Thursday 31 May 2012

Not Viable

"31 year old female, in labour"

People say that they attract a certain type of job. Some are trauma junkies, some are shit shovels, some get mental health and some get nasty RTCs. I think I get a nice mix, but if I had to pick one type of job I get more than most it would be maternity. This can be a good thing, with the bringing life into the world part, but equally it has its downsides. When things go wrong there is no greater fear or feeling of helplessness. On this particular day we were sat at the roadside filling in paperwork from a job that was a complete waste of time. Over the radio control did a broadcast asking for an ambulance for a woman in labour at 23 weeks. We were only two minutes away so offered up for it and left our paperwork for another time. On route we got an update:

"Patient is 23/40 pregnant, PV bleed, having contractions every minute, can hear patient screaming in background, husband on scene, access OK"

I have dealt with miscarriages before and they are not pleasant. I can only begin to imagine the emotional pain that it causes beyond our involvement, but from my point of view they are one of the hardest jobs to deal with. Have a read of this blog, 'Darling Iris' by Bookworm Mummy to try and understand the immediate and lasting pains miscarriage brings. Death and loss is always tough, but in children and babies it feels ten times as bad. The high emotion and grief is an added thing to deal with on top of your patient's condition. All we could hope for was that this call was not as given; I wasn't full of optimism though.

We pulled up to the house; an extremely anxious looking husband was standing at the kerb side waving frantically. We jumped out and grabbed the usual plethora of bags.

"Quickly, please, this is too early, please help us"

There was a distressing, desperate tone to his voice. Normally requests to make me move quicker are futile but there are also times where the seriousness of a situation is paramount and warrants an ambulance 'run'. I headed in to the house and up the stairs. In the bathroom was our patient. Within a couple of seconds it was clear she was going to give birth. In all honesty I was scared. There was a weight of expectation on us do something; anything. I know my resus guidelines but I also know none of our kit, even masks, will fit a 23 week old foetus. At 23 weeks, for all intent and purposes, it's a baby. They are in proportion; they have finger prints, fully formed limbs and a face. 24 weeks is the point a pregnancy becomes 'viable'; such a horrible turn of phrase and one I hate to use but maternity units need a number. Being that she would be 24 weeks in 2 days we acted as such. Another contraction began and any hope I had that this job wouldn't be as I feared dissolved. Two contractions later the baby was born. 

No longer than a ruler from crown to toe, was a little baby girl. We cut the cord and laid her on a blanket. For maybe 10-20 seconds she was making respiratory effort but that soon stopped.

"Do something, do something, please, save our baby", the mother wept.

I started CPR with my index finger, I knew it was futile but I couldn't be seen to be doing nothing. And was it pointless? I don't really know. If 24 weeks is 'viable' then 23 + 5 is too. I told her we would take her daughter straight to hospital and another ambulance would take her. It wasn't an easy decision to make but 2 of us could not get both the mother and baby downstairs while doing CPR. The second ambulance arrived as I scooped up the baby and headed to the ambulance. I passed the other crew in the hallway, doing CPR as I walked. My crew mate gave a brief handover and we left. Holding an oxygen mask just over her face we travelled through the traffic. I felt strangely alone in the back of the ambulance; it was shaking quite a lot, the muffled sound of the sirens clearly audible and a very clear noise of the engine screaming. All the while I was staring at this tiny baby, trying to keep it alive. Realistically I knew my efforts were ineffectual but in a pre-hospital setting sometimes you have to do things for the sake of relatives. In this case I was probably doing it for me also. The distraction of being task-focused takes you away from the reality of what is happening around you. It's much easier to say 'it's just part of the job' if you are actively trying.

We pulled up at the hospital and ran in. There was a small team of people waiting for us and I gave the handover as I placed her on the bed. A few moments later the doctor decided to terminate the resuscitation. His rationale? Not viable; there are those words again, so scientific and detached, but I suppose it has to be. Yes, 24 weeks is viable but only in a controlled environment with everything at hand to keep the baby alive. Born in a bathroom, without proper oxygen for 13 minutes and without the expertise of a hospital she didn't stand a chance. I knew that they thought I shouldn't have started, but they have the knowledge and job title to be able to make that decision; I don't. I had a distraught mother and father begging me to try and save their baby and I would make the same decision again. Minutes later the mother arrived. She knew without being told. We shared a look from opposite ends of the corridor. No words were needed. Nothing could be said to make the situation anything other than what it was. I left the department and went back to the ambulance where my crew mate was waiting. He puffed out his cheeks and exhaled slowly. I just nodded.

Monday 28 May 2012

Here we all are

"28 year old male, fitting"

It was 05:10. I was tired. My crew mate was tired. In five minutes we could only be given a Red 1 (Cardiac Arrest). The clock was ticking by and we were ever hopeful of being off on time. It was not meant to be! Our radios went through their routine of beeping in the most annoying, cutting tones whilst frantically vibrating. I'm not going to lie, there were a few expletives uttered about being 'stitched up' with a late job! Never mind, it was nothing new, we kind of expected it. At least it was a genuine job, a fitter, still fitting, wife on scene blah blah blah. I was glad I wasn't going to be late off for a 19 year old reveller in stilettos, a skimpy dress and hair matted with vomit that was lying in the kerb after over doing it on the Jaeger-bombs. We arrived at what was probably the worst signed estate I have ever seen. Numbers were not consecutive at all. We were looking for 87. We found 85 and 89 but not 86, 87 or 88. Eventually we found them on the opposite side of the compound on the top floor. By now the FRU had joined us, so up we went. It was now 05:30. All three of us had finished yet we still hadn't met our patient, *grumble, groan, moan and bitch*

We were met at the door by the patient's wife. We were shown into the living room where our patient was lying on a mattress. He wasn't fitting but had been. He was post-ictal, giving confused answers whilst looking around with very vacant eyes. We gave him some oxygen to bring him around a bit whilst we asked his wife about what had been going on. She said he had been fitting for about 10 minutes:

"Is he epileptic?"

"No"

"So is this his first seizure?"

"No he's had 3 before"

"Has he been treated at hospital?"

"Yes, he has had scans and everything"

"And what have they said? Have they not said he has epilepsy or given any medication?"

"Yeah they gave him a prescription after the last one"

"When was that? How long has he been taking the medication?"

"It was three weeks ago but he hasn't started taking it yet"

"Why not?!"

"Because we haven't picked it up yet"

"Why not?!"

"Because we didn't think it would help"

Seriously, what is wrong with people? Why do they not take the advice they ask for?! It's madness! Yet they seem surprised they are not cured! Whilst I helped cannulate the patient the FRU continued the conversation where I had left it.

"So he has had previous seizures, he has been diagnosed with epilepsy, he has been given a prescription for Epilem to stop the seizures but he hasn't taken it because he doesn't think it will help. Now he has had another seizure and here we all are"

"We don't think that taking loads of the tablets is the best way to treat things. The body doesn't need all the chemicals"

"It's the only way to stop the seizures!"

"Oh, we didn't realise"

Tired and frustrated, we got the chair and carried him down the many, many stairs and onto the ambulance. We did his ECG and gave Diazepam when he had his second seizure en route to hospital. Really though, would this make him change his ways? Would a fourth trip to hospital do anything? Would we be back in a few days or weeks because he is still 'anti medication'?! This was a totally avoidable waste of resources, not only for the ambulance service but for the hospital too. It's as bad as parents 'not agreeing' with antibiotics, being 'against' immunisations or not 'believing' in giving paracetamol for high temperatures, then being surprised their kid has had a convulsion; it's nonsense, and irresponsible. Billions of pounds are invested from taxpayers' money to find cures and treatments and pay for medications to reduce an ongoing cost for continued treatment. Failure to heed the advice given and take medication prescribed should trigger charges to pay for future treatment & combat this avoidable use of the NHS. It's ignorant at best, which really riles me.....especially when it makes me 2 hours late off! Rant over! 



Sunday 27 May 2012

Pains, Cranes and Automobiles

"19 year old female, stuck in house"


This week saw an article in the news about how 19 year old Georgia Davis, who weighs 63 stone, needed to have part of her house dismantled so she could get out and to a hospital. A team of 40+ people including doctors, paramedics, fire crews, police, council workers and scaffolders worked hard to 'free' her from her house. She had been confined to her bedroom for a number of months, due to her size, and it took the team 10 hours to cut a 10ft by 10ft hole in her 1st floor bedroom wall. She was then lifted by crane on to a purposely build ramp and onto a specially strengthened stretcher and into the reinforced bariatric ambulance. Weighing the same as a young elephant at just 19 she has diabetes, kidney disease, spinal problems, multi-organ failure and respiratory problems. This is a topic I have discussed at length before in Fat people, Stairs and Backs & Obesity: The cause, the cost, the solution due to my experience craning someone out of a window, but seeing these articles just highlights how little is being done. 


Georgia's obesity isn't just through being greedy and lazy; it would be naive to assume that. There are many other factors at play, none more so than her profound psychological problems. In her defence, she had a miserable childhood. She was the carer of her disabled mother and her father died when she was young. This doesn't excuse what spiralled and what has continued to do so unchecked but it goes some way to explaining where it began. She needs continual support, not just sporadic intervention, which she had when sent to 'fat camp' in the USA. What she needs is the constant support and treatment from a multidisciplinary team including doctors, dieticians, psychologists and counsellors. Yes, all this costs money in the short term but surely we are passed the point of prevention. Cure is the only way to stop the spiralling costs of her care. 

Once labelled 'Britain's Fattest Teen', Georgia had more help than most people get. She lost 15 stone in the USA, all paid for and began to look like she had turned the corner. Unfortunately, on her return, her first meal given by her 'loving' mother was a chip supper. Since then, her weight has ballooned to almost twice her pre-USA weight, to the point of having to be cut out of her house. Then again, with a daily diet of up to 13,000 calories are you surprised?! I'm not. Despite her psychological issues, this eating to excess has been allowed to continue, encouraged and supported. She can only eat what she is given and the blame lies solely with her mother. This didn't just happen overnight, it has taken a short lifetime. It isn't as if no one saw it coming either. She was over 20 stone aged 12, she was on the at-risk register at 13 but threatened to harm herself if social workers took her away from her family. She was removed from the register. At 14 she was 29 stone. There were chances to intervene. There were chances to stop it. Apparently threatening self-harm is reason enough to stop being 'at risk'.  She needed help and was let down by 'the system'. Now an adult, she is no one's responsibility. To be 33 stone at the age of 15 is more than comfort eating and there should be protocols in place to stop cases like this to continue. It is child abuse, plain and simple. How can you allow your daughter to put on 40 stone in 3 years?! To fuel the feeding frenzy her mother sold interviews about her extreme obesity and this has been tolerated because in our 'freak obsessed' society, her body was a money spinner, rather than something to be ashamed about. Her mother needs to be held accountable and charged for the abuse she has caused. That has to be the deterrent. I see little difference between this and beating children. The punishment should be the same. She was let down by the adults there to look after her. That is the bottom line.

Childhood is where it all starts. Nearly a quarter (23.1%) of children are overweight or obese by the time they start primary school, this increases to over a third (33.4%) by the time they finish. Health promotion is fraught with difficulties in school-aged children as poor management of obesity can result in life-long unhealthy eating habits and avoidance of medical help. The NHS has been forced to focus on treatment of illness rather than prevention due to increasing demands and costs. Obesity costs the economy not only in health care but also in sick days, workplace injuries and disability pay. The cost to the NHS is in excess of £500 million a year and to the tax payer, a cost of £2 billion in lost productivity. When will a stand be made? When will prevention be the focus? When will people see that paying for reinforced beds and ambulances, knocking walls down and sending fat kids to America is a short term fix for an ever growing problem (quite literally!)? Without the procedures in place to monitor these children the same will happen time and time again. It is estimated that by 2030, half the population will be dangerously overweight and at risk of an early grave thanks to diabetes, cancer, heart disease and pretty much any other illness you care to mention.

Clearly something has to be done. The tax payer will foot the bill for the scaffolders, the repairs to the house, the fire brigade, the doctors, the police, the ambulance service, the hospital fees, the treatment, the surgeries, the medication, the after care, the counselling, the calorie controlled diet, the benefits, the disability allowance and everything else she will need.  Sadly I have no faith that, even with all the recent costs incurred, anything will change. I hope I'm wrong, but I doubt it.




Here are some other articles about the extraction from her house:

Saturday 26 May 2012

None of your business

"56 year old woman, headache"

The first night shift is always the worst. Like I have mentioned before, as a poor sleeper at the best of times, by the start of the shift I've been awake for 12 hours already. Between 3am and 5am is the worst time. We are sat at hospital and I was nodding off left, right and centre. Head drifting forwards and then a sudden jerk upright over and over again. Seeing a "headache" appear on the screen did not thrill me either; far from it. We headed round to the address, it wasn't far away so we were there within a few minutes. At this time of night it's normally pretty easy to spot the patient's house as it's normally the only one with lights on. Tonight however we were not so lucky. No lights in houses and no street lights. We crawled along at 2mph with the search lights on peering through hedges and gates trying to see a house number. Eventually we found it. Sorry to digress but seriously, there should be laws about house numbers! They should be a good size and easily visible for all, not black, 3 inches tall and covered in leaves! Just sayin'!

It was a big property, a large Victorian terraced house, by the looks of it 3-4 bedrooms and high ceilings. We wandered up the drive to the large oak front door which had a heavy black knocker. I gave it my usual 'ever so sarcastic' three slow knocks; nothing. I knocked again, this time with more force; nothing. We shouted through the letter box and knocked again but you guessed it... nothing. We asked control to give the caller a ring back. We heard the phone ringing and after only a few rings it stopped. She had answered. After another 5 minutes the door was opened. She looked me up and down and walked off into the living room; it wasn't until she was a few feet away she began talking:

"You took your bloody time"

Not the best way to endear me; in fact, it's highly likely to get my back up. Needless to say I bit my tongue and moved swiftly on, ignoring her snide remark.

"Well we are here now; I gather you have a headache?"

"No I don't, it's not a headache"

"OK then, what's the problem? What have you called for?"

"I have a feeling in my head"

"What kind of feeling? Does it hurt?"

"It's just a feeling, it doesn't hurt but I'm fed up with it. I need to be admitted to hospital"

"We can pop you to A & E if you like, I can't say whether you'll be admitted or not, that is down to the hospital"

She went on to say the hospital she wanted to go to. It wasn't the nearest by any stretch of the imagination, in fact there were 4 closer. Up to a point patients have a say where they want to go, and I am often more than willing to go, but she was being rude so I didn't commit. I said we would discuss hospitals once we had checked her over on the ambulance. After waiting 20 minutes for her to pack a bag she marched passed us at the door and said:

"Shut the door behind you"

As you can imagine, by now I was getting pretty ratty! It was 03:30, I was tired and not in the mood to be treated like a naughty ginger step child. I sat in the jump seat to get started on my paper work while my crew mate tried to do her obs.

"No, you don't need my blood pressure, you're not a doctor"

"You've called us, we are here to help, let us check you over and we can go to hospital"

"No, I don't want you to"

"OK then, what medical problems do you have?"

"That's none of your business"

"Well it kind of is! You have called an ambulance, we need to give a handover to the hospital as to why you are here, you medical history is pertinent to that"

"Well it's none of your business"

"OK, do you take any regular medication and have you taken any today or this evening for your 'feeling'?"

"You don't need to know that." 

"Yes we do, it is important for the hospital to know because it may effect what treatment they give you"

"Then I'll tell a doctor when he asks, not you"

"Fine, who is your GP?"

"I fail to see how any of this is your business, stop asking questions and take me to hospital"

She wasn't listening to a word I had to say, it was if her fingers were in her ears like a petulant little child. At this point I told her we would not be taking her to the hospital she wanted as it was too far away to justify, and quite frankly, I didn't feel like it. 

"Why not?"

"You are not willing to tell us anything about what is wrong with you, your medical history, your medication or you GP. You won't let us check you over yet you called 999 and asked for an ambulance. If you didn't want an ambulance then you could have got a taxi."

"I pay my national insurance and my taxes pay your wages. You will do what I say and take me where I tell you to take me. That is my right"

"You can go to one of the three nearest hospitals"

"You either take me where I want to go or I'm going back home"

"(I just looked at her blankly)"

"Fine, I'm going home"

With that, she got out of the ambulance and not before flipping me the bird, stomped off back inside. EMERGENCY AMBULANCE. That is what it says on the side. That is what it is there for. On speaking to another crew about it after the following job it turns out she is a regular. It just so happened our paths had never before crossed! 'I pay your wages'! Pah! It never gets old!!




Friday 25 May 2012

I Want It Now!

"30 year old female. ?Sepsis"

No one likes getting off late. No one likes getting off late especially when it is because of a GP! With only 45 minutes to go until we were off we got the 'Sepsis' job. I could tell before even arriving that it wasn't sepsis. I'd have been happy to stake my job on it! Besides, it was 17:45; call me a cynic but I'm sure this GP surgery closes shortly! We grabbed our bags and headed in. This GP surgery in particular has provided me with more blogs than any other. They leave more patients in the waiting room with letters and they call more ambulances on Monday mornings than any other. 'GPs: Take Note' and 'Gone Fishing' were the recent posts inspired by this abomination of a surgery. We were directed to the same room as we always are. Inside was our patient lying on the bed with her fiance by her side. In a change from the norm the GP was also still present; probably because we were on scene within two minutes and he didn't have time to palm them off to the waiting room. I listened to his sepsis handover with eager anticipation and it did not fail to deliver:

"This lady has a three day history of feeling unwell complaining of febrile symptoms. She is pyrexic at 38.2 and tachycardic at 101. She is expected by the medics to rule out sepsis"

Sepsis?! 30! A three day history of a cold in someone normally fit and well? I did her obs while she laid, whimpering on the bed. Her temperature was 37.9, her pulse was 84, her blood pressure was good, her oxygen levels 100%, her blood sugar normal and no cough to mention. She did have a 2 day history of urinary symptoms which I'm guessing could be treated by the GP with antibiotics. But what do I know, I'm just a stretcher monkey! I read the sorry excuse for a letter, and as much as every part of me wanted to tell the GP to do his job rather than palm her off to the hospital, I suggested to the patient we go to the ambulance. 

"She can't walk, can you get a stretcher?" her fiance quickly interrupted.

"How did you get here today? She must have got in here somehow"

"We got the bus"

"Right, so she can walk to the ambulance"

"She's been on the bed a while, she is probably feeling weak, I'd advise a chair" said the GP. 

Oh would you? Of course you would. You are not the one who has to carry her. Whilst continuing to bite my tongue I asked my crew mate for a chair. Whilst waiting I continued to try and get some more history. Unfortunately the patient was too ill to answer so her fiance answered for her. 30 years old and she is acting like a 5 year old. It was embarrassing. My crew mate returned with the chair, opened it up and asked her to sit in it. She sat up about 6 inches then dropped back.

"I can't, I'm too dizzy". 

Oh, she can talk after all. Her fiance then tried to dead lift her from the bed to chair. I stopped this attempt quickly in its tracks and respectfully explained she was perfectly capable of getting into the chair. At last the GP agreed and told her to get into the chair.

Once on the ambulance the drama continued and her refusal to talk returned. It was a relatively quiet journey to hospital as she wouldn't speak and her fiance couldn't answer my questions. We wheeled her into A & E as she 'couldn't walk' and joined the other 4 ambulances in the queue to hand over. We were quickly told there were no beds so it would be at least 2 hours to hand over. Her fiance asked what the problem was.

"There are no beds, it will be two hours until we hand over and then 4-6 at least to see a Doctor"

"Let me speak to the doctor, this isn't on, my fiance is sick and needs attention"

"The nurse is over there, she can direct you to a doctor but it won't change anything, there are no beds"

On over-hearing this news, our patient started crying. And I don't me a whimper and a tear, I mean full on balling-eyes-out crying and whaling. Everyone was looking, I was cringing, it was what you would expect from a 3 year old you have removed from a sweet shop without any sweets. She was 30 years old, not Veruca Salt stamping her feet saying 'I want it now'. This went on for 10 minutes until the doctor DID come and see her. Apparently she who shouts  the loudest does get seen. It wasn't the outcome either of them wanted though.

"I am the doctor in charge of the patients in this department, there are 42 people waiting to be seen ahead of you. They will be seen in order of clinical need. That is what 'triage' means. No amount of screaming, shouting and crying will change that. I have seen your letter from the GP and to be quite frank you are not a priority. You will wait like everyone else has to and if you don't like it, the door is over there, now stop this nonsense and act your age."

Silence! Chew on that! Now THAT is what I call a 'bedside manner'. It was exactly what needed to be said and it was exactly what everyone else was thinking. If only we were allowed to say it how it is! Unfortunately we are forced to bow and say 'yeth sir, no sir, thwee bags full sir'. That's just the way the cookie crumbles. 7 years at med school gives you the right to verbally bitch slap people!

Thursday 24 May 2012

OCD, Trees & GPs



"50 year old female, GP visited, states patient wants to kill herself by starvation, states patient's partner is assisting her suicide attempt. To be taken to the nearest A & E"

Well this job was pretty self explanatory. A GP (one that'll soon be in charge of the NHS) went round for a rare home visit, he couldn't get her to agree to hospital, so booked an ambulance. He did that in the full knowledge that if she refused hospital, with the information he had given us, we were now responsible for her! He knew she would refuse but it's easier to pass the buck. C'est la vie!

It was a baking hot summer's day, we had spend the morning broken down, sitting out outside the sweltering ambulance eating ice cream! It was a small victory! The second our vehicle was fixed, this job was sent to us. We headed to the address and went in to the building. The patient was lying in bed, only her head visible, the reason she wanted to kill herself was because she was fed up with her Obsessive Compulsive Disorder. She couldn't leave the bed without a 1 hour ritual which made going to the toilet the hardest and, I imagine, the most frustrating of tasks! So, the suggestion of hospital was not one she remotely considered. She refused all observations, any treatment and any transport. She just wanted to be left at home to die. I have seen a lot of patients with OCD but her's was severe. While I sat there talking, I observed the struggle she faced to do the simplest of tasks. She opened a brand new pack of 10 cigarettes wearing latex gloves. She removed a cigarette, cut the tip off with the scissors she removed from a sandwich bag and lit it with a match. She was then unable to smoke the remaining 9 as the pack was already open. Expensive habit!

Our problem was the age old one of capacity. In legal terms its a 'grey area'. The first question on our capacity assessment tool is 'Is the patient free from any external pressure?' Unfortunately we had already been told by the GP that she wasn't. The partner is of the opinion that starvation is a pain free way to die and as our patient was bed bound, by not feeding her, technically he is assisting the suicide attempt, thus preventing her from being free from the aforementioned external pressure! Sigh! We talked and talked about hospital and how we could make it easier for her. We agreed to 'sterilise' the ambulance by covering a seat in plastic bags, we fetched a 'sterile' infection control suit for her to wear and after a few hours we were making progress. She was out of the covers and had the suit on her legs. Then the partner returned:

"She doesn't want to go to hospital"

With that, all our good work was ruined. Within seconds she was back in bed, head poking out above the covers. We requested the police and one of our officers, as by this point we had been on scene for 3 hours and there was no end in sight. While waiting for the  grown-ups to arrive some family and friends of the patient arrived 'to say their goodbyes'. Please note, she was not about to die, nowhere even close, but the fact she wanted to die meant I was not happy leaving her, especially in the 'care' of her partner. Once the police arrived we had a lengthy discussion about what to do. A sectioning seemed the likely option. Being in her own home meant we were limited to what section we could use. We went back inside to discuss said sectioning and stumbled upon all 9 people who were now in the house singing 'Kum ba Yah' complete with guitars and drum. It transpired that the big tree outside the property was being felled by the council the following day, so they are all meeting up to sing it a song and have a group photo with it. Yes, a group photo, with a tree! Hippies!

Trying to arrange a sectioning on a Sunday afternoon took hours. Eventually it got to the point where all we needed was her GP, the one who phoned us! We had the police, we a had an AMHP, we had an OOH GP, all we needed was hers. Bare in mind we had now been on scene for over 7 hours. My shift finished 3 hours ago, we hadn't had a toilet break, we were more than a tad annoyed by now and then the following conversation occurred:

Ring ring...

"Hello"

"Hello there, my name is Ella Shaw from the Ambulance Service. Is this Dr Smith?"

"Yes, how can I help"

"Well, we are with Miss Jones, who you requested go to hospital earlier"

"Ah, OK, yes I remember"

"Well, we are trying to arrange a sectioning. We have the police, an OOH GP and AMHP on scene, we just need your signature so we can take her in as you requested."

"I'm sorry, but i've got plans this evening, afraid I can't help you."

What?! Have you?! Dont we all?! What a complete waste of time, we had spent most of the shift there, as had 2 policeman and all because the GP couldn't be bothered to do his job in the first place. The outcome was that the patient stayed at home, our officer in my opinion copped out and gave her capacity to refuse. He asked the police to take the partner out of the property and re-assessed her capacity. He came to the conclusion the external influence was now gone. It wasn't, it was standing outside 20 feet away. We were left bewildered and utterly frustrated. The doctor on scene didn't believe she was in immediate danger so a section 135 would be arranged the following day. At least she would get treatment but that didn't help alleviate my foul mood. 

This job did highlighted the issue of OCD. It was the first time I had seen it in such a debilitating way. When people think of OCD this think of excess hand washing, obsessed with tidiness, flicking a light switch on 'X' number of times before entering a room but it is much more varied and severe than people may be aware. It is an anxiety disorder characterised by intrusive thoughts that produce unease, apprehension and fear. The symptoms can vary from excessive washing and extreme hoarding to alienating nervous rituals. It is a mental health disorder that is far more common place than people may be aware and is now the fourth most common disorder to be diagnosed. It is now diagnosed  nearly as often as asthma and diabetes. Very rarely is OCD a stand-alone problem. It is often accompanied by depression, generalised anxiety disorder, anorexia, Asperger syndrome and frequent panic attacks amongst others and like all the above, it requires treatment. Our patient had gone without treatment for many years and the consequences were evident in the way she was now suffering. Like with most mental health disorders early recognition and early treatment is the best way to produce a positive outcome. No one wants to enforce a sectioning and no one wants to drag someone out of their own home for treatment but it is a necessary evil. To prevent this, services and referrals need to be more readily available and easily accessibly. I'm sure i've said that before! Why bother though, it's only OCD eh?! Hmmmm!

GCSEitus


When you hear about parenting you think of newborns, toddlers, the terrible twos, starting school and tantrums about eating peas. Everything is new when the responsibility of parenthood is thrust upon you and as a result, every new thing that happens gets talked about and analysed. Obviously, parenting is a lifetime thing and the teens are a huge part of that. GCSEs! I remember them like they were... oh god that is terrifying! 11 years! Now i'm annoyed! Is it really that long?! Anyway, I remember my parents badgering me to revise, the pressure of exams and being desperate for it to be over. It is therefore no surprise that so many kids are desperate to get out of it! What I am saying is in May be extra vigilant. It is not a coincidence that every teenager has a headache, a cold, and random pains, and funny turns that they don't normally have! Be aware, GCSEitus is real! Don't fall for it!

"16 year old female, chest pain"

Every year, May signals the start of GCSEs. Really, they are what 16 year olds have been working towards since day one at reception, at the tender age of 4. 12 years! It doesn't seem so long now; I can remember 12 years ago with relative ease, and these days the years are flying by. For a 16 year old, 12 years is an unimaginable length of time. Probably because they are far too busy worrying about being moody, petulant, image conscious and of course... their GCSEs. When I look back, it wasn't a pleasant time at all. Parents pushing me to revise (thank you), teachers drumming it home that these exams could well shape our future. No GCSEs means no A levels, no A levels means no degree, no degree means you might as well end your life as you will never get a job, never earn money, you'll be homeless and live a life on benefits inhabiting a studio flat that smells of Special Brew. You'll turn to crime, get arrested, go to prison and be stuck in that self-destructive cycle for the rest of your short life until you die from liver cirrhosis from all the excess drinking. OK, a bit dramatic, but I do think the scare mongering that goes on only adds to the stress, sometimes unnecessarily. GCSEs are important but they are not the be all and end all. I did OK, I don't have A levels and didn't do a degree and I like to think I turned out alright! 

During exam times, there is a sharp rise in what I like to call GCSEitus. As important as they are, the students will try anything to get out of them. To what end I don't know, a couple of days extra revision, a bizarre thought that they may be able to find out the questions for when they sit theirs maybe? We are frequently called to schools for all sorts. It normally comes down as 'a faint', 'a fit', 'DIB' or something which can easily be faked. The pseudo fits, pseudo faints and the dying swans are normally found in the first aid room with a member of staff, a pained look on their face and a fascinating aptitude for spontaneous recovery on making it to the back of the ambulance. I've never known one of these jobs to be anything worse than a panic attack and today was no different. In the first aid room was our patient (complete with pained expression), her teacher (with an exasperated look on his face) and her mum (with a terrified look on her face).

When I walked through the door my suspicion was confirmed. Apparently she had been breathing really fast and as she was about to go into the exam she 'fell' to the floor. After being 'unresponsive' for a few minutes, with the assistance of her teacher, she was able to 'walk' to the first aid room. Her breathing was now fine. Her mum was called and told her daughter had 'collapsed' and an ambulance had been called. Naturally she was worried. The teacher was standing patiently waiting for his fifth ambulance of the week. Naturally he was fed up! I spoke to the girl about her symptoms and she described a panic attack. She didn't have any symptoms remaining so I didn't see the need for hospital. When I suggested coming to the ambulance to check her over properly before leaving her, the pained expression turned to one of desperation. She stood up to come with us and 'threw' herself to the floor. On helping her up again, she could no longer walk or weight bare on her left ankle. My crew mate examined her. There was no bruising, swelling or obvious cause for her pain. She certainly didn't go over on it or suffer trauma to it. Little did she know that my crew mate used to be a sports physio. He knew she was making it up, I knew she was making it up and so did her teacher. Her mother still looked terrified!

Our problem is that although she was acutely suffering GCSEitus we are in no position to accuse her. We have to take what she says as true, so the 10/10 pain had to be treated with entonox. As she 'couldn't' walk he had to get a chair and carry her. It's all part of the game. We took her to hospital. The nurse taking the handover took one look at her and said to me:

"In the middle of GCSEs?!"

See, it's not just us who notices the increase in 16 year olds attending hospital in May. It's the whole health care system. Hospital waiting rooms are full of them and I'm sure GP surgeries are inundated with 8am emergency appointment requests for generalised pains and breathing problems. I don't know what the cure for GCSEitus is, there probably isn't one, but I reckon by starting off convincing them that a D in German will not resign them to a life of crime and Special Brew is a good place to get the ball rolling. As for our cherub of a patient, it turns out she self-discharged out of A & E after her x-ray showed no damage. Oh, and she walked without a limp by all accounts. Miraculous! Another life saved!

Wednesday 23 May 2012

Increased level of Consciousness

"25 year old male, increased level of consciousness"

There is often criticism of how well ambulance crews measure levels of consciousness. As a rule we use a combination of common sense and the Glasgow Coma Scale (GCS). A patient is given a score based on a number of variables to determine what level of consciousness they are. A score is given out of 15 and can be as low as 3. Someone who is completely unconscious is deemed to have a GCS of 3. Someone with a GCS of less than 8 is judged to be in a coma. There is often a discrepancy between the hospitals and us as to what score the patient has. We tend to over-triage and make out a patient is worse than they are and hospitals tend to under-triage and paint a rosier picture. In a hospital it doesn't matter so much as there is constant monitoring of a patient's condition. Pre-hospitaly we have limited time and limited expertise to do anything other than be over cautious.

This is the template by which we measure a GCS:




It is a crude tool in many cases; it's hard to use on patients with dementia or any other pre-existing cognitive impairment, it's very vague on paediatrics, and if someone is blind or a mute they could easily be judged to medically in a coma!! It has its uses, especially for head injuries and strokes, so it is a valuable assessment tool at our disposal. It's most often used to determine just how much alcohol has been consumed!

When call volume is particularly high, or there are not enough ambulances running, our control will do a 'general broadcast' of the calls being held. They do this in the hope that a crew sitting at hospital, or on a "non-conveyed", who are almost ready for another job will offer up for it. We were sat at hospital when the following came over the radio:

"General broadcast, all units, ambulance required for a 25 year old male with an increased level of consciousness. I repeat, general broadcast, all units, ambulance required for a 25 year old male with an increased level of consciousness. Please press green mobile of come up RTS Priority, time of 18:56, my initials are Echo Sierra, over"

Increased level of consciousness?! That's a new one even to me! I've heart of patients calling in their own cardiac arrest but this was highly original! Obviously, it was a slip of the tongue but it made us laugh no end. I imagine most other crews who heard it also had a laugh at control's expense! It did get us talking though. What would be an increased level of consciousness?! Going by GCS you'd need more points available than 15 to accommodate what I would presume would be hyperactivity! Maybe some recreational and 'class A' drugs could cause an increased level of consciousness! Maybe excess caffeine or too many E-numbers for kids would cause a 'raise' in the GCS! To that end I have created a new GCS table to be kept in your pocket books AT ALL TIMES! 


Clinically, it probably has its flaws, but I'm bored of documenting that someone is GCS 15 when it is quite clear that whatever they have taken has put them on a completely different plain to me! Clearly, GCS should be out of 18 on the count of really big eyes!

Sunday 20 May 2012

Hot Water



It pains me that I have to write this blog, but after two pretty shocking jobs in as many weeks, my frustration has boiled over (excuse the pun). It's simple really; kids and boiling water do not mix, skin and boiling water do not mix. Accidents do happen but these calls really did make me think that reproduction should only be allowed after passing written exams and parenting assessments! 

"12 year old girl, burns to foot"

It was a sunny day. Not a hot day, but a sunny one. In fact it was cold! We got the job and headed over to the estate. We located the flat, knocked and entered the open door. We were beckoned through to the living room, though the crying and screaming was enough to guide us in the right direction. On the sofa was our patient. The skin over her ankle was missing or peeled and there were scalds over her entire foot.  It looked extremely painful so we got her breathing on the entonox whilst we went to work applying burns dressings and cling film.

"So what has happened?" 

I said to her mum, who was sat, apparently not concerned and chewing gum on the other sofa. She was looking at her daughter as if she was making a mountain out of a mole hill, and us as if we were interrupting the football that was on TV.

"She dropped the water for the water balloons on her foot"

"Water balloons?!?!?"

"Yeah, we was filling up her water balloons"

"With boiling water?!?!"

"Yeah, it's cold outside innit and I din't want 'em to get a cold"

"Were you filling them up for them?!?!"

"Nah, but I was 'elping"

Personal feelings aside, we ignored what I had just heard and carried the girl out to the ambulance and off to hospital.

Three shifts later.......

"1 year old girl, burns to legs"

A similar setting, this time in a tower block. We bundled into the lift, discussing our previous burns job. The phrase 'seriously, what is wrong with people' was muttered by my crew mate. As we approached the door, again, the all too familiar sound of the screaming child could be heard from deep within the flat. We were let in and made our way into the living room. On the floor was the mother with the child on her lap. There was a nasty looking scald on both of her thighs. Like before we started dressing them with aqua gel and cling film as best we could. The mother didn't speak English but her neighbour translated for us

"Have you given her anything for the pain?"

"No"

"Any Calpol in the house?"

"No" (my crew mate grabbed ours and administered)

"How did this happen?" 

"I only left the room for 20 seconds and she grabbed the kettle and spilt it on her lap"

Obvious question: "How did she reach the counter top?"

"She was sat on the counter while I was cooking?"

"Next to a boiling kettle? You put her on the counter next to the kettle and left the room?"

"You make it sound worse than it is"

"Let's just get her to hospital, have you got her red book?"

"No, she wasn't born here"

"OK what GP is she registered with?"

"She isn't because she doesn't have a visa"

I left my line of questioning there, gathered up her stuff and ushered them out to the ambulance and off to hospital. 


Obviously, both jobs were reported to the necessary people, the outcome of which I will probably never know. But seriously... am I missing something?!! Do people really think it is OK for children to play with, or be near, boiling water? A water balloon filled with boiling water could have hit someone in the face. A 1 year old sat next to a cooker with a kettle of boiling water could have been much, much worse. Maybe I was naive, but when I came into this job I simply did not envisage that these things happen. I thought I'd see accidents, sure, but this?! Kids by nature are inquisitive, that we cannot stop nor would we wish to, it's how they learn; but ignoring hazards and putting them in harm's way is completely different. I often think and moan that health and safety has gone mad. 'Caution, Hot Coffee' on a McDonald's coffee cup was something I found bizarre, but maybe now not so ridiculous. Maybe the NHS needs to create a book or pamphlet called 'Don't give your 1 year old a kettle'. What is next?! Out of the bath and into the tumble dryer? Swimming lessons by dropping a new born in a pond and hoping survival instincts kick in? You know what, nothing would surprise me anymore!

Saturday 19 May 2012

The Laws in Practice

"56 year old male, Cardiac arrest, CPR in progress"

It was the end of a very long, arduous run of nights. I was tired and only had half an hour to go until home time and, to be perfectly honest, I couldn't wait! My bed was calling me.  Due to poor time / job management by the student who was with us we were 'on the hook'; basically, at very high risk of getting a late job and thus being off incredibly late! I wasn't annoyed as I made similar mistakes when I first started, but that didn't prevent us winding her up and piling on the guilt trip! I was getting hungry so as we were at the station I decided to take advantage of having a table and chair at my disposal. I poured myself a bowl of cereal and made a cup of coffee. I sat down to enjoy this rare treat and yep... you guessed it... we got a job!
The first law of EMS: All emergency calls will wait until you begin to eat, regardless of the time.
The timing of the job was not lost on any of us. Had it been any other job we would have politely pointed out that we would be finishing our shift in 17 minutes, as it was it was a Red 1; A cardiac arrest. We might not like finishing late but no one really minds if it's for a genuine job. This was, so off we went.
The EMS law of Time: There is absolutely no relationship between the time at which you are supposed to get off shift and the time at which you will get off shift.
We began our journey through the early morning traffic. I don't know if everyone was tired and in a 6am daze but drivers seemed intent on ignoring us! (please see 'Drivers: Take Note'). If by chance they did see us they simply stopped where they were. It was a highly stressful journey and that's without contemplating the job we were on our way to.
The EMS rule of Warning Devises: Any Ambulance, whether it is responding to a call or travelling to a Hospital, with Lights and Siren, will be totally ignored by all motorists, pedestrians, and dogs which may be found in or near the roads along its route.
We arrived at an extremely lush block of apartments in a particularly lush part of town. We were the second ambulance and there was already a car on scene so we grabbed a spare oxygen and headed in. We were met at the door by the concierge (I know!) who directed us to the 5th floor apartment. Of course it was the 5th floor of 5! Why would it be anything but?
The EMS Law of stairs: The severity of a patient's illness or injury is directly proportional to the number of stairs said patient has climbed to get away from the front door. The worse the patient is the more stairs they will have climbed.
Luckily the lift was working, but as the door slid open I saw a future problem. It was tiny! Just about big enough for 2 or 3 people to stand in like sardines in a tin. It was barely big enough for a chair and certainly not big enough for a patient in cardiac arrest. Gulp! As we exited the lift we were greeted by a long, long, long corridor of least 100 meters. Guess where the apartment we wanted was?! Yep! Last one on the right! We entered and followed the noise. The patient was in the bathroom. 
The EMS law of Bathrooms: If a call is received between 0500 and 0700, the location of the call will always be in a bathroom.
A resus can appear to be chaos, organised chaos, but chaos nonetheless. There is kit everywhere; defib, lifepack, oxygen bag, suction, paramedic bag open, cannulation roll out, intubation roll everywhere. Plus, on top of that 6 of us present; 2 doing CPR alternately, 1 bagging, 1 cannulating, 1 coming and going fetching things and one writing stuff down, attaching leads and monitoring etc. There simply wasn't enough room for all of us in such a tiny bathroom!
The EMS law of Space: The amount of space which is needed to work on a patient varies inversely with the amount of space which is available to work on that patient.
As far as cardiac arrests go, the resus part was simple; 3 shocks and his heart was beating again. IV access and airway had also been easy, it was now just a case of getting him to a hospital and quickly. It's probably worth mentioning that the patient was large. Very, very large! At a guess I'd say 22-23 stone. 
The EMS Theory of Weight: The weight of the patient that you are about to transport increases by the square of the sum of the number of floors which must be ascended to reach the patient plus the number of floors which must be descended while carrying the patient.
  • Corollary 1: Very heavy patients tend to gravitate toward locations which are furthest from mean sea level.
  • Corollary 2: If the patient is heavy, the elevator is broken, and the lights in the stairwell are out.
It wasn't that the lift was broken thankfully; it was that he wouldn't fit inside. We got a carry sheet and began preparing to get him out. A few of us 'ran' back down to the lobby with as much kit as we could carry and got the bed set up and ready at the bottom of the 10 flights of stairs. Back up we then went for the extraction. Whilst 1 bagged the remaining 4 of us carried him along the corridor, watching the monitors as we went. We slowly worked our way down to the stairs, followed closely by the family. We were all sweating. Even the simplest of resus's take their toll, but a confined space and a nightmare extraction with a heavy patient meant we were all feeling it. Eventually we were at the bottom and loading him on to the truck. A short journey to hospital and he was handed over and getting the treatment he needed. We had a clear up operation and a mountain of paperwork to complete!

I didn't write about this job because it was a cardiac arrest. I didn't write about it because we saved him, nor did I write about it because we were 2 hours late off. I wrote about because it made me laugh! Every stereotype we see, joke, and moan about was all present in that one job. We can never eat properly, we are always off late, the sick patients are all upstairs, in a tiny room and if they need carrying they are heavy! That's a fact. That is of course how they became Law! (The Laws of EMS

Personally, I think Murphy was an optimist when he said if it can go wrong, it will go wrong!