UK Street medic

Bright lights and shiny steel

2010-08-04T23:28:00.003+01:00

I get a call, Cat C, the lowest priority call. Female unwell. I'm working on a response car and arrive within a few minutes. The door is open and I'm faced with an elderly lady sat in her arm chair complaining of abdominal pain. As I get closer I notice the beads of sweat running down her face and chest. This lady isn't well at all. There is no back up available, I'm on my own. A quick examination reveals no radial pulses, indicating that her blood pressure is very low. She has abdominal pain radiating through to her lower back. I don't need a medical degree to work out what's going on. This lady has a leaking AAA (abdominal aortic aneurysm) and the clock is ticking. I call for a crew and start my other observations, ECG, blood pressure and oxygen saturations. She has an enormous vein on the back of her hand which is a dream come true in a seriously unwell person. I place a 14g IV with ease. The crew arrive and another BP is obtained, it's 70 systolic. 500ml of Hartmans is run through by the time we get to the Resus room, pressure now 99 systolic and before we know it the consultant is performing an ultrasound scan. Diagnosis confirmed, leaking AAA.
The last place this patient needs to be is A/E or in the back of an ambulance, she needs to be in the operating theatre or as one of my old training officers likes to put it "She needs to be where the bright lights and shiny steel are".
When I last checked she had gone to the operating theatre (OR for my US colleagues). I don't know the outcome. I hope she made it.
The job came in as a Cat C call, it turned out to be a genuine Cat A. If a Cat A breathing difficulty came in I would have been redirected to that and chances are it would be a 15 year old hyperventilating having a panic attack. My Cat C lady may not have made it.

Chronicles of EMS

2010-08-04T22:51:00.002+01:00

I'm back! Don't know how often I'll post or what about. Many seem to have fallen by the way side. Shame really. Just been watching chronicles of EMS with Mark G (aka medic999) and it reminded me of when I was in Richmond VA. Wish I'd had a camera and filmed it know. Doh!
Anyway I've added the link (look left), Enjoy.

What a beauty

2009-09-19T16:01:00.002+01:00

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

9/11 Never forget.

2009-09-11T10:27:00.002+01:00

God bless

Running on empty

2009-09-05T08:38:00.004+01:00

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

2009-08-22T00:55:00.001+01:00

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

Bang and the dirt is gone!

2009-08-21T23:57:00.002+01:00

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!

2009-08-20T22:09:00.002+01:00

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

2009-08-20T10:51:00.004+01:00

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

2009-08-20T00:49:00.001+01:00

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

2009-06-15T17:01:00.005+01:00

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

2009-06-15T11:18:00.002+01:00

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?

2009-06-11T00:15:00.000+01:00

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

2009-06-09T23:28:00.002+01:00

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...........................

2009-06-07T23:51:00.004+01:00

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

2009-06-03T23:56:00.004+01:00

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.

2009-05-25T11:18:00.002+01:00

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.

2009-05-23T23:49:00.002+01:00

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.

2009-05-18T20:52:00.003+01:00

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!

2009-05-16T11:53:00.002+01:00

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

2009-05-11T15:07:00.003+01:00

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.

2009-05-11T01:08:00.003+01:00

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

2009-05-08T22:31:00.003+01:00

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

2009-04-28T22:27:00.002+01:00

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

2009-04-27T23:07:00.002+01:00

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!

2009-04-25T09:13:00.002+01:00

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!

2009-04-24T23:18:00.002+01:00

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.

2009-04-17T08:22:00.001+01:00

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

2009-04-10T12:27:00.004+01:00

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?

2009-04-10T08:27:00.003+01:00

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

2009-04-09T23:12:00.002+01:00

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

2009-04-08T11:17:00.003+01:00

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

2009-04-07T00:31:00.002+01:00

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!

2009-04-06T00:16:00.003+01:00

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.

All done

2009-04-03T12:34:00.003+01:00

This weeks shifts are now over with but I lied (unintentionally) that I had 4 days off. I had completely forgotten that I'm doing an overtime night shift on Sunday, Doh!

In the end we only did 4 jobs last night and managed to get some shut eye which is a rare occurrence.

1. Cat A Unconscious. A lady was found on the promenade by some people out walking, she collapsed in front of them and they dialled those 3 magic numbers. We arrived to find a group of people congregating around her. My crew mate took one look at her, looked at me, rolled his eyes and said 'Come on Gill (not her real name) get up. We know you can hear us!' She didn't respond. I touched her eye lash and it started to flicker. She wasn't unconscious at all. After thanking the bystanders they all started to disperse, we could then get on with the task of finding what was wrong this time. Our lady was a regular patient but she was a bit far from home, 7 miles to be precise. I got the trolley out and moved it over to her but as soon as we mentioned moving her and the 'police' she miraculously recovered, got up and walked towards the sea. She told us she wanted to go into the sea and die but because she had informed us of that we couldn't allow that to happen. We called the police and then spent the best part of an hour preventing her from going in the sea. The usual crowd of spectators had gathered and some annoying kids kept getting closer and closer asking all manner of questions. Eventually our friends in blue arrived and we got her up to the patrol car. They arrested her for being drunk & incapable and took her to the local custody suite.

A quality start to the shift, not!

2. Fall. Male fallen in the road. ? dislocated knee. A male in his fifties had been out walking his dogs when one ran off pulling him off balance causing him to fall. It was now dusk and after meandering down what seemed to be a dirt track we found our casualty. He was on the floor and his wife was comforting him. One look at his knee told us all we needed we to know. His knee cap (patella) was sticking out to the side of his knee and he was in immense pain. Out with the Entonox and he was soon away with fairies. Sometimes we can manage to relocate a knee cap just using Entonox, relaxation and gentle pressure with both thumbs, using both forefingers as guides. Not this time, it was stuck fast so we weren't going to mess about. After checking for a pulse in his foot and immobilising his leg we got him onto the trolley using our scoop stretcher. Asked whether the gas and air was working he replied 'I feel pissed as fart, I love it!' No need for anything stronger so off we went to hospital. I felt sorry for him as he was such a nice chap and being self employed he wouldn't be able to work for quite a while. His knee didn't look like all the other knee cap dislocations that we've seen before. It was more deformed and a passing DR took one look at it and said 'We'll need an X-ray of that to rule a tibial plateau fracture.' Oops, that could mean months off as may mean surgery. Poor guy.

In between jobs I had to provide a statement to the police with reference to fatal RTA that I attended where I had to pronounce the driver dead.

3. Fall. A chap with Parkinson's had fallen out of bed and wasn't injured. We helped him back in but discovered he had a high temperature, 38.5. He was also prone to urinary tract infections (UTI) but refused hospital or for us to even get the out of hours (OOH) GP to contact him. He did agree for me to contact the OOH GP to get them to pass on his details to his surgery in the morning.

4. Overdose. Not an overdose at all but a young girl who had been out drinking with friends and couldn't find the entrance to the holiday park she was staying at. A totally inappropriate use of an ambulance. Come to think of it, why were we even dispatched? She was cold and intoxicated so I wrapped a blanket round here and gave her a lift to the main gate. It was far simpler and quicker to do that than try and find security to come and open up the beach gate. The whole call lasted less than 5 minutes and I soon was back on base to continue my power nap.

An easy night shift and finished on time again. Nice.

Nights again

2009-04-02T23:42:00.003+01:00

I'm now, thankfully, on my last of 2 night shifts. Last night was steady with us racking up 7 calls.

1. Chest pain. Female in her 30's. It initially came through as a Cat A chest pain but was downgraded to a Cat B. She recently had her gall bladder removed and was now experiencing excruciating epigastric (upper abdominal) pain. This pain was exactly the same type of pain she had before her gall bladder removal. Her surgeon had told her that she may get this if there were some gall stones left in the system. There obviously was. She had taken the usual pain killers but they hadn't touched it and was on all fours on the bed as this was the most comfortable position. The Entonox wasn't doing anything for her so I had no choice but to cannulate her. Her veins were tiny and I failed the first time. To be fair I managed to get it in but it wouldn't advance as there was a valve and a kink in the vein. Another go on the left hand was more successful (should have tried that one first!). It took a while for the Morphine to kick in but when it did, it worked a treat. She was looking forward to going back to work at the Fire & Rescue control room but was now faced with more time off.
2. Chest pain. Another Cat A and this time it was over 30 miles away! It wasn't a Cat A at all. A lady basically getting anxious because she woke up disorientated at the health spa she was staying at.
3. Fall. ? fractured arm. We got this job on the way back from our previous call. A lady had been putting her shopping in her car when she felt her arm 'go'. Someone called NHS Direct aka NHS RE-Direct (standing joke in the ambulance service) and they said call an ambulance! She has a tender bicep and that's it, she can move her arm and there is no bony tenderness or deformity. 'Do I have to go to hospital?' she says.
'You don't have to go anywhere you don't want.' I reply.
She didn't want to go to hospital anyway and said that it was her family fussing about her. I suspect she pulled a muscle so referred her to her GP for the morning. Before leaving we gave her some advice on RICE (Rest, Ice, Compress & Elevation) and to take some simple painkillers.
Why call an ambulance for that? I would be too embarrassed to.
4. Breathing difficulties. On the way to this job we passed one of our other crews who were supposedly on a cardiac arrest so we offered our services. The Paramedic came out to stand us down and said 'It's not a cardiac arrest at all, I don't what the **** is going on!' There were police every where so I suspect that it probably alcohol related or a punch up. We were reassigned our original breathing difficulties and got going. This chap was struggling and had refused to go to hospital a few days before with similar problems. The previous crew had then passed him on to his own GP who diagnosed a chest infection and prescribed antibiotics. This time it had got a lot worse. His Oxygen levels were low, SpO2 of 80% even on O2, his pulse rate was 140 and his blood pressure was very low. A Salbutamol and atrovent nebuliser was having some effect en-route and we also took bloods and set up some IV sodium chloride to keep his vein open. I didn't really need a stethoscope to hear how terrible his chest sounded but did anyway. I had to just to make sure he had air going in and out on both sides. We alerted the hospital and were greeted by a Dr & Nurse on arrival. I was thinking along the lines of Pneumonia.
5. Urgent journey which wasn't, 999 call which wasn't? We had a phone call from control to say that an ex-paramedic who now works for the urgent care team needed us to go out and do an ECG on a chap with chest pain. It was for a cancer patient who this ex-paramedic was looking after over night. The patient had a 20 minute episode of chest pain which was right sided and moved slowly up to his neck and then eased off. We checked all his obs including his 12 lead ECG which looked better than yours or mine. In fact it looked like a text book sinus rhythm. The patient didn't want to go to hospital and the urgent care team were happy with this. After so much chemo he was just fed up and who could blame him.
6. Breathing difficulty. Cat A. A lady with a history of chest infections, heart attacks and fluid on the lungs. She was very breathless, especially on exertion and needed to be in hospital. She had wet sounding lungs and was basically drowning in her own fluid. Her ECG showed a left bundle branch block (LBBB) which was probably from her previous heart attacks so we couldn't do much about that. After some nitrates and a salbutamol nebuliser her breathing eased and she had settled. At hospital she thought she could transfer her self on to one of their trolleys but soon gave up when she became breathless again.

Another pretty standard night shift.

I'm on my last night shift now as I type this and it's nearly over. I'll post about it tomorrow. Then I'll have 4 days off, I wonder how many garden centres and kids clothes shops my wife can drag me round in that time!

Critical Hemorrhage Kit

2009-04-02T09:14:00.001+01:00

Here are the items we carry in our critical hemorrhage kits which are on each front line truck.

Photo 1

Kendrick traction splint - This is a compact bit of kit for the use on adults or kids who have snapped their femur aka mid-shaft femur fracture. This is a serious injury and can result in major blood loss especially when there is bilateral open fractures (both bones broken and protruding through the skin). Also bloody painful. Shed loads of Entonox, Morphine and traction. And if you have a handy BASICS Dr, Secamb Critical Care Paramedic or flight paramedic from EEAT available then you might get some Ketamine as well. We also have the sagar traction splint on board which can be used for bilateral fractures where as the kendrick is only suitable for a single fracture.

Photo 2

Military pressure dressings - We have various size dressings including an abdominal one. They do exactly what say on the tin, apply pressure.

Photo 3

CAT or Combat application tourniquet - These are for life threatening hemorrhage from the arms or legs. There has been a lot of debate about the use of the tourniquet in recent years but when used in the right circumstances can and have saved lives. We carry 2 on each truck.

Photo 4

Asherman chest seal -This is for open chest wounds/sucking chest wounds. If someone has this sort of injury then this bit of kit acts as a one way valve. It prevents air from being drawn into the space between the chest wall and the lungs but allows air to escape. If air was allowed to enter it would cause all sorts of problems.

Photo 5

Pelvic splint - If someone has suffered a fractured pelvis we can stabilise it with this device. It helps by reducing the bleeding which can be fatal.

The observer rides again

2009-03-31T23:31:00.002+01:00

As I said in my last post we would be having an observer coming out with us again. He was a medical student in his 5Th and final year and had been doing a GP placement locally.
I recently had a phone call from an Emergency Care Practitioner who works at the same surgery, he asked if I minded if a med student came out with us for a shift. No problem. So today was the day that he experienced first hand exactly what we get up to at the sharp end. Or something like that. First we went through all the kit. I think he was impressed with the EZ-IO http://www.vidacare.com/ez-io/index.html and the amount of drugs we carry. It's surprising just how many Drs and other health care professionals don't know just what we carry.
After a brew I had him sign some paperwork, gave him the observer PPE kit (personal protective equipment) and adopted the usual morning pose....................................in other words we took up positions on some comfy chairs and waited for the first job to come in.
It wasn't long before we were out, not a job but out on standby at a local GP surgery. We weren't there long before being sent back to base. We didn't make it and were soon on our first call.

1. ? CVA/stroke. Female collapsed. We checked her over and found no real signs of a stroke. The only abnormality was that her blood pressure was elevated and she was a bit vague. She perked up with a bit of Oxygen and we decided to her take to A/E for further assessment. Whilst on scene a gardener ran over shouting that there was a man in a door way feeling unwell. I went over and saw that he was conscious and that there was no life threatening problems. I reassured the gardener and said that another vehicle would be on it's way soon.

2. GP 999 chest pain. This was a guy with obstructive airways disease who the GP thought was having a PE (pulmonary embolus-blood clot on the lung). He was having problems breathing, severe chest pain and was coughing up blood (also known as haemoptysis. Some Oxygen, IV Morphine and some bloods before heading off to the hospital. His breathing and chest pain was now bearable after the pain relief.

3. GP Urgent renal problems. According to the GP this guy was nephrotic and had current renal problems. After getting some blood results the GP decided that it was best to organise an ambulance for this chap. He was waiting at his door with his bag packed, walked onto the ambulance and walked off again at the hospital.

4. Cat A Fall. Life status questionable. We thought it was going to be a cardiac arrest in the street but it turned out that a passing motorist saw an old man fall over, rang 999 and carried on going. We spent 10 minutes driving around looking for our patient but found nothing. Control called us back and said that the motorist saw someone fall, get up and walk off. How this came in as a
Cat A I'll never know! Stood down and back to base..........................................and more tea!

5. RTA/RTC/MVA (whatever it's called this week!) Car vs Cyclist. A lady was cycling when a car (just pulling out of a junction) clipped her back wheel. Nothing serious, only some abrasions to her knees. What we call a brush and dust off job. We checked her over and offered her a trip to A/E but she declined. I quizzed her why she wasn't wearing a cycle helmet and her reply was that she read some research that stated that their was no real evidence to support wearing them. 'I only wear them on serious rides, I didn't expect this' she said. Unbelievable. We dropped her and the bike back at her house which was just around the corner.

6. Fall. Lady who twisted her foot on the way out of a dentist surgery. Slight discomfort on the instep and little toe. An ice pack was all that was needed. Her husband picked her up and took her to the minor injuries unit as she had declined A/E. I doubt she broke any thing.

7. Cat A fall. Male in his 70's who had collapsed/fallen, we really didn't know. His head was covered in blood and he had a nasty laceration to the back of his head. He appeared dehydrated, short of breath and was very repetitive and confused. He wasn't well at all and was covered in vomit and faeces. Oxygen and an IV as his blood pressure was initially low and off to the hospital.

We also finished on time for a change. I think the med student enjoyed himself and after thanking me and shaking my hand he said that it was nice to see what we got up to. I just said that that was a typical day. Not like casualty where there is major incident every shift!

Welcome to the ambulance service!

2009-03-30T22:48:00.002+01:00

I turned up at work this morning expecting yet another manic Monday only to find out that we were having yet another observer out with us for the day. Well that was it, cursed again!
We had an A/E nurse with us, in fact she was due to start in A/E today but was told to come the ambulance station instead.
We did 6 jobs in total and it was pretty much bread and butter work.

1. Diabetic/Vomiting. Regular caller (alcoholic & ex IVDU) who had D&V all night. 'I can't breath, I can't breath, I can't breath!' she kept saying (SPo2 98% on air & would give any one a run for their money at the world fastest talking person championships). She had vomit on her night dress and wanted us to get her changed. Begrudgingly we obliged. She had a broken shoulder from a previous fall and was playing on this, her care package had now run out and wanted us to get her up. I knew the moment we got her changed that she would refuse hospital. We spent 40 minutes on scene waiting for her to make her mind up. 'Wait a minute, wait a minute, wait a minute, I can't breath, oh I'm panicking now!
'DO YOU WANT TO GO TO HOSPITAL?!' I said.
'Naaaah, I fell a lot better now.' she replied
AAAAARRRRRGGGGGHHHHHH! I thought to myself. So after checking her observations (which were unremarkable-surprise, surprise) and completing the paperwork we left her to it. My first words to our nurse observer were 'Welcome to the ambulance service'.
Back on base and I called up the patients GP and referred her to them.

2. Fall. Elderly lady who fell in the bathroom and was wedged behind the toilet. A local DR was already on scene and gave us the low down before leaving. 'Your the experts at this, if you don't need me I'll leave you to it.' were his departing words. She was riddled with arthritis and had a recent knee replacement which was now hot and inflamed. She was in a lot of pain. It wasn't long before we were on the road to hospital and her concious level had decreased. I popped her on some oxygen and tried to get a line for pain relief but as soon as I touched her wrist with the cannula, she flinched.
'Stop hurting me you're hurting me! she said.
'Sorry'
' You're not sorry at all!' was her reply.
I wasn't going to persist so we just got her to hospital, moaning in agony all the way. I thought it was me but as we wheeled her through the ambulance bay doors she took one look at the floor and started moaning about the type of floor it was. I put her comments down to an infection originating in her knee which was making her delirious.

3. Fall from a height. We were backing up an EMT on a response car who was on scene with a guy who had fallen backwards off a ladder.
'You'll need a collar and backboard lads!' shouted the EMT as we approached. Our man had a large laceration (approx cm) to the top of his head, complaining of pain in his arm and lower back. After immobilising him and getting him on the truck I set about giving him some Morphine. His head wound started to bleed profusely, he had an obvious fractured arm and considerable back pain. With the Morphine now kicking in and my crew mate controlling the bleeding we rushed him in. We called ahead and were greeted by a full trauma team who set about repeating the Primary survey and then on to the secondary survey and scans, X-rays etc.
It took us an hour to clean out the back of the truck; head wounds bleed alot!
We later found out he had fractured his spine but will hopefully, in time, make a good recovery.

4. Overdose. Young female who took 30+ paracetamol last night and now had abdominal pain. Less than 2 minutes on scene and we were on our way to hospital. She had been waiting outside her parent's house and had called the hospital for advice, apparently they said dial 999. I doubt it, it was probably more along the lines of 'Get yourself to hospital and we'll see you'

5. Mental health patient under section. On scene were 3 police officers, a Psychiatrist and 2 social workers. We were called to transport this lady to a mental health unit. She remained silent so the police had no other option but to force her to come. They kept apologising as one of the officers carried her down the stairs into the ambulance. She remained silent all the way there. As I opened the side door to let her out I said 'Come on then we're here, don't worry there's no police about. Let's get you inside.' and with that she got up and walked into the unit.

6. Fit. Known epileptic lady who had recently undergone shoulder surgery. She had a small fit, nothing out of the ordinary but was now complaining of severe pain in her bad shoulder. In the past she had dislocated it (13 times this year!) during her seizures and needed it repaired in surgery. She now feared it dislocated again and was in agony. I started her off on Entonox but en-route I had to give her some Morphine as the Entonox wasn't really doing it's thing. She threw the old IV challenge thing at me.
'You'll never get one on this arm, all the veins here have been scarred and used up by the Paramedics and DRs when I've been status (Status Epilepticus-continuous seizures which is potentially life threatening) and when I've dislocated my shoulder before. The only good ones are on this hand!' She said wiggling her fingers on her bad arm. I couldn't see a vein but could feel one so I went for it........................................and got it in..............................albeit a small blue 22g cannula. It didn't matter, a line is a line and it was only for analgesia. At hospital she said thanks and we bid her farewell.

And that was Monday, the usual bread and butter work and finished an hour late!
Tomorrow we have a med student coming out with us. I wonder whether it will be the curse of the observer on that shift?

Breaking bad news

2009-03-29T16:35:00.002+01:00

Here is some great advice from an experienced DR. I'm sure he wont mind me posting a link to his blog. Click here http://basicsdoc.blogspot.com/2009/03/worst-job-in-world.html and look at the 5th comment.
To some our job looks easy but breaking bad news never is.

Leaving people at home

2009-03-29T16:31:00.002+01:00

For those of us that work in a prehospital system that on occaision leave people at home click this link for some excellent advice http://medicblog999.wordpress.com/2009/03/28/leaving-patients-at-home/. It also is useful info for our prehospital friends around the globe, gives a bit of an insight.

The end of another week

2009-03-28T21:47:00.002Z

A weekend off at last! Well not quite. I spent all day today finishing off my daughter's bedroom.
I had to take the day off on Wednesday to look after my family as they all, in turn, were suffering from a horrible bug. I rarely have time off but in this instance it was justified. Family first! I on the other hand have seemed to escaped the wrath of the D&V bug, touch wood. Must be that good old ambulance immune system kicking in!

Back to work on Thursday and to be honest it I can't really remember what calls I went to. All I know is there was nothing of any real interest. We did have an army medic come out with us. We have a lot of these at our hospital and they frequently ride out with us to get an insight as to what we do. Trouble is, like any observer, they bring with them the dreaded observer's curse. It's well known that when ever an observer comes out with us nothing interesting ever happens.
We did do a transfer from a private ward at our local hospital to a private hospital 30 miles away. It really annoyed me because it didn't warrant an A&E ambulance at all. The patient was a pleasant man who was going for an operation. He was having a CABG, pronounced cabbage; CABG stands for coronary artery bypass graft. We took the stretcher up to the private ward but as soon as one of the nurses saw it she said ' He won't go on that, he'll probably walk down'. I couldn't believe it. 'Does he not need to be monitored?' I asked. 'No, he's been in all week and is not having the op til tomorrow, he's OK.' He didn't even have a line in.
Control told us that we had to do the job as the patient needed monitoring and that the urgent journey vehicle couldn't do the job as it didn't have the required kit. Oh well. He was fully clothed and looked a picture of good health (and if you didn't know what he'd been in hospital for you would have thought he was a perfectly fit & healthy man ). He walked down to the vehicle and sat on one of the seats and we chatted on the journey. He couldn't have a stent fitted as the narrowing of his arteries were on a junction and a by pass was the only option. Naturally he seemed a little nervous and so would I if that was me. When we got there we had to wait while he filled out a registration form and then escorted him to his room. In the lift he apologised and said that he felt embarrassed that we had to bring him over and that he thought it was an inappropriate use of an A&E ambulance. Although I completely agreed I just made up some excuse about the other vehicle not being available. He was a really nice chap and I hope everything went according to plan. But I can't help thinking that these sort of jobs don't help when the government are putting increasing pressure on ambulance trusts to get to people in 8 minutes. When a transfer is booked with ambulance control I think more questions need to be asked as there are more appropriate resources available and they need to be used properly.

Friday and I was working with my old school mate. No matter what jobs we go to we always have a good shift, he is a top bloke! And true to form it was a pretty unremarkable shift. We did have one patient who was in an awful lot of pain. He was only in his 40's and suffered IBS (Irritable bowel syndrome) but for some reason he was experiencing severe abdominal pain. The pain was the worst pain he had ever experienced and was also vomiting. Another problem was that he had difficulty in breathing (DIB) and he said that he felt like his whole chest was in spasm. His wife was really concerned and said that this is so out of character for him as he usually has a very high pain threshold. Because off the spasm in his chest it was actually impeding his breathing and as a result had actually caused his oxygen saturations (SPo2) to drop, they were in the low 90's. On board the vehicle I gave him some IV Maxalon and 5mg of Morphine, this wasn't doing much so I gave 1mg every minute until his pain was controlled, he had 8 mg in total. It took the edge off the pain and also helped his breathing. He was now able to take a deep breath and his SPo2 was now a more acceptable 98%. I probably would have started with Entonox but due to his DIB I was doubtful that he would have inhaled it effectively.
As with all the other patients I'll probably never get to find out what was wrong with him. All I know is that we delivered him to hospital in a better condition than when we first saw him.

Everyone says that I get all the decent jobs but it's just not true. Yes I do usually get a lot of unwell patients and regularly get to use my skills but I too get days when not much happens.

Back Monday for 2 days and 2 nights. We'll see what that brings.

What a difference

2009-03-25T05:25:00.003Z

What a contrast between Monday & Tuesday. Yesterday I turned up for my car shift as per usual and started to check the equipment on the car. I was just about finished when I saw an off the road notice, it needed a securing bolt for the Lifepack. So I started to check another car but found that the lock on the boot was faulty, so off to find another car. I started checking the ECP car but was told not to use it for some reason; even though there were no ECPs on duty. There was another car at the other end of the garage but that too was off the road, blue lights faulty and a flat battery! Now there were only two more to choose from, a ropey old car and a 4x4. I opted for the 4x4 as there was someone from my base station coming over to use a car for a course. Finally an hour and a half into my shift I was ready to go. What a joke!
After that charade I was sent to a station on standby in the north of the county and spent 3-4 hours sat there twiddling my thumbs hoping for a decent RTA to come in, if you are going to get one then this is usually a good area for those. But no, nothing. I was sent back to base for my break. By this time on Monday I had already done 5 jobs.
Later on I got sent for standby at a Dr's surgery near my base station. First I must explain that where I have been working for the past two shifts is in my home town but not my base station. I sat there for a while reading and about 45 minutes later I heard an all call go out, 'Any fast responder available for a Cat A fitting please call, responding a Technician crew from ***** base.'
The call wasn't far from base and I knew a local car was starting at 15.00, I hadn't done anything all day so I decided to call up for it. And sure enough I got the job. It was a regular patient who had a history of epilepsy, he had a couple of seizures earlier and was now vomiting. Initially I was going to let the double EMT crew deal but the patient started fitting so I stayed in case he needed some IV Diazemuls. It was a nightmare getting him out as there was no real room to manoeuvre and he was a big lad as well. He kept having lots of short seizures with little recovery time in between so I put a line in him and gave him 5mg of Diazemuls. Sorted. I got the usual from his partner 'They have a hell of a job getting a drip into him usually.' Right, that's a challenge I thought to myself. No problem, straight in. I left the response car where it was and accompanied the crew in just in case I needed to give some more drugs or in case he lost his airway. If he lost his airway I may have needed to intubate him. I didn't need to do either.
Into resus he went and for some reason they weren't that interested so after a quick look they said he was alright to go into majors so off they went. Within 10 minutes he was back in resus. The problem is we have a brand new box of junior Drs so things don't always go to plan. Bless them, they are still finding their feet.
We cleared at the hospital and the crew were taking me back to my car. We nearly made it when we got a Cat A chest pain back near the hospital. So we turned round and blue lighted 7 miles back to the location. It was a Patient transport (PTS) ambulance who called us, they had a lady complaining of chest pain and they had her on Oxygen when we arrived. Funnily enough the crew I was with had taken her in earlier and the PTS crew were taking her home. I had also taken this lady in recently with the same problem. She worries alot and pretty much suffers chest pain on a daily basis. This time she just happened to mention that her chest was tight and she didn't have her nitrate spray with her so the PTS crew called for back up. We caused chaos as it was rush hour but we had a job to do so everyone would just have to put up with it. To cut a long story short she point blank refused hospital and wouldn't let us do a 12 lead ECG, she just about let us do her blood pressure! She said it was just like her normal angina and that she panicked as she didn't have her spray with her. All we could do was let her carry on back to the home and for the PTS crew to advise them of what had happened. Anyway she was pain free after the Oxygen. If they refuse then there's nothing we can do.
We cleared from that and were given a RTA back in the other direction, it was a Cat C female cyclist had collided with another cyclist. I called up and asked if the crew could drop me off back at my car (seeing as it was a Cat C and an officer had already booked on scene). That was fine with control and I was finally back at the car. I did a little bit of standby at my base station before returning back to end my shift on time. Now there's a first.

I'm supposed to be working today but my baby daughter has been ill all week with vomiting and now my youngest son, wife and now my oldest daughter are all sick. I've been up all night with them and will now have to run the show at home today. That'll be fun. I just hope I don't catch what ever they've got. I hate having time off sick especially when I'm not even ill!

Virginia USA

2009-03-24T10:00:00.001Z

I will post some more on my trip to Richmond VA, when I get round to it. So much overtime and not enough free time! Hey ho

A busy start

2009-03-24T08:56:00.004Z

Mondays are the new Friday & Saturday nights, well that's what I think anyway. It seems to me that nowadays Monday is one of the busiest days of the week. People always say to me 'Cor, I bet you're busy at the weekends aren't you?'. In fact everyday is busy in this day and age.

And it was no different yesterday. I was supposed to be on a RRV but crewed up on a vehicle as someone was sick. AGAIN! It was non stop. 8 jobs in total (and an assist) and the other crews were exactly the same.

1. Dr's 999, GI bleed. This guy wasn't very well at all. White as a ghost, tachycardic, hypotensive and had high blood sugar. He was also in a lot of pain. After some fluids and pain relief from us he stayed in resus while he had a blood transfusion.

2. Chest pain. Female with severe chest pain. The usual Aspirin & nitrates, took some bloods and gave her some pain relief which worked well. Unable to thrombolyse though. AGAIN! Story of my life.

3. Head injury. Male who had sustained a head injury before the weekend and wasn't feeling right. He had a bruise on the brain and some slight bleeding.

4. Unconscious. Male who found at the front on the street with vomit by his mouth. We backed up a car but when we got there he was insistent on walking to the photographic shop. We managed to check his pulse, blood sugar and temperature but nothing else as he kept walking off. I suspected he had a seizure. We cleared from that job but the car went off looking for him. Another crew brought him in later.

5. Seizure with hip pain. A young epileptic girl had a seizure in the street and developed hip pain. She had a previous problem with her hip as a child so we took her in to get it checked out.

6. Chest pain. Elderly lady with chest pain on and off for 2 days. Her blood pressure was 71/45! Aspirin, IV & bloods and also some sodium chloride just to keep the vein open. She was blue lighted in and stayed in resus for a while. Not very well at all.

7.Dr's 999 Bowel obstruction. Lady with terminal cancer of the brain, as you can imagine she wasn't very well at all. All we could do was make her as comfortable as possible. This was the same lady I went out to before who was having seizures while still conscious. I was toying with the idea of cannulating her in case I needed to give her diazemuls (She is prone to recurrent seizures which has needed our intervention in the past) but decided not to. The last thing she wanted was for me to be poking her around and anyway she had good veins so if she started fitting I would get one in when I needed to.

8. Back pain. A lady with arthritis had developed central lumbar back pain and couldn't get up. We managed her pain with good old gas and air. We used a scoop/orthopedic stretcher to get her out and took her in to get checked out.

We also stopped to assist an officer who was dealing with a regular patient who was on the side of the road. He had taken an overdose of paracetamol & alcohol and was not really with it. We stayed with the officer until a volunteer crew turned up (we were off the road and heading back to base for our 1st break). The patients face was a picture when he was being loaded into the ambulance, it was right in the centre of town and everyone was staring at him. That will teach him although I doubt it will be the last time we see him!

Money Grabbing Again!

2009-03-21T01:18:00.002Z

I know I know, I said I was having 7 days off but on Wednesday night a mate from my station phoned me and asked for a favour. Could I cover his late car shift (on overtime of course!) as he couldn't do it. To be honest I wasn't that keen on doing it but as I had nothing planned for the next day I said yes. After all, the way the current economy is I'd be a fool not to. This constant stream of overtime wont last, I just know it. Grab it while you can I say!
It was a quiet shift, for me it was anyway. All the day crews had been rushed of their feet, by the time I started things were calming down. I did an hours standby at a local DR's surgery where I started to read my book by Stuart Gray http://www.mondaybooks.com/Life_And_Death/lifeanddeath.html, he's another Paramedic with a bloghttp://theparamedicsdiary.blogspot.com/ . I thought I was going to get a call to back up a crew at an RTA but I wasn't needed. Next thing I heard on the radio was the crew calling up for Fire & Rescue as they couldn't free the patient. Well they knew where I was if they needed me.
I got my first job, it was Cat C non-traumatic back pain (Cat C meaning low priority call). I t was to a young guy who for no obvious reason developed severe lumber pain. When I got there he was in absolute agony. I have never seen anyone with this sort of problem in so much pain. Usually it's a bit of gas & air and then off to the hospital. Not this time. I ended up giving him 10mg of Morphine. Eventually after a combo of Morphine and 2 bottles of gas & air he started to fell slightly more comfortable, the exception being when his back went into spasm. Although after the drugs he did say at one point that he felt completely pissed! It turns out that he is best friends with one of the guys at work and also knows several members of my family who do a specific job. I'm not going to say too much about that. I went with the double EMT crew (as I had given Morphine) to hospital. On arrival at hospital it was absolutely heaving, ambulances everywhere with crews queuing to handover their patients. We left him in good spirits albeit still suffering the odd agonising spasm.

My 2ND and final job was a chest pain about 2 miles from base. I received no updates on the way so naturally assumed that I was going to male/female of mature years. Actually it was to an 11 year old. She had recently been diagnosed with chrons disease and was still being fed via a nasal tube. After doing my obs the crew turned up and got her on to the ambulance. She had left sided chest pain and it radiated into her left arm. Her 12 lead ECG showed no acute changes. So after discussing the various pain relief options with her and her mum, the patient declined pain relief. All we could do was transport her to hospital.

I still have 3 days off........................................filled with all sorts of things such as taking the kids to the cinema (movies), swimming, and laying wooden flooring.
Definitely no more shifts until Monday!!!!!!

Time off

2009-03-17T00:11:00.002Z

I've now got 7 days off! I could do some more overtime but I'm not going to, there is enough of it going around afterall. I think I've done more than my fair share and it's not like I haven't got any more shifts lined up!
I've already plumbed in the new washing machine that arrived this morning and cleared the garden of the old furniture that we've been slowly replacing. I'm sure the wife has got more jobs lined up for me. Ha Ha.

So just to conclude my shifts.

Wednesday night:

our first call was passed as a cat A Asthma, 3 year old. When given a potentially serious job, especially a child, I usually look up the possible drug dosages and jot them on my glove. This saves time when initiating treatment. So there we are racing to this child with 'Severe Respiratory Distress', I've written down the hydrocortisone dose on my glove, 57mg. I knew the salbutamol and atrovent neb dosages and was thinking to myself 'If it's bad we'll just load and go and I'll treat on route'. If I have to give hydrocortisone I'll probably give it via intramuscular (IM) injection into the thigh. I could give it IV but in a child with severe breathing problems trying to cannulate will be far more distressing for the child and that's the last thing we need. If the child needs assistance with their breathing then hydrocortisone will be the last thing on my mind as supporting breathing will be the main priority. Even more so if working solo or part of a crew. To provide effective ALS in kids you need more than 2 crew in order to maintain good uninterrupted basic care.
With all this in mind we arrive on scene only to find a response car already on scene. Nobody told us, no change there then. Inside we see a senior officer chatting to the mum and I start to scan the room for this apparently really poorly kid. I do however find a cheeky 3 year old sat on the sofa cuddling a teddy bear, grinning at me. No breathing problems. The child has been ill for 3 weeks, has a temperature and not drinking much water. The GP has already prescribed antibiotics but the mum wants him checked out at hospital as he can't keep any meds or fluids down. So after deciding which toy he wanted to take we got him & his mum on board. On the way he said he was a bit breathless so we gave him some oxygen which made him feel a little better. At hospital we handed over to the nurse and sat them in the paediatric waiting area. Personally I would of just rung the out of hours GP or popped in to my own DR in the morning but there are some people who think hospital will be the best option for every thing. Oh well it makes no difference to me as I get paid the same whatever calls I go to.

The rest of the jobs are just routine falls and drunks.

Thursday night:

We did have what was initially a serious job. An unconscious female who had recently been discharged from hospital earlier that day. Carers couldn't wake her and she was foaming at the mouth. We sorted her out after plying her with oxygen and got her to hospital in a better shape than when we first arrived on scene.

Another child, this time a 7 month old with a fever of 40.2. When going to a child that is potentially seriously ill I want to rule out certain things, hypoxia (lack of oxygen), menningococcal septacaemia (by searching for a rash amongst other things & then rapidly treating with antibiotics), seizures (terminating them with anti convulsants if needed) and hypoglycemia (which can be common in ill kids, not just diabetics either, and treating appropriately with IV glucose etc).
As we pull up I recognise the house. A very nice house in a nice part of town and after seeing the mum I knew why I recognised the place. Just before Christmas I took her husband into hospital with pneumonia and he was really poorly. I remember that he had severe chest pain and was hypotensive (low blood pressure).
The young mum burst into tears when we arrived and told us that she was awaken by her baby's erratic breathing. She been off her food for 2 days and then later that evening started getting irritable and developed a fever. Thankfully there was no sign of a rash and her sugar level was fine too. We had to wait a while for the grandmother to arrive to look after the 2 other sleeping children. Prior to our arrival the mum gave the child 2.5ml of ibuprofen. With a temperature so high the child risked having a febrile seizure so all we could do was watch as we took them both to hospital.
After we handed over, my crew mate made a remark which annoyed me.
'What was her problem? Is she spoilt or what!' I couldn't bite my tongue so I told him what I thought. Not in a nasty way but I just said that this woman was scared shit less about her baby and was probably panicking. I wasn't going to lose my temper as we actually get on really well but as my crew mate doesn't have kids and I have 4 I think I have a right to share the benefit of my past experiences.

More routine calls.

Overtime Sunday:

On the response car yesterday for a couple of jobs and then on a vehicle for the remainder to cover sickness, AGAIN!

Another child, Allergic reaction. It was a mild reaction to penicillin but didn't warrant any treatment by us. Some liquid piriton would have done the trick but we only have IV/IO/IM piriton and she wasn't going to get any of that as her symptoms weren't causing her any discomfort or distress. There was a long history of penicillin reactions in the family so the crew took her in for a check up. It didn't help that she had chicken pox as well and had been put on antibiotics as 2 of her blisters had become infected. You could see a fine rash developing on her skin, completely different from her chicken pox.

More falls, one which took us over 9 minutes just to get into the building thanks to all the key safes and care line buttons etc. Good job it wasn't an emergency!
We also went to a diabetic lady who was discovered by her friends. Her sugar level was low and she refused to eat any thing. After giving her 100ml of IV glucose she was wide awake again. This wasn't the first episode this week and she refused hospital so we referred her to her diabetic nurse in the morning. I also contacted the out of hours GP so the incident would be recorded and left the lady in the care of her neighbour.

I was due to finish at midnight but got caught with a late job, a chest pain. 69 year old male and there I was rubbing my hands thinking I may get to thrombolyse. I wouldn't have minded being late if that was the case but no such luck!!!

Back next Monday when I'm on a response car....................................................on overtime!

This week so far

2009-03-12T00:43:00.002Z

Monday:

Crew mate sick. 9 jobs, 7 on the response car, all before 13.00! 3 chest pains and 3 falls with varying injuries and 1 woman whose carer couldn't wake her up. When I woke the lady she shouted 'I'M NOT GOING TO HOSPITAL!, she was fine and after examining her & doing her obs stayed at home. I then jumped on a truck with a Paramedic who was due on the car. We did 2 more jobs before I went home. He then went on the car til midnight.

Tuesday:

Crew mate still sick. Back on the car but a much quieter morning. Only 4 jobs. Then the same as Monday back on a truck for the remainder of the shift with the same Paramedic. We again did 2 jobs but these were proper jobs. The first was to a 12 year old who was playing football at school and someone went to clear the ball and kicked it at full pelt. Problem was that it connected with this young lad's hand and bent his wrist back. When we get there we are confronted with a sobbing boy with a grossly deformed wrist. It looked like his radius & ulnar were about to pop out of the skin. He was in agony so my crew mate plied him with Entonox while put in a 22g IV and gave him 2.5mg of Morphine. It did the trick. After a brief examination by the DR he went straight to the operating theatre to have it straightened and put back in alignment.

Half an hour til the end of my shift and a cardiac arrest call came in. We thought it was to a 19 year old but it turned out to be an elderly lady. A double EMT crew had just arrived moments before us and starting Basic life support. I cannulated the external jugular vein and started drug therapy while my crew mate intubated. But despite our efforts the lady didn't respond to our treatment so we decided to terminate resuscitation as she was asystolic (flat line on the monitor).

That brings my total of 3 cardiac arrests in as many days!
I did, however, find out that the lady from the second cardiac arrest on Sunday is still on ITU and the staff were thinking about bringing her round to see if she could breathe for herself. I'm doubtful but you never know.

Another 5 shifts!

2009-03-08T23:17:00.002Z

Well I've had 3 days off and I'm back for another 5 shifts. Today I did an overtime shift on a response car at my local station (not my base station). There were some good people on today and it started off well with one of the guys cooking bacon baguettes. They were delicious. It was a quiet start for me while all the crews were either given calls or tasked to standby somewhere. I got a call later in the morning to go to one of the sub stations in the north of our area, I didn't mind. I had a good book and my sunglasses and the sun was shining, what more could I ask for on a Sunday morning. I had to get some fuel for the car and before I left the service station I was asked to go the hospital for standby. I remember thinking that this was going to be a cushy shift and being paid at time and a half aswell. I was only there a short while before being given a cat A chest pain in the next town. A young lady with a recent NSTEMI (as some would say-a minor heart attack) and a recent stent experienced chest pains. I and another officer got there first soon followed by a crew who took her into hospital. I cleared up and was sent back to base.
Back on base a call came in for one of the crews, I volunteered as one of the crew was talking to a police officer. It came in as a fall, no big deal. I'll be done and dusted in no time I thought. I find out that it's a 6 year old who has fallen from some playground apparatus. She's in agony, pale and has a deformed right arm. It looks blue and mottled from the elbow and her hand is cold compared to the other one. While I'm there she nearly drains a CD size Entonox bottle and I manage to get a small 22g IV into her left hand and give her 2mg of some much needed Morphine. She was in that much pain that she offered me her hand for me to pop the cannula in. A crew eventually turned up to take her in to hospital but before we moved her we splinted her arm with a vacuum splint. This is a slpint that has all the air sucked out and becomes rigid, this will keep her hand nice and still. At the time I suspected that she fractured her humerous and possibly dislocated her elbow. I later learned that she had in fact dislocated her shoulder and elbow and also completely snapped the end off of her humerous. The DRs also think she may have fractured her wrist. En route the paramedic gave her another 2mg of Morphine which made her high as a kite......................again! The combination of Entonox and Morphine really did the job. The last time I asked about her she was in having emergency surgery.
It's not often we have to stick an IV in a child but sometimes it's needed. All I did was treat her as if she was my own. I couldn't believe how brave she was compared to some adults that we go to. You know the ones when you take a sugar sample from their finger and there they are wailing about on the floor, GET UP!!! Well that's what I feel like saying to them sometimes.
I'll pop in to the children's ward and check on her tomorrow.

No sooner have I cleared up from that job I get a call to back up a double EMT crew at a cardiac arrest. Elderly lady, witnessed collapse. To cut a long story short there are 2 community first responders and an EMT crew on scene doing basic life support. I get there and intubate and put an IV in so I can give some resus drugs. We work her for 20 minjutes and after that I halt resus. There is no sign of improvement and the monitor is showing a flat line.

I had to get back to base to swap cars as I couldn't get into the boot, the lock was jammed. On base I restocked my kit and checked another response car.
A short while later another cat A call came in, it was another cardiac arrest. I got there to find one of our staff responders already doin CPR. She was showing Asystole (flat line) on the monitor. Her airway was a problem as it was filling with vomit. I managed to get a tube in and secure her airway. Next I got an IV into her left arm. A crew from a station 35 miles away backed us up and helped with the resus drugs and fluids. After a short while we got a pulse back. I hooked her up to the ventilator on board the ambulance and travelled in with the patient. She held her own all the way into A/E and at around 22.40 this p.m I was told that she was in ITU. Unfortunately she may die but never say never in this game. We did our best.
I get a lift back to my locked and abandoned response car with a local crew.

I then get another job but soon come to the conclusion that it's a GP 999 so query why I'm backing up a more than competent Paramedic crew. I then get stood down only to be given yet another cat A. This time an asian shopkeeper has fallen from his shop counter and landed on his head. His daughter stated that he collapsed in to her arms. A crew turn up so I assist them with a collar and full immobilisation. The patient smells like he has been drinking and is confused and lethargic. The crew take him in and I clear up.
6 six calls in all, not a bad day at all. Most importantly they were all genuine incidents.

Back tomorrow to do it all over again.

2009-03-05T22:58:00.002Z

Finally I have 3 days off. I feel knackered after 5 days on the trot.

Monday:
Chest pain from a DRs surgery. There was one of our Paramedics already in the surgery, he was on a placement for his Paramedic Practitioner training and he handed me a 12 lead ECG. It showed flipped T-waves which is an indicator of ischaemia. On board we connected him up to our monitor and started treating him. He had chest pain for 24 hours which wouldn't go away and had difficulty breathing when lying flat through the night. I suspected that he had a heart attack the previous day. He had probably had a sub-endocardial infarct which basically means that it hasn't affected the full thickness of the heart muscle. Never the less it is still serious and needs prompt treatment. When transferring him from the carry chair to the trolley he became very breathless but as soon as the oxygen was on it eased off. He still had pain which wasn't relieved by nitrates so I put a line in to give him some morphine but he declined this.
At hospital he was told off by one of the CCU nurses for not having pain relief even more so because his heart rhythm was now in fast AF and the ST segments were now starting to elevate. The team then started to fuss about him with some urgency. By giving pain relief to cardiac chest pain patients not only does it take the pain away it also takes the strain off the heart and reduces the risk of nasty heart rhythms which can be fatal.
Our next call was to a COPD patient who was staying at his holiday home with his wife. He also had a double colostomy and abdominal fistula. The call was a possible bladder infection. He had an infection alright, probably septic. He was more breathless than usual, had a temperature of 39.9 and was also tachycardic & hypotensive. He had a total of 1000mls of IV fluids en-route and a 500ml bag connected as we arrived at hospital to keep the vein open. His blood pressure was still only 83/40 when we got there. I saw his wife the next and found out that he had a serious chest infection amongst other things and would be in for a few days.

The rest of Monday and the following day were pretty unremarkable with the usual routine jobs.

Wednesday:

I was on overtime again. I know what your are thinking, MONEY GRABBER! Too bloody right, take it while you can. It won't last forever.

I was on the new response car and was soon on my first job. It came through as a penetrating injury. A 12 year old managed to get a knitting needle stuck in her thigh. When I arrived I was shown up to the bedroom where the young girl was being comforted by her dad. There was a wooden knitting needle sticking out of her thigh. Compared to the other one I could tell that it had gone in approximately 4 inches and it taken some of her pyjamas in with it . I cut up the leg to get a better look. Being in a lot of pain I started her off on some Entonox which really hit the spot. She was out of it at times. I did say that I may need to put a drip in her hand and give her something stronger if when we come to move her it starts to really hurt. She didn't need it, the Entonox was more than effective. I was backed up by a critical care ambulance who then took over care and transported her to A/E.

A collapsed female who kept passing out while sitting/standing. She was taken in by a crew.

My third and final job was to a lady in her 40's who had a stroke a year ago and had only just started to recover. She phoned her friend in a distressed state who then called 999. Her friend recognised that she may be having another stroke and went straight round there. I used the FAST and Miami emergency neurological deficit exam and quickly concluded that she was indeed suffering a stroke. I checked her other observations and got on the radio to see where my back up was. The crew arrived about 60 seconds later and our patient was quickly on board and en-route to A/E. The stroke team were ready and waiting and according to the crew the DRs think that she may have suffered a sub-arachnoid haemorrhage. I was thinking of a clot at the time and thought that she may have been a candidate for stroke thrombolysis, sadly it wasn't to be.
I'm not sure what happened to her maybe she got transfered out to the neuro centre for an operation.

A boring helicopter clip, sorry!

2009-03-03T00:18:00.002Z

2009-03-02T23:07:00.003Z

Saturday:

1. 101 year old chest pain. Yes you saw it right, 101 year old! This chap was a surprisingly young looking 101, still self sufficient and lived alone. Complaining of chest pain through the night, worse than his usual angina pain, he didn't want to bother any one. He called his daughter who popped round to see him and had obviously took one look at him and decided to dial 999. He had a non-stemi late last year and apart from that he hadn't been too bad. We soon sorted him out and after some aspirin, GTN, O2 and morphine he was looking a far better colour on arrival at hospital. He even managed a cheeky smile, something he didn't feel like doing when we first arrived on scene. Just imagine what he has seen in his life, all the changes, war and hardship. Bless him. I hope he has many more years ahead

2. Paediatric burns. 18 month old who had tipped hot coffee over himself. Mum was cooling his burns as we arrived. All we could do was apply water gel dressings and give ibuprofen & paracetamol oral suspension for the pain. This job pissed me off because what I really wanted to give him was oramorph (oral morphine) which is a drug we are supposed to have. We are still waiting to get it. He was too young to understand Entonox and there was no clinical justification to give IV/IO morphine due to the size of burns. The A/E staff completely agreed with my annoyance. Don't worry I'm on a mission to get this sorted and wont stop until until we get the extra drug.

3. RTA, 2 cars and 5 patients. Every man and his dog was there including the neighbouring air ambulance. See above photo. The rear of the car shown was pushed right under the back seat. The other car had relatively minor frontal damage, it was a brand new Audi. A case of new versus old.

4. We cleared from that incident and within 60 seconds were given a breathing difficulty in the next county. It was lucky we were so close because the other county would of taken ages to get there. It was a lady with COPD/asthma who was really struggling. She had a high temperature aswell so she needed to go in. We treated her with salbutamol and atrovent nebulisers which helped considerably, bringing her O2 saturations up from 85% to an exceptable 92%. We try and maintain COPD patients at around 90-93% so as not to mess there blood gases up. They rely on low levels of oxygen in the blood to stimulate their breathing where as us healthy types rely on low levels of carbon dioxide. This basically means that if we increase their oxygen levels we might remove the stimulus to breathe and cause them to go into respiratory arrest. This is rare and only happens in a few cases where the disease is advanced.

The hospital was over 20 miles away but by the time we got there her breathing was now fine. She still needed her underlying infection treated otherwise if we treated her at home with nebulisers and left her there another crew would be out later. In these patients with COPD or asthma who have an underlying infection a nebuliser is only a tempoary fix and sometimes can fool the patient and even the crew that they are cured.

5. Non-injury fall, left at home.

6. Paediatric head injury. A baby had fallen off a chest of drawers face first while having his nappy/dyper changed. Cryed straight away and alert. Small bruise appearing on the forehead. Mum and dad concerned so we popped them in to hospital just for their piece of mind.

Sunday:

Again 6 jobs, only one of any real note.

Elderly male with a history of Myasthenia Gravis who collapsed at the dinner table. He started having mini seizures and was a bit agitated. I popped in an IV because I thought I was going to have to give some Diazemuls to stop the siezures but after some O2 he recovered on the way in to hospital. His wife and daughter were in tears before we left because they thought he was going to die. They were relieved when they saw him smiling at hospital.

2009-02-28T16:26:00.002Z

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'.

Last night

2009-02-25T03:10:00.002Z

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

2009-02-25T02:50:00.003Z

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.

Continued

2009-02-24T21:53:00.002Z

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.

Another typical week

2009-02-21T21:45:00.002Z

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.

More overtime! Yeah!

2009-02-10T11:25:00.002Z

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!!

Is it Just me?

2009-02-07T23:18:00.002Z

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

2009-02-07T19:45:00.003Z

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!

Another night cont'd

2009-01-28T13:43:00.009Z

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

2009-01-28T00:53:00.002Z

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.

ASLS

2009-01-23T15:27:00.004Z

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.

2009-01-22T23:52:00.002Z

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!

2009-01-22T16:33:00.006Z

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!

I'm Back!

2009-01-18T00:02:00.002Z

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.

I'm still here

2009-01-14T00:03:00.001Z

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

See ya soon.

Merry Christmas and a happy new year.

2008-12-24T11:09:00.003Z

Stay safe people!

Puffy eyes

2008-12-21T20:14:00.003Z

All night long we had been dealing with people with high temperatures and nothing much else. A quick assessment including obs and all were referred to the out of hours GP (OOH GP). We had just finished our break when right on time the station alerters went off. We checked the MDT to see what the job was, it was an allergic reaction. So many times we get to these jobs and find that some one just feels sick and nothing more. But this turned out to be the real thing. A few minutes later we arrived on scene to met by the patients mother who was grinning. 'Here we go again' I thought. On entering a small bedroom we were faced with a wriggling mass on the bed. Some where underneath was an 18 year old girl who was supposedly having an allergic reaction. Some swollen & puffy eyes popped up from the duvet. Eventually a whole head appeared and it soon became apparent that the young girl was genuinely suffering from an allergic response to something. We went through the usual checks like checking her tongue for swelling and listening to her chest etc. They were fine but both eyes were completely swollen and her top lip was about three times its normal size. Her face was flushed and she had urticaria (hives) all over her neck and arms. I checked her pulse and BP which were 100 bpm & 100/60 BP. She was a tiny thing in fact my eleven year old son was bigger than her so I wasn't overly worried by the BP reading however she was tachycardic. I asked of any known allergies, the answer was none. I also asked if she had started any new meds or had been in contact with any shellfish or dodgy plants, again the answer was no. The only thing they could think of that could have possibly caused the reaction was maybe an orange jelly that she had eaten earlier but without the proper testing we wouldn't know. I decided to administer some antihistamines to counter act the reaction. Everyone including our young patient were in good spirits but you could see she was uncomfortable with her symptoms. I had a look at her arms & hands for a vein, nothing! Great! I could have given it via IM injection but really wanted a line so the meds would act quicker and also in case her BP dropped suddenly enabling me to get fluids into her. I spotted a tiny one on her right hand so I tried to get a blue 22g cannula in, I got the flashback but it wouldn't advance. Out it came and into the sharps bin. Last try. I put the tourniquet on her right arm and waited patiently and within a short while a nice vein came up in her ACF. I opted for a pink 20g and got it in straight away, my crew mate then handed me 10mg of Chlorphenamine (Piriton) which I administered slowly.

'OK then let's get some shoes on and we'll pop you over to the hospital.'

Her boyfriend came with us and sat holding her hand on the way. I was busy doing more obs and filling in the paper work. The rash had now started to subside although her eyes were still really puffy and her top lip still swollen. I constantly checked to make sure her breathing was OK and that her tongue wasn't swelling. All was well until we pulled into the road leading to the hospital. Her boyfriend grabbed my arm and said that he thought she was struggling to breath. I asked her and sure enough her chest was getting tight and she was complaining of a feeling like there was a lump in her throat. I put her on some O2 and quickly administered 500mcg of adrenaline 1:1000 intramuscularly. I didn't have time to give any Hydrocortisone so I left that to the hospital. By the time we got into the dept her breathing was now easier.
Job done!

Thanks you know who.

2008-12-21T00:09:00.002Z

Thanks for sending me those, you know who. Although each clip is brief they were filmed in Ney York, Time Square and Madison Square Garden. Now what would be funny is if the Paramedics/EMTs that were in these 'Rigs' saw this blog and could tell me what the calls were. They were filmed between the 4th Dec - 9th Dec, I think. A needle in a haystack springs to mind.

There's one............there's another one...........there's another.........

2008-12-20T23:29:00.007Z

Last weekend cont'd

2008-12-14T00:31:00.004Z

G.I Bleed
Sunday was busy as usual. The moment the shift started , at 06.30, we were straight out on our first job. We had been called to a nursing home about 7 miles away for a Cat A haemorrhage/lacerations call. The only extra info was that the patient had been vomiting blood, also known as hemetemisis. We were met by an oriental nurse who showed us where the patient was. I seem to remember repeatedly asking her 'what's wrong with the patient?' only to be ignored. That really gets my back up. In the room we find a male in his 70's lying on the bed. Another member of staff was in the room tidying up. The patient had vomited up what the staff described as looking like 'coffee grounds'. That is an indicator that the patient could have been suffering from a G.I bleed. I asked if there was a lot of vomit and they said yes but unfortunately the staff had stripped the bed and disposed of the sheets. We could have at least gauged how much blood he had lost. He had a good radial pulse although a little on the rapid side which gave me a quick indication of what his circulatory status was. If an adult has a good palpable radial pulse it tells us that their estimated systolic blood pressure is above 90, therefore an adequate blood supply able to keep the vital organs perfused. We got the patient on to the vehicle and did some more obs. His O2 saturations were a little low and his pulse was around 125 however his blood pressure was an acceptable 128/76. A few minutes into the journey I retook his BP and it had dropped to 77/44. He then started to vomit more of the coffee ground liquid. I quickly swapped his O2 mask for a vomit bowl and cleaned him up. As we were on a straight piece of road I decided to pop in a cannula and run some IV Hartmans to boost his BP and maintain it at around 90. He had 500ml in total. Because I had pre alerted the hospital we were greeted on our arrival and ushered into the resus room.

While I was filling out my paper work an Irish Dr came over to speak to me and asked what had happened.

'I know I shouldn't say this but it was a job to speak to some one who actually spoke English in this nursing home!' I said. 'It was a real struggle to get any history out of them.'

'Don't worry about it, I always believe you should say exactly what you think.' came his reply.

'RIGHT my friend'. boomed the DR to the patient. 'Let's get some blood out of your arm and find out what's going on!'

Proper job!

Fall
We also had a lady who slipped on an icy path right next door to the Fire Station we use as a response post. Unusually there wasn't a vehicle there so we responded from about 8 miles away.
She had an obvious fracture/dislocation to her wrist. The fact that it was bent like a dinner fork and unusually rotated 180 degrees in the opposite direction kind of gave it away. She was clearly in agony and was a little pale & dizzy. She pleaded for some pain relief but couldn't get on with the Entonox. I said that the only other pain relief we had was the sort we give through a drip to which she replied 'Please give me something!'
When I said that it was Morphine she said 'Ooh I can't have Morphine it makes me sick!'

'But you're not actually allergic it are you.'

'No but I was ever so sick after I had it last time after I had an operation.'

'Some people can be quite sick anyway after an operation.' I said

'Well I've had lot's of operations and never been sick before.'

'Well I can give you an anti sickness drug before I give the Morphine and if I give it nice and slow (which we do anyway!) that should prevent you from feeling sick.'

She declined but soon changed her mind as the pain was clearly became unbearable. She had 10mg of Metoclopramide and 2 x 2.5mg doses of Morphine which helped considerably.

Another Fall
A call came in for someone who had fallen from a horse and as we were sat at the hospital we were the closest. It was about 5 miles west of the city. We received updates en route which stated that the woman was in her twenties and had fallen from a horse, she had apparent back and chest injuries. We pulled up on the side of the road and were met by a young girl , she said that our patient was about 100 metres along this country path. More like half a bloody mile! It took us ages to get to her and to top it all the path consisted of mud only. My trousers and boots were filthy. On the floor was quite a large woman covered in, yep you guessed it, coats. She still had her safety helmet on and looked uncomfortable. Not surprising really considering it was bloody brass monkeys (freezing), wet and muddy that day. Her horse was tied up to the fence close by and was being calmed by another woman. We quickly assessed the woman on the floor and established that she was short of breath, had significant pain and bruising to her left chest & epigastric region (this is just below where the breast bone ends). She was also complaining of some thoracic back pain (in the middle of the back). She had good air entry but I was reluctant to give her Entonox for pain due to the fact that if she did have a collapsed lung then I would cause it become worse. We put her on some O2 and then out with some more Morphine . Without being rude she was a large girl but only needed 5mg to make her comfortable. We have to be careful when giving Morphine to chest injuries because it can cause respiratory depression which in turn will worsen hypoxia if we are not on top of our game. On the other hand this girl's pain was inhibiting her breathing and by me administering some Morphine eased her pain thus enabling her to take deeper breaths, avoiding hypoxia. However prior to giving her the pain relief I had to get a line into her hand but her previously calm horse started to get a bit skittish. There was a brief moment when the horse 'neighed at 150 decibels' and raised it's front legs. Although not in immediate striking distance it wouldn't of taken much for it to get loose. I very nearly crapped myself!!
My crew mate had done nearly the equivalent of a half marathon getting various bits of kit from the ambulance. For a split second I nearly even felt sorry for him. Naaaa. He gets paid enough, ha ha. From the start it was a chopper job but out of four possible options none were available. Our two HEMS choppers were both on trauma jobs and the Police/Ambulance combo chopper was grounded due to an equipment upgrade, even the neighbouring ambulance service's helicopter was busy on a trauma job. There were no other ambulances available so we ended up getting Fire & Rescue to assist us carrying the girl out to the vehicle. We only needed a few extra bods but two Fire appliances turned up, one from our county and another from the next county. Before they arrived my crew mate went to the road to wait for them and while I was waiting I had a little bet with myself. I bet they come walking up the path with their helmets on. Sure enough through the trees I saw all these yellow helmets. I shook my head. Joking aside they were a great help.

Another proper job.

Last weekend

2008-12-13T23:37:00.002Z

Last weekend I worked with a Technician who is on his 3 year Paramedic Uni course. Nice guy, competent, reliable and best of all has a good sense of humour. An absolute must in this job! Anyway Saturday dragged on with nothing really going on, a few routine 999 calls, Lot's of pointless stand-by and a Dr's admission which was about a 70 mile round trip. We cleared up at this hospital and they even tried to send us on some more stand-by. I don't think so.

'Er we haven't had our second break yet and if we do have to go on stand-by somewhere can it be somewhere with facilities!'

'Roger, sorry about that, I pushed the wrong button, you can RTB (Return to base)'

'Roger, will do'.

So off we went. Stayed on base for a while but copped a job at 18.10. We where on a 18.30 finish with no one else on base. As Dick Dastardly would say 'Drat and Double Drat!!!'
It came through as a sick person and that he had been to the hospital earlier.

'Right let's get him on board and go' said my crew mate.

We were on scene within minutes and went inside. A lady directed us into the living room where a young man in his early thirties was lying on the sofa not looking too clever. On the other side of the room was a baby asleep in a small chair and another child was quietly playing. It transpired that this chap had been to the hospital earlier with chest pain, had x-rays, bloods and an ECG. He was discharged with anti-biotics and pain killers-diagnosed with a chest infection. Well he may have had 'just' a chest infection then but now it was bit more serious. He was pale, breathless, pulse of 140 (which was barely palpable), blood pressure of 100 systolic and had a tympanic temperature of 40.8. I quickly exposed his chest and abdomen to check for any signs of a bacterial rash, although more common in children and adolescents, I didn't want to miss anything. No rash.
Now on the vehicle we repeated his obs. His pulse oximetry read 89% on air and his blood pressure was still low. We did a 12 lead ECG which looked fine but he was still complaining of severe chest pain. We gave him high flow oxygen, cannulated & took bloods, IV Metoclopramide, IV Morphine and in total a litre of IV fluids. Despite the IV fluids his blood pressure and pulse remained the same although he did say that he felt considerably better by the time we delivered him to the hospital.
I handed over to one of the A/E nurses and before we could off load him onto one of their trolleys the DR who had seen him earlier came over. He looked worried, may be he was thinking of what he may have missed. I briefly explained our findings to the DR, bid fairwell to our patient and booked him in at reception.
A late job but I didn't mind as it was a worth while job. I found out later that he was admitted to a medical ward.

Credit Crunch

2008-12-13T23:16:00.002Z

The world is in economic meltdown, businesses going bust, people losing their jobs and homes being repossessd. It's like going back to the recession of the eighties. It's at times like these I'm glad I'm a Paramedic, glad I work in an area where at some point someone will need me. Everyone needs healthcare and always will.
Even at a time like this there is shed loads of overtime and I am taking full advantage of it, after all I need the money. Don't we all! Not only is christmas as expensive as ever but I've also got to pay for my wife's New York trip. I don't mind though, she deserves a break. Which reminds me I may be getting some video clips of FDNY because a couple from my local station have just been to the 'Big Apple'. Watch this space.

My timesheet looked odd, it showed mainly annual leave and overtime with only a hand full of rota'd hours. You see I get 277.5 hours annual leave but up until recently had only taken 44! I was politely informed by our scheduling dept to 'Hurry up and book my leave or have it allocated for me'. I've now done this but because we get a fair amount of time off any way I decided to book some overtime shifts.........................on days that I was on annual leave. Loads a money!!

2008-12-09T01:27:00.002Z

On another night shift, on my own, been run ragged going all over the county. All crews have been non-stop. I've now been on base for a while and have had time to think........
Our friend's sister and husband lost their 2 and a half year old little girl under tragic circumstances two weeks ago. Her funeral was yesterday. I couldn't bare loosing any of my children and wouldn't know how to carry on. To think we were all at a birthday party only two days before, celebrating. If only it had happened there, I know I could have made a difference.

God Bless Little One

A stone's throw

2008-11-24T21:35:00.002Z

I don't know about places like the USA etc but over here in blighty the majority of opiate overdoses' involve IVDU (IV drug users) and that bag of gear that takes them just over the edge. But occasionally we get called to the intentional/accidental OD on prescription opiates such as co-proxamol/co-dydramol/co-codamol etc etc. A couple of weeks back I was working out of another station with an old colleague from my PTS days. As usual we were having a good old laugh n' a joke and generally catching with all the gossip. We get a call for an OD. It's to a 40 year old female who has taken ? Tramadol (synthetic opiate). We arrive at the location but have a job deciding which gate way to use, the house is that big! Soon we see a man appear on the road who starts to wave to us so we make our way over and park the vehicle in the drive. The house is up for sale and if I had the money I would have snapped it up. It was up for £1.4 million. (Just a few more overtime shifts might do it!). A woman (who also happens to be a nurse, a proper one for a change) obstructs the front door and starts to tell us about our patient.

'She's my sister-in-law and she has taken 60 of these.' as she hands me an empty packet of solpadol.
n.b we were initially informed that the drug was Tramadol although it wasn't

'She is having problems with her husband and I'm really worried about her!'

'OK let's go in and see her shall we.' I say

Inside I'm gobsmacked at the size of it all, beautiful wooden floors and the sweeping stair case and the kitchen, well my wife would have a field day. Inside the open planned kitchen there is a woman lying semi-conscious on the sofa. To cut a long story short she appears to have taken all the solpadol (solpadol is an opiate containing Paracetamol and codeine) and is showing signs of an opiate OD such as pin point pupils, decreased respiration's and reduced conscious level. We treat her with O2 and IV Narcan which does the job and take her to hospital. What we later learned was that at the end of the road and at the exact time of
our job there was a car accident. A local teenager had pulled out of a junction on the busy dual carriage way and had been struck by a van travelling at high speed. She was in cardiac arrest. A couple of crews and the air ambulance attended and despite bi-lateral chest drains and every thing else that goes with a serious trauma job she died.
A sad tragedy had occurred with in a stones throw of where we were. Even if we were there as it happened there would have been nothing that we could have done to save her. It's still horrible to think that someone died right under our noses.

Another OD

2008-11-23T03:00:00.002Z

Finally we've just got back to base and had our break. A little while ago as we were approaching town the MDT started to beep and flash, it was a job. Cat A unconscious in the street ? overdose. We were only a couple of minutes away and had no other details. As we pulled into the street there were 2 men standing over another man on the ground. This guy had overdosed on heroin and had done it big time, he was in respiratory arrest.

'Yeah man he's only done 20 quids worth of gear and drank some beers, that's all' said one of his mates.

Out with the BVM and an OPA (oral airway), his pupils were pinpoint (a classic sign of opiate OD) and even in the moonlight he looked pale. As I started to ventilate I asked my crew mate (who is a trainee) to get out the drugs bag and give 800mcg naloxone/narcan via intra-muscular injections, one in each arm. It's funny because only earlier I was talking to him about what skills he has used so far and what did he need to get signed off. Although he had given Glucagen IM in the past he didn't get it signed as this was before the new policy had come into effect. The new policy being that all trainees now need to be signed off (twice) as competent at administering drugs via IM injection, this was his chance.
At this point the police turned up and quickly arrested his mates, why I don't know.
With a good patent airway the next step was to administer the narcan. My crew mate did well and pushed 400 mcg into each arm. I carried on ventilating him for a good few minutes but nothing was happening, he was still not breathing. I opted for a tube and attempted intubation there and then but as I got through the cords he gave a massive cough so I withdrew the tube. I reassessed his airway and breathing but still nothing so I swapped positions with my crew mate so he could practice his BVM technique. Next step was to give more narcan but first I needed to get IV access which can be pretty tricky in IV drug users. Not in this case, the patient had cracking veins so I popped in a 20 g pinky and gave another 800mcg of narcan. Within about 30 seconds he was back in the land of the living. A life saved.
He was no bother on the way to hospital which makes a change! Most of the time when you have ruined a heroin addicts hit/fix they usually moan like hell but not this guy, he was nice as pie and happily came to hospital to be checked over.

It's now 03.30 am and I'm tired. Must try and get some sleep. I'm not holding my breath though!

Asthma

2008-11-21T23:06:00.002Z

It's 04.00 am and I feel someone shaking me and soon realise that it's my crew mate.

'Come on we've got a red call!'

Now, I'm not great at waking up at the best of times. The night shift had been pretty quiet and we were lucky enough to have had about 4 hours sleep on base.
I manage to haul myself up and make my way to the vehicle. On the mobile data terminal (MDT) the message reads 'Lights and sirens response, SOB, GP advises patient will need oxygen.' From that I knew that it was a Dr's red call but what I didn't know was whether a DR had actually visited or not. Probably not. We usually get updates of the job en-route but didn't get anything extra.
When we arrive on scene about 5.5 miles away we see that the front door is open so make our way over. Inside there is a lady, about 70, who was really struggling to breath. You didn't need a stethoscope to listen to her chest as the wheezing was so loud. I still had a quick listen so I could detect/rule out a pneumothorax (collapsed lung). Her air entry was equal with a pronounced bilateral expiratory wheeze so straight on with the high flow oxygen while my crew mate was moving the vehicle.
On board I gave her a Salbutamol nebuliser which only provided mild relief so after about 5 mins I gave her another, this time we added Atrovent (Ipratropium Bromide). Her peak flow was only 150 (her normal was around 350 which in itself is pretty poor), O2 saturation's was 90% with a pulse rate initially running at 110 bpm. I decided to cannulate her and administer 200mg of Hydrocortisone. She knew exactly what we were doing as she was an ex nurse and repeatedly kept thanking us for what we were doing even though she wasn't out of the woods yet.
It all started around 2 am when she was woken from her sleep with severe breathing difficulties so she decided to contact the out of hours GP. The GP obviously heard her breathing on the phone and called us.
By the time we reached hospital her O2 saturation's were 98% and her pulse rate had come down to an acceptable 90 bpm although she was still a bit wheezy. We were greeted by a DR and 2 nurses who took my hand over as we transferred the patient to the hospital trolley. As I turned round another nurse came into the cubicle with a tray with 2 vials of hydrocortisone drawn up into syringes and bloods tubes.

'What do you want them for? I've done all that.' I said.

'Have you?' said the nurse.

'Yep, I did say when I gave the pre alert.'

'Oh OK I didn't know. I'll get rid of them them, thanks for that.' she said.

Our patient is now doing much better and after doing an arterial blood gas the DR looks at a loss as to what to do next. He wanders off and starts to write some notes while the nurses get on with repeating some obs. Our patient thanks us and we wearily make our way back to the vehicle hoping to get back to base for a bit more shut eye.

After a week of doing nothing of any significance it was nice to have a proper job just to remind us of why we are here.....................even if it was at 4 am!

2008-11-19T23:06:00.004Z

After reading http://theparamedicsdiary.blogspot.com/2008/11/whisky-night.html and the bit about the diabetic, I felt I needed to comment.

We were called to a care home for an unconscious female. She was in bed, unresponsive, malnourished, dehydrated and no heavier than 5 stone in a wet raincoat.

'How long has she been like this then?' I said knowing full well that this wasn't something that had suddenly happened.

'Don't know, I've only just started my shift and I don't know much about this lady.' came the reply.

'Really' I thought to my self.

It amazing how many times we get the same old story, no-one knows anything about the patient, they've just come on shift or 'it isn't me that usually looks after her.'

'Medical history?'

No-one seems to know!

This lady is poorly sick and needs to be in hospital. She is severely dehydrated with barely palpable radial pulses. She is also hypoglycemic (although not diabetic). She needs some fluids and IV glucose. One attempt and that's it. This was before we had the
EZ-IO (http://www.vidacare.com/ez-io/index.html) We're in! A 22g bluey in her hand. 50ml of glucose and a bit of fluid en route. She starts to stir.

Overworked, understaffed, don't know this, don't know that. We've heard it all before. There is no excuse to allow patients to get like this.

To the clampers

2008-11-19T20:44:00.001Z

No hard feelings eh! Ha Ha

2008-11-19T20:42:00.000Z

Although I had to laugh when I saw this.

Pissed off!

2008-11-19T20:28:00.002Z

Today my car was clamped at our local hospital, yes I know it was my own fault but I'm still pissed off! I had to take my 9 year old daughter to A/E as she had been suffering severe abdominal pains. We suspected appendicitis as all the signs were there i.e positive Rovsing's sign etc. Anyway we waited for the blood results to come back and thankfully she was suffering from nothing more than severe constipation. We went to the pharmacy to pick up her meds and when we got back to the car we saw 2 car park attendants (I like to call them parking police) walking away from the parking area with a camera, clipboard and clamping gear. I thought nothing of it until I saw my front wheel with it's new yellow friend bolted to it. Of course I got it in the neck from my wife because she had told me to move the car into the staff area but I knew better,'It'll be all right' I said. Famous last bloody words! I paid the £45 release fee and off we went.

OK MY OWN BLOODY FAULT, still pissed off though.

Knowing my little girl is fine and I soon forgot about the slight inconvenience of the clamp and fine.

2008-11-17T23:06:00.002Z

We offer lots of help and advice to newbies/trainees and this short & sweet gem on ECGs is one of my favourites; 'If there's lots of ink it ain't good!

Oops again

2008-11-17T23:03:00.002Z

I forgot I took these.
I was working on the RRV when I got a call, 'Rollover, 1 female trapped'. Everything was being sent including the air ambulance, basically every man and his dog.
The accident is on an S bend and road is slippery after some light rain. Within minutes I was there. The usual helpful member of the public was there directing traffic, he gets every where that bloke! Before I pulled up I spotted the windmills, these are those people that think that we are blind and have a need to stand at the scene waving frantically. Perhaps they think we have got multiple incidents along the same stretch of road and need to wave us down in case we drive by. Funny old thing the car on it's side gives it away! Never mind.
I grab my kit, analyse the scene for hazards and quickly check to make sure there aren't any other casualties that have been ejected from the vehicle. There are 4 people gathered at the side of the overturned car and one kneeling by the boot.
'There's some one in the car', says someone. 'We didn't want to move her just in case.'
As I lift up the boot hatch I am confronted with a wriggling mass of coats and bags.
'Can I get out now?' a voice says.
'Hold on.' As I crawl inside. 'Are you hurt?'
'No'
'Any neck or back pain, did you hit your head, seat belt worn?'
No, no and yes were the replies.
'Well let's get you out then.' I said.
'Yes please' said the woman.
Before I get her out I call up control and ask for just one vehicle to attend and to cancel the air ambulance and fire & rescue. Although standing down fire & rescue in this country is pretty much impossible.
I have to detach the back seat and slide it out and then remove the coats and bags that are now only partially covering the woman. As I guide her out I am deafened by the sirens of the approaching ambulance. As it pulls up the trainee tech driving turns them off, her crew mate gives her a filthy look and shakes his head. I thought she parked it on my head they were that load! Never mind she'll learn.
The woman is now out and is unharmed so we put her on board the ambulance to have a proper look at her. The crew move the vehicle down the road so it is out of the way. While I'm talking to the Police two fire appliances turn up.
'She's out mate.' I say to the watch commander.
He turns to his colleague from the other fire truck and waves him goodbye. He walks off looking disappointed.
'Right, we'll make the car safe then.' he says.
The woman is being checked over in the ambulance so I pop over to see if the crew need anything. The woman is fine and doesn't need to go to hospital. I then make myself available for calls.
I got another call to the same spot on Thursday this week for a car on it's side, again non-injury. We have been to a lot RTAs on this stretch of road with most incidents thankfully being only minor injuries. Although 4 lads in one car were killed not that long ago at the same spot.

Richmond Fire dept visit to RAA

2008-11-15T23:29:00.002Z

Some more pics from my trip to Richmond. The FD dropped in and told us about their role in prehospital care with RAA. One thing I found amazing is this; Like us in the UK, RAA have a response standard, theirs is 8 mins 59 seconds. But the only thing that stops the clock in Richmond is an ALS ambulance, that's a vehicle with at least one crew member who is a Paramedic. If a fire truck or a RAA field supervisor or BLS ambulance turns up first with in this time it doesn't count. Irrespective if they save a life it still doesn't count. Another thing I found astounding is that Richmond's population size is very similar to that of Southampton in the UK but in Richmond they have 20 fire stations and that RAA put out on average 16-18 ambulance crews daily and about 8 crews at night. This doesn't include the rescue volunteer squads dotted about the city. I know for a fact that there aren't that many fire stations in Southampton and that South Central Ambulance probably don't put out that many ambulance crews during the day.

Richmond FD have a few nationally registered paramedics as firefighters and the FD work closely with RAA.

Sicko

2008-11-13T00:18:00.003Z

Anyone seen Michael Moore's documentry 'Sicko'? People have the cheek to moan about the NHS well just watch this and see how lucky we are!

http://www.watch-movies.net/s/sicko.html

2008-11-12T13:57:00.000Z

Bare with me, I'm tinkering with the layout of me blog.

Oops!

2008-11-12T13:39:00.003Z

The little old lady who had been driving this car had just been to the Dr's surgery. I'm sure she was expecting nothing more than an uneventful drive back home. Oops, does help if you stick it into drive and not reverse love! 'Ooh my foot slipped' she said repeatedly.
Once we managed to prize her hands from the steering wheel we checked her over, she was fine. She managed to take out a brand new wooden fence. So new in fact the council workers were just packing away their tools. Didn't they laugh.......................not! Oh well at least I know my £1500 annual council tax money is being put to good use.

Non-injury, sign here!

2008-11-12T13:04:00.002Z

I've just opened one of my work e-mails and was shocked when I read it.

" There has been a number of incidents nationally involving housing association properties where tenants who are suspected users or suppliers of drugs are secreting DIRTY NEEDLES with in the bottom corner of light switches.
The needle is placed in between the rocker switch and the front plate, meaning that any person attempting to turn the lights on is likely to get a needle stick injury to the finger."

Unbelievable. So to my fellow emergency workers across the land, BEWARE!

Hallelujah

2008-11-12T09:32:00.004Z

Pulling up at the drive way to this £1 million+ house we both look at each other, shaking our heads thinking we are in the wrong business. To make us even more jealous there were two brand new Mercedes Benz sat on the drive. We had been called to a lady who was possibly having a stroke. The vast majority of the properties in this part of town are in excess of £500k which is surprising considering where I work.
After the 'Big Ben' style door bell stopped ringing the door opened and we were face to face with an overweight male in his fifties. 'Quick come this way' he said as he ushered us in. 'Are you all right?' I said to him, he was ever so wheezy and sounded like he was having an asthma attack, In fact I nearly gave him a nebuliser there and then on the spot. 'No I'm fine, it's my wife. Come up here, quickly please.' he replied.
It seemed to take ages to climb the enormous sweeping staircase. The patient was sat on the edge of her bed and was crying. As she looked up we could see the frustration in her eyes. It wasn't the fact that she couldn't speak it was more that what ever she said made no sense. We managed to find out that she suffered from high blood pressure and was taking tablets for it. After doing her temperature and sugar level we moved on to her BP which was 146/78, nothing remarkable there then. As she was symptomatic we popped her on some oxygen.
She still needed to go to A/E and within a few minutes we were on our way. Her husband, whose wheeze had now calmed down, came with us. The patient had been on O2 for around 5 minutes when her speech started to become clearer, it was no longer garbled. A few more minutes and it was getting better, by the time we were at A/E it was back to normal. As we unloaded her on the trolley her husband was leaping around shouting 'Hallelujah, she's cured! You boys are wonderful, you've cured her!' and he was repeating this up and down the corridor. I kept expecting James Brown to pop up and shout 'Can I get a Witness, amen'. With what we were presented with we queried a TIA (transient ischaemic attack, a sort of angina of the brain), did some obs and gave O2. That was it! But the husband thought we were miracle workers. A little while later the grateful husband came up to us and asked if we thought it was definitely a TIA but all we could say was that he should let the Drs run their tests to confirm it. He was more interested in our opinions than those of the Drs.

He was over the moon that his wife was doing well.

A TIA is sometimes called a 'mini stroke' and it is where there is a brief interruption in the blood supply or temporary blockage of a blood vessel in the brain. Patients usually recover within 24 hours but if patients have lots of these it is just a matter of time before they have a full on stroke. Patients with high blood pressure and/or an irregular heart rate (known as AF or atrial fibrillation) are particularly susceptible.

Just a quick thank you

2008-11-09T09:41:00.002Z

Every now and then I click on my cluster map to see where some of my visitors are from. Even though I've only had 2000 + visits (that's a lot more than I thought I'd get) it's nice to know some people actually read my blog. I just want to say thanks for reading.

Frustration

2008-10-30T23:28:00.007Z

'111, we have a cardiac arrest for you, you're being backed up by a Paramedic Practitioner.'

'Roger, book us mobile.'

We were 'green' at the hospital when the job came through.

'I know that address, it's only round the corner.' I said to my crew mate. We turned up 60 seconds later.......................................................at the wrong address. I had to recheck the road name and sure enough I got it wrong. The actual address was the other side of the hospital about a mile away so we made our way there. Still got there in under 8 minutes though. The problem was that both road names were very similar and I cocked it up, after all I am human.

I took in the response bag and my airway kit while my crew mate followed with the drugs and suction. As we climbed the stairs we could see a lady attempting CPR while still on the phone to one of our call takers.

The patient was a 70+ year old male whose health had been steadily going downhill for a couple of weeks since changing some medication. The Dr said that there was no link and that it was a coincidence. Any way the gent was in the bathroom, had a episode of diarrhoea and was trying to get in to the shower when he collapsed in front of his wife.

We started CPR and attached the defibrillator, flat line! It's a witnessed arrest which had only happened moments earlier, we had to give him a chance so we pressed on. A few moments later a Paramedic Practitioner (PP) arrived to help. He was on the airway, my crew mate carrying out chest compressions and I was trying to get IV access. As I inserted the cannula I got a flash back but it wouldn't advance so I tried to reposition but to no avail. I could of had another go or tried the external jugular, with the PP at the head end and me at the lower half of the patient I opted for the Intraosseous route (see the picture above). Out came the small battery operated drill, I placed an adult needle on the end and drilled into the patients tibia. Once it was in I flushed it with saline and started to administer adrenaline and atropine. With every adrenaline the ecg rhythm would throw out a few complexes, something which is all too common after adrenaline administration. The problem with resuscitation drugs is that there is no real evidence that they actually work and the key components of a successful resus is good quality CPR and defibrillation. This was not a shockable rhythm so defibrillation was out straight away. All we could do is CPR and use drugs. After about 30 minutes of full Advanced Life Support (ALS) it was agreed to terminate resuscitation. If we weren't going to get him back there then there was probably no chance of getting him back in hospital besides he remained in Asystole throughout. The PP went down stairs and spoke to the patients wife and told her that her husband had passed away, he also explained what would happen next. Once death is confirmed then we contact the police and they attend. They will act on behalf of HM coroner and offer help and support to the relatives. If something is suspicious then they will deal with that as well.

One thing with this job is that out of all the cardiac arrests we attend most will die. It has nothing to do with us, sometimes it is just their time or no one will have been doing any CPR before we get there. I do get frustrated with just 'going through the motions' time and time again only to prolong a death and not save a life! It would be nice to get someone back from time to time but it's beyond our control. May be next time.

More nights!

2008-10-30T11:11:00.002Z

Again I find myself on more night shifts. This is due to me being on what we call 'relief', we have relief weeks incorporated into our rota which covers annual leave and sickness. Most of the time we are put on night shifts and they never seem to follow any logical pattern, we are just there to fill in the gaps.

The last week hasn't been exactly busy or exciting but at least I have attended a small amount of needy patients. There has been the usual mix of drunk and overdose patients with a sprinkling of regular fallers for good measure.
After attending a couple of patients suffering from MI's (heart attacks) I have become a little fed up, I mean they didn't even have the decency to have an MI that I could Thrombolyse! I don't know, some people eh.

One of the better jobs I went to was a guy in his 30's who thought it might be a good idea to start weight training again...............................at home. The job came in as a GP admission (urgent journey) stating that the patient had back pain. His initially sympathetic partner briefed us about what had happened and showed us the GP's letter. I say initially sympathetic because soon after we arrived and started giving him Entonox she thought he was a bit of a light weight and was playing on his pain. She then started comparing his back pain to 'man flu'. By this point we were all laughing, even the patient. However he was clearly in genuine agony. The GP had queried a prolapsed disc and had refered the patient to the orthopaedic surgeons. His partner said that she had started exercising recently and had joined the local gym, he on the other hand opted for a bit of DIY weight training and put his back out soon after starting. Two Drs had visited over the course of the evening and had given the patient a whole array of pain killers including Diazepam, Paracetamol, Ibuprofen, codeine and even a 100 mg Tramadol injection. In fact the patient was convinced that the Dr must have injected him with water as it had absolutely no effect. He was also surprised that the Dr didn't have any Entonox.
It was time to move him on to the carry chair and get him down stairs. The Entonox was doing the trick up to this point but when he moved, the air turned blue. After a back breaking carry down the stairs we got him on to the vehicle. Back on the Entonox but this time it wasn't as effective so I asked if he wanted anything stronger, I already knew what the reply was going to be. I started with 5mg of Morphine which just started to take the edge off but gave him another 5mg which made him a lot more comfortable. The last thing he needed was to be bounced about in agony on the way into hospital. I think his partner was especially impressed when we, including the patient, said to her that women simply don't understand what us men have to go through. She rolled her eyes and laughed. Good job, nice couple.

Overtime..................and some.

2008-10-21T23:43:00.002+01:00

Well I was supposed to be working on the RRV for the day but no sooner had I got to my local station (not where I'm usually based) the red phone rang, it was control asking if I could go to my base station to crew up with a trainee. They were one man down, 'No problem' I said and off I went. The good thing about overtime is that it's paid at time and a half or you can take it as time in lieu. I opt for the money every time as I always seem to end up with loads of annual leave and have to try and take it before the year ends. Because I had started earlier than the person I was due to be working with I thought I'd be able to get away earlier........................................

9 calls today:

1. PR (rectal) bleed, elderly male who happened to be a DR. Lost a considerable amount of blood and was still loosing some. He ended up being infused with blood. Poorly patient. It's not every day you can say you've cannulated a DR!
2. On the way to a standby post we got a Dr's urgent admission into a local community hospital but when we arrived the patient wasn't ready. We passed the call back to control and were told to carry on to the original standby post. Bahh
3. After watching Bondi Rescue on SKY we were given a 999 from the psych unit to the A/E.
4. Before we got on scene we overheard a call for a cardiac arrest so we were passed that call. There was a Technician responder on scene who stood us down as the patient was deceased.
5. Another cardiac arrest call but this was just to lend our ECG monitor to another crew as their machine wouldn't print out a trace. They went and got a spare machine afterwards.
6. Homeless guy with apparent chest pain, more like intoxicated but due to a couple of other contributing factors he needed to go to A/E.
7. Fall in the street, female who was on Warfarin (blood thinning meds) was rushing around town trying to sort out her last minute holiday details when she tripped hitting her head. Patients on Warfarin who hit their head, whether they cut it or not, need to go to hospital due to the internal bleeding risks.
8. Chest pain, young girl at work who became unwell with chest pains but we put it down to one of three things, gastric as bringing her knees to her chest eased the discomfort, possible chest infection brewing as her temp was slightly elevated or anxiety. It was a sharp pain and was causing her a lot of discomfort, enough to make her cry.
9. The Icing on the cake! Transfer up to the big smoke 'London'. A trauma patient needing pelvic surgery and we were the only available vehicle. We had 2 1/2 hours to go and knew we would be late. He was on a morphine PCA pump but had to have it disconnected for some reason. He was ok for pain relief on the journey and didn't need any morphine from me which was surprising. I only finished 3 hours after my shift ended but at least I get paid for 21 3/4 hours! Every cloud and all that. One good thing though, my dinner was in the oven when I got in and it tasted bloody great.

Thank god that's over!

2008-10-17T23:49:00.006+01:00

Don't get me wrong I like my job but just lately I feel like I do nothing but work! 4 days off and then back in for an overtime shift on a RRV.

Update on my last 2 night shifts.

Wednesday: 5 patients.

1. Passed as a stroke but was a diabetic having a hypo. We weren't needed as their was a RRV Technician on scene who had given a Glucagen injection. We hung around for a little while just in case the patient needed some IV glucose. She didn't so off we went.
2. Fall, assistance call only.
3. Unconscious, female in a care home. Very pale and blue around the mouth. Her blood pressure was also low and she had a history of chest infections and heart failure
4. Psych/suicide, female who was intoxicated and decided that it might be fun to slash her arm and belly with razor blades. We cleaned her up but she declined hospital. She went off with friends who were going to look after her and take her to the DRs in the morning. They weren't best pleased that she wasn't going to hospital. What can you do? If someone is alert and orientated they have the right to refuse.
5. Chest pain, male in his 30's who had an episode of chest pain. After wasting over 20 minutes deciding whether or niot he wanted to come with us he declined, opting for a lift with a mate. All he was worried about was how he was going to get back from the hospital! I doubt he was having a heart attack, his ECG looked fine and he was too well looking. Anyway he had similar episodes in the past with nothing found and was due a scan.

Thursday: 6 patients.

1. GP admission, suicidal male and at risk of self harm. This was a paranoid schizophrenic that I later learned had a history of violence and assaulting staff! This information wasn't relayed to us with me finding it out by reading the GP letter & notes. I was pissed off to say the least. To top it all the GP failed to refer the patient to the right dept which kept us hanging around at the hospital for ages. The patient was as good as gold and asked me not speak to him on the way in. Fine by me!
2. Fall, elderly female who fell in the morning and now had severe right sided back pain. TLC and a little diesel to get to the hospital.
3. Abdo pain, female with severe abdo pains, occasional chest pain, sob and looking pretty poorly. It all started of with vomiting earlier that evening. Her ECG was horrendous and she was in lots of pain. I managed to get a little bluey into the back of her hand and sort out her pain with some GTN & Morphine. She refused to take any Aspirin. After being seen in resus we moved her down to the coronary care unit where I gave her the rest of the Morphine as her pain started to return. This saved the staff a job as I already had it with me and they didn't need to go to the drugs cupboard and draw it all up. My suspicions of a heart attack were right. Her ECG showed Left bundle branch block (LBBB) and as she had no apparent cardiac history I assumed that this was a new cardiac event. The problem with LBBB is that it basically blocks the view of the left side of the heart making it a bit more tricky to diagnose a heart attack. A proper job!
4. Fall, regular dementia patient with very minor abrasions, the staff admittedly panicked on this one. We left him there.
5. Fall, intoxicated female who fell with someone landing on her arm. This was an obvious dislocated elbow. I screwed my face up like a bull dog chewing a wasp and said to my self 'Shit, that's gotta hurt.' I gave her 10mg of Morphine with gas & air which completely knocked her out for the journey. We have to be extremely careful when administering Morphine to patients that are under the influence of alcohol as they can both depress the central nervous system and lead to a patient who is no longer breathing. We had no problems as I gave it nice and slowly. At A/E resus the DR gave another 10mg of Morphine, I thought I was brave giving 10mg to begin with but she clearly needed it. The nurse said wait till she has some Midazolam then and we'll put it back in. Another proper job.

6. Unconscious, young male who work up suddenly, fell out of bed and bumped his head. He was all panicky that he had a brain abscess, something which he had a few years back. I wasn't convinced with this job but I guess you had to be there. He decided to see his own GP when they opened.

2008-10-15T13:35:00.002+01:00

Tuesday: 3 patients.

What a contrast from Monday, only 3 patients! Having said that we had 4 RRVs and an ECP running around taking some of the heat off of us. And only an hour of standby, great!

1. Fits, male with a history of epilepsy who had suffered a small seizure whilst out shopping in town. He was on floor and conscious but a bit dazed. All he wanted to do was go home and sleep it off so after checking him over we took him home, which was only about 500 yards away. We then contacted his GP surgery with a view to them reviewing why he was having more and more seizures.
2. GP 999, male with post operative hernia problems had visited the GP who decided he needed to go to A/E. There was a technician on a RRV on scene who after giving us a handover said that he would of taken the patient to A/E but the Dr thought it would be more comfortable for the patient to lie down. The hospital was half a mile away and it took my crew mate longer to fill out the clinical report form than it did to drive to the hospital and off load the patient!
3. SOB, female with Emphysema who had been seen by a GP an hour earlier at home. As we looked at the GP's note it said in the top left corner 'Advised to dial 999 if gets any worse'. I asked if her breathing was this bad when the Dr was there to which the husband replied 'Oh yes.'
I couldn't believe it so I told them that next time it gets this bad just to call us straight away. The lady was really struggling so we needed to move fast. My crew mate gave her a salbutamol and atrovent nebuliser while I was securing an IV line, the last patient I went to like this ended up having seizures and going into respiratory arrest. I didn't want to take any chances. On the way in to hospital her condition improved with the treatment so we took her down to the medical assessment ward but within a few minutes her breathing started to become worse again. 'Over to you then' I said to the staff. The lady still managed to thank us for what we did and then blow us a kiss and wave us goodbye.

Oh well another couple of night shifts to contend with next. I'm not the biggest fan of night shifts as I personally think that the quality of work isn't the same as during the day. Some may contest that fact but all I can do is go on personal experience.

Oh dear

2008-10-14T23:37:00.000+01:00

I don't know what to say really!

2008-10-14T07:40:00.002+01:00

Monday: 7 patients.

1. Fall, female who had fallen down the stairs of a double decker bus as it was pulling away. She was conscious and alert with an obvious head injury that had been bleeding briskly. The usual c-spine precautions were taken. When at A/E her head started to bleed again quite heavily and she ended up in Resus.
2. Dr's 999, male in his 40's at a GP surgery. One of our RRVs was on scene first and when we arrived the patient was on O2, had a line in with some fluids running. The Dr queried an upper respiratory tract infection (URTi) and had administered 1200mg of Benzylpenicillin. I couldn't work out whether the GP had used the RRV guy's drugs or his own as the RRV's drug bag was in the treatment room. The patient was in a bad way with a pulse rate of 140 and a temperature of 39.0, he was septic and also in a lot of pain. The DR said asked if we could give him some morphine and another litre of fluid on the way in which is what we did. We have to be particularly mindful of the airway in these types of patients, even the Dr suggested we may have to nebulise him with Adrenaline if he deteriorates. The patient was so poorly he ended up in Resus and then eventually he was intubated and taken to intensive care.
3. Fall, female in a care home. Was is it a simple trip or was it a collapse? No one knew. She had a couple of lacerations to her wrists and a nasty one to her lower leg with her ankle also being considerably swollen. Monitored, wounds dressed and a bit of TLC en route to hospital. She was discharged a couple of hours later.
4. GP Urgent journey, male with a history of recent bladder operation had suffered post op complications. The Dr had seen him at home and deemed it nessecary for him to be admitted.
5. Abdo pain, female college student with what initially sounded like appendicitis. We were only 2 minutes from the hospital so one rounds of base line obs and some gas & air for pain relief.
6. Cat A convulsions, female well known to us standing in her doorway who said she couldn't cope! Inside she had an 8 month old baby which I spent nearly an hour playing with, having a young one myself I was in my element while my crew mate was busy on the phone arranging social services and getting things sorted. She stayed at home and when her mum turned up she gave her daughter a right roasting because she didn't call her first. I would like to know where the Cat A came from seeing as it was the patient who made the call!
7. RTC car into a hedge, a middle aged man was shunted from behind at high speed and ended up being pushed up an embankment into a field which was 8 feet higher than the road. The other driver tried to do a runner but was caught by police. He had been drink driving and had no insurance or MOT, his excuse was that he had an argumant with his girlfriend and was going round to see her as she said she was going to kill herself. Our patient declined transport, against our advice, despite having neck discomfort. 'I feel fine lads, if I'm not good in the morning I'll pop up to A/E myself.'

Bread and butter stuff really, overall not a bad days work.

Business as usual

2008-10-11T22:12:00.004+01:00

After last weeks trauma it was business as usual. Here is a round up of my last three day shifts.

Wednesday: 7 patients attended.

1. Unconscious, female in a care home who had been deteriorating over the last few days. Although she was unco she was maintaining her own airway but had very low blood pressure. High flow oxygen, IV fluids and a pre alert call to the hospital.
2. Unwell, male with lots of medical history who had been vomiting blood and passing bloody stools. All obs fine and relatively well looking. Transported to hospital for further tests.
3. Hemorrhage/lacerations, 15 year old female with a cut to her hand. After spending all of 2 minutes on scene dressing her hand and convincing her that she wouldn't loose it we took her to the local Minor injuries unit.
4. Neck pain, 8 year old on holiday who was on a water ride and was shunted by a boat. His pain had just about disappeared by the time we got there. He was more upset than anything. Mum and dad happy to look after him.
5. Deceased, male not seen for two weeks with flies at the windows. Police already on scene and broke in when we arrived. RIP.
6. Fall in the street, elderly female who had slipped on the kerb sustaining a nasty gash to her eye. TLC and taken to hospital for proper wound care.
7. Diabetic , male having a hypo at home. His wife had tried to give him lucozade and milk with sugar but he was getting worse. After popping a 18g IV in the back of his hand and giving him 100ml of Glucose 10% he was right as rain. Although when he came round he looked at our name badges twice and rubbed his eyes 'Oh I haven't had one of them bloody hypos again, have I?'. 'Yes you have!' said his wife, 'He's gets all silly when he goes low and there's nothing I can do!' she added. Nice couple and a nice job to round the day off with.

Thursday: 5 patients attended.

1. Fall, non-injury. Assistance and advice only. Not transported.
2. Chest pain, 999 call from a local DR's surgery. Female who had suffered chest pain for the last couple of days. Already on O2 and had Aspirin and GTN before we arrived. There was nothing on the 12 lead ECG and as she still had some tightness we gave her some more GTN. We took her straight to the medical assessment ward.
3. Headache, male with frontal headache which came on gradually, assessed at home with advice given. His wife had given him 2 paracetamol about an hour earlier which had kicked in while we were there. His wife said she panicked and wasn't sure if he was also suffering from one of his 'panic attacks'. Nice couple and very grateful as well as apologetic.
4. Chest pain, another female who had been having chest pain for several days! Two community responders were on scene when we arrived. We gave her O2, Aspirin and GTN which seemed to help slightly. She said to me that they have terrible trouble with her veins at the hospital. 'Right then, that's a challenge.' I said. I couldn't see any veins or really feel any but I managed to get an 18g in her right ACF and draw off 4 tubes of blood. I was pretty impressed even if I do say so myself. Careful, I may not get through the door if my head gets any bigger. Ha Ha. Knowing me I'll mess up an otherwise easy one next time.
5. Passed as a fall but turned into some thing a bit more interesting. We managed to find the location which was an alley way, after stopping at the wrong one up the road, DOH! Male in his 50's, he was a council worker who had fallen into bushes and thought he had been stung by nettles until he reached down and felt a metal spike sticking out of his leg. When we arrived he was in great pain but in good spirits. His work mates thought it was highly amusing, he was their boss. After putting a built up dressing around the spike to stop it from moving we got him onto the trolley and then onto the vehicle. He drained a bottle of Entonox (gas & air) and received 5mg of IV morphine. When we wheeled him into the A/E dept he became the centre of attention for the afternoon/early evening.

Friday: 5 patients attended.

1. Breathing problems, regular male caller. COPD (chronic obstructive pulmonary disease, such as Bronchitis or Emphysema) who was using his own nebuliser when we arrived. We gave him some salbutamol and atrovent using our nebuliser mask and O2, his mask was pretty naff so we left him one of ours. His breathing had eased after our treatment and he refused to go to hospital so we called his DR's surgery to arrange for a home visit.
2. Fall, male with Parkinson's who had sustained a head injury some time during the night but couldn't remember it. He made a good job of demolishing his sink unit when he fell. Collapse query cause, he had to go in. There was a Community responder on scene before us who had gathered all the patients meds and history for us.
3. Fall, female on a bus who had twisted her hip when the bus started to pull away without warning. She had an obvious NOF (neck of femur fracture/hip fracture). Her leg was shorter and was externally rotated, no need for an X-Ray it was that obvious. She was really calm and kept repeating her self stating that she was so angry with herself. She declined any analgesia.
4. DR's urgent admission, we were sent to another station 30 miles away for a bit of stand-by when we got this urgent job. When we arrived at the address my crew mate opened his door and before he could step out of the truck a male in his late 70's came out of the house with a holdall, strolled over to the truck and asked 'Where do I sit?' TAXI! I thought to my self. We had to take this patient to a hospital that neither of us had ever been to before and after being passed from pillar to post by various staff we finally got him to where he was supposed to be. Just a 40 odd mile drive back to base. Fortunately we didn't get any calls on the way back.
5. DR's 999 from a local surgery. Two Emergency care Practitioners were there and handed the patient over to me. Male in his 70's who was sweating profusely and had a high temperature. All his obs were fine and after an uneventful journey he ended up in A/E.

Weekend off but back in Monday to Thursday for a mixture of day and night shifts.

They say they come in 3's

2008-10-09T12:01:00.003+01:00

Over the last week I have attended three horrendous RTCs. The first two happened at the exact same spot but on different days. Both cars were a complete write off with the engines ripped from the cars landing about 50 yards away on each occasion. How on earth anyone got out of the alive is nothing short of a miracle. Neither patients were trapped and both were out of their respective cars on our arrival. The first guy had some chest pain but was said to be fine at hospital. He had been working 7 days a week for the last few weeks and was clearly worn out, he went on to tell us that he feared being fired if he didn't put in the hours! In the UK we have laws that prevent people having to work excessive hours, his boss obviously wasn't up to speed with them. We thought he might have fallen asleep at the wheel.
The next lad, who had only passed his test six weeks ago, was only a teenager and after being questioned by the police officer on scene it was discovered he had been drinking needless to say he failed his road side breath test. Why do they do it? This car was actually slightly worse than the first and it was only due to the car being modern and with lots of airbags etc that he survived. I don't think he'll be driving again for quite a while
The third accident was to a car that had gone side on into a wall, the patient was also a teenager. This was a lot more serious. Fire & Rescue were on scene along with police and another Paramedic crew. No time for the roof to come off, this was a rapid ex job. Rapid ex is a way of extricating someone from a vehicle who has life threatening injuries but using very basic c-spine care. He was on O2, had an oral airway in situ and a c-collar on. With the help of the firefighters we got him out onto a long board and then started assisting his breathing with a BVM while quickly wheeling him to the truck. On board he was hooked up to the monitors, while the other Paramedic was ventilating him, I got a 16g IV in his right arm and started fluids. We had a Basics Dr attending as well who is an anesthetist at the local hospital and as he arrived I put in a 14g IV into the patients chest to decompress it. After explaining what we had he said 'Right, let's RSI him and then I'll do bilateral thoracostomies.' 'OK Doc.' we said and that's what happened. We weren't on scene long and raced this young lad to hospital. Sadly he lost his battle to survive a few hours later in the operating theatre.
Some times people who are badly injured are so far down the dying line that no matter what you do it's just not enough.