When Foundation Year 2 trainee Graeme Nicol came on the scene of a road traffic accident he was able to provide vital treatment for an injured motorcyclist.
‘It felt strange to be dealing with such a traumatic incident away from a hospital, but I was lucky to have had the training to deal with it’Driving home one evening, after a late shift as an FY2 in paediatrics, I came across a motorcyclist lying on the road. I could quickly see he was conscious, yet in a lot of pain, and my eyes couldn’t help but be drawn to a pool of blood and bodily fluids around his midsection. Most noticeable was that his left ankle was severely damaged. Whilst convincing him to lie still, I asked a fellow passer-by to stabilise his head and neck whilst I assessed and covered him as he began to lose heat through his exposed skin. I then supported his foot to stop the weight of his boot deforming the ankle further. After that, nothing more could be done until the ambulance arrived, so the 15-minute wait felt like an eternity.
Once paramedics arrived, and analgesia was administered, the injured motorcyclist’s helmet was removed and a neck brace was attached. This simple act was a huge relief. Cutting his boot off revealed an open fracture dislocation of his ankle. It was everted by 90 degrees, displaced laterally and had impacted by around 2 inches with the distal fibula protruded through the skin by approximately one centimetre. The skin over the distal end of the tibia appeared extremely taught and looked as if it was going to break. Most worrying was the white mottled appearance of the foot, from which I could feel no pulse.
I recalled experience from my FY2 post in trauma and orthopaedics, and felt an overwhelming urge to improve the position of the foot so instructed the paramedic to hold his leg whilst I applied traction. Once out to length, I then applied pressure to the lateral border of the foot whilst stabilising the medial malleolus. The ankle fracture appeared very displaced and, together with the patient not being fully relaxed, made it extremely difficult to get it reduced. A brace had to be applied immediately as once in position it simply slipped back out. Fortunately, the pulse and colour quickly returned.
On removal of his other boot, which had appeared normal, we found this foot was also dislocated. This time, inverted by 90 degrees but again mottled and pulseless. Fortunately, this went in with a definite clunk. We were then able to log role him, this revealed he had complete de-gloving from his scrotal region to the lumbar region of his back. Knowing nothing could be done at the side of the road, he was put on a spinal board and loaded into the ambulance.
It felt strange to be dealing with such a traumatic incident away from a hospital but I was lucky to have had the training to deal with it. I don’t know if I would have been able to handle it two years ago before starting my foundation years and, especially, before I had done my orthopaedic rotation, and the incident has furthered my interest in trauma and orthopaedic surgery.
The patient required a defunctioning colostomy and underwent skin grafting to cover the area of de-gloving. His left ankle was treated with external fixation and might need to be fused at a later date. His right ankle was treated in POP cast. No injury was sustained to his head or spine.
Graeme Nicol, FY2 in Dundee