Child cardiac arrest

Warning:  this is a grim post with a tragic ending – some of you may find it distressing (I do).

Tony and I were on a day shift.  We were in good spirits; it was our last day shift before our shift break so we were both looking forward to a few days rest.  We cleared from a job at one of the local hospitals, time was passing and it was nearly the end of our shift.  We still hadn’t had our rest break and were ‘out of the system’ meaning control had to return us to our base for twenty minutes.  The radio bleeped which tells us control are about to speak to us.  I expected it to be them telling us to return for our rest. I was wrong.

“Guys, I know you’ve not had a rest break and I hate to ask, but, I’ve got a 3 year old child in cardiac arrest.  I’ve got another ambulance running but we need to use you too…”

One of the improvements to the ambulance service recently is our management of cardiac arrests.  When I first started, a single crew would be sent to a cardiac arrest and would be expected to perform CPR, Advanced life support then transport to a local ED – too much for a single crew to achieve properly. Now the service sends at least two ambulances to each cardiac arrest.  When it’s a child they send at least two ambulances and normally senior staff in cars to help too.  A child cardiac arrest as well as being more emotionally taxing is more complex.  Drug doses and fluid volumes have to be reduced according to the weight of the child.

We arrived onto the street a few minutes later. As I pulled onto the street another ambulance was already parked outside the address.  A senior paramedic, Joe, arrived in a car just behind me.

I saw the paramedic, Andy, from the ambulance carrying a child onto his ambulance.  I went straight onto his ambulance and saw that Andy had already connected the defibrillator and was doing chest compressions.  He quickly told us what had happened when he went in the house; the child was lying on the floor in cardiac arrest (no breathing and no pulse) in a pool of vomit.  Mum and auntie were obviously distraught and screaming – Andy made the decision to move straight to the ambulance so we could treat the child, Naz, more quickly.

I went to Naz’s head to clear his airway and start to ventilate his lungs.  His mouth was full of vomit so we quickly turned Naz to his side to empty his mouth.  Then I inserted a small tube to keep his tongue free of his airway, but his mouth immediately filled with vomit again.  I used the suction machine to clear his mouth and decided to intubate.  This involves inserting a plastic endotracheal tube (ET) tube into the patient’s mouth and through the vocal chords into the top part of the trachea.  Once in place vomit can no longer block the airway or sink into the lungs.  I connected a bag ventilator to the protruding end of the tube and was able to breath for Naz.  While I was doing this Andy was continuing with chest compressions.  Part of the procedure for resuscitation involves regular doses of adrenaline (epinephrine) into the blood stream.  With a child it is quicker and easier to get intra-osseous (IO) access than intra-venous (IV) access.  This sounds brutal but is quick and effective – a drill is used to drill into a long bone in the leg or arm and a cannula is left giving access to the marrow space within the bone.  This leads directly into the blood stream for drugs and fluids. While I was intubating, Joe was getting IO access and started the drug therapy.  Tony was assisting each of us as we needed and trying to reassure Naz’s mum while at the same time getting some details and general medical history.

We were ready to go to hospital.  We all decided to travel in the ambulance to assist with on-going resuscitation on the drive to the ED.  This meant leaving our ambulance and Joe’s response car on the street to be collected later.  We just had to hope they would still be there and not vandalised when we got back later.

The journey to the ED seemed to pass very quickly with me ventilating Naz, Andy compressing his chest and Joe periodically giving a dose of adrenaline (epinephrine).  Tony was in the back with us too trying to comfort Naz’s mum and get some basic details for us for when we arrived at the ED.  Andy’s mate, Jack was driving.

When we arrived at the ED Andy scooped Naz up in his arms to carry him into the resuscitation room (much quicker than using the tail lift and wheeling the stretcher in). I followed a step behind with the bag-and-mask ventilator still attached to the end of the ET tube protruding from Naz’s mouth.  The resuscitation room was crowded with the receiving medical team – anaesthetist, consultant ED doctors and several junior doctors plus a range of ED nurses – they were pulling out all the stops for little Naz.  The team listened to our handover as they took over the resuscitation.  We stayed a while to watch. It may seem a bit strange that we hung around just watching but that type of job is hard to just walk away from – we wanted to see if the medical staff could pull off the miracle that we hadn’t been able to and restore life to Naz.

Sadly after nearly an hour of effort they had to tell Naz’s mum (and dad who had arrived at the hospital now) that they weren’t able to resuscitate Naz.

A few days have passed and I’ve managed to process things.  Typically with me for a couple of days I tend to ruminate on jobs, playing them over and over again in my mind wondering if I could have done anything differently.  I can’t imagine the pain and suffering that the family are going through now and feel for them.  I don’t suppose mum and dad will ever forget or get over that day.

The less serious side of emergency care work

There’re a lot of serious issues in the world today, especially in the world of the emergency services so I’ve decided to take a light hearted look at some funny episodes I’ve encountered over the years.  No one was seriously harmed in any of these jobs and everyone involved saw the funny side of the event at the time so I’m not laughing at peoples misfortunes, I’m laughing with people at their own misfortunes, so that’s ok!

  1. At a Halloween party one guest had a nose bleed and another guest fainted at the sight of the blood. You guessed it, the fainter was dressed up as count Dracula.
  2. All the ambulances have fire extinguishers on them, one in the cab and one in the back where the patients are. They are fixed to the wall in a wire frame from which we can quickly remove them if needed.  This particular day, the extinguisher was stored at floor level on the side wall near one of the fold down chairs.  For some reason the safety pin had been knocked clear and a particularly heavy footed colleague accidentally kicked the trigger and discharged all the foam.  The back of the ambulance looked like an Ibiza foam party after a few minutes and he was covered from the waist down in foam.
  3. A young lady had spent ages working on her hair for a party and had used a large amount of hairspray. She was admiring the finished result and stopped to have a cigarette.  As the lighter sparked, her hair on one side of her head ignited due to the hairspray fumes. All that work, not to mention a significant amount of hair disappeared in a flash.  Luckily her skin was not burned.
  4. I was dealing with a hiker who had fallen down a steep, rocky slope. Due to the possibility of spinal injury from the fall we had immobilised him on the scoop stretcher before moving him onto the ambulance.  He was complaining of a lot of pain from his arm.  It was not possible to take his jacket off in the normal way because he was strapped to the scoop stretcher and also his arm was causing too much pain to move and bend.  The only way was to cut it off.  Sometimes people are more worried about us cutting and ruining their clothes than they are about their injuries.  This hiker had a lovely warm duvet jacket, as soon as the scissors cut into it the feathers seemed to explode out of it.  There seemed to be an impossible amount of feathers crammed into that sleeve, we were finding them in the ambulance for days after.
  5. It was ladies night in a club and a troop of male strippers were entertaining the local ladies. As part of his act one stripper picked up a lady to swing her round. Unfortunately the baby oil she had just rubbed into his arms and chest had got onto his hands to and she slipped from his grip onto the floor straining her ankle.
  6. One young man had enjoyed a night at a club with his friends. When he got home he was hungry.  Looking round his kitchen, he fancied a can of beans.  He couldn’t find the tin opener so to save time his drunken brain thought he would stab the tin open with a screw driver.  One slip later and we were called to tend to the self inflicted stab wound in his hand.
  7. A young lady had spent a boring evening with her boyfriend and his best friend. The friend had called round for a quick drink and was still there hours later while she wanted some quality alone time with her boyfriend. Finally the friend left and as the door shut she leapt into her boyfriend’s arms expecting a passionate kiss at last but unfortunately he dropped her and she sprained her ankle.  She spent the next few hours of quality time with her boyfriend in the waiting room of the local Emergency Dept.
  8. A young couple were trying things to spice up their love life. This particular night they were playing with a pair of toy handcuffs.  Unfortunately when they were finished one of the handcuff bracelets jammed on the man’s wrist and wouldn’t unlock.  The more he tried the tighter it got until the circulation was being restricted and his fingers were tingling.  I managed to break them without hurting him by using a pair of pliers and a screwdriver so he didn’t have to face the embarrassment of sitting in a waiting room at the hospital wearing a pair of toy handcuffs.
  9. A woman was in her loft organising the stuff she kept up there. The loft didn’t have floorboards so she was balancing on the rafters.  She misplaced her foot and stood on the plasterboard between the rafters.  It didn’t take her weight and she fell through to the bedroom below.  Luckily she landed well and didn’t hurt herself.  Unluckily she was disorientated and couldn’t see because of lots of plaster dust which had got everywhere and she staggered to the top of the stairs and fell down them too.  Thankfully the xrays showed that there were no broken bones, just bruising and a big job of redecorating her bedroom to look forward to.
  10. One day we were dealing with a fall and had immobilised the patient on the scoop stretcher.  My mate and I went to pick the scoop up and place it on our trolley.  As I bent and squatted to get in position for the lift, with a loud rip my trousers tore from front to back.  Despite it being a warm summer day I had to wear my jacket to cover my embarrassment until I could get back to base to change.

 

Death – the elephant in the room

Warning: this blog may be distressing to some.  It’s not particularly graphic but I talk about death and describe a patient dying peacefully.

Death here in the UK still seems to be a bit of a taboo subject.  We don’t like to talk about it and mostly try to ignore that death will happen to all of us – as they say, it’s an ‘elephant in the room’.

It’s getting better than it was.  Twenty some years ago when the rusty siren was still shiny and well polished (when I started my training), death was regarded as the enemy.  It was to be defeated at all costs.  A patient who died was to be resuscitated and wherever possible brought back.  Things were starting to change though.  It was acknowledged that sometimes when we arrived on scene it was impossible to resuscitate.  Some patients would have needed resurrection not resuscitation.  A protocol was introduced in our area called the ‘Diagnosing the fact Of Adult Death’ (DOAD).  This set out various situations, such as prolonged down time with no bystander Cardio-pulmonary Resuscitation (CPR), or obvious, unsurvivable injuries, in which case we did not attempt to resuscitate.  Over the years, in line with evidence-based best practice this guideline has evolved and extended to include children and is now the Diagnosis of Death (DOD) guideline.

It’s now quite common in the UK for a person, especially one who is approaching the natural end of their life to decide with their doctor to establish a ‘Do not attempt CPR’ (DNACPR) document.  If the person, in consultation with their doctor and if possible family, agree that a resuscitation would not be successful due to various serious medical problems (co-morbidities) or if successful would not result in a good quality of life then a DNACPR is raised.  This tells us that if a patient with us goes into cardiac arrest we are not to attempt any resuscitation.  The DNACPR is a distinctive A4 sized single sheet of paper, printed on distinctive lilac paper to be kept in a prominent place in the patient’s home or care plan file so it is known about and easily located if needed.

In addition to the DNACPR document in the UK there are now ‘advance decision’ documents – legal documents where a person can dictate the level and limits to care they wish to receive in the event that something happens and leaves them unable to make or communicate a decision at that time.

Don’t get me wrong: we still resuscitate.  I often think that we paramedics are ‘jack of all trades, master of none’.  Most of the time we arrive at someone who is ill or injured, assess them to have an idea of what is wrong, come up with a differential diagnosis (list of possible medical problems which would cause the displayed signs and symptoms), treat the symptoms and refer to specialists for definitive assessment and treatment (often the Emergency department (ED) of the local hospital but sometimes other specialist centres).  When it comes to resuscitation though I think we are the specialists.  We keep up to date with best practice; and now when we get a confirmed, viable cardiac arrest even in these resource-scarce times control send several resources, including senior staff to carry out a full resuscitation at scene.  If someone collapses in cardiac arrest now I think they have the best chance ever of survival – provided someone witnesses the collapse, calls for immediate help and starts CPR immediately.

Because we carry out Advanced Life Support (ALS) on scene; when dealing with a medical cardiac arrest, if after 20 minutes of ALS there are no signs of response it is clear that further efforts would not be successful, we terminate the resuscitation and diagnose death.

Over the years I have attended many collapses; some we have successfully resuscitated, some we have not, some we have terminated after starting and some we have not started because of a valid DNACPR or the DOD guideline has been applied.  Last week for the first time I witnessed a patient die and was not able to attempt resuscitation.  It was very strange and unnerving.

We were called to a care home in our area to a 69 year old female.  I’ll call her Josephine in this (obviously not her real name).  She was short of breath.  My usual mate Tony was on leave, I was on with a fairly new EMT called Mark.

We arrived to find Josephine on the bed in her room.  Her daughter and care staff were present.  Josephine was obviously struggling to breath.  She was on supplemental oxygen but it was not helping.  A few quick questions to the care staff and I established that Josephine had breathing problems due to asthma and also heart failure which can manifest as difficulty in breathing.  While trying to reassure Josephine and her daughter I listened to her chest with a stethoscope and decided that a nebuliser would provide some relief.  Mark quickly set this up for me and I started to explain that we needed to take Josephine to the ED for further help.  Josephine shook her head.  Her daughter (Sam) explained that Josephine had made it clear to everyone that she had had enough of hospitals and treatments and now just wanted to spend her remaining days in her room in her care home.  Sam showed me Josephine’s DNACPR.  I explained that the DNACPR was limited to resuscitation and that while Josephine was alive I had a duty of care to her and the hospital may be able to ease her breathing and make her comfortable.  Josephine was adamant that she did not want to go.  I could tell that Josephine had mental capacity (was able to understand what was going on, understood and accepted the risks of staying home and was able to communicate this to me even though she was breathless).  I reassured Josephine and Sam that because Josephine has mental capacity I would respect her wishes and was not allowed by law to take her anywhere against her will.  Josephine seemed to relax a little and her breathing improved a little, helped a little by the nebuliser we administered.

I still had to do something though.  Josephine agreed to allow me to speak to her doctor by phone to see if her doctor had any further help to offer.  I rang the receptionist and gave an outline of the situation then had to wait for the doctor to ring back.  While we were waiting I tried to make Josephine as comfortable as possible.  I gave another nebuliser and gave a hydrocortisone injection (to lessen the squeezing of her airways caused by the asthma) and a nitrate tablet to dissolve under her tongue (to take the strain off her heart due to her heart failure –  her blood pressure was high enough to tolerate this).  Her breathing seemed to ease and Josephine relaxed and smiled at her daughter who was holding her hand.

The doctor rang me back and agreed that Josephine would be better off going to hospital.  She also agreed with me from knowing Josephine that I would never be able to persuade her to go.  She agreed with my treatment so far and agreed to call in and visit after surgery.  The doctor rang off and I explained what the doctor had said.  I once again offered Josephine a trip to hospital; she grinned and said “not a chance.”  She seemed relaxed and comfortable now.

I sat down in a corner of the room to document what had happened and been decided while Sam and Sam’s daughter who had just arrived held Josephine’s hands.  The room was very pleasant and fresh and the sun started to shine through the window.  Without any words or drama Josephine stopped breathing.  It was remarkably unremarkable, Josephine was breathing and then she wasn’t.

I gave the family a few minutes to process this then confirmed that Josephine had died.

It brought home to me how my early training has hammered home the message that death is the enemy to be fought and defeated at all times.  Yes, death is often very wrong, stealing life away – but – sometimes it is a natural end to life.   Sam thanked me for making her mum’s last hour of life comfortable and for making her death ‘beautiful’.

I’m still trying to process all this myself and wonder about my own attitude to death.

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.

Male on the road – no sign of life.

Warning:  contains material some might find distressing.  No happy ending.

It was a cold and rainy early morning in winter.  Tony and I were looking forward to the end of our night shift.  The shift had been busy with the usual routine type of emergencies – nothing too taxing for us.  We were on our way to the last job of the shift, a category 2 emergency – an 83 year old male who had fallen while making an early morning visit to the bathroom.  With a bleep on the data pad our plans were changed.  We were passed a category 1 emergency – immediately life threatening.

It was a report of a male lying in the road outside a bar; the caller didn’t want to get too close but was unsure if the male was alive.  It was about 6am, most bars in this area had closed hours ago so it was unlikely to be a drunk sleeping it off.  We were only a few minutes away so we would know soon.  We arrived at the bar and stopped.  We looked around but could find no trace of any male lying in the road.  Two police cars arrived shortly after us and started to look around the immediate area as Tony contacted our control room (EOC) to ask for any further details about the location.  We were both thinking that this was after all a case of a drunk male who had miraculously come back to life and wandered off before we arrived.  The message came back from EOC that the man was a few hundred yards further along the road, hidden from our view by a hill.  We jumped back in the ambulance and set off.  As we got to the crest of the hill we saw our patient.  He was lying on his back in the road with just his feet on the pavement.

We didn’t know his name, I still don’t know what his name is as I write this but I’m going to call him Jack.  This is to make the account personal and to honour the human being.  In the medical reports and police statements I referred to him as ‘the patient’ or ‘the male’.  This feels horribly impersonal and makes us forget that this is a person with a life history who has family and friends who love him.  This is for Jack.

We parked near Jack, using the headlights to provide as much light as possible on this dark rainy morning.  The police had already blocked the road in front of and behind us so at least we didn’t have to look out for cars speeding past inches from us.

I grabbed the first response bag and walked to Jack.  We rarely run, that’s when you miss things and risk having an accident yourself or further hurting the patient.  As I approached I was taking in the scene, trying to get an idea of what had happened. It was hard to see in the dark but I could see a quite large amount of blood on the downhill side of Jack’s head – obviously a head injury which was bleeding profusely.  He was fully clothed against the winter weather so it was hard to assess any other injuries.  He looked about 45 years old.  I knelt by his head to quickly assess.  Jack’s mouth was open and was full of blood so his airway was totally blocked, he was obviously not breathing and I couldn’t feel a pulse in his neck.  He was in cardiac arrest (No heartbeat and not breathing).  As I was assessing him I noticed that Jack was still quite warm.  Since he was lying on the road in the rain I knew he hadn’t been down very long.

This was decision time.

We don’t automatically try to resuscitate every cardiac arrest we attend.  Some are beyond all hope of help.  Medical cardiac arrests (caused by medical emergencies such as heart attack, stroke etc) have a slightly better chance of survival.  Studies indicate that recovery rates range from approximately 36% to 3% depending on the presenting heart rhythm, assuming immediate resuscitation attempts are made at the time of collapse.  This was a Trauma cardiac arrest (caused by trauma = physical injury).  Studies show that survival rates from traumatic cardiac arrests are 6% at best.  Certain injuries are deemed to be unsurvivable and if a patient has an unsurvivable injury we don’t attempt to resuscitate. If we decide resuscitation is viable and we start, trauma resuscitation guidelines advise that the resuscitation attempts should continue as the patient is transported to a specialist trauma centre.

The decision we had to make was: did Jack have a survivable or unsurvivable injury?  We couldn’t take long over this decision – if, after a prolonged examination we decided his injuries were survivable we would have killed him by delaying resuscitation attempts.

I decided we couldn’t say his injuries were unsurvivable here in the dark and rain on the floor so I decided to start working on Jack while we moved him into the ambulance for a closer look.  A police officer was ‘volunteered’ to do chest compressions then my next priority was to clear his airway.  Tony had brought the suction unit so I could use a tube to suck the blood from his mouth.  As soon as I cleared his airway it refilled with blood.  I decided to intubate as soon as possible.  I do this by kneeling above his head and use a laryngoscope.  This has a blunt blade at right angles to a handle with a bulb on it.  By using it to lift the tongue and lower jaw gently up I can then see the vocal chords – the structure at the top of the trachea – the windpipe.  After a last attempt to suction the blood out of the way I inserted an endotracheal tube (ET) through the vocal chords and into the top part of the trachea.  The ET is about 10 inches long and the end of the ET which sits in the trachea has a balloon on the outside, I inflate this and this seals the trachea, blood in the mouth can no longer block the airway.  The other end of the ET is projecting out of Jack’s mouth and by connecting to a ventilator we can breathe for Jack.

By this time a second ambulance, an off-duty paramedic on his way to work and a senior paramedic in a response car had arrived.  Tony was organising them to get the equipment we needed to immobilise Jack and move him to the ambulance.  Under Tony’s supervision as I concentrated on protecting the airway and neck, a police officer continued chest compressions we immobilised and moved Jack into the ambulance.

In the ambulance where it was brightly lit (and warm and dry) we could fully assess Jack.  While still carrying on the resuscitation attempt, we cut all Jacks clothes off.  It was obvious that Jack’s injuries were severe; this wasn’t just a case of falling over and banging his head on the kerb.  Multiple fractures were now obvious throughout Jack’s body and his head injury was substantial.  As a team we sadly decided that continued resuscitation would be unsuccessful so we stopped.

This was a breach of our guideline.  If we decide not to attempt or to terminate resuscitation we’re not supposed to put the patient on the ambulance. Legally speaking, the site of a traumatic death is a crime scene until the police have ruled out foul play.  By moving the patient to the ambulance the ambulance becomes the crime scene.  Our managers frown on this.  In the debrief, the senior staff agreed that this was an exceptional case and I couldn’t have done anything else.  I couldn’t have said that Jack’s injuries were unsurvivable without a proper examination and I couldn’t do that in the dark on the road.  They all reluctantly agreed that they would have done the same.

I still don’t know what happened to Jack that morning.  His injuries suggested high energy impact, not just falling over.  One possibility was a hit and run RTC – the injuries weren’t typical of impact with a vehicle though.  The road where Jack died passes through a cutting in the hill with steep embankments about 60 feet high on both sides.  The most likely explanation was that he fell or jumped from the top of one of the embankment walls.

It was a sad, late and wet finish to our night shift.

Brand New Babies!

If there’s one type of job most ambulance people, especially male ambulance people, are apprehensive about it’s maternity jobs.  For me they’re the scariest type of job.  Part of our job is to deal with obstetric emergencies (emergencies in pregnancy), delivering babies and life support/resuscitation, and general newborn baby care.  I’m always reassured by the thought that Homo sapiens have successfully been giving birth to their off springs for about 200,000 years.  It’s only in the last 100 years or so that birth has moved into the domain of the medical profession.  Still scares me though.

Most of our maternity cases are in early stages of labour.  Birth is not imminent.  These types of jobs get called ‘maternitaxi’.  This isn’t really an appropriate case for an emergency ambulance, if we politely question why the ambulance was called, normally we are told that the potential mum has rung the Maternity Unit (MU) and “they told me to ring 999”.  When we arrive and hand the patient over, normally the midwife scolds them and says that they said to get a taxi not and ambulance!

Maternity cases differ from other emergencies in many ways; one major difference is the destination.  When we deal with most non-maternity jobs the destination will usually be the emergency department (ED) of the local hospital.  Certain conditions are taken to specialist units but generally for a given emergency in a given region the destination is determined by location and condition.  Maternity cases however the potential parents choose in advance which hospital MU they want to go to.  Obviously this has to be within reason – if a mum-to-be is hundreds of miles from home and labour starts an ambulance can’t travel hundreds of miles we have to settle for one of the local units.  The other main difference is that we can’t just turn up at a MU unannounced.  If the mum or dad hasn’t rung the MU then we have to get our dispatcher to ring and we can’t set off until the MU agrees to accept.  It can and sometimes does happen that a particular MU is full, in which case we are told to go elsewhere.  This is stressful for the prospective parents because they will have had lots of visits to the MU they chose during the pregnancy and to be told at the big moment that they have to go to an unfamiliar unit must be scary.  It’s scary for us too because it normally means longer before we can hand over to the midwife!

When we arrive and birth is imminent we don’t transport, we deliver the baby at home.  One of the first tasks is to request a community midwife to come to the address.  If he or she arrives before the baby then that is fantastic, midwifes are the experts in assisting birth.  If not it’s down to us.  The area where I work is covered by several MU’s.  One is a specialist MU where it is recommended all high risk pregnancies in the area book into.  Ironically, that one MU does not send midwifes into the community so the higher risk home births are left to us.  Another benefit of a midwife attending is that if all has gone normally and mum and baby are well we don’t need to transport anywhere and the new family can stay at home.  If we deliver with no midwife present then mum and baby have to go to the MU.  We then have 2 patients: mum and baby (possibly 3 if dad has fainted during the birth!).

The biggest risk to a new born is the cold.  A baby comes into the world naked and very wet.  They have very little body fat at that stage so lose heat quickly.  A priority once we know the baby is alive and breathing is to dry baby off and get them in skin-to-skin contact with mum to warm up, then wrap both up and make sure the room is warm.  A hat is an excellent idea for baby.  My regular mate Tony is a big fan of baby hats and it has become a bit of a catch phrase for him once baby is dried off: “get a hat on that baby!”

I have assisted with many births over the years, some stick in my mind:

One dad tried to drive his wife to the MU but had just left it a bit too late (or baby was impatient) and mum started to deliver in the car.  Luckily we were driving past and he was able to flag us down.  I opened the passenger door of the car to find mum with one foot on the dash board and baby’s head just visible.  I assisted the birth in the car foot well then quickly got mum and baby into the ambulance.  I asked if mum and dad had a name for their new daughter and dad joked that he would call her Corsa after the car.  I asked if he was glad he didn’t drive a Skoda…It seemed funny at the time.

Another time we were on the way to an imminent birth and we were told that the baby was breech.  The normal position for a baby about to be born is head down in the uterus so the baby comes out head first.  Breech means the baby is bottom first.  This is a complication because the head may get stuck after the body has been born.  This is a very scary situation.  As we arrived the response car was already there.  To our great relief Stella, on the car was assisting the delivery and thankfully baby came out with no complications.  Stella said that when she got there baby’s foot was visible and that was all.  She had a very anxious wait for the next contraction when mum managed to push the rest of the baby to the world.  Since no midwifes had been available to attend we had to transport mum, dad and baby to the MU.

One final birth which sticks in my mind is a 17 year old girl who lives with her parents.  She was 36 weeks pregnant and hadn’t yet figured out how to break it to her parents – she had spent the last few months wearing baggy clothes.  One Sunday morning she thought she needed the loo and baby decided to make his appearance.  Mum and baby were fine the new grandparents were shell-shocked, they had no idea when they went to bed the night before that they would be grandparents in the morning.

Typical day at the office

This is a timeline of a typical dayshift I worked last week.  It developed into a longer blog than normal for me.

06:40  

I arrived at work.  My mate, Tony arrived pretty much at the same time.  The station we are based at is in a pretty rough area.  We are allowed to put our cars in the garage as there is a high risk of them being vandalised while we are out and about on emergencies if left out on the street.  We walked into the mess room and I made straight for the kitchen to put my food in the fridge and more importantly make coffee!  The night shift had already arrived back on station and were pleased to see us.  They handed over the radios and Pat, the paramedic I was taking over from gave me the key to the safe in which the controlled drugs are stored.  We chatted about their night shift and they started to get their belongings together to get home to bed and a well earned sleep.  Tony and I drank our coffee while we contemplated the 12 hours ahead of us.

07:00

Time to sign on.  We carried our personal equipment onto the ambulance.  We take it in turns to drive – Tony and I usually swap half way through the shift.  This morning Tony was driving first.  I got into my side of the ambulance and put our staff numbers in the data pad in the cab.  When I pressed ‘send’ this told our dispatcher who we were and that we had signed on for the shift.   Our dispatcher called us up on the radio to say good morning and check we had all our equipment and were ready to go.  While I had a brief chat Tony had started the engine, put all the lights on and was walking around the vehicle making sure that they were all working and that the tyres all looked ok.  In an ideal world we would be given time to check equipment in the back of the ambulance, restock any consumable equipment we were running low on and check and sign for the drugs and the controlled drugs.  However….

07:04

The first job of the day was passed.  An 86 year old lady had fallen in her bedroom; her elderly husband had made the call because she was unable to get herself up.  It was fairly local so we were there in minutes.  I got the First Response Bag from the side door of the ambulance.  This is a (heavy!) rucksack which has all the equipment we need to assess and start treating just about any emergency.  Mr J was waiting at the door for us and he pointed up the stairs.  “She’s up there lads, don’t think she’s hurt, but I can’t lift her.”  We found Mrs J lying on the floor next to her bed; Mr J had covered her with the quilt to keep her warm while she was on the floor.  After checking her, there was no sign of injury and from her baseline observations no sign of illness.  She said that she had not fainted or felt unwell, just lost her balance while getting up from bed. We helped her up and she was able to walk down the stairs as normal.  There was no need to take Mrs J to hospital or arrange a doctor’s appointment.  I rang her son to let him know what had happened and then, with Mrs J’s permission I passed her details onto the local falls team, a multi-disciplinary team who would visit Mr and Mrs J with a view to giving advice to prevent further falls.

09:30   I cleared the job, making us available again for the next emergency.

09:30

We were passed details of a 13 year old boy who was unwell with stomach pains.  We arrived and were shown into the front room where Toby was curled up on the sofa hugging a bowl.  He had vomited twice while waiting for us.  From the history and his presentation the most likely diagnosis was appendicitis.  We needed to take him the hospital for assessment and possible operation.  Appendicitis is difficult to diagnose with absolute certainty.  Toby would be seen by the Emergency Department (ED) doctor and referred on to a surgical specialist.  Even the surgeon would not know for certain, they operate if the “index of suspicion” is high that it is appendicitis.  We dropped Toby and his mum off at the ED and took the chance to make a cheeky coffee to take out to the ambulance while we checked and signed the drugs check sheet.

10:30   I cleared the job.

10:30

The next job was passed, a 93 year old gent who had fallen in the night and his carer called us because he “wasn’t himself”.  We arrived to find Albert sitting in his chair.  His morning carer had visited and was about to leave as we arrived.  He was annoyed that his carer had called us, he didn’t like fuss.  There was no sign of injury from his fall and he was able to walk with no problem since his fall, which he said was just down to being half asleep when he got up in the night to go to the bathroom.  His baseline observations were all normal.  There was no need to go to the ED.  Once we told him this he brightened up and started to talk.  He was feeling low because he didn’t want to leave the house he had lived in for 50 years and was scared that we would take him away and that would be it.  I reassured him that we were all there to help him and to keep him well so he could carry on living in his own house.  He agreed that I could phone his grandson who he was close to and Tony made him a cup of tea while I did this.  His grandson agreed to call round with fish and chips after he had finished at work.  I suggested that Albert made an appointment with his GP (GP = General Practitioner: the doctor who looks after us in the community and co-ordinates our health care) for a general check up and review of his medication, which they agreed to do.  I also passed his details to the falls team – we were keeping them busy this morning!

11:58   I cleared the job.

11:58   We were told to Return to Base (RTB) for meal.

We set off back to station but two minutes later…

12:00

We were passed another job (dinner would just have to wait!).  This was in the next town, a 27 year old female who was 30 weeks pregnant and was passing blood with abdominal pain.  We arrived and the family met us at the door.  They had phoned the local maternity unit (MU) and they had said to come in.  We helped Safira onto the ambulance and her mum then after quickly assessing her baseline observations set off to the MU.  They were obviously subdued on the journey in and didn’t want to chat so after getting the essential details I needed I let them have peace.  We cleared at the MU and this time we would have to be allowed back for a break because we had been out more than 6 hours.  Sometimes ‘Health and Safety’ works in our favor.

13:20   RTB for meal.

13:35   Arrived on station and demolished our packed lunches.  Sometimes I pick up a take away but generally prefer to bring a packed meal.  Meal break is 30 minutes long and when we have been out longer than 6 hours cannot be disturbed by control.

14:05

Right on cue, the next job was passed to us.  It was my turn to drive.  We were given a 55 year old man who was in severe abdominal pain. We walked into his flat to meet Joe.  Joe admitted he was alcohol dependant (we guessed by the empty cider bottles next to the sofa).  He suffered with chronic pancreatitis as a result, and the pain had flared up this morning.  This is a long term condition where the pancreas is damaged, in Joe’s case by many years of daily drinking cider.  Joe had taken his usual amount of cider this morning (it can be dangerous for an alcohol dependant to suddenly stop drinking) but the pain was not subsiding.  We helped him onto the ambulance, checked his observations and I cannulated him and gave some morphine.  This dulled his pain and we took him to the local ED.  We raided the ED staffroom for a cheeky coffee and a few biscuits.

15:20   Tony cleared the job.

1520

The next job was waiting for us, the jobs were stacking up in control now and this had waited 50 minutes before an ambulance was available to allocate.  It was a 25 year old male who had cerebral palsy, development problems and epilepsy.  He lived in an adapted house with 24 hour care support to enable him to live as independently as possible.   Jamey had had a seizure.  The care staff were concerned that the seizure had been triggered because Jamie had an underlying chest infection and had contacted Jamie’s GP to arrange a check up.  The GP had insisted an ambulance was needed.  We checked Jamie’s observations.  We worked slowly and got the carer to help keep Jamie calm as we explained each test as we did it.  Jamie had fully recovered from his seizure by now and was back to his normal self.  There was no need to take Jamie from his secure, familiar house to a noisy, busy ED, so Tony convinced the GP service that Jamie was safe to stay home and wait for a doctor to start treatment for a chest infection.  (This sounds straightforward but actually is frustratingly time consuming: we make a phone call to one of the GP services we use and give the basic details to a call taker.  We then wait for A GP to ring us back to discuss the case.  This can be up to an hour later.  Then, during the daytime office hours the GP will often ring the patient’s own GP (we’re not supposed to do this directly ourselves – don’t ask!)  Then our GP will ring us back with a decision).

17:10   We cleared the job.  We were over due our second rest break of the shift, 20 minutes this time, but control asked if we would take a look at a child involved in an RTC they had no ambulances available to cover.

17:10

We were passed the job, a 14 year old girl who had been struck by a car.  The girl’s friends had made the call and were hysterical so our call taker had no idea of any injuries.  We arrived at the scene and were relieved to see everyone was on their feet – no one was lying on the road – a good start to the job!  Chelsea had been checking Facebook on her phone and had stepped out into the road. A car had managed to almost stop in time but had connected at low speed with Chelsea’s right leg, knocking her to the ground.  She had managed to avoid banging her head and jumped up immediately.  She was more upset that she had dropped her phone and the screen was smashed.   We got her onto the ambulance and checked her over.  We were happy from the mechanism and from the examination that there was no spinal injury.  She had some bruising to her right thigh and bruising and a cut to her left elbow where it had hit the road.  As we were checking Chelsea we heard raised, worried voices approaching – mum was here. Chelsea’s friends had rung her mum as well as phoning for the ambulance.  With a loud hammering on the ambulance door mum arrived.  I opened the door to let her in and calm her down as Tony was getting some details from Chelsea.  When mum saw that Chelsea was basically ok she burst into tears of relief then started shouting at her and threatened to kill her for the worry she had caused.  I asked her to wait until after 7 o’clock before she killed her because that was when we went off duty.  That lightened the mood.  We took Chelsea and her mum to the ED to get her elbow x-rayed and the cut closed.

18:35   We cleared the job and were RTB’d for our belated rest break.  At least it meant we would finish on time.

18:45   We arrived back on station, for the second time since we left at 07:04 this morning.  We took our gear off and I grabbed a mop to give the floor a clean as Tony got a few things from stores that needed restocking.

The night crew arrived and we handed the vehicle, radios and controlled drugs keys over to them.

1900    Time to go home.  Quite rare to finish on time, normally we are still on a job when finish time comes around and we obviously have to finish the job before we can go home.

Time now to relax until 07:00 tomorrow when we get to do it all again.

When a summer swim turned to tragedy.

Today this is a guest author spot.  It is written by my long term, long suffering workmate Tony and describes an incident he dealt with one day while not working with me.  I leave him alone for one day and see the trouble he gets into… Over to you Tony…

Thanks.  It was a sunny day.  I was working with Rachel, an experienced paramedic on an overtime shift.  Overtime always seems like a good idea when you book it, never seems quite so good when you actually come to start the shift, especially on a sunny day.  The day started pretty uneventfully – A steady stream of routine jobs, nothing too taxing.  Everyone was enjoying the sunny Saturday afternoon, the parks and pub beer gardens were all full of happy people.

We were driving back to base after a job when we were passed the next job.  It was a possible drowning at one of the local reservoirs.  We live about 50 miles from the nearest coast and on hot, sunny days we often see groups of children and teenagers climbing over the gates and fences into the reservoirs and dive and swim around.  The water authorities issue warnings every year about the dangers of swimming in reservoirs yet every year people ignore them and carry on swimming.  The problem with any body of water in the UK is that it tends to be cold.  Even on a run of hot weather it rarely warms the water below the surface layer; experts say the water below the surface doesn’t rise above a breathtaking 10˚C.  Reservoirs have the additional problem that there can be unexpected strong currents due to underwater valves and suction pumps.

We arrived at the reservoir to a crowd of bystanders all frantically waving us forward.  We had to climb over a fence to get to the edge of the water.  Two teenage lads were treading water a distance out from the edge.  They were shouting for help saying that they had hold of their mate but couldn’t get him out of the water.  They had been jumping from the edge of a building into the water on the opposite side of the reservoir all afternoon with no problems but on the last occasion their mate just never surfaced again – maybe he had banged his head on the paved floor and become unconscious, maybe the cold had made his muscles cramp, maybe the diving reflex kicked in – a reflex which all mammals have where the body responds to sudden immersion of the face in cold water by slowing the heart rate and diverting blood flow from the outer parts of the body, possibly leading to a faint.  Whatever the reason was, he never surfaced again.  Two of them tried to find him and drag him out while the rest called for help.

I shouted to the lads and asked if they could drag him to us.  They replied that they were struggling and couldn’t keep hold of him much longer.  The lad on the left was starting to have problems keeping his head above the water.

With some trepidation I took off my heavy work boots, emptied my pockets and waded out into the water.  It was cold! The deeper I waded the colder it got. The stone floor of the reservoir sloped steeply and the water quickly became deeper and colder.  The lads were still some distance out so I had to swim a short distance.  The lads by now had to let go of their friend to stop themselves from going under, one of them swam himself to the shore and I helped the lad who was struggling.  By now an ambulance response car and the police had arrived.  Stuart on the response car was taking his boots and tunic top off and one of the police officers was taking off his boots and body armour.  Rachel dished out blankets to the two friends and was preparing the resuscitation equipment on the shore.  After a quick conference we decided that since we knew pretty much where the lad had last been seen we would swim back in and have a look.  The fire service had mobilised the specialist water rescue unit but that would be ages before it arrived.

Back into the cold water we went.  The second time was no better; it still took my breath away.  We swam to where the lads had had to let go of their friend and looked around.  The police officer spotted him under water and we dived and managed to get a hold. We made our way slowly to the shore, Stuart joined us and we managed to get him back to the shore where we quickly dried off as Rachel started to dry him off and assess him.  He was in cardiac arrest: no pulse and not breathing.  We started to resuscitate and as we did his heart started to beat again.  He still wasn’t breathing for himself and was completely unresponsive.  We headed off to the local hospital after pre-alerting them that we were on our way, me driving (still damp and shivering) and Rachel in the back still ventilating the patient (using a machine to mechanically push air into his lungs and then allow the lungs to breathe out relying on the ribs and chest wall muscles to relax and force the air out).

He was kept alive for a few days on Intensive care but sadly was only alive because of the drugs and machines, the decision was made to turn off the machines and allow him to die.  I like to think that at least his family had time to see him before the machine was turned off and hope they got some slight comfort from that to help them through the grief.

That’s it really, all I’ve got to say.

Thanks for that Tony.  Just one point I’d like to add:  Tony and Stuart got a bollocking from the service for the risk to their lives they took that day, apparently there are rules somewhere which forbid us from doing stuff like that. However, they and the police officer got a very well deserved commendation from the Royal Humane Society for their bravery that day!

Halloween (true) anecdote

This is a true anecdote and seems appropriate for Halloween time.  Here goes…

One morning Tony and I had signed on for our 0700-1900 shift and we were given a job straight away.  It was a reported elderly male who had collapsed and was unresponsive to his family.  A suspected cardiac arrest.  The family had declined to attempt CPR.  On the way to the job, we didn’t speak much – neither of us are morning people.  I was mentally preparing what equipment to take in – all the gear we would need to attempt resuscitation.  I would grab the first response bag and drugs bag and go straight in, Tony following shortly behind me after gathering the monitor/defibrillator, suction gear and advanced airway bag.

We arrived outside the address, a terraced house.  The front door was open so I went straight in.  I walked through the front room into the kitchen dining room where several family members were gathered: an elderly gent was sitting next to a low table looking at his cup of tea and toasted tea cake, an elderly female was standing, in tears with a middle aged man holding her.  As I walked in, the lady pointed to the stairs in the corner and sobbed “He’s up there…”  As I walked across the room to the stairs I asked what had happened.  The Lady said her husband had collapsed on the way to the bathroom and she had been unable to wake him.  She called her son who came straight round and then rang the ambulance.  By now the gentleman had been down about 30 minutes.  I always feel that on jobs like this I must seem very abrupt and almost rude, but at this point of the job we quickly need some basic information as we are assessing the patient to make the big decision whether to attempt resuscitation or not.  I walked quickly up the stairs, Tony behind me with the rest of the resuscitation gear and found the gentleman collapsed on the hallway.  After assessing him we decided that it would be pointless to attempt to resuscitate – we would have had no chance of success and would have only prolonged the pain of false hope for the family.  As Tony started to pack the equipment away, I went back down the stairs to break the news to the 3 family members in the kitchen.  I was quite struck by the resemblance the patient had to the elderly gent sat down by the table, I presumed they must be brothers, maybe even twins.

I walked into the dining room and now there were only 2 people there, the patient’s wife and middle aged man who was his son.  The elderly ‘twin’ was not there.  I broke the news as gently as I could that the patient had died and we would not be able to resuscitate.  I gave his wife and son chance to comfort each other as the terrible news sank in.  As I got the paperwork ready to get some details, I wondered where the patient’s twin had gone, I assumed he must live very near; I made a mental note that we would have to make sure he was also offered support along with the family before we left.  I started to get the gentleman’s details from his wife and son and generally chatted about his life as I was explaining to them what would be happening over the next few hours and advising of the various means of support available to them.  As part of our conversation I asked about the gentleman’s brother and if he had any other brothers or sisters.  His wife looked puzzled and said that he had no brothers, sisters or any other family than her and their son.  She saw me looking at the small table with a cup of tea and toasted tea cake on a small plate and started sobbing again – that was the table he always sat at for his breakfast, she had prepared it and put it there just before he collapsed – he never got chance to have it.

Later in the ambulance talking to Tony, I decided to risk his derision and told him what I had seen; normally very skeptical of anything supernatural he said that he had goose bumps because he had seen him too.

Heroin Overdose.

One autumn afternoon, Tony and I had just cleared at a local hospital and were hoping to be RTB’d (Returned to Base) for meal.  Instead, with its usual irritating bleep, the data terminal announced another job for us.  It was a few streets away and was a reported heroin overdose, possibly more than one patient; the caller was too agitated and panicking for our call taker to clearly get all the details, but possibly the patient was not breathing.  This is the thing with heroin, as with all opiates such as morphine, as well as being excellent pain relievers they act on the cardiac and respiratory systems to reduce the respiratory effort, ultimately causing respiratory arrest which if left untreated rapidly leads to cardiac arrest – death.

We were on the street within minutes. Unfortunately we weren’t 100% sure which house number we were going to.  The caller had been hysterical and shouting making it hard for our call taker to understand clearly what he was saying.  Our call taker said to try number 51, that’s what it sounded like.  The caller had ended the call and wasn’t answering when our call taker tried to ring back.  We knocked at number 51 – no reply. By now we were joined by Stuart, a paramedic on the response car.  We waited for control to listen to the tape recording of the call to have another attempt at interpreting the address (all calls to the service are recorded and it has often been proved useful to get vital information on a second or third listen).

As we waited, a man further down the street popped out of the door and started waving and shouting frantically.  It was number 31.  We quickly moved the vehicles and Tony and I grabbed the equipment we needed for resuscitation.  Stuart followed us in.

As always seems to be the case when you need to act quickly, the house was cramped and the room we needed was hidden by the open front door so we had to enter one at a time and close the front door behind us to get in the bedroom before the next one could open the front door get in.

I was in now. Instantly I had a flash back to training school where as part of the training for resuscitation we set up scenarios for each other and as we got the hang of the resuscitation procedure we would make the scenarios more ‘interesting’ with multiple casualties and confined spaces.

One patient, a lad in his mid twenties was asleep on a single bed near a window.  He was breathing but only occasionally and his lips were blue.  A male aged approximately 50 was on the floor next to the bed and was in cardiac arrest.  The man who had called us down the street was doing chest compressions on him.  A third patient was in the doorway, also in cardiac arrest.  There were needles and syringes scattered over the floor.

Stuart updated control and requested two more ambulances as I managed to shake the patient who was breathing occasionally and wake him up enough to breathe normally.  Then I took over the resuscitation of the 50 year old, with assistance from the man doing chest compressions.  Tony and Stuart started to work on the third patient.  I also had to keep an eye on the sleepy lad, make sure he didn’t fall back asleep unnoticed and stop breathing.  I could reach him with my outstretched leg as I was resuscitating my patient so every so often I had to kick him to wake him up. All the while we were working we had to be very careful not to injure ourselves on any of the discarded needles scattered around the room. Luckily the service wasn’t too busy that afternoon and the backup crews arrived quickly.

The first crew took over the resuscitation of the patient in the doorway and moved him out of the door.  The next crew took the sleepy patient so then Tony and I could concentrate on my 50 year old patient.

Despite the initial chaos, the job flowed smoothly.  We had all three patients out of the house and in hospital within about 20 minutes from first arriving on scene.  The sleepy patient survived and was discharged from hospital that afternoon.  Sadly the two cardiac arrest patients died.  What made the job more poignant was that the 50 year old patient was not a regular heroin user – today on a whim he’d decided to try it for the first time because his friend was a user – first and last time.  The man who had tried to help with the resuscitation had supplied the sample for the three of them.  Because our patient had never used before, his ‘friend’ the supplier had actually injected it for him.  The last I heard he was arrested and being tried for manslaughter.

After this we did eventually get RTB’d for meal break – a somber and reflective meal break.