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.

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!!

Child RTC – unknown if breathing

(SPOILER ALERT: To avoid undue distress this anecdote ends happily)

 

One Saturday afternoon Tony and I were passed details of a job: it was a reported child RTC (Road Traffic Collision – in other words the child had been hit by a vehicle).  Due to the panic of the caller and language differences, our call taker was unable to establish if the child was breathing, responding or conscious.  All we had was the street name and possible age, 7.  The street was not far away and we were there in minutes.  On the way we were both apprehensive and anxious.  There’s something about an unwell or injured child that that I dread. I think that every emergency worker feels the same – it’s just so heartbreaking when a child is harmed or killed and even after 20 years I feel very scared when a child’s well being and even life is in my hands.

I turned the ambulance onto the street, blue lights still flashing, and the sense of dread increased.  A large crowd of people were standing in the street and on the pavement.  As soon as we arrived members of the crowd started waving and shouting at us.  At this point we couldn’t see the child through the crowd.  We got out of the cab and the shouting got more frenzied as people tried to rush us.  Tony got the response bag (a large rucksack which contains most of the equipment needed to start treating almost every conceivable emergency) out of the side door and we started to walk toward the area of the crowd that we were being jostled towards.  People sometimes think that ambulance staff are too casual and slow when approaching an emergency, they expect us to run.  During training it is emphasized that you should never run – that’s when mistakes are made and injuries happen.  We are trained to take a calm, measured approach and observe as much of the scene as we approach to evaluate and minimise any dangers to us, the patient and any bystanders.

We pushed through the crowd and finally got to the young boy, Bilal, who was lying on the street on his side with his mum cradling his head and sobbing and praying.  A multi-person-vehicle (MPV) was parked a short distance away with a large, obvious dent in the front where it had collided with Bilal.  We had to gently get Bilal’s mum to let go of him so we could roll him onto his back so we could protect his neck and assess his breathing and circulation.  Tony gently held Bilal’s head in neutral alignment so his spine was in its natural position and to our relief we saw that he was breathing and had a pulse, both were in the normal range for his age and there was no obvious difficulty with breathing.  His blood pressure was normal for his age. A man came forward and introduced himself as Bilal’s uncle, Ash, who offered to interpret for us as Bilal’s parents spoke very little English.  Tony knelt on the floor holding Bilal’s head in neutral alignment, also protecting his airway and explained to Bilal’s parents, via Ash, what we were doing and what we needed to do.  I tried to clear some space around us by shepherding some of the crowd away onto the opposite pavement.  I went to the ambulance to get the equipment we needed: a rigid collar to help immobilise Bilal’s neck, scoop stretcher plus padding to fully immobilise and various straps and a blanket.  As soon as I started back to Tony and Bilal the crowd had resumed their position in a tight circle around them.  I forced my way in with the equipment and Tony and I began the delicate task of immobilising Bilal so we could safely move him from the floor to the ambulance and then on to the Emergency Department.

Bilal had a large swelling above his right eye from his collision with the MPV and a swelling to the back of his head which had a small laceration on it: as with all scalp wounds this had bled profusely.  His level of consciousness was reduced from normal and was constantly changing.  He would be restless and agitated crying in pain then lapse into a quiet phase then return to the restless phase. We tried to apply the rigid collar but he became very agitated, fighting us off.  We made the decision to compromise and leave the collar off.  Although this was reducing the immobilisation of his spine this was one of those cases where it’s better to leave the collar off and keep the patient calm than try to keep the collar on and have the patient agitated and restless – probably doing more damage to a potentially damaged spinal cord.  We managed to get Bilal on the scoop and place the padded head blocks and body straps on without disturbing him too much, and moved to the ambulance.

In the ambulance we settled Bilal’s mum and uncle Ash and closed the doors so we could work in relative quiet.  We rechecked all Bilal’s vital signs and checked him thoroughly from head to toe.  His main injuries were the swelling above his eye and the laceration to the back of his head.  There were several other superficial cuts and abrasions on his elbows and his back.   His pupils were equal size and both reacted when a light was shone into them.  If one or both pupils became dilated and stopped responding to light that would be a sign that there was internal swelling in the brain.

Before we left the scene we had a quick word with the driver of the MPV and some of the witnesses, they all said that he had been driving along the street at about 25 mph when Bilal had run out in front of him giving him no chance to stop.  Bilal had been knocked to the floor and had been completely unresponsive for a few minutes before recovering to the agitated state he was in now.

We set off to the ED of the local hospital with no further delay (this was before we had specialist trauma centres).  As we set off we asked the control centre to pre alert the hospital so they were waiting for us as we arrived.

The rest of the shift carried on as normal but both Tony and I kept dwelling on the job, analysing everything we did and wondering if we should have done things differently, if there was a better way to have handled the job.  As always, I had a vague sense of guilt that I had not done enough for Bilal, although I couldn’t put my finger on anything specific.

A few days later we checked and were relieved to hear that Bilal had made a full recovery and was discharged home.  A happy ending this time, hopefully in future he’ll be more careful on the roads!