Tuesday, 31 July 2007

Sick in the heart

Nine emergency calls and one running call. One false alarm, two conveyed (including the running call) and seven required an ambulance.

I nearly drove past my first patient of the morning, a 42 year-old man with chest pain. He was sitting in one of those little alcoves (can’t think of a better name) on London Bridge. I almost drove past but I didn’t because he looked so obviously in distress. He was very pale, diaphoretic and had that look of deep concern for himself. Real illness is obvious.

He was on his way to work when he passed out on the tube train. He recovered and made his way across the bridge but suddenly felt unwell again. Chest pain began to develop and he felt sick and faint. He didn’t pass out on me but he had a damned good try. Ironically, he felt better standing up, despite my advice that he should sit down.

The motorcycle responder arrived to help and I could hear the ambulance a short distance away. I’m sure the MC paramedic thought the same as I did; this guy was going to suspend on us. He didn’t though and the crew arrived and took him aboard. He was given everything he needed to help him through this event – courtesy, comfort, dignity and respect. He also got pain relief. He had kidney problems so morphine wasn’t an option – entonox was provided instead.

My next call was for a 19 year-old female having an asthma attack. Her inhaler had failed to provide relief, so she was taken to the ambulance, which had arrived on scene at the same time as me, to be nebulised. She worked in a casino. I’ve never seen the back end of a casino...it’s like Fort Knox (I’ve never seen Fort Knox either)...so much door security...so many doors. I’m willing to bet banks are less secure.

Then off to the north for a male in his fifties who was found lying in a garden with his face ‘covered in dried blood’. When I got there a neighbour, who had spotted him and made the call, described him and said he had wandered off. It sounded very much like a local alcoholic had planted himself on someone’s posh lawn for a few hours and had been caught. These tidy neighbourhoods cannot abide the stench of the street in their territory, so who do they call?


I carried out an area search and sure enough, around the corner I found him sitting on the pavement of the high street. He smiled and waved at me and I poodled over to chat to him. His face had a few bruises on it and he had a swollen eye – there was no dried blood. He told me he had been given a “good kicking” the night before. This is common and it didn’t surprise me; he probably offended a comrade.

He told me he didn’t want an ambulance (so I cancelled it) and he didn’t need my help, so I prepared to leave him alone. I gave him directions to the tube station, which I thought he should know and bid him farewell...until next time that is.

He wasn’t rude, he didn’t swear and he had his lunch in a plastic bag; apples, sandwiches and cake...no booze. It was probably too early in the day for him.

My next call threw me a spanner. A 78 year-old male was having an ‘asthma attack’, according to my MDT. When I got there I was shown in by his very worried wife. He was sitting on the edge of his bed, leaning forward (this is what severe DIB makes you do), gasping for air. He couldn’t complete a sentence and he looked exhausted. His blue ventolin inhaler was next to him.

He told me that he was asthmatic and that he had suddenly developed DIB. His inhaler had brought no relief and he was getting worse. His sats were very low (89%) and when I listened to his chest I could hear a familiar high pitched wheeze on both sides. I could hear nothing else, just a wheeze. He also had a niggling non-radiating chest pain. He described this as just like an asthma attack for him.

I looked at him again and there was something wrong with the picture. He was sweating profusely. I asked about other medical conditions but didn’t get a clear answer from him or his wife (I think they were both too panicky). I was still focussed on his asthma and prepared a nebuliser for him. The crew arrived as I put this on and we took him straight to the ambulance.

He was still very sweaty and the salbutamol I had given brought no relief, so I asked the crew to give him Atrovent (the 2nd line drug). I was going through the drug regimen for asthma but my inner voice was telling me it wasn’t asthma. I considered something else; congestive heart failure, (CHF). I listened to the patient’s chest again but all I could hear was a wheeze. I asked the EMT to listen so that I had a second opinion but he heard nothing else. The added sound I was listening for was a crackling or bubbling sound that would indicate fluid in the lungs – a sign of possible heart failure. I needed something to go on before I made a decision to give this patient a drug he quite possibly didn’t even need. He could still have been having a severe asthma attack, notwithstanding the chest pain.

I had checked the man’s ankles but there was no swelling. Then I asked again about his medical history and his wife told me he had high blood pressure. I asked what medicine he was on for it but she couldn’t name it and started rooting around in her bag for it but time was running out.

I could stay on scene in the back of ambulance and wait for a 12-lead ECG. I could cannulate this patient and give him Frusemide, which would deal with the symptoms he was experiencing if my hunch was correct or I could let the crew get him to hospital now. The hospital was three minutes up the road and it would take me that time to prepare and administer the drug, so I decided to leave him alone. I discussed this with him and told him what the options were – he agreed that it was best to get going.

When he got into resus, the doctors were no wiser and continued the treatment for DIB related to asthma. I left after twenty minutes, just as an x-ray was being set up. This would confirm CHF if that was indeed the problem.

If you don’t eat for days on end, your body will start to rebel – especially if you are elderly. I was asked to attend a 70 Year-old woman who hadn’t eaten for three days. An ambulance had been called for her because she felt dizzy and generally unwell. She had lived a healthy life until now but had lost her appetite recently, resulting in her three day fast. She told me that she vomited when she ate, so she didn’t bother trying. She was quite pale and very tired looking. I think that despite her years of good health, something sinister may have caught up with her. She went to hospital.

Then I had to deal with an extremely distraught (and badly behaved) woman at an embassy building. She and her husband had allegedly been given bad news about their immigration status and she had reacted by stripping off to her underwear, tearing her wig from her head and throwing herself wildly about the floor, screaming and wailing. I’m not the world’s most patient person for this kind of display.

The ambulance had been called on the basis of her having ‘chest pain’ but she had nothing of the sort. She was hyperventilating and stressing while reeling around on the floor like a mad woman. Her husband did nothing to help and communication was impossible. Her screams were so loud and piercing at times that I had to plug my ears with my fingers until she reduced the volume. I got kicked and slapped by her as I tried to keep her calm.

When the crew arrived, they spent a lot of time just settling her (when the husband was taken out of the room, she calmed down) but I couldn’t help thinking what a waste of emergency resources this was. She had no illness and her immigration status would not improve because we were there. I sympathised to some extent but then I remembered my last seriously ill patient and even that connection evaporated. I’m not a social worker and I wouldn’t be good as one either; everyone has problems...everyone. Most people stand alone and deal with them.

The police had been called for this job and when I got outside there were armed cops at the door and up the street, which had been closed off. They thought it was a siege! One of these police officers had even drawn his hand gun as he approached the area. It was a Wild West farce brought about by a single irrational woman.

My next call took me back into the West End for a 23 year-old who had fainted. She was lying on the floor of her office and a colleague was standing next to her. She had felt faint but hadn't actually passed out. I could see that she was stressed and that there was probably more to this than she would tell me (there usually is), so I coaxed her to sit up, chatted with her and cancelled the ambulance, telling her that I could take her and her friend in the car, which would be less stressful. She was happy for me to do that.

When she got to hospital, she looked just as depressed as when I met her. She was wary of everyone and everything that was being done to her (I didn’t carry out a BM because she was clearly frightened). When her mother arrived and I showed her where her daughter was, I was almost physically swept aside. I felt like a servant delivering a package. Some people still don’t get the whole mutual respect thing.

A smelly call for a 35 year-old alcoholic at a hostel. He had been lying in his own filth for days and the staff just wanted him out. They claimed he was having a fit but this was news to him and his mates. He didn’t appear to be recovering from a seizure at all, he just looked drunk. He smelled drunk but all the other smells soon put that into perspective. At first the gag reflex kicks in but then you recover...looking away for a few seconds and reminding yourself that you have no choice but to deal with it is the only true way to cope.

As we stood him up (the crew were on scene with me) the inevitable happened; his trousers fell down, exposing him to the entire room (they never have underwear on). So, we pulled them up, secured them and took him into the ambulance, where my part in the drama ended, thank God.

My last call of the day was a real drama. I was asked to proceed with caution to a collapsed male. The police had cordoned off the area in which he was lying because of a separate incident – a suspect rucksack. I had to enter the cordoned area and, with the help of a police officer, deal with the man on the ground.

He was, of course, drunk. He was Estonian and again my Russian/Estonian failed me miserably, so we had to revert to broken English and drunken insults (mainly from him I should add). We got him up and walking, with reasonable force (support) until he was clear of the cordon. He wasn’t happy at all to have his beloved bottle of alcohol left behind and kept trying to breach the cordon to get back to it. Eventually he capitulated and slunk off beyond the watching crowds.

I stayed on scene at the request of the police and Control advised me that an ambulance was on its way. When it arrived I told the crew that the ‘patient’ had gone and they stuck around in case they were needed.

A rucksack had been thrown to the ground by someone who had then run off, causing a panic and the evacuation of the buildings in the surrounding area. Police had arrived with bomb disposal units and a cordon had been placed around the area, just off Piccadilly. We watched as the remote controlled robot went around the corner to investigate the suspicious bag. A controlled explosion was to be carried out and I waited for it because I had never seen or heard one of these. The police told me it would be a ‘pop’ and I felt a little disappointed but when it went off it was no pop...it was a huge bag. I thought a device had exploded. We could feel the blast wave hit us from the next street. I was impressed and deaf.

At the same moment, a man had been coming out of one of the buildings in the cordoned area (he obviously didn’t take it seriously and had stayed behind to finish his work off before leaving). When the explosion took place he legged it around the corner and hid. He must have thought it was for real.

When the dust had settled someone’s personal belongings were strewn all over the buildings and shops in the street where the bag had been left. I was told that this is becoming common; individuals are leaving bags and packages around just to see this happen. Meanwhile, a real threat will go unchecked thanks to these idiots. I wouldn’t be surprised if they become Youtube video favourites.

I was late now, so I made my way back through the horrible traffic to my base station. On the way, just at the end of Westminster Bridge, I came across an accident, so I stopped to help. A young girl had been knocked off her bicycle and injured her face. She had lost a tooth on the road (she was looking for it when I stopped) and had a deep cut to the bottom of her chin, which would need stitches. I offered to take her to hospital – St. Thomas’ is literally across the road and she was happy to get checked out and treated.

Unfortunately for her the hospital was very busy and she looked a little less happy when I left her sitting in the reception area waiting to be seen...in about three hours. Oops.

During my shift I returned to the hospital where the ‘asthmatic’ man had been taken and was told that he had improved on nebulisers but then deteriorated again. It wasn’t until all else had been tried that he had been given Frusemide, which immediately helped. He went up to Intensive Care in a stable condition. I also learned that the medicine his wife was trying to find was Frusemide – he was already on it but hadn’t taken it.

The man from a few days ago who had been taken to hospital with what I suspected to be a bleed in his brain had suffered a subarachnoid haemorrhage – he was transferred to the National. I don’t know if he survived.

I have written about the great politics out there when it comes to paramedics and the ‘stay and play’ decisions we can make but nothing should ever be done that isn’t in the best interests of the patient. The past few days have shown me that some of my decisions will leave me with a bad feeling. I will wonder whether I made the right choice. I will worry about whether using my skills or not using them would amount to a dereliction of duty and thus negligence. Then I remind myself that I’m not the only one living with these stresses...every other medical professional is doing the same and I’m guessing it doesn’t matter how many years you’ve got in, the feeling is still the same. Doubt is part of the curve.

Be safe.


Anonymous said...

You're right: doubt is ALWAYS part of clinical decision making, if one has any insight at all! The difference with paramedics vs doctors (and this is not your fault, in any way) is that I have 5 years of training and at least a year of fully supervised practice before I am allowed to make my own decisions. You have very much less than that, and chucked out to do your best in very difficult circumstances (of which I'm aware, having spent 120 hours in the back of ambulances in the last year). If I had been 'on scene' with that gentleman, I would be aware that you can get isolated left ventricular failure (as distinct from congestive, or biventricular failure, without any peripheral oedema) I would be aware of the concept of 'cardiac wheeze', a wheezing noise produced in LVF. I would be aware of the pharmacology and pharcokinetics of frusemide, such that if I were to give it I would seen an early response within 20min due to peripheral vasodilatation, akin to giving GTN, and a later, sustained response due to the diuretic effect, lasting up to 6 hours. I would also know that the risk of harm was minimal, and the risk of benefit potentially significant, so would be more inclined to try it.
Not trying to patronise, enjoy your blog.
Best of luck.
Dr Lauren

Xf said...

Dr Lauren

Thank you for your concise comment. I appreciate all you have said. We certainly get less training - 3 years - and you sound like you are still on top of your game but we also have the disadvantage of not being able to think out of the box without risk of suspension for 'taking risks'. You have more ownership of your patient, as it were, but I must make a quick decision to stay and play or to go. If I get it wrong, no matter what my reasons are, I am finished.

Your points are well taken too, I understand the effects of Frusemide and I too know that to use it would have been quite harmless and I have used pertinent drugs in other situations to the patient's benefit but it has always been when I have had time to think it through.

Even in the A&E dept. they chose not to go ahead with Frusemide until they had an ECG and X-Ray...and a bad feeling about it all.

Please don't hesitate to comment when you see something else I could learn from. I don't feel patronised at all.