I Want It Now!

"30 year old female. ?Sepsis"

No one likes getting off late. No one likes getting off late especially when it is because of a GP! With only 45 minutes to go until we were off we got the 'Sepsis' job. I could tell before even arriving that it wasn't sepsis. I'd have been happy to stake my job on it! Besides, it was 17:45; call me a cynic but I'm sure this GP surgery closes shortly! We grabbed our bags and headed in. This GP surgery in particular has provided me with more blogs than any other. They leave more patients in the waiting room with letters and they call more ambulances on Monday mornings than any other. 'GPs: Take Note' and 'Gone Fishing' were the recent posts inspired by this abomination of a surgery. We were directed to the same room as we always are. Inside was our patient lying on the bed with her fiance by her side. In a change from the norm the GP was also still present; probably because we were on scene within two minutes and he didn't have time to palm them off to the waiting room. I listened to his sepsis handover with eager anticipation and it did not fail to deliver:

"This lady has a three day history of feeling unwell complaining of febrile symptoms. She is pyrexic at 38.2 and tachycardic at 101. She is expected by the medics to rule out sepsis"

Sepsis?! 30! A three day history of a cold in someone normally fit and well? I did her obs while she laid, whimpering on the bed. Her temperature was 37.9, her pulse was 84, her blood pressure was good, her oxygen levels 100%, her blood sugar normal and no cough to mention. She did have a 2 day history of urinary symptoms which I'm guessing could be treated by the GP with antibiotics. But what do I know, I'm just a stretcher monkey! I read the sorry excuse for a letter, and as much as every part of me wanted to tell the GP to do his job rather than palm her off to the hospital, I suggested to the patient we go to the ambulance. 

"She can't walk, can you get a stretcher?" her fiance quickly interrupted.

"How did you get here today? She must have got in here somehow"

"We got the bus"

"Right, so she can walk to the ambulance"

"She's been on the bed a while, she is probably feeling weak, I'd advise a chair" said the GP. 

Oh would you? Of course you would. You are not the one who has to carry her. Whilst continuing to bite my tongue I asked my crew mate for a chair. Whilst waiting I continued to try and get some more history. Unfortunately the patient was too ill to answer so her fiance answered for her. 30 years old and she is acting like a 5 year old. It was embarrassing. My crew mate returned with the chair, opened it up and asked her to sit in it. She sat up about 6 inches then dropped back.

"I can't, I'm too dizzy". 

Oh, she can talk after all. Her fiance then tried to dead lift her from the bed to chair. I stopped this attempt quickly in its tracks and respectfully explained she was perfectly capable of getting into the chair. At last the GP agreed and told her to get into the chair.

Once on the ambulance the drama continued and her refusal to talk returned. It was a relatively quiet journey to hospital as she wouldn't speak and her fiance couldn't answer my questions. We wheeled her into A & E as she 'couldn't walk' and joined the other 4 ambulances in the queue to hand over. We were quickly told there were no beds so it would be at least 2 hours to hand over. Her fiance asked what the problem was.

"There are no beds, it will be two hours until we hand over and then 4-6 at least to see a Doctor"

"Let me speak to the doctor, this isn't on, my fiance is sick and needs attention"

"The nurse is over there, she can direct you to a doctor but it won't change anything, there are no beds"

On over-hearing this news, our patient started crying. And I don't me a whimper and a tear, I mean full on balling-eyes-out crying and whaling. Everyone was looking, I was cringing, it was what you would expect from a 3 year old you have removed from a sweet shop without any sweets. She was 30 years old, not Veruca Salt stamping her feet saying 'I want it now'. This went on for 10 minutes until the doctor DID come and see her. Apparently she who shouts  the loudest does get seen. It wasn't the outcome either of them wanted though.

"I am the doctor in charge of the patients in this department, there are 42 people waiting to be seen ahead of you. They will be seen in order of clinical need. That is what 'triage' means. No amount of screaming, shouting and crying will change that. I have seen your letter from the GP and to be quite frank you are not a priority. You will wait like everyone else has to and if you don't like it, the door is over there, now stop this nonsense and act your age."

Silence! Chew on that! Now THAT is what I call a 'bedside manner'. It was exactly what needed to be said and it was exactly what everyone else was thinking. If only we were allowed to say it how it is! Unfortunately we are forced to bow and say 'yeth sir, no sir, thwee bags full sir'. That's just the way the cookie crumbles. 7 years at med school gives you the right to verbally bitch slap people!

OCD, Trees & GPs

"50 year old female, GP visited, states patient wants to kill herself by starvation, states patient's partner is assisting her suicide attempt. To be taken to the nearest A & E"

Well this job was pretty self explanatory. A GP (one that'll soon be in charge of the NHS) went round for a rare home visit, he couldn't get her to agree to hospital, so booked an ambulance. He did that in the full knowledge that if she refused hospital, with the information he had given us, we were now responsible for her! He knew she would refuse but it's easier to pass the buck. C'est la vie!

It was a baking hot summer's day, we had spend the morning broken down, sitting out outside the sweltering ambulance eating ice cream! It was a small victory! The second our vehicle was fixed, this job was sent to us. We headed to the address and went in to the building. The patient was lying in bed, only her head visible, the reason she wanted to kill herself was because she was fed up with her Obsessive Compulsive Disorder. She couldn't leave the bed without a 1 hour ritual which made going to the toilet the hardest and, I imagine, the most frustrating of tasks! So, the suggestion of hospital was not one she remotely considered. She refused all observations, any treatment and any transport. She just wanted to be left at home to die. I have seen a lot of patients with OCD but her's was severe. While I sat there talking, I observed the struggle she faced to do the simplest of tasks. She opened a brand new pack of 10 cigarettes wearing latex gloves. She removed a cigarette, cut the tip off with the scissors she removed from a sandwich bag and lit it with a match. She was then unable to smoke the remaining 9 as the pack was already open. Expensive habit!

Our problem was the age old one of capacity. In legal terms its a 'grey area'. The first question on our capacity assessment tool is 'Is the patient free from any external pressure?' Unfortunately we had already been told by the GP that she wasn't. The partner is of the opinion that starvation is a pain free way to die and as our patient was bed bound, by not feeding her, technically he is assisting the suicide attempt, thus preventing her from being free from the aforementioned external pressure! Sigh! We talked and talked about hospital and how we could make it easier for her. We agreed to 'sterilise' the ambulance by covering a seat in plastic bags, we fetched a 'sterile' infection control suit for her to wear and after a few hours we were making progress. She was out of the covers and had the suit on her legs. Then the partner returned:

"She doesn't want to go to hospital"

With that, all our good work was ruined. Within seconds she was back in bed, head poking out above the covers. We requested the police and one of our officers, as by this point we had been on scene for 3 hours and there was no end in sight. While waiting for the  grown-ups to arrive some family and friends of the patient arrived 'to say their goodbyes'. Please note, she was not about to die, nowhere even close, but the fact she wanted to die meant I was not happy leaving her, especially in the 'care' of her partner. Once the police arrived we had a lengthy discussion about what to do. A sectioning seemed the likely option. Being in her own home meant we were limited to what section we could use. We went back inside to discuss said sectioning and stumbled upon all 9 people who were now in the house singing 'Kum ba Yah' complete with guitars and drum. It transpired that the big tree outside the property was being felled by the council the following day, so they are all meeting up to sing it a song and have a group photo with it. Yes, a group photo, with a tree! Hippies!

Trying to arrange a sectioning on a Sunday afternoon took hours. Eventually it got to the point where all we needed was her GP, the one who phoned us! We had the police, we a had an AMHP, we had an OOH GP, all we needed was hers. Bare in mind we had now been on scene for over 7 hours. My shift finished 3 hours ago, we hadn't had a toilet break, we were more than a tad annoyed by now and then the following conversation occurred:

Ring ring...

"Hello"

"Hello there, my name is Ella Shaw from the Ambulance Service. Is this Dr Smith?"

"Yes, how can I help"

"Well, we are with Miss Jones, who you requested go to hospital earlier"

"Ah, OK, yes I remember"

"Well, we are trying to arrange a sectioning. We have the police, an OOH GP and AMHP on scene, we just need your signature so we can take her in as you requested."

"I'm sorry, but i've got plans this evening, afraid I can't help you."

What?! Have you?! Dont we all?! What a complete waste of time, we had spent most of the shift there, as had 2 policeman and all because the GP couldn't be bothered to do his job in the first place. The outcome was that the patient stayed at home, our officer in my opinion copped out and gave her capacity to refuse. He asked the police to take the partner out of the property and re-assessed her capacity. He came to the conclusion the external influence was now gone. It wasn't, it was standing outside 20 feet away. We were left bewildered and utterly frustrated. The doctor on scene didn't believe she was in immediate danger so a section 135 would be arranged the following day. At least she would get treatment but that didn't help alleviate my foul mood. 

This job did highlighted the issue of OCD. It was the first time I had seen it in such a debilitating way. When people think of OCD this think of excess hand washing, obsessed with tidiness, flicking a light switch on 'X' number of times before entering a room but it is much more varied and severe than people may be aware. It is an anxiety disorder characterised by intrusive thoughts that produce unease, apprehension and fear. The symptoms can vary from excessive washing and extreme hoarding to alienating nervous rituals. It is a mental health disorder that is far more common place than people may be aware and is now the fourth most common disorder to be diagnosed. It is now diagnosed  nearly as often as asthma and diabetes. Very rarely is OCD a stand-alone problem. It is often accompanied by depression, generalised anxiety disorder, anorexia, Asperger syndrome and frequent panic attacks amongst others and like all the above, it requires treatment. Our patient had gone without treatment for many years and the consequences were evident in the way she was now suffering. Like with most mental health disorders early recognition and early treatment is the best way to produce a positive outcome. No one wants to enforce a sectioning and no one wants to drag someone out of their own home for treatment but it is a necessary evil. To prevent this, services and referrals need to be more readily available and easily accessibly. I'm sure i've said that before! Why bother though, it's only OCD eh?! Hmmmm!

GCSEitus

When you hear about parenting you think of newborns, toddlers, the terrible twos, starting school and tantrums about eating peas. Everything is new when the responsibility of parenthood is thrust upon you and as a result, every new thing that happens gets talked about and analysed. Obviously, parenting is a lifetime thing and the teens are a huge part of that. GCSEs! I remember them like they were... oh god that is terrifying! 11 years! Now i'm annoyed! Is it really that long?! Anyway, I remember my parents badgering me to revise, the pressure of exams and being desperate for it to be over. It is therefore no surprise that so many kids are desperate to get out of it! What I am saying is in May be extra vigilant. It is not a coincidence that every teenager has a headache, a cold, and random pains, and funny turns that they don't normally have! Be aware, GCSEitus is real! Don't fall for it!

"16 year old female, chest pain"

Every year, May signals the start of GCSEs. Really, they are what 16 year olds have been working towards since day one at reception, at the tender age of 4. 12 years! It doesn't seem so long now; I can remember 12 years ago with relative ease, and these days the years are flying by. For a 16 year old, 12 years is an unimaginable length of time. Probably because they are far too busy worrying about being moody, petulant, image conscious and of course... their GCSEs. When I look back, it wasn't a pleasant time at all. Parents pushing me to revise (thank you), teachers drumming it home that these exams could well shape our future. No GCSEs means no A levels, no A levels means no degree, no degree means you might as well end your life as you will never get a job, never earn money, you'll be homeless and live a life on benefits inhabiting a studio flat that smells of Special Brew. You'll turn to crime, get arrested, go to prison and be stuck in that self-destructive cycle for the rest of your short life until you die from liver cirrhosis from all the excess drinking. OK, a bit dramatic, but I do think the scare mongering that goes on only adds to the stress, sometimes unnecessarily. GCSEs are important but they are not the be all and end all. I did OK, I don't have A levels and didn't do a degree and I like to think I turned out alright! 

During exam times, there is a sharp rise in what I like to call GCSEitus. As important as they are, the students will try anything to get out of them. To what end I don't know, a couple of days extra revision, a bizarre thought that they may be able to find out the questions for when they sit theirs maybe? We are frequently called to schools for all sorts. It normally comes down as 'a faint', 'a fit', 'DIB' or something which can easily be faked. The pseudo fits, pseudo faints and the dying swans are normally found in the first aid room with a member of staff, a pained look on their face and a fascinating aptitude for spontaneous recovery on making it to the back of the ambulance. I've never known one of these jobs to be anything worse than a panic attack and today was no different. In the first aid room was our patient (complete with pained expression), her teacher (with an exasperated look on his face) and her mum (with a terrified look on her face).

When I walked through the door my suspicion was confirmed. Apparently she had been breathing really fast and as she was about to go into the exam she 'fell' to the floor. After being 'unresponsive' for a few minutes, with the assistance of her teacher, she was able to 'walk' to the first aid room. Her breathing was now fine. Her mum was called and told her daughter had 'collapsed' and an ambulance had been called. Naturally she was worried. The teacher was standing patiently waiting for his fifth ambulance of the week. Naturally he was fed up! I spoke to the girl about her symptoms and she described a panic attack. She didn't have any symptoms remaining so I didn't see the need for hospital. When I suggested coming to the ambulance to check her over properly before leaving her, the pained expression turned to one of desperation. She stood up to come with us and 'threw' herself to the floor. On helping her up again, she could no longer walk or weight bare on her left ankle. My crew mate examined her. There was no bruising, swelling or obvious cause for her pain. She certainly didn't go over on it or suffer trauma to it. Little did she know that my crew mate used to be a sports physio. He knew she was making it up, I knew she was making it up and so did her teacher. Her mother still looked terrified!

Our problem is that although she was acutely suffering GCSEitus we are in no position to accuse her. We have to take what she says as true, so the 10/10 pain had to be treated with entonox. As she 'couldn't' walk he had to get a chair and carry her. It's all part of the game. We took her to hospital. The nurse taking the handover took one look at her and said to me:

"In the middle of GCSEs?!"

See, it's not just us who notices the increase in 16 year olds attending hospital in May. It's the whole health care system. Hospital waiting rooms are full of them and I'm sure GP surgeries are inundated with 8am emergency appointment requests for generalised pains and breathing problems. I don't know what the cure for GCSEitus is, there probably isn't one, but I reckon by starting off convincing them that a D in German will not resign them to a life of crime and Special Brew is a good place to get the ball rolling. As for our cherub of a patient, it turns out she self-discharged out of A & E after her x-ray showed no damage. Oh, and she walked without a limp by all accounts. Miraculous! Another life saved!

Increased level of Consciousness

"25 year old male, increased level of consciousness"

There is often criticism of how well ambulance crews measure levels of consciousness. As a rule we use a combination of common sense and the Glasgow Coma Scale (GCS). A patient is given a score based on a number of variables to determine what level of consciousness they are. A score is given out of 15 and can be as low as 3. Someone who is completely unconscious is deemed to have a GCS of 3. Someone with a GCS of less than 8 is judged to be in a coma. There is often a discrepancy between the hospitals and us as to what score the patient has. We tend to over-triage and make out a patient is worse than they are and hospitals tend to under-triage and paint a rosier picture. In a hospital it doesn't matter so much as there is constant monitoring of a patient's condition. Pre-hospitaly we have limited time and limited expertise to do anything other than be over cautious.

This is the template by which we measure a GCS:

It is a crude tool in many cases; it's hard to use on patients with dementia or any other pre-existing cognitive impairment, it's very vague on paediatrics, and if someone is blind or a mute they could easily be judged to medically in a coma!! It has its uses, especially for head injuries and strokes, so it is a valuable assessment tool at our disposal. It's most often used to determine just how much alcohol has been consumed!

When call volume is particularly high, or there are not enough ambulances running, our control will do a 'general broadcast' of the calls being held. They do this in the hope that a crew sitting at hospital, or on a "non-conveyed", who are almost ready for another job will offer up for it. We were sat at hospital when the following came over the radio:

"General broadcast, all units, ambulance required for a 25 year old male with an increased level of consciousness. I repeat, general broadcast, all units, ambulance required for a 25 year old male with an increased level of consciousness. Please press green mobile of come up RTS Priority, time of 18:56, my initials are Echo Sierra, over"

Increased level of consciousness?! That's a new one even to me! I've heart of patients calling in their own cardiac arrest but this was highly original! Obviously, it was a slip of the tongue but it made us laugh no end. I imagine most other crews who heard it also had a laugh at control's expense! It did get us talking though. What would be an increased level of consciousness?! Going by GCS you'd need more points available than 15 to accommodate what I would presume would be hyperactivity! Maybe some recreational and 'class A' drugs could cause an increased level of consciousness! Maybe excess caffeine or too many E-numbers for kids would cause a 'raise' in the GCS! To that end I have created a new GCS table to be kept in your pocket books AT ALL TIMES! 

Clinically, it probably has its flaws, but I'm bored of documenting that someone is GCS 15 when it is quite clear that whatever they have taken has put them on a completely different plain to me! Clearly, GCS should be out of 18 on the count of really big eyes!

Hot Water

It pains me that I have to write this blog, but after two pretty shocking jobs in as many weeks, my frustration has boiled over (excuse the pun). It's simple really; kids and boiling water do not mix, skin and boiling water do not mix. Accidents do happen but these calls really did make me think that reproduction should only be allowed after passing written exams and parenting assessments! 

"12 year old girl, burns to foot"

It was a sunny day. Not a hot day, but a sunny one. In fact it was cold! We got the job and headed over to the estate. We located the flat, knocked and entered the open door. We were beckoned through to the living room, though the crying and screaming was enough to guide us in the right direction. On the sofa was our patient. The skin over her ankle was missing or peeled and there were scalds over her entire foot.  It looked extremely painful so we got her breathing on the entonox whilst we went to work applying burns dressings and cling film.

"So what has happened?" 

I said to her mum, who was sat, apparently not concerned and chewing gum on the other sofa. She was looking at her daughter as if she was making a mountain out of a mole hill, and us as if we were interrupting the football that was on TV.

"She dropped the water for the water balloons on her foot"

"Water balloons?!?!?"

"Yeah, we was filling up her water balloons"

"With boiling water?!?!"

"Yeah, it's cold outside innit and I din't want 'em to get a cold"

"Were you filling them up for them?!?!"

"Nah, but I was 'elping"

Personal feelings aside, we ignored what I had just heard and carried the girl out to the ambulance and off to hospital.

Three shifts later.......

"1 year old girl, burns to legs"

A similar setting, this time in a tower block. We bundled into the lift, discussing our previous burns job. The phrase 'seriously, what is wrong with people' was muttered by my crew mate. As we approached the door, again, the all too familiar sound of the screaming child could be heard from deep within the flat. We were let in and made our way into the living room. On the floor was the mother with the child on her lap. There was a nasty looking scald on both of her thighs. Like before we started dressing them with aqua gel and cling film as best we could. The mother didn't speak English but her neighbour translated for us

"Have you given her anything for the pain?"

"No"

"Any Calpol in the house?"

"No" (my crew mate grabbed ours and administered)

"How did this happen?" 

"I only left the room for 20 seconds and she grabbed the kettle and spilt it on her lap"

Obvious question: "How did she reach the counter top?"

"She was sat on the counter while I was cooking?"

"Next to a boiling kettle? You put her on the counter next to the kettle and left the room?"

"You make it sound worse than it is"

"Let's just get her to hospital, have you got her red book?"

"No, she wasn't born here"

"OK what GP is she registered with?"

"She isn't because she doesn't have a visa"

I left my line of questioning there, gathered up her stuff and ushered them out to the ambulance and off to hospital. 

Obviously, both jobs were reported to the necessary people, the outcome of which I will probably never know. But seriously... am I missing something?!! Do people really think it is OK for children to play with, or be near, boiling water? A water balloon filled with boiling water could have hit someone in the face. A 1 year old sat next to a cooker with a kettle of boiling water could have been much, much worse. Maybe I was naive, but when I came into this job I simply did not envisage that these things happen. I thought I'd see accidents, sure, but this?! Kids by nature are inquisitive, that we cannot stop nor would we wish to, it's how they learn; but ignoring hazards and putting them in harm's way is completely different. I often think and moan that health and safety has gone mad. 'Caution, Hot Coffee' on a McDonald's coffee cup was something I found bizarre, but maybe now not so ridiculous. Maybe the NHS needs to create a book or pamphlet called 'Don't give your 1 year old a kettle'. What is next?! Out of the bath and into the tumble dryer? Swimming lessons by dropping a new born in a pond and hoping survival instincts kick in? You know what, nothing would surprise me anymore!