopped at impact. Via a gap between the platform and train, a hand appeared holding an oxygen mask. I popped it on the patient and then a blood pressure cuff followed. With a bit of a stretch I got it on his arm. All the numbers were relayed back to me. His blood pressure was a little low but if he had a fractured pelvis he could easily bleed out into that and it would only get lower. 

OK, a plan......erm......

"How are we getting him out?" I said hopefully.

"We are going to jack the train up off of him and slide him out." 

No idea who I was talking to!

"How long?"

"Half an hour. 45 minutes maybe."

"Is that the only timescale we have? If he has to come out quick to we have other options?"

"Afraid not"

That's was a long time as far as I was concerned but it wasn't as if he could just be dragged out! He was well and truly wedged! I stuck an orange cannula in the back of his hand as that was the only part of him I could get purchase on. Thank god for big veins! I wanted to give morphine but in the circumstances I felt a grown up should be consulted first. Luckily, as I fixed the cannula down a head torch appeared. It was the HEMS Doctor! 

"You look like a chimney sweep."

Oh goody.....a mascara joke! 

TO BE CONTINUED........

Failed by the system........

"43 year old male, brain injury, feeling suicidal"

I have very little empathy for most of our regular callers, normally it is an attention thing or poor management of a chronic illness. I had similar feelings for Mr Smith but after the first 10 or so meetings I realised he needed empathy, and he needed help. Mr Smith called a lot of ambulances. Sometimes as many as 5 a day. More often than not he went the 600 yards to hospital but sometimes he stayed at home. Mr Smith suffered from schizophrenia which is a mental disorder characterised by a breakdown of thought processes and by poor emotional responsiveness. It most commonly manifests itself as auditory hallucinations, paranoid or bizarre delusions, or disorganised speech and thinking, and it is accompanied by significant social or occupational dysfunction. I believe he also had some learning difficulties. His usual complaint was feeling suicidal, stating he wanted to jump in front of a train. He claimed he had had a traumatic brain injury aged 11 but there was never any evidence to suggest this. Every attendance to him followed a similar pattern. We took him to hospital, the nurse sent him to the waiting room and he walked home where he would then call another ambulance. You can see the cycle.

Regular callers are very frustrating. It's a waste of resource and when they are so prolific in their calling the expense is huge. In one calendar year Mr Smith had 478 ambulances at a cost of over £250000 to the ambulance service. Unfortunately this is a bi-product of the system we are in. As previously discussed the care pathways for mental health patients are poor at best. The nearest mental health unit to Mr Smith knew him well but wouldn't allow us to convey him to them without him being assessed in A & E first. On the rare occasions where he did stay in hospital long enough to be assessed, the unit would discharge him to be 'treated at home'. The problem with mental health in A & E is that there are not only very few staff trained to assess him but there is usually a very long wait. Certain nurses knew if they left him for long enough he would just leave. To be honest, myself included, no one really took his threats of suicide seriously. He didn't seem the type. There was no history of self harm and he'd been threatening it for so many years it didn't seem likely. Regardless, he wasn't getting the treatment he desired or needed. He was being let down by the system in a never ending loop of hospital admissions and self discharges and no one who could buck the trend was willing to do so.

It's a far too familiar sight with mental health. No one wants to know. Even the mental health units generally are not interested. They certainly aren't helpful. They make admitting a patient as hard as possible for us and the police. They have so many rules and conditions that must be met before they'll consider even laying eyes on a patient. Because of this the cycle continues. If i'm honest I didn't really know what Mr Smith wanted. He never really said. I tried talking to him, I tried referring him onto every service I could. I filled out frequent caller referrals, vulnerable adult forms and flagged his address. I tried to argue on his behalf to immediate assessment in A & E but everyone has their priorities and he was never going to be one of them. He only ever called from his home. He was never rude, always polite and therefore never had anything to do with the police. The police have more powers than us and can be very useful with mental health and enforcing assessments but this was an avenue which was never open to us. He always agreed to go voluntarily and as such, was never in a position to be held against his will. Unfortunately about 4 months ago a crew not familiar with Mr Smith attended his home. I imagine he told them the usual and he was taken to the hospital. Once at hospital the nurse sent him to the waiting room. 20 minutes later he walked out. 20 minutes after that the following call was sent to a local crew.

"'One under', male jumped in front of Intercity train. ? Life status"

Like he always claimed he would, Mr Smith jumped under a train. From what I have heard he would have died instantly. The train was travelling in excess of 90mph, he didn't stand a chance. Or did he? He had a chance twice on that particular day. Twice he was taken to hospital and twice he was ignored. I suppose it was only a matter of time before he did it. He'd been let down by the system that is there to help him, and he was let down because he was submissive. He didn't complain about lack of treatment. He never raised his voice. He just quietly walked away unnoticed every single time. The cynic in me would say that now he is dead, that is a huge financial burden lifted and it's what he wanted. In reality, I felt crap. He didn't need to die, he needed treatment and help but it was treatment and help I wasn't able to provide. It was treatment and help 'the system' wouldn't allow him to have. I'd like to say that would be little consolation for his family and friends but he didn't have any. All he had was us and we failed him.

One under

"42 year old male, jumped in front of train"

Alarm bells ring. This is not a job even the most enthusiastic of trauma junkies particularly enjoy. A 'one under' is a term used to describe the rather unfortunate situation of a person under a train. This unfortunate situation occurs through either accident or suicide but more often than not, its sadly the latter. In almost 50% of 'one unders' the result is a fatality. This number is much lower than I had suspected it would be. I was expecting mortality to be in the 90s. After all, the human body is not designed to cope with the trauma, of the best part of two hundred tons of train, hitting it at a speed of 30mph. Over the past 10 years in the city there have been 568 'one unders' of which 261 have been fatal. That's over 1 a week. 

Today we had about 2.5 miles to drive. Just enough time to get a game plan and remember what we need to do. Hi-vis's donned, safety helmet on and as much kit as we could carry including all our response bags, paramedic bag, rescue board, collars and pockets stuffed full of everything we might need under a train. We were met at the RVP by the Rail Incident Officer (RIO) and confirmed we had 'power off, trains stopped'. Short circuit devises were in place on the tracks and it was a confirmed 'one under' suicide attempt. 

This was a deep station, a very long way underground, therefore it took a good few minutes to get down there along the maze of corridors and plethora of escalators. It also meant there was a high chance we would be incommunicado and would have to rely on station staff relaying messages to our control. We got to the platform, the train was three carriages out of the tunnel.  There was an ominous spreading of blood on the front of the train. The 'jumper' had jumped when the train entered the station. Doing so at this end of the platform signifies much more intent on suicide and a decreased chance of survival. We climbed down onto the tracks and into a 'suicide pit'. These pits were introduced in the 1930's during the depression when suicide rates were extremely high. With the use of emergency lighting and torches we were able to see the motionless body, the length of a carriage away. He was just a silhouette against a back drop of track and train. 


I made my way towards him, staying as close to the floor as I could. The heat under the train was like nothing I have ever experienced. So intense. The sweat was dripping of my brow with every movement I made. I could here the commotion on the platform, I could hear creaking from the train as the cooling metal constricted but more than anything I could hear my own breath. It was an aery experience. I was also all too aware that I may come face to face with rats but I tried not to think about that! The closer I got to this guy the more evident it was that this was futile. I could see the pool of blood he was in, I could see he was missing a shoulder and arm and I could smell burnt flesh. I finally reached him. He was lifeless. There was massive cranial and thoracic destruction. He was partially entangled between the wheel and the track. His torso contorted to the point where I didn't really know what part was what. This guy had been successful in his suicide attempt. There was nothing anyone could do. I laid there, on my front, under a hot train, filthy, covered in blood, just staring. I wasn't upset, to be honest I don't know what I was but I just starred. What could possibly have happened in this guys life to lead him to such desperation? I just don't  understand the thought of killing oneself, and especially in such a public place in such a unreliable and disruptive way.  I can’t help thinking that if I was at the point of taking my own life I would not go and buy a ticket at a station and stand amongst the silent commuting throng waiting for the next southbound train to greet me.

I climbed back on to the platform. Removing him wasn't our job. We spent a little while with the driver. Luckily it appeared not to affect him. He had an air of apathy about the whole thing. If anything he saw it as a bonus. He'd get a few months off work so was perfectly happen with the outcome. Morbid? Heartless? Maybe its just a coping mechanism. Maybe he just doesn't care. By this time, the platform was swarming with masses of people. HEMS had arrived, the British Transport Police were there in large numbers as were the Fire Brigade. We made all the relevant smalltalk, regaling the crawl, taking the jokes about looking like a chimney sweep and grabbing call signs for our paperwork. We collected our kit and made an attempt to remove ourselves from the circus. As we got to the top of the first escalator a smartly dressed man approached us, 

“Did someone jump under the train?” 

I looked at the blood on trousers and hi-vis momentarily before assuring him that, yes, they have. He paused for a moment, looked at his watch and said, 

“So, how long before we get on the move again?”

I was to look back on this exchange with amusement and also, strangely, comfort: in the midst of the horror, normality was briefly restored by a commuter asking for alternative travel arrangements.