Wednesday, 11 June 2008

Real work

Six calls – two assisted-only and four by ambulance.

The first call of the shift was for a female ‘unconscious’ on a bus. She was asleep, of course and all I had to do was wake her up and move her on.

A strange fitting call next for a 65 year-old Chinese lady who was in the middle of a gambling session on the fruit machines at a casino when she was seen to suddenly collapse and begin twitching in her seat. She was still sitting there when I arrived with the MRU following close behind.

Her upper body was convulsing and she had a left-side head tilt, making it difficult to get eye contact with her. She responded to questions initially and every so often but then became completely unresponsive. When the crew arrived she was moved, still twitching, to the ambulance where I gave her a little diazepam, bringing her erratic muscular convulsions to a slow, although they never quite disappeared, even in hospital.

It’s possible the lady had suffered a neurological insult and had fitted as a result or she had a localised epileptic episode, although nobody knew her and she had denied having any medical problems when she was lucid enough to answer my questions.

More diazepam was given at hospital but she continued to twitch, now more on her left side than the right.

I made accidental friends on my next call to a 48 year-old male ‘not responding’ at a homeless shelter. It was breakfast time and there was a queue outside the door, as always. The patient was known to me – he’s an alcoholic who visits hospital almost every day for no reason other than the fact that he drinks too much and collapses as a result. He wasn’t responding because he didn’t speak English and his brain was probably in a near-liquefied state after decades of abuse.

On my way out, after the crew had come along and scraped him from the pavement, a pack of noisy, swearing Glaswegian drunks decided to quiz me on where I came from and whose part of Glasgow was the toughest. The toothless, cackling woman among them was more vociferous and wanted to me join them for a drink and a remembrance session for the homeland. I declined and smiled politely, as you do. She looked like she was 100 years old but she was probably only 35 – that, I must add, was the extent of my interest in her.

An emergency call for a 49 year-old man ‘lying rigid in bed’ had me racing further south than I usually like, with a delay on my arrival time due to distance. I arrived at an old school that had been converted, quite tastefully, into private mezzanine flats and I was guided by the patient’s partner to his bedside. He lay on his back, thrashing around, soaked through with sweat and posturing in a decorticate manner. I was informed that he had suffered a stroke in the past and this certainly looked like a neurological problem but he was also an insulin-dependent diabetic and my obs revealed a very low BM; 1.7 – and that had to be sorted out before I could be sure of what I had here.

The crew arrived as I completed the primary and we quickly got to work with Glucagon and IV Glucose. He was calm enough during the treatment but became highly agitated and thrashed around again every few minutes, making life difficult for everyone in the confined space around his bed.

He remained unaware of his surroundings for another ten minutes and then his condition began to improve; his BM rose to 6.0 and he became easier to manage, although he complained of severe cramps in his legs. A quick trip to the toilet (supervised by his partner) and then onto the ambulance, with chocolate if he needed it and he was back to normal. He was still taken to hospital because his medical history was significant, his earlier posturing was suspicious and he’d never been in such a critical state with his blood sugar level before.

A 25 year-old female who was knocked down by a bus on Oxford Street had no more than a bruise on her leg but the incident produced two ambulances, a MRU and myself – so you’re pretty safe if you get hit by a big vehicle in Central London. She refused to go to hospital, which was fair enough and two other people, who’d been passengers on the bus when it stopped suddenly, began to complain of leg and back pain as a result of falling over on the top deck as they stood to alight.

Neither of the new patients went to hospital – a quick check by myself and the crew revealed no real injury, although one of the complainants – a young girl – had a good long cry about it until she was over the fright.

My last call of the shift was for a 65 year-old man who’d collapsed onto the floor of a restaurant during a family birthday meal. He had been drinking but his behaviour didn’t scream drunk to me – he seemed genuinely unwell and could possible have suffered a neurological insult. He lay on the floor unconscious for a time, then he became rousable on oxygen, although he tended to slip back into unconsciousness from time to time during my primary. He was agitated when conscious and completely unaware of his surroundings. His frantic family tried to get him to make sense but you can’t force someone who’s not there to be there.

The crew arrived and we packed him into the ambulance where he began to vomit violently and uncontrollably. His airway was in danger because he was unconscious again, so over he went onto his side. When he regained consciousness he fought with us and was difficult to keep still.

His ECG revealed a bradycardia with no P waves (idioventricular rhythm). I had noticed his slow pulse in my primary but the lack of P waves was a significant development. Now that he was vomiting, his condition was more critical than before and alcohol, although probably part of the problem, could be ruled out as the major factor. His BP was dropping and this also had to be addressed, although I had no intention of staying and ‘playing’ with him – we’d already been on scene a while and his condition was deteriorating rapidly – time to go I thought.

I stayed with the crew as we ‘blued’ him in. I cautiously suctioned his airway (overdoing it could drop his heart rate even further) all the way to hospital because he was completely unconscious now and still producing big lumps of vomitus, most of which I pulled out by hand to avoid excessive use of the catheter). He was in real danger of choking on the stuff if I didn’t keep a close eye on him. His family had been asked to meet us at Resus; they weren’t getting aboard because the man was in a much worse state than when they’d last seen him.

Although atropine may have been useful, I had no time to administer it – his airway became the priority and managing it became a full-time activity. He was given the drug in hospital but it had no effect on him (there are certain types of bradycardia where atropine is ineffective). They too had to make do with managing his airway as he continued to vomit all over the bed and floor of the Resus room.

I’d worked with my bag several times today, so it felt like I’d earned my money. I was put into proper thinking mode on half of these calls, which is unusual but refreshing and it made my day go quickly and that is always good.

Be safe.


Chris said...

Interesting to read your comment about suctioning having the potential to lower the heartrate further. I googled it (and google scholar), and couldn't find anything. Would you mind either explaining why, or pointing me in the direction of somewhere that explains it?

Glad you had a 'good' day(although it could be argued that the last thing anyone wants is for you to have a 'good' day in this manner - means someone's in a bad way!)

Louise said...

Did you get the opportunity to find out what happened to this last patient....... would be interesting to know what the cause was.

This is my problem with the job......... in some cases I like to try and follow up even just knowing a particular ward admission or hospital transfer can help reveal what happened.

Xf said...


Yes, unfortunately a 'good' day for us can rarely be good for someone else...

As for suctioning - if the catheter stimulates the vagus nerve it can further slow the heart rate - this is why mechanical suctioning of the airway is restricted to a few seconds at a time.

Look up vagus nerve stimulation by suctioning.

Xf said...


Like you, I find it almost impossible to get the time to follow up on patients and before you know it I've moved along to the next.

Xf said...


Sorry...forgot to give you this link

It will explain the vagal effect and the oxygen reduction effect caused by excessive suctioning.

Chris said...

Cheers - I wondered if it might be to do with the vagal nerve, but couldn't see how the stimulation may occur. Thanks for the link