Sunday, 27 April 2008

Survival of the fittest

Five calls; one assisted-only and four by ambulance.

The day started with a call to a 45 year-old male, ‘collapsed ?cause’. I found him lying on his face in the street; the caller, a concerned passer-by thought he might be dead but changed his mind when he realised the body was moving a little.

When I see young, badly-dressed skinny people laying in the street in broad daylight I usually (rightly or wrongly) assume one thing – drug addict. I wasn’t wrong this time because when I shook him awake and he lifted his torso, I found a blue tourniquet – exactly the same as the ones we use – underneath him.

‘Have you just taken heroin?’ I asked.

‘Yes’ he said, nodding in confirmation.

I could be asking a perfectly ordinary person if they were wearing trousers or not, such was his casual nature of his response.

‘Then can you get up and move somewhere less public, otherwise we’ll get calls all day for you.’ I suggested.

Now, I know you’re probably thinking he needs to go to hospital and that moving him along is unprofessional but the fact is, he doesn’t want my help and my colleagues in the assigned ambulance have better things to do.

He stood up and staggered off to the nearest phone box, inside which he’ll slump on the floor and pretend not to be there while he’ll actually not be there, if you know what I mean. His breathing was fine and he showed no interest in anyone’s concerns about his health or welfare – he had his habit and that was all he needed.

A minor knock in which a young moped rider was thrown from her ride by a bus when she veered into its path at slow speed next. She had a sprained ankle but the call was given to me and when I arrived, it had also been given to the MRU, which was on scene and dealing with her. Then another FRU turned up, followed by another ambulance and…for good measure a second ambulance – all despite me cancelling further resources. Thankfully, we didn’t hear the clatter of rotor blades from above. Someone had itchy fingers today.

I took the FRU I was running off the road and got a replacement because the siren wasn’t performing properly and it tended to sound like it was being strangled as the pitch and volume rose and fell to almost nothing each cycle. It confused the motorists because they had no idea where I was coming from and I had a few near-misses when vehicles roamed in front of me. Now I had the much older Astra to run – it’s out of date but it’s fast and responsive, so I was happy with it regardless.

A young Ethiopian man called us for DIB he didn’t have because he’d just had breakfast at a café but no money to pay for it. He feigned illness to escape the bill and the crew had no choice but to take him to hospital. He walked casually out to the ambulance and went through the well-rehearsed motions but we all knew he wasn’t sick.

The mother of a Bulgarian family that had just got off a train began to have chest pain as she walked the concourse. I knew how she felt after having to lug all my bags the length of the damned thing to get to her. Every patient will be the maximum distance possible when you have to carry everything – it’s an unwritten rule. They’re on the top floor every time or, as in this case, miles away from where you park.

She may have had a cardiac history but it was undetermined because of the language barrier – her vital signs were normal and she seemed more upset than in physical distress but she was wheeled to the waiting ambulance and taken to the nearest hospital – you never know with these things and it’s better to trust the patient sometimes, in any language, pain is pain.

My last job of the shift was the worst. I was called to a 30 year-old male who’d fallen from scaffolding. No other details were given but HEMS had been contacted, so I knew it must be significant.

The MRU had just pulled up before I arrived and I saw my colleague taking the stairs two at a time into the office building that was being refurbished. A man came out of the building to see me and I asked him how the patient was.

‘I think he’s stopped breathing now’, he said.

Oh, I thought.

I grabbed whatever gear I thought would be needed and ran up the stairs, through an open plan office to where my colleague was. On the way through, another man led a woman out of the door – she was crying.

On the other side of the office the balcony doors were open and they led onto a scaffolding platform at the first floor level. The scaffolding surrounded the building and rose to the fourth or fifth floor. I looked out through the doors as I approached and saw my colleague kneeling beside a young man, probably in his late teens or very early twenties, lying flat on his back. When I got close I recognised cardiac arrest – a pulseless person can be quite obvious sometimes.

We started working on him immediately and it was looking very bleak from the start. He’d fallen through a gap in the scaffolding platform directly above us and crashed onto the deck where he was now, with a serious head injury, bilateral pneumothoraces and God knows what other injuries. He was a lean, strong, fit looking young man and he was younger than my son.

Another FRU pilot arrived and helped with equipment as we continued the fight to save the man’s life. Nobody had seen him fall; a scream had been heard and then he was seen landing on the wooden platform at this level. The crying lady had witnessed him land and that must have been a terrible shock for her.

Another crew showed up and work continued – preparations were made to get him to hospital while we carried on resuscitating him but then the situation changed when two things occurred; first I noticed that his upper abdomen was moving quickly and realised his heart was beating rapidly. I felt it and sure enough, that familiar muscular throb could be detected easily through his abdominal wall. The adrenaline he’d been given would have been responsible for that and the frantic speed of its beat was a typical response to the drug. Then the HEMS team arrived and more intense work began on him, delaying his removal but ensuring the stability of his condition.

The pneumothoraces had been dealt with by punching cannulae into the chest wall and he was put on a respirator – no chest compressions were needed now that he had a steady heart beat.

He was collared and put into a vacuum splint for the journey to hospital. We carried him awkwardly down the stairs and outside. His eyes were open and he stared up at me with large motionless pupils. If he survives, he may have brain damage.

Traumatic cardiac arrest in young people is one of the worst scenarios we have to deal with and, personally, I have a tendency to want to work harder and faster at keeping them alive, probably because I’m a family man myself, I don’t know. I’m not suggesting I’d work with less care if it was an older person, I’m just more motivated because I know that young people, although capable of surviving trauma better than old people, have less of a chance when oxygen deprivation kicks in since their demand tends to be greater normally (leaner muscle mass and healthier organs require more fuel). A drop in oxygen levels for a sustained period may lead to organ failure or brain damage in a shorter time than it would for an older person – even second-long delays with a young person in cardiac arrest could, therefore, have life-changing consequences.

I think he will survive. I’m just not sure how life will be for him if he does.

Be safe.


Anonymous said...


Hope your traumatic arrest does ok. It's amazing that you got him back at all. Traumatic arrest has an almost universally poor outcome.
We had a fall through a skylight of only 10 feet (on his head onto concrete) that was retrieved to hospital by rotary over the weekend. He was GCS 13 during my care, collared oregon spine splint and bilateral 16 gauge canulas. Found out today he had a subdural haematoma and is most likely going to be an organ donar.

Some you win, some you lose.

Regional Para

northern nurse said...

What a sad case to end the shift. I quite like (well, like isn't the right word, but you know what I mean!) dealing with big, serious cases like this, putting my skills to the test. But then I often think, after a long day in ICU, what good have I actually done? We support their organs to the very edge of life and death, flogging the patientf for hours or sometimes days, and for what result?

Congratulations on the save, though.

Anonymous said...

What a terrible accident. I do hope that he survives and is able to live life with at least some quality.

It is of course tragic when any person dies, but I find it just a bit more tragic when a young person (with their entire life ahead of them) dies as the result of an accident.