Car driven into a crowd

It’s been a while since my last post, family things have taken over my life recently but all’s well again so I can get back into my writing.

Tension relief alert:  No one was seriously injured in this job.

This is about an incident which happened recently.  I’ll write it to show that the way we receive details about an emergency is not always straightforward: sometimes information is drip-fed to us piece by piece as we approach and can be quite misleading and even dangerous.

It was late one evening; I was working a nightshift with my longstanding, faithful colleague Tony.  We were sitting at a local hospital outside the Emergency Department after dropping a patient off.  We had just finished our obligatory coffee when Tony tapped the keys on the vehicle data pad telling our dispatcher that we were available for the next emergency.

A job came through immediately.  It was a category 1 (the highest priority) and the computer dispatch system automatically sent the address to us so we could set off while the  call taker was still getting details of what was in store for us.  The address was about 4 miles away from us.  I switched on the emergency lights (blue lights) and set off.  Our dispatcher opened up the radio to say that the details were still coming through but it appeared that we were going to an RTC – a car had hit a pedestrian. These jobs are unfortunately quite common on our busy roads.

Less than a minute later she voiced us again to say that multiple calls were coming in about this job.  This is a sign that it was going to be chaotic on scene – when an accident in public happens, normally bystanders help the casualties until we arrive and are organised enough such that only one person rings for the ambulance.  The bigger the emergency, the more chaos on scene and usually this means we get more than one call for the same job.

As she was speaking to us more information was arriving on her screen from the call taker: the scene was becoming ‘volatile’.  A volatile scene is one where emotions are running high and can be quite dangerous for the ambulance staff as people’s fear, stress and frustration can boil over into violence against us.  She suggested that we pull over and wait until the police arrived (who were also attending on a high priority) if we wanted.  It still seemed to be a pedestrian RTC at this point.

We still had no idea of the severity of the casualty’s injuries so Tony and I decided to go straight to scene, normally we can tell the mood as we approach and we can usually diffuse a volatile situation by dealing promptly with the patient.

Just as we decided this radio bleeped again and she told us that the accident was outside a mosque and that the car had been driven deliberately into a crowd of pedestrians – potentially a terrorist attack. Possibly also weapons involved, armed police units were being mobilised.  The decision was made for us: we were not to go to scene, we were to wait at a nearby area (Rendezvous point – RVP). We were told a second ambulance was also attending and a manager to oversee things.  I parked at the RVP and Tony and I waited.  All sorts of scenarios were going through my mind, thinking about similar recent types of jobs.  A ‘major incident standby’ was declared,   not actually a major incident but everyone was preparing for one if it was declared.

The second ambulance arrived shortly after this and parked next to me.  Matt, a senior paramedic and the EMT he was crewed with got out to compare information with us.

We still had no idea of the number of casualties and severity of any injuries.  As we were talking lots of police cars and vans were passing us, blue lights and sirens disrupting the evening, heading in the direction of the incident.  It was frustrating beyond belief wanting to get there and assess and treat the casualties.  We were told that the HAR Team (Hazardous Area Rescue Team – a section of ambulance staff with extra equipment for managing hazardous situations) would be joining us.

The first HART ambulance arrived at the RVP with us and parked next to us.  People were starting to wonder what was happening at the RVP – 3 ambulances parked up and a constant flow of police vehicles streaming past us.

Finally a police car pulled up next to us and told us we were to go to scene, it was declared safe.  Matt set off in the lead with us close behind.  Our manager was still en-route to the RVP, he would have to follow on.

Within minutes, Matt and I arrived on scene and parked our ambulances as directed by the police officer in charge.  Although there was a large police presence the scene was still chaotic.  Emotions were understandably running high although thankfully no aggression was directed towards us. Luckily there were no serious injuries.  We were directed to an elderly gentleman who had been caught on the leg as he jumped out of the way of the car.  Matt was assessing him as I searched for any other injured parties.  This can be surprisingly difficult, in the chaos injured people sometimes are hard to find, they don’t always make themselves known to us.  The only other casualty was a young male who had punched through the side window of the car to try and stop the driver; he had several superficial cuts to his arm.  The driver had driven away after running into the crowd.

It turned out that the incident had been caused by a family feud.  Two children had earlier in the day had a disagreement while playing which ended in a fight.  The older cousin of one of the fighters had driven the car to attack the family of the other as they were leaving the mosque after prayers.  Although it was a terrible, irresponsible act it was not classed as a religiously motivated hate crime.  Thankfully it was down to the police not us to resolve that one; I’ve no idea if they caught the driver.  Hopefully the family feud ended there.

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.

My top ten favourite moments at work

I think it’s time for another top ten list.   This is my list of my favourite work related moments.  Not in any particular order.

 

  1. When we’re trying to resuscitate someone who is in cardiac arrest (not breathing and no pulse), it’s a great feeling when we get a pulse back (Return of Spontaneous Circulation (ROSC)). Even better if the person starts to breath for themselves too although this normally happens a bit later when the person is in the resuscitation room and we’ve handed over to the hospital staff.  It’s nice to track the patient’s progress through the hospital to the point where they are discharged home and back to their families.
  2. When a job flows smoothly. There is a certain flow from the point when we are given a job to the point where we hand the patient over in the Emergency Department (ED).  Sometimes the job flows more smoothly than other times.  Things can go wrong, equipment can let us down or the patient may not agree to the recommended care path way.  Sometimes it’s not easy or possible to cannulate the patient if required (insert a small tube (cannula) in the patient’s vein by inserting a needle which is encased in a plastic tube on the outside and then removing the needle leaving the tube in place).  A range of our drugs are given through the cannula (intravenous (IV) so if I can’t cannulate then I can’t give the patient any of the IV drugs or fluids.  It’s great when everything works and flows smoothly.
  3. When pain relief starts to work. Many of our jobs are people who are in pain.  This can range from sudden pain due to an injury or illness or ongoing pain caused by a long term condition which has gradually got worse to the point the patient can’t cope and calls us for help.  We have a range of techniques and drugs (analgesics) we use to relieve pain.  For an injury, eg broken limb, using a splint to immobilise the injury helps to ease the pain.  Reassurance also helps because fear plays a part in making the perception of pain worse, particularly in children.  No one likes to see another human in pain so it’s a great feeling when the patient starts to relax as the pain eases.
  4. When an unwell, scared child relaxes and starts to smile and laugh. When children are unwell or injured they are usually scared too which makes the feelings much worse. As long as the illness or injury is not time critical, we take a while to let the child get used to us.  We involve mum, dad or any other care-giver and encourage the child to show us their favourite toy or book.  It’s a good feeling as the child starts to relax and even laugh.
  5. When we can hear back up crews approaching. When we’re on a big job and have requested back up, it’s a huge relief to hear them approaching in the distance.
  6. When someone says thank you. I know it’s our job to help and it’s what we get paid to do, but we’re human too and it’s fantastic when someone appreciates the help we’ve given them and thanks us.
  7. When we get a free coffee. Very cheeky one this but some places give us free coffees while we’re on duty. Fantastic!
  8. Seeing a student progress. I’m a mentor so I quite often have a student for a year.  In the UK paramedics study at university and have frequent placements with us on the road during their course.  I love to see the student progress over the year from being nervous and confused to become a confident, competent paramedic.
  9. Hearing the relief crew arriving at the end of the shift. If we happen to be on station towards the end of the shift (very rare but it can happen) it’s an unbelievable relief when you hear the relief staff arriving.
  10. End of the shift. Home time!!

It was on the news, it must be right, right?

I’m writing this week’s blog about a recent news article in our area.  It featured some community first responders (CFRs) speaking out to a news team.  They were expressing various concerns among which were that CFRs were spending a long time on scene waiting for the ambulance staff to arrive and another concern that CFRs were being asked by the ambulance service to ‘discharge’ patients without the need for an ambulance to attend.

The tone of the article was quite negative.  It implied that the ambulance service were being quite negligent and trying to do things ‘on the cheap’.  The general public may have their confidence knocked in the ambulance service.  Some of our excellent (and very competent) volunteer CFRs and ECFRs feel de-motivated by the article.

As always, these are my own opinions and do not necessarily represent my employing ambulance service, my union or any of my colleagues.  It is all just my own humble opinion.  I also only speak about my own area, other areas may and probably do have different procedures and guidelines.

Community First Responders are volunteers who undertake training in their own time and at their own expense.  They are then provided with a uniform, pager and some equipment.  In their spare time they log on duty with the emergency operational control centre (EOC).  Then when certain categories of jobs come in details are passed to the CFR by pager and they set off (in their own car, no emergency lights or sirens) to the address to assess and provide initial first aid until the ambulance or response car arrive and then lend a hand to the paramedic or technician.  Some CFRs have undertaken extra training to become Enhanced CFRs (eCFRs).  ECFRs are trained to the same level as Emergency Medical Technician level 1 (EMT1).  ECFRs respond in the same way as CFRs and use their extended skills to assess the patient and provide certain treatment while waiting for the ambulance or response car.  I’ve already blogged about them here.

Getting back to the article:

CFRs (and eCFRs) waiting on scene for long periods with no ambulance response.

It’s true that people are waiting long times for an ambulance response.  At the time of writing it is winter and the well known ‘winter pressures’ are putting a seasonal strain on all aspects of healthcare.  Phenomenal demand for services means that a high volume of 999 calls are coming in.  Added to this, hospitals are pretty full with very few spare beds.  This means that patients in the Emergency Departments (EDs) are waiting for beds on wards with no beds available so they have to wait on trolleys (gurneys) in the ED.  This in turn means that the EDs become full so ambulances have to wait longer to hand over our patients meaning that ambulances are tied up at EDs and not out responding to emergencies.

I know it’s difficult for the CFR/eCFRs on scene for ages but I know that the members of the public are relieved and grateful to have you there, every one generally understands the current political climate and know that you (and us) on the ‘front line’ of emergency care are not to blame.

Discharging patients.

This is an emotive point.  The word ‘discharge’ in this context means to provide a safe, appropriate plan for a patient without the need to attend the ED.  This can mean a visit to or from a doctor (General Practitioner (GP)), either the patient’s own GP or the Out of Hours GP service (OOHGP).  It may also mean a visit from a nurse, or it may mean that after assessing a patient reassuring them that they don’t need to do anything now, just wait for natural healing to occur and see their own GP in a few days if needed. The minimum level of education needed to discharge a patient is nurse, paramedic or EMT2 (the cover-all term for medical staff is clinician).   Some cases the clinician can discharge with no further referral, some cases the clinician has to consult a doctor (usually one of the OOHGPs) by phone to affect the discharge.  The emphasis with any discharge is always safety.  Advice is always given about what to look out for which may show that the patient is deteriorating and what to do in that case after the clinician has left the patient.  This is called ‘escalation advice’.

The point of the article seems to be that CFRs are being expected to discharge without the patient seeing a trained clinician.

Discharges have already for many years been safely made by phone without a clinician actually visiting the patient.

If a patient rings the OOHGP or their own GP for a consultation the patient will speak to a call taker or receptionist who will take basic details.  The patient will then speak to a clinician who will ask detailed questions about the symptoms experienced by the patient and their detailed medical history.  From this, sometimes the patient is then safely discharged with a safe, appropriate care plan without seeing the clinician.

When someone rings 999 for an ambulance the call taker asks lots of computer generated questions.  Based on the answer to these the job is categorised in terms of seriousness.  Certain of the lower category jobs are then passed on to a group of clinicians in the EOC who ring the caller back.  In the same way as the clinician at the GP service they will assess over the phone and may be able to safely discharge the patient without an ambulance or any clinician visiting the patient.

The CFR or eCFR would never be expected (or allowed) to make a discharge decision alone.  The CFRs have access by phone to clinicians in EOC who with the benefit of the clinical observations measured by the CFR (pulse rate, respiration rate, blood pressure, blood sugar level) in addition to the signs and symptoms experienced can safely make a discharge decision if appropriate before the ambulance or response car arrives.

I guess my messages from all this are:

  • Although far from ideal response times are currently being experienced, if a discharge decision is made it is by a fully educated and trained clinician to national guidelines. Safety of the patient is always foremost in a discharge decision and escalation advice is always given.
  • CFRs and eCFRs should be proud to serve their communities and I know from talking with many of my patients that they are admired for their unselfish contribution to the local community.

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.

Gravity always wins!

It’s no secret and no big surprise but all aspects of the NHS in the UK are overstretched now.  The pressure is felt as much in the Ambulance service as anywhere.  The impression given by the media is that drunk and drug related incidents are the main cause.  We do get these jobs, of course, but in my experience these are not the most time consuming of our jobs.

My experience is that most of our jobs are elderly people unwell or falling.  NHS (in the UK) stats tell us that 1 in 3 people over the age of 65 will have at least 1 fall per year, about half of these fallers will have more than 1 fall.  At the end of the 20th century and start of the 21st we are living longer than our ancestors.  This means that the age range of the population is increasing and the proportion of elderly in the population is increasing.

With age can come weakness, balance problems and reduced co-ordination – these all contribute to the increased risk of falling.  The highest risk times for falling seem to be late at night and early morning.  Many of our elderly population seem to be prescribed medication to help them sleep at night this obviously leads to drowsiness and increased risk of falling when getting out of bed to visit the bathroom.

The consequences of falls in the elderly can be severe.  A common injury is a fractured ‘neck of femur’ (#nof (the hash symbol in this case is not a hashtag, it’s medical shorthand for fracture)).  The femur is the thighbone, the longest bone in the body.  At the top of the femur there is a ball shape which projects at an angle and fits in a socket in the pelvis forming the hip joint.  The portion of bone between the main shaft of the femur and the ball joint is called the ‘neck of the femur’ and is the weakest part of the whole bone.  With increasing age the bones can become less dense and more brittle.  If a person then falls and lands on his or her hip then this easily causes a #nof.  This requires surgery to repair with all the associated risks of surgery in the elderly and then a period of immobilisation in hospital (typically 6 weeks) followed by a period of physiotherapy.  Another common problem is a head injury – many elderly people are on ‘blood thinning’ medication (anticoagulotherapy).  In this case a trip to the Emergency Department is needed for a CT scan to rule out a bleed on the brain.

What do we do when we get to a fall?

First thing, as always, is to quickly assess airway, breathing, circulation and responsiveness.  Once we’re happy that the patient is alive and breathing we make them as comfortable and warm as possible on the floor while we assess their baseline observations and examine for injuries.  If there are no injuries and the patient is medically stable the next step is to get up from the floor.  If the patient is unable to get up themselves with instruction and assistance from us we use an inflatable cushion to lift.  When deflated, the cushion is flat and can be slid under the patient’s bottom (with some shuffling, leaning, sliding and under-the breath-swearing!).  Once in position we connect a series of pipes to a compressor and inflate the cushion.  The patient can then simply stand from sitting and we can assess his/her mobility.  If all is well, we can safely leave the patient at home (after we have completed the mountain of associated paperwork).  One further service we perform is to refer the patient on to a falls prevention team.  This is a multi-disciplinary team of people who visit the patient and get involved to try and prevent further falls.  This may involve physiotherapy to improve strength and balance, it may involve a review of possible walking aids with training in how to use them and it usually involves advice on lifestyle and adapting the home to remove or minimise trip hazards.

I’m not for one second suggesting that falls are not a genuine part of our job but falls do take up a lot of ambulance time.  What’s the answer?  I don’t know if there is an answer.  We are always going to be needed when elderly and vulnerable people fall.  I believe falls prevention plays a huge part in preventing repeated falling.  It’s a pity that you have to have a fall before the falls prevention team get involved; it would be good to see the falls prevention team’s roles increased so they could get involved with everyone as a certain age is reached to prevent even the first fall.

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!