Code Red Induction

This week I have started a new job as a Surgical SpR in a Major Trauma Centre. I was assured by my service manager that I had be allocated a two week ‘shadowing’ period, as I am new to the hospital and therefore have no IT access, badge, any idea how the system works or any experience of working in a Major Trauma Centre. He then went on to say that unfortunately due to a rota gap, there would not actually be anyone to shadow and would I mind awfully holding the trauma bleep. I cannot say I was terribly surprised that, as in most new positions in the NHS, I would be starting very much in the deep end. Shortly after this less-than exhaustive induction, the trauma bleep went off for my very first Code Red trauma call. Time to start shadowing myself!

As I couldn’t find my way to the Resus Bay from within the hospital, I walked out of the hospital and came back in the patient entrance to A&E from the street. The patient was just being wheeled into Resus by the Air-ambulance doctor at the same time that someone swiped me in. The patient was a vehicle vs pedestrian who had been intubated and had bilateral thoracotomies performed on scene to decompress a tension pneumothorax. They had received one bag of blood and one of FFP in transit, and on arrival had no recordable blood pressure. Primary survey identified clinically broken ribs but no obvious source of haemodynamic shock. FAST scan was negative.

The blood pressure didn’t respond to two further units of blood pushed in by the Belmont, and I set about trying to get hold of the theatre coordination to tell them that we would be bypassing the CT scanner and coming straight to theatre. The Trauma Team Leader, an A&E Consultant, helpfully suggested that I consider asking the Cardiothoracic SpR to join me in theatre. A short faff then ensued whilst I worked out how the bleep system in this hospital worked. Eventually however I got through to the Cardiothoracic SpR, and he helpfully suggested that given the clinical picture, he would start with a thoracotomy. Unhelpfully he also said that he was currently in a different hospital and I would have to start without him. Bugger! It looked like I was on my own to perform my first ever thoracotomy (outside of a cadaveric lab or elective oesophagectomy).

At this point, the adrenaline started flowing somewhat. Turning back to the patient however, I was extremely relieved to discover that whilst I had been messing about inducting myself to the bleep system, the patient had actually been perked up a bit by a further two units of blood and FFP and was about to be wheeled off to the CT scanner. This turned out to be a real stay of execution, as the scan identified a number of injuries that would not have been fixed by my inexperienced cracking of the chest. These included an aortic dissection (equivalent to a DeBakey IIIa, starting at the ligamentum arteriosum), a Grade IV splenic injury, left flail chest, pelvic fracture and various vertebral fractures.

As her numbers had continued to improve with further blood products, with a sense of relief I followed her up to the hybrid theatre and watched the interventional radiologists insert a  TVAR to address her aortic dissection, in the process learning on which floor theatres are located on! Later, I reflected how in a few (albeit somewhat stressful) hours I had been rather more thoroughly inducted to my new job than all previous NHS corporate inductions. Now I just have to find where I can get coffee.

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