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. 

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

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.........

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....