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.

Shooting in a nightclub

Many years ago one Friday night shift, Tony and I were directed by our control room to a reported shooting at a night club in our local town.  There were possibly multiple casualties, but the local police were on scene so the scene was ‘safe’.  This was long before our service had response vehicles (ambulance cars with solo clinicians), HART teams (specialist paramedics with extra training in all sorts of hazardous conditions) or a structure of senior clinicians (senior or advanced paramedics with extra education and responsibility) to talk to on the phone or radio.  There was Tony and me.

We arrived to a scene of utter confusion.  The few police officers on scene were trying to organise the large crowd of party goers into some sort of order.  We joined the melee and tried to find the wounded patients.  At this point we did not know how many patients we had or the extent of their injuries.  A hysterical girl grabbed my arm and pointed at a lad who was sitting on the doorstep holding his chest.  He was very calm and didn’t seem drunk.

“I think I’ve been shot” he said, more unbelieving than anything.

A quick look revealed a wound to the back and a wound to the front of his chest.  There was very little external bleeding. He was obviously conscious and his airway was safe, a quick feel of the pulse at his wrist indicated no sign of immediate major bleeding so I left a police officer keeping a very close eye on him while I joined Tony who had found another casualty.  This lad had a single wound in his abdomen with no other obvious wounds; he was also conscious and couldn’t quite believe what had happened.  He was conscious but was quite sweaty and breathing fast.  His airway was safe so an off duty nurse from the crowd who seemed quite sober was left to watch him while we continued to search.

No other casualties were obvious. I couldn’t quite believe I heard myself shouting at one point: “Has anyone else here been shot?”

For now, we were happy that, miraculously, there were only two casualties.  I asked control to ‘make vehicles two’, the concise and unambiguous way we ask to make the total number of vehicles two.  Of course we were told that there would be a delay as there were no available vehicles anywhere in the area.

There began a hectic period of treating the two casualties on the pavement while we waited, oxygen and fluid lines for both and constant monitoring of vital signs.  All the while a large crowd of noisy, drunken partygoers were jostling around us as the police barely managed to impose order and give us space.  As the backup vehicle arrived I handed them the lad with the abdominal wound, his heart rate was increasingly rapid, along with his rate of breathing and his abdomen felt rigid to touch.  These are sure signs that there was significant internal bleeding, for now his body was managing to compensate but it wouldn’t take much longer for his blood pressure to crash.  This was long before we had haemostatic dressings or the drug tranexemic acid to help slow down blood loss.

I was then able to concentrate on my lad with the chest injury.  Once on the ambulance it was possible to listen to his chest to assess the degree of pneumothorax, that’s where air gets into the space between lung and chest wall causing a collapse of the lung, I couldn’t hear a thing outside in the crowd. Incredibly there was still good air entry despite the entry and exit wound in his chest, his vital signs were stable and didn’t indicate much internal blood loss.  There was no respiratory distress and he claimed he was in very little pain.  He said that the most pain came from my cannulation (IV line); obviously a little bravado was coming out to mask his fear.

After a final quick check that no further victims had been found we were able to set off to hospital.  Several people had come forward to say they were “in shock” from seeing the shooting and wanted to be “checked over”.  We gave self care advice to these and managed to not be delayed any further.  It was finally time to set off for the local hospital.  This was before we could go direct to specialist trauma centres, so the ED of the local district general hospital would have to cope.  Our control had already given them a warning that there was a shooting with possible multiple victims in their area as soon as the job came in but now we gave them specific details of our patient.

On the brief trip to hospital, the bravado (and the adrenaline) wore off and he changed from the laughing ‘gangsta’ with his ‘badge of honour’ gunshot wound and he became the scared little boy who was terrified of death. I reassured him as best I could and I was very touched when he said he was glad I was with him as I was a very kind man.  He shook my hand. The gangsta mask went back on at hospital as the nurses were hooking him up to the monitoring gear.

I still have no idea why the two lads were shot, were they just in the wrong place at the wrong time? Were they deliberately targeted?  Rumours were widespread in the following weeks, most seemed to be that they were selling drugs on someone else’s territory.  Sadly the lad shot in the abdomen died in the ED from blood loss, the lad shot through the chest survived.

I think people like to have a reason to justify or explain horrific incidents, if the lads brought it on themselves then it somehow reduces the risk of any of us being shot at random for no reason, although this ignores the fact that opening fire with a handgun in a crowd is as likely to injure/kill the innocent as it is the targets.

As a parent of two children who are now at the age they enjoy a night out at a club with friends, this is one of the reasons I feel such secret dread whenever they are out and feel such relief when I know they are safely home.

This was many years ago before it was routine to offer the crews time out after an intense job and the chance to debrief (talk the job through with a manager or senior colleague, a very therapeutic process).  The next job was waiting for us….

Motorway Tragedy

One Saturday evening several years ago, I signed on for my 1900-0700 night shift. I didn’t have a crewmate that night so I told the control room and left them with the task of finding another un-crewed person to put us up together.  A short while later, my partner for the night arrived.  Sue was a new technician who had not done many shifts since leaving training school; this was her first set of weekend nights, she was happy but nervous.  I did my best to put her at ease as we signed on and she put her personal gear on the vehicle.

The night started uneventfully, the normal hectic set of weekend night type jobs: mainly alcohol and drug related mishaps, with some normal medical problems mixed in too.  About 3 o’clock in the morning we did a transfer from our local hospital to a specialist urology department – an elderly gent whose urinary catheter had been causing problems needed a specialist review.  After we dropped the gentleman we cleared and were told there were no outstanding jobs so we could head back to station for now (this was in a time when we did have quiet patches during a night shift with no 999 calls, not like now where every minute of the day we seem to have calls waiting for us).

I was driving back on a short stretch of motorway and Sue and I were chatting about the job, I remember saying “This has been a typical shift; this is what weekend nights are like…”  Sometimes I should just keep my big mouth shut!

A few miles further on we noticed a crowd of people standing on the hard shoulder of the opposite carriage way.  This was a region of motorway with a sharp bend in it – lots of cars misjudge the bend here and lose control (not long after this incident a permanent reduction to 50mph was imposed on this stretch). As they saw us they started waving.  From a brief glance in the dark it was impossible to see what the problem was.  Sue contacted the control room to see if there was a call for the group of people we had seen – the answer was no.  I decided we should leave the motorway at the next exit and join the opposite carriage way and come back to investigate.  As we were rejoining the motorway, control called us up on the radio to tell us the job had just come to them from the call takers – it was an RTC – details were sparse but possible fatalities.

The motorway was fairly quiet, not too much traffic at this time in the morning.  As I approached I slowed down so we could take in the scene and pick the best place to park the ambulance.  From a distance we could see debris in lanes 2 and 3 with two cars at angles in lane 3.  A crowd of people and several parked cars were on the hard shoulder.  I left the ambulance a distance from scene straddling lanes 2 and 3, the blue lights left on to warn traffic and with our helmets and high visibility jackets on we approached on foot.  Sue said on the way that she had not had a job like this yet so I  said to stay close and follow my lead.

What had at first glance seemed like debris in lane 2 was actually a body, a young male in his twenties.  Two other bodies were in the carriageway between lanes 2 and 3.  One car had its nose in the central reservation barrier, a second car was parked in lane 3, its windscreen was broken in a ‘bulls eye’ pattern, a circular and radiating pattern of cracks from a central point of impact – typical of when a head hits the screen.  The screen was deflected inwards, implying that the car had hit someone who was outside the car rather than been hit by an un-restrained body inside the car as it crashed.

The first priority as I was assessing the scene was to start to triage the casualties in the road.  I was confident that we were as safe as we could be, the ambulance was protecting us, we just had to be mindful that cars were still using lane 1.  Sue updated control and requested police and back up vehicles as I quickly assessed each casualty in turn using the ‘triage sieve’ system we use for multiple casualties. This is a first triage system where a casualty can be assessed very quickly (mass triage has evolved since the incident to include a first step of addressing any massive bleed as a first step, this describes the triage sieve in use at the time).  The next step is to check is if a potential casualty is actually injured, if not they are directed to a clearing station area.  If they are injured but can walk, they are categorised as priority 3, the least urgent category of injured casualty. If the patient is not breathing despite an attempt to open the airway, he or she is classed as dead. For the breathing patient, rate of breathing, heart rate and capillary refill is quickly assessed and the patient is categorised as priority 1 or 2.

As I started to triage the police arrived and quickly closed the motorway, at least we were safe now and we knew the bystanders were safe from further injury.

Sadly, all three casualties all came out of the triage system as dead.

By now it was daylight and an hour past our scheduled finish time – quite a subdued end to what had started as such a routine shift.

The next night shift all the crews involved were called to a de-brief, a meeting where we have a chance to discuss the incident, run through the decisions made at each stage and also to get an overview of the whole incident.  When you are busy dealing with parts of a large incident you often do not know the whole story which is quite frustrating.  The de-brief is a very therapeutic thing and it helps to get things off your chest and have your peers and managers justify the decisions you made.

The three young adults who died were travelling in one of the cars and had lost control on the sharp bend in the motorway and had over steered and collided with the central reservation.  They were all fine at this stage.  They all got out of the car and were standing on the motorway looking at the damage when the second car came round the bend, didn’t see them in time and hit the three.  This explained the ‘bull’s-eye’ in his windscreen and why the three were widely scattered.  The driver of this car did not make himself known to us when we were on scene.

It still moves me how suddenly events like this can happen:  A moment of bad judgement by the three young victims and an instant of inattentive driving leads to such a sudden, tragic end to three young lives and three families devastated forever.