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The Complete Blood, Sweat and Tea
Tie in a hyperventilating adult, a 14-year-old with hay-fever and a drunken Colles’ fracture and you have a pretty good night.
We had one serious job, someone who had a CVA (a CVA is a ‘stroke’) on a train. The CVA wasn’t so much the problem as the extrication of the patient, who couldn’t move, and yet was combative with his unaffected side. To start off, the space between the seats on the train was not large enough to allow our carry-chair to pass. The man was large and heavy so we basically had to manhandle him (in a very undignified manner) through some connecting doors and out onto the platform. The train station has a big flight of stairs towards street-level and only one lift, and the lift was not on the platform we were on. It would have been unsafe to carry this man up the stairs because of his weight and combativeness. In a rare spark of genius I realised that if we waited for a district line train we could carry him through the train onto the other platform. We ‘blued’ him into hospital as his pulse-rate was 40 (should be 60–100).
When I went to see the patient later in hospital he had started to regain his speech and wasn’t confused. He was about to go for a CT scan so, with a bit of luck, he might make a good recovery …
This is just another part of the job that I like – that sometimes I have to out-think problems. I can’t see me doing this in an office job.
There is something that I’ve learned over many years of health-care work. When you are lifting little old ladies with senile dementia, they will sometimes grab you by the testicles.
And squeeze …
This hurts.
I swear, the greater the degree of dementia, the greater the accuracy and the stronger the grip.
And for the love of all that is holy …
Don’t drop them.
That hurts even more …
When I went to the Clap Clinic for my HIV test, I was referred to a ‘Health Adviser’, which is a new name for Counsellor. I am, as regular readers may appreciate, a fairly simple, pragmatic person: within hours of my HIV exposure I was aware of transmission rates, odds of infection and the rates of death caused by electrocution (1 in 5 000) and shooting in America (1 in 2 500). So, to be honest, counselling was the last thing I needed.
I did a counselling course when I was a nurse, and it did nothing to disabuse me of the notion that all counsellors are hippies who consider themselves ‘worthy’.
She asked me a load of questions about how I would cope if I were to be found HIV positive (answer: get over it), and cautioned me not to tell anyone I was testing, unless I was happy for them to know the result (answer: the whole world could know – if they read this site). There was some other stuff that is just too dull for words, and definitely too dull to read.
The thing that amused me the most, however, was not that the ‘Advice Room’ had the only comfy chairs in the place but that the counsellor was wearing a sari (the Indian dress). In and of itself not unusual, except that the woman wearing it was ‘whiter’ than me.
I’m well used to ‘white’ women wearing various Muslim dresses – it’s a religion after all – but as far as I’m aware a sari is a cultural thing. I’m guessing that in her ‘equal-opportunities, worthy, multicultural’ world that she is proving how non-racist she is. This is handy because to be honest out of the 20 or more people at the clinic I was in a race/culture minority of one. Not a problem, I know Newham well … it’s very diverse, but I wonder if Asian people would be impressed or nonplussed by her wearing a traditional Indian dress?
Maybe I should start wearing nothing but a Papuan penis sheath?
The HIV test result should be received by the 28th …
I’ve tried as hard as possible to make this sound as non-racist as possible – at no point have I meant to cause offence. I hate no ‘race’ more than another – I hate them all.
‘I hate them all’ – a philosophy to live by.
Our second call of the day was to an address where the elderly woman who lived there was believed deceased – the neighbours had called the police, and the police had called us. What this often turns into is us struggling to gain entry to the house, normally resulting in an injury to me, only to find someone who has been dead for some time.
We rolled up to the house and met with the neighbours who led us around to the back garden where, peering through the rear window, we could see the old woman sitting in her chair looking pale, still … and very dead.
Simultaneously, my crewmate and I jumped back in shock as we saw her take a breath!
She was breathing about six times a minute, and surely didn’t have much longer left to live – I rushed around the front and kicked in the front door (in one hit – something I’ve never managed before) and we got her out to the ambulance in double-time. We quickly decided that it would be wrong to ‘stay and play’, instead opting to ventilate her via ‘Ambubag’ and to monitor her cardiac rhythm and her pulse (which was strong and regular).
The hospital had a team standing by, as we had notified them of the patient on leaving the scene. The transport time to hospital was about 2 minutes, and on arrival the A&E team leaped into action, intubating and ventilating her, gaining venous access and running the various blood tests. Family members were contacted and plans for her treatment were drawn up. At no time did I feel that this 88-year-old woman was receiving anything other than the best treatment possible.
We cleaned the ambulance and restocked before going onto our next job; each time we returned to the hospital we popped our head into the Resus’ room to check how she was doing; there were plans to CT scan her head and to move her to ITU (intensive treatment unit). The family arrived and after some discussion it was decided that the best care for her was going to be palliative (that is to make her comfortable, but not to do any invasive procedures and to allow her to die). This was, I feel, the right course of action – the lack of oxygen would make any survival short and probably result in serious brain damage.
It has been a very long time since I’ve felt a great deal of sympathy towards someone, but this was one patient that I did actually care about, and not just because I’m soft on ‘little old ladies’. She had little chance of recovery, but we hoped for it anyway. She fought for her life, and had probably been doing that for the whole of the night. Because of our actions, and the actions of the hospital team, she wasn’t going to die alone, and she wasn’t going to die without her family saying a final goodbye to her.
It’s a small victory, but sometimes those are the only ones you get.
Yesterday we got a call to a 27-year-old male, diabetic having a fit. It was only 4–5 miles away, but travelling through Newham on a Saturday afternoon is always slow business – this was compounded by one of the roads which we use as a shortcut being closed for resurfacing. It took us 14 minutes to travel those 4 miles. Then it was up 5 flights of stairs into a flat where the first thing we could hear was hysterical sobbing. As I’ve mentioned before it’s one of those sounds you know means trouble.
Squeezing past a large bed we entered the bedroom to find a First Responder ‘bagging’ the young man, who was lying motionless on the floor. Sitting on the bed wailing, was a young woman who we discovered later to be his fiancée. The patient was connected to one of our cardiac monitors and it was showing sinus rhythm. Kneeling on the floor I did a quick pulse check – beat, beat, beat … then nothing, no pulse for 10 seconds. During the pulse check I was getting a history. Apparently the patient was an insulin-dependent diabetic, who had possibly been neglecting to take his insulin injections. He had become more agitated during the morning until he collapsed and started fitting after having an argument with his fiancée.
With a monitor showing an apparent sinus rhythm the patient was in ‘pulseless electrical activity’ – we can’t ‘shock’ this rhythm so I started CPR. From out of his mouth flew some bloody saliva, straight towards my face, luckily impacting on my forehead rather than ending up being swallowed (I don’t want to make that a habit).
One round of CPR (3 minutes later) and we got a pulse – the patient started ‘cramping up’, all his muscles had gone into spasm. A very quick blood sugar measurement reading showed ‘HI’ (a reading of over 32.0 mmols of sugar – the normal is 4–7 mmols). Immediately I started thinking of DKA (diabetic ketoacidosis) – a condition that occurs when blood sugar goes too high – a life-threatening condition that could explain his cardiac arrest. There was little that we could do on-scene as he needed immediate medical treatment beyond what we could provide.
With a ‘Load and Go’ order my crewmate set up the chair and the three of us dead-lifted him over the bed that was blocking the door and into the chair – I felt the familiar trickle of urine down my leg and looking at the patient he seemed to lose all colour. Another pulse check followed – his heart had stopped again.
I had to make a decision then: would we start CPR again only for him to continue this cycle of pulse/arrest, or do we make a run for the ambulance – all the time starving his brain of oxygenated blood – so that we could get him into hospital to correct the cause of his arrest?
I decided that we should ‘run for it’: if we got a pulse back it would be a purely temporary measure until his high blood sugar could be corrected. It was a very difficult removal – my back was spasming as we carried him down the 5 narrow, dark, winding flights of stairs and ran him across the 100 yards of pavement to our ambulance. Throwing him and his fiancée in the back of the ambulance we started the long run back to the nearest hospital. For 10 minutes I did CPR in the back of the ambulance while my crewmate tried his best to get through the exceptionally busy traffic – stopping and starting, swerving across the road, over pavements; he drove to the limit.
Throughout transport the only rhythm we had was ‘asystole’, which is when the heart isn’t beating at all. With our First Responder ‘bagging’ him and myself doing CPR we were doing all we could to support his life. During the transport the fiancée told us that he had had a previous arrest when he had stopped taking his insulin, but that he had, obviously, recovered.
Rolling up to the hospital we were met by the ‘Arrest Team’ – senior doctors from across the hospital. They descended on the patient, trying to get IV access, a secure airway and running diagnostic checks. It seemed, however, that the team leader didn’t want to listen to our handover. I was later told that he was concerned about getting the audit times right. The first thing he said was ‘the patient is biting on the airway’ suggesting that the patient wasn’t actually in cardiac arrest – because he hadn’t listened to my handover he didn’t know about the cramping episode earlier. The hospital staff did their own ‘pulse check’ and were confused about feeling a pulse (in a stressful situation doctors often feel their own pulse rather than the patient’s). It was only after some time that I could actually give the team leader a complete handover that he paid attention to.
The team worked on him for over an hour. His blood tests showed that his potassium was a sky-high 7.5; this was probably the main cause of his arrest. It transpired that the patient had renal failure and the high potassium and high blood sugar probably meant that the normal biochemical reactions in the body were being interfered with, leading to his fitting and cardiac arrest.
One hour later the patient was declared dead.
His fiancée was distraught; the patient’s parents had to travel 170 miles to the hospital and so it was necessary to tell them what had happened over the telephone – I can only imagine the drive down to London. The fiancée was convincing herself that it was her fault, that it was the argument that killed him, or that she should have recognised his symptoms of a high blood sugar before they became fatal. Both I and the nursing staff tried to console her, to tell her that it wasn’t her fault – but would the parents blame her?
I was thinking, would he have survived if we had remained on scene longer? Was making a run for it the right decision, given that I knew we had to carry him down the stairs? Would he now be alive if he had lived in a house rather than a flat? Did he die because he was an ‘angry young diabetic’ who didn’t want to comply with this treatment? He did have a history of taking an insulin overdose 2 weeks before.
It was a bad job, travel time was longer than it should have been, the flat was awkward to reach, it was difficult to remove the patient and the return journey to hospital was too long. It could have gone so much better. Although the patient might still have died it would have made us feel better. The job has left my crewmate and me a little depressed. Two deaths in as many days, one a ‘victory’, the other a real loss. I have today off so I’m going to relax and prepare for the joys of a night shift tomorrow.
One question for my medical readers: in the same situation would you ‘Stay and Play’, or would you ‘Load and Go’?
I got a couple of replies to the question above when I originally posted it online. The best was a mnemonic that I have taken to heart: L.A.T.E.R (Load And Treat En-Route). I don’t want to fool around on scene with a sick person who needs to be in hospital.
I’m feeling a bit fragile at the moment – these nights are really taking it out of me for some reason. I think the main thing that is getting me down is that I should be getting my HIV test result on Friday; as predicted, I haven’t been worrying for the past 3 months (is it really that long ago?) but with the result due, it is sitting at the back of my mind nagging away. I’m confident that I’ll test negative – even so I have the framework for two blog posts, one Negative, and one Positive.
Either way, I think I’ll be having a drink or two after I get the result.
At the moment there is some confusion about how I actually get the result. The receptionist at the clinic didn’t know if their telephone text messaging trial was still being used – I suspect that on Friday I’ll hang around the ambulance station after the end of my last night shift and then walk down to the clinic and get them to give me the result at 9 o’clock. It would be cruel to make me wait until after the weekend …
… So it’ll probably happen, or they will have lost the sample or something similarly evil …
Tonight, the only job to really stick in my mind was a ‘purple plus’ (someone who has died and is beyond our help because of the amount of time they have been dead). It was an 85-year-old female who died, leaving behind her husband of nearly 70 years holding her hand. A very sad job, he was putting on a brave face, but I think later today it’ll sink in. Hopefully, his son will be with him when it does.
So, dear readers, the next update to this blog (unless my leg drops off) will be after I get my HIV result; I’m not in a frame of mind to write anything legible at the moment (as I’m sure you have noticed). Hopefully, my next post will be Friday, but I’m a strong believer in the inherent evil of the Universe … so I’ll talk to you on Monday.
Yep, the title says it all: the HIV test is negative, the syphilis test is negative and hepatitis tests are negative.
Needless to say I am so far beyond ‘relieved’ as to be numb with it all.
I spent the last 20 hours awake, first at work, then in the ‘Clap Clinic’ waiting room; I now think I deserve a deep relaxed sleep.
Goodnight, I’ll write more when I wake up …
Posted at 11:13 a.m. local time.
Well … I’ve had some sleep so I can now post in a slightly more focused fashion.
First off, thanks again to everyone who has shown support, either through the comments box, or via personal emails – it’s all gratefully received. It looks like I’m going to have to find something else to die from now.
Tomorrow my brother and I shall be going for a nice relaxing drink, the first proper pub visit in over 3 months – there may well be a hangover involved.
I only had to wait 45 minutes at the ‘Clap Clinic’ for the test result – pretty hard to stay awake, but I think the emotional numbness that comes with exhaustion only helped me deal with the wait. The ‘consultation’ was over in less than 15 seconds: led into a room, asked to sit down and then told by a shaved-head counsellor that everything was fine. I didn’t have a massive flood of emotion (possibly owing to the aforementioned exhaustion), but afterwards I sat on a stone outside the hospital, rang my mum and brother, text messaged my old crewmate and breathed a sigh of relief. (Old crewmate told me that I had to go and repopulate Newham – something I don’t think I’ll be doing quite yet …)
I didn’t sleep well last night – I think a total of an hour and a half – so if I’m a bit incoherent I’d like to register that as excuse number one. No real reason for the lack of sleep, it’s a disadvantage of rotating shifts that every so often your body clock just throws up its hands in despair and goes to sulk behind the sofa, leaving you suffering insomnia and/or intense fatigue.
Last night was actually quite pleasant. The first job of the shift (at around 4 p.m.) was given as an 80-year-old male collapsed in the street. Making our way there we were beaten by not only the police and fast response car, but also by a Duty Officer who had taken an interest in the job. It turned out to be a drunken Russian, actually in his early fifties, who had decided to lie down and sleep it off in an alley. I suspect he was very surprised when he woke up to find himself surrounded by three police officers and four ambulance bods of various ranks. He was a pleasant enough fellow, who didn’t speak a word of English, so to be on the safe side we loaded him onto the ambulance and took him to sunny Newham hospital. When we got there (and remember that this is around 5 p.m.) the crew before us, and the crew who followed us, both had people who were worse for wear for drink. Luckily for both our patient and the hospital a Russian nurse was working, so he could translate that the patient had indeed just drunk too much and would very much like to be left alone so he could go home. I’m always impressed by people who can speak another language, two people talking what sounds like utter gibberish, yet making complete sense to each other never fails to entertain.
When taking this gentleman to hospital I drove past six known drunks in the space of one street. Alcohol and alcoholism is a big blight on our society. On some shifts the only jobs we have are those influenced in some way by alcohol. Most assaults can be attributed to alcohol, frequent callers (sometimes 6 times in one day) are very often alcoholic, and the amount of ‘collapse ?cause’ jobs that turn out to be drunks is frankly astounding.
My personal view (and not the view of the LAS by any means) would be to prohibit alcohol, but legalise cannabis. Not only would it cut our workload by, at my estimate, 60–70%, but I’ve never had anyone high on cannabis try to hit me. Cannabis users are very rarely violent, tend to be generally easier to handle and seldom get loud and annoying. It’s true that there are long-term health consequences, and that heavy ‘stoners’ can waste their life away, but the same holds true of alcohol and alcoholics.
On the rare occasions that I get called to someone on cannabis, it’s normally because it is their first time and they feel ‘dizzy’. Often a pat on the head, and an explanation that this is what is supposed to happen is enough to calm them down, and they will rarely require a trip to hospital. Because the intoxicant effects are fairly self limiting, people tend not to overdose on cannabis, unlike alcohol (which is why you find drunk people collapsed in the street).
There is one problem with the use of cannabis – I’m never sure what to call it in order to sound ‘hip to the kids’, the slang just befuddles me. Is it ‘green’, ‘pot’, ‘hash’, ‘reefer’ or ‘draw’? At least alcohol is just ‘booze’.
And now the government has made it even easier to get hold of alcohol with extended ‘open hours’. Oh well …
(What I’m going to post about might come across as being heartless, or myself being lazy – I don’t think I’m either of them, but if you disagree with this post, as always, feel free to visit the blog and leave a comment.)
Tonight we got called to a residential home for an 87-year-old female with ‘difficulty in breathing’; once again it was way out of our area of coverage, but we made good time to get there. I’ve been to this home before, and it is one of the better ones I’ve visited; the residents are always clean, and appear well looked after. The care staff know their ‘charges’, and are always friendly, helpful and courteous towards ambulance crews.
I knew there was something wrong from the face of the member of staff who met us. She had a look of total concern, and I don’t like to see that look on someone’s face – it never bodes well. We went through the clean corridors and busy lounge of the home into one of the residents’ rooms. There were three nurses there, one of whom was crying (something I don’t think I’ve ever seen before); lying in the bed was a little old lady who was extremely close to death. Her pulse was weak, and thready, something I could have guessed by the patient’s colour. I very quickly told the staff that, yes, she was extremely ill and that she would have to go to hospital unless she had a ‘Do Not Resuscitate’ order. The staff said that it would be best to take her to hospital. We scooped her up, and her heart and breathing stopped in the lift to the ground floor.
I don’t believe in a ‘slow blue’ (where CPR is performed by ‘going through the motions’ knowing that the patient will not survive and that the CPR is for the benefit of the relatives), so I started active, aggressive treatment while my crewmate drove us the 5 minutes to hospital. The patient remained in asystole (no heart activity at all) and on reaching hospital the doctors there declared her dead.
I may have previously mentioned the study that showed that ‘out of 185 patients presenting with out of hospital asystole arrests, none survived to be discharged’. Both my crewmate and myself – and the hospital staff – knew that this patient had no chance of survival and that the reason we started CPR was because of our policy to commence resuscitation except in certain tightly defined circumstances.
