Thursday, 6 September 2007

Hanging about

Ten emergencies, all of them required an ambulance.

I started my day with a minor leg injury, possibly a sprained knee, as the result of an RTC in which the patient, a 39 year-old male, was knocked off his moped by a white van driver. Quite a few moped riders are getting knocked about on the roads these days. I assisted the crew on scene and made my way back to finish cleaning the car. I’m the only FRU out of the station at the moment because of the number of people who are off on holiday, so I’m being fully utilised.

Just around the corner from the RTC an 81 year-old woman with chest pain diverted me from my mission to complete the cleaning chore. Her daughter is a doctor and had called an ambulance because her mum was suffering from unstable angina. When I got to the address, however, the old lady wasn’t complaining of any pain whatsoever. Without pain, there is no angina, stable or otherwise. She was feeling unwell and had vomited several times overnight and this morning but she was good on her feet and sharp enough to contradict most of what her daughter was trying to tell me.

Only after a long period of questioning and re-questioning did she admit to having an ‘aching’ left arm. She had suffered a heart attack in the past but was categorical about the difference between that pain and the arm numbness she felt now. Fine but she still had to go to hospital – her age, her medical history and that aching arm said so.

I felt for the daughter. The old lady had contradicted her and made her look stupid before the true story came out. Patients sometimes do that. I don’t know if they have a specific agenda but when it happens it’s embarrassing. I don’t think any one of us have escaped it.

‘This is Mrs Miller, she has left sided pain and has been vomiting’

‘No I haven’t’

‘But you told me you had been sick and that you had some pain’

‘No I didn’t’

And so it goes.

A weekend of boozing fun is all very well until you have to wake up on a Monday morning and face the responsibility of earning your week’s party funds. My next patient was a very weak, very tired and just recently fainted 20 year-old woman who had been travelling to work on the underground when she blacked out. Her body simply had enough and needed a rest. She had no medical history of significance and she was conscious now that I was kneeling beside her on the platform. She made me feel tired just looking at her. The crew took her to hospital where no doubt her state of health with be verified and she will get a couple of hours sleep.

If you call an ambulance please send someone to meet us, especially if you work in a large office building. I won’t have a clue where to go unless I am directed. A delay of even a few minutes could be significant if the patient is suffering from a time-critical condition.

My next patient had chest pain but I couldn’t find him. He was secreted somewhere on the second floor of an office building but nobody came to meet me and when I got onto the second floor, by sheer guesswork, nobody knew what was going on. A young girl had to go walkabout to find the patient. It cost him three minutes.

Eventually I was shown into a meeting room where the patient sat, colleagues in attendance. He had chest pain and had suffered a similar attack before but nothing was ever found to cause it. He didn’t look particularly in agony but he pointed to his chest and left arm when I asked where the pain was, so it was prudent to take him seriously. I gave him GTN and aspirin and the crew too him to hospital after an ECG which revealed nothing important. Before he left, he admitted that he was the ‘nervous type’.

Court buildings attract ambulances on a fairly regular basis. The defendant will ‘collapse’ as soon as the verdict has been read out or during the immigration hearing or when they have been called to appear. This doesn’t mean that there isn’t a genuine medical reason for calling an ambulance but I have never genuinely treated anyone from a court house.

A 35 year-old male had collapsed and was shivering outside a court room and I was called to support the ambulance crew who were on scene. Someone had said epileptic fit too hastily. The guy had mental health issues and was at an immigration hearing that was probably not going in his favour. He was jerking about on the floor (more of a shivering motion) and refusing to speak or open his eyes for the crew. Since this was taking place in public it was best to move him into the ambulance for a proper assessment.

In the ambulance he still refused to help us and I began to wonder if he was epileptic. He had no history of epilepsy, according to his cousin who was with him, but it can never be ruled out conclusively. Luckily before I started to take him seriously, he stopped shivering and opened his eyes. He even spoke to me. I think the fact that I had been taking to the crew about options had helped him ‘recover’ more speedily. Nobody likes a needle in their arm.

I was asked to check on a man who had attempted to hang himself and was now fitting. It was a couple of miles away and when I arrived the ambulance crew was on scene and dealing. The man had bought himself a brand new step ladder, taken it to the nearest standing post, pulled a sign over his chest proclaiming how unfair Britain was, gone up the steps, chucked over a ready-noosed rope, covered his head with a brown hood (execution style) and prepared to step off into oblivion.

Luckily for him, two police officers happened by and casually asked him if he was ok. It seems hilarious when you hear this story but in essence these two cops potentially saved this man's life because, as he replied he toppled over and began to hang in his very effective noose. The quick cops grabbed him and held his weight whilst he was brought back down to Earth.

Now he lay on the pavement, not talking to anyone and being treated for a suspected neck injury. It was a bizarre call and the whole incident took place at the side of a very busy main road - for maximum impact I'm sure. I have no doubt he intended to kill himself; everything was too well thought out...except the possibility that two police officers would stop for a chat mid-suicide - inconvenient to say the least.

The biggest irony of all is that the post he chose for his death was a speed camera. If his luck is very bad he will also get a fine and three points.

Hyperglycaemia causes internal dehydration because water is dragged out into the renal system along with glucose as the body seeks to remove it as it builds up in the blood. Slow rehydration is important and not usually carried out on scene but I was waiting for an ambulance with a 20 year-old female at an underground station who had developed a BM of 32 over a 24 hour period despite using her regular insulin and not eating. She had been vomiting and was extremely thirsty. Her blood pressure was normal but I gave her a hundred mils of fluid to be on the safe side while I waited for an ambulance to take her to hospital. I like to think ahead on these jobs.

After my break, which was given later in the day than usual, I headed up to W1 for a 35 year-old female who was fitting in the street. She was surrounded by people trying to help but all they could do was stand over her as she thrashed around, her waist and legs on the pavement, her upper body and head in the road. Only a helpful soul at the junction stopped vehicles from hitting her as he signalled them to slow down. None of them thought to move her out of immediate danger.

After I had dragged her from the road, with the help of a few volunteers, I tried to establish how far gone she was. She had stopped wriggling about and was (hopefully) recovering from her episode. Nobody knew her and her ‘phone kept ringing in her bag. I ignored it as I did my baseline obs but eventually relented and answered it when it rang for the third time in quick succession. Her husband was on the other end and he told me he had heard everything that was happening – the ‘phone must have been answered at some point when the woman put her hand in the bag and he had listened to my attempts at communicating with his wife.

He told me she was epileptic and had suffered a few fits this year. He told me how long they usually lasted and how long I would expect to have to wait for a full recovery – all valuable information. I told him where I thought she would be going and advised the crew that he wished to be called back when they got on scene. I had moved her to my car when she was steady on her feet. She had lost bladder control and was still in full public view, so it was a good idea to get her (and her loss of dignity) out of sight. She also had a large bump at the back of her head – the result of her rapid and unchecked descent to the ground.

One of the bystanders/helpers at the scene was wearing a stethoscope around his neck. He declared to the woman that he and his friends were doctors but I suspect they were medical students. Not many doctors are keen to keep their stethoscopes on their necks when they go out for lunch. None that I know anyway.

Recovering epileptics converse using language that starts with grunting, moves into gibberish, through nonsense and eventually lucidity. My patient was somewhere between gibberish and nonsense when the crew arrived to take her away. She was on the mend.

Another fit, this time non-epileptic, at a busy train station. The man had collapsed suddenly and burst his lip on the concrete floor. He had fitted and become unconscious for a short time afterwards. I arrived with the crew and we checked him out. His BM was low (3.3), so that was possibly the cause of his seizure. He wasn’t diabetic, however, so there had to be a mechanism for his hypoglycaemia – alcohol could be the culprit but he hadn’t been drinking (according to him and as far as we could tell). He was a respectable looking businessman but I have learned never to let that influence the possibilities.

He was recovering well by the time he was in the ambulance, although his memory still wasn’t functioning properly. He was given glucose gel and his BM began to improve. The oxygen also helped him recover. He went to hospital in the hope that the reason for his sudden crash could be determined.

I got back to my base station and was ready to pack up and go home when a Sector request had me heading south for a 72 year-old lady with breathing difficulties who had been waiting for an ambulance.

Her concerned family were with her and she was definitely short of breath, although there was no discernable wheeze or other added sound in her chest. She had been recovering from a recent bout of pneumonia and had been under investigation for a suspected DVT, so one or the other was causing this acute change.

There was no chest pain and, although her ankle had been swollen the previous night, it had gone down. Her legs weren’t hard or hot and there was no change in blood pressure either side of her body. It was reasonable to assume that her pneumonia hadn’t fully cleared or that there was a residual infection. Whatever the cause, oxygen sorted her out within minutes and she was talking in full sentences and looking a LOT more relieved when the crew arrived to take her to hospital.
I like straight-forward jobs at the end of a shift.

Be safe.


Anonymous said...

Astute observation about medical students and stethoscopes, and shame on the nursing staff of their hospital for not heaping crap on them.

From our unofficial student guide (printed by students rather than by staff)...

"The 5 Golden Rules for (students entering the hospital system):
1. Do not wear your stethoscope. Ever."

David Holland said...

"Young people shouldn’t have cardiac problems so it is usually non-cardiac when you receive a ‘chest pain’ call to a 19 year-old
never met the patient because an ambulance was already on scene so I wasn’t required but I’m willing to bet they weren’t too concerned about his imminent demise"
If only my healthy 23 year old brother had known that he should not have died of cardiac problems - he might not have done so.
Have you ever seen this website ?

Xf said...

Please read the paragraph I have written in 'Torrential' - I acknowledge the small number of cardiac related deaths in young people and have seen a few myself but they represent only a small number compared to the vast majority of inherited and self-inflicted heart disease cases.

This is why we know that a young person with chest pain is unlikely to have a cardiac related problem but if you read what I have written you will see that I still treat them all the same way - including an ECG where I am suspicious.

Young cardiac death is still a relatively unresearched field, so I apologise if I sounded insensitive.

Anonymous said...

Chest Pain in young females is almost always non-cardiac (although always treat for the worst until proof otherwise) whilst young males have a greater incidence of cardiac problems ususally associated with arrythmias such as Wolfe-Parkinson-White syndrome.... I know because I have JUST returned to base after conveying a very scared 16yr old lad with h/r of 130, associated chest pain and breathlessness... and he told me.
A 19yr old footballer recently collapsed and died with an undiagnosed cardiac condition.
Teenage girls usually have chest pain as a result of hyperventilating, I find.

steph said...

Schools re-opened in Ireland recently after the summer break and in the past week 4 students (all boys, and all aged under 16) collapsed and died while at school. Resuscitation was attempted with defibrillators in all cases but this was to no avail. None of the four boys had a history of heart problems and only 2 of them were engaged in sports at the time of the collapse. Scary stuff, and very, very sad.