Sunday, 30 March 2008

Doctor Duck

Twelve calls; one hoax, one gone before arrival, one home by taxi and the others went to hospital by ambulance.

I started my run of four nights tonight. I never look forward to this part of my rota; it’s demanding, tiring and sometimes soul-destroying because it spans the entire weekend...and summer is just around the corner. Summer means more booze, more drunks and people staying out much, much later in the day.

I don’t sleep well during the day when I do nights, so after about the second or third shift, depending on the workload, I begin to look haggard I think. Still, it’s not all about image, right?

A 55 year-old man had a seizure of some kind on a bus; he had no history of epilepsy but witnesses told me that he was definitely fitting. I found him sitting on a seat near the back, confused and unable to answer the simplest question, like ‘what’s your name?’ He would try, then fail and look frustrated. He was either post ictal or he had suffered a neurological event, possibly a TIA.

I sat on the bus with him for almost 30 minutes before an ambulance arrived (that’s always the first indicator of the kind of shift I’m going to have) and it took a lot of persuading to convince him that he needed to go to hospital. By this time my obs had been completed twice and he was recovering enough to make sense, although his sentence completion skill was still fragmented. The crew led him to the ambulance and he conceded that something was wrong – they took him to hospital to find out what.

A call to an ‘unknown female’ (that means we don’t have an age for her) with diabetic problems, ‘collapsed, now unconscious’ took me to a hotel room in Euston. The woman’s friend was in the room with her – they were both middle-aged and were visiting London to see a show. Unfortunately, that plan had been scuppered by the woman now lying on the floor, conscious but extremely agitated.

‘She used to be a nurse’, said the friend, ‘She’s been feeling unwell all day, then she suddenly fell down.’

This woman had no medical problems and the issue of diabetes was irrelevant – she wasn’t a diabetic. She lay there shaking and moaning. Every now and then, she would clutch at her throat and say she couldn’t breathe. Her sats were high but I put her on oxygen while I fathomed this one out. Everything about her screamed neuro and, although the rest of her obs were normal, I couldn’t help thinking I had seen this behaviour before. I suspected another TIA and when the crew arrived they agreed. It was impossible to get the woman to comply with any instruction – even opening her eyes was difficult; you could see her trying but failing to get those lids to pop up on demand.

She was taken to the ambulance and I got IV access in case she decided to go off on us. She was still shaking and fairly non-communicative. Her concerned friend went with her to hospital and I watched as the doctor carried out more tests to see what was going on.

My first drunk on a bus tonight and it was a five foot tall Polish man who just refused to budge. He’d open his eyes when I asked him to, then he’d shut them again when he realised I was irrelevant to his stuporous world. It took the combined efforts of the police, who arrived five minutes after me, and the crew to remove him by walk/dragging him into the ambulance. He was far too incapable to be left anywhere. Oh, and we knew he was Polish because he swore at us all in Russian and nodded when asked if he was ‘Polski’. It’s a sad state of affairs when we start learning Russian expletives simply by hearing them so often.

I thought I was going to a drunken male who’d passed out when I got a call to attend a 35 year-old man who’d fainted at a railway station but he walked out to meet me, which surprised me.

‘Are you here for me?’ he asked as I unloaded my stuff, ‘I fainted in the toilets’. I guessed it must be him.

I sat him in the back of my car while I carried out obs and when the ambulance arrived a few minutes later I walked him over to it. We listened to his story and got more and more suspicious about his condition. He had been sitting on the loo and suddenly passed out, recovering a few minutes later. He had never fainted before and he had no medical problems whatsoever but now he told us he ‘felt weird’. He looked pale and unwell, so we looked at his ECG. The delay between his ventricular contractions and the resetting phase of his heart was too long and this is known as Long QT Syndrome if persistent. I have seen a few of these cases but they are relatively rare and I could be wrong but I was confident enough, given the circumstances, that this was what I was looking at.

I can’t treat this condition unless it deteriorates and there is always a risk of sudden cardiac arrest, so we got him to hospital promptly. I’ll try and chase this one up to see if I was correct; it’s always good to know whether a diagnosis like that has been confirmed or denied.

I went to an all-girl fancy dress party next. Out in the east, a 21 year-old who’d had too much to drink collapsed in a heap in her bedroom. The party was in full swing at the little flat, shared by students, and I found her vomiting into a cooking pot. I do hope they don’t use that again.

She was very drunk, even though, as usual, her friends swore blind she’d only ‘had a few’. The crew arrived to pack her off to hospital and as we picked her off the floor, I noticed a lost tail on the floor (from a costume someone was wearing obviously). I picked it up and asked if it belonged to anyone. I tried to match it with the appropriate outfit but they were all dressed as animals and most of them required a tail. It was too confusing, so I left it where I found it.

As she was made comfortable in the ambulance, her friend came up to me and said ‘So, what’s wrong with her?’

‘She’s drunk’, I said and with that I left the scene. Her friends had that ‘drunk? Surely not’ look about them.

Back in the east, after returning to my station for a couple of minutes, for a 46 year-old man ‘fitting’ in the street. After an area search with the crew, who arrived shortly after I did, we found him. He wasn’t fitting. He and his alcoholic mate had been staggering about and he’d fallen. A MOP had called us because he was concerned that the man was epileptic and while I don’t deny he could have had an alcohol-induced seizure, he was in fine fettle now, as he and his friend chatted to the ambulance crew about their woes. I left them to it.

A hoax caller from Luton has been allegedly harassing a couple living near my home station. He ‘phoned them at home, demanding that the man’s wife join him in Luton later on, or he would kill himself. When she didn’t comply and their phone was unplugged, he dialled 999 and said that someone was having an epileptic fit at the address. Cue me and my yellow car.

The tenant of the flat was extremely apologetic when I buzzed for entry. ‘Sorry, this is a hoax call, we’ve been getting them all night’, he said with a fed-up tone.

‘Do you mind if I just come up and check that you are alright?’ I asked.

He buzzed me in and I went to the fifth floor. When the lift door opened he was standing at it with a sheepish look on his face. He was genuinely sorry to have wasted our time, even though he wasn’t the culprit. He took me to his flat and I met his wife. Both explained the situation and I bid them goodnight. As I left he called after me.

‘I have a heart condition and might need you guys sometime. Will this stuff cause me problems?’ he asked.

‘No’, I told him, ‘we’ll still come, even if your address had been flagged'.

Addresses are often flagged on the system if there is an issue we need to know about, such as a person who’s known to be violent. In this case, the address was known because of the frequent hoax calls directed at it. I felt sorry for that couple.

Three times I tried to get IV access for a 30 year-old female suffering sickle cell crisis; she had severe pain in her chest, back, abdomen and legs. I’ve seen a lot of this and the pain is genuine, usually scaled at 9 or 10 out of ten – the only effective relief for many of them is morphine and this is why I needed to get a line in. However, as with most of the sickle cell patients I’ve dealt with, access to a vein is never easy – they have been ‘got at’ so many times that they have worse peripheral circulation than a drug addict. On many occasions I’ve watched nurses and doctors struggle to find the best vein possible in the lower extremities; the ankle or foot is a favourite site but even then, there’s no guarantee of getting in.

I’d been with her for almost 30 minutes and she had to settle for the entonox I’d given her – it was reducing her pain score and that was the target – I just wish I could have done more for her on scene. When the crew arrived, she was a little more comfortable, although moving from her bed to the ambulance chair was going to cause some pain, so she continued sucking on the pain-relieving gas. Any good technician will tell you that the basic stuff, like entonox, is often enough for a call like this and paramedics often forget that they have a first line analgesic there. It’s easy to jump straight into giving IV pain relief but it wastes time while the patient is suffering, so they’re right, go for the good stuff first, if that doesn’t work or it’s not enough, then find a vein. She’d needed fluids too but the hospital staff were left to work that one out.

The most serious calls aren’t only sent to my MDT in the car; they are followed up with a phone call from Control. A 25 year-old man was trapped under a bus and it took me no more than three minutes to get there from the station. Police were already on scene and there were a lot of people milling about very close to the patient. I parked up and saw that a bendy bus had stopped close to the kerb and a few people were around a man lying on the ground – his leg appeared to be under the wheel of the vehicle. There wasn’t a sound from him as I approached.

When I got to him, I saw immediately that his leg wasn’t trapped but his jeans were torn away at the shin bone, revealing a pulped mass that was his lower leg. I quickly uncovered what I could of the wound and saw that he had extensive tissue and muscular damage, right down to the bone. Bleeding seemed under control and I tried to find out what happened but all I could hear was one voice ringing in my ear continually.

‘Are you a doctor?’ I asked the man who had given me the hand-over as I inspected the patient. He had gone into some detail in describing the wound and had begun to give me the man’s vital signs. He had forgotten, however, to tell me the patient’s name.

‘Yes, I am. I’m off-duty’. He then went on to tell me where he worked. His behaviour was strange and it was about to get stranger.

I spoke to the patient and he was very calm. He had been drinking and that may have acted as an analgesic because his injuries looked terribly painful and I expected him to start screaming at any moment but he didn’t. In some ways that’s good but it’s also ominous.

I grabbed my stuff out of the car and began cutting away at his trousers. I’d put him on oxygen and there was someone taking care of him at the head. The doctor told me he had used something to control the bleeding. He pointed to the limb and then I saw his handiwork. On the man’s leg, just above his injuries, was a very tightly tied makeshift tourniquet; a completely unnecessary device in pre-hospital care, except where bleeding is so serious that it can lead to imminent death. In this case, the leg skin and muscle had been sheared away but the major blood vessels were intact, as were most of the tendons and ligaments.

‘Do you have a cannula?’ he asked while I cut away the constriction he’s placed on the leg. I think he wanted me to give him one so that he could put it into the patient. Doctor or no doctor (no ID), he wasn’t touching the patient. The crew arrived and they got to work preparing the man for hospital. He was still conscious but we didn’t know how long that would last. His leg was in very bad shape and as we moved him out of the way of the bus, we could see that his ankle had also been badly damaged.

‘I’ll get this bus moved for you’, said the doctor without any request to do so.

‘No. The bus stays where it is, thank you’, I told him. Now he was beginning to annoy me.

I asked the police to get rid of anyone who wasn’t directly concerned with the incident. The crowds had grown around us and they were noisy; some of them were behaving very badly – taking photo’s, making retching sounds – that sort of thing.

I had cleared the wound area of clothing and the man had been moved back so that his feet were no longer under the bus. We had tied a secure dressing over his wound and were almost ready to go when I looked up to see the doctor’s head inches from mine. He was staring down at the injured leg.

‘Oh, that’s pretty bad, isn’t it?’ he said in an almost schoolboy tone.

Now I knew he couldn’t be for real. He was either in his first week at medical school, or he wasn’t a medic at all. This wasn’t the kind of behaviour I expect from a medical professional. He seemed to be there for the drama. Its high time doctors carried identification with them; everyone else does. I’m glad to have a doctor working with me but someone in the street who simply says he’s one is an unknown and potentially dangerous threat. A genuine doctor understands the need for a controlled system of patient management, especially on a scene like this. Real doctors deserve to be protected from imposters who are tarnishing their profession, so an ID card seems logical and unobjectionable.

‘Can you please move away from here, you’re breathing onto his wound?’ I said. He backed off, apologised and moved to the side of the patient for a look instead. I was seconds away from asking the police to move him along when he stood up and I got an excuse to get rid of him.

‘Thank you for your help, we’re fine here now.’ And with that, he walked off into the horizon.

The police had a proper cordon around us now and we could safely move the patient into the ambulance. It had to be done carefully because we still didn’t know if his bone had been damaged by the crush but it all went smoothly and a few minutes into our secondary survey in the back of the ambulance, there was a knock on the door. I thought I was going to see my 'doctor' friend again but it was a genuine medic from HEMS that I saw smiling up at us.

The HEMS team carried on where we left off and I put a line in for fluids. All the while, the man lay there, quietly shaking his head from side to side as if to say ‘what an idiot I’ve been’. He never once cried out or complained or gave us any trouble whatsoever. I wish all my trauma patients were like that. His obs were stable but he was, understandably, very pale. His leg had been torn away from the upper part of his shin, just below the knee, to just above the ankle joint. Most of his muscle was gone. He would need extensive reconstructive surgery and he’ll know pain and immobility for some time, I suspect.

He had been standing near the bus when it was pulling into a stop when his jacket somehow got caught in the doors (this is the second such case I know where bendy buses have caught someone like this). He was dragged to the ground and his legs were pulled under the bus. The rear wheel went over one of his legs as he tried to pull free but it must have gripped at the fleshy part, rather than roll over the bone, thus no fracture (that we could determine). This caused massive tissue damage, however, and that will take a lot longer to heal than if he’d just snapped his leg.

My next call, once I’d cleaned up, was for a hysterical 19 year-old who was very drunk, very loud and insisted on thrashing about on the pavement. She had other issues besides being drunk and stupid, I was sure of that. She’ d slump into silence while her friends and boyfriend stood over her, wringing their hands about how ‘ill’ she might be. I told them she wasn’t ill. I told her she was behaving like a baby. She had already clubbed me a few times around the head and legs with her over-active fists and feet and I’d shouted at least once that she best behave herself. It took another ten minutes to get her to stop assaulting me.

Eventually, after I’d cancelled the ambulance for this fraudster of a ‘patient’. She went quiet again and seemed to settle into exhaustion. Minutes earlier, I’d been treating a man who was lucky to have kept his leg after his encounter and now I was kneeling over a large, emotional wreck. Instead of baby-sitting her on behalf and at the expense of the tax payer, I suggested they all go home by taxi. Her boyfriend would be with her all night, so if she suddenly ‘deteriorated’, he could call us again. She didn’t want to go to hospital anyway; she was an obdurate child in a teenager’s body and I had no time for her.

As they dragged her to the taxi, I asked her surname. The boyfriend turned round and gave me a blank look.

‘Oh, I’m not sure actually’.

True love.

A call for a 44 year-old man who was hypothermic and had chest pain (that sounded alarm bells – it was probably a rough sleeper trying to get a bed for the night) had me searching the location for my patient. A drunken man approached the car and told me his mate, the ‘patient’, had stormed off after waiting five minutes for me to arrive.

‘He’s pi**ed off that you didn’t come for him, so he’s gone. I’m f**king annoyed at him!’ he spat into the car. They always lean right in, no matter how much your hand tells them not to. His breath was like the breeze from a rubbish dump.

I thanked him for his valuable information and set off on my last intrepid adventure in ambulance land. It was for a 26 year-old male who’d been found lying on the kerb, bleeding from his head. He’d probably fallen down drunk and cracked it open, or he’d been assaulted by someone (again most likely drunk) and left there. Whatever it was, I never found out because the crew were on scene and dealing with it. I wasn’t required and I set off back to my base station and crossed my fingers that the phone wouldn’t go until I had ended my shift. The minute hand of the clock crawls when I wait like this.

I got off on time and went home to sleep in preparation for yet another night of drama and stupidity.

Be safe.

10 comments:

Anonymous said...

Now we know you're famous - there's an autographed copy opf your book on ebay!!!!!

Tabitha said...

I've still not seen one of these bendy buses, but I'll remember to stand well back when I do. Poor guy, what a horrible thing to have randomly happen.

Oliver Smith said...

These bendy buses are everywhere where I am - they are really annoying and it's only a matter of time before someone gets hurt (like your patient). I really don't see any point to them.

Interesting and informative as always! I really don't understand why people would pretend to be a doctor - after all impersonating one is an offence!

Medix311 said...

Unresponesives and drunks--you have to love a shift with a theme. I think my tolerance would have been gone by the second call.

Xf said...

anon

Can't find it myself...only two unsigned copies on there but if there is one, I hope it raises money for charity.

:-)

Anonymous said...

150231297000 is the item number on Ebay

Anonymous said...

“All the while, the man lay there, quietly shaking his head from side to side as if to say ‘what an idiot I’ve been’. He never once cried out or complained or gave us any trouble whatsoever. I wish all my trauma patients were like that.”

That man was probably too embarrassed about having been drinking in the first place to cry out, complain or give you people “any trouble whatsoever”, and as you say his drinking acted as an analgesic. However, some people are in traumatic incidents through absolutely no fault of their own. They then find themselves having to go into an ambulance, go to hospital and face injections and other painful treatment. You should not therefore expect them all to be so compliant and ‘no trouble whatever’, as if you should somehow have complete control over their bodies with total submission. In fact, your job should be doing the hard work to make them feel secure and not threatened, and if they do not want to receive certain treatments they should not to have to.

If that lorry had hit you the other day and you were lying there seriously injured in your car, I doubt very much that you would have been quiet and uncomplaining about it. In fact it sounds more like you are the one who would have been moaning and complaining about how other paramedics were treating you!

Xf said...

Anon

'you people' - you don't like 'us people', do you? You are obviously very offended by my phrasing, which is mainly incidental to the sentence and is not intended to insult or patronise. In this context, I meant that he made it easier for us to preserve his limb.

And you don't know anything about me, so you don't know how I'd react at all to injury. Neither do you know how much effort and 'hard work' I put into reassuring patients and making them feel safe. You simply have no idea what I do and how I do it but the way I write has set you off.

You then wander off on a tangent about not having to receive painful treatment. You may be dealing with personal issues here and they are nothing to do with me or this posting.

Please confine your comments to less emotive personal issues and read what I've written carefully, or not at all.

Thank you for your comment.

Anonymous said...

How can I not know anything about you? I have been reading your blog for about a year and you have been putting enough information in for me to at least know something about you. For example, I know your real name, the sound of your voice, the name of your son and some of the treatments you have been carrying out – unless of course you have been changing all “facts in order to protect patient confidentiality”.

As for having no idea what you do, I do not have to know exactly what YOU do. I sure hope I know something about the work you do because I have been watching programmes about or that include the ambulance services in the UK for a specific reason, and it is also why I had been reading your blog. (Your blog led off from another ambulanceman’s blog but yours seemed easier to read.) Also, no way would I allow anyone to touch me if I did not know anything about what they did, particularly if it might involve invasive procedures.

As for the “painful treatments” bit, I meant that some people who are involved in traumas through absolutely no fault of their own are unwilling patients. They may never have had to go to hospital before whereas this bus accident man may have done, and not a few times. He would therefore know the score. This victim was also a full grown adult male and less likely to cry anyway.

I also believe in informed consent and the right to refuse specific treatments which would require having to speak up. This would require that medical staff be patient, understanding, and not treating patients as though they were children who should be seen and not heard.

Your writing does sometimes sound insulting, sarcastic and patronising because you have to deal with so many drunks and time wasters that you seem to carry your attitude about them over to some patients who are genuine, and you once did reply “The job makes cynics of us, I'm afraid”. I do not like this attitude at all in people who deal with the public and especially when it is from medical staff. This is what can “set me off”.

Do not forget that some of your thoughts and writing could still give some readers the wrong impression of the ambulance service in general. Whether you like to believe it or not that what you say “does not purport to reflect the views of the London Ambulance Service NHS Trust”, it could still be shown to reflect on the crews anyway.

Xf said...

anon

I really don't understand what I've written that has got you so hot under the collar. All my references to this patient's behaviour were simply personal reflections - 'giving us no trouble' simply means we are able to work with him. It doesn't deny him his right to refuse but any doctor will tell you there are times when even this is overriden by the need for manageable patient care to save life and limb.

And the reason you know my name is because I am transparent and don't hide behind anonymity. All you read is the way I think. Cynicism, whether you like it or not, is ingrained in everyone working in this field and applies to almost every nurse and doctor I've worked with. Seeing it on telly just isn't the same as doing it for real.

If I am exposed, every day of my career, to the risk of assuault and abuse and possibly serious injury then I feel entitled to air MY views MY way without obstruction.

I do not insult people; I speculate on the human condition. Perhaps my blog is easier for you to read because of this. Email me with your concerns if you think I am truly a bad reflection on the service, use you real name - don't snipe.