Collapse in the street

I’ve just noticed that most of my anecdotal blogs seem to end in tragedy.  Just so people don’t get the wrong idea about me and my paramedic skills I thought I’d include this one which has a HAPPY ENDING!

It was a Saturday afternoon, Tony and I were just over half way through our day shift.  Through the morning we had drifted further away from our normal area and were in a neighbouring town.  We were on our way to the next emergency when a category 1 emergency jumped the queue and was passed to us – a 45 year old female had collapsed on a street and was in cardiac arrest.  Luckily a bystander who saw her collapse was first aid trained and recognised cardiac arrest and started CPR immediately while other bystanders called 999.

It didn’t take long to get to the general area, a pedestrianised street of shops on the edge of the town centre.  We were lucky; the lady had collapsed conveniently near an access road so we could get the ambulance near.  As we arrived a response car arrived too, a local paramedic, Steve got out joining us.  We took a mixture of our and Steve’s equipment to the pavement where the lady, Amy, was lying on the pavement with a first aider, Carol, doing CPR.  A local shop keeper had thoughtfully brought some screens out and arranged them round Amy to give some privacy.  I asked Carol to continue with chest compressions while we prepared our equipment.  Tony connected the Bag-Valve-Mask (BVM) device to an oxygen cylinder. A BVM is a rugby ball shaped rubber reservoir connected to a face mask.  The mask can be placed over the patient’s mouth and nose, then the reservoir is squeezed and this forces a lungful of oxygen-enriched air into the patient’s lungs.  He inserted a basic airway into Amy’s mouth, a small plastic tube which prevents the tongue from blocking the airway and took over the job of breathing for Amy as carol continued chest compressions to keep the blood circulating.  Steve and I were preparing the defibrillator – we placed 2 large, sticky gel covered electrodes to Amy’s chest.  We could monitor Amy’s heart through these and, if needed, deliver electric shocks.  In the old days we had 2 manual paddles which we had to coat with gel and hold against the chest while we analysed the rhythm and delivered the shocks. The stick-on pads are much more efficient and safer to use.  Amy’s heart rhythm was not one which would benefit from an electric shock (she was in Pulseless Electrical Activity (PEA)).

At this point we decided to move Amy to the ambulance.  We used a ‘scoop’ stretcher (a long board which splits long-wise in half so can be fed under the patient from each side and clipped together with minimal movement of the patient) to pick Amy up from the floor onto our stretcher (gurney) and then onto the ambulance, all the while continuing with chest compressions and breathing for Amy.

On the ambulance Tony took over the chest compressions (Carol the first aider was exhausted by now).  I moved to the head end of the stretcher to monitor Amy’s airway.  She had a basic airway protector in but I intubated her to fully protect her airway.  This involves putting a tube (Endotracheal tube (ET)) into the top of the wind pipe (trachea). The ET has a small balloon around the outside which once in situ in the trachea this is inflated to seal the airway and prevent vomit or other secretions getting into the airway and lungs.  Once this was in place we attached a mechanical ventilator to the projecting end of the ET.  The machine now takes over the breathing for Amy. While I was intubating, Steve was finding a vein in Amy’s arm and had cannulated.  We could now give drugs directly into Amy’s blood stream.  During resuscitation we give the drug adrenaline (also known as epinephrine) every 3 to 5 minutes.  This circulates round the body and causes surface blood vessels to constrict so all the blood is concentrated to the major organs.  We also give fluid, water with salt dissolved in to the same concentration as in the body.

During this activity I thought I noticed a slight flicker of movement on Amy’s face.  This can be a normal part of CPR, we compress the chest quite vigorously and this tends to move the whole body but as I did a pulse check I was excited to feel a pulse on the side of Amy’s neck.  We stopped the chest compressions immediately and checked Amy’s baseline observations.  Now the heart had resumed its duties in driving the blood around Amy’s circulation her baseline observations were surprisingly normal.  Her heart was beating at a normal rate, her ECG (trace of her newly started heart) looked surprisingly normal too. Amy’s blood pressure was good, she was still unresponsive and not breathing for herself but things were looking good.

This was the time to get to the local hospital.  Tony gave the hospital a pre-alert call via our control room so the staff would be ready for us and have time to prepare for us.  During the short drive to hospital I sat with one hand on Amy’s neck feeling the pulse.  She still wasn’t breathing for herself but the ventilator was breathing for her.  We transferred Amy to the care of the Emergency Department staff and then began to tidy up and make a list of the equipment we needed to restock (over a well earned cup of coffee).

Over the next few weeks we were happy to hear that Amy progressed from Intensive care to a general medical ward and was finally discharged to home having made a complete neurological recovery.   The key to Amy’s survival was the immediate good quality CPR provided by Carol, the first aider.  No amount of work by us will resuscitate a person who has been down with no CPR for the 5 minutes or more that it takes us to get to the collapse.  I can’t stress enough the respect I have for first aiders and feel that everyone should learn basic CPR – it really can make the difference between life and death.

Male on the road – no sign of life.

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

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

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

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

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

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

This was decision time.

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

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

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

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

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

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

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

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