Collapse in the street

I’ve just noticed that most of my anecdotal blogs seem to end in tragedy.  Just so people don’t get the wrong idea about me and my paramedic skills I thought I’d include this one which has a HAPPY ENDING!

It was a Saturday afternoon, Tony and I were just over half way through our day shift.  Through the morning we had drifted further away from our normal area and were in a neighbouring town.  We were on our way to the next emergency when a category 1 emergency jumped the queue and was passed to us – a 45 year old female had collapsed on a street and was in cardiac arrest.  Luckily a bystander who saw her collapse was first aid trained and recognised cardiac arrest and started CPR immediately while other bystanders called 999.

It didn’t take long to get to the general area, a pedestrianised street of shops on the edge of the town centre.  We were lucky; the lady had collapsed conveniently near an access road so we could get the ambulance near.  As we arrived a response car arrived too, a local paramedic, Steve got out joining us.  We took a mixture of our and Steve’s equipment to the pavement where the lady, Amy, was lying on the pavement with a first aider, Carol, doing CPR.  A local shop keeper had thoughtfully brought some screens out and arranged them round Amy to give some privacy.  I asked Carol to continue with chest compressions while we prepared our equipment.  Tony connected the Bag-Valve-Mask (BVM) device to an oxygen cylinder. A BVM is a rugby ball shaped rubber reservoir connected to a face mask.  The mask can be placed over the patient’s mouth and nose, then the reservoir is squeezed and this forces a lungful of oxygen-enriched air into the patient’s lungs.  He inserted a basic airway into Amy’s mouth, a small plastic tube which prevents the tongue from blocking the airway and took over the job of breathing for Amy as carol continued chest compressions to keep the blood circulating.  Steve and I were preparing the defibrillator – we placed 2 large, sticky gel covered electrodes to Amy’s chest.  We could monitor Amy’s heart through these and, if needed, deliver electric shocks.  In the old days we had 2 manual paddles which we had to coat with gel and hold against the chest while we analysed the rhythm and delivered the shocks. The stick-on pads are much more efficient and safer to use.  Amy’s heart rhythm was not one which would benefit from an electric shock (she was in Pulseless Electrical Activity (PEA)).

At this point we decided to move Amy to the ambulance.  We used a ‘scoop’ stretcher (a long board which splits long-wise in half so can be fed under the patient from each side and clipped together with minimal movement of the patient) to pick Amy up from the floor onto our stretcher (gurney) and then onto the ambulance, all the while continuing with chest compressions and breathing for Amy.

On the ambulance Tony took over the chest compressions (Carol the first aider was exhausted by now).  I moved to the head end of the stretcher to monitor Amy’s airway.  She had a basic airway protector in but I intubated her to fully protect her airway.  This involves putting a tube (Endotracheal tube (ET)) into the top of the wind pipe (trachea). The ET has a small balloon around the outside which once in situ in the trachea this is inflated to seal the airway and prevent vomit or other secretions getting into the airway and lungs.  Once this was in place we attached a mechanical ventilator to the projecting end of the ET.  The machine now takes over the breathing for Amy. While I was intubating, Steve was finding a vein in Amy’s arm and had cannulated.  We could now give drugs directly into Amy’s blood stream.  During resuscitation we give the drug adrenaline (also known as epinephrine) every 3 to 5 minutes.  This circulates round the body and causes surface blood vessels to constrict so all the blood is concentrated to the major organs.  We also give fluid, water with salt dissolved in to the same concentration as in the body.

During this activity I thought I noticed a slight flicker of movement on Amy’s face.  This can be a normal part of CPR, we compress the chest quite vigorously and this tends to move the whole body but as I did a pulse check I was excited to feel a pulse on the side of Amy’s neck.  We stopped the chest compressions immediately and checked Amy’s baseline observations.  Now the heart had resumed its duties in driving the blood around Amy’s circulation her baseline observations were surprisingly normal.  Her heart was beating at a normal rate, her ECG (trace of her newly started heart) looked surprisingly normal too. Amy’s blood pressure was good, she was still unresponsive and not breathing for herself but things were looking good.

This was the time to get to the local hospital.  Tony gave the hospital a pre-alert call via our control room so the staff would be ready for us and have time to prepare for us.  During the short drive to hospital I sat with one hand on Amy’s neck feeling the pulse.  She still wasn’t breathing for herself but the ventilator was breathing for her.  We transferred Amy to the care of the Emergency Department staff and then began to tidy up and make a list of the equipment we needed to restock (over a well earned cup of coffee).

Over the next few weeks we were happy to hear that Amy progressed from Intensive care to a general medical ward and was finally discharged to home having made a complete neurological recovery.   The key to Amy’s survival was the immediate good quality CPR provided by Carol, the first aider.  No amount of work by us will resuscitate a person who has been down with no CPR for the 5 minutes or more that it takes us to get to the collapse.  I can’t stress enough the respect I have for first aiders and feel that everyone should learn basic CPR – it really can make the difference between life and death.

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