Saturday, 28 February 2009

I'm back on 4 day shifts now and it's been steady, all genuine jobs again. I like it like that. After 2 days and 3 nights I was whacked out. My last rostered night we had 2 diabetic hypos one after the other. The first, a regular patient, I treated with IV glucose. He stayed at home. The second, we had to give him an IM glucagen injection. I tried to get IV access but as I put the cannula into the vein he flinched and sent it flying. I've been to this chap before and gave him IV glucose but he wasn't happy after he came around because he said it sent his blood sugar too high. This time after the injection he was OK. It worked quicker than I expected but was still a bit fussy about eating some sandwiches because again he was worried that his sugar would end up too high. There's no helping some people. He stayed at home as well.

I did yet another overtime shift with yet another trainee. First job was to an 83 year old who fell down a full flight of stairs and was suffering severe respiratory distress. Asthmatic. Although she had no visible injuries she was really struggling to breath. Good air entry and no wheeze but really struggling. She had chest pain which seemed to be restricting her breathing so I cannulated her in view of giving her some morphine. By the time we immobilised her and got her on the truck the pain had subsided although her breathing was still causing her problems. At hospital they could find no sign of any injuries so put it down to an asthma attack brought on by the fall.
Another call, this time to a male in his fifties with no cardiac history. Unwell with dizziness, shaking, slight shortness of breath and palpitations. ECG showed AF at 150 beats per minute.
Third call was to back up one of the other night crews who had got their vehicle stuck in the mud. We took their patient, who had been suffering chest pain, and loaded him up on to our vehicle and took him in. Nitrates and O2 eased the pain but once the O2 came off the pain returned.
Our last job that night was an ITU patient who had a bleed on the brain. He was intubated and ventilated and an anaesthetist was travelling with us. At 04.00 am there isn't much on the road so we didn't take long to get to the receiving hospital. When we arrived the DR got out looking rather green and was feeling nauseated. On the way he nearly vomited, obviously doesn't travel that well then! LOL. I did offer to cannulate him an give an anti-emetic. He smiled and politely refused. We handed over our patient to the neurosurgeons and put the kit back in the vehicle. The DR asked if he could sit in the front on the way back. 'Fine by me, I'll get my head down on the trolley on the way back'.

Wednesday, 25 February 2009

Last night

Last night was quite a quiet night really. Our last job wasn't the best finish to have. We were called to an entrapment RTA, 3 cars and a patient still trapped. As we left base one of the other night crews also were assigned the job as well. As we approached the scene we could see two badly damaged cars which had collided offside to offside. One car was empty and another was rear facing a fence. As I got the kit out a police officer ran over and the driver is still trapped but he thought he was probably dead. All the airbags had been deployed and sure enough a male was still trapped in the front. No pulse. I shouted to one of the other crew to get the cardiac monitor. Flat line. Sadly he was beyond any ones help. The occupants of the other car walked off but have since been found. The road was shut for over 10 hours while the Fire & Rescue cut the deceased from the wreckage and also while the Police crash investigation team did their bit.

Weekend days

I worked at the weekend, a bit quiet with the usual routine jobs. We did have a couple of genuine jobs though. The first was a lady suffering severe chest pain and breathing difficulties. A paramedic practitioner (PP) and a couple of local community responders were on scene well before us and were administering oxygen. The PP had done some obs and dipped the patients urine to see if there were any signs of bleeding or infection. The test came back negative. The patient was now wheezing which became exacerbated on movement. Her local DR had seen her the previous day and upped her dose of oral furosemide which didn't seem to be doing any thing for her. We blue lighted her in as a LVF/CHF. I gave her Aspirin, GTN, Salbutamol, Metoclopramide and some Morphine and en route her breathing was now a lot easier. She still had chest discomfort but nothing like before. Job done.

Another call was to a care home where the staff found one of the residents on her side blue and struggling to breathe. When we got there she was on her back but unconscious but breathing. She had no radial pulse and her systolic pressure was in the 70's. She was also a Diabetic with a high blood sugar. O2, some IV sodium chloride and off to hospital. Her arms were rigid but occasionally she would move them and eventually she caused the IV site to bleed where her wrist rubbed against the cannula. At hospital I disconnected the IV fluids as they had finished. I must of done something right because she managed to open her eyes for the first time.

The next was an unconscious Diabetic. She responded well to some IV Glucose and stayed at home in the care of her husband and daughter. It was quite funny because we heard their pet dog snoring so my crew mate (also a bloke I sat next to in school) asked if they wanted us to check it's sugar level while we were there. They found it highly amusing.

Tuesday, 24 February 2009

Continued

I know I said I was going to post the following day but to be honest I've been so busy I haven't had the time. So here goes (before the station alerts go off again!). Yep that's right I'm on another night shift.

Back to last week or was it the week before? I can't remember. Anyway I was working with the same trainee as in my previous post. Two shifts, midweek. The first call of the day was to a diabetic with prostate cancer who was due in at the treatment centre for a surgical procedure. We were called because his wife couldn't move him. He had collapsed on the toilet and was 'off legs', a term commonly used in the UK. We took one look at him and realised that he was unwell. He was grey in colour, lethargic, had low blood pressure and was also hyperglycemic. His wife thought that if she called us he would get his procedure carried out quicker. Sorry, it doesn't work like that, we need sort out immediate problem before anything else. On with some high flow O2 and some IV sodium chloride. By the time we got to hospital he had perked up but still had to assessed by a DR before he had his surgery.

Our other two crews had been called out to a male who had jumped from the top of a multi storey car park. He was critically injured. The crews did an excellent job as usual but unfortunately he died of his injuries later that day.

Our next call was to a lady having a possible stroke. When we got there we were confronted with an unconscious lady on the floor. She was gurgling and her breathing was laboured. She tolerated an oral and nasal airway. It wasn't looking good. Her airway was becoming a major problem and after lots of suction I intubated her. Although she was still breathing, it was ineffective so I took over. Getting her out of the house was a nightmare, there were right angles everywhere and trying to get her out flat was impossible. In the end we had to get her on a carry chair and weave our way through the property eventually reaching the ambulance. I hooked her up to the ventilator and all the other monitoring equipment, her BP was 214/115! On the way in I tried to get a line but there were no veins anywhere so I left that to the hospital. We arrived about 15 minutes later with lady still ventilated, en route she had stopped making any respiratory effort so I had to support it fully. I carried on ventilating as the A/E DR assessed her. He struggled to get a line in but after several attempts he got one. I didn't feel so bad that I missed. There's nothing wrong with knowing when to give up and let someone else take over or have a go. I see no point in digging around leaving the patient like a pin cushion, if you can't get a line you can't get a line. She had a CT scan and a massive stroke was confirmed. She died later that day.

We also had a couple of elderly patients with hip fractures who needed morphine and a chest
pain. Plus the usual non-injury calls, nosebleeds and chest infections.

A couple of days later I was with yet another trainee and got a call to an asthmatic. She only lived about a hundred yards from the surgery so she made over to there. The GP had started her on a salbutamol nebuliser and added some ipratropium bromide to the next. It wasn't doing much for the patient. I switched of the electric nebuliser and plugged into my oxygen. On board the vehicle I checked her peak flow which was only 120 (her normal being 450). She had a pulse of 128, resps were over 40 and O2 sats of 90% so I gave 200mg of IV solu-cortef (hydrocortisone) and a further neb. This seemed to make things a little easier by the time we got to hospital. They say steroids can take hours to start to have any effect but I've researched solu-cortef and have learnt that it is a rapid acting steroid with an onset of action between 30-60 minutes. I now always try and give it early in patients suffering acute/severe asthma unless of course we are round the corner from the hospital, then it's a neb and heavy right foot.

Saturday, 21 February 2009

Another typical week

Well it's been a busy old week again. To begin with I was working with another trainee. When ever I work with this particular trainee I always seem to get lots of genuine work. I remember the first time I worked with her last year in the summer it was hectic.

This is how that particular weekend panned out.

Before I had time to even introduce myself properly the station alerters were sounding and we were off. First call was to a 19 year old who was complaining of flu like symptoms and a rash. When we got there we found out he had already phoned the out of hours GP who, on hearing his symptoms, suggested he phone 999. He had been unwell for a day or so with a headache, stiff neck, nausea & vomiting and was now developing a strange rash. His temperature was high and when I examined his rash I could only think of one thing - mennigococcal septicaemia (MS). You see the rash looked hemorrhagic in nature, it was under the skin and was spreading. With his symptoms I had to treat him for the worse case and that meant administering 1200mg of IV Benzylpenicillin. I basically said to him and his mum that if I didn't give it to him and got it wrong he could be very ill. The earlier it is given the better. If It wasn't MS the worst thing that could happen is that he would have a bad case of the shits. Both he and his mum wanted me to give him the antibiotics. At hospital the staff grade DR looked unconvinced and gave me the sort of smile as if to say I was acting over the top. He left one of his junior Dr's to deal with the patient. When we returned later we found out that the patient had indeed been admitted with Meningitis. I truly believe you should go with your instincts and I'm glad I did that day.

We also went to a GI bleed, blood pressure barely readable and two buckets of dark coffee ground coloured blood (hemetemisis). We managed to get some IV fluids into her and whisk her off to hospital.

A horse rider had fallen on the Downs. Just from the location details I knew we need to get one of the helicopters to transport. At the end of the track a walker approached and said that we could drive up the track for half a mile and then walk to the patient. "It's not that far!" said the walker. Famous last words, it was about another half a bloody mile! Obviously I can't name the patient apart from he was a famous publisher. He was pale & sweaty, complaining of severe pain in his hips and left hip. Fractured neck of femur and a fractured pelvis, not the best of combinations. I gave him some morphine on the hill side and waited for the chopper. His blood pressure was only 90/40 so I didn't risk giving him any more. Soon the helicopter was there and within 10 minutes he was packaged and ready to go.
With the odd bread & butter job thrown in for good measure as well, Saturday was over!

Sunday was pretty much the same.
About 10 miles from the hospital reports came in of cyclist in collision with a car at high speed. Not good I thought. We get there and by the side of the road is sitting a man in his forties in full cycling gear. He didn't look right at all, grey, sweaty and lethargic. I took a look at his bike which was unrecognisable. He was cycling at full speed, head down and arse up, trouble is the man driving the brand new BMW didn't see him and pulled into the pub car park right in the path of the cyclist. Bang! " He didn't half make a bang" said the BMW driver. No shit! I thought. The patient was drifting in and out of consciousness and not looking well. We had him immobilised and loaded within minutes. He said he was feeling sick so I gave him some IV metoclopramide for the journey. It's not the best anti sickness drug but it was all I had. The last thing I wanted en-route was to have to deal with an added airway problem. It worked.
In resus the A/E consultant (who looked really pissed off for some reason) asked if I had given an anti-emetic. "Yep and here are some bloods as well!" "Oh, thanks, well done" she said. "That saves us a job" I think she even managed a half hearted smile. Mind you it was hectic in the dept that day. I managed to get a peek at the x-rays. The patient had hit the side of the car with such force that he managed to impact his upper front teeth into his lower jaw bone. By that I mean he no front teeth, they had literally been pulled from their sockets and were now embedded in his lower jaw. OUCH!

A poor old man in his 90's had fallen and broken his hip. He was crying in agony. I've seen elderly people in pain before and usually they aren't complainers. This frail old gent was sobbing. His leg was shortened and externally rotated (obvious sign of a neck of femur fracture) and we had to move him. We couldn't get near him due to the severe pain. I tried Entonox but he was too frail so I gave him some morphine. It was a balancing act because his blood pressure was low so I had to set some IV fluids up and alternate fluids and morphine doses (morphine can drop blood pressure). We had to use a scoop stretcher to get him on to the trolley. This saved him from further pain by keeping him in the same position as he fell.
I had been out to him before and also had the unfortunate task of telling him his wife had died when we were called to her one morning, he was devastated. In fact he was in yesterday with abdo pains. I spoke to his daughter about the fall and his hip and she told me that they operated on him but he later went on to have a massive heart attack. He was in hospital for over three months.

Another call was to a lady who fell onto her knee on a hard tiled floor. She had a fracture/dislocation of the patella (kneecap). It wasn't the usual lateral patella dislocation that can easily be relocated on scene and needs nothing more than Entonox to achieve this, oh no, it was a superior dislocation with her knee cap in 3 parts. She had Entonox and morphine which worked a treat. Her neighbour and friend (a local GP) seemed unaware that we had morphine and said if he had known that I was going to give her something strong he would have used some injectables form his car. I thought if you were such a good friend then why didn't you give her something before instead of sitting with her for 15 minutes while she writhed around in agony in front of her family. Once in hospital she was to go on to have surgery to wire up her knee cap.

Not a bad weekend's work.

I was originally going to post about the jobs over the last week but got carried away with the above . I'll have to continue this tomorrow.

Tuesday, 10 February 2009

More overtime! Yeah!

Yet another overtime shift, this time on a response car. Only an 8 hour shift, money for old rope!
I did ONE job and a bit of roadside standby and that was it. At least the one and only job I did was genuine. 60 year old male with chest pain. I got there and started to assess the patient and within 60 seconds a Paramedic crew from base was standing next to me. His 12 lead ECG showed ST elevation in lead III only and he had reciprocal changes most notably in AVL, there was slight ST depression in some of the V leads. He was having an Inferior MI. The crew gave him O2, Aspirin and a squirt of GTN which reduced his pain. He wasn't a candidate for prehospital thrombolysis, doh! The on scene time was literally minutes and the crew soon whisked him off to A/E. He was thrombolysed at hospital. Hopefully his MI was aborted before any lasting damage to the heart muscle had occurred. Oh well maybe next time I get to thrombolyse. Oh well whether he lived or died at least I got there in under 8 minutes to keep the dept of health happy!
Next shift will be on a truck and that's overtime too! Show me the money!!

Saturday, 7 February 2009

Is it Just me?

video

Is it just me or is this Paramedic over the top? Basically they are going to an elderly chap whose chief complaint is CHF/LVF. He is nasally intubated. What I was concerned about was the fact that the Paramedic said that there was no time for drug therapy so he just went straight to the top of the tree, INTUBATION! Now don't get me wrong if someone needs an airway I wont shy away from it but this guy is fully conscious! Sure, he's struggling for breath but surely trying nitrates, diuretics etc first should have been first line treatment. I've been to a lot worse than this patient and treated them with drugs and by the time they've arrived at hospital they are a completely different person, quite often with the A/E staff looking blankly at me asking why I rushed a relatively well looking patient in! What about assisting his breathing with a BVM, supplementing each breath increasing his SPo2 then trying drugs? I don't know perhaps I'm doing something wrong.

Having said all that the patient supposedly said thank you to the Paramedic for saving his life. All I'm saying is that I would of resorted to a more stepwise approach.

ASLS: All done and dusted


I set off at 07.15 thinking that I had bags of time to get to the hospital. After all the snow I thought I'd give myself extra time. Depending on which way you go it's no more than 40 miles. I opted to go the scenic route up country instead of the motorway. Big mistake, I turned left instead of straight on and ended up stuck in traffic for over an hour! I was soon on the last stretch thinking I would make it in time until I got to the hospital slip road. More traffic!!!!! Into the car park, skidding on the ice and to top it all I was given the directions to the wrong building. The ice & snow were so bad that you could hardly stand up and every footstep I took I was just waiting for that slip & crack of my hip. Luckily I didn't fall. I managed to get to the right building and lecture theatre a mere 15 minutes late. Not bad for a journey that should have taken an hour tops!

The room was full, mostly with unfamiliar faces and as I entered they all turned to look.

'Sorry, traffic was a nightmare' I said as I found myself a seat. At least I wasn't the only one late, a few others turned up a few minutes later.

The majority of us were from the ambulance service but there were also 3 A/E Dr's and 5 or 6 nurses. This was an uncommon sight because it's not often we do training together which is a shame. The only other multi disciplinary course I attended was a Paediatric Life Support course at our local hospital 4 years ago.

We were all given an Advanced Stroke Life Support course book and the course was soon under way. The main topics were stroke recognition and stroke thrombolysis. http://www.asls.net/introduction.html

The lecturers were a battalion chief firefighter/paramedic from Florida and another paramedic also from Florida who also teach for the University of Miami. It was like being back in the states. The course delivery was excellent and these guys really knew their stuff. It was funny when we were talking about treating and transporting the patient with regards to accents, they would say 'in rowte' and we would say 'on root', both meaning 'en route'. Apart from the different accents the treatment principals remained the same. Good Airway and breathing management if required and correction of sugar levels if hypoglycemic (Hypoglycemia is a common mimic of stroke so needs to be recognised and treated first). With stroke patients the key is recognising the symptoms, initiating rapid transport and giving the hospital a pre alert call. One of the lecturers said that in the Florida keys there are no hospitals offering a stroke thrombolysis service so these patients will be flown over 130 miles to a main hospital. He also said that recently he had 4 patients that fitted the criteria but by the time he flew into hospital they all recovered! They were all suffering TIAs (Transient Ischaemic Attack), this is basically 'Angina of the Brain'. A small clot temporarily lodges and blocks blood flow to a certain part of the brain this then produces the same signs and symptoms as a stroke. A TIA will usually resolve itself within an hour but can last for up to 24 hours. At least it shows that the system works because if these patients were indeed having a stroke they would have got the treatment within the time window which is 3 hours from onset of symptoms.

The reason why there is a strong emphasis on improving stroke care is because a lot of hospitals in the UK are now offering a stroke Thrombolysis service. The quicker we get these patients to hospital for this clot busting treatment the greater chance of reducing disability or even death. As Paramedics we can give this treatment to patients suffering from a heart attack but not in stroke patients as we are unable to determine whether it is caused by a clot or a bleed. These patients will need a CT scan to determine the type of stroke which in turn will determine the course of treatment.

A lot of the course was refreshing pre existing knowledge but also included more in depth examination techniques such as the MEND exam or 'Miami Emergency Neurological Deficit' exam. We already use the FAST exam, the MEND is just an improvement on that. There were practical skill stations so we could all practice and also scenarios for us to work through. We covered major stroke syndromes and stroke mimics as well as Thrombolysis. A local stroke consultant also gave a session on patient treatment and care when in hospital. Nice chap who seemed very pro Paramedic. He even brought the lunch in! Overall a very enjoyable day and if any one gets a chance to do this course in the future, do it!


And if there are any members of the public reading this remember: If someone develops sudden slurred/jumbled speech, facial droop and loss of power on one side of their body then call 999/911. Don't wait to see if it gets better! TIME IS BRAIN!