Saturday, 22 August 2009

This just cracks me up

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

Friday, 21 August 2009

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

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

Thursday, 20 August 2009

Sorry to bother 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.