What a beauty

Nothing ambulance/EMS related but I've just been watching this fly. Such a beautiful aircraft.

9/11 Never forget.

God bless

Running on empty

Sat at the hospital waiting to push clear. We pause as we hear the crew, that had previously cleared, get a job. It was to a person in a car on the side of the road and they were having real difficulty locating the person. Oh well, so we pressed clear. Next thing we get a job and it's also to a person in a car on the side of the road. Psychiatric problems. I was wondering why we copped the same job seeing as the other crew were closer. As we are so often reminded by control "You don't know the bigger picture", I wasn't going to argue. Even if we really wanted to get back to base for a cuppa. Details were sketchy and the location was somewhere along a road that stretches pretty much from one end of the county to the other. It was passed as a Cat C, non-life threatening. We heard some radio traffic and it appeared that the other crew were still attending, not because it was serious but because there was two separate incidents. Two cars, both psychiatric patients, both wanting our help and both crews non the wiser of the exact location of either. We eventually got a description of the car and went to search in the west. The other crew were searching the east. As soon as we were on the dual carriageway we spotted a car in a lay-by on the opposite side of the road and people were waving. Because of the central reservation we had to drive 9 miles to the next slip road and back again to get to our patient. Police were also thundering up and down the road. "They must know something we don't" I thought. We arrived and pulled up in front of the car. As I got out I could see someone lying in the front passenger seat and as we drew closer he appeared to be dead! His colour was appalling, white and grey with blood and faeces mixed in for good measure. Not quite what we were expecting at all. I took a closer look and spotted a deep laceration to one of his wrists. It had stopped bleeding. He was incoherent and moving around without any real purpose. I tried to put an oxygen mask on him but he kept tearing it off. A severe lack of oxygen in the system will do that. While he was waving his arms about I spotted another deep laceration this time it was at the crook of his elbow on the same arm as his wrist laceration. He had done this to himself and had done a good job too. I glanced behind him and in the rear on the floor was a mass of congealed blood. He must have lost half his blood volume. I was surprised he was still alive! As my crew mate was bringing the trolley over I decided to get some IV access in the chaps arm as everything else was proving fruitless. A couple of police officers helped stabilise his arm while I inserted a 16g (grey) cannula. I stuck it down and then secured it with a bandage so he couldn't rip it out. I didn't attach any IV fluids at that point because I knew that the IV would be pulled out for sure. We managed to get him out of the car and onto the trolley and then into the vehicle. I got the fluids running (as there was no radial pulse) while my crew mate desperately tried to obtain a blood pressure. Unrecordable. I needed another line. The only other real option was one in the leg. I could have gone IO but spotted a vein on the inside of his ankle. And in went another 16g and another bag of fluid. No time for blood samples, the hospital could get them via the femoral route later. All while we were working on this guy I spotted a German couple in a motor home filming us, cheeky buggers! We weren't there long and were soon off to hospital. His blood pressure was now 82/36 after a 800ml of fluid and there was a weak radial pulse present. He had also settled and was now tolerating the O2 mask but was still incoherent. This guy needed blood and not basically water in a bag.
I think he had cut himself sometime earlier as his blood vessels had clamped shut and were no longer bleeding (the critical hemorrhage kit was not needed). A few minutes later we arrived at hospital and went straight into resus. The young DR seemed impressed that I managed to get a 16g IV in his arm especially after all the blood loss but when I lifted up the blanket and showed her the 16g in his ankle, TA DAAA!!!, she grinned "Blimey, we had a bet when we got the pre alert and it said Paramedics have an IV, we all said it will only be a green (18g). And you've got 2 greys in! Well done!" (I'm so glad I work where I work. The hospital staff are great and we are like one big family)
Anyway we clear up the truck and off we go on to the next job. Later we see the guy who is now a nice pink colour and reasonably coherent, enough to have a simple conversation with. He received 6 units of blood and was due to go to theatre to have his tendons, nerves and blood vessels repaired.
Why he harmed himself, lord only knows. A good job though!

This just cracks me up

I have no experience of the private ambulance sector but this picture just cracks me up!

Bang and the dirt is gone!

Working as a Solo responder
Cat A chest pain 8 miles away
Get there in 7 minutes despite traffic
Well looking lady with mild chest discomfort (4/10 at worst) with no previous history
O2, Aspirin & Nitrates = pain free
Complete paperwork whilst waiting for a crew
Told that crew are coming from over 20 miles away
Asked "Do you want them on red?"
Reply "Er Yes"
Nearer crew comes clear and arrives a little while later
Patient still pain free
More obs on truck
12 lead ECG showing inferior MI (heart attack)
Still no pain, what to do?
Get a line in and take some bloods
Get husband into truck
Go through thrombolytic check list
Now patient is experiencing mild chest discomfort
Before checklist completed patient goes into cardiac arrest
Immediate CPR whilst defib pads applied
Charging, stand clear & shock
1 minute CPR
Charging, stand clear & shock
1 minute CPR
Oh crap this is turning into a training scenario, all colour now drained. She ain't gonna make it
Charging, stand clear & shock
CPR then blip blip blip
Pulse check = palpable carotid and radial pulses
20 seconds of BVM ventilation
Patient responding
Patient bradycardic at 30 bpm and not improving
500 mcg IV Atropine done
Pulse 68, BP 115/74
GCS 15/15
Consent given
Heparin and Tenectaplase given (or as I like to call it drain cleaner aka cillit bang)
Pain free
Husbands jaw picked up off the floor
Soon into resus and off down to CCU
JOB DONE!

Check up on patient on my way home
ECG back to normal
Patient pain free and doing well
Transferred to cardiac centre a few days later for angiogram
No further treatment required
Discharged home
Thank you letters to the service, myself and the double tech crew that backed me up

Message to crew: Thanks for getting there when you did and thanks for a great team effort
Message to patient: Glad you are now OK, thought we were going to lose you briefly
Message to self: Be proud of what you do no matter how many routine or inappropriate jobs you go to
There will always be that one person who will require your skills where you will make a difference

Sorry to bother you......................er what!

A couple of weeks ago............

After a non eventful day of transfers, GP admissions and Cat A calls 'that weren't' we were on our way back to base when we were asked to standby at another station in the next town. I was fuming, after all we only had an hour til the shift ended. Had we done something to piss control off? I doubt it. As we are so often reminded "You don't know the bigger picture!"
Anyway we arrive at the station to see 2 ambulances there. I was fuming again and so was my crew mate. But before we could even enter the station we got a job. Cat A allergy call midway between this station and ours so off we went. A tech on an RRV was also dispatched. It was to a child stung by a bee.

Mum is at the door and is already apologising for calling us out but stated that she was worried as her son was struggling to breath. Good enough reason to call I thought to myself. Sure enough he had been stung and was showing early signs of anaphylaxis. Reluctantly he got on board the truck after we reassured him that we would take good care of him and that we wouldn't hurt him. My crew mate stood the RRV down
Respiratory rate increased with a mild wheeze and chest tightness. Puffy eyes and his lower lip had started to swell. Tingling on his top lip and tongue and difficulty swallowing coupled with a sensation of a lump in his throat. Pulse rate 115. Alarm bells were ringing. He was also starting to feel itchy although I couldn't see any obvious hives.
We needed to start treatment but a child is not always the best patient to convince. Sometimes they are great and if they are that poorly they'll let you do anything as long as it helps. Other times you can't do anything but drive. I said I wanted to give him some medicine to make him better and that I didn't want him to have to wait until we got to hospital 20 minutes later. I must have said all the right things because he allowed us to treat him. I pinched his hand to let him know that the IV I was about to insert wouldn't hurt too much which he was a bit hesitant to start with but gingerly offered me his hand again. I prayed to god that I wouldn't cock this IV up. You only get one shot at a child. Funny thing was that he covered his ears with his hands but because I needed one of them to cannulate he substituted a hand for a shoulder.
And in went the 20g IV, no problem. A sigh of relief came over his face. "All done, that's the worst bit" I said proudly. Mum then lifted her jaw off the floor "Bloody hell, I'm surprised he even let you go near him!" she said. As I administered the Chlorphenamine and the Hydrocortisone I explained to the child, his mum and now the dad who had just turned up, what I was giving and why I was giving it. At the same time my crew mate had drawn up some adrenaline and injected that into his upper arm, again with no incident. Both parents proud of their child for being so brave. As a dad myself I couldn't have agreed more.

A pre alert to the hospital and we were soon there. We arrived with a child that was showing a good recovery. One of the regular Docs was on duty and said "This the anaphylaxis, airway OK?" "Yep" I said. "OK pop him over there and I'll see him in 2 ticks. I see the guys have taken good care of you, they've done our job for us." she said. "Not quite Doc, I didn't take bloods", "Doesn't matter we don't need them, good job though". The mum had a look of relief on her face that she had done the right thing.

Moral of the story especially when kids are concerned, never apologise for thinking that you bothered us. This is one of many examples of why we are here. If the mum hadn't bothered to call and decided to wait and see or chose to put her son in the car things could turned out a lot worse.
Anaphylaxis is life threatening and does and will continue to kill if it isn't recognised and treated early.

A good job to finish off the shift even if we did finish late.

It's all in the history

999 call chest pain, young guy, mid thirties. Unless the patient is a cocaine user or has some congenital heart defect then usually these calls tend to be nothing too serious. But you can't be complacent in this job and have to keep an open mind. Too dismiss such a call prior to arrival on scene is a dangerous thing.

On arrival the patient was providing the dying swan act but was in obvious discomfort. A history of a cough with mild left sided chest pain which started the previous evening. It had now become more severe. I could see my crew mate raise his eyebrow with some disbelief that this was nothing too urgent. Admittedly I was probably thinking along the same lines. He was showing signs of primary hypervetilation with pins and needles in his hands and mouth, cramping of the fingers and a rapid respiratory rate. His pulse was over 100. I took his temperature which was normal. BUT until we have examined the chap and carried out some other observations, including a 12 lead ECG, we needed to keep an open mind. Taking a deep breath aggravated the pain even more and he was wriggling around on the bed.

Whist taking his BP and acquiring the 12 lead ECG it transpired that he had a previous infection....................................around his heart and and some form of heart scan. I took this to be an echocardiogram. When I asked earlier about any previous medical history this had obviously slipped his mind. This is so often the case when in hospital a patient will admit to having a whole array of ailments that they failed to disclose whilst in our care. Can make us look daft at times.

A quick listen to the chest revealed clear & equal air entry and o2 saturations were in the high 90's. Leaning forward eased the chest pain but when asked to take a deep breath or lay back caused the pain to get worse. Now for the 12 lead. Abnormal to say the least. There was ST elevation (sign of a heart attack) and alot of it. But there were clues that lead me to believe that this was not a heart attack. The type of pain was wrong for a start. The ST elevation was wide spread (showing in leads II, II, AVF, v2,v3,v4,v5,v6) and saddle backed. There was also very slight reciprocal changes in I & AVL. My provisional working diagnosis was Pericarditis (an inflammation of the sac surrounding the heart). There are many causes but is usually caused by some form of infection. I popped in a line and took some bloods. Why? Well for one the hospital gets busy and it's one less thing for them to do. They don't have to recannulate, they use our lines and it lets them get on with other things. Also because I like to be prepared for the worst. There is a rare complication of Pericaditis which is caused by blood/fluid filling up the pericardial sac. It's called cardiac tamponade which is life threatening and is usually only seen in severe chest trauma and only a small amount of blood is needed to impede cardiac function. Like I said I like to be prepared.

I also gave some o2 and bags of reassurance. He soon settled and we chatted on the way to hospital. I let the hospital know we were coming in and had an uneventful journey to A/E.

We were met by one of the staff grade DRs and a CCU nurse and made our way into resus. They did do a double take when looking at our ECG and quickly wanted to rule out a heart attack but after I handed over and gave them the history they were thinking the same as me. But they still wanted to check their own ECG. It was agreed that it was pericarditis.

He was discharged some hours later with anti inflammatory drugs and some strong oral analgesia.

I read recently in a DRs blog about how Paramedics can't take a history and are not diagnosticians and how we are all bound by protocols. All I can say to that is that agreed I am not a DR and would never compare myself to one. But as a Paramedic I can obtain important information, examine the patient (obviously not as thoroughly as a DR, we don't have the time or facilities to allow for this) and carry out certain observations which can point towards what the problem may be. Sometimes we may not have a clue. But in this case it was the history and ECG that provided me with a pretty clear cut answer.

As for protocols, yes it was cardiac chest pain but not typical to a heart attack. Yes I know all too well that a lot of heart attacks present with atypical (different to the norm such as no pain, abdominal pain etc) signs & symptoms but this all pointed to Pericarditis. And yes I know that Pericarditis can mimic an MI and that there have been occasions where a patient has received unnecessary thrombolysis (mainly in hospital and occasionally out of hospital. Did I give aspirin or GTN? No. I didn't give morphine and pre hospital thrombolysis certainly wasn't indicated. I could have given Ibuprofen but in the short time he was our care it probably wouldn't have provided any benefit. We work from guidelines now and I try and provide the most appropriate level of care to each of my patients. I don't believe in filling people up with drugs when there is no indication for it.

The ECG is one I found on google and NOT the patients.

Back again

I've given all this blogging lark a bit of a break but now decided to carry on.
Back soon with what I've been up to.

Addison's Disease/Adrenal Insufficiency

Ok here we go.

What is it?
Addison's disease was discovered by Dr Addison in 1855. It is a rare condition affecting mainly, but not exclusively, people between the ages of 20-50.
Right, we should all know that we have 2 kidneys. On each kidney sits an Adrenal gland. The adrenal gland is a bit like a Cadbury's creme egg. For example the chocolate is the cortex and the soft fondant centre (yum yum) is the medulla. Cells in the cortex produce hormones called Aldosterone and Cortisol. Together they help to control/regulate the blood pressure, regulate salts in the blood stream and help regulate the immune system. They also help balance the effect of insulin in regulating blood sugar and helps the body respond to stress. The cells in the medulla produce adrenaline and noradrenaline which have various actions throughout the body.
Now in Addison's and adrenal insufficiency the adrenal glands produce little or none of the above hormones. I think I'm right in saying that Addison's is known as primary insufficiency. Now just to complicate things there is a secondary insufficiency. Lying under our brain we have the Pituitary gland. This produces a hormone called ACTH which controls the amount of cortisol produced in the adrenal glands. With me so far? Good.

There are many reasons why we may fail to produce these hormones:
Primary Insufficiency:
Addison's ( >80% of cases), surgical removal, trauma, Infections (TB/HIV etc) and cancer. There are more.

Secondary Insufficiency:
Congenital, trauma, surgery, radiography, cancer, long term steroid use for other conditions and tumours of the pituitary gland. Again there are more.

What ever the cause these patients require life long steroid treatment. They do this by taking oral steroid tablets every day.

What's a Crisis?

Basically anyone who has the above conditions and for whatever reason are unable to keep their oral steroids down or is affected by other factors that increase the body's natural demand for cortisol such as trauma, stress etc. If someone is having surgery then the surgeon usually has to ensure the patient will have enough steroid cover for the procedure. This helps the body cope with the extra stress.

There are many causes of a crisis such as infection/ tummy bugs, stress, trauma and any form of serious illness. If patients vomit or become unwell then they usually double up on their own steroid tablets and if necessary give themselves a hydrocortisone injection. Not everyone is given a home injection kit though. A lot of sufferers manage their condition extremely well even if they start to feel a crisis coming on. Once they feel better then they will slowly wean themselves off the higher steroid doses and back on to their normal dose.
Sometimes people become very ill very quickly and are unable to keep their tablets down. That's when they need an injection. That's when we come in.

People may feel weak, dizzy, have a low blood pressure, rapid pulse and sometimes a low blood sugar. People can have seizures and become unconscious. If left untreated death will occur. It is a potentially life threatening condition. On the outside it could be just someone vomiting but when you find out they have Addison's (and understand the problems that causes) it changes the game somewhat. Be aware, not every one will present with the classic signs of shock. If they can't keep oral steroids down they need Hydrocortisone. The aim is to prevent a crisis not just to treat it when it comes along.

There are some good websites that explain the condition far better than I have. All you have to do is GOOGLE ADDISON'S DISEASE and go from there.

It's amazing reading some of the patients's stories from a few years ago and you will see that back then hardly any ambulance staff knew anything of Addison's. We didn't have Hydrocortisone (HYC) back then. Well we do now which is a step in the right direction.

Some advice though. Make sure you have a medic alert bracelet or some other obvious means of letting us know that you have this condition. If you are an Ambulance Technician (and you can't give HYC) use common sense and ring A/E to get permission to administer it IM. You may just save someones life. Actually I don't know why Techs can't give it nationally, it comes under the same drugs act that covers Glucagen, Adrenaline and Narcan (which enables techs to give these drugs in the first place) All UK Paramedics can now give it IV/IM and where I work via the IO route.

Hope this has helped. I'm waffling now so I'll sign off. Byeeee.

Adrenal Crisis

I've had a busy week. Cardiac arrest, sudden death, diabetic hypo, countless falls and an imminent birth (That we managed to get to hospital just in time. It was close though, she wasn't budging initially but as soon as I opened up the mat pack she shouted "No, not here! I didn't want this!" "Well you've two choices, take some really good breaths on this gas and air and let's get you down to the vehicle or we'll have to deliver here. Your choice." I said. With that she gulped the gas and air and made it to the truck. We were only 2 minutes from the hospital and were there in no time. They had called the midwife but she refused to come out. I phoned maternity and requested one to come out as birth was imminent but then cancelled her as we were en route.)

I was on the car over the weekend and Saturday was spent mostly going to calls but being stood down again. Then 25 minutes towards the end of my shift in comes a call, Sick person, Cat B. "Bugger!" It's not far and en route I get an update. Female with a histroy of Addison's Disease. I'm greeted by the woman's kids who show me into the front room. My patient has been vomiting for 24 hrs plus, unable to keep her oral steroids down and had already given her self her own Hydrocortisone injection 5 hours earlier. She was not good. I needed to get some more steroids into her but her veins were non existent. I tried twice but there was nothing. The ones in her hand were like trying to cannulate an electric cable, tough. I gave up and gave her an IM injection instead. She did say that she had terrible veins and that they always had trouble at hospital. She did ask me to put an IV in her ankle as that is what they usually end up doing in A/E. I said I'd rather not if I can help it. She also had severe abdo pain radiating into the back so I gave her some gas and air. No sign of a crew so I called up control. "Nothing assigned to you yet, why, did you need one then?" "Er yes please, bearing in mind this lady is suffering from an Adrenal crisis and it is potentially life threatening." "OK, we'll get one running." They took ages and my patient was pleading for me to have another go at getting a line in. She wanted some anti-sickness meds and as her BP was low I needed to get some IV fluids going. Her sugar was OK (this can be low in a crisis) and she had good oxygen saturations. The crew arrived and after a little bit of banter (she was in remarkably good spirits despite her condition) we got her onto the truck. Now she was lying down I had a look at the vein in her ankle, it was a beaut. "Right I'll have one attempt and that's it." I said. "Please do, I'd rather you got one in now." She said.

And in it went, 4 vials of bloods, some IV Metoclopramide (she was already taking the oral version) and some IV sodium chloride and they were ready to go. I gave a pre alert to A/E and off she went. The vast majority of my on scene time was taken up waiting for the crew to arrive. I finished 45 minutes late, at time and a half mind you, and it was for a genuine patient so I didn't mind. It didn't help that I left my house keys at home and had to wake my wife up at 1.15 am to let me in. Whoops.

For those non-medical types and trainee techs etc that might read this blog my next post will be a brief overview of what Adrenal crisis and Addison's disease is about. Stay tuned.

Oops, where's my bloody car door gone?

Is it me....................what do you think?

This call occurred a couple of weeks ago and I still find myself questioning one of the decisions made by the DR at A/E.

Our first job of the night was to a child who had fallen from a rope swing that his dad had just put up in the garden. We arrive on scene to be greeted by a panic stricken father who leads the way round to the back of the house. On the floor is a small boy lying on his side, conscious and breathing (always a welcome sight in any ill or injured kid, I'm sure you will all agree) and covered in the customary emergency layers of blankets. A quick assessment reveals that his ABCs are good. However he has bony tenderness in the centre of his neck (C-spine), he also has some thoracic bony spinal tenderness. It is causing him great discomfort despite his mum having already giving him some oral paracetamol solution. He has no neuro deficit and all his limbs are moving. Because of the 'mechanism of injury' we need to be very careful and immobilise him. We pop a collar on him and keep him chatting. Despite the pain he is very compliant and I offer him some oral morphine to ease the pain of which he is grateful. Next we roll him onto a vacuum mattress for comfort and suck the air out. On to the trolley, into the truck and of to hospital with mum. Dad follows in the car. On the way I do the usual observations which are normal for his age and I find out that mum is a paediatric nurse at the local hospital.

Now, back to the mechanism of injury; the swing is my height-over 6' and according to dad the swing managed to unhook it self when the kid was at full height. He landed on grass but his back took the full brunt.

I phone the hospital and speak to one of the Jr DRs, as I know they were busy, just to let them know what we have and how long we will be. We arrive 10 minutes later with a child who is now relatively pain free. This is the bit I'm stuck on. After releasing him from the vacuum mattress I take control of the head and direct the log roll while the DR examines his back.
"when I press you tell me yes if it hurts, OK?" says the DR
"OK" says the child
Pressing on the neck soon generates a yes and another yes and another. Now onto the thoracic spine and another yes etc. The DR then says "I think he'll be OK" and asked the boy to move his head left and then right, no problem. However when the DR asks him to lift his head up off the trolley he can't because it is too painful..................in the middle of his neck and back! The DR still says "I think he will be OK".
Dad shakes my hand and both parents thank us, we book in the patient and are off on the next job.
What I don't understand is why didn't the DR refer him for an X-ray? Yes I know kids have soft bones, yes he landed on grass (which wasn't that soft) and yes he probably will be OK. But if there is CENTRAL bony tenderness over any part of the spine, child or adult, then surely that warrants an x-ray. Again I know x-rays shouldn't be dished out 'willy nilly' but if the mechanism is there.................................


I'm sure/hope he was fine. I should really follow it up (too busy that night) and have a chat with the DR.

This is no way a dig at any A/E DR just my curiosity. I'm pretty sure if it was one of the more senior DRs then investigations might have been slightly different. I don't know.

At the end of a night shift...........................

For me it was a rotten end to a night shift. I was fortunate enough to go home to my wife and family. The driver of this car was less fortunate.

RIP

The Fall

Another 999 call. A fall in a retail park
"It's probably some old dear who has tripped over in one the shops" I joked.
About 3 minutes later we pulled into the retail park.
Jokingly I said "Nah it's probably someone who's fallen through the roof"
Before we knew it we had an update on the radio "Cardiac arrest, young male fallen approx 40ft through the roof"
"SHIT!"
Now on scene, ambulance doors swung open. I grab my Para bag, response bag and drugs kit. My crew mate grabs the suction and critical hemorrhage kit. Through the doors we are confronted by a crumpled heap. Above him is smashed ceiling panels and about 40-50ft above that is a smashed skylight.
The patient isn't in cardiac arrest but he's not far from it. Massive head, facial and chest injuries are obvious. We needed to act fast if we were going to give him any chance of survival.
By now a RRV Paramedic from base had arrived and we quickly set about suctioning the airway and then moved the patient onto his back. He wasn't breathing adequately and his radial pulses were virtually non existent.
First thing to sort was airway. I had a quick look with my laryngoscope but saw nothing but blood so I suctioned some more then started to assist his breathing with a BVM. Another look, more suction and then in with an ET tube. Airway was now secured. Next was breathing. It was quite evident that there was significant blunt chest trauma. One side of the chest was higher than the other, breath sounds were diminished and it was hyper resonant. I opted to insert a wide bore IV into the chest to allow the air to escape. Radial pulses started to get stronger. All the while my colleagues were getting other kit sorted. My crew mate then took over ventilations while my self and the RRV Paramedic both got big IV lines into the arms. At this point various other colleagues turned up including a local Basics DR. He just wanted to know how far we had got and then we reassessed ABCs. Next thing we know HEMS are en-route and within minutes they are walking through the door. The HEMS DR gave some RSI drugs to make sure the patient was properly asleep while the HEMS Paramedic performed a thoracostomy on the damaged chest. This made a huge improvement with ventilations, my needle decompression improved things as well but the thoracostomy really did the trick. Next we started some Hypertonic saline. Epistats were also inserted as there was significant bleeding from the severe maxillofacial injuries. A pelvic splint was also applied just as a precaution and a rapid ultrasound of the chest and belly was carried out to detect internal bleeding. Now with everything in place and all the best possible treatment it was time to load the patient into the aircraft. Many shoppers were filming us as we walked through the car park, probably out of morbid curiosity. When the helicopter lifted off there were even more people filming on their phones and as soon as the helicopter vanished they had all practically disappeared. The young lad was flown to the Royal London by passing all the local A/E units as it is the UK's main trauma centre.
We had to give our details over to the police, which is the norm in these situations. Next was the task of clearing up which was now like a war zone. Police asked if we could check over the patients work mate who was in a state of shock so I went over and had a chat with him. He was just dumbstruck.
After a quick debrief in the car park we were back on base restocking.



I've since found out the poor lad died this morning.
Everything that could be done was done right there and then. We gave him a chance.

Late meal breaks, crews down, no spare trucks and vehicles breaking down but yet we soldier on. Beautiful sunshine over the bank holiday weekend and I'm stuck at work. It didn't help when my wife text me with 'Hope you're having a nice day at work, I'm off to the beach with the kids.'
Talk about rubbing salt into the wounds! By all accounts they had a nice time. I on the other hand had to slog it out at work.

RTA neck pain, falls, bowel obstruction (requiring morphine-did the trick though and she wasn't very well at all), collapse ? cause, dying swan hyperventilation (after being accused of stealing, this patient just wound me up inside. I'll post about it in the future. Arrgh!), CVA that wasn't a CVA, back injury etc etc. You name it we pretty much had it.
We also had a young lad who fell off his BMX and the brake lever went into his inside thigh and ripped it open. I could have put my whole fist in the wound! He was brave and I'm sure by the time we arrived at the hospital he was now an Entonox (nitrous) addict. Ha Ha. He didn't want anything else for the pain which surprised me. It was a big wound for a kid to have. He asked the A/E consultant if he could go to sleep when they stitched it up. 'I think that might be a good idea' she said softly. I thought 'Too bloody right!'
Cardiac arrest, middle aged man collapsed and smashed through a glass door backwards. He'd been down too long and was beyond help.
The other crews had been to a premature baby who had stopped breathing and was grey and floppy. Airway & breathing management was all that was needed, sugar level fine as well. No other interventions or drugs needed, just a heavy right foot and 20 litres of diesel. The baby took a little while to recover at hospital but by the time the crews had cleared up the little bundle of joy was trying to eat the 02 tubing! A job well done!
My last call yesterday was to guy who had fallen heavily onto his foot the evening before. It had now ballooned up and was bruised. You could feel & hear the crepitus and the swelling was creeping up the outside of his leg. He drained both an F size and CD size Entonox bottle and in the end I gave him some morphine. I'll check up on him tonight. I know it's rare but I think he has broken his Fibula. Usually both Tib & Fib break but there something about where the pain was and how he landed that made me think. I was also worried about compartment syndrome developing. I suppose I'm just being over cautious.
Back in tonight for one of two nights.

Never ending.

It seems like I'm always at work just lately. Over the last few weeks I've had a run of 4 shifts but thankfully they will end soon.

Monday night wasn't that busy, 4 jobs in total if I remember rightly.

Cat A S.O.B. A Lady in her 50's who had been diagnosed with Chickenpox and Pneumonia was having a job to breathe. She was very ill and in a lot of pain. Her sp02 was 85% even on high flow 02 which was very worrying. Her skin was mottled and her chest pain was impeding her breathing. We weren't on scene long and on the way in I drew some bloods and gave her 5mg of morphine which worked well. She ended up in ITU. I've never known someone of her age having Chickenpox before. Basically her lungs had become so infected it was interfering with her gaseous exchange therefore she wasn't oxygenating properly. Very poorly indeed.

Acute abdo. Male, 60's complaining of severe abdo pain. He had a massive scar which ran down his belly due to diverticulitis and had a small hard mass which was causing him agony. My crew mate said that there was nothing we could do and that we would just go. I was less than impressed with that. There was something that we could do and that was to relieve his pain. One thing I will not do is take someone to hospital writhing in agony especially when I know as soon as we walk through the doors a DR will want the patient to receive pain relief. Treatment of pain is humane, the patient can think clearer and physiologically can help to improve outcomes. This patient was more than grateful for the 10mg of morphine he received.
We did 2 other jobs but I can't remember those.

Tuesday, another quiet night.

Cat A S.O.B. Man in a car on the side of the road. As we pulled up we could see he was on O2. He had COPD and had been driving his car with his own O2 on when he became SOB. He was grey and sweaty and struggling. We gave him some nebs and ran him into hospital. After handing him over to the staff my crew mate was strolling back to us when I noticed our patients eyes rolling back. He was retaining carbon dioxide and had gone into respiratory arrest. I slammed back the head of the trolley and raced him into resus as my crew mate ran for help. In resus I started suctioning his airway, dropped in an OPA and started bagging him. Soon there was a hive of activity and IVs were put in, bloods drawn and blood gases taken. I had the easiest job maintaining his airway while everyone else got a sweat on. 10 minutes later and an Anaesthetist turned up and took over airway management, eventually performing an RSI.
The staff grade DR said well done on managing the airway and he thought that it went very smoothly. It's always nice to get a complement from a member of the hospital staff. I also thought how much easier it is managing a patient in a well lit environment with every thing to hand, not like an ambulance.

We also had an impressive RTA where a front axle had been ripped from a drink drivers car. Luckily there was no one hurt so we left the police to arrest the youngster.

Asthma, pretty much in the middle of nowhere, a lady who reluctantly came to hospital. She had some nebs and IV Hydrocortisone. We had to take her to another hospital in a different area so after clearing up we where desperate to get out of there and back to base. We managed it.

I did some overtime on Wednesday night and to be honest I can't remember what calls I went to, all the shifts lately seem to blur into one long one.

All in a days work.

The weekend was run of the mill stuff, nothing exciting. On Saturday I fluffed the only IV that I could of justified on the last job of the day. A lady with renal colic who was in agony. She needed some decent analgesia but I couldn't get a vein. She said the hospital always had trouble in the past. We had to manage her on Entonox which was OK but not really hitting the spot.
Sunday was pretty much the same. However we did have a birth. A lady who's waters had broke earlier that morning and was just being driven to the maternity unit. But before they could pull off she had one almighty contraction and the baby started to crown. We arrived just as the baby did. Pouring down with rain (bloody typical English weather!) we had to work to get her and the baby out of the front seat of her car. I had to cut the cord on the roadside and after wrapping her in some hooded towels I rushed with babe in arms into the truck to quickly give the baby the once over. She was perfect with an APGAR score of 10 both at 1 & 5 minutes.
All the other drivers were rubbernecking as usual. With the mum now on the trolley, her husband helped my crew mate get her on board. Her placenta was still in situ and there had been minimal bleeding (no need for the syntometrine then!) so we decided to stick the lights and sirens on and cruise over to the hospital.
We also had a chest pain which on the ECG looked like the early stages of an Anterior MI but there wasn't enough ST elevation for me to thrombolyse (damn it!). We gave Aspirin and doses of nitrate spray but when the patient took his O2 mask off the pain started coming back so we gave him some buccal nitrates which helped. We had to wait for an escort (I wont go into detail but he had to have one) which was taking longer than we liked so I put in a cannula and drew some bloods for the hospital. I think he was having either an MI or Prinzmetal angina as the nitrates were helping keep the pain at bay. Anyway at hospital he was soon whisked off some where.
I'm on tonight as well but so far it's been quiet. SHHHHHHHHHHHHHHHHHHHHHHH

Good news!

Just a quick update about our Intubated guy from my last couple of postings.
I enquired at A/E reception about his where abouts and found out that he had been transferred from ITU down to an acute ward. This meant one of two things to me, either he was fine or that he was not going to make it. I took a stroll over to the ward and as I walked along the corridor I looked in one of the side rooms and saw this guy. Was it him? I checked the names on the board and sure enough it was him. The staff were all busy so I went back to the room. I couldn't believe it. He looked healthier than you or I. I introduced myself and we chatted for about 10 minutes. He told me that the DRs still didn't have a clue what was wrong with him and that he had all manner of tests. He asked if we had to shock him, I told him we didn't but he wasn't in good shape at all. He thanked me and I left him in his side room.
These sort of jobs don't happen that often but when they do it makes you realise just why we are here.

Update: Unconscious male

I managed to get back to the hospital in the early hours and spoke to one of the A/E DRs regarding our unconscious chappie that I intubated. He had a head CT and that was fine. In fact they still hadn't reached a diagnosis and didn't have a clue what was wrong with him. He is now in Intensive care and the plan is to wake him up and see how he does. Unfortunately I'm not back to work until the weekend so I'll have to check up on him again, if I remember that is.

It's not often that as a Paramedic I get to intubate. If I do then it is usually Cardiac Arrest or severely head injured patient and even then those patients usually die. I said most, not all. Now this job has puzzled me. Yeah OK I had to give 10mg of Diazemuls for his ? seizure but surely that is not enough to knock him flat enough in order for him to tolerate an ET tube. The other puzzling thing is that they haven't been able to find anything wrong. At the end of the day, his airway was compromised big time and he was having some sort of seizure. I did the best I could with skills that I had available.

Time to earn my money.

Cat A unconscious, backing up the car. We arrive on scene 6 minutes after the car. A few people are frantically waving us down. A man in his 40's had collapsed, was barely breathing and blue. The RRV tech already had him on O2 and had done some baseline obs by the time we had arrived. His airway was clamped shut and a nasal airway was proving unusually difficult to insert. There was dark red blood and vomit coming from his mouth. His pupils were dilated, his Oxygen levels were 71% initially rising to 94% on O2 and his BP was a little low at 110/72. He was a big chap! Was he having a bleed or some kind of seizure? I didn't know, all I knew was that we had to get him out quickly. While my crew mate moved the truck to another doorway I stuck a line in and drew some bloods. It took a while to get him out because he was heavy and we had trouble getting him round the corner through the door. But with some help we managed it. Now on the truck we connected him to the monitors while I suctioned his airway. He looked like he was having some form of seizure so I gave him 10mg of Diazemuls which seemed to settle him down. I still wasn't happy with his airway so we positioned him on to his back and carried on suctioning. I popped in the laryngascope and swept his tongue to the left, a bit more suction and then in with an 8.5 ET tube. He was tolerating it so I inflated the cuff and connected him up to the BVM and assisted his breathing. Although he was breathing, it wasn't adequate so I just gave a helping hand. His BP had also dropped to 91/61 so I had some fluids running as well. I pre alerted the hospital and carried on ventilating him en route. Another check of his BP and it was down to 85/40 so I opened up the fluids a bit more. His O2 levels were 100% and he was still tolerating the tube. But when I re checked his BP it was unrecordable and he had no radial pulse. I connected him up to the transport ventilator and shouted through to my crew mate that I was going to put in another line. I waited until we went through a few roundabouts and found a big vein in the crook of his elbow. I managed to get in a 14g brown (this is the biggest size IV we carry) and set up some more fluids. As we pulled into the hospital his BP was now back up to 99/64. At this point I had got a little bit of a sweat on! We handed over to the staff and by now his resps had increased with good tidal volume so they connected him to a patient circuit. Surprisingly he still tolerated the tube and was trying to wake up. They also tested the bloods that I had obtained but found nothing out of the ordinary. Puzzling! There was a bit of a discussion about whether to paralyze him or just to continue sedation. The decision was to keep him sedated with propofol.
As of yet I haven't been back to the hospital to see how he is getting on but hopefully I might find out later on as I still have nearly 6 hours of this shift to go.

Expectations

Today I was crewed up with another Paramedic (recently registered) and the expectations were high. By that I mean everyone else thought that we would go to all the 'proper' jobs.
'Oh, those two are together today. We'll be doing all the falls and probably wont get a look in' said one colleague. To top it all after our first job we had an army medic jump on the truck to observe for the shift. That was the kiss of death! Even my crew mate thought because he was working with me that he get some good jobs. The trouble with all this expectation is that nothing usually happens. I always say 'If you come in and don't expect proper jobs then you might be lucky and get a couple that require our skills. But if you come in with high expectations then you'll go home disappointed.' And that is how it usually happens.

1. Seizure. 11 yr old who had stopped fitting on our arrival. History of a single seizure 2 yrs ago. Thoroughly investigated and found that strobe lights affected him. This AM he had been sitting close to the TV and had a seizure. Monitored and transported to A/E for further assessment.
Picked up our army medic at A/E
2. Chest pain. Lovely elderly lady who was cheeky and could talk for England despite being severely breathless. O2 and into the truck and around the corner to A/E. Her heart rate was 150+ and climbing, it was also irregular. Turned out her problem was fast AF.
A stint of stand by at the Dr's surgery.
3. Chest pain. Whilst at the surgery one of the DRs came out and said 'Just to give you the heads up lads, I've got a patient inside with SVT who'll need to go to A/E' And sure enough the job came through. Must have been the quickest Cat A response time ever! We were slightly miffed as we were tucking in to sausage rolls and a steak slice as he came out! Middle aged lady with a pulse rate of 190+and feeling light headed. O2, IV access and a 12 lead then blue lighted in. On the way I tried the valsalva manoeuvre with a 20 ml syringe which worked briefly and brought her heart rate down to 115. It was short lived and despite repeated attempts her heart rate was still banging away at 190+.
4. Urgent journey. Urinary retention from a nursing home. By the time we got there the patient had managed to empty his bladder but had now developed diarrhoea. The nurse in charge didn't really want him to go in because of this so we agreed to let her contact the GP and arrange further assessment. At last a nursing home that actually uses common sense!
5.Fall. Assistance only. GP was attending anyway and did so while we were on scene. We left her to deal with the patient.
6. Fall. Elderly lady who fell down a few carpeted steps and bumped her head on the plaster board wall. Very anxious and not completely recovered. A trip to A/E.
7. Entrapment...................................................In HANDCUFFS! Young lad larking about with mates in the street put on one of the cuffs and couldn't get it off. A friend was worried about circulation. On scene within a minute and quickly followed by Fire & Rescue. I was going to get our bolt croppers out but seeing as Fire were right behind us decided to let them get on with it. In the end they used a leatherman tool to pick the locking mechanism and set the lad free. The funniest part was when said that it was too tight and would have to take his arm off below the elbow. His face was a picture! He walked off with his mates soon after.

With shift now over, my crew mate looking thoroughly peed off, said 'Thanks for a thoroughly average day!'
Well I did say don't come in with high expectations didn't I!
I spent a little time chatting on base with some of the night crews and an officer who had been at a Police shooting during the day before driving home.

Back Saturday and Sunday night. I wont be expecting much!

Sunday

After a similar start to Saturday we eventually got our first call. It was passed as a Cat A Stroke, usually they are Cat B so I thought that this must be a bad one.
Our patient was a few weeks post op (total hip replacement) and was in her bed in the front room. Her husband had woken her and discovered she slurred speech with right sided weakness. We quickly assessed her using the FAST exam (Face, Arm, Speech, Time) and confirmed the right side had been affected. Her blood sugar was fine and as her O2 saturations were slightly low I placed her on 2 litres of O2. We reassured her as best as we could and she even managed the odd smile in between the tears. She had expressive dysphasia which meant she couldn't put words together properly but could understand what we were saying. Many stroke patients suffer this and causes them to become frustrated. As a result her husband jotted down the personal details (so I didn't have to ask her and increase her frustration) and said he would follow on.
After pre alerting the hospital I assessed her in more depth using some of the stuff I had learnt on the Advanced Stroke Life Support course. This was the first genuine patient that I could do this to since doing the course. One thing I was stumped by was that her blood pressure was low, usually it is high. She was on meds for arrhythmia but her ECG looked nice and regular so it wasn't that. Oh well, the DRs can look into all that while I do my bit and get her there.
Unfortunately the Stroke team weren't available as it was a weekend so I just hope she is alright or it was just a TIA (transient Ischaemic Attack-temporary blockage). But for a TIA to be diagnosed 24hrs need to pass with the patient being symptom free. I'm in tomorrow so I'll enquire and let you know.

Next call was to 4 month old baby with chickenpox who had vomited. I think the parents panicked and called us. They had taken the baby to hospital twice the previous day and were told the same thing. We reassured the parents and referred them to the OOH GP. They were happy with that.

While we were sorting out the paper work we could hear it all kicking off over the radio. There were Allergic reactions, unconscious diabetics etc and we could hear the sirens of other trucks around us.

We cleared and were given a Cardiac Arrest but it was soon passed as cold and stiff in a warm environment. This meant the patient was obviously deceased. On scene we met the neighbours who had found the unfortunate individual in her own home. They hadn't seen her for 24 hours and decided to see if she was OK. She wasn't. After confirming death and recording a 30 second ECG trace we waited for the Police. They were there within 10 minutes which had to have been a record as they usually take 30 minutes plus. This is not their fault because it's not deemed a priority once death has been confirmed (as long as it's not suspicious). Again we found ourselves clear and ready for the next one.

No sooner had the clear button been pressed another job came through. This was getting silly now, I was getting hungry and desperately needed the toilet. No time, it was another Cardiac Arrest!
It was only round the corner and we were there within 1 minute. A local off duty Paramedic (who also responds as a community first responder) arrived as we did. A lady met us and said that she thought he (her husband) had gone. She showed us into the conservatory where our patient was sat in a chair. He looked asleep but we knew he wasn't. He was a big chap and it took 4 of us to place him on the floor. There wasn't much room to work but we quickly set to work. I placed the defib pads on his chest whilst my crew mate started CPR. The other Paramedic got the BVM out whilst I tried to get a line. He had no veins in one arm and on the other there was a bruise from a recent IV or blood test. I got it in but it wouldn't advance so the other Paramedic managed to get one in the external jugular vein. The rhythm on the defib was PEA (pulseless electrical activity- meaning that there was electrical activity but the mechanics, i.e the pump, wasn't working) so it was CPR for now. Another crew turned up to give us a hand and started sorting the trolley and the drugs. I went to the head and prepared my airway kit. I inserted my laryngoscope and lifted up the tongue but couldn't quite see the vocal cords so asked one of the other EMTs to apply some gentle pressure on the larynx, it worked and quickly placed the breathing tube into the patients windpipe. I connected the catheter mount and BVM then listened to the stomach; No sounds, good. I then ventilated again and heard air entry on both sides of the chest, I was in! Next was some Adrenaline and soon after we had VF on the screen. We were now able to shock. After 15 minutes, 6 shocks, more Adrenaline and some Amiodarone we were now back into PEA so we needed to make a decision about moving. The trolley was set up at the front door so we placed our patient on to the scoop stretcher and carried him out. On board the ambulance I disconnected the BVM and attached the catheter mount to the transport ventilator. I was now hands free to do drugs and fluids en route whilst my crew mate continued CPR. A quick checked of the rhythm showed a slower PEA rate which was turning into an agonal rhythm so I decided to give 3mg of Atropine and a further Adrenaline. No change.
At hospital we were met by the usual resus team who quickly took over but eventually gave up. I wasn't surprised as this is usually the case, if we don't get them back there and then the chances of getting them back at hospital are slim. Sad but true. The A/E consultant said we tried our best and also said well done on a good tube and line. That was nice but in the grand scheme of things not important.
We had the usual tea and a chat and made our way back to base to restock and have something to eat. The ambulance was surprisingly tidy and needed little cleaning. Makes a change!

The last job of the day was passed as a Cat C fall, 17 miles away! it was to an 8 year old female who had a ? fractured arm. Mum met us outside and told us what had happened while we walked through the garden. Her daughter had been climbing a small tree and fell landing on a hammock and then onto her out stretched hand when she hit the ground. Her mum had seen it all and said she immediately knew it was serious by the type of cry her daughter had let out. Our patient was in the front room sat on the sofa sporting a trendy makeshift sling. It was similar to the bandanna worn by Marco Pierre White of Hell's Kitchen. She was very distressed and crying with the pain. After excluding more serious injuries I turned my attention to her arm. Her forearm was deformed and basically looked like a big banana so we started her on Entonox. I checked her pulse and capillary refill on her injured arm which were fine. Because the Entonox wasn't really having the desired effect and the extended travelling time to hospital I opted for some Morphine. I had a look on her hand and found one straight vein. I took my time and it paid off. Straight in and she didn't even flinch, phew! Now with her pain under control we popped a sling on and got her out to the truck and mum came with us. Dad and her sister would be following later. On the way I reassessed her and had to give her some more Morphine. I called ahead to the hospital because I knew it was busy and I didn't want this child to have to wait any longer than she had to. A good job too because as we arrived the trauma team were waiting at the doors for a critical patient from an entrapment RTA coming in by HEMS. It gave mum a fright because she thought they were all for her daughter, we soon put her at ease. We weren't in resus long before being transferred down to the paediatric A/E section. As I booked her in at reception the DR came over and said well done on the line and giving her Morphine. Personally I would have preferred to have given Oramorph but because we haven't got it yet I couldn't. However I have been reliably informed that Oramorph is imminent which will be an important addition to our drugs bags although 3 years late! Better late than never!

Business as usual again

I was on a night shift the day after getting back from Devon and it was uneventful. My trainee crew mate drove all night as none of our patients went to hospital. Even the one and only genuinely ill patient refused! She was short of breath with oxygen saturation's of 87% on room air and her lungs sounded like they were filling with fluid. Her oxygen levels increased with a nebuliser but that was only easing her symptoms and not treating the cause. She said she felt better even though her levels had dropped again but still refused multiple times. She thought she could leave it until the morning but I wasn't happy with this so I referred her to the OOH GP. I also made sure that I noted my concerns on our paperwork and left her a copy. Her daughter was due to visit so hopefully she would have read them. Outcome unknown.

I was on the early day shift over the weekend with a newly qualified EMT and the majority of work was genuine.

Saturday:
Got off to a slow start and after a couple of stints of roadside standby things picked up. We did 6 jobs in total. Here are 2 of them.

We were passed a 'Headache' call 9 miles away. 'Here we go again!' I thought. But when we saw our patient she looked dreadful. She was clutching her head and was very pale and clammy. The light was hurting her eyes and she was vomiting. Her husband said that she never had headaches and wasn't one to complain. I honestly thought we were dealing with some sort of cerebral bleed. The lady said that it was more than a headache and it was really debilitating her. On board we took some obs and because she was in a lot of pain I was going to give her some pain relief. It was going to be a long journey to hospital so I started off by giving her an IV anti emetic. I with held pain relief because after some oxygen the pain was easing slightly. Was this just a migraine or cluster headache or was something more sinister? I don't know but if I treat her for the worst case I should have every thing covered. I called ahead to the hospital to let them know we were coming. By the time we arrived she was so much better. No vomiting and the pain had eased right off, her colour had started to return. She apologised for wasting our time but I told not to be so daft. The main thing was that she was going to be alright. I'd rather treat something like that seriously and it turn out to be nothing than get it wrong.

Another call was to a male with chest pain. He wasn't too clever. He had previously been into hospital with lung problems and was now suffering left sided chest pain. His temperature was 40.9 and he was breathless. His pain was severe enough to impair his breathing so I gave him some Morphine for the journey. I pre alerted the hospital and continued to observe him.
We were met in Resus by a DR and Nurse where I handed him and his blood samples over. Within a few minutes the DR ordered IV Paracetamol and thanked us.

Sunday:
Stroke, sudden death, cardiac arrest, baby with chicken pox and vomiting and a paediatric who fell from a tree and fractured her arm.
I'll post about Sunday soon as I'm now feeling very tired. ALTOGETHER NOW...............AHHHHH!

I'm on base with not much to do, it's been a quiet start. My crewmate has just shown me this picture which made me chuckle. If only all our elderly residents were as fit as this!

I'm Back!

I'm back from Devon and I must say I do miss the place. There's something special about the West Country and that's the reason why we go there as much as possible. It's nice being home but you can't beat getting away from it all and forgetting about the hum drum of everyday life. From the moment we got there it was non stop, swimming, bowling, walking, eating (a favourite pastime of mine!), Zoo, woodland leisure park, more swimming and more food etc etc. It was great!

I'm back to work this weekend on days with a newly qualified EMT. We'll just have to wait and see what happens.

I'm off to Devon for 4 days with the family so I'll resume posting when I get back. I have been working over the last week but haven't had any time to post. Oh well, see ya and stay safe.

Cricothyroidotomy

Sorry another 'What do you use?' post.

In this one I'd like to know what you use for cricothyroidotomy. In the UK Paramedics are taught the traditional and less than ideal 'Get out of jail for 5 minutes' Needle cric using a large bore IV cannula and jet insluffation. Where I work we have the Quicktrach SAD (surgical airway device), pictured above, which I have used in anger and have also assisted in it's use. It's a good bit of kit. I've also found this link to it's new and improved model http://www.vbm-medical.com/cms/97-1-cricothyrotomy.html.

I'm not sure what devices are used by other UK services or in fact across the world. Although I do know that some US/Canadian EMS providers perform open cric with a scalpel.

Capnography: What do you use?

I'm just wondering what sort of kit is used to measure ETCO2 around the world. At the moment we have the disposable detector shown at the top. We're supposed to be getting the EMMA (digital capnography, displayed underneath) soon. Our Critical Care Paramedics already have them and our local BASICS Drs have them. It looks like a cool gadget.

I know London Ambulance Service has capnography and use their Lifepack 12. Not sure about anyone else.

More can be read on this item here http://www.phasein.se/Products/EMMA-Capnometer/. Also click this link to read up on capnography via Peter Canning's blog http://emscapnography.blogspot.com/.

Another life saved cont'd

After the heroin OD I was sent to a Cat A 16 miles away. It was passed as unconscious and then downgraded to a Cat B Not Alert. I arrived at the care home and was shown through to my patient. He was flat on his back and drifting in and out of consciousness. Airway was good and his breathing was adequate so I went on to the other usual checks such as pulse (which was irregular), blood sugar, blood pressure, pulse oximetry (this was a little lower than we liked) and pupils etc. The staff heard an almighty thud and found this chap completely out of it lying flat on his back. Although he was struggling to stay awake I was able to assertain that he had central neck pain. He was in reasonable health and surprisingly not on a great deal of medication. A crew arrived sometime later and I was pleased to see the Paramedic. He was on my Uni course and also on my in-house Paramedic course, a really decent bloke.
I relayed my findings to the crew and we quickly set about immobilising our patient and giving him oxygen. As usual it was a struggle getting him out as there were so many right angles and door ways we had to stand and tip the long board. I helped load the trolley and stayed with crew as they connected him up to all the monitoring equipment. Within 15 minutes of their arrival the crew were off to hospital.

Last night I had a text from the Paramedic on that job, he said that the patient deteriorated en-route so he popped a line in him, he also confirmed that the patient had bad fractures to both C2 and C3 (two of the bones in the neck). Hopefully it's just fractures and no spinal cord damage. There were no signs of SCI (spinal cord injury) on scene so I am hopeful.


Apart from the OD and Neck fracture on Tuesday I also attended:

A collapse: Young male at work recently diagnosed with tonsilitis who collapsed. He had a high temperature and hadn't been eating or drinking properly for the last few days. He went to hospital and was later transferred to a specialist ENT unit. Probably a condition called Quinsey.
Fall: Elderly male who had a live in carer. He bumped his head and was initially going to hospital as he was on the blood thinning drug Warfarin. It turned out his carer got confused between Furosemide and Warfarin and he wasn't taking the latter. He changed his mind and refused to go to hospital so when my back up arrived they just turned around and left. He should of gone really but if they refuse there isn't a lot you can other than refer them to the GP.
RTC: Minor rear end shunt, Police on scene. A male just wanted his neck checked out. He was walking about and complained that the right side of his neck and shoulder was uncomfortable. He declined immobilisation and was happy for me to take him to the hospital in the car. I'm no DR and not at all cynical but I was thinking along the lines of Acute Compensitis.
Fall: A regular faller who had slipped whilst transfering from his wheel chair to another chair. It was passed as an assistance call but on examination I found that he had a temperature of 38.5 (the norm being 36.9-37 depending on which book you read! Like everything else in medicine.) and his heart rate was up. As he had a catheter in situ I figured it was a UTI (Urinary tract infection), he declined hospital as he would prefer to be treated at home. He wasn't that bad so I called the OOH GP service to arrange a visit. A catheter change and some Trimethoprim would probably sort that out.

Finished on time again.

Another life saved

After attending a so called unconscious patient and then a minor injury fall I was sent to another station for a bit of stand by. I wasn't there long before being sent back to base and on the way I decided to stop at the local petrol station to get some munchies. As I got back into the response car I could hear the MDT bleeping and control calling me on the vehicle radio. I had a job. It was an unconscious person in some public toilets. Another message came through to say that the patient was blue and grunting. I knew exactly where it was and made my way over there. An EMT crew were backing me up but managed to go to the wrong location, they were given slightly different directions. As I pulled up on scene I was met by a guy with his 2 daughters. He wasn't best pleased as his kids had wanted to use the toilet but were confronted by a scary looking man, acting strangely and then collapsing to the floor. I did the usual mathematical equation; Unconscious man + In the public toilets + Blue + Not breathing = Heroin overdose! I grabbed my response bag & drugs, approached the door and gently pushed it open. As I peered round the wall I could see the man on the floor, sure he was blue and not breathing. I could hear the sirens of my back up on the other side of the park and within 30 seconds they were pulling up next to my car. I waited for them to turn up before going in and treating this chap because I didn't know if one of his drug crazed mates was hiding in a cubicle waiting to stab me with a dirty needle. Remember people, SAFETY FIRST! There was now three of us in the toilets, no sign of any one else so we set about treating him. After inserting an oral airway one of the crew started ventilating him with a bag & mask (BVM) and high flow oxygen, the other EMT started checking pulse, blood sugar & pupils etc and I sorted drugs. He was a classic text book heroin overdose, blue, not breathing and had pin point pupils. Now, a job like this requires team work and it went very smoothly, everyone getting on with their own thing all the time looking out for each other. You see, where I work it is notorious for heroin addicts/overdoses and there are a lot of us who have encountered situations where things have changed rapidly and found ourselves having to 'Get the F*** Outta Dodge!' pronto. I gave him 2 Narcan injections and while all the time still ventilating him waited for the drug to take effect. 'He's in respiratory arrest, why didn't I go IV?' I hear all you pro's ask. Well he was in a confined space, poor veins and he was a stocky chap who may just 'kick off' if we wake him up too quick. I also have to tell you that this chap was the same guy from a previous post http://streetmedic-coocoocachoo.blogspot.com/2008/09/old-faces.html. Also he overdosed last week and eventually the Paramedic had to use the EZ-IO (his veins kept collapsing after numerous IV attempts) and gave him Narcan through that, 2.4mg in total as he just wouldn't respond to IM Narcan. He wasn't best pleased to have a needle sticking out of his shin bone and it took 4 police officers to hold him down on the way to hospital. Back to the job in hand. We now had to think about moving him as the Narcan wasn't really doing much. One EMT set up the trolley out side and I set up my intubation kit so that I could secure his airway while getting him out. When on the truck I would try diluted IV Narcan if I could get a line and then remove the breathing tube. But as I sorted out my kit he started to breath for himself albeit slowly. We cleared our kit and gave him some room. Eventually he started to wake up and within a few minutes he was upon his feet with our help. A police community support officer turned up to see if we were OK and keep some of the by standers away. Unexpectedly our patient was OK, no kicking off and even agreed to get in the back of the ambulance. The first thing he said was 'I ain't going to hospital', like most of the other heroin OD patients. We weren't going to argue with him. After doing his obs he agreed to having another 2 doses of Narcan to help prevent him relapsing into respiratory arrest again. That's the problem with heroin, it has a far longer half life than Narcan and it has been known for ambulance staff to treat a patient only to find they've walked off and either collapsed or even died somewhere. As everything was fine I left the crew to deal and sort the paperwork while I packed away my kit. Back to base for me for a nice cup of tea. I didn't make it, I got a Cat A fall 16 miles away, the tea would have to wait!

You can read more about some of my dealings with heroin ODs here http://streetmedic-coocoocachoo.blogspot.com/2008/08/od.html

And the rest of last night

6 attended, 1 stand down and still no sleep!

1. Abdo pain. When the details of this job came through I had to do a double take as I thought I had already been to this patient last week http://streetmedic-coocoocachoo.blogspot.com/2009/04/nights-again.html. It was a different address but it was a female the same age who recently had her gall bladder removed.
This lady was doubled up but as soon as we got her on the gas & air she settled. After a set of obs and the pain now under control we started to head off. But a few minutes later she was now in unbearable agony and the gas & air was having little effect, she was in tears. I couldn't sit there and see her suffering like this especially with her husband sat next to her. I put in a 20g cannula and administered an anti sickness drug and then some Morphine. As expected it really hit the spot and made her journey more comfortable. I found out she was a nurse and that she worked at the local hospital, she knew exactly what I was doing and told me so.

Psych/suicide stand down

2. Chapped lip, see last post!
3. Leg pain. A sweet elderly lady, also a regular patient called us because her leg hurt. She has arthritis and the pain came on whilst at rest. After checking her over and reassuring her we give her some of her co-dydramol. She doesn't want to go to hospital anyway so we speak to her family on the phone and offer advice.
4. Breathing difficulties. Passed as a Cat A, it was a teenage girl suffering the mother of all panic attack. She was really going for it and at one point I thought we were going to have to take her in. But just as things looked like they weren't going to get any better we managed to settle her breathing and coach her respirations. We made her hyperventilate again to demonstrate that she was in control of her breathing. After nearly an hour on scene we left her having a smoke in the garden.
5. Psych/suicide attempt. Elderly male who was threatening to pull his catheter out and jump down the stairs . He had a live in carer who had just about had enough and called us as she had reached the end of her limit. we managed to check him over and get him settled into bed. Carer to call GP in the morning.
6. Fall. Irish lady who slipped in the bathroom and banged the back of her head on a tiled wall. Severe head pain and living alone, she was always going to go in. I think my crew mate was especially impressed at my door entry skills. We didn't have a key and there was no answer at any of the other doors so I used one of my ID cards and managed to open the Yale lock.

While at hospital our 2 other crews and the critical care crew were on the way in with a Paediatric cardiac arrest. Although we weren't directly involved in the job we still couldn't escape the sight of the child being vigorously worked on by the crews before handing over to the A/E team. The crews did everything possible, Full ALS inc IO line & drugs etc but unfortunately like most Paediatric arrests it wasn't successful.
We left the hospital hearing the harrowing screams of distraught parents who had just lost their baby.

Real Trauma: NOT FOR THE FAINT HEARTED!

Sat on base, relaxing in our comfy chairs and watching some TV show on special effects. We're like coiled springs, ready to jump into action. Ready to face anything that's thrown to us. Cardiac arrest, anaphylaxis, heroin overdose, catastrophic hemorrhage or RTA entrapment we are ready! Within seconds the station alerters go off and we are soon in our vehicle. It's to a Psych/attempted suicide call just round the corner from base but no sooner are we out of the garage we get a call on the radio 'Stand down, stand down, we have a higher priority coming through to you.' The job comes through and it's a Cat A hemorrhage/lacerations call but it's 5 miles away. 'Better get a wiggle on' I say to my trainee crew mate.

Winding our way through the bends and through a couple of villages we make it to scene. The call is to a pub, to a male bleeding heavily.

We park up and take our kit in with us. As we enter the pub we are greeted by a member of staff with 'Thank god your here!', another says 'Are we glad to see you, you're like gods.' The pub is busy and I can't help thinking that this would somewhere nice to take the wife and kids for Sunday lunch. There are oak beams, nice pictures and a really nice atmosphere as we walk through. There's no time for that, better get on with the job in hand.

'Right, where's our patient' I say looking round.

'Over there by the table' comes the reply.

'Where?' I'm having difficulty spotting anyone who may need our skills.

'Right there!' says a waitress pointing behind us.

'What him!' I'm thinking to my self (and I know my crew mate is thinking the same just by the look he is throwing me).

We turn and move towards the overweight chap sat tucking into Gammon, Egg, Chips & a side of onion rings.

'Thank god you're here lads' he says.

'What's the problem?' says my crew mate.

'Well, it all started about 2 years ago.'

'Let me just stop you there, what's happened tonight?

'Right, it's my lip, it wont stop bleeding! I can't go on like this, look at it, look it! I've been bleeding all afternoon, it's been gushing.'

At this point we have now both completely lost the will to live but being the professionals that we are we remain focused.

'Where are you bleeding exactly?' I say desperately trying to find anything vaguely resembling a laceration.

'Right here.' says our patient pointing to the middle of his lower lip.

We are now both leaning over the table pulling the 'Bulldog chewing a wasp' face trying to find this wound.

We need a torch as we are still struggling to see anything. Now with a bit of light we can see the cause of the problem...........................a split lip! Basically this guy has a problem with his lips getting dry and then they crack and on this occasion started to bleed. He sips his red wine as he talks and starts saying that he wouldn't of called us unless it was an absolute emergency. After spending what seemed like an eternity doing his obs and reassuring him that he wont bleed to death, we give advice and get him to sign our paper work. We brief the staff who at this point are now getting fed up with him being there as he was worrying the customers. Luckily he has a room booked in a hotel next door so persuade him to go to his room and rest. We walk out shaking our heads in disbelief, although we do joke with bar staff about getting 2 pints of Fosters to take away.

We couldn't believe we had been called to a chapped lip. I think alcohol may have played a part in it and the fact a little bit of blood can often look alot.

We drove off into the sunset knowing we had done our bit. I say sunset, it was actually pitch black.

I'm sorry for misleading you with the title of the post (I bet you thought it was something juicy) but I think it is important to highlight that although we have 8 minutes to Cat A calls, not all are Life threatening. In fact a lot don't need an ambulance at all. It's not the call takers fault, they can only go on the information given to them at the time and then input into the AMPDS system.