Monday, 19 November 2007

Too late

Eight calls – one no trace, one cancelled on arrival, five required an ambulance and one didn’t make it.

I’ve written a chapter in my book about the access difficulties we have with many of the housing estates (mainly council) in our area. The chapter, ‘Horrible Housing’, details a few calls that have been made difficult for us and the patient because we couldn’t get in quick enough due to heavily secured gates, doors and barriers – often on every floor. In the book, I suggested that sooner or later, these obstructions, however necessary for the security of the residents, would lead (indirectly or not), to the death of a patient.

My first call this morning was to a 78 year-old male having an asthma attack. That’s all I got on my screen, nothing else. The address was a minute away and I got there in plenty of time to make the ORCON Gods smile. But there was a problem. I had arrived at an address I knew only too well. It was a veritable fortress of council flats, stupidly (and I suppose in its day artistically) layered so that each block contained a certain number of flats and each level was ‘crazy paving’ layered for aesthetic reasons. The whole place is a shambles and once you locate the actual block that houses the flat you are going to, there is an immediate obstruction to entry. The front door.

I stood there pressing the buzzer for the relevant flat. Nothing. I called Control and asked them to ‘ring back’ the patient and ask him to let me in. Still nothing. I was waiting outside this heavily built door for three minutes. I pressed the Warden buzzer, the Service buzzer and a few other buzzers at random and all I got was an ear-piercing scream from the Warden alert system. A scream that is supposed to let the Warden know I am waiting there. He or she must have been a ghost because I never saw him/her.

Five minutes passed and the crew arrived. I was glad to see them. They were friends of mine and they would soon be valuable to me.

I was standing at the door with everything I needed for an asthma attack. When the crew got out of the ambulance, one of my colleagues held up the FR2 (defibrillator) and asked if I needed anything else. I said no and they approached.

‘Why the defib?’ I asked.

‘We got this as a query suspended’, came the reply.

Now I was confused. I hadn’t been given an update and when I last spoke to my Control I was told they were ‘calling the patient back’. I decided to grab my paramedic bag, just in case. I should carry it with me every time but, with everything else I have to take in it becomes impractical, when working alone, to do that for every job, so I try to assess what I might need based on the call details and my gut feeling.

Now the three of us were waiting outside the front door, pressing buzzers. It was at least another three minutes before we finally got in. Control called me back just as the door release sounded – they told me that they had tried to ring back but the patient didn’t answer. I told them we were in now anyway.

We made our way to the relevant floor and stepped out of the lift. Now which way was it? This place is a nightmare and finding the right flat is hit and miss, regardless of the numbering system. We walked to the right and found the flat immediately – not because it was easy to locate but because the patient was lying on his back, half in and half out of his door, suspended.

My colleague checked him as I prepared for a resus. He was pulseless. From that moment, our focus was to try and save him. He must have collapsed after buzzing us in. We worked very hard to get him back but he was in persistent PEA throughout and unless the cause is identified and reversed it is impossible to save someone in this condition. We were in the middle of the corridor, resuscitating a man on the floor and not one neighbour - not one - bothered to peer out to see what all the commotion was about. Society is going down a very deep drain.

I tried adrenaline, atropine and Salbutamol, which was given via the bag-valve-mask by the crew but nothing changed. He had a bradycardic rhythm but remained pulseless.

I couldn’t intubate him because he had a grade III airway and all I could see was part of his epiglottis. I made three attempts to secure it but we were forced to continue with basic airway management and that’s how we transported him.

He arrived at hospital in the same condition as we had found him and the resus team continued what we had started but they stopped after ten minutes and ‘called it’. The man turned out to be in his late 60’s and had been to hospital a few days earlier with breathing problems. Sooner or later his asthma was going to get him. Today it did but I can’t help thinking that the delay at the front door of that ugly building had contributed somehow to his death. Getting to him five minutes earlier may have meant he was still conscious. Ten minutes earlier and he was going to get to hospital alive. Whether or not he would have survived in either of those scenarios will never be known.

And so my day started badly (no disrespect to the patient, of course). I was sent to a 35 year-old male having a ‘panic attack’ a few hours later and I felt no sympathy for him. I was professional and smiled when dealing with him but I couldn’t see his emergency. I let the crew take him to the ambulance and I went back to my station.

A call to north London next and I was with a crew outside yet another locked door. This time, it was the front door to the flat itself and there was no reply to our knocks and shouts. The call was for a 29 year-old male diabetic who was hypo and couldn’t move. We were also told he may have dislocated his knee, although quite how he did that I don’t know.

The police had been called to assist us with entry and call-backs were going to voicemail, so concern was growing. Control called me to say that the police had no units to send just yet, so we decided to force the door ourselves. My colleague lifted his leg and threw the weight of it towards the door. Just as it neared the frame, a shadow appeared on the other side of the glass and the door clicked. My colleague must be a ballet dancer in his spare time because he somehow managed to stop at the most critical point, where the leg muscles are committed to finishing the job, and drop his leg back to the ground without making any contact with the door at all. It was a close one though.

The door opened and a young Chinese girl peered out.

‘Ambulance’, we said, rather obviously.

‘Yes?’ she asked as if we were selling her some free healthcare, door-to-door.

‘Did you call an ambulance?’ my colleague asked.

‘No, I didn’t’, she smiled.

We double-checked the address and confirmed it with her (as if she didn’t know where she lived) and all was in order...or so it seemed.

‘Is there anyone else in the house?’ I asked.

‘No, I’m alone.’

‘Is there a diabetic in the household?’

I was expecting her to say ‘look, dumbass, I’ve already said I’m alone, so why would I now say yes I have a diabetic with me?’ Luckily she understood what I meant.

‘No, nobody is diabetic who lives here.’

The young Chinese don’t generally live alone. They live in couples and groups, so I figured it was a logical question. It still didn’t help us though.

I called it in and Control updated me, saying that the patient had called again to say he was at a different location, miles from this one and that he used to live there but was confused. I’ll bet he was. The same person had given three separate locations for where he was, so the call was cancelled as a hoax until proven otherwise.

A regular patient called us from King’s Cross station to report that he was having a fit. I went to see him and he was sorry that he had called us but he felt he might have a seizure. He has a history of epilepsy and diabetes but I have never had to treat him for either – he always seems to be ‘feeling funny’ and that’s enough for him. It’s cold and damp on the streets, so he went to hospital for warmth and sympathy.

I was cancelled as I arrived on scene later on when I responded to a collapsed female in a large department store. She had obviously recovered and decided an ambulance was over the top.

Speaking of large department stores, I see that the Selfridge building has been entirely secured with netting up on scaffolding, presumably as they make emergency repairs to their roof. At least the Christmas shoppers below will be safe from any falling debris. The management are being pro-active and responsible.

There seems to be a rush to get as many of us out to the shops as possible for Christmas. What’s going on? Most of the Christmas lights are now on. What about Global warming? How come we are being asked to save energy by switching off the lights and every greedy giant corporation can carry on burning it up? I say every shop and office building should switch its non-essential lights off during the night. Who on earth cares where the nearest tile shop is at three in the morning anyway? Switch your damned shop signs off!

A hotel near Marble Arch for my next call. The patient had severe back pain which went into spasm whenever he moved. He was a 38 year-old Egyptian man with a wicked sense of humour, despite his discomfort. He had been lying on his room floor for three hours before calling us out. The hotel staff told me that they had called an ambulance hours ago but had been told nothing was available but I’m not sure how true that is; it seems very unlikely.

Anyway, it took half an hour, three of us (me and the crew) and 5ml of morphine to get him out of the room and into the ambulance.

The weather is cold, did I tell you that? Well, another regular came out of the woodwork for his trip to hospital. Mr. Colostomy bag. This time he claimed his bowels were leaking out of him. They were, kind of, but then they always are – he doesn’t take care of his stoma. Neither does he care about us or the inconvenience he puts emergency crews to.

I wasn’t taking him to hospital in the car because he smells very bad and I had to consider the possibility that a decent member of the public would have to travel in it immediately after him so I waited for the ambulance to arrive.

When the crew got to me, I had been with him for twenty minutes and had heard all of his grievances. I had remained fairly passive with him because he has a reputation for throwing his faecal matter at us when we annoy him but he still got the riot act from the crew, who took him to hospital...again (he’d been in and out twice so far today).

I left the scene feeling guilty that I had passed this on to my colleagues and I’m sure they will repay me in kind.

My last call made me late. I was dragged up to Oxford Street for a 22 year-old male who had been fitting and had a leg injury. He was at a tube station and was lying on the bench when I arrived (the crew were on scene ahead of me but only because they cheated and cut me up on the drive in):-)

The patient was in his 40’s in fact and had not been fitting. He was a homeless man with a painful knee and it was obvious to us all that he was looking for a warm hospital bed. He did a lot of moaning and groaning about his knee. He did a bit of writhing about too. There was no pain on his face though. Not real pain.

‘So when did your leg start giving you trouble then?’ my colleague asked.

‘In the 1980’s’, said the man on the bench.

Be safe.


Stephen said...

were you at the dept store on sat, saw an FRU car ouside one! They are a nice piece of kit, they use estates over here for the ALS paramedics. i was over from ireland visiting friends. london is a crazy city i wouldn't fancy getting through london traffic on a run! well done. hopefully i will apply for an emt position when they come up again!

Anonymous said...

Hi there, I was just wondering about something to do with the chap who unfortunately didn't make it. When you can't secure someones airway, when do you do that thing when you make a hole in their trachea to access their airway (not sure if that is an actual tracheotomy or not, as I heard it called something else on that live autopsy programme the other day). I looked at the definition of a grade III difficulty of airway but still wasn't sure whether it meant the airway was blocked or swollen etc. Also when is your book coming out please? Have just applied for the paramedic science degree at Greenwich uni - so might be needing some advice soon!!!!

Thanks Maria

Xf said...


Yes that was probably me as I was the only FRU in the area. I used to dislike the Zafira but now I use the SPORT button when I am running on calls and it is a lot zippier than without it.

I still think the vehicle is unfit for purpose generally though.

Xf said...


The grading of an airway is determined mainly by the anatomical structures that cause obstruction, or difficult visual access to the trachea. I couldn't see everything that I needed to, even with cricoid pressure, to ensure that the tube went into his trachea and not his eosophagus.

Crichothyroidotomy, or emergency tracheostomy, is the procedure you are referring to. We don't carry this procedure out in cases like the one I talked about simply because it is designed to bypass blockages and obstructions higher up in the airway. This man had deep, bronchiolar collpase which could not have been remedied using such a procedure.

In cases of impossible intubation, we resort to basic airway management. He wasn't vomiting and there was very little fluid in the airway, so our continued resuscitation with a BVM was sufficient.

John said...

Do you carry LMAs in your kit bag?

I've never tried it myself, but I read an article a few months ago now describing a technique whereby you insert the LMA, then put a bougie through the LMA into the trachea, withdraw the LMA and slide in an ET tube.

It was being suggested as a technique for people who perform intubation relatively infrequently if at all (e.g. ward nurses) to get a tube down in an emergency, as it avoids the need to view the cords with a laryngoscope. I would imagine that it would also have some benefit in unobstructed, but poorly visualised airways such as your patient's.

It probably wouldn't have made a difference in this case as you say, but I still thought it was a pretty neat trick when I read about it!

Xf said...


No, I don't have one. Never been issued with one but I will be buying my own soon. I could have done with one on that job.

I did try using a bougie but there was still difficulty and I think it was because his upper tract had begun to swell - he was almost certainly shut down below the tracheal biforcation.

At the end of the day, all my messing around would have simply delayed getting him to hospital and we had already been on scene long enough. There's nothing worse for a Tech crew than having a paramedic holding things back by trying to be too clever.

Anonymous said...

"We were in the middle of the corridor, resuscitating a man on the floor and not one neighbour - not one - bothered to peer out to see what all the commotion was about."

This is disturbing for me to read. This is just one of the main reasons why I would hesitate to call an ambulance. You would draw attention to yourselves like some kind of show. I would not want crowds excitedly gathering around to watch what was happening to me.

Just because ambulance crews are not afraid to be in the front line with the general public does not mean their patients are going to be too. I believe you should be shielding patients from public intrusion not expecting them to gather around and watch the "show".

Xf said...


You have completely missed my point and have gone off at an extremt tangent. I DO NOT want my patients exposed to freak shows and do everything in my power to prevent it. I was merely commenting on the lack of any interest in the noise going on outside people's front doors. I was commenting on human society and its downright lack of interest in its fellow man!

Please try to read me the way I write.