It's the sharp end of the medical profession.
Every year an estimated 30 million people are admitted to intensive care worldwide, of whom 24 million will survive.
At any one time, doctors may be required to draw upon more than 13,000 potential diagnoses, 6,000 drugs and 4,000 surgical procedures.
One of those people is 39-year-old Dr Matt Morgan, Director of Research and Consultant in Intensive Care Medicine at the University Hospital of Wales.
Here, in an exclusive extract from his new book Critical: Science and Stories from the Brink of Human Life, he explains how he had to answer one of the most difficult questions any medic faces…
The year 2016 was going to be a great one for Gwen and her young family. She loved her job as an art teacher.
It allowed her infectious creativity to be passed on while affording her a lifestyle suitable for watching her three children grow up.
In their mid-30s, Gwen and her husband were ready for their next adventure.
The pull of the Welsh coast, combined with their love of coffee, led to plans being drawn.
Just one week after I met Gwen, the family were due to open their coffee shop sewn into the coast road around a beautiful rural Welsh village.
All that changed.
The first paramedics to arrive saw a troubling scene.
The tangled metal from three separate cars was virtually indistinguishable, like three shades of paint messily mixed together by hand. Gwen’s eldest daughter was limping away from the ball of steel, holding on to her grandmother’s hand, shaking with shock.
"Where is mummy?" she asked, looking backwards over her shoulder.
Gwen had been a passenger as her mother-in-law drove safely towards a busy junction. What happened next remains unclear but it resulted in Gwen being trapped following a major road traffic collision.
It took more than two hours to get her out safely while the other occupants escaped with only minor injuries. Lying next to her car once she had been freed, Gwen was critically ill.
She was unconscious and bleeding from a ruptured aorta (the largest blood vessel in the body), and she couldn’t breathe due to multiple rib fractures.
Landing in a muddy field next to the small rural hospital where Gwen had been taken, helicopter doctor Owen McIntyre and critical care practitioner Chris Shaw were tasked with transporting her safely to the regional trauma centre.
The helicopter team worked as quickly and as smoothly as a Formula One pit-stop team, yet with far more at stake than an oversized bottle of champagne.
Using their specialist training, regular practice and standard operating procedures, they saved Gwen’s life.
Using his finger and a scalpel, Dr McIntyre drained the blood surrounding Gwen’s lungs.
Simultaneously, the team prepared equipment to put her on to a life-support machine.
Meanwhile, donated blood and clotting products were being squeezed through a strong needle buried deep into Gwen’s shoulder bone as her veins were so collapsed due to the cold and her illness.
Travelling through her bone marrow vessels, they stopped Gwen bleeding to death.
It wouldn’t have mattered if Gwen had still been at the roadside, this helicopter team regularly delivers advanced medical interventions while on tarmac, hammered by the weather .
The fact that Gwen had even arrived at hospital alive can be traced back to the English glider industry.
George Cayley was an English engineer who created the first seat belt to keep pilots inside gliders during the 19th century.
It was not until the 1950s that Volvo introduced the three-point system used today. This changed the spectrum of injuries we see in critical care today from severe head injuries to mainly thoracic, abdominal and skeletal trauma.
Wearing a seat belt more than halves your chances of dying in an accident.
The blood that Gwen had received also had its roots deep in the history books. Many medical advances are derived from the horror of war.
The evolution of a blood-transfusion service was one of the most significant medical outcomes of the First World War. The millions of soldiers dying from severe bleeding accelerated research into blood storage using chemical additives.
The capability to maintain liquid blood thus established the first blood bank capable of forward planning for managing massive blood loss.
As Gwen was loaded into the Airbus EC145 helicopter, the team noted that she hadn’t once moved her legs.
Three hours after the accident, her husband asked me a difficult question, while sitting in the relative calm of the ICU. Gwen was in theatre, having a ruptured bowel repaired and a severe spinal injury stabilised.
She hadn’t moved her legs because her spinal cord had been damaged as a result of multiple fractures of the bones in her spine.
Spinal fractures are a major concern when treating patients with serious trauma. Your spinal cord runs half a metre down the middle of your back, from the base of your brain to a level at the top of your hips.
This smooth rope-like structure has a hundred billion nerve cells packed into a space just the width of your little finger.
Such is its importance to life that the hard bony case of the spine wraps around it, protecting it from damage. In many ways this bony vertebral column can be considered the scaffolding of life.
When the spine is shattered, shards of bone turn from a protective structure to a lethal weapon. This damage had occurred at the level of Gwen’s spinal cord responsible for signals being sent to and from her legs.
After I had told Gwen’s husband what had happened, a brief moment of cotton-white silence hung in the air.
He then asked me one of the most difficult questions I had ever been asked: ‘What should I tell my children?’
I didn’t know what to say.
Answering tricky questions is a staple part of my job.
"Will he survive?", "Should I stay the night?" and "Will she ever be the same again?" are pleas uttered by loved ones every hour of every day, right now in critical care units worldwide.
The answers are universally difficult yet the same regardless of language.
I could guess the answers, I could use statistics to quote death rates of 95% in certain situations.
However, that would mean little for the patient who defies the odds as that rare one person in 20 who lives.
Instead, as critical care doctors, we should answer these impossible questions with honesty: "I do not know."
These four words are the most underused in medicine.
They hold much power, allowing for hope yet preparing for grief. They are also hard to say.
People want certainty, they want answers gained from years of education and experience. And doctors want to give this.
Admitting to yourself that uncertainty cannot be eliminated takes guts.
"I don’t know" is the most honest, and wise, summary that I can offer.
Two years after I met Gwen and her family, I finally had the answer to her husband’s question.
My family and I had travelled to the ancient capital of Wales, now a market town called Machynlleth. Just a short drive from where Gwen lived, it was a perfect location to get away from busy clinical shifts and to spend time with our new puppy.
More importantly, it allowed me to visit Gwen’s family in their own home.
Were I able to go back in time and answer Gwen’s husband’s question, it would be much easier.
I would say that his children should know that – thanks to the combination of her seat belt, the air ambulance team, blood donors and healthcare workers – Gwen would not only survive her critical illness but she would eventually thrive.
That the journey would be long and hard, and her family would play a key part in her recovery.
Gwen’s husband should tell his children that their mummy is an incredibly brave and strong woman who would not let any stumbles through the fabric of life blunt her fondness for it.
It was a pleasure and privilege to be able to see these things myself when I met Gwen and her family in their home in 2018.
Gwen’s coffee shop never opened and the accident had indeed changed the family’s life dramatically.
Despite extensive rehabilitation, Gwen still needs a wheelchair.
This is likely to remain the case for the rest of her life but, overall, a busy, happy family life had continued. She told me that she has dark days when she feels just like "a head on a stick" and that she misses simple things like dancing with her children.
Source: Read Full Article