24 - Season 3: Episode 1

For some it’s the season to be jolly. For other’s it’s the season to reflect on what an utterly crap year it’s been. For me, it’s overtime season. It’s the time of the year where I literally sell my soul to the ambulance service in the vain hope of affording a holiday at the end of it. Tonight was a self inflicted overtime shift, but with someone I very much wanted to work with so you won’t catch me complaining. 

I couldn’t write that with a straight face! Of course I’m going to complain!

The following takes place between the hours of 12:00pm and 18:30pm

12:00

Despite volunteering to work a night shift I wasn’t happy about it. I had given up a lovely little 8 hour day shift on request of my crew mate who going to be single on the night and wanted someone to do all the work for her. As requests go it was pretty outlandish! Asking ME to do a night shift instead of an early! Despite my faux protestations I was more than happy to and even offered to provide the grub. I’m nice like that!

So, instead of sleeping before the night shift I slaved away in the kitchen! Mainly because I can’t sleep during the day and also, because I predicted severe hunger throughout the night and didn’t want to leave anything to chance! 

Food made, washed and groomed, packed and dressed I was just about ready to head off in to the night. All we needed now was pleasant patients and we would be in for some easy money!

18:30

That ominous feeling that every night shift brings was well and truly upon me as I walked into a rather strange looking ambulance station. I chucked my stuff on the vehicle and headed for the kettle. Caffeine was going to feature heavily! 

‘Breakfast’ was prepared by my crewmate and we feasted like kings. It made a nice change from my usual routine. The bliss didn’t last long…..

19:00

“36 year old, asthma attack”

We headed off into the night. True to form, my cremate was driving and I was writing. When I suggested that maybe at some point she could write and talk to patients she laughed. And laughed hard! This was going to be me for the night!

We pulled into the alley way where we’d been sent to. It was in a particularly grotty part of town and the alley itself didn’t offer anything up, other than a bad smell and sludge. Up the metal staircase we trotted, full of unparallelled enthusiasm. The front door was open so we headed into the smoke filled hovel. It was like walking into a cloud of irony. Sure enough, sitting in the smoke filled room was our patient, wheezing away like a good’un. He had been treated in hospital that day already for his asthma and unsurprisingly, was having a relapse. They really didn’t seem to grasp that sticking an asthma patient in a smoke filled room would cause a problem. In fact, they blamed the bad treatment of the hospital for his current predicament! Gotta love the NHS! Failing patients at every turn….by not making them immune to cigarette smoke! The scoundrels!

Anyway, my crewmate handed out a speech, laden with sarcasm and health promotion do’s and don’ts whilst I gave him a nebuliser and off we all went to hospital like one big dysfunctional family! We handed him over to the nurse, making sure she was aware of the environment in which he was found and headed back to the ambulance to eat some dried mango. Yep. Mango. If you don’t like it, you have no place being here!

20:19

“66 year old male, chest pain.”

I’ll be honest with you. From the information we were given I wasn’t holding out much hope for this being a job that could hold my attention. Some chest pains read like proper chest pains, others read like chest pains for a quick ambulance. This looked like one of them. It had all the tell tell signs. Abdo bad, DIB, symptom after symptom, and eventually chest pain chucked on at the end for good measure. All was just itching to be revealed. 

We pulled up, grabbed our stuff and headed inside.

“Wheeeeeeeyyyyy.”

That is what we heard as we walked down the corridor. In the living room, sitting in the chair was a beard. Well, the beard had a rather large man attached to it, but the sheer magnificence of the beard was overwhelming. It made Santa Claus look like he only had designer stubble! I’m serious! It was most off-putting!

“Wheeeeeeeyyyyy.”

“Hello Sir, what’s the problem today?”

“Wheeeeeeeyyyyy.”

This could be a long conversation….. Luckily, I was quickly interrupted and told that he doesn’t speak any English. So, all history taking was done through a translating relative. I was dubious about some of the answers because I asked about the pain score the patient spoke at lighting speed for about 10 seconds only for the relative to say “8”. 

“Wheeeeeeeyyyyy.”

I muddled through and established he’d had chest pain for about 3 days but this evening it was much worse. I also learnt that trying to stick ECG leads onto someone who effectively has a mature weeping willow hanging off their chin requires a unique set of skills and preferably three arms! Eventually we were good to go!

“Wheeeeeeeyyyyy.”

*presses print and waits*

“Wheeeeeeeyyyyy.”

*’analysing ECG…….’*

“Wheeeeeeeyyyyy.”

*prints out ECG*

“Wheeeeeeeyyyyy.”

MASSIVE HEART ATTACK! Shit! My cremate quickly vanished to get the chair whilst I stuck a cannula in. We gave all the drugs, wheeled him to the ambulance, put in the blue call and headed off to the cath lab!

“Wheeeeeeeyyyyy.”

Once there, we handed over to the cardiologists and assisted transferring him to the operating table for the procedure. During the transfer my cremate was unfortunate enough to get an eyeful of old-man-penis. (“Wheeeeeeeyyyyy.”) I didn’t ask for details but going by the beard on his face and the pained look on her face, I imagine there is more to that encounter that met her eye. Poor lass. Bet she wished she was on the board! As if……

Despite the short period of excitement we’d just encountered, we needed coffee and some more mango so we quickly made our exit and headed back to the safety of the truck! As we wondered down the corridor all that could be heard was “Wheeeeeeeyyyyy.”. I'm still not sure what that noise was all about!

To be continued…….

Twas The Night Before Christmas

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

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

"52 year old male, chest pain"

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

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

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

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

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

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

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

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

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

"I've got a pulse!"

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

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

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

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

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

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

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

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

"64 year old male, cardiac arrest."

Here we go again......

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

*          *          *          *          *          *          *

UPDATE March 2014:

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

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

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

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

"Dear Ella, 

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

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

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....

The Ass in Assumption

"56 year old female, chest pain"

Chest pain is a funny old job. More often than not it is a LOB. Muscular chest pain, panic attacks, drugs, abdo pain, heartburn and indigestion. Obviously due to risk of heart attacks it is a very high priority call and rightly so. Cardiac care in London is of such a high level, if there is a chance it is a heart attack the sooner we are there the better. Survival rates are improving year on year and if it is a heart attack you will normally be on the table in the Cardiac Catheterisation Lab within an hour of phoning for an ambulance. This particular day had been a day full of rubbish. A collection on man-flu, vomiting and period pains. This job had 'potential' but we'd have to wait and see if it followed the calibre of the jobs thus far. We pulled up outside the house to see an FRU already there. The job was only 4 minutes old so he must have been round the corner. We went inside and were taken to the UPSTAIRS bedroom by the patients husband. 

The FRU was knelt down at the bedside, the patient was sat up in bed and to be honest looked like crap. Pale, sweating and in obvious discomfort. Unfortunately the guy on the car looked equally like crap but for different reasons. Hair was a mess, unshaved, shirt untucked, no epaulettes, creased, chewing gum and laces undone. Uniform is a pet hate of mine. We are a uniformed service and as such you represent your service and your colleagues when you wear it. The is no excuse to look as scruffy and unprofessional as he did. My crew mate had disappeared off to get the chair while I found out what had been going on. She had a sudden onset of pain 15 minutes ago in the centre of her chest, the pain was also in her jaw and left arm. She described it as a crushing pain.  The FRU took her pulse, blood pressure, temperature and BM and then said the following:

"Well, your OB's are fine, I'm pretty sure it's not your heart, grab your things together and come down to the ambulance"

He then looked at me and rolled his eyes. Was he for real?! Was he not seeing or hearing what I was?! She had a great cardiac story, she had risk factors (overweight, smoker, diabetic and hypertension), she was clammy, the pain was radiating and she had chest pain!!!

"It's OK, you stay there, my crew mate is getting a chair for you, we'll pop you down to the ambulance and do an ECG to have a look at your heart and then decide what to do. Is that OK?"

She agreed and looked rather relieved. That clearly pissed off the FRU but at this point I didn't care one iota. We got her down to the truck and wired her up to the Lifepack. As here initial rhythm came up on the screen the FRU chipped in again and said to the patient in a cocky tone and a wink:

"From here it looks alright, you'll be fine"

What an ass! About three seconds later the ECG printed out. Unsurprisingly she WAS having a heart attack. For those in the medical know it was a huge anterior MI with reciprocal changes and at least 12mm of elevation in V 1, 2 & 3. For those not in the medical know, it was a massive heart attack! The FRU sheepishly moved to the back of the truck whilst I explained to the patient and her husband what was happening and what was about to happen. A lot was about to happen very quickly, I was going to cannulate her, give her morphine, more GTN, blood pressures and ECG's galore on route, lights and sirens, a procedure in an operating room and all within the next half an hour. It is daunting but she took it in her stride and stayed calm. We put in a blue call to the cath lab (heart attack centre) and headed off. The FRU chose not to come with us........

We pulled up at the hospital and the back door swung open. The lead cardiologist was waiting to see the ECG. I passed them out to him and gave the handover whilst we were wheeling her into the hospital and to the lab. We transferred her to the table and left her with a swarm of Dr's and nurses prepping her for the procedure. We sat in the viewing gallery and watched. 20 minutes later the cardiologist came out with a petri-dish in his hand. In the dish was the clot that caused the heart attack. It was tiny! Our patient was now pain free and her ECG was normal and would make a full recovery, albeit on medication for life. Amazing! The joys of modern medicine.

This was a great job and highlighted a number of things good and bad. Firstly, call 999 for chest pain. If it IS a heart attack you will get the best treatment in the world and quickly. If you look at the times on this job, you can see why survival rates are so high.

Onset:                  21:50

Call connect:        21:58

Dispatch:              21:59                   *Balloon is the term for when a stent is in-situ

On scene:             22:03                     and the coronary blockage is cleared.

To hospital:          22:21

At hospital:           22:29

Balloon*:              22:55

Onset to Balloon:    1 hour and 5 minutes

Secondly, never, never, never, tell a patient they are fine when they clearly are not and never say "It's not your heart" when it clearly is. Don't commit to a diagnosis and don't mislead or lie to a patient. You get caught out will look like an ass. Finally if you have a uniform wear it properly and if you have an attitude, loose it.  It makes you look like an ass. I can't stand these people, luckily they are rare but they are ones who get the complaints and their image is reflected onto all of us. If you have the job and hate your patients leave. Rant over! x