Tea And Toast

"89 year old male, collapse, irregular breathing, not responding"

I remember my first ever shift on an ambulance. I remember everything about it, every job, every patient, the two people I was with, where I was working, how I was feeling etc etc. There was a job that day which was given as 'COPD patient, difficulty breathing, not responding'. My mentor turned to me and said 'this guy could be very unwell, he may die on us'. I didn't understand how he could possibly know that! He told me it was just a feeling he sometimes got. Sure enough the patient was unwell. Very unwell indeed! On route to hospital he went into cardiac arrest and despite our best efforts he died. I remember feeling quite amazed that my mentor had predicted it from the minimal information we had. Well, years later, and I get those feelings, and today I had one! 

I told the student with me to grab everything we would to take to a cardiac arrest. She looked at me like I was drunk, but I was insistent! We headed into the care home and were told the patient was on the second floor. My student pressed the button for the lift, I didn't wait and with surprising vigour, I bounded up the stairs. My student didn't follow, and waited for the lift with one of the carers. I was quickly located to the room and sure enough, lying on the floor was our patient, well and truly in cardiac arrest. I started CPR, got the oxygen on him and attached the defibrillator. The student was no where to be seen. It turns out they had to wait ages for the lift, then went to the wrong floor and then couldn't find the room. I later explained that no matter what floor the patient is on, as a first responder, if you suspect the patient could be very unwell, never take the lift! 

As resus attempts go, this was quite long and drawn out. Once everyone had arrived, there were 5 of us in total sharing the workload. By sharing, I mean the two students were doing the lions share of the CPR, I was doing nothing but running the resus (perk of arriving first) and the other two were administering the drugs etc. We got his heart started at least 10 times but it was never sustained for longer than a minute or so. Each time it started beating it was slow and weak. We tried external pacing to no effect and it quickly became clear he was just reacting to the adrenaline we were pushing into him via the vein in his neck. After 90 minutes we stopped. We'd exhausted all of our options for the guy and after seeking advise from some grown ups we ended CPR, removed the oxygen and called a time of death. 

It was quite sad. He hadn't been unwell, and only just moved into the home so wasn't known well by the staff. It was just his time. As is protocol, we requested police for the unexpected death and started our reams and reams of paperwork whilst the students started clearing up! A carer appeared in the doorway.

"Would anyone like some tea?" she said.

We all unanimously nodded away! How very British! There is nothing a good brew can't fix!

"How about toast? Would anyone like toast?"

Again, we all kind of looked at each other and started nodding away! 

"Yes please, thank you!"

She disappeared off and we continued with the writing. Five minutes later she and another carer appeared with two large trays and set them down on the dressing table. There was pots of tea and coffee, sugars, milk, a selection of biscuits and about slices of toast with a pot of butter! Amazing! One of the students took up the role of 'chief butterer' and the other begun taking orders and pouring drinks. It was much needed and very appreciated. We sat around talking about the job, looking at the patients photos of himself and his family and talking about the life he had had whilst drinking tea and eating warm buttered toast. 

The door then opened and two police officers entered the room. Take a freeze frame of what they saw:

5 members of the ambulance service, one sitting in an arm chair, one sitting on a bed, two sitting cross legged on the floor and one leaning against a chest of drawers, all with a cup and saucer of tea in one hand, toast in the other and a dead 89 year old man lying in the middle of them.

This sums up our job and a picture paints 1000 words. Some may think it's not appropriate, some may think it's extremely weird. To me, the last 5 people this man had contact with, who tried for 90 minutes to save his life, were sitting around toasting (excuse the pun) his life with tea. I like to think that he would have looked down and enjoyed his very British send off. 

R.I.P

Don't forget, nominations are now open for the MAD Blog Awards 2014. Please go and nominate me by clicking HERE. Thank you! 

Twas The Night Before Christmas

Christmas is that time of year where you get to see your family and friends and be merry! You get to over indulge, share gifts and sit at home in the warm, watching your kids enjoy the magic that Christmas brings! Being Christmas eve, they have the excitement of leaving treats for Santa and his reindeer. It's the time of year where we all have our own traditions and I think that is what we all look forward to most. Well, by we, I mean those who are not working. Christmas this year consisted of 12 hour late shifts so I would be enjoying none of the above. It's one of the sacrifices we make to do this job. In all honesty, I hate it. Every single minute of it. I don't want to be at work in the slightest and it is part of the job I didn't think about when applying. There is only one thing worse than being stuck on an ambulance over Christmas, and that's being stuck on a car. Yes, I want you ALL to get the violins out and throw sympathy in my direction. And chocolate. An absolute tonne of chocolate. Anyway.......

Full of joy and Christmas spirit (not Baileys), I headed out of the garage to my first standby point. After only 5 minutes of sulking I was heading through the Christmas eve traffic on way to my first job. 

"52 year old male, chest pain"

The words ' Chest pain' don't provoke any emotion in me anymore. As someone who works on the car it is my most common job. More often than not there is no chest pain at all. It is probably the most abused term within ambulance triage. People know chest pain will get an ambulance immediately. If they cough and it hurts, chest pain. Panic attack, chest pain. Headache, chest pain. Got a cold, chest pain. Rib injury, chest pain. I could carry on forever. Within about 2 seconds of seeing a patient I know if it is proper chest or not. 

I pulled up at the address and headed in. Due to the patients age it was feasible it was genuine so I took everything I might need. I headed up the stairs and into the bedroom. There he was, lying on the bed. I knew instantly he was having a heart attack!

His skin was ashen, he was pouring with sweat and had central, crushing chest pain that came on at rest, which was radiating into his jaw. A classic cardiac story with a classic cardiac look was as good as a blood test and ECG! Sure enough, within minutes I had the ECG in my hand and it was one of the biggest heart attacks I've ever seen! The type of heart attack know as a 'Widow Maker' and elevation on the ECG known as 'Tomb Stoning'. I think you'll agree, both are ominous descriptions!

I requested the ambulance on the hurry up and then explained to the patient exactly what was happening and what was going to happen now. I gave him a variety of drugs to help with the pain and as soon as the ambulance arrived we were gone and off to the heart attack centre. The cardiologists were waiting for us and he was wheels straight into the cath lab. As we were transferring him he went into cardiac arrest. 

He was shocked immediately and was back with us within seconds. We had an anxious wait while the doctors prepped him for his angioplasty. He arrested a further three times during the procedure but eventually the clots were removed, stents fitting and the good news was passed to his family that he will be fine. Job well done by all!

Back in my car, I recommenced my sulking and the hours ticked by slowly. Apart from the first guy, no one needed hospital. I made referral after referral and with about an hour to go was clock watching until midnight. Then I could wish myself a merry Christmas and go home. Or not.....

"63 year old male, cardiac arrest, CPR in progress"

It wouldn't be Christmas without a cardiac arrest! I pulled up on scene seconds after the ambulance, grabbed everything I could and headed in. Sure enough, lying on the floor was our patient. The relatives were still doing good CPR so the crew had got them to continue. The patient had vomited so his airway was soiled and that became the priority. We suctioned and secured the airway, got the pads attached and shocked him. 

The crew was one of my good friends so working together in a situation like this was easy. No egos to deal with, we each just did our think. IV access was obtained and subsequent shocks were given. 

"I've got a pulse!"

Back in the room!! We set about stabilising him. His heart was in a very unstable rhythm so we couldn't move him quite yet. It was only now that I realised the sheer volume of family that was in the room. There must have been about 20 of them. This is why I hate working Christmas. I don't like to be part of the reason peoples christmas' are destroyed. I don't want to be there when people die. I don't want to have to give bad news to people during a supposed joyful time. 

We did his ECG and it showed another massive heart attack. Back to cath lab we shall go. We got him off the floor and into the ambulance. The hospital was alerted that we were coming and we left. On the journey the patient begun rejecting the airway. On one hand this a good thing, because he's getting function like his gag reflex back. On the other hand, a vomiting patient with a soiled airway is difficult to manage in a moving ambulance. Unfortunately, he started vomiting again so we had to remove the airway. He still wasn't breathing sufficiently on his own so we inserted nasal airways and between the two of us, ventilated him until we got to hospital. 

Same old routine, arrive, handover, to the cath lab, angioplasty, blockage cleared, stent fitted, high 5's all round. We had missed midnight but we there were smiled a plenty in the back of the ambulance. It was now Christmas day, we were late off and covered in vomit but none of us cared. I suppose we gave the best Christmas present that family could ask for. Puts my sulking into perspective really doesn't it?!

With the ambulance cleaned up and paperwork done we headed back to my car. I waved the crew off and started to head back to station almost 14 hours after I started. At least the shift was over!

"General broadcast, all mobiles. Need an ambulance and an FRU for a cardiac arrest. Can any unit please press Green or come up on priority. I repeat, we need an ambulance and an FRU for a cardiac arrest. Can any unit please press Green or come up on priority. We currently have no one to send."

I was one mile away from it and it was Christmas. Fuck it! 

"Red base, I'm currently returning to base x-ray but if you have no one else you can send it to me. I'm feeling festive!"

"You're a legend, on it's way to you now"

"64 year old male, cardiac arrest."

Here we go again......

To cut a long story short, we got him back (again), massive heart attack (again), off to cath lab (again), angioplasty (again), blockage removed (again), stent fitted (again). Happy family (again). What are the chances?! 

*          *          *          *          *          *          *

UPDATE March 2014:

One of my biggest gripes about this job, is the lack of follow up of patient outcomes. We may get people back from the dead and get them to hospital 'alive', but very often, that isn't maintained. Obviously going into cardiac arrest is a HUGE event for the body and survival relies on a number of factors, none more important than early CPR. Without that, there in no chance at all. IF, there is early CPR then there is still a huge set of circumstances that will lead to survival. An ambulance quickly, quick defibrillation and then being taken to the right place for definitive care. Even then, the is such a long road ahead before discharge that the chances are slim.

In the ambulance service, we generally count a successful resus as heart beating on arrival at hospital and as we rarely find out the outcome of the patient journey, that's where our thinking stops. I left these patients on Christmas Eve, pleased that we had done our bit and given their families some hope to cling onto, but that's all it was, hope. No one knew how their recovery would go, least of all me, and to be honest, since writing this post, I hadn't given them a moments thought. Just writing that makes me feel a little cold and heartless but such is life!

That is, until I had the most extraordinary day! I turned up at a familiar address on a 'chest pain'. I couldn't place it, but as soon as the door swung open I recognised that family! It was my first patient from that day! He was discharged three weeks later, had lost a lot of weight and was on the mend! He thanked me for saving his life, but wanted another favour! An ECG and a trip to hospital and I was more than happy to oblige! I was so chuffed! You never hear the good news and it makes such a difference! High fives all around!

Anyway, at the end of my shift, I returned to my ambulance station to find a letter in my pigeon hole.

"Dear Ella, 

It is with great pleasure that we send this letter to you as recognition of your hard work  on 24 December when you attended a 63 year old male who was in cardiac arrest. We are delighted to inform you that thanks to your efforts in resuscitating this patient, they survived and have since left hospital."

Now THAT, is one way to send me home in a good mood! Two out of three ain't bad! I like to think the third one survived but perhaps I will never know. Here is hoping! At least two families definitely had a happy christmas! 

A Force To Be Reckoned With

"41 year old male, hit by car, injuries unknown"

The traffic was already at a standstill so it took me a good few minutes to get to the scene of the crash. As I pulled up I could see some colleagues already doing CPR. I did not know it was this bad! I jumped out the car, grabbed some bags and headed over.

"Hello guys, what going on?"

"This guy has been hit by a car, he was unconscious but breathing when we arrived but stopped shortly after. We started CPR and ventilations."

"OK, you OK to carry on CPR?"

"Of course, not a problem."

"What do you want me to do?"

"Can you grab the spinal collars and the suction unit please?"

"Yep, no probs."

I set about attaching the pads to him. He wasn't in a rhythm that can be shocked so we continued working on him, best we could in the circumstances. The rain was absolutely bucketing it down, the three of us soaked through to the skin.

I suctioned his airway which was filling with blood, he wasn't in a good way. I needed to put in an airway but couldn't do it on my own.

"Can you suction here for me?"

"Yep, say when you want me to stop."

"Will do, give me one sec.......OK now."

I pushed the airway into his throat and started ventilating. It was a bubbly initially but air was going in. Unfortunately, the chest wasn't rising properly.

"You got any more gloves on you?! Mine are covered in blood!"

"In my back pocket! Take over CPR will you?!"

"Sure, thanks!"

Once gloved up again I got my cannula roll out and decompressed his chest. I got assistance securing them down and then moved onto the cannula. Amazingly at the next rhythm check we had a very faint pulse. That freed up another pair of hands at least.

"Let's get his legs raised, just use one of those bags. In fact, can you also grab some blankets, try and keep him warm and dry as much as possible. Well done guys, that's great stuff!"

It had only been 10 minutes since I had arrived but it had seemed like an age. Eventually, the ambulance arrived and between the 5 of us we got him onto the bed and rapidly off the to trauma centre. I don't know whether he'll live or not but he'd been given the best possible chance.

That chance came about not because I was there within 8 minutes of him being hit, and not because the ambulance came and we got him to hospital. He has that chance because 2 people had done an incredible job. An incredible job in extremely difficult circumstances. Those two people were police officers. They happened to come across the RTC within minutes of it happening. Not only were they there quickly but they treated him extremely well. They recognised he'd stopped breathing and started CPR early. They didn't have a Bag Valve Mask that we have. They had a micro thin face shield and blew air from their lungs into that of a stranger. They basically kept him alive until I arrived. Once I was there they acted as an ambulance for me. Irrelevant of uniform they did what they had to do to save the life of a member of the public. This is our police force.

This is the same police force facing cuts after cuts. The same police force that has lost tens of thousands of officers. The same police force having their pensions reduced. The same police force who get maligned on a daily basis by all of the gutter press. The same police force who are expected to work in the face of abuse and violence on a daily basis. The same police force we all rely on when the shit hits the fan. The same police force who's morale is at an all time low. 

I for one am fed up of reading the snippets of misinformation reported. We should be proud to have the best police service in the world and I'll be shouting from the rooftops at every given opportunity. We work alongside side them every single day. We rely on them for our safety. We rely on them to investigate crimes. We rely on them to do just about anything to keep the public safe. Well today I relied on them to keep a man alive and they did. We have an amazing police force. Let's not forget that, through all the politically motivated propaganda we are forced to read. 

I wonder of the Daily Mail will report on this. I shall be sending it to them!

51 minutes earlier

"You ready? 1...2...3...lift."

"Get me out of here!"

"Stay there, we'll be with you in a minute, OK?"

"Right, I'm on airway, I need some suction. Get the clothes cut off, start a top to toe."

"Have EOC come back to us yet?"

"Not yet.......excuse me, can you help us?"

"Sure."

"Can you go to other the guy in the back, talk to him, reassure him, find out where he is hurt, tell him we'll be with him in a minute."

*radio rings*

"HEMS on way, eta 12 minutes."

"Rog, we need another crew and the fire brigade. We have 3 casualties, 1 deceased, 1 peri-arrest and 1 trapped."

"Received, police and fire on way. Your second crew is 3 minutes away"

"Rog"

"I've got no respiratory effort now, pulse check?"

"Nope, no carotid."

"Time of arrest, 21:42, start CPR."

*police and fire brigade arrive*

"Hi guys, only 1 car involved, 3 occupants, driver is deceased, rear passenger is trapped but no obvious serious injuries and this guy, front passenger has just arrested on us."

"What do you need from us?"

"Can you take over CPR from my colleague......and can you guys deal with the guy in the back please. The other ambulance should be here in a minute."

"Right, let's get this airway sorted, chuck me a size 4."

"There you go, we are in asystole, I'll get a line in."

"Any long bone fractures?"

"Maybe foot, looks like it's just the head injury and anything we can't see."

"Stop CPR for a moment........I haven't got much air entry at all, let's decompress the chest. Carry on CPR, thanks."

"Here you go, I'll get the right side."

*second ambulance arrives* 

"Hi guys, what needs doing?" 

"If one of you could help here, and one of you help the fire brigade with the guy in the back, I have no idea what's going on there."

"What about the guy in the front?"

"Massive cranial destruction, in cardiac arrest on arrival and trapped. This guy was unconscious but breathing and the guy in the back was talking."

"F#%ing hell!"

"Yep........right where are we at?"

"Airway is being managed, chest is decompressed, CPR is constant, just getting fluids up now, he's getting dressings on the head.....want me to take over for a few minutes?"

"Yeah cheers fella, I'll stop after the next cycle."

"Does anyone know what happened?"

"That guy standing over there saw it, apparently they lost control, swerved around the road, flipped over and finished in this tree."

"Still in asystole."

"Carry on. Let's get stuff ready to move if we have to, can you get bed, scoop, blocks and straps. To be honest, I doubt we'll be going anywhere but you never know."

"Chuck me another cannula, I'll get a second one in."

"I'm all out of orange. Grey?"

"Yeah that'll do......how's the guy in the back?"

"Nothing major at the moment, seems stable, distressed obviously, having to cut him out"

"HEMS are here."

"Hi guys, where are we?"

"This guy was front seat passenger, on arrival he was unconscious, irregular respirations and some airway compromise. We pulled him out the car and he arrested a couple of minutes later. He's bleeding into his airway but it's being maintained with an iGel and suction. We've got bi-lateral IV access and bi-lateral chest decompression. He's been in asystole throughout. There was nothing we could do for the driver and the rear passenger is walking wounded by all accounts."

"OK guys, great stuff, let's move him a few feet so we get good 360 access."

HEMS took over and went about their business. We held units of blood and did what we were told! The scalpels appeared and they cut holes in his chest to assess his lungs properly.  It was at this point the police officer who had been helping us decided to go and stand somewhere else! 

After about 5 minutes the resus was terminated.

"Are we all in agreement?......*head nods all round*......time of death 22:03."

A blanket was places over the guy and everyone turned their attention to the one in the back of the car. The fire brigade were cutting the car away and one of them was holding his head still through the boot. There was a mass of bodies all working towards one common goal. I remember looking through the mass of people and seeing the lifeless dead body of the driver just sitting there. It was first time I'd been involved in a job where I've had to ignore the dead. It was an uneasy feeling, I have to admit. 

After about 20 minutes the patient in the back was freed from the wreckage. He was place onto a spinal board and loaded onto the ambulance. HEMS travelled with the patient and the other ambulance crew to the hospital. We picked up all our kit and followed, leaving the carnage behind for the police to deal with.

51 minutes earlier......

Three 18 year olds were driving along. Where they were going I don't know. Where they had come from I don't know. What they were talking about I don't know. I'm sure there was laughter and banter. There always is when friends are together. I'm sure they were enjoying the freedom that a car gives you. They had their lives laid out in front of them with endless possibilities. I don't know exactly what happened next, I only know what we were told.

"RTC Car vs Tree, 3 patients, 2 unconscious and trapped."

We weren't far away, I knew the road and knew it had potential to be serious. Nothing, however, could prepare me for what lied waiting for us. Within a few minutes of the call coming in we were on scene. A number of cars had stopped and blocked the road in doing do. The car itself was utterly destroyed. I was surprised to find anyone conscious to be honest. It was truly horrendous.

It was a 3 door car and due to the way it had impacted the tree I go only get to the passenger door. The driver was dead. I don't need to expand further than I have but there was nothing that could be done for him. The passenger in the back was dazed but talking. He was complaining of pain in various places but being behind the driver there was no way we could get him out without the fire brigade. The only person we could meaningfully help right now was the front seat passenger. 

He was unconscious, covered in blood and breathing very slowly. He had a pretty awful head injury and needed to be out of the car very quickly. The door wouldn't open fully but after some gentle persuasion it was bent out the way. I lent in and grabbed him under his arms. My crew mate grabbed the legs.

"You ready? 1...2...3...lift."

*          *          *          *          *

No matter how hardened we all are to this job, these events do effect us. Whether or not we lie awake thinking about it, day dream about it or just think long and hard about what has been lost, it effects us all. Three young men had their lives destroyed. One may have survived but you can rest assured that his life won't be the same again. Neither will that of their families. All I can think about and keep revisiting is how much fun me and my friends used to have whilst driving along in a car. Perhaps the only difference between a great time and a life changing tragedy is a mis-timed glance over the shoulder  and some bad luck. Who knows. Life is so fragile.

“To die is poignantly bitter, but the idea of having to die without having lived is unbearable” Erich Fromm

A Chance - Part 2

continued.......

Moving a patient in cardiac arrest isn't easy. He needed to be put on the spinal board, lifted to the bed and wheeled onto the ambulance. All the while, CPR had to continue, as did ventilations and suctioning. Neighbours were holding up fluids and moving cars to enable the ambulance to get closer. The patients wife, son and daughter were stood watching, grief pouring from them. Their pain was palpable for all involved. A neighbour suggested they didn't watch but nothing was going to stop them being by his side. When someone is begging you to save their loved one it is a pretty chilling feeling knowing that you probably can't.

We got him on board, put in the blue call and left. The other FRU took the relatives and we left en mass. 2 ambulances and 2 cars in convoy to the hospital. On route there was no change to the patients condition. As every minute passed, the outlook became bleaker. One hand on the hand rail and one on his chest, CPR continued over every bunch and round every corner. When we arrived at hospital he'd been 'down' for well over an hour. The only thing that could save him now was the definitive care provided by the hospital. If they could find the cause and it was something they could treat and reverse then maybe, just maybe he had a shot.

People watched on in shock as we emerged from the back off the ambulance on to the tail lift bouncing up and down on the patients chest. As the lift was being lowered my eyes met with his wife. I felt a lump in my throat as I pushed back the tears. The six of us, all doing or carrying someone, wheeled the patient into resus to the waiting crash team. There were fifteen members of the hospital staff who swarmed around him. He was transferred to the bed, the anaesthetist took over the airway, a nurse took over CPR, junior doctors begun getting further IV access and blood gasses, a scribe was writing everything down and the consultant insisted on silence for everyone to listen to my extensive handover. 

"62 year old male, witnessed collapse, 1 minute tonic clonic seizure followed by cardiac arrest. CPR started immediately. Initial rhythm was VF, he received 6 shocks and has been in slow, wide PEA ever since. We have a patent airway with good CO2 maintained with suction. He has patent cannula and IO access in the humeral head. He's had 18 x Adrenaline, 500ml of saline and 300mg of Amioderone. He's been down for 1 hours 18 minutes. We've been through the 4 H's and 4 T's."

I stood back and watched. The consultant was fantastic. Clear direction, paying personal attention to each member of his team, giving individual instruction and calming down the junior doctors who were getting a bit flustered. I've never seen a doctor so clear and articulate. He asked us to bring the family into resus which I haven't seen before. Normally they are left outside. They appeared in the cubicle, eyes red and clearly distressed. Blood gasses were sent of, focused heart echoes were done and to be honest I wasn't holding out much hope. He went over and quietly spoke to family explaining what was going on. 

A nurse returned with the blood gasses and handed them to the consultant.

"Right guys, this patient has been down now for nearly an hour and a half. He's had the best care possible. His blood gasses have returned suggesting he's at a point no longer compatible with life. On two focused echoes his heart is showing complete myocardial standstill. I've discussed this with the family and following that discussion, combined with what we are faced with I am of the opinion we should terminate the resus. Does everyone agree or does anyone have strong feelings that we should continue on?"

His statement was met with silence from the 21 of us in the cubicle. 

"OK, with regret, time of death 18:04. Thank you everyone for your efforts." 

The body of our patient was then covered, his face cleaned and airway removed so his family could spend some time with him and say their goodbyes. I was choked up. Everyone was. It is impossible to remain emotionally detached from your patients. Impossible.

The consultant called all the staff outside of the room. 

"Brilliant job guys. You guys in particular (talking to us) did a phenomenal job and thank you to everyone who helped out here. Lets all have a cup of tea, I'm here to answer any questions you may have or if you want to get anything off your chest, let me know"

He then did a full debrief, explaining his decisions, explaining possible causes etc. I've never had a consultant like him. Not only genuine care for his patient and the relatives but for all the staff under him. He didn't talk to anyone like a subordinate, but like an equal. It was refreshing and we all left somewhat lifted by his manor. Today the NHS can be extremely proud.

This job goes to show that death can't be avoided. Sometimes, even when all the cards are dealt in your favour, the house still wins. 

NB: I tried to find out who the boy was. No one recognised him and he left half way through the resus. Our patient only had a chance because of him. I wish I'd got his name. His efforts deserved recognition.

A Chance - Part 1

"82 year old male, collapse, ? seizure, O/S"

This wasn't just a collapse in the street, this was a cardiac arrest on a residential street on a weekday afternoon. It was witnessed by neighbours, family members and children. For many of them, it will be the single most distressing thing they will ever have the misfortune to see. Cardiac arrest survival is always improving but survival relies on a three things:

Early CPR. If CPR isn't started by a bystander within a couple of minutes the chances of survival decreases by 10% for every minute that passes. It takes an ambulance roughly 8 minutes to arrive. No CPR in progress means only a 20% chance of survival and they'd most likely be brain damaged. 4 minutes without CPR means the brain will almost certainly be damaged, regardless of whether we can start the heart again.

Early intervention. We need to arrive quickly to do advanced life support. On top of the CPR we need to secure an airway, oxygenate the patient, de-fibrillate and give various drugs to try and start the heart again then stabilise the patient and transport.

Good definitive care. A hospital with a crash team and any specialities that are required to treat the cause and assist recovery. Once stabilised, the long road of treatment lays ahead before the ultimate goal of discharge is reached. Only then do the government get what they want.....a return to tax paying status.

Miss one of those three and it is quite simply, Game Over.

"UPDATE: Patient now in cardiac arrest, CPR in progress"

I felt my foot push down on the accelerator, drop-gear kicks in and I accelerate. I'm only about half a mile away, I'm likely to be first there and on my own. Scrap that, as I crossed the next roundabout an ambulance appeared in my rear view mirror, driving with the same intent I was. We pulled into the street and headed to the crowd. About 8 adults of various ages waved frantically in the road. I screeched to a halt, grabbed my bag and rushed over. Lying on the pavement was an elderly man with CPR being done by a 13 year old boy. All the adults started talking / shouting at me trying to tell me what happened when the boy doing CPR shouted...

"QUIET.....I saw this man fall to the floor, he had a fit for about a minute so I called 999. He then stopped breathing and the lady on the phone told me to roll him over and start CPR. I've been doing it since. I've also done rescue breaths like I was shown in first aid."

Wow! Just wow! Despite the chaos the adults were causing, a 13 year old boy had taken the initiative and done an incredible job. I was so amazed. He didn't even know the guy, just saw him collapse while walking to a friends house. If the patient survives it will be down to him and him alone. I was a tad speechless. Clearly someone has had the sense to teach him first aid.

Whilst talking to him, one of the ambulance crew took over CPR and we began the 'Advanced Life Support' part of his treatment. As chaotic as these situations are it is important to recognise and encourage the efforts of others. Like I said, this is the most distressing thing they will ever see and they need to know they did well. As I have mentioned before, a resus is not as glamorous as 'Casualty' and 'Holby City' would have you believe. It isn't a case of a few gently chest compressions, a shock after rubbing metal pads together, shouting 'Clear' and one shock followed by High 5s and celebrations. It's messy and to be quite frank, brutal. 

The patient had been incontinent of urine and his stomach contents was filling his mouth which required constant suctioning through the airway. There was the unmistakable sound of ribs cracking, when the cannula went in there was a lot of blood. Throughout the resus this blood got spread about onto gloves and kit. To gain further IV access we drilled into his shoulder and his clothes were cut off. There is no dignity in a public cardiac arrest and no way to soften the blow to the watching friends, neighbours and family. With every shock, the electricity surges through the body causing it to jolt violently. All the while there is someone forcing air into his lungs, there is someone doing CPR with enough power to physically squash his heart through the rib cage to pump the blood around the body. I'm knelt by his side vocalising everything we are doing, giving drugs, trying to ignore the watchful eyes, many of whom are crying. This is the reality of a resus. Brutal.

After 5 or 6 shocks from the defibrillator his heart rhythm changed to one that couldn't be shocked. He had what is known as pulseless electrical activity (PEA). All we could do was continue CPR and push through adrenaline every few minutes. After half an hour or so we knew we had to go. There was nothing more we could do here, his only chance remained at the hospital.

To be continued.........

Bloody Immigrants

"48 year old male, cardiac arrest in street, CPR in progress"

Our Greatest Ever Team

It is not often that I agree with anything David Cameron has to say, however, when he describes UKIP voters as “fruitcakes, loonies and closet racists” I'm inclined to agree. They seem to be getting carried away with their recent success but the better known they get, the more skeletons from their dirty closets keep appearing. I have every faith that the great British public will see the light and this will be nothing more than a puff of hot hair and a protest vote against austerity.

It's 2013. Any party that expels their members for being pro gay marriage has no place in politics. However, quotes like “I just wish they would keep their homosexual nature and practises to themselves and stop trying to ram it down my throat telling me they are ‘normal’ when they are not.” seem part of the UKIP norm. Then again, that is little surprise when UKIP candidates like Alex Wood are photographed doing neo-nazi salutes. How very British! Last night I was told by someone from UKIP that "people fear the volume of immigrants in the UK" and when pushed he said it was "the fear that the UK they grew up in is changing beyond their control. It's just not England anymore." Ah yes, immigrants making us less English! Sound familiar? Sounds very BNP to me! Personally, I think they put the Great into Great Britain.

The England I grew up in was was a multicultural one. I lived in a nice part of the city and went to a good school. In my primary school class there were two boys from Nigeria, one from Pakistan, a few from India, one from Egypt, one from Ireland and *deep breath* one from Somalia! (UKIP voter shivers!) Some of them were born here, some weren't, to some of them English was their first language, to some it wasn't. Who cares?! Certainly as a 7 year old I didn't, they were just my school friends and still are. Perhaps the innocence of a 7 year old personifies what this country has stood for. It doesn't matter where you are from, what colour your skin is or whether you fancy boys or girls, you can be part of this wonderful country. By the way, forgot to say, there was also an American girl in my class but she doesn't count does she, because she's not considered an 'efnik'.

THIS is the NHS. THIS is Great Britain

This country is held together by 'immigrants'. The NHS alone, would implode without them. They do the jobs that these 'proud to be English' types won't do. Rather than sit there scrounging off the state, never doing a days work in their lives, do you see any of them offering to do a cleaning job? Becoming nurses? Becoming police officers? Doing anything to improve themselves or the country? No! They sit there and bitch about all the 'foreigners' taking their jobs. Well jobs don't fall from the sky, you have to go and earn them. The only reason an 'immigrant' has a job is because they applied for it. They met the criteria, did the training and work bloody hard to keep it, in the face of constant criticism and abuse from the uneducated racists this country harbours. 

This country has done a good job of demonising the BNP over the years and quite rightly so. Sadly UKIP has given these racists a legitimate party to vote for and a forum to start airing their far-right views. As far as I'm concerned, UKIP supporters are a bunch of racists who are pleased that their evil ways are being validated by a political party. 'Oh it MUST be OK, the politicians said so,' Well let me share a little story with you.....

Dear UKIP voter, 

UKIP see a turban. The rest of us see 3 coppers.

Last year I was called to a man who had collapsed in the street. A police officer was on scene and was doing CPR. (This CPR would go on to save the mans life.) The patient was a white man with an English name. Do you think he would have cared that the police officer doing the CPR was wearing a turban? Blooding immigrant eh?  

The guy I was working with that day was gay. Not just a little bit gay, very gay. You know the type, the gay that is proud to say he is. Don't worry, he won't try and turn you with his dirty gay ways, instead he will help try and save a mans life (without ramming his gayness in your face). Amazingly it doesn't effect his job, or prevent him contributing to society. He is also one of my closest friends. He may even want to get married one day! *shock horror face* Bloody homos eh?  

We started the resus and another one of our colleagues arrived. English was his second language. He was born in Kenya. KENYA! Proper immigrant eh? He suctioned the vomit out of the patients mouth and then secured the airway. (This action would contribute to saving the mans life) Can you believe he was allowed a job as a paramedic when English is his second language?! I'm starting to understand the fear. Bloody foreigner not speaking proper English eh?

The 4 of us worked tirelessly. We all communicated well together and were working to one purpose. Eventually we got him back! Wow! The guys heart was beating again! And he was breathing? So, me, the gay, the turban wearer and the immigrant got the guy onto the ambulance and rushed him off to hospital. This guy was a fighter. So bloody English eh?  

We burst through the doors of resus. Well this is awkward, the Consultant in charge was not only a woman, but a Muslim one wearing a Hijab! Surely she shouldn't be allowed to wear that?! Not in THIS country. We handed over anyway and she took charge, continuing the excellent treatment this tax paying Englishman deserves. Still though, bloody Muslims eh?  

As I looked around at the doctors, anaesthetists, nurses and HCAs there was a huge mix of backgrounds. Some born in England, some probably were not. Some were brown, some were black, one was even chinese! One might have even been a lesbian. *shocked face* (She may also want a wedding). My gay crewmates gaydar was working overtime! Anyway UKIP, here is a question for you. If this was your dad, your brother, your uncle or your friend would you care that he was being saved by a bunch of bloody homos and immigrants? Do you think the patient would give a dam? Or the patients family? This man lived and returned to tax paying status. His life was saved by the people of Great Britain. 

You really should have a long hard think about that, because it isn't just a one off. This wasn't a hand picked job to make my point. That is every job I do, that is every hospital in the country, that is every police force that protects you. In fact, that is every school, GP surgery, dentist, supermarket, fire service, coast guard, builder and every other single business, service and institution in this country. England is a multicultural country, always has been and always will be. Your racist policies will not stand up. We pride ourselves on the fact that no matter what the colour of skin, sexual orientation or religious beliefs that someone has they are no less valuable or have any less right to be here than you and me. 

Oh did I mention. I'm a second generation Eastern European. I should probably go back where I came from. Bloody foreigners eh?  

Go on, say it, I know want you, don't be shy, all together now.... 

"We are not racists, we just don't want immigrants in our country." 

Well UKIP, without invoking Godwin's law, your party is starting out in the exact same way as the German Workers Party (Deutsche Arbeiterpartei - DAP) began in 1919. In 1920 Hitler became a member and shortly after that it became the Nazi Party (Nationalsozialistische Deutsche Arbeiterpartei - NSDAP) and we all know how that ended. 

Lots of love 

Ella Shaw (part immigrant, proud brit) x

Flowers

"Am I going to die?" she said softly. 

How do you answer that? I'm a terrible liar at the best of times but in situations like this I can be read like a book. That said, as much as I am able to tell someone that their loved one has died, I couldn't bring myself to tell someone they are going to die. Maybe my eyes told the whole story but my words didn't. They simply didn't answer the question.

"Stay calm, we are going to get you out of here and off to hospital."

With that, I rested the blood stained oxygen mask back over her face knowing all too well this would be her last few minutes. She closed her eyes. It was chaos around me. Every emergency service, a sea of blue flashing lights and rain. Heavy rain. I was in the car with Claire. I had climbed in through the boot, clambered to the back seats and then through the front of the car. Claire was trapped in the mangled wreckage of her car. There was no quick exit, the oak tree was where the drivers seat should be. Claire was where the gear stick should be, I was in the gap that was left. I followed health and safety procedures in that I had a high-vis jacket on and a helmet. The visor quickly steamed up and due to it's size I couldn't move. The helmet came off. It was just me and Claire in the car. Getting her out wouldn't be down to me, I'd just be the passenger in all this.

9 minutes earlier......

"RTC Car vs Tree, 54 year old female, trapped"

It was about 10pm and the weather was grim. I didn't relish this job at all but off we went. Strangely, we were first on scene. The second we turned the bend I could see the headlights through the mist of the rain pounding on the floor. That one image was all I needed....

"Red base, can we have Fire, Police and HEMS please."

"Roger, on way"

It's not often I request everything without assessing the patient but the car was on a blind bend, the car was quite literally wrapped around the tree and from the damage I could see from 10ft this patient would not have escaped serious injury. Within seconds the police and fire rounded the corner blocking road in both directions and I headed over to the car. The passenger door wouldn't open, nor would the back door but the boot was open so in I went. I got oxygen on her but she panicked with the mask. I tried to fit a collar on her but she panicked. I held her hand and assured her we would help her. She was pale, blood was pouring out of a wound of her head, her arm and leg were clearly broken and she couldn't breathe. I managed to get a cannula in her hand but she ripped it out. Bugger. She squeezed my hand tightly and starred at me. It's a look I will never forget and one that will stay with me for my entire life. That I am sure of.

"Am I going to die?" she said softly. 

"Stay calm, we are going to get you out of here and off to hospital."

As we were........

The fire brigade were working tirelessly around the car to get her out. The sawing, the banging, smashing and shouting drowned out my voice. 

"Claire, Claire, open your eyes!" I shouted. 

Another face appeared in the back of the car. It was my crew mate. 

"Claire, open your eyes!"

I felt for a radial pulse. Nothing. I felt for a carotid pulse. Nothing. It was the first time in my career I didn't know what to do. I felt helpless. Do I start CPR? I'm just going to pump the little blood that's left in her body out. I turned to my crew mate, we had a brief discussion of her injuries and decided any resus attempt was pointless. The fire brigade were about 15 minutes away from freeing her, that was too long to make any resus worthwhile. I started CPR though, I felt I had to. My crew mate spoke to our clinical support who agreed that we could stop. Then I stopped. Stopping is strange feeling. In my heart I knew she was gone but it's against our instincts to stop and walk away. I wish i'd known when she closed her eyes, eyes full of fear and pain, that it would be the last time. 

I clambered out backwards. Numb about what had happened. Claire. That's all I knew about her and in reality, all I will ever know. 

The other cold, harsh reality is that now I had to do paperwork for us and the police. Then, without much further ado and moping around I'd have to press that magic green button and go and do another 5 or 6 jobs before bed time. And that is what we did. It doesn't mean Claire wouldn't enter my thoughts but realistically it wouldn't be until I'm lying in the dark, staring at my ceiling, that I will have a chance to spare her a proper thought.

"22 year old female, headache, nauseous, states has run out of paracetamol"

C'est la vie.

1 week later......

You know when people die at the road side, tributes are left by friends and family to mark the spot where a tragedy occurred? Be it someone run over or victims of a crash there are always tributes left behind. I often see them at places where me or my colleagues have been or what is reported in the paper. It's a constant reminder of what happened, it triggers memories, evokes emotions and shows what someone has left behind. 

We were driving along the very road where Claire's time had come to an end. I slowed down as I rounded the corner and the tree came into view. The tree stood proud and tall. If you didn't know any better you wouldn't know that a Ford Focus had been wrapped around it 8 days previous. There was no debris, no fragments of glass, no nothing. 

No flowers. No memory. 

Death Becomes Her

“51 year old female, collapsed in street, ? unconscious O/S”

Remember me banging on about presumption?! Well, this is the kind of job where the jilted cynic in me says that it will be a load of tosh. It’s where I decide or suspect before we arrive on scene that alcohol will be involved. The fact that the call was made by a passer-by immediately makes me suspect they haven’t checked the patient and instead call 999 and walked off. This job would be a simple walk-on, walk-off kind off job. Let’s be honest, i’m usually right! Maybe repeated success can lead to complacency, I don’t know. As bad a habit as it is, doing the job we do and seeing the stuff we do I think it’s impossible not to pre-judge based on information given. People’s behavior and thought processes are based on experiences. That’s what makes us who we are. All I can say in my defense, is despite any pre-assumptions that I have made I approach every job in the same way. I still take all the bags with me and until my suspicions are confirmed I remain open to any outcome. This is why!

Having raced through the busy streets, jumping red rights, driving on the wrong side of the road and under taking down a bus lane we pulled up on scene 7 minutes and 52 seconds after the call begun. The clock is stopped, everyone take a bow, this job is a resounding success. Lying on the pavement about 6 feet from us was our patient. She was conscious and surrounded by 5 or 6 people; the same 5-6 people who had frantically waved en masse as we pulled into the road! I’ve mentioned before that people who are really ill, look ill and people who think they are really ill but are not, don’t! Well, despite my previous presumptions I was wrong. She was sober, well dressed and looked like crap. The world of medical diagnosis is all about best guess. Based on how she looked, by best guess was that this was a cardiac problem. I took some basic obs off her and to my surprise everything was normal; her pulse, blood sugar, blood pressure and oxygen saturation we fine. Despite that we got her up, on a chair and inside the truck, out of the glare from the crowd and the rubber-neckers.

The weird thing about this job, was that she wasn’t complaining of anything specific. She kept saying she didn’t feel right but that was about it. No pain, occasional light headedness but nothing that led us to suspect anything we could treat. We did an ECG, that was completely normal. We did a neurological exam, an abdominal and respiratory assessment yet still couldn’t find anything wrong. The only thing that was obvious was she appeared to be getting worse. She was sweating more, appearing more drowsy, talking was becoming more of a problem and she was panicking slightly. We decided to just go, we put in a blue call for a ’51 year old female, collapse ? cause’ and off we went. It was only a 4 minute drive to hospital. In the end it took a while longer. 

After a minute of driving she started going blue. Extremely blue. I watched over a 10-15 second period as her oxygen saturation dropped at alarming speed from 98% to <50%. I put her on full flow oxygen but it didn’t change for the better. I silenced the oxygen alarm on the monitor, only for the respiration alarm to start going off. Her resp rate had dropped from 24 a minute down to 14, then 8, then 4 and the 0. F**K!! 

“Pull over, she’s gone into respiratory arrest.”

“F**K!”

At no point before that did I think that the Angel of Death had been circling above. I grabbed the Bag Valve Mask (BVM) and started bagging her whilst my crewmate got the defib pads attached to her. Within about 20 seconds of the ambulance stopping her heart had also stopped. My crewmate started CPR. An ominous flatline appeared on the screen as we checked for a rhythm. What the hell had we missed?! We had done everything?! I called control and told them to update the hospital that the patient was now in cardiac arrest and we would be there in 3 minutes. We decided that as there was just 2 of us and we were so close, we would just go and give basic life support on route rather than waste time at the roadside delaying definitive treatment. Some crews would act differnetly but these decisions are made in a split moment based on what is in front of you. We felt her best chance would be a crash team at the hospital. 

Off we went for the second time, this time with me doing CPR with one hand whilst hanging onto the ceiling bar. As we pulled into hospital the crash team were waiting outside. The back door swung open and to my relief a nurse jumped on to help out. Because she had just gone on us without warning we were not ready for it. When transporting a patient in cardiac arrest, you do so in a way that transferring at the hospital is easier. This patient however, was attached to the main oxygen, the blood pressure cuff, the ECG leads, the CO2 lead, the pulse ox, everything. After basically ripping everything off we got her inside and onto the hospital bed while I gave a pretty vague handover. 

“This is a 51 year old lady who collapsed in the street. No memory of the event. Denied any pain, complaint of slight light headedness. On arrival she was sweating and pale but all her observations were normal. She was FAST negative, her ECG showed a normal sinus rhythm and there was nothing untoward on a neuro exam. Same with resp and abdo. No recent travel or surgeries, no allergies, normally fit and well, doesn’t take any regualr medication. On route she became heavily cyanosed and rapidly desaturated. Within 30 seconds she was in respiratory arrest and about 30 seconds after that went into cardiac arrest. She has been in asystole (flatline) throughout. She has been down now for 5 minutes give or take.”

We left the department scratching our heads as to what had just happened. I suppose that’s healthcare right there. Whether you are a paramedic, a nurse, a health care assistant, a doctor or porter, at some point in your career someone will die whilst in your care. It isn’t nice and isn’t something that sits well with me but it’s true. I have gone over this job from start to finish over and over and over and over again. As has my crewmate. She should not have just died like that. How can someone who is fit and well, and relatively young just die without any obvious cause. I think that is what troubles me still. What did we miss?! It is hard feeling to describe watching someone die. I watched the life drain from her as death took over and I was absolutely powerless to stop it. It’s one thing to die at home alone but when inside an ambulance surrounded by medical professionals? I hate to think what was going through her mind. She must have known. I remember her eyes fixing on me, gripped with fear. I can only imagine what my face looked like. 

Normally i’m very blasé about death. I'm very much a ‘when it’s your time, it your time’ kind of person but it’s a very different dynamic when you arrive on scene to someone who has already died or is dying. Be it old age, a stoke, a heart attack, a fall from height or an RTC you can distance yourself from it and follow your cardiac arrest rule book. When it happens unexpectedly in front of you there are no coping mechanisms in place to rationalise it. Problem is, I couldn’t dwell on it, I had to get to a 27 year old with a 4 day history of lower back pain to rush off to....