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.

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.