Tuesday, 20 May 2008

Death by bread

Ten calls; two assisted-only and eight by ambulance.

Well, not exactly death...but a serious enough wound that could have been a lot worse and even potentially fatal. This was my third call of the morning and I had just bought myself a nice warm bacon sandwich. A 30 year-old female had cut herself on a knife and blood was ‘squirting’ from the palm of her hand, according to the details on my MDT. My sandwich would have to wait and I knew because of the distance I was being asked to run, that it would be cold when I got back to it. My stomach would rumble all the way through this call.

I arrived at a delicatessen (and that seemed like a wind-up, considering my bacon sandwich sat, unloved on the seat of the car) and was guided downstairs to the basement, where food is prepared for serving to the customers above. A Pale, sweaty woman sat on a chair, holding her bandage-covered hand up in the air whilst a colleague (the owner’s daughter) tended to her. The wound was covered by a flimsy paper triangular bandage, not a dressing as it should have been, despite the fact that the first aid box was open and contained plenty of sterile dressings.

Then I heard the incredible story of what probably happened. She’d sliced her hand open, down to the deep muscle at the small finger but the knife that had initially been blamed for the wound was clean. Blood was spattered all over the sink area and could be seen on the floor around her but not a drop was on the blade of that cutting tool. So what had done the damage?

It turns out she’d slipped and fallen whilst carrying frozen crusty bread (defendant above). This stuff is lethal enough inside your mouth when it’s thawed and I could see how a frozen, jagged loaf could easily cause a deep laceration to soft tissue. Luckily the pointy bread hadn’t cut through an artery or we may well have had a serious problem, especially as the owner of the establishment had no idea how to use his first aid kit properly (it’s a legal requirement). She could have bled to death as a result of her brittle mishap if her carotid had been taken out.

I dressed the wound, elevated her hand in a sling and advised the owner about his first aid issues. Then the crew arrived and I showed them the photo (I take these with the patient’s permission and to serve as a record for the crew after I’ve covered the wound up) – they were stunned that bread could have caused so much damage. It was a rare call, that’s for sure and I doubt I’ll see many more injuries of this nature caused by floury products!


I’d started my day off with a call to a 40 year-old man with chest pain and DIB but I wasn’t required because a crew was on scene when I arrived and I got taken away from that call immediately for an 83 year-old man ‘? TIA’. He was living in a very posh residential care home but it was awkward to get to as the entrance gate was padlocked and nobody came to meet me. The ambulance drew up alongside as I called Control and the crew managed to find another gate further away, so I went on foot and walked beside the vehicle as it headed to the main building, a large Georgian house.

The man was in bed and a nurse had called us because his behaviour had suddenly changed; he was confused and pale. He had a history of CVA and when I checked him I found his pulse to be slow at around 43 per minute. The crew quickly took him into the ambulance, where an ECG and other tests were carried out before he was ‘blued’ to hospital.


A 65 year-old man who worked in a club in the West End called an ambulance for his dental pain because his emergency dentist was unavailable. I know the agony of toothache but I wouldn’t call an ambulance. He decided to add ‘chest pain’ to his report and that got him a 999 response. He may well have had both because of the stress the painful tooth was putting him under and so he was given the benefit of the doubt, as would anyone, and taken to hospital on that basis. His ECG was absolutely normal.


A pale, shaky 35 year-old man was hit by a lorry as it turned into a street. He hadn’t seen it because the roads were closed off for emergency gas repairs, causing chaos for traffic and for me when I tried to get there. He’d assumed nothing would be travelling along it, so he got a shock when the truck knocked him off his feet and into the road.

His family were with him because he’d called his wife when it happened, after picking himself up and staggering back towards a car dealership (which he was on his way to visit). He was inside when I arrived and looked very out of sorts, as you’d imagine. Although he only complained of a minor pain in his leg, he was a bit vague and had also bumped his head on landing, so I advised him to go to hospital, despite his reluctance to do so. The crew added a bit more persuasive pressure and he eventually relented.


Brittle asthma is an unpredictable danger and my next patient, a 38 year-old woman, was suffering an attack, even though she’d used her home nebuliser. She sat, leaning forward in the classic asthma attack position, on her sofa as her children watched telly. She’d been to hospital many times and it was obvious she was in danger if her breathing wasn’t corrected quickly. I put her on my O2 driven neb and she began to feel better by the time she was taken to the ambulance. I’d had time to do a peak flow and her PEFR was 40% below normal, which is significant.


Stubborn elderly people, especially men, with SOB are usually genuine cases that need to go to hospital but try and try as we did, the crew and I could not persuade this man that he was ill. His daughter had called us and when I arrived he simply said that he was ‘fine’. I put him on oxygen and he felt better than ‘fine’, conceding that his breathing was being helped. He still didn’t want to go and asked if we could just leave him on the oxygen at home. Of course, we couldn’t and he was waiting for his GP to get him a home oxygen system, so we argued that corner for a while.

Just as we were leaving (I’d taken him back off the oxygen) he felt a little worse and shouted out for us to come back because he was, after all, going to travel to hospital. We weren’t happy about leaving him anyway but his earlier insistence gave us no choice. Taking the oxygen off him had proved that he couldn’t do without it and he’d relented.


I rushed out into the rain for a 31 year-old with DIB which was brought on ‘after an argument’. I knew I’d probably be looking at hyperventilation but stress brings on many, more serious conditions. She was sitting inside a cafe and her friend, who’d started the argument, was trying to calm her. She was breathing way too fast and all the associated symptoms were making her feel worse. I spent twenty minutes calming her until she felt fit enough to carry on her journey, friend in tow.


Then a Red1 to a bus parked near Oxford Street for a 16 year-old ‘foaming at the mouth; unsure if breathing’. I felt sure myself that this wouldn’t be as given and I also knew there would be a LOT of fuss for this call. I turned up and boarded the bus. Three managers and the driver were present and they pointed to the back seat in which slumped a man, much older than 16, who was most definitely breathing. In fact, he was sleeping.

None of the guys on board dared to get near enough to him to establish his problem and now I was shaking him awake, much to his disapproval, as the police, MRU and ambulance turned up.

‘You need to get off this bus please’, I shouted.

‘No!’ he shouted back in my face.

‘Okay then the police will move you off’.

I met the officers at the door, explained the problem and one of them made it clear to the man that he was getting off or being arrested. He chose to do the sensible thing and walked off the vehicle as the sheepish bus driver and his managers stood by.

The new mayor of London has pledged to make it an offence to drink alcohol on buses and expects the drivers to enforce it. How is that going to work if they won’t even try to wake up a sleeper for fear of bodily harm? We are going to be used even more to do their jobs. Boris really has to think this through properly...oh, and while I’m addressing him (‘cos I’m sure he reads this!) – can NHS staff have free travel on public transport (like the police do) and exemption from the congestion charge, please?


It all ended with a 28 year-old pregnant woman with a cough. The call was given high priority because she told us she had (can you guess?) ‘chest pain’. The crew arrived soon after I did, so I left it to them because, quite frankly, she was producing pathetic little burps with no wheeze or rattle of any kind and my cat, Scruffs does that when he’s playing sometimes.


Be safe.

5 comments:

Sewmouse said...

You and several other emergency medical bloggers that I read regularly have often mentioned the "chest pain" symptom problem re: non-emergency calls.

I've only once experienced "chest pain" - and drove my own self to hospital - but now I am curious - would you or your collegues have considered this to be "ambulance worthy"?

6 mo. pregnant 24 yr old woman with no family medical history available having severe pain directly below the right breast and continuing in a "band" around chest. Severe nausea, occasional dry-heaves (had eaten nothing since the previous day).

Probably very increased blood pressure, pain-induced odd breathing and accellerated heart rate?

I couldn't imagine calling an ambulance, but I'm stubborn like that. (Turned out to be gall bladder stones)

Xf said...

sewmouse

Yes, that would be ambulance-worthy. Pregnant women with chest pain are always taken seriously.

Helen said...

Do you mind if I ask you a question?
How insistent does someone have to be about not going to hospital for paramedics to leave them?
I only asked because when someone called paramedics for me (16 year old, no medical history, vomiting, hyperventilation, inability to see or speak or move limbs - it sounds worse than I think it was) they asked me several times if I wanted to go to hospital and I said no, which is true, I didn't WANT to go, but I probably would have if the paramedics really thought it necessary. Although I wasn't in a state to be able to explain that.
With hindsight I really regret saying no because that was the start of some long-term medical problems for me.
So I'm just wondering, if paramedics really thought that hospital treatment was needed, would they ignore the refusals or would they be forced to leave?

Thanks

Xf said...

Helen

Paramedics won't try to force anyone to go to hospital if they have capacity to say no and at least they tried to persuade you to go. Beyond that, even if they have concerns, they will stop short of persistence.

Next time, if you are worried, trust their judgement and go with them to hospital.

helen said...

Thanks, I'll remember that in future. I just didn't want to bother anyone - I know that's stupid now, but I know I'm not the only person who's done it.
Keep doing your amazing job and saving people's lives! :)