Tuesday, 2 September 2008

Back again

Just got back from a well earned rest. Well I say rest, it was actually a hectic family camping trip in the West Country. Thoroughly enjoyable I must say. It's great to just get away and forget about the reality known as home life. When ever I go away I just completely forget about work and the bills, I love it.

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.

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