Memories

"74 year old male, back pain, feeling dizzy and weak"

I've met 1000's and 1000's of people through my job, some good, some bad, some made me happy, some made me sad. To be honest, as harsh as it sounds, most don't get a second thought. That isn't to say I don't care, but if I take the thoughts and feelings of every job home with me I'd be a jibbering wreck! Doing this job however, it is inevitable some things you see will stay with you forever. It's an unavoidable part of the job. That said, delivering twins is a memory I'm fond of, as is meeting a man whose life I saved, or seeing the child start breathing again who had been choking. These are memories that I will cherish. The flip side, is there are people, faces and events that I can't un-see or forget about. There are people who you share moments with who have a profound effect on you, who stay in your thoughts when you'd rather they wouldn't. 

I was called to this guy with back pain and dizziness. At one point I thought that I'd be cancelled as it wasn't a high priority call, but due to my proximity to the address and the fact the service was busier than normal I was on scene before a cancellation appeared. The door to the flat was unlocked so after knocking, I let myself in. 

Lying on the bed was my patient. He was smiled at me and I introduced myself. He was white as a sheep and pouring with sweat though didn't look in too much discomfort. He spoke very quietly to me, so much so, that I could hardly hear him. He had had back pain throughout the day which he scored at around 5/10. He was feeling very light headed and felt especially dizzy with blurred vision when he sat up. He had no other symptoms to mention but was understandably anxious. I set about doing his observations, already thinking that I'd probably want an ambulance sooner rather than later. 

His blood pressure was in his boots. In fact, it was one of the lowest, conscious blood pressures I'd ever seen. I raised his legs with cushions and then nipped back to the car to get my paramedic bag. I also used the opportunity to request an ambulance ASAP, without having to worry the patient.

By the time I returned, his breathing was notably faster, but he wasn't complaining of feeling short of breath. It was still just the back pain causing him concern. Due to the extremely low blood pressure, finding a vein was a pig! Eventually I found one and got some fluids running. Despite his protests that he was feeling okay, as far as I was concerned, he was deteriorating and I myself begun to get anxious about not having an ambulance. It is one of the perils of working on a car. Sometimes you get stuck in a waiting game and it is a pretty helpless feeling. Luckily, the ambulance arrived a few moments later so my anxiety was put to rest for now!

I was aware that the guy's abdomen was somewhat distended, more so than when I arrived. There was  still no pain but I was pretty confident in my suspected diagnoses. I had a horrible feeling that he was having an Abdominal Aortic Aneurysm (AAA) and that it was at risk of rupture. A ruptured AAA outside of hospital means death. A person can bleed out into their abdomen and die within minutes. We were all well aware that he needed surgery immediately if it was what we suspected. We also had to make sure of minimal movement and a very smooth, yet fast blue light run to hospital. 

We get the bed into the flat and carefully transferred him to the bed. Without any delay we left,  driving off almost the instant the door was shut. We put a blue call in to the local hospital on route. By now the patients breathing was visibly strained. His oxygen levels that had been 100% dropped rapidly so we put him on high flow o2. We were at the hospital within 3-4 minutes, his abdomen now distinctly distended. As we were wheeling him in I knew in my heart of hearts that he was going to die. I still really hope my face didn't show that.

We transferred him to hospital bed in resus and attached him to their monitoring. He turned to us and said:

"Thanks guys, you've been brilliant.......thank you.........."

At that point his eyes closed. 

"Crash call!" shouted the nurse as his breathing stopped.

Within seconds, he was surrounded by nurses, junior doctors, SHOs, registrar's, surgical consultants and us. CPR was started as I handed over to 15 people surrounding him. Five minutes later, he was declared dead.

His medical records will show a 74 year old, male smoker who died of a ruptured AAA. A relatively common cause of death in male smokers aged 65-75. It's life and not something anyone will be too concerned about. He had no family to speak of and lived what a appeared to be a very solitary lifestyle. He is however, one of the patients which will stay in my thoughts. 

There are some patients you create a bond with, not through common interests or friendship, but because you were there when they needed you most. You were the face that appeared when they called 999 for help. You were the person that reassured them when they needed reassuring. Yours was the hand they grabbed when they knew something was wrong. Yours were the eyes they starred into as they drew their final breath. And you were the person they thanked with that final breath. 

I'm not naive enough to think I can save everyone. When he picked up the phone and called 999 he was dead. Nothing was going to save him and I know that. No one is to blame, there are no fingers to be pointed but sometimes that is of no consolation. What I can take solace from is that he didn't die alone, and as much as I don't want to still be thinking about him all these months on, at least someone is. At least he isn't forgotten.

Don't forget, voting are now open for the MAD Blog Awards 2014. Please go and vote me by clicking HERE. Just select Trying My Patients from the list in the Best Writer category!
Thank you! 

Reality vs Reality

WARNING: This post contains graphic descriptions and scenarios that some people may find very extremely distressing.

So there I was after an awful day at work, sitting in a local pub, nursing a couple of drinks. It's a good way to unwind after a bad day, offloading to people that really know you. No bravado, no showmanship, just good company with people who care about you. Perfect! Unfortunately, even the nicest pubs attract idiots. And drunk idiots at that! The one tonight was harmless, but latched onto us as his new best friends. It didn't take long for him to find out I was a paramedic, and then that was it. Suddenly I was immersed in tales of the '24 hours in A & E', 'An hour to save your life', and '999:What's Your Emergency?'. Apparently he watched them all and therefor was an expert. He was under the impression that everyone we met, we saved and obviously had no comprehension about death and what death involves. It isn't anything like they show it on Holby City and they can't show the reality of it, even in the fly-on-the-wall documentaries. I didn't want to sit there and set him straight but for those not in the know, this is what I associate with cardiac arrests and death.....

"36 year old female, cardiac arrest, CPR in progress."

My heart sinks, just 36 years old. I really hoped it wasn't as given, but the more information I got, the more I knew I was about to walk into pre-hospital hell. I pulled up with a screech and grabbed everything I could carry. I was first on scene and had no idea how long I'd be on my own. I rushed up the garden path to see a kid, no older than my son, standing at the doorway. 

"Please help my mummy, she's not breathing."

I literally can't deal with that stuff, so I ignore it. Children add a huge amount of emotion to any situation and cardiac arrests, are not a place for emotion. I need to stay calm, get in my zone and focus. It sounds very 'self help' but I do get in a zone and we all do what we have to do to keep our head in the right place. I bounded up the stairs to find our patient lying on the floor, her husband desperately doing CPR under the instruction of a call handler counting out the compressions over the speaker phone. I asked him to carry on whilst I got set up.

There was vomit all over her face and her hair was matted in it. When my hands touched her face, I could feel the vomit on my fingers. I begun ventilating her. With every ventilation, blood squirted out of her nose. I begun to suction the airway. I could tell the husband was beginning to really struggle with what he was seeing, and I didn't want this to be how he remembers his wife. I also can't deal with his emotion either so I sent him off to find someone to take the 3 children who were in the house. Again, the fact they were in the house and the fact that he was crying was something I chose to ignore initially. It's my way of focusing and my way of staying calm. 

I took over CPR as he was leaving the room. A number of ribs cracked, the sound of which made the husband visibly cringe. I could feel my knees in the vomit and blood but it didn't matter. Neither did the blood spray up my forearms. Luckily for me, the second car arrived. I secured the airway with an i-gel and continued to suction the blood and vomit that just kept coming. The other FRU started trying to get IV access. The was no joy on the hands or arms, her veins were so shut down, it was futile. I then tried on the external jugular vein (EJV) on her neck but again, no joy. The only way we could now get access was to drill into her bone.

I continued to manage the airway whilst the drill was set up. Just as she was about to drill into her leg, a child appeared in the doorway. You can try as hard as you want to ignore certain situations but some you simply can't. The little girl was no older than 5. Her mummy was lying on the floor covered in vomit and blood, a tube coming out of her mouth, blood trickling down her arms from failed cannulas  and a paramedic kneeling on the floor holding a drill. We both paused for moment not knowing what to do. 

"Excuse me!" I called out. The husband appeared in the doorway. "Your daughter really won't want to see this."

She was quickly whisked away. The needle was drilled into the bone so at least we could now start giving drugs. Unfortunately, as one problem was solved, another appeared. Despite the constant suctioning, the airway was becoming increasingly unmanageable and full of blood. We decided to remove the airway that was in place and intubate. This was not without risk but on balance seemed the best thing to do. I took over chest commissions whilst my colleague get everything set up. Luckily the ambulance arrived, so with their student we now 5 people to work with. The student took over CPR, I started running drugs through, the other medic assisted with the intubation and the other went about do temperature, blood sugar etc and rotating the CPR duties. 

The longer the CPR went on the worse the chest was looking. After about half an hour the top layer of skin on the breast bone had been pulled away due to the friction of constant compressions. Her chest was covered in blood and stomach contents was seeping out of her peg feed site. She had also become doubly incontinent, which is common in cardiac arrests. 

We did everything we could and did so for over an hour, but to no avail. We called a time of death and all just sat around looking at each other, not really knowing what to say. We all had blood on our hands, arms and clothes. We all had blood, vomit, urine or a combination of the 3 on our trousers. Me and the other FRU had blood on our faces due to the original CPR and ventilations. I cleaned myself up the best I could so I could go and speak to the husband. 

I stood at the top of the stairs and was reluctant to go down. Breaking bad news is not something we are trained to do, even more so in people so young. I had to tell a young man that his wife, the mother of his three children, had died. I had to tell him that everything we had tried, had failed. I didn't know, standing at the top of the stairs if the children were down there. I didn't know if I was going to the person they associate with hearing their mummy is dead. I didn't want to be the person to do any of that, but it had to be done. I started making my way down, and the husband appeared at the bottom of the stairs. 

"Is she dead?"

"I'm so sorry sir, we tried everything we could but I'm afraid she has passed away, I'm so sorry."

With that, he dropped to his knees and wept. I just stood there, choking up myself. I didn't want to turn around and go back upstairs, but also didn't feel comfortable watching him. I put my arm on his shoulder and apologised again. A neighbour appeared in the doorway. It turned out that all the children were in her house. She knew what had happened and took over front me. I couldn't get up the stairs quick enough, it was just awful.

There is often very little dignity in death. This young mother laid dead on the floor between us. She was lying in her own urine, faeces, she was topless, she had friction burns on her chest, she had a needle drilled into her leg, a tube coming out of her month and clamped to her head, she was covered in her own vomit and blood and her grieving husband and children were a floor below her crying and not having a clue how to cope and deal with her sudden death. This is why these things are not on Holby City, this is why fly-on-the-wall documentaries stay outside of jobs like this and only tell you what has happened. It's because no one ever needs to see this stuff. We see it, and are part of it because we have to be. Any other eyes have no place being there, in person or through a TV.  Death is not a soap or entertaining and that is why it is sugar coated for everyone. It may be considered reality TV and but it is as far from reality as can be.

Perhaps if I hadn't just done this job three hours earlier, the man in the pubs enthusiasm for pre-hospital entertainment might not have irked me so much. 

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! 

New Years Day

It was New Years Day and the people of our fine city were not feeling well. I spent most of the day observing the pained expressions on people faces as they struggled with the simplest of tasks, like walking. The previous nights celebrations had clearly taken their toll and as per the norm, the ambulance service were left to pick up the pieces! Here is a rundown of what treats the day gave us! Bear in mind, I too was tired. Like everyone else, I had seen the new year in with friends, had a few drinks, mindful I was on an early it was limited to a few! When my alarm went off at 4am I wasn't amused in the slightest but I got on my bike and headed into the night for my 6am start! 

06:05 - '23 year old male, collapsed. He was drunk and asleep.'

Not collapsed. A good Samaritan had called us. They didn't stick around though. Shocker! Taken to A & E to join the heap of drunken delinquents.

07:00 - '21 year old male, collapsed, head injury.' 

He was drunk. In a skate park. He'd fallen over and cut his head. His friends found the whole affair extremely funny and used words like 'wack', 'nang' and 'rad' with worrying frequency. Bandage on head, a large cannula with fluids and trip to A & E.

08:15 - '23 year old female, vomiting blood.' 

She wasn't. She was vomiting red wine. And 'Purple Rain' which I was assured was an 'aggy' cocktail. Her main problem was a hangover. I gave her 2 x Paracetomol, a glass of water, sound medical advise and a few of my best hangover cures. Left in care of friends.

09:06 - '29 year old male, chest pain.'

He did indeed have chest pain. The cause was the copious amount of cocaine, MDMA and skunk that he had taken with alcohol the night before. Due to the fast heart rate and various other things he was given Diazepam to treat his cocaine toxicity. He was promptly taken to the New Years Eve recovery centre for monitoring and further treatment.

10:32 - '30 year old male collapsed.'

He was indeed collapsed. He'd taken an overdose, presumably of heroin.  He was ventilated, filled with Narcan and then once the effects of his high were reversed we were left with an angry, verbally and physically abusive patient who was arrested and conveyed to hospital. 

11:48 - '24 year old male, chest pain.' 

This one was in a police station. He was claiming to pain to avoid being at the police station. Much to his dissatisfaction, once I'd assessed him, done his ECG and spoken to the duty nurse I told him he could stay in the comfort of his room. He called me a cunt. I left.

12:55 - '14 year old female, intoxicated.' 

This one was in a park. She was smashed, well and truly. He blood pressure was in her boots so she got treated to cannula, fluids and a journey to hospital. Because of her age the police had to attend. She vomited all over the ambulance. And my leg.

*change uniform, clean vehicle*

14:10 - '25 year old male, cardiac arrest. '

Sadly, it was as given. He was dead, nothing we could do for him. His friend found him sat on the sofa. He'd been there 2-3 hours. The nights drink and drugs had stolen a young life. A very sobering affair for all involved. Happy New Year eh? 

15:35 - '26 year old male, severe headache, pains in chest.'

He had a hangover. I told him to take his own paracetomol and drink more water. I told him I had just attended a 25 year who had died. I asked him if he felt us being there was a good use of an ambulance. He apologised. We left.

16:20 - '46 year old male, unconscious on bench.' 

He was drunk, on a bench. He told us to fuck off. We did. The caller hadn't stuck around.

16:40 - '19 year old female, feels weak, chest pain, vomiting.' 

She seemed genuinely shocked that her symptoms were caused by lack of sleep, no food, consumption of weed and too much alcohol the night before. I gave her a dose of health promotion and left her with her proud parents. 

17:25 - '40 year old, collapsed in toilet.' 

Clearly the best had been saved until last. We arrived outside a heaving McDonalds and headed inside. A member of staff met us and took us downstairs to the toilets. Hundreds of pairs of eyes stared at us as if they had never seen an ambulance crew, as they chewed their Big Macs. Despite all watching us head into the toilet, within seconds people were trying to come in and seemed utterly shocked that they couldn't use the facilities! Inside was the wonderment that was our patient.

He was a big man, clearly an alcoholic and was locked in the cubicle. His head was slightly protruding from underneath was wall of the cubicle. He was well and truly unconscious. Oh, and his face was lying in a pool of other peoples urine. It appears McDonalds had fallen foul of their hourly toilet cleaning policy, much to the detriment of the patients big ginger beard and open mouth. We requested a chair to look over the top of the cubicle. 

I climbed on top and peered over. There he was in all his glory, trousers around his ankles, and lying in a pool of his own urine and faeces. He had literally keeled over from sitting on the toilet. It really was a wonderful advert for alcohol!

Unfortunately,  despite the treat waiting for us inside, there was the very real problem of how to get him out. I managed to reach down and unlock the door but we could only force the door open slightly, such was his position. My crew mate was slighter than I was so she begrudgingly agreed to be the one to squeeze through the gap and attempt to move him enough to get the door open. Despite her best efforts, the dead weight drunk man could not be moved and in fairness, such was his condition and covering in bodily fluids, she didn't bear hug him with gusto! Luckily for us he started to wake up of his own accord. His personality was every bit as endearing as his appearance. 

"What the fuck are you doing, get out of my cubicle!"

"You collapsed to the floor sir, we are trying to get you out."

"For fucks sake." he mumbled in a thick Scottish accent. 

"Sir, can you move your legs and sit up, we can't get the door open until you do!"

"Yeah.....I know......I'm not fucking stupid you know!"

It's at times like this I like to freeze frame the moment. Ideally I'd like to take a photo on a Polaroid camera and pass it to the patient for them to digest. I was curious as to which part wasn't stupid. Was it the amount he'd drunk? Or the falling off a toilet? Or the double incontinence? Or his face in puddle of strangers urine? All of the above smacked of stupidity, but who am I to judge?! 

Eventually he was up and out. With every passing moment he became more and more abusive and the smell got more and more offencive. After telling us both to, and I paraphrase, 'go away' he headed out back into the restaurant. After attempting to start a number of fights and verbally abusing everyone he passed he staggered up the stairs and out onto the street. During this short journey he only fell over 4 times so that should be looked at as some kind of achievement. He went off into the distance cursing at all he past. I never got his name. What a treat he was!

So, that was New Years Day! Entirely predictable, totally exhausting and all too familiar. Lives wrecked by alcohol and drugs again. When will people learn?! I could sit and reflect on the 25 year old that died but won't. He isn't the first and sadly won't be the last. Perhaps that's cold of me, perhaps it's just self preservation. I'm sure next weekend will bring similar. 

"It's like gambling somehow. You go out for a night of drinking and you don't know where your going to end up the next day. It could work out good or it could be disastrous. It's like the throw of the dice." Jim Morrison

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! 

Sync Complete

I should probably start this post with an announcement. I HAVE A NEW LAPTOP! How amazing is that! I've been wanting / needing one a long time! My old one was bought in 2007 and can no longer cope with the simplest of tasks! 2007! It's amazing when you think back THAT far! My son hadn't been born, I was married, I was working Monday to Friday in a tragically dead end job! It is amazing what can change in just six years! Anyway, yesterday when I finished work I wandering into the Apple store and bought my new MacBook Air and totally abused my 'old' student card to blag the discount! I was pretty damn chuffed as I walked out, new toy in hand! I drove home, opened the box and started syncing! What a day!

Then I thought, 'yeah, what a day'. My mood descended somewhat into one of reflection. It's easy to get caught up in a moment. Like I said, it is amazing how much can happen in six years. It's also amazing what can happen in 12 hours. It is also amazing what I'd managed to forget over 12 hours. Maybe not forget, but certainly the prospect of indulging in a new laptop had become top priority in recent hours. So much so, that it wasn't until now, starring at the words 'Sync in progress' that I realized that there were other people, people who I had seen today who weren't enjoying their evenings. 

"09:05 - 57 year old female, cardiac arrest"

I shot off up the road, dropped into 'sport' and started tackling the remains of the rush hour. I knew the road well having walked down it twice a day, to and from school for many years. I knew I would be the first to arrive and wanted to get there as quick as I could. 

Four minutes after someone had dialed 999 I pulled into the street. I screeched to a halt, grabbed all my stuff and rushed inside. I was beckoned up the stairs by the distraught looking husband. Lying on the floor of the bedroom was my patient. There was nothing I could do. She was dead and had been dead for quite a while. Rigor mortis had set in and there was post mortem staining present. I exited the room and closed the door behind me. 

"I'm so sorry, but there is nothing I can do. I'm afraid your wife has passed away."

The man fell forward, wrapping his arms around me and began sobbing. As he cried, their son appeared on the landing in his dressing gown, also sobbing. I managed to escape his grasp and let them cry together. I went and put the kettle on to make some tea and I cancelled all other resources. In situations like this, tea always seems sensible. They came downstairs and sat on the sofa crying. They looked totally lost. No idea where to turn, no idea how they will move forward. 

I waited with them, comforted them as best I could until the police arrived. I left them to deal with their unmeasurable loss. A very tragic start to the day for all involved.

"12:09 - 33 year old male, ? slurred speech, ? stroke"

My initial thoughts on being sent this were skeptical. Come on! 33 years old! Having a stroke! Not likely! It only took me 3 minutes to get on scene and my patient was sat at the roadside waiting for me! He staggered towards me like someone who's been drinking! I kept him at arms distance whilst I spoke to him. Within about 10 seconds it was clear he wasn't drunk. He was having a stroke.....

His speech was slurred and he couldn't find his words. He was limping and had very little power on his left side, hardly any grip at all and he was drooling slightly. He had no risk factors which made it all the more bizarre. I called control to tell them it WAS as given and I needed an ambulance ASAP. 

33! Unbelievable. He was a successful guy, had a lovely house in a lovely area. He was very confused and had been found staggering around the front garden by a neighbor. He was due to get married in a few weeks time to the woman pregnant with his child. Surely his life can't be ruined at 33? Surely he will get a chance to do all the little things with his baby? Surely he can still get married to his childhood sweetheart? So much was suddenly unknown. So much had changed. 

The ambulance arrived and rushed him off to the stroke centre. I phoned his fiancée to give her the news......

"16:01 - 26 year old male, RTC, Car Vs Motorbike, ? unconscious"

Again, I knew the road well. It's a busy, fast, duel carriageway. This guy could be in a serious condition. That ominous sense of urgency engulfed me. As I approached the stretch of road, it was clearly serious enough to cause a complete standstill to all lanes of traffic. I managed to get myself into a bus lane and shot down the inside of the traffic to the incident. Lying on the floor, surrounded by people was the motorcyclist. About 100 meters further down the road was his bike. By all accounts he'd been clipped, flown through the air and then hit by a car. 

The guy was unconscious, he had a pulse but his breathing was extremely slow. Under normal circumstances, you need two trained staff to remove a helmet. It was just me and the ambulance would have a nightmare getting through the traffic. Based on my initial findings I immediately called and requested HEMS. Luckily the helicopter was 'on line'. ETA 8 minutes.

I couldn't wait to take his helmet off. I enlisted the help of a by stander and got it off. I got someone to kneel either of his head and hold it still whilst I started cutting of his leathers. His battered, blooded body was fighting to survive but I got the sense he was deteriorating. I attached him up to the machine to get his blood pressure. It was extremely low. I put in an airway and started ventilating him. I was aware of what was being said by people around me but was trying to ignore it. 

"Red base, this patient is about to go into cardiac arrest. Any other resources near by?"

"Rog, we have a car about two minutes away from you."

As she said that, I heard the sirens. What a relief.....

Too late....his pulse had gone and there was now no respiratory effort. I started CPR. The police and FRU arrived together and now the chopper was circling above. We set about running the resus. Airway, chest decompression, IV access and secondary survey. HEMS landed in the road ahead of us and promptly took over. He was given blood infusions, injuries were treated and eventually his heart started beating again. He was taken off in the chopper to the trauma centre by the HEMS team. 

He was pronounced dead shortly after arrival at the hospital......

"20:12 - 28 year old female, starring at new laptop"

Not such a great day after all. Whilst I sit here enjoying my new laptop there are three families who's lives have been destroyed today. Three families where I have been a huge part of their day. Telling them their wife and mother have died, telling them their husband to be and father to their unborn child is having a stroke and trying in vein to save a husband, brother, father and son. Two lives over, one changed forever. It is too easy to forget about these people. They aren't my family or friends and I have no obligation to mourn their losses and in all honesty, after today I'll most likely forget about them. That doesn't mean they didn't have an impact on me though. They did. 

'Sync complete'

Little Angel

WARNING: Some may find this post extremely distressing. It's on the subject of Sudden Infant Death Syndrome and contains some very upsetting descriptions. 

I remember when I first started training, being told about all sorts of things that we will see. Some rare, some common and some unheard of. The prospect of the sheer volume of things I would see scared me  but having never seen anything, it was all a big unknown. I didn't know how I'd cope with the shifts, the people and the emotions of what is commonly touted as 'A job like no other'. I was assured that when the time came I'd be with a 'grown up' and all the training would come flooding back. I could only hope.....

It soon became apparent that the training did come flooding back, time and time again. As the weeks, months and years went by more and more things became second nature. My body got used to the shifts (kind of), I got use to the people (kind of) and on the whole my emotions were kept in check. You do get an emotional attachment to some patients from time to time. Some faces stay with you. Some are gone within seconds of leaving them. There is a constant emotional tight rope with me thinking that I'm either dead inside or too fragile to do the job. I suppose that balance is what has kept me grounded most of the time.

We'd been having a pretty non-descript shift. I couldn't begin to tell you the patients I had seen or what was wrong with them. That would be the 'at arms length' approach to ambulance life. The first real detail I remember of this day was my index finger reaching out and pressing 'Green Mobile'. Within a couple of seconds the job appeared on the screen.

"4 months old male, cardiac arrest, CPR in progress"

I felt the blood rush away from my face, my hands became cold and my heart rate doubled. I started imagining everything that could happen next. I pictured the child in his cot, his parents frantic. The only image of the room he was in that I could conjure was that of my own son's room. The thought choked me. Surely, this can't be. It must be an error. He must just be asleep. It must be a false alarm. I don't know why, but this felt different to all false alarms that have come before. This had a strange reality. I knew this was real. Then the radio started ringing.....

"Guys, I believe this is as given, we have another truck and an FRU on way but you are currently nearest. I have also requested the police."

My heart genuinely sank. I couldn't for the life of me remember the resus protocol. I knew it, but I convinced myself I didn't. I was the clinical lead. My crew mate was a student and was equally terrified. I tipped my bag upside down and started flicking through pages of A4 paper with recent clinical updates. I had about 0.3 miles to refresh my memory and then it was all on us. 

We screeched into the road, the familiar waving met us at the kerb. This time it was all the more frantic. All the more desperate. All the more real. The child's dad, consumed with grief, overcome with fear was begging us to do something before I'd taken my seatbelt off. I jumped out, grabbed some bags and ran into the house while trying to find out what had happened. A woman, who I assume was the grandmother was stood in the hallway clutching on to two young children. Tears were pouring down their faces. A shiver ran the length of my body.  This is as real as it will ever get. As I neared the top of the stairs I saw the mum. She was kneeling on the floor, desperately trying to breathe for her beloved baby boy. 

"Please, do something!!" she cried at me. 

Her voice alone broke my heart. I'd never experienced such pain and hurting. I could imagine the desperation and her thought process but without living through it, imagination won't ever come close to reality. 

I looked down at the boy. He laid there lifeless, peaceful, like he was sleeping. He was dead. His short life had come to a tragic end and I knew there was nothing I could do. There was nothing anyone could do.  

"Do something, please!" she wept. "My beautiful baby boy. I'm so sorry, I'm so so sorry."

In that split second I made a decision that I have questioned over and over, ever since. I held the mask to his face, filled his lungs with oxygen and started CPR. I lifted his lifeless body off the floor. With him lying on my forearm and using just two fingers I continued the chest compressions down to the ambulance. My crew mate followed with the bags. The FRU had arrived by now. He saw me rushing out of the house with the baby, and opened the back doors for me. The mum and dad got on board and we left. We had been on scene no more than 2 minutes. I looked at the guy on the FRU and just shook my head slightly. 

As we drove through the streets all I could do was go through the routine of CPR and ventilation. I felt in that moment it was what the parents needed to see. They needed to see us do something. Anything. I struggle with the morality of giving false hope though. Was I prolonging their pain? Who am I doing it for? Was it me who felt the need to do something? 

"I'm so sorry my baby boy, I'm so so sorry I wasn't there when you needed me, I'm so sorry my little angel."

Despite my best efforts, tears started trickling down my cheek. I couldn't help but see my son lying there, imagining what I would do in this unimaginable situation. 

The doors swung open, I picked him up and ran into resus. A small team was waiting. They'd been warned by control we were coming with a patient who was deceased and all our efforts were for the benefit of the family. I handed over the brief history I had. He was put to bed at 6pm. At 9pm, mum went to check on him and he wasn't breathing. Here we are now. 

The doctor told them he had gone. He tried to do so in the most compassionate way he could. Maybe that's why I started CPR. Because I couldn't have that conversation. I couldn't be the one to break that news. News they most likely already knew. Maybe I fell into the trap of having to do something. I don't know. To be honest, I didn't know anything. I couldn't process what was happening. 

I left. It wasn't until I got back to the ambulance that I realised we were all crying. We sat there in silence for a good ten minutes. What could we say? What could we discuss? There is no job more distressing, more tragic and more emotional. What we were feeling however, pales into insignificance in comparison to what the family were going through. The more I thought about it, the less I was able to comprehend the impact this event would have on a family. It literally didn't bear thinking about.

The police arrived and asked us some questions, and then one of our officers arrived. We were told once we were finished at the hospital we could go home if we needed to. We all did. I didn't come in for another week. I couldn't. We were offered support and counselling if we wanted it but I turned it down. I suppose the last thing I wanted was to talk about it. I didn't want to think about it. I wanted another job. I couldn't do this again. Ever.

I did come back. I still don't think I could go through that again. I know there is a chance I will and that will have to be dealt with if and when the time comes. Those parents have to not only come to terms with the loss of their child but somehow be strong for their other young children. The least I can do is carry on offering that false hope where it's needed. It would be selfish to walk away.

You cannot quantify events like these. Saying 'these things happen' doesn't do the loss any justice. I felt like a fraud moping around, feeling sorry for myself. This will be with that family for the rest of their lives. There are no answers that can be given. No meaningful explanations as to why. Nothing will make it better. The words 'I'm so sorry my baby boy' will forever be with me. I will always remember their little angel. I know she did nothing wrong, the doctors know she did nothing wrong, but I also know she will probably take a feeling of blame with her to her grave. I imagine all parents would. I know I would.

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.........