Bemused

"63 year old female, cardiac arrest"

There's that all to familiar ominous feeling when we get dispatched to a cardiac arrest. There is a heightened tension in the cab and my senses are much more focused on the drive. I can feel my eyes fixed on the road ahead, assessing the movement of everything ahead of me. What our advanced driving course taught me most was awareness and hazard perception. After 5 years of practice it's all second nature but still requires concentration. At any one time on a blue light drive we are planning our movements based on everything in the distance and just in front of us. It's changing constantly. 

I was racing through the high street, watching for pedestrians on both sides of the road, scanning the parked cars for potential movement, monitoring all 3 sets of traffic lights and looking for gaps in the traffic for me to weave through. A car 100 meters ahead on the other side of the road flashed to let me through. They were just before a traffic island which had a pedestrian standing on it. I pulled out onto the wrong side of the road, my lights and sirens were on and headed towards the gap the car had created for me.

As I approached the island, I could see a man waving at me. I started to slow down in case he was flagging us down. As I got closer I could see the expression on his face. I could also see it wasn't a wave. He was doing a 'wanker' hand gesture, whilst mouthing expletives at us. His eyes full of of hate and anger. As we were drawing level with him he raised his middle finger and spat at the ambulance. We continued on our way.......bemused.

Please, someone explain why people like this exist! How can anyone have such hatred for the ambulance service?! You could see the hate in his eyes. Is it a uniform thing?! I genuinely don't get it!

I'd loved to have stopped and asked for an explanation or to hear what he was saying but a lady was dead and we needed to fix that! We arrived, fixed it, she survived and wrote a thank you letter. I wonder if he would have behaved the same if he'd walked past us doing CPR! Hmmm......

Thoughts on a post card please. I'm looking for answers and solutions! Sensible or not!

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.........

I Didn't Think

Welcome to Facepalm Friday! I've decided that each week I will share with you a patient, or a conversation or an encounter that has simply left my head in my hands. Far too often I'm left questioning how some people manage to exist being so moronic! If anyone has their own tails to share, of people they've met or contenders for the Darwin award, I'm happy to have guests posts! Enjoy!

So......

"47 year old female, dizziness, pain in jaw, headache"

10:15am: Patient phones NHS 111 and lists her symptoms. She told them she had chest tightness radiating to her jaw. She said she had severe ear pain. She said she was dizzy. She also had a headache. Despite it's faults, NHS 111 correctly requested an ambulance to be dispatched because of the priority symptoms. 

10:26: Because the patient has told the call taker she has chest tightness it is categorised as a high priority of call. An FRU (Fast Response Unit) and an ambulance were dispatched.

10:32: FRU arrives on scene (me!)

10:33: Ambulance arrives on scene

10:51: After much knocking and shouting and several attempts by control to phone the patient back the door is answered by the patient. 

"Sorry, didn't think you'd be so quick, I normally have to wait ages for my ambulances. I thought I'd have a shower before you arrived."

In my humble opinion, if you are well enough to jump in the shower whilst you are waiting for your emergency response you are a) not that ill and b) not an emergency. Also, the phrase 'my ambulances' grated on me. It means she has us out a lot, probably for similar symptoms. 

"What's the problem today?"

"I already told them on the phone!"

"But that wasn't us was it?!"

"OK, I've got this awful headache and dizziness and this pain in my jaw."

"Do you have any chest pain?"

"Nope."

"Oh, you told the call taker you did! What pain killers have you taken?"

"I haven't taken anything."

"Why not?"

"I didn't think they would work"

*Facepalm*

Seriously! Why do people not take pain killers! The clue is in the name! Time and time and time again it's the same futile conversations! "Are you in pain?", "Yes", "Taken pain killers?", "No". Why?! Why?! Why?! Can someone please suggest an answer to this age old question!

"So what time did the symptoms start?"

"About 2 weeks ago."

*Facepalm*

"Has you seen your GP?!" I asked, fully expecting her to say 'No'!

"Yes."

"And did he diagnose anything or give you any medication?"

"Yeah, these." she said as she passed 2 packets of drugs.

Ah, clarithromycin and prochlorperazine! The former, an antibiotic which she was given to treat an ear infection and the latter is a medication used to treat dizziness caused by inner ear problems. Both should be alleviating her symptoms.

"How long have you been taking these?"

"He gave them to me a week ago but I haven't taken them."

*Facepalm*

"Why not?!"

"Because I thought they'd make me feel sick ."

*Facepalm*

Notice she said 'thought'. She hadn't felt sick because of them. Her, an expert in general practice and pharmacology (not) had opted against the medication given to treat her symptoms. Instead, she called for us! The conversation continued in much the same way whilst we were checking her over. We did her ECG and the full battery of tests we do on most people and found nothing untoward. 

"How about we leave you at home, you take your course of medication and if that doesn't work make another appointment with your GP?"

"Nah, I think I should go to hospital. I know my body, something's not right."

*Facepalm*

Yeah, you have an ear infection and needed clarithromycin and prochlorperazine to cure your symptoms! It's not rocket science! Why do people go to their GP, call 111 or 999 and then ignore all the advice they are given?! Why?! Why?! Why?!

I gave it my best shot at convincing her she didn't need to go to hospital but she was dead set! We walked her out to the ambulance. On board I continued to ask her questions about her symptoms, specifically the jaw pain. 

"So how long have you had this pain in your jaw?"

"About a month, I've seen my dentist about it and he says I have a tooth infection."

"And did he give you anything for it?!"

"Yeah, these." 

She produced a box of Amoxicillin from her hand bag. I don't know why I had to ask, I knew what the answer would be but I was curious!

"And have you been taking them?!"

"No, I don't agree with antibiotics."

*Facepalm*

11:17: I got out of the ambulance to let them get on their way.

11:37: (ish) Patient arrives at A & E and her 4-6 hour journey of waiting, triage, waiting, being told off, waiting and discharge begins. 

There are times when I write my blog and I really really wish that what I was writing about isn't true. Frustratingly, it is painfully true and not uncommon or an isolated incident. It happens every day!

NHS 111 has its faults, the GPs have their faults, hospitals faults are well documented as are those of the ambulance service. As for dentists, again, it isn't perfect, but we know we have to a) wait and b) pay. People have a got over the 1996 semi-privatisation of dentistry so don't moan as much! My point is though, all areas of the NHS have faults, but people like this are not the fault of anyone. The GP and the dentist saw the patient and offered treatment. She didn't take the medication. NHS 111 had to call an ambulance because she lied about her symptoms and we had to take her to hospital because she insisted. The hospital then had to see her, triage her and waste the valuable time of the doctors and nurses; for what?! To give her another prescription that the tax payers are funding and she isn't taking. She can't be charged the £1000s she cost the NHS. She is unemployed. She can go home, not take her medication and then call us back in a few days because she's still ill and the cycle continues until her body heals itself....until the next time anyway. Unfortunately you can't medicate stupid.

*Facepalm*

Playing Cards

"24 year old female, chest pain, DIB"

I tend to be very cynical about young people with chest pain. It is very, very rare that the chest pain is anything sinister at that age. However, I'd reserve judgement until I met the patient and oh what a treat I was in for!

The door was ajar when we arrived, so pushing it tentatively open I shouted a speculative 'Hello?!' as I entered. We were summoned through to the living room where our patient was sitting on the sofa, smoking and watching TV. 

"Hello there, what's the problem today?"

"I got a cough innit."

"OK, how long have you had it for? What has your GP said?"

I always ask that question knowing full well that 99% of people haven't bothered with their GP, but it's my way of subtly making a point!

"Bout 2 days, I ain't bovvered wit ma GP coz they are useless innit." 

She said that while exhaling smoke into my face. 

"Can you put that out please?"

*kisses teeth* "Ya can't tell me what to do in my OWN house, ya get me." 

"Firstly I asked you, I didn't tell you, and secondly can you also refrain from kissing your teeth at me."

*kisses teeth* "Whatevs man."

There is nothing I hate more than teeth kissing. It winds me up something chronic. We don't ask to go to people's houses, they ask us to come to them. Show us some respect and courtesy. In this case, that means no teeth kissing and no smoke in the face. It really isn't asking much!

We checked her over, did an ECG etc and decided that she should go to hospital. The reason for this, she didn't know who her GP was so we couldn't refer her on. She was also complaining of pain in her chest and although it was most likely to be caused by the excess coughing, without a blood test we can't rule out cardiac problems as the cause. As we were getting ready to go to the ambulance she said:

"I can't walk, I feel dizzy."

She wasn't about to be carried. We explained there is no medical reason she can't walk. Her legs are fine all she has is a cough. Cue farther teeth kissing. We assisted her to standing and started walking her to the truck. She then took it upon herself to throw herself on the floor and pretend to faint. I've seen enough people actually faint and plenty that fake it to know the difference. After a few stern words she magically came round, of course, with selected amnesia and no memory of dropping to the ground. Miraculously, she made it to the ambulance. As she climbed up the steps I told her to take the second seat on the left. She laid down on the bed. Brilliant!

The journey to hospital was uneventful and lacking conversation. Her dying swan routine was in full swing and she didn't seem in the mood to answer questions. When we arrived she wouldn't get off the bed, so rather than arguing, we took her in on the bed. I handed her over to the nurse in charge who promptly directed us to 'the lounge! (The waiting room!)

*kisses teeth* "I ain't goin' to da waiting room, truss me bruvs." she said to the nurse.

He looked at her, looked at me and simply said "waiting room"! I love the power nurses have! We started wheeling her back down the corridor as her expletives and mood began to worsen. She had certainly found her voice again! We largely ignored her rant. It was nothing to do with us, it was the hospitals choice where she waited! 

The waiting room was packed. We wheeled the bed up to the chair and asked her take a seat. After a slight delay and a little fuss she clambered onto a chair. My crew mate took the bed back to the ambulance whilst I booked the patient in at reception. Suddenly there was a commotion from the waiting room. I cast my eye over and my beloved patient was lying on the floor, half faking a faint and half faking a seizure. Her movements were not involuntary. It was was one of the worst fakes I'd seen, but the waiting room was in uproar, demanding help and a bed. As people were looking at me to do something, I wandered over. 

"Up we get, sit on the bench, this won't get you seen quicker."

*keeps up charade*

"Come on, you're embarrassing yourself." (and me).

At this point another patient of similar age decided she'd seen enough. Not of the patient faking illness to get seen quicker, oh no. Of me and my failure to treat her!

"You're a disgrace, how can you stand there and not do anything, it's well out of order."

"She is faking it. I know it, and she knows it."

"If she was white she'd have a bed and you wouldn't leave her on the floor."

Ahhhh, the race card. If at first you don't succeed, accuse someone of being racist! At that point, I decided to walk away. I wasn't going to get drawn into a race row in a crowded waiting room.  I never discuss the colour of my patients in my blogs or in real life unless it's relevant. It very rarely is. Today it wasn't. It makes absolutely no difference to me. I don't see a difference, race doesn't even register on my radar. Yet here I am, stood in front of 40 odd people, being publicly labelled a racist. 

I could have informed her that I have siblings that are black. I do. I could have listed to her my Indian, Chinese, Egyptian, Polish, Romanian and Nigerian friends. I could have told her about my black gay friend who I shared a flat with. But I didn't. I don't need to defend myself. I don't need to acknowledge her ignorance. I don't need to feed her desire for an argument. If anything, my being white was an issue to her. I left the department with my patient pretending to fit on the floor and her new found guardian shouting obscenities at me! 

Living the dream.....