Wednesday, 28 January 2009

Another night cont'd

Our first call was to a Dr's surgery for a young woman with a PV bleed, it was a surprise because this was 19.00 and all the surgeries are shut by this time. Before we got there we were given another call but soon stood down and re assigned the Dr's call. By the time we had turned around and had been up and down the road several times our heads were spinning. We eventually made it to the surgery and were greeted by a young DR who handed the patient over. All her obs were stable so we just took her in to hospital plus her 5 month old baby.

The next call was passed as a diabetic, Cat A unconscious. Like most of these calls we were expecting a hypoglycemic patient which we usually treat on scene, job done. But not this time, her sugar level was 13.4. The care home staff had also done it prior to our arrival and it was 11.2. That's not the problem then. The patient was a reasonably large lady whose airway was compromised by her tongue flopping back and partially blocking off her windpipe, there was also copious amounts of phlegm in her airway as well. I inserted a nasopharyngeal airway (NPA) and then an oropharyngeal airway (OPA) and with the help of an off duty staff responder we got her onto the trolley and into the truck. The only real abnormal observation was her diastolic pressure which was 114. The lady appeared to be having a massive stroke. I said to my crew mate that I would have to stay in the back with her as I wanted to secure her airway which he was fine with and the fact that her oxygen saturations (SP02) were now dropping to 77% despite assisted ventilations. I was unable to intubate her due to her anatomy (large short neck which can make intubation very difficult) but was able to insert a Laryngeal airway (LMA). She tolerated this for a while but as her SP02 were now rising, her gag reflex was also returning. In the end I removed the LMA and just had to manage the airway as before which also involved lots of suctioning. On arrival we were ushered into the resus room. Whilst the DR examined the patient I maintained the airway. Unfortunately the ladies pupils were fixed and dilated, massive stroke as we thought. See pictures above to see the airways that I used.

Third call, DRs 999 and the DR was still on scene! It was the same DR from the previous evening who we took the abdo pain from. When I told him that the lady had a leaking aneurysm his jaw nearly hit the floor. After a couple of minutes chatting about her we got on with the job in hand. Male in his fifties with COPD & schizophrenia. He queried an MI because the patient had an hour and a half of sweating and severe breathing problems but no chest pain. On board the truck we came up with a different diagnosis, chest infection! His SP02 were 78% on air so we put him on 4 litres of O2 which brought them up to an acceptable 93%. Again he denied having any chest pain but did have a rattly cough producing thick green sputum. He looked white as a sheet and he eventually went to the assessment unit down the corridor from A/E.

The last job was at 03.50 this morning. Overdose. 19 year old who had taken 8 co-codamol with vodka and wine. The problem was that she is possibly allergic to co-codamol, she also had a Chinese take away earlier and according to her relative she also had an allergic reaction to one of the ingredients in the past. Her pupils were pin point (a classic sign of opiate overdose), her was breathing laboured and she was lethargic. And on top of that she also had swollen eyes, lips, a flushed complexion and hives all up her back and neck. Airway wasn't compromised and her lungs were clear. For a young girl she certainly was on a lot of meds including beta blockers (these can often masks the signs of severe allergic reaction). She responded well to some IV Narcan which I followed up with some IV Chlorphenamine. I would have set up some fluids as her blood pressure was 60/38 but it soon rose to 95/52 after the Narcan, I didn't bother with them in the end. After I handed the patient over the hospital staff rolled their eyes. I mean if you know you are allergic to something then why take it? She obviously had issues and didn't really want to talk about them.

Although not as busy as usual we did have some pretty genuine work over the last couple of nights.

Another night

I am work tonight and was on last night. It's not been too bad really, only did 3 jobs last night!
We were first given a Cat C psiam call to a 3 year old with flu like symptoms, drowsy and was developing a bruise like mark on his head but as we were getting close to the address we were stood down for a higher priority call. It was to an acute abdo pain. I got on the radio and asked why were we being stood down and how was the abdo pain more of a priority. They got back to me and said that the higher priority call was from a GP on scene and as the other call was only Cat C it was deemed less important. My reply was 'Well I hope the kiddie hasn't got menningococcal septicaemia then!' Silence, there was no reply. You see just because the call was triaged by phone it doesn't mean to say that this child wasn't potentially seriously ill. It probably was a cold but I like to rule out the worst case first. As it happens the abdo pain turned out to be quite serious. The DR was in fact just leaving as we arrived, he gave us a smile and when I asked if the lady was in a lot of pain he just smiled and said yes. He wasn't wrong, this lady didn't know what to do with herself and was wandering around in agony. We got her on board and sorted her out with some Morphine, 10mg in total. By the time we got her to hospital, which wasn't long, she was a lot more comfortable. She did say to her daughters (one is nurse at the hospital) that she felt fine now and wanted to go home. Nice job, didn't hang around on scene long and sorted the ladies pain out. We turned up at the hospital later and saw a hive of activity in Resus, it was our lady. She had just returned from CT and was found to suffering from a leaking aortic aneurysm. The staff weren't sure if she was going to have the operation there or if she was going to be transfered. I have since found out that she is on the high dependency ward.

We did a small bit of standby and our next job was to a 3 month old baby. Basically mum panicked about her not breast feeding properly and that there were breathing problems. The baby was fine just a bit bunged up with a cold and teething. All that was required was for one of the parents to have to expect having to sit up all night but because the parents were worried and also eastern European (nice couple actually) we thought we would take them to hospital just to give them piece of mind. Although I am an experienced father of 4 and been through exactly the same thing I would never of forgiven myself if we had left them at home and something had happened to the baby in the night.

The next job was to a diabetic man whose wife called because he was half hanging out of the bed and she couldn't move him. His BM was 1.7 and he was semi-conscious and snoring. I treated him with 100ml of IV glucose 10%. He fully recovered within minutes and soon scoffed down tea and sandwiches. His BM was now 7.3. We referred him to his GP as he was having hypos more frequently.

Friday, 23 January 2009


I have just found out that I am going on an Advanced Stroke Life Support course, apparently I will be amongst the first in the UK to do this. It originated from the University of Miami. I'm looking forward to it. After I've done it I may write a post on it.

Thursday, 22 January 2009

I've had a couple of good days with our latest trainee, I think he'll fit in fine. He has a nice way with the patients and is keen to learn without being too over the top. It was also easier than normal as we had three crew members on the vehicle. After the Anaphylaxis first thing yesterday it was all pretty genuine jobs. Another patient that wasn't very well was a Diabetic who had been seen by a GP in a care home and had been then refered to the medical assessment unit. When we got there her GCS (Glasgow Coma Scale- what we use to assess a patients conscious level) was 12, the norm being 15. She was severely dehydrated with deep sighing respirations (known as Kussmul's resps) and we could smell the ketones on her breath. This was DKA (Diabetic Ketoacidosis). The DR had booked this as an urgent journey (and not a 999 call). I wasn't happy with the patients condition so I alerted the hospital. After some O2 and IV fluids she perked up a bit, just enough to respond to us. A short while later we delivered her to hospital, there they administered insulin and more fluids to try and bring her sugar down.

Today the jobs were mainly elderly people who had fallen over (a common call for us).
We did got to a collapsed patient who I thought I was going to Thrombolyse. He had central chest pain and had collapsed at his desk. A RRV Paramedic was there first and when we got there the first thing she said was 'Chair!'. You know it's bad when someone barks that to you. He was grey in colour and pouring with sweat. He looked like a text book heart attack. After we gave him Aspirin, GTN, Metoclopramide and Morphine he was pain free and a slightly healthier pink colour. His 12 lead ECG showed no evidence of a heart attack, I couldn't believe it. We still rushed him in though. The next thing was for the hospital to test his bloods, other than an ECG this is the way to determine if he had suffered a heart attack. I really thought I was going to thrombolyse this chap, never mind, we did our bit and got him to hospital in a better condition than when we found him.
He might still be at the hospital now and like so many other patients I'll probably never get to find out was going on with him.

Oh well, back to work Sunday morning.

Another genuine job!

Yesterday and today I have been working with a brand new Technician, nice guy and easy going. He just wants to keep quiet and learn. The best way really. We also had another Technician out with us 'Third manning' for a few hours after being off for 11 months with a bad back. I was glad about this as he is the best tea maker around. After checking the truck over and having a chat the station alerter went off. Someone shouted to the new guy 'Watch it mate, if you're working with him it'll be all decent stuff!'

The call was a Category A Allergies/envenomations. A lot of the time these calls turn out to be something different but not this time, this time it was the real thing.

The patient was a lady in her early forties who had got up for work and was putting on her make up when she suddenly started to get breathless and felt her tongue swelling. She had asthma (this morning her inhalers had failed to relieve the symptoms) and a previous history of reactions 10 years ago but she didn't know to what. All the allergy tests had been carried out but they couldn't find a cause. She was even issued an epi-pen but her GP obviously thought she didn't need it for some reason as she longer had it.

On our arrival we were presented with patient with a very flushed face, audible expiratory wheeze and an aggressive bumpy rash all over her. She had taken an antihistamine called Piritize (Cetirizine Hcl, commonly mistaken as the same as Piriton) and said she was feeling better. 'Yeah right!' I thought. It wasn't doing anything for her. I had a quick listen to her chest, put her on O2 and took her pulse which was 110. One of my crew mates went to get the carry chair as I prepared some adrenaline. She was quite calm and very apologetic for getting us out and said she was thinking of driving her self to the hospital if only she knew where it was. I told her off and explained that was why we were here. Again she apologised. Although she seemed calm on the outside I could tell she was very anxious so we did everything we could to keep her reassured and calm. Just before we got her on the carry chair I injected 500mcg of adrenaline into her left arm. She said thank you and as we were getting her on to the truck she said that her breathing was now a little easier. Now on board I quickly did a BP which came out at 60/50! I popped a quick IV into her right ACF and told one of the others to drive. En route I set up some fluids and ran them in wide open, next was 10mg Chloraphenamine (piriton) and then Hydrocortisone 200mg. As she was still wheezy we gave her 5mg salbutamol via a nebuliser mask. By the time we got her to hospital she looked a different woman, no rash, breathing easier but now was quite dopey. 'I don't know what you've given me but I feel out of it, but thanks for everything I do feel a whole lot better'. The antihistamines we had given her also have a sedative effect although I have never seen anyone quite as spaced out after giving it before. Her BP was still very low despite having a bag of IV Hartmans, 71/52!

In resus I handed over to the specialist A/E registrar (nice bloke, good DR and buggering off to another hospital for a consultants post-can't blame him though).

'Well my dear, you look a lot better now after these ambulance chaps have sorted you out' he said, 'there's not a lot else for us to do other than to take some bloods from you and you'll have to stay in for a while to be observed'. The DR also set up some IV colloids to try and bring her BP up.
She stayed in all day and was discharged 8hrs later.

I don't think our patient realised how serious she was. Genuine Anaphylaxis is rare but is an immediately life threatening condition. Without the right help some one will die from one of two things if not both and they are: complete airway obstruction from gross angio-oedema (swelling in the tissues including the tongue and throat) and massive hypotension (low blood pressure), both can lead to cardiac arrest. To think she wanted to drive herself to hospital, she never would have made it!

Sunday, 18 January 2009

I'm Back!

Well I had a nice Christmas, luckily I had the day off but unfortunately I was back at work on Boxing day night. I haven't really stopped, doing overtime and more overtime etc. I've got to pay for the wife's New York trip somehow.

Since Christmas I've attended three cardiac arrests, several sudden deaths and numerous other ill people along with all the usual minor stuff. Two cardiac arrests were on the same day.
The first was right at the start of a day shift. It was to a male who had collapsed in the toilet and had stopped breathing. His neighbour was an A/E nurse and some relatives had knocked on her door to see if she could help. When we arrived she was doing CPR. Together we worked on him for an hour but it was to no avail. He had long standing respiratory problems and countless other ailments even if we had removed him to hospital he would never of made it. We found out from one of the responders also on scene that he was an ex ambulanceman from our station and that the responder was in fact his old crew mate. All I can say is we tried our hardest.

We needed to restock but before we could get back to base we were given another job, this was to a male fitting. This was another genuine job. This male had a previous stroke and was very unwell when we got to him. He was very pale and sweaty with a high temperature and kept going in and out of consciousness. He would fit and then stop and would then fit again, stop and then into another with no break. We had to intervene and give him some I.V Diazemuls. That did the trick. He wasn't well.

A few more jobs that day and it was time for a break. As soon as our break was finished we were called to a RTA and whilst on route it was now a cardiac arrest. We arrive to find a car had gone through a fence and was wedged on top of another, there was a group of people crowded round and someone was performing CPR. To be honest I thought someone had been knocked down by the car but in fact it was the driver. From what I can gather the patient had swerved off the road, crashed through the fence, got out holding his chest and promptly collapsed on the grass.
We shocked him 9 times and gave him I.V Adrenaline and I.V Amiodarone. We got a pulse back. In the back of the ambulance I intubated him for the journey and put him on the ventilator so I had my hands free. His BP was 98/56 but his pulse rate kept slowing down, way below 40 bpm. I ended up keeping him going with 6 x 500mcg doses of I.V Atropine on the way to hospital. In resus his 12 lead ECG showed a massive heart attack so the team decided to give him thrombolytics (clot-busting drugs). The patient was now waking and trying to sit up. As I had already secured his airway the resus team thought it be safer to sedate him. We also got a 'well done' from the consultant, which was nice. The last time I checked he was still alive.

The last cardiac arrest was last weekend. It was to a 58 year old male who had been experiencing chest pain all day. He was getting ready for bed at around 10pm when it suddenly got worse, his wife called 999 but he went into cardiac arrest whilst still on the phone. A crew had been dispatched while I was sat on base (I was doing an overtime shift on a response car at my local station). I was sent shortly after to back up the the crew. We shocked him 11 times and gave this guy all the resus drugs/fluids but nothing seemed to work. Over an hour we worked on him but we ended up calling it as he was in a flat line. He appeared to be relatively fit and healthy and wasn't on any meds either. A real shame. If only he had called earlier we may have even been able to have thrombolysed him. This was probably a family that just didn't like to bother anyone.

Chest pain, it's not worth taking the chance.

I've also been to few other really ill people but to be honest I can't remember.

Wednesday, 14 January 2009

I'm still here

Sorry have been really busy what with christmas and my kids. I will resume posting shortly.

See ya soon.