The EMS Diaries - Charlotte Didn't Say Anything
She didn't have to, we knew what had happened.
A call always started with a radio dispatch from Ambulance Control. A brief description of the incident, an address, and the time the incident was reported, was enough to get us on our way. The description was always a placeholder though; to be updated after we'd arrived on site and assessed the incident.
It usually takes 12 minutes to drive an ambulance from the Cape Town CBD to Table View, with the lights and sirens on. We made good time up the West Coast Road that Saturday afternoon. The gate to the single-storey residence was open, and we were greeted outside the front door by a wide-eyed, barefoot young boy. He directed us into the house, down a short hallway and through a bedroom door.
As we entered a tidy, nondescript room we found a small, teenaged girl perched upright on the edge of a neatly made bed. Against the wall stood a small dresser. A poster adorned the wall above the bed. A large man stood behind her, between the bed and the opposite wall. The teenager's arms were bandaged but fresh blood stained her jeans, t-shirt and the duvet she was sitting on. Not much blood, but enough for us to identify her as our patient. Her quick furtive glance in our direction indicated that she was Alert on the AVPU scale and that she was maintaining her own airway. Patient assessment starts as early as possible and continues throughout the call.
"Good afternoon, sir, miss, we're from Metro EMS. You called for an ambulance. How can we help?" I directed my introduction towards the teenager.
"She hurt herself," the man answered. His presence was bulky and jarring in the small room.
"Sir, please may I ask you to step over here, out of the way, there isn't much space in here." I needed him in the room as a witness, a guardian, and a possible source of information but I also wasn't sure yet if he was a danger to the patient or us.
With the man out of the way, I squatted down next to the teenager and pulled on a pair of gloves. My partner stood next to me, close enough to assist with the patient if it was needed, and close enough to prevent the man from interfering if he tried.
"Hello miss," I repeated. "I'm a paramedic. Do you mind if I try and help you," I asked, gently?
She didn't look up, but she nodded. Consent is implied with unconscious or unresponsive patients, or patients suspected of suffering from some form of mental impairment. For conscious patients though, medical treatment can only commence once the patient gives explicit, informed consent.
Touch is a thing too. In order to treat someone physically, you need to physically touch them. Many student medics, nurses, doctors, etc, moving from theory to practical, need to move from touching books, cadavers, and medical equipment to touching people, people who move, talk, laugh and cry. And for a patient, someone who is in pain, afraid and in distress, a stranger touching them, even to help, is unnerving, sometimes terrifying.
"Miss, I'm going to examine you now. First, I'm going to take your pulse. Is that okay with you?'
She nodded again. Mindful of her bloodied and bandaged arms I reached forwards and placed two fingers over her radial pulse. I relayed my findings aloud as I made them: tachycardia, weak radial pulse. To be expected given that haemorrhaging had clearly occurred.
"What is your name," I asked? I needed to gauge her mental state.
"It's Charlotte," the man answered from behind me. Not ideal. "I'm her uncle," he further offered.
"Charlotte. I am going to quickly listen to your breathing. Is that okay?" She nodded again and I loosened my stethoscope from around my neck and quickly assessed her breathing. "Lungs: apex and base, bilaterally clear," I informed my partner.
There's a framework for managing medical emergencies in the field. No two calls are ever the same, but a systematic approach to emergency medical calls, supported by evidence-based medical interventions, is key to providing life-saving treatment. I had not appreciated well enough the A, B, C's until I had applied them in a hundred different scenarios.
"Charlotte, can you tell me what happened?" I didn't really need to know exactly what had happened yet, but I wanted Charlotte to talk.
"She slipped in the hallway, and as she was trying to stop herself from falling, she accidentally broke a window and cut herself." The uncle answered for Charlotte again. "I can show you," he continued.
Both arms, I thought to myself? Doubtful.
"Charlotte, did you fall and cut yourself?" I looked at her. Charlotte pursed her lips but didn't say anything. "It's okay, you don't have to say anything if you don't want to." I reassured her. "I'm going to give you some fluids, intravenously. You probably have seen a 'drip' before. You've lost some blood and this will help." My partner was pulling a Ringers Lactate out of his bag. "May I do that," I asked Charlotte again? Charlotte nodded. "And I'm going to have a quick look under the bandages, is that okay too?" Charlotte nodded again. "Thank you, Charlotte."
I unwrapped the bandages and inspected the lacerations. Deep. Long. Straight, not ragged. Looked deliberate, not accidental, a blade, not glass. No active arterial bleed though. No sutures required onsite and fluid administration wouldn't be compromised. I packed the lacerations tightly, applied fresh bandages and started IV fluid administration.
"Charlotte, will you do a few quick tests for me?" She nodded. No apparent neurological issues but a slightly reduced grip structure in the left hand. "Charlotte, are you right-handed," I asked? She nodded. That was consistent with an initial right-hand cut. "We need to take you to the hospital to get those lacerations sewn up." I said to her.
Charlotte looked up at her uncle nervously.
"We'll go," he said.
Charlotte nodded.
"Thank you, Charlotte. My partner is going to get a stretcher from the ambulance and we'll get you on it."
"We can walk," her uncle said.
"Sir, you and I will walk. But Charlotte will go on the stretcher." We helped Charlotte onto the stretcher and wheeled her to the ambulance. My partner called in a sitrep to Ambulance Control and informed them that we would be transporting one patient to New Somerset Hospital. I sat in the back of the ambulance, periodically checking her vitals, as we drove back into town. I tried to get her to talk but she wouldn't say anything. Her uncle sat in the ambulance with me. He wasn't angry or aggressive, but he was silent for most of the trip, except when I asked him some questions pertaining to our paperwork. Parents? None. I put him down as the legal guardian.
It was hot in the ambulance. The sleeves of my jumpsuit were rolled up. The sweat on my forearms made my own scars itch.
We wheeled Charlotte into the ER at New Somerset Hospital and handed her over to the doctors. Clinical presentation, supposed mechanism of injury, treatment given, allergies, and other pertinent details were provided by us.
"Charlotte, these doctors will look after you now. Please ask them for anything you need." I smiled at her. She nodded.
I took the receiving doctor aside. "Doctor, the uncle is reporting this as an accident. The supposed mechanism of injury is not consistent with her actual injuries though. Charlotte has been non-communicative for the duration of our time with her, obviously emotionally distressed. I cannot medicolegally record this as an attempted suicide but I would strongly encourage you to involve Psychiatry and Social Services in her treatment."
The doctor nodded but I never knew if she had received the treatment she needed.
Note
The EMS Diaries is a collection of stories, recounting actual emergencies that I attended while working with Metro Emergency Medical Services (EMS) in Cape Town, South Africa. Patients' names have been altered and locations, though named, do not identify any individuals.
Some calls have stayed with me, over the years, for one reason or another. They are recounted here.