Wednesday, 26 March 2008

Lethal weather

Eight emergencies; one assisted-only, seven by ambulance.

The cold, snowy weather reminds me that our climate has probably changed for good. This is the time of year when tourists usually enjoy the first sunny spells in London but those days seem to be gone, or at least are becoming rarer. I’d like to think we were doing our part to reduce the carbon footprint but we will, as always, be out and about in our diesel vehicles, running up the debt for the sake of the sick (and more often the not-so-sick).

First off, a 75 year-old with SOB, especially when moving about. She has recently had her Aortic valve replaced and was fine for a few weeks but now she feels lethargic and can’t get a breath. All her obs were normal, including her sats, so there was nothing screaming out. Her BM was a little high but that can happen in times of stress. Nevertheless, given the recent medical history and her present complaint it was prudent to have her taken to hospital on oxygen.

Next, a 25 year-old man complaining of chest pain. He worked at a hotel and I found him in the basement office. He made no eye contact with me or the crew when they arrived and throughout the entire examination he mumbled his answers to my questions. He seemed evasive…or maybe that was just him. Whatever it was, my gut instinct was to think he was lying about his condition. I go to a lot of hotels where foreign staff feign illnesses to get off work, I think it may be because they feel (or maybe it’s true) that they will lose their jobs if they don’t show up.

Tachycardia in young people is fairly common and can often mean nothing at all and so when I was called to a 22 year-old with a history of undiagnosed periodic fast heart rate, I had to reassure her. She had been scared by the last event she experienced, when she was told that her HR was so high that her heart might fail. She was waiting in a reception area at work with a heart beat of 250 per minute. Of course, being told by a medical person that you might die if it goes on for too long will only exacerbate the condition, causing an increase in rate to the point where, well, yes…you could die. So, in these cases, reassurance and confidence is required, not scaremongering.

The crew carried on the work of calming her and by the time she was in the back of the ambulance, her resting heart rate had dropped to almost normal. No drugs, no manoeuvres, just quiet chatting and continual reassurance.

She was taken to hospital because her condition needed to be checked again. Regardless of how common this might be, without aetiology, there are always cases that throw up cardiac defects when looked at closely enough.

After a short break and during a period in which the weather worsened, I was sent to check on a 3 year-old girl with severe DIB, a high temperature, tachycardia and who was vomiting. The call description also included the words ‘eyes rolling’, so the whole thing sounded like a febrile convulsion, with the addition of a few extras, which may or may not have been the result of panicky parents.

However, when I arrived I immediately recognised the little girl and her mother. She has a suspected congenital condition, which is yet to be identified, giving rise to these signs and symptoms. She often goes into respiratory arrest as a result and this means that she requires emergency (blue light) transport to hospital whenever the condition affects her like this. This was the second time I had encountered her; the last time was at her aunt’s address, so I was initially confused by the presence of a pulse oximeter in the room and a very knowledgeable mum, who could explain in technical terms exactly what was going on. Only when I looked at them and thought for a second did it dawn on me.

The crew arrived within a few minutes and I explained that we needed to get this patient to hospital fast. None of us wanted to be holding a young child as she stopped breathing. The last time I met her, she was very lethargic and wanted to go to sleep – this time, thankfully, she was more alert.

‘Hello’, I said, ‘do you remember me?’

‘Yes’, she says, nodding her head. She’s not in the mood for smiling.

‘Are you getting fed up of this?’


Of course she is. She’s in and out of hospital with this frequently and every time her mother gets to the Resus room with her, she has to explain, all over again to a new doctor, what the problem is. It must be exhausting for them both. I left the little girl sitting on the bed being poked and prodded by the medics. She looked annoyed with them.

A 23 year-old who was ‘not alert’, greeted me with an embarrassed smile as she lay on the floor of her workplace at the behest of the first aider, who had called us because she was genuinely worried. The Croatian patient didn’t want an ambulance called as she was having a heavy period and had felt a bit faint as a result, that’s all. She could deal with it on her own. The appearance of the ambulance crew made her want to shrink into a corner. Croatians, from my limited experience of them from visiting their country and seeing their healthcare system at work, don’t tend to call ambulances for minor problems. They come from a generation of people who were sniped and killed during the Balkans War, just for crossing the street.

She declined our offer to take her to hospital if that’s what she wished and, after a check-up in the ambulance, went home to rest it off.

Then my day turned sour. The wind was blowing hard in gusts of 40mph and the weather was generally wintery – a miserable combination for a call outside for a 23 year-old female who had been hit by scaffolding. At first the call described a head injury, then the details changed and now she was unconscious. I was asked to report for HEMS on arrival, which means the job may be serious enough to warrant the helicopter, although I doubted it would fly in this atrocious weather. There was a doctor on scene apparently but I had to assume it was an off-duty GP because he didn’t give much in the way of details.

As I drove to the scene, an update informed me that the girl had been hit by heavy boarding (the type used to screen off building sites) and she was bleeding from the head and nose. This was not good and I requested the assistance of the Fire Service when a further update informed me that she was buried under rubble. What the hell was going on?

I arrived to find an ambulance crew on scene and one of them shouted that I needed my bag. A crew will only do that if things are serious. I confirmed that HEMS was needed and radio’d in before grabbing my bag and running over to where an MRU technician was kneeling over the patient. She may have been covered in the material that had blown down at some point but now it was strewn around her. At first I thought she was a he because her hair was matted in blood, making it look short and boyish.

Her boyfriend was there and he stood among us as we worked on her. He was pale and stricken; you could read the shock on his face.

His girlfriend was in and out of consciousness and had blood pouring from her ears and nose. She had skull fractures for sure and I learned that the large board had been ripped from its frame by the wind as she and a group of friends walked past. She was the only one to be hit and she took the full force of the thing on her head. It was clear from the heavy, nail-spiked wooden debris around that her injuries would be very serious.

I could hear the familiar clatter of the helicopter above us; they must have been despatched earlier and I couldn’t believe they were going to land that machine in this wind…but they did and the pilot has my highest admiration for it. They set down neatly on a small mound of grass between a bus station and the scene. They can land on a penny if they want, I think.

A quick examination was carried out following my secondary survey and the girl was rapidly moved because her condition was getting worse. She was scooped up and taken into the back of the ambulance. The HEMS team piled in with her. My role ended there, as it did for my MRU colleague.

There were now a number of ambulance personnel on scene, including the HART team, who’d been called out because of the nature of the accident. The Fire Service were there too and a few ambulance officers turned up later.

As we stood outside the ambulance, the LFB (London Fire Brigade) began the task of dismantling the remaining boards to make the area safe. A main road ran directly in front of the scene, so any further flying structures could cause more trouble. Out of the corner of my eye I caught a glimpse of something big and black flying towards me and a few of the others who were milling about. Another board had come off and it flew at speed across the pavement at head height, smashing with some force into one of the fire trucks. It caused a bit of commotion because we now realised just how dangerous things were for us. I looked up and saw a Fireman standing on the frame with a claw tool in his hand. He looked shaken and very sheepish. He had been loosening the board when the wind caught it and took it from him.

The girl’s boyfriend had been a few feet away from the flying panel and it would have been a horrible irony if he too had been injured.

When I looked into the ambulance, just before I left the scene, I saw that the girl was being put to sleep. I heard later that she had become combative and that she had deteriorated so much that the only safe way to deal with her was to carry out an RSI.

I went back to my station to recover from that call but I didn’t get much time to think. I was off again for a 4 year-old who had fallen and had a head injury with ‘serious bleeding’. In fact, when I got there the child was standing in a bath with a wet towel on his head, courtesy of his father. The bleeding was never serious and the injury amounted to nothing more than a scalp wound. The family obviously lacked the experience to understand the difference.

My shift ended with a second major call. A 30 year-old male had collapsed and was now unconscious and bleeding from his nose. This wasn’t weather related but it was still unusual. He had fallen outside a pub and I was expecting to find a frequent flyer drunk on the pavement. Instead I found a small crowd of people tending to a man who was out cold after collapsing suddenly and crashing head-long into a tree. He had a massively swollen eye as a result of his encounter but, as he had collapsed before the trauma, I knew there was more to this.

His girlfriend was with him and she explained that he had high blood pressure but nothing else wrong with him. She hadn’t seen him fall because she was walking slightly ahead of him but plenty of other witnesses confirmed that he just fell suddenly – no trip, no sound.

The guy was older than given – he was 52 years-old and his pulse was very slow; around 32 bpm when I looked at it. I checked again and again as I put oxygen on him and he began to stir but it remained low. A drop in pulse rate will often be accompanied by a drop in BP, which results in collapse. The problem was his pulse wasn’t improving, so something could be wrong with the conduction system of his heart. He hadn’t complained of chest pain prior to falling and he had no history of MI.

The crew arrived and we quickly got him into the ambulance. His ECG clearly showed third degree heart block; his pulse remained extremely slow and his BP was dropping by the minute – dropping into his boots, as we say. He couldn’t survive this if it was allowed to continue, so my colleague raised his legs and set up fluids to bolster his circulatory system but that wouldn’t be enough. He needed something to speed up his heart rate, so that everything else normalised and he became stable. Atropine is the answer.

I drew up a small amount of the drug and administered it slowly. The technical bit now; the block was causing two separate impulses to work his heart at different rates – the normal atrial contractions were continuing but the ventricular contractions, the ones required for circulating blood and therefore systemic blood pressure, were firing off at a slower rate from somewhere else in his heart – probably way down in what’s known as the Bundle of His or even the Purkinje Fibres. His QRS complexes were not too wide, so he could be getting his ventricular impulses from high up in the fibres. Atropine would affect this and take the brakes off his heart, allowing it to increase in rate, pumping more blood around and normalising his system until something definitive, like transcutaneous pacing, was carried out.

Too much of the drug could be detrimental. Not enough of the stuff could also be detrimental. I needed the right dose, so he got 0.4mg and that was enough. By the time he got to Resus, his condition had improved significantly.

I learned a lot from that call but my feeling of satisfaction with a job well done was tainted by the earlier call for the girl who had been hit by that huge board. Sadly, I was to learn from a colleague later on that her condition is so serious (she has multiple skull fractures) that her prognosis is poor. She is unlikely to survive.

Be safe.


JackB said...

Wow, you've got to admire those HEMS guys and girls. Theres a lot of fundraising in Herts to provide one. Money well spent.

Anonymous said...

My mum always told us not to walk under scaffolding or even park near it, even on a calm day.
I always thought she was being overprotective.
What a terrible tradegy.

kethry said...

just out of curiosity. you often post the long term prognosis of more seriously injured patient (e.g. that girl who was hit by the boards, multiple skull fractures) but do you get told after a period of time if they're okay or not? or is it incumbent upon you to ask if a particular case catches your attention (as they must do)?

thanks for an interesting blog!


deborah said...

Poor girl. Makes you realise that you can be there whole, hale and hearty one minute and poof! gone the next.

Anonymous said...

Very sad story about the young woman with the head injury.
I related to your comment about the little girl - her mum having to repeat herself to new doctors regarding her condition. I frequently have to do this. My 7 yr old son has CVS (Cyclic Vomiting Syndrome) and, under the Consultants instructions, has to be admitted to hospital with each episode. Most doctors I come across have never heard of his condition yet the last ambulance crew to convey him to hospital seemed to have heard of it! I may add he doesn't usually go by ambulance but due to vomiting blood (an oesophageal tear) he went via ambulance as a precaution.
Keep up the good work!

Martin said...

I'm not sure if HEMS is worth every penny. It is incredibly expensive to keep the helicopter in the air - the Herts website says "Maintaining a life-saving helicopter service will cost approximately £80,000 per month."

Would that money not be better spent on many more ambulances? Maybe put a doctor in a fast response car instead? The cost-benefit analysis done by the NHS means they don't pay for them. A million quid a year would buy a lot!

Anonymous said...

What do you mean that the young woman was being “put to sleep”? What with, and was this done by a doctor or a paramedic? Also, what is an RSI?

Martin said...

RSI - rapid sequence induction. It is basically a quick anaesthetic in order to intubate her. They do this to protect the airway. That is what he means by "putting her to sleep".