Monkeying Around

"25 year old male,? Fall from height"

Aaahh, the old ? is back! It's like a magical mystery tour! What illness or injury is behind the closed door?! Or in this case, the woods! The ? is kind of important! HAS he fallen from height?! If so, is it extreme height?! I really need to know this stuff, especially as I'm on my own! 

UPDATE: No one available to meet you at the gate. Patient is about half a mile from the entrance near the stream. Caller staying with patient.

"F%#k!!!" (Sometimes you HAVE to swear)

I arrived at the entrance to the park. There was a height restriction on the gate which I could fit under, but the ambulance would not. I drove about 400 yards to the start of the footpath by the woods. Now a long walk.....

UPDATE: Fall from extreme height. ? 40 feet out of tree. Drifting in and out of consciousness.

"F%#k!!!" (Again, this is a 'sometimes' moment)

This job will not allow me the luxury of popping back to the car for kit. I needed to take everything I need or may need. I also have no idea how long I will be there due to the location. It could take a while to get him out! So, paramedic bag on my shoulders, oxygen bag and spare cylinder, dressing pack, Lifepack 15 (weighs a tonne), Entonox, spinal collars and a blanket. I literally couldn't carry any more if I tried. After 15 minutes of walking / shuffling / plodding I heard some shouting coming through the trees. I followed the noise and eventually saw my patient and the caller on the other side of a small stream. I clambered down the bank, tip-toe'd across, up the bank on the other side and go to work!

The guy was in a bad way and was indeed drifting in and out of consciousness. When awake he was in a lot of pain and had various obvious injuries that concerned me. Significantly, a head injury, a possible broken pelvis and a broken neck. That's not to mention the arm and leg injuries he had but I was limited to what I could do on my own. It is these jobs where you learn a lot about yourself and your abilities. The buck stopped with me to a point, I can only do what I can do but lone working means you put an awful lot of pressure on yourself to do a lot.

I requested HEMS due to his injuries and location. HEMS were unavailable. They were my safety net! (Ironic mention of safety net given the circumstances!) In a semi-angry / desperate rant, I basically said, and I paraphrase:

"This guy is literally in (not up) shit creek, I have no means to get him out quickly and safely, I don't care if HEMS are offline, I need someone and quickly. HART, extra crews, anything, but I need it 5 minutes ago. Capisce?!"

I think for poor girl on the radio sensed my stress levels and basically said, and I paraphrase:

"Oi! Chill your beans, leave it with me, I'll get you all the help you need as quickly as I can, we are here if you need us for anything! Comprende?!"

I got it and she got it. Our poor allocators often get the brunt of our heightened stress levels! The good ones understand that and respond with kid gloves and know it's nothing personal. I know it's not their fault HEMS aren't available and I know it's not their fault that I'm in the middle of nowhere, on my own and feeling out of my depth! I know that! Sometimes we all lose our cool! 

The helpful caller continued to be helpful. I got him lying on his front holding the patients head still. It transpires that my patient, James, had decided to climb a tree, on his own, in the middle of woods. About 30-40 feet up, the branch he was standing on snapped. He dropped like a lead balloon. The branch was lying next to him and I could see where it had been, high up in the tree. *shudders* By sheer luck, the caller had been walking his dog and happened to see James lying on the floor. We had no real idea how long ago he had fallen. It was a remote part of the wood and off the beaten track. If he hadn't been found when he had been I wouldn't like to think how long he could have been lying there.

I had oxygen on him and set about cutting off his clothes. I got him linked up to the machine and starting monitoring him. For now, his blood pressure was stable. I fitted a spinal collar and them got IV access in both arms. Still no ambulance!! 

Gradually James became more and more coherent which was a good sign. However, the more alert he became, the more pain he was in. I had Morphine available, but with his injuries I wanted to hold off until it was totally necessary. I began a top to toe survey, to check for all injuries and make sure I hadn't missed anything. I carefully ran my fingers slowly down the small of his back. I felt an ominous ridge in his spine causing him to gasp. As I assessed his legs, it quickly became apparent he wasn't aware of what I was doing, or that I was even touching him. 

After a brief radio conversation with control, I guided the ambulance crew to my location. Eventually they found me and had brought supplies! We now had a spinal board, head blocks and straps. One thing we didn't have was a plan. There was no way we could realistically and safely carry him back to the ambulance. We needed HART team with all their fancy kit and extraction expertise. They, however, were still 20 minutes away because they'd had to get their special off road vehicles ready. All we could do was treat what we could, keep James warm and reduce pain as much as possible. Time really does grind to a halt when you are desperate to fly by. There was a very real possibility that James could be paralysed or even die from his injuries and I think he knew it too. 

It's a horrible situation to be in. As much as you want to talk candidly and be honest, in a patient who must remain completely still, you don't want to cause panic. I made it painfully clear he mustn't move at all but the pain was making him fidgety. I decided that despite the potential risks of morphine, the benefit would outweigh them and with three of us now, any side effects could be managed. So I loaded him up with it and he responded well.

Eventually a guy from the HART team arrived, panting! He'd run! Run! Weirdo! He said they were all here and were trying to get their vehicles inside! Not 1, not 2, not even 3, but 4! The incident response vehicle (big ambulance with tea making facilities), the 4 x 4 jeep thingy which the boss drives and then 'Thunderbird 2'. Well that's what I call it anyway. This....thing has a crane, it lifts off a huge box, and then out the back of said box, comes a special ambulance golf buggy thing with blue lights and stretcher! Anyway, they all arrived and slowly but surely found their way to us. Amusingly, the HART team were stood around in their protective jump suits and hard hats and we were stood next to them in our normal uniform. They didn't get the joke! To be fair though, we couldn't have got him out without them. Today they more than proved their worth!

Once everyone was assembled we got James off the floor and into the vehicle. Whilst he was driven round to the ambulance, we traipsed back with all the kit and met back at our vehicles. James was loaded on board the ambulance and we took him off to the trauma centre. 

I often say that in this job you generally see people when they are having a really bad day. Let's be honest, if you need an ambulance, or think you need an ambulance, clearly things aren't great! That aside though, we are also in the unfortunate position to see people when they are suffering truly life changing events, often with disastrous consequences. People's reactions vary from fear to denial but they all have an unmistakable look in their eyes. Sometimes I think I know the right things to say, sometimes I don't. Today I didn't. James looked at me and said:

'I've really fucked up haven't I?'

Hope can be a dangerous thing and I didn't want to give him any on a false pretence. I suppose my avoidance of the question was very telling. 

'Let's see what the X-rays show.'

A tear trickled down his cheek. I guess the gravity of the situation had hit home. 

I have no idea if James ever walked again. 

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.........

A Bridge Over Troubled Water

"29 year old male, cardiac arrest"

Even before we got this job I had a strange feeling. I can't describe it, something just didn't seem right! I was on edge like I was waiting for something to happen.  Well,  a 29 year old in cardiac arrest was enough to snap me out of my odd state! Generally the cardiac arrests we do are on the elderly. In fact, I'd say at least 95% are over 65, maybe even higher than that. I'm not saying it's any easier doing a resus on a 80 year old but on some one younger it seems a lot more of a waste. Initially we only had a road to go by, so headed off in the general direction.

"UPDATE: Patient on a boat"

A boat. Of course he's on a boat. It's a big city, where else is he going to be?! The actually location we had been given was to an incredibly narrow, slippery concrete staircase, leading down to an canal footpath. Only problem was there are two sides to a canal and boats lines both sides. There was also two staircases to chose from and we had a lot of kit to carry! Oh, and obviously it was dark.

With all the kit you can envisage for a resus we headed down the stairs that were nearest us and started looking / shouting speculatively for a response. After about 100ft we got on! On the other side of the canal.....

So, about turn, and back we went, up the stairs, across the bridge, down the other stairs and along the footpath to the boat. Now, the boat. The clue is in the name, a 'narrow boat'. There isn't going to be much room to work, nor will there be room to stand or  move around. Once I'd taken a step of faith over the gap to the water I felt a tad safer. My crew mate passed me the kit and then followed me over. Then it was a case of squeeze down a tiny, shallow stair case into the heart of the boat and there was our patient, lying lifeless on the floor.

I quick primary survey showed that luckily he wasn't in cardiac arrest. He was however on the verge of respiratory arrest so I got ventilating him while my crewmate started doing 'other stuff'. His pupils were pinpoint and there was plenty of evidence to suggest a drug overdose to we treated as such. We have a wonderful drug called Narcan that reverses the effect opioid drugs pretty rapidly so we loaded him up with that. After about 8 minutes he started to respond and began breathing effectively himself. 

By now, the FRU had arrived, unfortunately, owing to the fact that it was a narrow boat he was made pretty redundant by the lack of space. He decided to go and fetch our carry chair! Good call! Although the patient wasn't conscious enough to talk in sentences our walk he was opening his eyes and thrashing around slightly which was kind of what we expected. He had already been cannulated by the time the chair arrived back so we got him strapped in and started the the arduous process of extraction! 

Up the stairs we went and on the stern (?) of the boat. Now the plan of how to safety get him, us and our kit across the gap of water to the foot path! Scrap that.....he started fitting. Full blown seizure and pretty violent at that. BALLS! We got him out the chair and onto the deck. This job was really going from bad to worse. We waited a few minutes to see if the seizure would stop. It didn't. We gave Diazepam and waited some more. Still fitting and we are getting pretty desperate now. More Diazepam. Still fitting......aaaaaand stop. A quick ABC check and he was up, on the chair and across the back faster than you can imagine! Sure enough, the second we got him on board the truck the fitting started again and this time it didn't stop. 

You'd think after all of that, the hospital would be appreciative of what we'd been through, but no, the Dr was just plain rude! He interrupted my handover with:

"Well he's probably still fitting because you waited 5 minutes to give him Diazepam"

He then ignored the rest of the handover and talked over me. He looked at us like we'd dropped a baby and spoke to us as if we were naughty children. He criticised and questioned why we waited to give diazepam despite showing him our guidelines. He wasn't interested. Professional courtesy and respect works both ways and today both were distinctly lacking from the doctor. It was a sour end to what had been a challenging and difficult job.

In hospitals you have every level of experienced medical professional at your finger tips. You have every drug, lots of expertise and the patient is on a bed. Pre-hospital you have 3 of us, one of which is a paramedic, one is a student paramedic and the other a technician, a patient not breathing and then seizing uncontrollably, on a narrow boat, in the dark. We are not miracle workers. We are not giving a gold standard of care that the hospitals are capable of. We are simply making the best of a bad situation. And as far as situations go, this was pretty dam bad!

Deja Vu

"12 year old male, rash on body"

My first thought was 'as opposed to the rash not on the body'! Lucky I had arrived to work early as is the norm because even with the best will in the world, I couldn't have signed in, drawn out drug packs, morphine, got my bags from my locker, checked the vehicle over and been ready to go in 17 seconds as they had hoped. That is why we are all compelled to come in half an hour early, unpaid, so we can be ready to go when the first job comes in. 99% of calls that involve a rash are minor, that is, if it is even visible. Very rarely it will an allergic reaction, even rarer it will be anaphylaxis and even rarer than that, it will be meningitis. Due to the latter two, in children especially, most calls with the word 'rash' are given a high priority of call to be on the safe side. I think this is a good thing, especially as even the most calm and reasonable of panicking parents don't want to answer multiple questions about the rash, they just want an ambulance. Also, if it is serious, time really is of the essence. 

Needless to say, we weren't very panicked! We weren't judging the call but the in the information we had there were no priority symptoms like difficulty in breathing or swollen lips etc or anything that would lead us to think the patient was going to be particularly unwell. Oh how wrong you can be! 

We pulled up outside the house to be greeted by 'that frantic wave'. You know, the wave I have mentioned before that tells you something isn't right and you really need to get a wiggle on. I followed the mum through the front door straight in the lounge. The boy was just wearing his underwear which enabled me to see most of his skin. Every part of him was bright red and covered in the worst hives I have ever seen. His face was swollen and he was in untold discomfort. He stood up and rushed to the toilet. It turns out he also had uncontrollable diarrhoea. Although his tongue wasn't swollen and he denied struggling to breathe I felt his condition was bad enough to treat for anaphylaxis and after a brief conversation with our Clinical Support Desk they agreed. 

Once I'd decided what we were going to do, I then had to do it and this is where the second guessing begun! It is very rare to have to cannulate a child and if we had been 5 minutes from hospital we'd have just run but the fact it was longer and the fact his rash was getting worse by the second I wanted to try for a vein before they all completely vanished. The panicked parents didn't help my nerves. I got everything prepared but suddenly became 'a dropper'! More by luck than judgement the cannula was successful. I then checked and double checked dosages for the drugs I was giving. Whilst I was cannulating my crew mate had drawn up and administered the Adrenaline into his muscle and had given full flow oxygen. I then gave some Chlorphenamine (Piriton) and Hydrocortisone  and we left. I felt very conscious that I was shaking slightly, and even managed to drop the radio when putting in the blue call! How embarrassing!

We arrived at the hospital and went straight into resus where the team of paediatricians were waiting. There had been no improvement from any of the drugs we had given and his rash and breathing were now notably worse. At least he was in the right place, and I could breathe! 

This is a weird job, in the sense that you are taught about what to do in a lot of situations for a lot of medical conditions yet you obviously only get to see the conditions you are dispatched to. I can count on one hand the amount of times I have seen anaphylaxis and this was by far the worst I had seen it. It had been maybe two years since the last time I'd seen it too and in all honesty I felt very rusty during the job. Nothing was missed but was I bit slow in treatment? Probably not. Did I do it all correctly? I think so. Did I look or sound confident when doing it? NO! I tend to stay calm in some of the most frantic of situations like most people in the ambulance service but like everyone else, the thought of having a really sick child deteriorate in front of you is by far the worst feeling there can be. At least I will have this memory to draw on the next time I'm faced with it. Anyway, no time to ponder! Time for the next one......

"5 year old female, allergic reaction, known allergy to nuts, has ingested nuts, swollen tongue, DIB"

Are you serious?! I've said before that jobs tent to cluster in a shift and the first generally dictates the rest but really?! Again?! Well, at least I had a clear plan in my head! Off we went and after a short drive it was like deja vu! Out came the waving parent, the only difference was this time, she was followed closely but the father, carrying what looked like a limp child. *cue shiver down spine*

I'm sure I was out of the vehicle before it had stopped moving. The kid was conscious, just, but extremely floppy. We got her straight on to the bed, dad at the head end, mum next to me and crew mate moving around in any space available. The fact she was so compliant said a lot. Hardly any whimpering, all her energy was concentrated on breathing and that was a clear struggle. She got high flow oxygen a nebuliser, IM adrenaline followed by hydrocortisone & chlorphenamine a few minutes later. I didn't even look for a vein, she was so small and we were only a few minutes away from hospital so the latter drugs were given on-route into the muscle. If the last job had scared me, this one terrified me, but in a different way. This time, I knew I'd done everything quickly accept in my head I was planning a resus. She was that bad. 

9 minutes after arriving on scene we were at the hospital again and for the second time in 45 minutes the team of paediatricians had seen me rush in with an extremely ill child! Only difference was this time I was a lot calmer. Amazing what effect the lack of doubt had on my ability to hold things steadily! We weren't even two hours into the shift and I was pretty much out of drugs and totally exhausted! Once the paperwork was done and signed I called up control. 

"Red base, due to the last two jobs we are all out of drugs, can we start heading back to station to re-stock please."

"Rog, no probs, start heading back and we'll try and leave you alone."

We can't be shown unavailable as we can still 'render aid' apparently! What that means is if there is a job we will be sent and they will hope we have enough kit to get by! As long as it's not another allergic reaction we'll be fi....

"10 year old male, allergic reaction, eyes swollen"

Of course it is, what else was it going to be?! The one thing we can't deal with is the one thing we need to find a way to deal with! 

"Red Base, we have no drugs to deal with an allergic reaction. Is there a Hotel car running on this?"

"Rog, they are 3 minutes away."

'Hotel' is ambulance jargon for paramedic and I don't know the origin of it. If there is a paramedic on a vehicle it becomes a Hotel crew. Anyway, we pulled into the road just before the car and I took great pleasure in ticking the 'first on scene' box! Like we had done twice already we jumped out and headed in. This time it was slightly calmer. The boy had a huge swelling under his eyes and a rash over his torso and arms but wasn't too unwell. It was very itchy and causing him a lot of discomfort so thanks to the FRU, we gave him some Chlorphenamine which worked well and within 10 minutes the itching had stopped and the rash was decreasing. By this point we were back at the hospital where we handed him to the waiting paediatrician who looked at me and laughed!

"Again?!"

That was it! Not for the shift, but for the allergic reactions and quite frankly, I don't think I could have coped with another! As for the shift, there was still 10 hours to go! *cries* 

As for the patients:

Patient 1: As of 8 hours after we arrived he was still in a very, very bad way. The doctors didn't know the cause and despite a list of drugs and therapies as long as my arm he hadn't improved. The kid was awaiting a transfer to a specialist hospital. I won't find out how he did.

Patient 2: Fine and dandy, sent home 6 hours later and told to stay away from the macaroons.

Patient 3: Discharged 4 hours later with another washing product to add to the list he is allergic to. 

Kids eh! Aren't they fun!

Black Wednesday

“77 year old female, everything is fine.....no wait.....she’s dead”

The first wednesday in August each year is known as Black Wednesday and so begins the ‘killing season’. It is the day that junior doctors start working in a hospital. It is also when a lot of other doctors change job role and as such, this day results in a significant increase in mortality of emergency patients. It is fair to say that Black Wednesday and the two days that follow are the worst days to fall gravely ill in the NHS. Saying that, is there ever a good one?! Up to 7000 graduates enter the halls of their respective hospitals and with it, the sudden burden of responsibility of the lives of their patients. The death rate in these three days each year rises by 6%. 

I don’t blame the newbies for this, they are thrown in at the deep end, they are made to do operations and procedures on patients way beyond their capabilities. On top of that they end up working the graveyard shifts when there are little or no senior staff around. They are in charge of wards, departments and health and wellbeing of all patients inside them. Someone who has just passed their driving test drives off and starts learning how to drive, someone who passes their law exams then goes off to learn how to be a lawyer. These kids, and they are kids, have spent years with their heads buried in text books. Their only patient contact and bedside manner has been learnt from corpses so it’s no wonder the proverbial shit hits the fan. 

I’m all for a steep learning curve. In those situations you learn a lot. In most walks of life, when you are learning, the mistakes that are made, end up costing time and money. In health care, the mistakes that are made, end up costing lives. It was daunting the first time I was in an ambulance as a crew of two! I didn’t really have a clue what I was doing. I always had a safety net. Firstly, I was never alone, secondly I was always with someone better trained than me and finally, if the shit really did hit the fan we were never more than a short drive to a hospital where the grown up could take over! Junior doctors don’t always have that safety net. The buck stops with them and that added pressure probably has a lot to do with labeling of ‘killing season’.

Personality has a lot to do with it to. Becoming a doctor is very competitive and as such there are egos at play. When we have dealing with a junior doctor there are generally three types that we me. 

• The Flapper: These newbies are terrified. They know their stuff but don’t show it! The pressure is all to much. They look around to everyone else for the answers and are yet to have any confidence in their abilities. They drop things and actually look scared. Their patients will likely die from their inaction.

• The Ego: These ones think they have made it. They know all there is to know. They walk around looking the part, walking the walk and talking the talk. They won’t ask for help because let’s be honest, they don’t need it. They talk down to nurses and ambulance staff because they are a DOCTOR. They try to do to much over and above their ability. Then patients die. They are ignored by all and they slowly realise they are not god.

• The Awkward: These guys have all the social skills of grizzly bear. They know their stuff, they were probably top of every class they have ever been in. The problem is, they have absolutely no people skills and no bedside manner. They will not spot a sick person because they won’t look at their patients. They will not talk to their patients because they don’t know how to. They just look at numbers.

All three will learn and all three will improve, however once an arrogant arse, always an arrogant arse in my experience. 

This year during Black Wednesday week the A & E was absolute chaos. We were coming and going every hour on the friday night with another puzzle for the newbies to solve, as was every other ambulance in the area. Although they didn’t take the handover I could see them looking as the double doors swung open, hopeful there was nothing majorly wrong with them. At about 3am, we’d handed over our patient to the nurse, my crewmate was booking them in and I was changing the sheet on the bed. Suddenly, in a cubicle a few feet away there was a commotion. A junior doctor was in there with a patient and her son. 

“What do you mean she’s dead?”

“Sorry”

“You said 3 hours ago that she was fine.”

“I know”

“You said she was asleep.”

“I know”

“How can you not know she was dead?”

“...................”

*awkward*

I left the department so as to avoid the furore. Ah.....Killing Season, and so it begins with a key lesson......check your patient is breathing at regular intervals and ensure the monitoring equipment you have connected them to is switched on!

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....

Back to Basics

“23 year old male, hand injury”

Right, the time has come to get back to basics. This blog is aimed at anyone who isn’t in the know or is confused about what’s what when it comes to getting treated by the NHS. So, first things first.

Hospital: A hospital is a health care institution providing patient treatment by specialised staff and equipment.

Accident and Emergency: Accident and Emergency is a department within a hospital and is a facility specialising in acute care of patients who present without prior appointment, either by their own means or an ambulance. Due to the unplanned nature of patient attendance, the department must provide initial treatment for a broad spectrum  of illnesses and injuries, some of which may be life threatening and require immediate attention. All A & E departments in the UK are financed and managed publicly by the NHS. As with most other NHS services, emergency care is provided to all, free at the point of need and regardless of an ability to pay.

Ambulance: An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury. The word is most commonly associated with road-going emergency ambulances which form part of an emergency medical service, administering emergency care to those with acute medical problems.

Triage: Triage is the process of determining the priority of patients’ treatments based on the severity of their condition. This rations patient treatment efficiently when resources are insufficient for all to be treated immediately. The term comes from the French verb trier, meaning to separate, sift or select. In a hospital setting patients are divided into three main categories based loosely around the old wartime triage process:

• Those who are likely to live, regardless of what care they receive;
• Those who are likely to die, regardless of what care they receive;
• Those for whom immediate care might make a positive difference in outcome.

Ill people go to hospital. Really ill people go initially to accident and emergency. If they can’t get there due to their illness or injury they get an emergency ambulance. Once at hospital they are triaged. That triage will determine the speed of their treatment. Those rules apply to everyone.

So, we were called to a young guy with a hand injury. Not a bad hand injury but a painful one all the same. He had managed to close his finger in a door. It was swollen. It was bruised. He couldn’t fully bend it. He was in pain. He didn’t take any pain killers. He called 999 and asked for an EMERGENCY ambulance. This was deemed to be one of the acute medical problems that we are there for. He lived half a mile away from the hospital. His girlfriend was there. She had a driving licence. She owned a car. Her car was parked outside. His brother was there. He had a driving licence. He owned a car. His car was parked outside. His mum was there. She had a driving licence. She owned a car. Her car was parked outside. His dad was there. He had a driving licence. He owned a car. His car was parked outside. On the notice board in the kitchen was a business card for a local taxi service. They did not use it. 30 yards from the front door was bus stop. The bus which stops at said bus stop also stops outside the hospital. The patient had legs. They were not injured. He could have walked to the hospital. He chose not to. 

After a brief assessment in the £750-a-call-emergency-ambulance we drove him the half a mile to hospital. His girlfriend and mum came with us. The brother and dad followed in the car and parked in the pay & display car park. We walked the patient into the accident and EMERGENCY department. We spoke to the triage nurse and gave her a detailed history of what happened, what we have found and how he has been with us. She then triaged him based on what we told her and what her cursory look at his finger told her.

• Those who are likely to live, regardless of what care they receive;
• Those who are likely to die, regardless of what care they receive;
• Those for whom immediate care might make a positive difference in outcome.

“Waiting room please”

The girlfriend with a driving license and car stepped forward.

“The waiting room? He’s in pain, you haven’t even treated him yet”

“He has a hurt finger. I have 46 patients in the department now, all of which are a higher priority. There is a baby in there who may die. There are 2 patients in there who also may die. There are 16 patients in here who NEED a bed and require treatment because they are THAT ill. There is 1 doctor on duty, 4 nurses and 2 health care assistants. There are no beds free at all. The fact you called an ambulance for a finger injury is a gross abuse of the NHS. The fact I am sending you all to the waiting room should tell you that his hurt finger never has and never will be an EMERGENCY, now go and wait for your name to be called like everyone else.”

With that, she walked off. I was in awe! She summed up in 30 seconds what I have wanted to say to every single patient who has called an ambulance for nothing and who has been sent to the waiting room.

Why do people think there are long waits in hospitals? 

Erm...because there are people who could wait to see a GP who are sapping resources.

Why are people surprised they sometimes have to wait a long time for an ambulance? 

Erm...because so many people are calling an ambulance for the most puerile of complaints.

Why are people surprised that they are send to the waiting room? 

Erm...because they don’t need to be there.

Why do people seem to want to spend night after night sat in a hospital? 

I have no answer to that. Maybe a hospital lover can enlighten me!

When I am ill I want nothing more than to lie in bed and feel sorry for myself. I will ONLY go to hospital if I absolutely have to. I would never called an ambulance unless it was a life or death emergency or if I was too injured to get myself into a taxi or a car. People seriously need to get a grip and stop expecting miracles from our free health care service. The NHS is being killed by its misuse. Accident and Emergency. THE CLUE IS IN THE NAME. Emergency Ambulance. THE CLUE IS IN THE NAME. When someone picks up a phone and dials 999 they are greeted with a question. ‘What’s your EMERGENCY?’. How anyone can hear themselves say ‘I need an ambulance because I have hurt my finger’ or ‘I have a headache’ or ‘I can’t sleep’ is beyond me! In London alone the call rate has doubled to around 1.7 million calls per year in less than 10 years. Of that, 1.2 million people get an ambulance. This jump is not down to an increase in population, nor is it down to a population that is more ill or more accident prone. It is because people are not using the services as they are intended to be used. They have become lazy and reliant on a free service and are abusing it.

Please please please people! Stop killing our NHS. Once it’s gone, it will not come back.

What happens if.....?

“38 year old male, throwing around his job title”

What happens if you park on a double yellow line?

You get a parking fine

What happens if you park in a car park and don’t buy a ticket?

You get a parking fine

What happens if you over-stay in a car park?

You get a parking fine

What happens if you park on or near a crossing?

You get a parking fine

What happens if you park anywhere where it says ‘No Parking’?

You get a parking fine

What happens if you park in an ‘Ambulance only’ bay?

You get a parking fine

Social status or job title does not exclude anyone from having to pay for parking illegally. Typically, at most hositals there are 4-6 ambulance bays outside a hospital marked in yellow or red lines with huge signs on the walls and the ground saying ‘Ambulances only’. It is perfectly clear and there for a reason......so ambulances with ill patients can park outside the A & E and get them into the hospital quickly and easily. Hospital staff, patients, relatives and members of the public have to use the ‘car park’. The clue is in the name! Patients or relatives or members of the public being dropped off or picked up can use the ‘drop off zone’. Again, the clue is in the name. It is very common for all the ambulance bays to be full of ambulances and throughout the day there is always a constant stream of ambulances coming and going. 

This particular day we were sat at our local hospital in one of the 4 ambulance bays. There were 3 ambulances including us, the only one free was the one directly outside of the doors which we typically leave clear if possible, incase a ‘blue call’ (critically ill patient) arrives. We were scoffing down our venting machine food and watery Maxwell House coffees when a brand spanking new, black, Mercedes SLK convertible pulled in and parked in the ambulance bay. A middle aged man in a suit got out, locked it and walked off.

“Excuse me, you can’t park there.”

“Yes I can.”

“No you can’t, it’s an ambulance bay.”

“I’m a consultant, I can park where I like.”

“No you can’t, it’s for ambulances, there is one on route here now.” (massive lie)

“I haven’t got time to talk to you, I have work to do”

With that, the pompous, arrogant, prat, walking into the A & E. Being rather hot headed, I couldn’t let this lie. I stormed into the A & E after him but he’d vanished. So, I took down his registration number and went to the reception.....

*over the tannoy*

“Would the owner of a black Mercedes, registration number LK60 BFU, parked in the ambulance bay please remove it immediately.”

After a few minutes, he had not appeared.

“Would the owner of a black Mercedes, registration number LK60 BFU, parked in the ambulance bay please remove it immediately.”

Still no sign.

With that, the receptionist  picked up the phone and called security. The security at this particular hospital also monitor the car park. He came outside, wrote out a ticket and slapped it on the windscreen. As her did, the alarm started sounding. Within about 30 seconds the self proclaimed consultant appeared. I was sat back in the ambulance by now and watched the argument unfold. He talked to the security guard like he was dirt on his shoe using such phrases as ‘do you know who I am’ and ‘I’ll have your job for this’. In an indignant last ditched attempt to throw his muscle power around he stormed to the front of my ambulance and started writing down the registration number. 

“This won’t be the last you hear about this.”

I wound my window down.

“There is a pay & display car park just over there, that you are welcome to use.”

“You’ve made a huge mistake.”

“Actually it’s you who is parked illegally, I did tell you when you parked it.”

“I’m a consultant here.”

“The sign doesn’t say Ambulance and Consultants only, don’t blame me”

With that, he got in and sped off, revving his engine as he went. What a tool! Funnily enough I never heard any more about it! I truly hate people like that, people who think they are better than others. People who treat people ‘below’ them without respect and with contempt. He may have spent years moving up the ladder and he may be a respected consultant. Unfortunately, that doesn’t give him the right to do what he likes when he likes. I don’t buy into giving respect when it has not been earned. I don’t care what his job title is, I don’t care who he is or how well respected he is professionally, he is still working for the NHS, he is still a colleague and he still has to abide by the same rules as everyone else.  A job title does not give anyone the right to talk down to or dismiss another person. Unfortunately for him, he chose the wrong girl to throw a job title at and despite his best efforts, I was the one who got to sit and watch him huff, puff and speed off in his rear wheel drive penis extension.

What happens if a consultant parks in an ‘Ambulance only’ bay?

He gets a parking fine

*smug face*