Tuesday, 28 April 2009

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!

4 comments:

medicblog999 said...

Since the publications of "mending hearts and minds" all CVAs, TIAs or suspected cerebral events,are now sent to us as Cat A jobs.
Puts a little bit more pressure on the ORCON and call connect times!!

brendan said...

WTF, does the NHS think people don't have strokes on weekends???

mac said...

I completely agree with you Brendan. But if you think back to 3 years ago there were no where providing stroke thrombolysis (except the odd hospital carrying out clinical trials and research). Although Mon-Fri 9-5 is not ideal it is better than nothing. I know for a fact that there will be more 24 hr centres in the future but it takes time. You need a Stroke consultant for a start and an acute stroke care team not to mention CT scanning facilities as well as the radiography staff. Some centres just don't have enough staff with the right knowledge and experience etc. A lot of hospitals may only have 1 stroke consultant which isn't much good when trying to implement a 24hr fastrack policy. There is also a lot of behind the scenes stuff such as red tape, funding, meetings etc to wade through before anything can change. All I can say is watch this space and be patient, however frustrating.

brendan said...

Just in my small area of the US I have 3 stroke centers with another coming on-line soon (where the othre three all send their head bleeds to).

The hospital with the oldest stroke center has had it for years, and they couldn't even BE a stroke center under our rules without providing 24/7/265 service.

They also have a cardiac cath lab, and have a whole team on-call from home if a STEMI comes in after-hours.

The more I read blogs like yours the more determined I am to fight any attempt to enact nationalized medicine in my country.