Sunday, 17 August 2008

While I'm thinking about it.

Thinking back to the diabetic lady on my last shift got me thinking of one of my first hypoglcaemic (low blood sugar) patients. When we get a call stating diabetic problems it's usually for a 'hypo' obviously the last patient wasn't the case. Anyway I was a trainee technician and working with a clinical team leader, we also had a trainee paeds nurse observing for the shift as well. We get a call to a diabetic. Arrive on scene to be greeted by a frantic 10 year old shouting and screaming from her front room window, I later learned that she was hard of hearing. I grab the response bag & drugs and run over to the window, the girl beckons me in and with out stopping I jump onto the window ledge and step into the front room. I'm confronted with a heap on the floor, it's our patient, the young girl's mum. She's unconscious and snoring. Now at this point I turn left to see my crew mate and the nurse. They are looking at me rather blankly. 'Didn't fancy the door then?' said my crew mate. DOH!, a vision of homer simpson pops up in my head. It was a real casualty moment, Josh would have been so proud!!! Anyway I sorted her airway with a basic chin lift which sorted out the snoring, gave some oxygen and then gave her an intramuscular injection of glucagen which worked a treat, after some oral carbohydrates she was left in the care of a friend. This would turn out to be a regular patient in the years to come. I made a mental note to myself - always try the door first.

We also had a heroin overdose that day. It was in a part of town that was notorious for ODs. Young lads from up north would descend on the south and get mixed up with drugs and we would frequently be called to pick up the pieces. 'Er it's me mate like, he's gone an stopped breathin ain't he like.' was the usual greeting. It was no different on this call. We pull up outside, grab our kit and make our way to side door of this 3 storey town house. The door is rotten and the inside isn't much better, no lighting and a horrible stale smell. We were shouting out but heard nothing, we carried on to the stair well and heard a faint voice. Up on the next floor in the hall was a young chap who stated that his mate had just had a £10 fix and was behind the bathroom door, he didn't think he was breathing and couldn't get in. Before I knew what was happening my crewmate had managed to squeeze his way behind the door, taking with him an OPA (oral airway) and a cannula. 'Chuck us some Narcan (naloxone-antidote for opiate OD/poisoning) and a flush!', 'It's here I say, passing it behind the door.' I was also getting the BVM & O2 out to pass to him but by that time I could hear a wretch as the patient gagged on the OPA. 'Bloody hell he's got the IV in and given the Narcan before I could even blink and the patients breathing & upright!' I said to the observer. This was my first heroin OD and couldn't believe how quickly this stuff works. If anyone has seen that Nicolas Cage movie - Bringing out the dead then you'll know what I mean. This was several years ago, these days we don't rush to give Narcan IV as it can wake people up so rapidly they can become aggressive. We usually sort airway and breathing out, get a line and give it diluted and maybe give a prophylactic Intramuscular injection to help prevent relapse, which can happen as heroin stays in the system a lot longer than Narcan.
Another thing to avoid initially is rushing in to secure the airway by intubation, yes the airway & breathing is extremely important but is usually managed with basic oral/nasal airways, BVM and O2. There was a paramedic locally who intubated a heroin OD patient, administered Narcan, the guy woke up rapidly and legged it off down the street. Trouble was he still had the endotracheal tube in his throat, tied in, most amusing watching him running down the road whistling like a kettle every time he took a breath.
No one saw him again, a lesson had been learn't.

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