Thursday, 27 March 2008

Time to think

Five emergencies; one assisted-only, one declined and the others required an ambulance.

Still snowing. The threat of it lying on the ground has been lessened by the mixture of sleet and rain we’ve had today, so I shouldn’t be skidding around the roads. We’ve been issued with special covers for our wheels so that we have a bit more traction in snow and ice – they look like condoms for tyres.

An 83 year-old female with chest pain was known to the crew when they arrived after I had started my obs. She’s lonely and needed sympathy but she also had an irregular heart beat and that warranted taking her to hospital where she will get all the attention she needs, if only for a few hours,

A 45 year-old man who was ‘unrousable’ on a bus and so the driver called us out to remove him, one way or the other. The usual way is to wake them up and walk them off with a few polite words and that’s all I had to do. The man was face down in the aisle between the seats and his tell-tale can of extra strength lager was nearby. I shook him and shouted into his ear so that he wouldn’t mistake me for the driver (he wouldn’t care at all if he knew it was him; these guys know the drivers can do nothing to them). He woke up and, somewhat groggily, began to recover himself and sit up.

‘Do you need an ambulance?’ I asked in the well-rehearsed and customary manner.

‘No’, he replied in the equally customary and completely expected fashion.

‘Thanks for your help’, he went on to say. Now that surprised me; it doesn’t happen much on the buses.

I walked him carefully to the exit and the bus driver decided to storm up to him and scowl. Until now, he had kept his distance while I got on with it (I don’t usually say much to the drivers – I just get on, wake them up, say bye and go).

This little face to face encounter annoyed the drunken man and he postured aggressively. Great, this was all I needed; he had been a lamb with me and now he’s getting ready for a fight because the driver has suddenly got all brave.

‘Okay, let’s go. Don’t worry about it’, I said to the man while simultaneously throwing a ‘back off’ look at the driver, who promptly turned on his heels and stamped down to the other end of his bendy bus.

As soon as we were clear of the doors they closed and the bus drove off, almost as if the vehicle itself was in a huff with me.

I looked at the man and he reminded me of someone. I said cheerio and he left after insisting on hugging me and polluting my uniform with the smell of fags and old booze (among other things).

When the crew turned up they caught sight of him as he walked off and I signalled that there was nothing to do here. That’s when my colleague jogged my memory of who he resembled; Eddie Murphy in Trading Places. The sleeping drunk dressed just as the actor had when he played the part of the legless beggar in the park. This time, the only relevance I could draw to the lookalike being ‘legless’ was in terms of his drinking habit.

My next call was to attend a 65 year-old male who had fallen at an underground station and sustained a head injury. Sometimes these falls produce dangerous injuries, so I hurried along to the scene and was led to the gentleman, an Italian tourist and his son, who were sitting in the station office, neither looking much the worse for wear. It was explained to me that the man had initially been dizzy after his spill but he had no injuries and he translated through his son that he had no interest in making a fuss.

I checked his obs and the crew did the same but we had no choice but to pronounce him fit and well. He declined the offer to go to hospital, just as any sensible adult who knows his own body would and we left them to get on with their day at the theatre.

Speaking of which, yet another collapse at a theatre – what are they putting in the water? This time an 81 year-old man had become very dizzy and faint whilst watching the show. Now he was out in the foyer, where a breeze (ice cold) was making him feel better. He went into some detail when asked about his medical history and I was an expert on his reflux problems (he has oesophageal stenosis) by the time the crew arrived. He belched a LOT during the conversation and that can sometimes suggest a cardiac problem but I honestly think he was suffering from gastric reflux (mainly gas). Whether this had any connection to his dizziness, I didn’t know but he seemed fine when he was taken to the ambulance. In fact, he seemed to welcome the trip. I shall be keeping an eye out for him in the future; I expect I’ll see him again.

My second encounter with a bradycardia requiring Atropine treatment occurred at a tourist attraction in north London. A 55 year-old man had collapsed and passed out in front of his young grandson and several witnesses. By the time I arrived he had recovered enough to be taken by wheelchair to the exit for fresh air. I examined him and found his BP and pulse to be very low; his pulse never climbed above 40 bpm. He was pale and still not fully recovered, even though he was lucid enough. He had a history of high blood pressure and was taking antihypertensives for it – he hadn’t missed any nor taken too many today, so his condition was a mystery, although I suspected we’d find a block on the ECG.

The crew took him to the ambulance and I assisted the paramedic with the man’s treatment. Atropine was administered and his pulse rate improved, as did his BP. I didn’t see it get as high as I would have liked – around 60 bpm but it had increased in rate sufficiently enough to suggest a recovery. His ECG looked normal but there were a few anomalies and neither of us could translate them – they would need to be interpreted by a cardiac specialist at hospital.

My calls were spaced out over the shift today and I got plenty of time to reflect on the last few weeks and the incredibly precarious position that paramedics can find themselves in without warning. I’ve spent my entire career avoiding issues which might lead to disciplinary action and possibly being struck off the professional register; it has happened to many paramedics and some of them have been punished simply because they were seen as the ‘clinical lead’, regardless of who else did the wrong thing at the time. Taking and holding that lead can be difficult within a culture that is yet to fully understand the changes the pre-hospital care sector has undergone. It’s not about ego or arrogance; it’s about completing a task that you started and being held accountable for the outcome – I think I’d rather make a few enemies by standing my ground than be struck off and end my career in shame because I relented when I shouldn’t have. I’ve been taught a sound lesson on a few calls recently and like all of my colleagues who must have experienced the same, such incidences put you back where you belong – in charge of yourself.

Be safe.


Tabitha said...

Thanks for another great post.

I wouldn't have thought the job attracted the kind of person who would need what we usually think of as disciplinary action. Do you mean occasions where the patient didn't recover as they should have done, or the course of action taken appeared wrong with hindsight?

Anonymous said...

I take it the HR of 40 guy wasn't in any sort of block. Initially that sounds like 3rd degree block with a junctional escape. Did he have any other S&S of parasympathetic dominance seeing as Atropine had an effect?

The whole "Paramedics getting struck off" thing is a bit scary. Can you talk any more about this, I'm interested as Paramedics in the antipodes are in the throws of professional recognition and registration can't be too far away.

Regional Para

Xf said...


I'm talking about professional culpability; if it goes wrong or someone who is not seen as the clinical lead makes a mistake under your supposed supervision. We don't yet have a fully structured culture in which a hierarchy for medical responsibility is recognised...this leads to disciplinary action, including sackings and being struck off.

I've had a few weeks where the risks were high for me, even though I had done nothing wrong myself.

Xf said...

Regional para

His ECG was almost normal, there were no obvious escapes and the few anomalies I found amounted to no more than possible bundle branch block.

As for your second question - see above reply to Tabitha.

Our regulatory body is made up of a mixture of disciplines. We are not on the same register as doctors and nurses, which is stupid in my view. We share a register with other 'periphery' medical services, such as chiropractics. We don't have a strong peer presence on the panel when disciplinaries are heard, so paramedics in the UK tread on thin ice every time a tricky job comes their way and there's not a lot of sympathy, judging by the reports I've seeen, for circumstances.

It is, as you say, quite scary.