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.

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.

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.

Why I wear a Remembrance Day poppy

This blog post has no ambulance anecdotes in it; this is what the symbolic meaning of the remembrance poppy is to me.

The poppy was first used in 1921 as a symbol to commemorate the fallen military in the First World War. It was inspired by the war poem ‘In Flanders Field” by Lt Col John McCrae.  Since then it has come to be a symbol of remembrance of military fallen in every conflict including and since the First World War.

Some see it as a political statement and a measure of patriotism, some as a glorification of war and others even as a racist slur.  To me it’s none of these.  I certainly don’t glorify war – I wish we as a species could at long last ‘grow up’ and accept differences, tolerate other viewpoints and all get on and love and help each other.  John Lennon summed it up for me in his masterpiece ‘imagine’.  End of rant.

I wear a poppy to remember and honour my great uncle Saville.

Saville was born in 1899 in a small Yorkshire town, Northowram.  He joined the army in 1915, joining the Royal Army Medical Corps as a stretcher bearer.  Some stories have been passed down through the family and one of my favourites is about how Saville and his colleagues dealt with wounds.  If a wound was bleeding and they were struggling to stop the bleeding one trick they found to increase the pressure was to place a dressing on the wound then place a small stone, or even once a potato on the wound then strap a bandage around it – the stone would increase the pressure to stop the bleeding.  Coming back to the 21st century, one type of trauma dressing we use has a plastic pressure bar insert (with a projection shaped like a small potato!) to be strapped over a wound to increase pressure and help stop bleeding.  It always makes me smile to myself because I think that my uncle and his friends invented this gadget!

Saville was awarded the Military Medal for bravery during a particularly fierce battle making several sorties out into no-man’s land to fetch wounded soldiers back to safety.  Tragically he was killed on the first of October 1918 – just weeks before the end of the war.  A shell exploded above him while he was on his way to pick up some wounded soldiers and a fragment of shell casing struck him in the chest, killing him instantly.  His mother, my great grandmother, never got over her grief at losing her son.

This is just one tragic story out of the hundreds of millions of casualties in the 20th century wars but it is very personal to me.  I obviously never met my great uncle but I would love to talk to him and hope that he would be pleased I’m a modern day stretcher bearer.

That’s what the poppy means to me and that’s why I wear it.