The complex issue of life

A reader sent me this photograph recently, it shows her 8 year-old sister reading my book. This picture is posted with her parent's permission.

Seven emergency calls: one assisted-only, all of the others went to hospital by ambulance.

My son Allan was out on an observational shift with me today. He is starting his degree in Paramedic Science this year and I’m hoping that some ‘on the road’ experience will open his eyes before he gets involved in classroom stuff. He is already highly skilled in first aid and teaches the subject professionally for my company, PRS. I was hoping he’d have a good shift and get some valuable experience but I didn’t expect him to be thrown in quite as deep as he was.

Sickle Cell Disease shortens the life of sufferers and can lead to periods of extreme pain which can only be relieved by utilising a care pathway that works for each individual patient. Our role is to ease the suffering and get the patient to definitive care quickly; specifically that means I will be giving oxygen, analgesia (entonox or, more likely, morphine), fluids and plenty of careful monitoring.

Our first call of the day was to a 21 year-old girl in crisis. She had pain in her legs and was unable to move them (movement of ischaemic limbs caused further agonising pain). She was lying on her sofa when we arrived; her mother and siblings were around but completely helpless. I tried to calm her down and got her on oxygen straight away. I knew the crew wouldn’t be too long because we weren’t far from the station but I got on with administering pain relief while I could. The girl was writhing in pain and I felt very sorry for her.

By the time the crew arrived, I had given a dose of morphine, which was now providing a little relief. We managed to get her to move enough so that she was on the chair and we wheeled her out to the ambulance. Inside, further morphine was given and fluids were put up.

‘I can’t go on living like this’, she cried, ‘this is the third time now, I can’t stand it.’

She’s only 21 but already she wants to give up. There wasn’t much I could say to help her cope with the way she felt because I really had no idea what she was going through and this disease was likely to end her life before she got another 21 years in and of course during that time, it would plague her like this every so often without warning.

By the time she was in hospital the morphine was making a difference and she was more relaxed. I said goodbye and she thanked me. ‘God bless you’, she said, which made the whole thing much more poignant.

Our next call was to a 30 year-old female who had fallen as she tried to board a tube train. She had a suitcase on wheels with her and it had caught on the high step as she got in, this caused her to tumble forward, hitting her mouth on the floor. When we arrived she was badly shaken up (and visibly shaking) but not severely injured. In fact, she only had minor scratches and a cut lower gum. The crew arrived but when I explained what had happened, they agreed that it could be left to me – she didn’t want to go to hospital anyway.

It took ten minutes of chat and obs to calm her down and she was ready to continue her journey but I suggested she might want to rest a little more and have a cup of tea. The underground staff were amazing; they helped me get her upstairs to the staff office, then made her a cuppa and arranged for a taxi (at their expense) to take her to work when she was ready. I stayed with her a little longer and got a second set of obs. She was fine. She signed my paperwork and we left her to it.

Our next call was further south of the river (where we had been working all morning so far) for a 5 year-old epileptic boy who was fitting. He was post ictal when we arrived and his mother told me that this was his fourth seizure today and that his medicine wasn’t helping him. The crew were on scene a few seconds after us, so I quickly handed the patient over. He could have another seizure at any time, so it was prudent to get him away as soon as possible.

Still in the south, a 50 year-old woman had been hit by a speeding cyclist who was undertaking a lorry (not the wisest thing to do). When we arrived, she was sitting on a chair on the road with a police officer in attendance. She had been crossing the road with her shopping and got hit as she stepped out after getting the all-clear from the lorry driver, who had stopped at the lights. I think the wind had been knocked out of her; the cyclist had braked so hard his rear wheel had lifted off the ground, according to witnesses.

The lady wasn’t badly hurt but she was making a big fuss and cried out loudly about the pain in her leg. Some people just don’t tolerate fright and mild pain very well and, although all her obs were normal and there was no visible sign of injury (and the mechanism just wasn’t serious enough), she continued to cry and wail until the crew arrived and she was persuaded to get onto the trolley bed.

I hadn’t completed my paperwork when Control called me and asked if I would go to a suspended call. Earlier I had warned Allan that if we got a cardiac arrest he would be expected to help – the more hands the better. Now he was going to be tested.

We arrived first but the motorcycle paramedic was heading towards us at the end of the road, so we had back-up. There was no access to the house because the back gate was locked and there was barbed wire on the top of it, so no chance of climbing it. The MRU paramedic went around to the front to see if he could get in and I continued to bang loudly on the wooden gate. I didn’t know if anyone was inside but a few minutes later and just as I was calling Control, a figure appeared on the other side of the gate. I could hear stuff being moved around but it was still a good twenty seconds before the bolt slid across allowing us access. The gate opened and a dishevelled man pointed into the house.

‘She’s in there’, was all he said.

Allan had grabbed the equipment I would need and I had my bag so no more time was wasted. To be honest, the calm demeanour of the man and the long delay in letting us in made me think that this was probably not as given. We would walk into the house and the patient would be sitting smoking a cigarette and moaning about her ulcers. She would be yet another timewaster who knows how to work the system.

But she wasn’t.

When I went into the front room the smell of Malaena overpowered my nostrils. A large and very jaundiced woman lay naked and sprawled across the sofa. Her head was back and her mouth was open and she looked to be very dead. Allan was right behind me and I held my hand out and said ‘forget it’. I meant he probably wouldn’t need to be getting the extra equipment out. I felt sure we weren’t going to resuscitate this woman.

I went over to her and checked her for breathing and a pulse; neither existed but she was warm. There was no rigor in her limbs either and that smell was fresh; she had evacuated an awful lot of bloody faeces onto the sofa. Everything seemed very recent about her.

‘Who is this lady?’ I asked the man.

‘That’s me wife’, he answered. Then he sat down in the chair next to her as if he had just received visitors for tea. I knew now that he didn’t fully comprehend the situation. There was no shock or fear or grief...or any emotion.

‘How long has she been like this?’

‘Since this morning. I couldn’t get her to wake up’.

This seemed odd. She seemed to be recently suspended and in those few seconds I was making my decision about whether or not we would progress to resuscitate her. The answer, of course, was yes. We had to.

I asked Allan for help and together we dragged her to the floor. She was very heavy. I asked him to start CPR for me; this is fine because he is a qualified first aider and in the same circumstances I would ask anyone to help me if they could. Not only did he get on with it but he did a great job of it. Good basic CPR is the key to survival. I needed to get IV access if there was to be any hope and the defib had to be attached. The MRU paramedic was now with us and, like a well-oiled machine, we just got on with it.

The ambulance crew arrived within the next ten minutes as we continued, without the likelihood of hope, to work on her. I had already given adrenaline but no shock had been delivered because she was in asystole and there was no electrical impulse going through her heart. This really was a messy, smelly and improbable scenario but we carried on and the arrival of another paramedic with the crew meant she could now be intubated and more hands were available to help with her removal when we were ready to go.

All the while, the man sat watching us, not saying a word unless he was asked a question but even then being incredibly vague with his answers. The resus was now easy to manage, so I asked the man if he wanted to go to another room rather than sit here because there was no change in her condition and we would be doing our best.

‘That sounds a bit final’, he said.

‘Well, we are doing everything we can but you do need to prepare for the worst I’m afraid’.

I couldn’t be more honest with him if I tried but his reaction was neutral.

Then something changed on the ECG. I caught a couple of complexes appearing on the screen as the defib analysed the heart rhythm. No compressions were being carried out because we don’t touch the patient during this short period, so the existence of a rhythm could be significant. I asked for a pulse check, but nothing was felt. Still, that rhythm was consistent. She was in PEA and this was an important development; it meant something was changing.

We carried on as preparations were made to get her out of the flat and into the ambulance. The exit was narrow and awkward but we had a carry sheet ready to make the job easier. There were five of us, so we could take the weight.

During the next period of analysis and just as I had decided she was to be moved, we heard ‘Shock advised’. She was in VF and the defib wanted to deliver a shock. I pressed the button and she jerked off the floor. The rhythm stabilised on the screen and there were definite QRS complexes – now they were more regular, slow but regular. I couldn’t believe it at first because none of us thought there was much chance of saving this woman. She was still terribly yellow (she was an alcoholic, so she probably had liver failure) and the changes we had brought about didn’t necessarily mean she would survive but there now existed hope where it hadn’t been ten minutes ago.

That was it; we had to get her out of there. We lifted her and got her onto the waiting trolley bed. We wheeled her to the ambulance and CPR continued all the way. Allan gathered all the equipment and litter we had left behind and the husband was brought out to sit in the front of the vehicle.

In the back, her heart rhythm had improved significantly. Her BP was managed posturally (her feet were raised), with fluids and a little dose of adrenaline every now and then. Things were looking reasonably good. By the time we were on our way (I left my car on scene and travelled with the patient), her vital signs were almost normal. She wasn’t breathing for herself, so that was being done for her but she had a good pulse.

At hospital, as soon as we moved her, the pulse weakened and threatened to stop, so I asked for compressions to re-start. I didn’t want her BP crashing.

Unfortunately, her Carotid (neck) pulse had all but disappeared when she was moved to the Resus bed and the doctor seemed unconvinced that she was viable, which surprised me after all the work we had put in to save her. He was about to call it when he found her Femoral pulse. My God, I thought, this woman just won’t give up.

So efforts were re-started and by the time I had cleaned up and had a cuppa, she was breathing for herself and was being taken up to Intensive Care with the possibility of going onto the liver transplant list. She’s only 47 years old.

I have to say that I felt proud of my son and proud of the way the job was handled. To me, this was a good example of professional team work and it saved a life. The MRU paramedic and the crew were invaluable because a patient like that has virtually no chance with just a single pair of hands working on her (or even two pairs and that was only because Allan happened to be with me today).

Now I was happy to face the rest of the shift; I had done what I am trained to do.

Our next call was to an 85 year-old lady who had collapsed in a shop in Mayfair. A crew were on scene and the MRU paramedic from the last job was there too, so I wasn’t required but it gave me an excuse to chat more about what we had done earlier. We all do that, it helps us to analyse the pro’s and con’s of our actions and it’s a great way of assuring yourself that you did a good job.
On the next call, a 65 year-old male with chest pain and no pertinent cardiac history was taken to hospital because he may well have been having his first heart attack. The lack of radiating pain or a sweaty pallor and the fact that it was relieved when I gave him GTN was beside the point.

Our final call was for a woman who claimed she had a broken arm after a door shut on her. She didn’t. She had been thrown out of a bank by the security staff and had been leaning against the door when it was closed. Now she was simply trying to get a lift nearer home. I refused to be drawn in by it, even though I was tempted to do the nicest thing and take her to the nearest hospital but she detected my critical questioning and stood up to leave.

‘I’ll get a taxi then. I have no money but I’ll get one anyway’, she huffed. Then she stood in the road and tried to get herself knocked down as she attempted to hail a cab, none of which stopped for her. Maybe they knew her.

Be safe.