Tuesday, 30 September 2008
Monday, 29 September 2008
On scene, nothing exciting as the fire is now out. I was too busy watching what was going on before I realised that I could be filming it. Oh well. The guy in green at the end of the clip is our fleet manager, he's not clinical staff but a mechanic by trade.
After another stint at a response post we were given a call in the centre of Richmond. It was a fire call. When we arrived it was no different to here in the UK. There were fire trucks everywhere. A shop was well alight and it had spread into the adjacent roof spaces of other shops. We stopped at one end of the street and liaised with one of the fire chiefs. A volunteer rescue unit also pulled up to where we were. Their role was to set up 'Fire rehab', this is basically a shelter where the fire fighters come to rest and get checked out to make sure they are OK to continue working. They spend no longer than 15 minutes in the fire and are then with drawn. They will then have their vital signs monitored and are given ice cold drinks. If their vitals are OK they get to go back in. This isn't all that popular with the fire fighters because all they want to do is their job. It's for their own safety which they accept. The RAA crew then supervise the overall health care needs of the fire fighters.
Sunday, 28 September 2008
After about 15 minutes a call came in for a chest pain and we were soon en-route. What surprised me was the relatively slow speed they were doing even on the highway. This has something to do with the 'black box' which is on every RAA ambulance. It monitors an individuals driving and will record any excessive speed, erratic changes or aggressive driving. It's one of the ways in which RAA are using technology to help reduce accidents involving ambulances and according to their management, it seems to be working.
We arrive on scene and pull up next to two Richmond PD cruisers. There are two police officers waiting for us and they give us a brief run down of the call. At this point I'm getting some starnge looks as I'm wearing my greens. A worried mother has call 911 because her 20 something year old son has done some crack cocaine and is now having chest pain. In side the house there is another police officer. He was standing with his thumbs tucked in his belt, side arm clearly showing. He looked like a stockier and older version of Eddie Murphy but a lot meaner. The Paramedic started to question the guy who continually refused any help but did allow a set of basic observations to be taken. His pressure was up and he was sweating. Even after the Paramedic warned him that cocaine in excess could cause a heart attack he still refused hospital. He signed a refusal to say he would accept responsibilty if some thing happened later on. His mom wasn't happy but that was his right.
Out side the cops finally spoke to me, 'Eddie' said 'What are you, some kinda state trooper or something?' 'Nope, I'm from the UK, I'm a Paramedic'. 'Get the Fuck outta here! I thought you were Canadian or some shit like that, what you doin over here?' So I told him and after a few minutes having a laugh and a joke with him and the other cops we left. At the time I wished I had a photo with these guys but didn't think it was appropriate given the neighbourhood we were in and the fact that we were technically still on a job.
One thing I found to be different was that the medics over here take the trolley in to virtually every job, probably because nearly all their patients go to hospital. Also when someone refuses, that's it. Over here we would probably have done an 12 lead ECG to try & rule out an MI or Ischaemia and even use it to try and sway the patient to go in. They obviously do things a little different. He's refused and in front of the Police as well, good enough.
Next, off to another response post to await the next call.
Saturday, 27 September 2008
After settling in at our hotel, The Linden Row Inn ,on East Franklin St we decided to head out and grab some food. The EMT who was our designated driver recommended Halligan's bar. This is an EMS/Firefighter bar. It was a saturday night and it was packed out but that didn't sway us. All we wanted was some decent food and of course a couple of beers to wash it down. We were definitely the 'out of towners' but everyone made us feel welcome. In one of the pictures is half a fire truck which forms the back wall, it also has all the drinks taps cleverly built in. A nice touch. 'Wanna bud?' said the girl behind the bar. 'Nah, give us some of that Yuengling stuff please'. Glad we did, it was bloody lovely. We learned that Yuengling is America's oldest brewery, personally I'd never heard of it until that night. Later on we were drinking a highly recommended drink, I think it was called The Hook & Ladder. Basically it's half a beer with a shot glass filled with various types of vodka dropped in the beer glass. When someone is about to drink these the lights and sirens go off on the fire truck. Again these were nice and really hit the spot. I didn't have a huge amount to drink but felt like I did probably down to the time difference. It was 23.30 in Richmond and 04.30 back home. We also met the owner and some of the guys in the bar, they really made us feel welcome. A thoroughly good night.
On the wall there are firefighter & EMS patches from all over, I'm thinking of sending some from my old uniform and getting the owner to send a picture back to me. Just got to get around to doing it.
Friday, 26 September 2008
Whilst I was on stand-by yesterday I added the IV from my first patient and happened to look at the page with all the incidents where I defibrillated, I noticed that I 'shocked' a patient on the 25th of August last year. I thought it was exactly a year ago but then realised that we are in fact September. Doh! That's what shift work does to your brain. I remember this cardiac arrest like it was yesterday for one reason..................it was a success! Now for those of you who are Joe public, pardon the phrase, survival from out of hospital cardiac arrest is poor. Really! you might think, 'but why?' I'll tell you why. A few simple reasons, when we arrive it is very rare that anyone is actually doing anything i.e CPR and the lack of public access defibrillators. Survival rates are on the up with the thanks to more and more defibrillators being made available to the public but we still have a long way to go. Especially when you look at places like Seattle and Las Vegas where either virtually everyone knows how to do CPR or there is an abundance of defibs available. Places like these have some of the best cardiac survival rates in the world.
Back to this job. We're at hospital and have just 'greened up' (made our selves available for calls) when a Cat A comes in, it's a collapse. It takes us 12 minutes to get there and that's with a heavy right foot! We arrive at the location, it's an old church which has been converted into a theatre, and are greeted by several well dressed people. We're ushered onto the stage where there is an unconscious male and two ladies performing CPR on him. They look round and see us coming in and stop CPR, 'Don't stop, carry on!' I say. The patient is Agonal breathing and this is best time to shock a patient. My crew mate then takes over CPR while I switch on the defib and apply the pads. It's a shockable rhythm. I charge up and deliver a 150 joule shock. A flat line appears and CPR is restarted. Within 60 seconds the patient starts to try and breath so we check a pulse. It's fast and faint but we've got one. I then start to ventilate him as my crew mate is getting a line in. The patient is now breathing adequately on his own and can squeeze my hands when requested. We know we're not out of the woods yet but it's a good sign. There was a second crew with us as well who helped getting him out and onto the truck. They got their trolley out as they had a different vehicle to ours and didn't know how to use our trolley, that was their excuse anyway. LOL. By the time he was on their truck he was fully conscious and alert and quickly blue lighted in to hospital. Later that night after taking someone else in I popped into coronary care to see how he was doing. He was in bed resting while obviously wired up to monitors so the staff could keep a careful eye on him. The CCU nurse told me he had a history of cardiomyopathy, this is a disease of the heart in which the heart muscle is abnormally enlarged. The heart's ability to pump blood effectively is usually impaired. I didn't want to disturb him so I left quietly. The next night I was also on and went down to CCU to see him and this time he was sat up, headphones on with classical music blaring. He turned and looked at me and must of realised while I was there. He shook my hand and said 'Thanks for what you and your team did for me, I really am grateful.' Just seeing him sat there was good enough for me, he didn't have to say anything. At the end of the day that's our job. OK we shocked him but the most important factor in saving this gent's life was the excellent CPR by the two middle aged ladies. The fact they managed to keep it going for 12 minutes is amazing. It must have been good CPR as he was agonal breathing when we arrived. As far as I know he is still alive and well today. As Gordon Ramsey says 'Successful Resus, DONE!'
This also highlights the inaccuracies with respect to Cat A response times and ambulance trusts performance; You get there in 8 minutes and they die = success, you get there in 12 minutes and they live = failure. It also highlights the need for everyone to learn CPR, just chest compressions will do. Like I said before it could save someones life.
Thursday, 25 September 2008
The crew pre alerted the hospital and blue lighted her in. Usually when we give a pre alert to the hospital we have at least a Dr & nurse waiting sometimes a whole team, dependent on the condition of the patient. No one was waiting! This does occur at our local A/E from time to time but on the whole they are generally pretty good. A consultant came over with a nurse soon to be joined by one of the staff grade Drs. A little bit whispering went on and the staff grade Dr went off again. They seemed completely uninterested. Having said that they still repeated all the observations and tests that we had carried out and treated her well. It was just the attitude.
In the ambulance service we treat for the worse case that way you can't really go wrong. When you start to become complacent that's when the problems start. I'm sure this girl was o.k and her tests were unremarkable. If we hadn't pre alerted and something had happened I can bet your bottom dollar that we would be the first to know about it!
Why do we bother? Because we care!
Tuesday, 23 September 2008
My first call was a Cat A chest pain. A 49 year old male undertaking some DIY started suffering chest 'discomfort' as he put it. He had a previous heart attack 4 years ago and said this discomfort was similar to that but not as bad. I was on scene within 60 seconds as it was only round the corner from base. He had taken a couple of sub lingual GTN tablets which had no effect. I started him on some O2 in the house and was quickly joined by a crew. On board the vehicle he was wired up so we could get a 12 lead ECG, it wasn't particularly good quality but I could see a slight elevation in his inferior leads. This is the underside of the heart and the leads looking at it are known as II, III & AVF. There was not enough elevation for me to thrombolyse this guy. Anyway he had some aspirin and 400 mcg of GTN and I put a line in his ACF and took 4 vials of blood so the Dr's could test it at hospital. His discomfort had subsided a little so we gave him another squirt of GTN spray. His discomfort was easing after the Nitrates which mean't that it was probably Angina and not a heart attack. He declined any pain relief. The hospital was pre alerted and he was run in on red. His ECG was borderline at hospital as well so I assumed he was kept in and observed, awaiting the results of his blood tests.
My next call was to an RTC, I was out on standby and was there first. The call was passed as 'female trapped'. When I got there the car was on it's side with the woman still inside, she was hidden by all the bags and coats etc that had fallen on to her. After quickly realising that she was ok, I got her out. I beat the firefighters to it. They did look a bit forlorn when they arrived. She was re assessed in the ambulance that had turned up. Witnesses said that she was driving relatively slowly and must of lost it on the bend. She was unhurt and refused hospital.
I was stood down from a couple of jobs and did a bit more stand by. My next call was to a man who couldn't cope with his wife who had dementia. She walked out of their caravan and refused to acknowledge that he was her husband. This wasn't a new problem and she was other wise OK. I walked them back to their caravan and gave the husband some advice. He then admitted that he had given her a Zopiclone tablet about 30 minutes previously. He apologised for calling and stated that he didn't know what else to do.
My last call was to an 18 year old dance student in his freshers year at the local university who had slipped and fell onto his left shoulder. It was definitely out but surprisingly he declined any pain relief as he wasn't really in any pain. His friend said that he was a good dancer, 'Not that good then'. I said jokingly. I took him to A/E in the car. And that is it, I'm finished as it is now 23.55 so I'll sign off and go put my morphine back in the safe. Next shift is Thursday on the RRV again.
1. Male in his fifties, OD. We were called to a methadone OD and as this was a potentially violent patient (so we were told) we stood off and awaited police attendence. The police were on scene so we made our approach. There was the usual gang of kids cycling round us being nosey, instead of being at home having an early night for school the next day! In the hall by the front door was a log splitting hammer, nasty looking piece of kit. I doubt it was used for it's intended purpose. In fact the house was home to a well known heroin user/dealer but we weren't there for this person. We were called to her so called partner who owned the house. He had drunk 6 cans of extra strength lager and thought he would see what her methadone tasted like. He necked 70mls of the stuff. Her daily dose was 30mls. He was actually charming and not violent at all and just wanted to sleep. We couldn't let him do that as the combined effects of alcohol and opiates would eventually stop him breathing and we would only end up there again later. Probably to resuscitate him. After much persuasion we got him on board the vehicle, pupils pin point, deep sighing respirations and sleepy we decided to give him some of the 'ole pick me up', Narcan. His partner was a right pain in the rear end, trying to tell my crew mate that he needed Narcan and constantly saying 'Look his eyes there pinning'. Yes thank you we do know what we're doing! He was in A/E within 10 minutes and being closely observed by the staff. Later we found out that he self discharged and was moaning how he was going to get home. I couldn't see what the big deal was it was only an 8 mile walk!
2. Dr's Urgent admission, patient in his 80's with urinary retantion and bleeding. This man was a dementia patient from a care facility. The GP hadn't even seen the patient but was referred to A/E after the staff had an several unsuccessful attempt at a bladder wash. A/E weren't impressed as the Out of hours (OOH) GPs next door hadn't even been out to see a patient yet and A/E was chock a block.
3. Female 50's, abdo pain. She was under investigation for gall stones and called us for pain relief. When we explained that if we did give her any analgesia then she would have to come to hospital. She point blank refused so my crew mate arranged for the OOH GP to come and visit her. Why she couldn't of rang them in the first place I don't, I mean it wasn't as if she was in agony. She had the pain on and off for 2 weeks.
4. Female 18, another abdo pain. This time the patient was 7 weeks pregnant and had some lower abdominal pain, no bleeding and all her observations were fine. To be honest she could of gone in a car.
5. Female 98, Cat A severe respiratory distress. An anxious little old lady who couldn't bring up some phlegm. 'I can't breathe, I can't breathe' she kept saying. 'But you are breathing' I said reassurringly.' We calmed her down and checked her over, absolutely fine. She coughed and said she bring anything up so we said cough a bit harder, that did the trick. We left her at home. Bless her she lived alone in a warden assisted flat and was very anxious. She just needed reassurance.
6. Female 81, Fall. This lady is a regular faller and this job was no different. Back on her feet and into bed. All observations fine and paperwork completed. One half of the day shift that was supposed to take over from us forgot that he was working and didn't show up and that's why we ended up doing this job. Fortunately for him it was a local job and a simple fall. We finished pretty much on time.
In amongst all the jobs over the weekend we also managed some stand by at various response posts and had several jobs that we were assigned to but were stood down before we got to them.
Oh well I'll be starting my RRV shift soon. As it's overtime I just close my eyes and see £ signs flashing. Kerching
Monday, 22 September 2008
1. Assault. Male 41 attacked with a baseball bat. Just a hard working family man who had a call from his or his mates stepson, I forget which to come and get him as a gang of people had threatened to 'do him in'. This guy went to look but couldn't find him so on exiting a car park by a convenience store a van pulled up. About 4 men got out with baseball bats and knives and proceeded to beat the hell out of this guy. 4 nasty head lacerations and a broken nose. Blood everywhere. Speaking to the police at the hospital, they said they had a good idea who was responsible and would stop at nothing to get them. They also said that they would have them all in custody that night. Yeah yeah yeah I thought. Half an hour later the whole gang was nicked, I couldn't believe it.
2. Male 55, headache. This chap had mental health issues and had similar events in the past. He was really agitated. I was on the verge of calling the hospital and asking a Dr to give me permission to give this guy some IV Diazemuls to sedate him. We only use the drug for fitting or for sedation in certain illegal drug ODs. Fortunately we were able to calm this chap enough to get him to hospital.
3. Male 31, diabetic with severe respiratory distress. It was only round the corner from the hospital so we were there in seconds. This guy was breathing at 30+ breathes a minute (the norm being around 12 - 20) he also had a temperature of 41.2 (again the norm being 36.9-37). His sugar level was slightly up and his O2 saturation's were slightly low. O2, base line obs, load and go. At hospital within a minute.
4. Male 40ish, history of Autism who had a fall. This was at a care facility, he had fallen in the bathroom and pulled the emergency cord straight away. A bit of blood but once cleaned up had nothing more than a cut lip and a bloody nose. Patched up on scene and left with the care staff who weren't too keen on him going to hospital anyway.
5. Female 28, Severe respiratory distress. This young single mum had been diagnosed with a recent chest infection and prescribed anti-biotics. She is also Asthmatic. For 2 hours she had been trying to self medicate an asthma attack, her own inhalers weren't working. She was clearly in trouble and trying to put a brave face on it. We gave her O2 and a salbutamol nebuliser in her flat while her daughter was skipping around merrily with a pink rucksack on her back. This neb failed to improve her condition so I handed my crew mate another salbutamol neb along with an Atrovent neb. Still no real response and she was getting worse. She had that exhausted look to her, not a well bunny. Her peak flow was only 200 at best (her normal was 450), O2 saturation's 92% and tachycardic. I had a look at her tiny veins on her right hand. There were two small straight blue lines and only one was good enough for an IV. I put a little bluey in (22g cannula, the smallest we have) and gave her 200mg of hydrocortisone (steroids). Steroids work by dampening down the immune response and in this case work in the lungs by reducing inflammation within them thus easing breathing. We gave the hospital a pre alert and ran her in on red (blue lights). We handed over to the 2 A/E Dr's waiting for us who didn't even realise that we carried hydrocortisone! The Dr seemed to be at a loss as to what to do after doing a blood gas. 'You've not given me much else to do.' he said smiling away. The girl was now beginning to recover and moved from resus down to the main A/E dept. I always thought the actions of Hydrocortisone was of a slow onset even when given IV but after researching it on the net it appears that it starts to take affect within the hour, usually within minutes. You learn something new everyday.
Our guidelines state that you can consider Hydrocortisone where the call to hospital time exceeds 30 minutes. Where I work this would be most cases because by the time the patient has called, we mobilise and get on scene, assess and initiate treatment and then travel to hospital it would easily exceed 30 minutes. Anyway in severe/life threatening Asthma steroids need to be given early.
It feels good knowing you've made a difference.
Let me see what did we get called to?
1. Apparently confused 87 year old male who according to police didn't have a clue where he was....................so they called us!
Not confused at all, not from these parts and couldn't remember where he parked his car. His wife also went missing with their dog. He was fine so the police took him to the border for another police force to take him the rest of the way home.
2. A lady who I thought was Irish had fainted, she was actually from Barbados. How could I have got that wrong! She had recovered and stayed at home.
3. Head injury, ETOH on the side of the road after a staff party. This was probably the highlight of the night but you needed to be there as it was comical in places. Basically he was violent, drunk and seemed to have an interfering friend attached to his hip. He needed to go in as alcohol can mask potentially serious injuries. Police helped us out on that one. He was so bad we had to transport him in the police van, he was cuffed and put on the deck. I had the response bag with me just in case he took a turn for the worse. The only Observation I was really able to obtain was his sugar level. All we got out of him was a lot of swearing. He even called his wife a C*** and told her F*** Off on the phone. Charming man. At hospital he kicked a nurse in the stomach while he was still cuffed.
4. 18 year old OD, 8 paracetamol. Started work at her new job and had an argument with her boyfriend. She wanted to go to hospital so we took her.
5. D & V, 66 year old lady who despite her 2 weeks of constant D & V looked remarkably well. Asked why she hadn't phoned the out of hours GP she replied 'What, at the weekend! Ooh I'm far too ill for that.' Need I say more! Having said that I saw her in A/E last night, same problem. The A/E staff were not impressed with her.
Sunday, 21 September 2008
When I have time and can remember the jobs, I shall start posting.
Too cut a long story short this RTC (Road traffic collision) occurred locally.
A mini van taxi goes through a red light at speed and is struck side on by another vehicle. The taxi is now on its side. Two ambulance crews are dispatched and the driver of the taxi is in cardiac arrest. The patient is successfully resuscitated and later transferred from the local A/E dept to an ITU in another hospital 30ish miles away.
Back to the scene; while one crew is transporting the patient, one of the other crew is talking to another taxi driver who pulled over to help. My colleague knows this taxi driver.
EMT 'Why didn't he have his seat belt on?'
Taxi driver 'Because we don't have to!'
EMT 'Yeah but If he had his seat belt on, his injuries wouldn't have been so bad!'
Taxi driver 'Yeah but we don't have to wear them'
EMT 'I know that but I think you're completely missing the point here!'
Need I say more!
Unfortunately the 25 year old taxi driver had broken his neck and was in cardiac arrest on arrival of the crews. Between the crews and the local A/E dept they were able to resuscitate him. One week later his life support was switched off.
So if there are any taxi drivers out there who happen to read this, belt up! It could save your life!
Friday, 19 September 2008
Tuesday, 16 September 2008
The first job of the night was for a haemorrhage/lacerations call. The patient was a lady in her fifties who had an illeostomy bag and it was filling with blood. This had started at 11 am and a slow trickle continued all day. Between 6 pm and 7 pm she emptied the bag 5 times, the bag's capacity was around 250 ml. If you consider the average circulating blood volume for an adult is around 5 litres, that's a lot of blood to be loosing! We got her on to the truck pretty quick. Her pulse was rapid and she felt thirsty, some of the signs of shock. I got a line in and set up some fluid. Her BP was intially 177/86 which I found hard to believe and her pulse was 130. After a recheck of her BP it came out at a more realistic 72/48.
At hospital a Dr tried to get another IV and messed it up twice. Eventually she managed to get one in. Oh well, a bit like me the night before where I missed twice. I don't usually miss and when I do I get annoyed with myself, but as my crewmate reminded me 'It's swings and roundabouts mate, swings and roundabouts!'
The rest of the night was pretty uneventful.
I've now got a few days off before yet another set of weekend nights!
Monday, 15 September 2008
Sure enough the guy wasn't responding, I shined a torch into his eyes, his pupils were constricted. Great a possible heroin OD! His breathing was slow and he had a pulse. On with some O2 and out with the drugs bag. Only minutes earlier my crewmate had been talking about heroin ODs and that she hadn't given Narcan yet, now this could be her chance! No such luck, the guy woke up, pupils now the size of dinner plates. He jumped up and started shadow boxing, it was quite possibly the worst Mohammed Ali impression I had ever seen. Very commical. 'What's your name mate?, 'Not tellin Ya, It's a secret', great another uncooperative punter. He was actually alright, not aggressive at all. He was infact grateful that we were checking him over. He was clearly drunk and had been assaulted, displaying a swollen cheek and multiple abrasions. Really he needed to go to hospital to be properly checked, especially as he was intoxicated. Alcohol is great at masking other potential problems such as head injuries.
After yet more dancing about in the back of the truck he eventually got out and said he was going home, information he wasn't going to disclose to use for some reason. We weren't going to pressurise him as that could make an OK situation into a potentially volatile one. We tried to give him advice but he was off on his heels and into the night.
Next job was a possible stroke. A very large lady who had previously suffered from 3 strokes and a had a permanent left sided weakness. She unconscious and snoring, a sign of a partially obstructed airway. She had saliva and blood coming from her mouth and was very clammy. Getting her out to the vehicle was a challenge but we managed it.................just. We could of got a second crew but we didn't have the time, we needed her out there and then. Her observations were unremarkable with only her pulse rate a little higher than normal at 106 bpm. I wanted to put a line in and get some bloods but she had poor veins, I got it in but the vein collapsed.
That wouldn't be the first cannula I fluffed that night!
She actually responded to oxygen therapy alone and by the time we were at hospital she was coherant again. I was now pretty convinced she hadn't suffered a stroke, the recovery was too quick.
The police called us out to a possible 'narcotic' OD. It was a patient familiar to me and he wanted to kill himself. Steaming drunk on cheap cider and claiming to have taken 20 tramadol tablets at 50mg a pop he was not in a fit state to be left alone. Convining him to go was tricky. He struck a deal with the police officer and shook on it. The deal was, 'You can have a smoke and then you go with these nice ambulance people to get the right help!' No, he wanted another smoke. He was also asthmatic and tried to fake an attack by holding his breath and stating he couldn't breath. This was our chance, we shouted 'Quick, we need to get you to the ambulance for some oxygen' and with this we rushed out to the truck. On the way in I constantly checked the onboard camera to make sure my crewmate was ok in the back. I noticed she was trying to wake him ans saw her approach the window in the bulkhead. 'I know he's probably faking but can you just check him quickly?' I pulled over and got in the back. The guy was lying on his back with his eyes wide open, motionless. Good colour, breathing fine, pulse oximetry 100%, not much wrong with him. I touched his eye lash and he fluttered them. 'Alright stop messing about!' I said. Up he shot and grabbed his own windpipe and repeatedly tried to strangle himself, he was squeezing so hard his head was going purple. I jumped in and wrestled with him removing his hands in the process. I read him the riot act and told him to stop being so bloody stupid and to grow up. 'Think about your child' I said. 'What sort of role model are you going to be if this the way you act!' he soon settled down again. He got a bit upset and said he wanted to die. 'No you don't, let's get you to the hospital and get you some proper help'. I'm normally very laid back but sometimes you've just got to be firm. He'll recover and get discharged and do it again just like all the other times.
We did a couple of other jobs and actually had a bit of time on base. At around 2 am we were called to a Cat A breathing problem. This chap was quite poorly and you could hear his breathing long before entering his bedroom. He had recently been discharged after spending nearly a year in various hospitals due to knee operation going wrong and suffering multiple complications including 3 heart attacks and a stroke. He awoke from his sleep with severe breathing difficulties and it wouldn't go. He sounded like he was drowning which he basically was. Fluid was accumilating in his lungs and starving him of the oxygen he so desperately needed. The fact he had 3 previous heart attacks and the way he was presenting to us my thoughts were Left Ventricular Failure (LVF). This condition can occur after heart attacks, the heart muscle becomes weakened as a result. After a period of time the heart struggles to pump effectively and the blood backs up in the circulation, with no where else to go the fluid component of the blood leaks back into the lungs and causes the severe symptoms. This guy was really struggling. He had already been through the mill and this was the last thing he needed, his wife was near to breaking point. We treated him with oxygen and nitrates and a nebuliser, this eased his symptoms eventually. I could have given him furosemide but we don't carry it in my part of the service. We could have provided him with continuous positive airway pressure (CPAP) ventilation but we are still awaiting ethics committee approval on this form of treatment. I could have given him morphine but he didn't have any pain. It would have had two effects, reduction in pain and because of it's depressive effects would have eased his breathing. I also wanted to put a line in but his veins were so poor I couldn't get one in. The most important thing was that he arrived at hospital alive and doing much better. It would have been nice to give him that little bit of extra treatment.
Saturday, 13 September 2008
We did two jobs.
1. Sick person, a lady who lived alone who had started some antibiotics yesterday and had been vomiting all afternoon. She didn't look too good. She had some IV Metoclopramide (anti-sickness meds) which seemed to do the trick.
2. Chest pain and shortness of breath (SOB), another elderly lady who had been getting chest tightness and palpitations this afternoon with increasing SOB. She is under investigation for this and is awaiting a 7 day cardiac monitor. She will be wearing it for 7 days funnily enough and when she goes back to the cardiac outpatients a cardiologist will check all the data to see what could be causing the symptoms. The lady's daughter said she went grey and thought she may have passed out but couldn't be sure. The lady described it as more of a tightness and discomfort rather than pain. We treated her as any other possible cardiac patient. High flow oxygen, an Aspirin and Nitrates which eased the symptoms slightly. I put a line in and drew some bloods for the hospital. Her 12 lead ECG wasn't too bad, just a bit of 1st degree AV block and lead 3 looked a bit suspect. Not suitable for thromolysis, she was too old as well being 88, our cut of is 80.
At 19.30 I chucked my stuff on the RRV. Only done one job so far. That was to a lady who had fallen. A community first responder was on scene before me and was looking through the letter box. The lady was on the floor and sounded incoherent. I thought she having a stroke or a diabetic hypo. The key safe code was the wrong one so I ended up breaking in. I used our 'Hi honey I'm home' kit, my name for our basic rescue kit. I had to prize open a solid PVC double glazed window. It came open a treat. After getting her up off the floor I assessed her and she turned out to be fine. It was tricky due to her recently suffering a previous stroke which had left her with a permanent speech and swallowing problem. I arranged for an out of hours DR to contact her son and discuss her social needs. She was happy with this. She did get upset with God and started to wave her fist at the ceiling. She was a nice lady.
I'm now back on base with only an hour and ten minutes to go. Fortunately there are two crews on base so fingers crossed I'll finish on time.
On board the ambulance I get the paediatric longboard out and we secure the baby to that. Even the paedi board with huge blanket rolls dwarfed the baby. Again the basic stuff such as O2 by tubing and monitoring equipment are applied. I decided to put a call in to the hospital so she could be seen straight away. With dummy in situ the baby fell asleep en route. It was like watching maggie simpson, quite comical really.
We got to hospital to be greeted by a full trauma team which I didn't expect. They started off OK but when it came to assessing the neck and back they were a bit stumped. The baby was conscious and now crying again. They could roll her and check for deformities but couldn't get the baby to tell them (obviously!) whether it hurt when the DR pressed along the spine. After a brief chat they decided the baby was OK.
After doing another call we found ourselves back at the hospital. Apparently after saying the baby was fine a DR later decided to get a c-spine X-ray which turned out clear. If they had missed a serious neck injury especially after we alerted them then there would have been hell to pay!
I walked past the resus room and saw the mum feeding her baby whilst sat on a chair. She saw me and beckoned me over. 'Do you think she will be OK?' she said. DOH!!!, another homer simpson moment. I mean she had DRs from all specialties fussing over her, had an X-ray and they said she was fine. And she's asking me! 'Well if the DRs are happy then I'm sure everything's fine' I said. With that we left and then on to the next job.
When we arrive the baby is in the young fathers arms and he hands us his screaming pride and joy. We strip the baby and see that there is wide spread superficial burns to the top half of the chest and on parts of the arms. Out come the water gel dressings and they are placed carefully over the affected areas. I got the mum to hold some O2 tubing over the baby's face whilst I attached the pulse oximetry to her tiny finger. I then covered the baby with a blanket. You see the secret with burns is to cool the burn but not the patient because hypothermia can cause further complications. Within minutes the baby stops crying. She is now sucking on her dummy as if nothing had happened. Both mum and dad were a lot more relaxed.
After some further treatment and a night in the hospital, the baby is discharged . No blistering, no scarring. A good outcome using good basic skills. That's what we like when it comes to kids!
Friday, 12 September 2008
(the picture is me with 3 of my 4 wonderful kids)
Thursday, 11 September 2008
My first call was a drowning on the beach, I rapidly went through in my mind what I would do until back up arrived. I had very little information on the call apart from that it was from the police and that it was a male in his thirties. I didn't even know whether he was conscious or breathing. Before I arrived I was made aware that the person had been in the water for about 15 minutes and was conscious. On arrival I approached the police van and was met by a police community support officer (PCSO) who stated that the patient had waded into the water up to his waist and that he (the PCSO) and a police officer managed to persuade him to come back to shore and subsequently placed him inside the van. I quickly assessed the patient and got him in some blankets. He was physically fine, mentally though he had a few problems which became too much and now felt depressed. I obtained his details and waited for the ambulance to pop him up to the hospital for a proper psychological assessment. I would have taken him myself if it wasn't for the fact that his lower half was still sopping wet.
After an hour and a half of standby in a nearby village I was on my way to back up a Paramedic crew at a cardiac arrest. When I arrived CPR was in progress and the patient had just recieved a shock from the defibrillator. The Paramedic had just put an IV in. The EMT doing the chest compressions asked if I could take over which I did. There was also an off duty EMT (who also responds as a community responder) on scene and he was ventilating the patient with a bag and mask (BVM). The lady had false teeth which had been removed as they were causing an obstruction. I then swapped roles with one of the EMTs and I was now in control of the airway. Before I intubated the patient I thought I would be clever (using past experience) and avoid kneeling on the floor while sorting the kit out so I sat in the armchair. It was the armchair that the patient had been sitting in prior to her cardiac arrest, the problem was I sat down and immediately felt a dampness seap through my trousers. She'd been incontinent of urine. I had to continue with job in hand and got on with the intubation. The airway was now secured but her lungs were full of blood which I had to suction numerous times. We worked on her for over 20 minutes providing full advanced life support which included drug therapy but it was to no avail. She had a lot of recent medical history including COPD, heart by-pass, a colostomy , fluid retention and a pacemaker, her health was generally poor. Our efforts were futile so we decided to call it. CPR was stopped and she was pronounced dead. Both of her sons were on scene and were very understandable of the decision we made.
I helped clear up and took one half of the crew back to base with me, the crew had gone way past their finish time. The Paramedic stayed on scene with the vehicle and waited for the police (we call the police on all unexpected deaths and their role is to act on behalf of the coroner's office and provide support and advice to the relatives). Back at base I had to strip and bin my trousers and boxer shorts and had a bloody good wash. I panicked about not having any spare but luckily I had some in my locker.
The night crews thought it was highly amusing.
My last job was for a headache. Turned out to be a polish guy who, two days ago, had a hell of a kicking. His face was swollen and grazed, he also had blood in his eye. He was quite cagey and didn't want to give me his address. It didn't matter, his mates had already provided that. He also smelled strongly of alcohol despite denying it. I grabbed some observations and his personal details and we made our way to the hospital.
After filling the car up with fuel I waited on base until my shift finished.
Tuesday, 9 September 2008
Thursday, 4 September 2008
Driving on the roads where I live there are constant reminders of lives lost in road traffic collisions. Similar signs to the one pictured are placed at every fatal incident. On the way to work I passed two. One was for a 19 year old girl who was a passenger in a car that went into the back of a tractor trailer, she later died in hospital and the other was for a guy who was hit and killed at high speed crossing the busy dual carriageway.
On one of my days off I was out locally with my family and driving home I saw more signs to the north of town. When I returned to work on my next shift I was to learn that I had been drinking with one of the people killed. It was a birthday celebration and we were chatting to his sister about her giving birth, it's horrible to think that none of us knew he would be dead just a week later.
I've been to countless fatal road accidents and unfortunately the vast majority of casualties have been young or middle aged, the prime of their lives some would say. And most are avoidable. It's just such a waste.
Personally I liked the Final Destination movies but I can't help but think, is death really waiting to pounce? And when young people die is it because they cheated death at a previous time and death is just catching up or is it just fate. I guess we'll never know and when we do it'll be too late!
Wednesday, 3 September 2008
This chap was as calm as you like and spoke pretty good English. As we stood him up I could smell a faint whiff of alcohol on his breath, nothing unusual there then. On board we had to remove the police officer's dressing that he had carefully put over the wound. It was well done but slightly too small although doing the job reasonably well. With the wound exposed briefly we quickly inspected it. There was a large laceration from the elbow nearly reaching the armpit, blood was still oozing with all the fatty tissue and muscle exposed. Now with a larger dressing applied and the arm still elevated, the bleeding virtually stopped. The police officer apologised but said it was the largest dressing he had. It didn't matter it was good enough. The patients BP was good although his pulse rate was 124, a possible indicator of substantial blood loss. You see the body is a clever machine, it will compensate in times of crisis. Simply put; blood carries Oxygen to all the organs and tissues, if there is any significant drop in circulating blood volume the blood vessels will tighten up (maintaining blood pressure for a limited amount of tme) and the heart will beat faster to get the remaining Oxygen to the vital organs.
As a result I decided to put a 16g IV into one of his bulging veins in case he suddenly needed any fluids, he didn't and suprisingly he didn't need any pain relief. After an uneventful run into hospital he was deposited into the minor treatment area.
Later we found out that one of the more experienced A/E DRs had stiched the wound , internally & externally, in the dept itself. There was no lasting damage, only a long scar, a souvenier of his his travels to the UK. Lucky him!
That was just one of many knife attacks here in the UK and one four in my local area. As many of you know there are constant news stories of more and more teenagers dying or being badly injured through needless knife attacks everyday. I don't know what's wrong with these kids, they must see the news...........or don't they, even if they do they obviously don't give damn. What is driving them to do this, it's now almost a daily occurance in the news. What a lot of the public don't realise is that there are actually hundreds of knife attacks daily and only a very small minority reach the national press. The teenage thing is relatively new but knife crime in general is not. We have a far bigger problem with it than we do gun crime, unlike the States and south Africa where it's probably the opposite, I may be wrong. I know the larger cities like London, Liverpool, Nottingham, Manchester, Glasgow and Birmingham etc etc have quite a lot of gun crime but in the smaller towns it tends to be knives.
Back to the local knife incidents in my area.
1. Murder, female in her 20's knifed multiple times in front of her two young kids by her estranged husband, 2 crews from my station attended that. She died shortly after arriving in hospital.
2. Male slashed across the face by his so called partner, suffering a large facial laceration.
3. The machete attack I spoke of earlier.
4. Suicide, male slashed his wrists and then stabbed himself in the heart. I know this is suicide but it's still related because of the mechanism of injury.
I know it doesn't seem many but if you multiply these incidents by the number of towns through out the UK over a year it soon mounts up.
Tuesday, 2 September 2008
The next was a guy in his 30's who decided one night that he would get completely hammered and hurl himself 20 feet off a building onto the concrete below. He was an ex heroin addict who's girlfriend (all of 2 weeks) said she thought he just got down from the building, walked down this dark alley and lay down. The fact that he was barely conscious and his left arm was the shape of the letter s seemed to go completely over her head. He couldn't have any morphine as he was on Naltrexone which is used to block the effects of heroin in addicts. His BP was low so he had a line and some fluid. I also gave him some narcan as I couldn't rule out an opiate OD either. He was later intubated & ventilated and moved to ITU.
I saw him wandering around with his arm in plaster. He was a lucky chap. Probably the alcohol making him all floppy which may explain why he got off lightly. Or is it a case of 'No sense, no feeling'
We popped her on some O2 and I put a line in and administered 5mg of Diazemuls. It worked a treat and she stopped seizing. She was now living with her daughter and son-in-law as a result of her current condition and her daughter travelled with her to hospital. The patient was now pretty much back to normal, which was good but we still needed to take her in just for observation if nothing else. As we were going in I could see her looking at the ceiling of the ambulance, a single tear rolling down her right cheek. I wondered what she was thinking of. Was she thinking 'How much longer do I have?'
Getting old is a scary thought.
I checked up on her later this morning, she had a big smile on her face and both her and her daughter said thanks.
That's good enough for me, jobs like that make it all worth while.
Previous to this on my last few shifts we had a pt with a big cardiac history suffering from chest pain. He refused morphine which is fine, although he had all the other stuff such as GTN spray and Aspirin. The annoying thing was when we arrived in the A/E dept one of the first things the DR asked was 'Would you like some pain relief?' to which the patient said 'OOh that would be lovely' What !!!!!!??????!!!!!!! Say no more.
Also dealt with a lady who fell down a small pot hole. Dislocated shoulder and possible fractured humerous. She didn't look too clever, rather grey looking. I dosed her up on Morphine and Entonox. That took the edge off.
Whilst working on the RRV I dealt with a patient with severe respiratory distress, Cat A call. And it was, this lady had Asthma and Emphysema and was breathing at about 40 breathes a minute, her own inhalers weren't working and she was on home Oxygen. I treated her with a combination nebuliser containing Salbutamol and Ipratropium Bromide and thought I was going to have to give her some IV Hydrocortisone as she wasn't improving. We only give it for Asthma but because she had two respiratory conditions it was difficult to distinguish which condition was causing the problem therefore I could have justified it's use. I didn't give it in the end as she slowly started to recover and after a bit of reassurance, a little O2 and observations she was back to her normal self. Like a lot of people we go to and have provided some form of treatment, she declined hospital assessment/transport. Advice given to the patient and her husband on that one. As I was leaving, the husband came back out and said that my control was on the phone. They apologised for the lack of back up as all the crews in the area were busy and asked if I could attend a cardiac arrest around the corner. It wasn't a cardiac arrest, there was a crew on scene and dealing, they didn't need me. So back to base for me to team up with a Technician (my crew mate went sick for the dayshift, hence why I was on the car for the morning).
Our first job was to a local well known holiday resort, nosebleed! Great. There was one of our Emergency Care Practitioners (ECP) already on scene. The patient was on O2 and didn't look well at all, his BP was sky high 231/122!! He also had a little bit of blood trickling from both sides of his mouth. The grandaughter was being a bit off with the ECP for some reason and as far as we could gather the patient had a multitude of problems from pacemaker, strokes and previous heartattacks. After getting the handover from the ECP we loaded the patient on board and did another round of observations which were pretty much the same, still hypertensive. The ECP was letting the hospital know that we were on our way. Just before we left, the grandaughter came out and started crying saying that didn't want her grandad to die. At this point I'm thinking yes he's ill but I wouldn't of thought he's going to die yet. Anyway on the way in I could hear coughing and spluttering in the back so I kept hit the interior camera button so I could see what was going on. My crew mate was using suction to clear the patients mouth which is fair enough. Now I'm thinking, is this guy just got a little blood in his mouth or is he vomiting? I decide to pull over and check it out, maybe pop a line in give him some anti sickness meds and take some bloods. I didn't canulate him earlier because I wasn't going to give the patient anything. As I'm getting out, my crew mate is calling me, I open the back of the truck and the first thing I see is a large bluey/purple head with my crewmate frantically trying to clear his airway. He had aspirated on his own blood and my crew mate couldn't keep up with blood loss. I took over and opted to immediately intubate him. I knew the patient wouldn't like it as he wasn't fully unconscious but his airway needed securing or he would die there and then. His oxygen staturations went from 97% down to 77% rather rapidly, he was in big trouble. I was thinking surgical airways, the lot. We use the quicktrach device which is better than the traditional needle version most paramedics are taught, but in this instance it wasn't really appropriate as it doesn't provide airway security, just ventialtion if the airway is completely blocked from above. Nope it would have to be a tube. I opened his mouth and with the larygoscope and swept his tongue to the left to see if I could see anything vaguely resembling the epiglottis. Nothing just blood filling up his airway, more suction was needed, we just couldn't keep up. The patient was now really struggling so I assisted his ventialtions with the bag & mask. Another look in the airway and I found the epiglottis, out comes my bougie and under the epiglottis and down his windpipe, I'm in! Now out with a 8.5 endotracheal tube, my crew mate passed it over the bougie and I then guided it down into his windpipe. Bougie out, hold the tube, connect the catheter mount and BVM, inflate the cuff on the ET tube and ventilate. Listening to his abdomen first, no sounds, good, both lungs, equal air entry and rise and fall of the chest, job done. I stayed in the back and we carried on to the hospital. I put him on the ventilator as I tried to get I.V access. He was too shut down at this point so I went back and sat at the head end and looked after his airway. Although he didn't like being intubated he tolerated it and his purple head was now a healthy pink colour. On arrival at A/E we were greeted by the team who quickly sedated and paralysed him in order to manage his airway even more effectively. After some propofol (anesthetic induction agent) his blood pressure came down slighty. After helping out in resus we cleaned up the truck and went back to base to restock. And then on with the next job!
Like I said earlier I've just returned from my camping trip and am now on another run of four shifts, 2 days & 2 nights. I have recently found out that our patient that I intubated has now sadly died. He was in intensive care for nearly a week. It wasn't just a nose bleed, apparently he was bleeding everywhere internally. Leaking like a teabag as one of my colleagues crudely put it. It was an unexpected death which would have happened earlier if we hadn't of intervened. I'm just glad we were able to give his family enough time to come down and visit him and say their last goodbyes.