Wednesday, 16 July 2008

Out of it

Maybe this registration will be easier to understand ( a few of you got confused over the last one!)
Night shift: Five calls; one assisted-only and four by ambulance.

Stats: 1 Unconscious ? cause; 2 ETOH; 1 assault with facial injuries; 1 Arterial bleed.

The start of my four night run of shifts – I don’t enjoy these at all and this weekend was set to become one of the busiest of the year so far.

My first call was for a 25 year-old man who was unconscious and had a history of sudden collapse for no medical reason…none that had been found anyway. He’d recently undergone an operation to have a bone implant hearing aid fitted (BAHA) and, according to his wife and mother-in-law, his ‘episodes’ had started after that. He would develop a headache, go to bed and not wake up until he was taken to hospital by ambulance, where he would remain almost comatose for up to eight hours.

I found him lying on his side on his bed, up on the third floor of the house. The stairs were narrow and crowded and I knew as I climbed them that we were going to have real problems getting him down if he didn’t wake up.

The crew arrived after I’d carried out a few obs and I secured his airway with an OPA. Deep pain had no effect except to make him posture decorticately, which usually means there’s a major neurological problem (but that seemed unlikely given my baseline obs). His wife denied the possibility of drugs but his pupils were pinpoint and his breathing, which I’d heard long before I saw him, was very noisy – this is what prompted the 999 call.

We spent two hours on scene with this patient. He was given loads of Narcan, which initially had an effect (he had been taking pain killers which may or may not caused this problem). I couldn’t figure out a connection between his bouts of unconsciousness and the recent implant, unless he had a brain infection but he’d been to hospital and they’d found nothing wrong with him, so it was a real mystery.

Eventually, after one failed attempt to get him into a chair for the trip downstairs, we called in a Delta Alpha (doctor). The patient was a huge guy – 22 stone in weight and it would have been very dangerous to move him while he was potentially able to unbalance us, even with the three of us there. More people would have been impractical because of the narrow stairs and he seemed to deliberately slide off the chair when we attempted to strap him in, so there was no option but to put him to 'sleep' so that he was safe to move. The doctor gave him Ketamine and he instantly relaxed. Now he was manageable but we still had to carry his large frame down those stairs and it took a lot of sweat to achieve that without everyone being injured in the process.

His wife stood crying as we got him out of the house. She was fed up not knowing what the problem was with him and I sympathised but there was something strangely not right with this. He had moved himself off the chair earlier, I’m sure of it and so was the crew. He seemed to know what was going on and what was being said but he didn’t flinch when pain was applied (and that included a few needles going in).

He was rushed to hospital and I tagged along to see what would come of this but even in Resus he remained a conundrum. The doctor wasn’t convinced he was genuine and if he wasn’t, why was he doing it? Also, if he was acting, then I applaud him because he’s bloody good!

They have a new born baby and the problems started with him soon after its birth, so if Munchausen syndrome is a factor it needs to be investigated. Strange but true.

An upset 22 year-old female at a hostel was lying on the landing at the top of the stairs (why don’t they ever go down a flight or two for us?) when I arrived on my next call. She’d vomited because she’d been drinking and her mates fussed around her until she decided she didn’t need anyone but them. I cancelled the ambulance and left her to deal with her emotions.

Two young lads requested the company of a local prostitute in Soho. They paid their money up front and the lady of the night disappeared, leaving them sitting outside the flat where all the action was to take place. Two men approached them and argued with them as they tried to explain that they were waiting for service. The men reacted angrily to the intimation that their flat was a brothel and beat the boys up, smashing one of them in the face. It was, of course, a scam and they were naïve.

I showed up on this call and the lads hid away because their alleged assailants were still nearby. Then, after I’d almost called it a no-trace, they approached the car and begged me to switch off the lights and ‘not make a fuss’. They wanted the police and they got me. Nice to know that if there’s a potentially violent situation I could find myself right in the middle of it.

The ambulance crew was waiting around the corner because they knew more than I did and when they appeared, the two men were put on board and checked out. Then one of the crew went into a club to tend to a female who’d somehow cut the tip of her toe off while dancing (how on Earth do you do that?). I went down into the hot, noisy cellar to see if I could help and he was dressing the wound. Her blood soaked sock lay on the floor and a puddle of the stuff lay next to it. She was in good shape and smiled at the irony (although I think her alcohol intake helped ease the pain). No doubt, in the morning when she’s sober, she’ll laugh less when she realises she’s lost a pretty toe-tip.

Between them, the crew managed all three patients and this was made easier when the two prostitute-scam guys decided not to stick around.

An ‘unconscious’ man on a bus demanded to go to hospital instead of doing the decent thing and just going home. He was drunk and the crew felt duty-bound to take him where he wanted to go. NHS taxis at your service.

Finally, a 21 year-old woman cut her calf during a drunken stagger, ripping open an artery and squirting blood around for a while until someone decided an ambulance might be a good idea. The crew arrived ahead of me and I had a quick look before leaving them to get on with it. I’m no good as an observer - I keep wanting to do something useful...then I get in the way.

Be safe.


Kat said...

How could he tolerate an OP airway if he wasn't properly unconscious??

Thats vv odd and must be really frustrating for you guys!

Webby said...

I've met a fireman who could sit there with an OP in place no problem.... was his party trick. The paramedic who did some of my training treated a girl who tolerated an ET tube in resus for 5 minutes... there's some freaks out there!

One the toe job I've done my fair share of event work and nightclub work and often it's dropped glass bottles, ladies wearing open toed shoes or shoes with thin fabrics don't see the broken bottle and accidently kick it resulting in injuries..

Aussiepara said...

We have a paramedic where I work that can tolerate an LMA whilst conscious, so tolerating an OP is possible. Is it possible that benzos were also involved? That can make the patient a bit flakey.

Regional Para

Anonymous said...

Your 'unconscious' male is interesting. I have seen two patients recently with 'functional' disorders and they both had similarities with your patient. Your statement about something being strangely not right is exactly what we felt when we were investigating these two.
One was a young male who had taken an overdose. He recovered fully within 24 hours then began having seizures. We CT'd his head which was normal and then watched and waited. What transpired was that he would talk to the nursing staff and his family (ie. GCS15/15), but as soon as we (medical team) came along he would lapse into 'unconsciousness' where he was unresponsive to deep pain/sternal rub and would tolerate airway adjuncts YET could maintain an airway.
He was diagnosed with a functional disorder secondary to his psychiatric state. From what you have said, this case sounds quite similar in nature...

Anonymous said...

Why would anyone want to feign unconsciousness … especially when you get a paramedic like Stuart Gray turn up to inflict “deep pain” on you?!!

Be very afraid.

Sue said...

"Why would anyone want to feign unconsciousness … especially when you get a paramedic like Stuart Gray turn up to inflict “deep pain” on you?!!"

Maybe that's the attraction... ;-)

We had a young frequent flyer at A&E that would regularly feign unconsciousness. Sometimes she would score a GCS of 3, yet everyone knew she was faking. She claimed to have a whole host of serious medical conditions, and was on some heavy duty drugs, yet no one had any proof of any diagnosis and she refused to undergo any further tests, and no other hospital had any record of her.

We had another one with pseudo-seizures. I was an in-patient on the medical ward once and she landed up in the bed opposite. She'd only "fit" if there was a nurse around... She tried it once when no one was there and I just ignored her - she soon stopped!

It really is amazing the lengths some people go to.

Xf said...


Thanks for the info on functional may be right and it does sound exactly like my patient. I'll do some reading, although it sounds like nothing would change 'treatment' wise out of hospital...

Xf said...


Thank you. She probably did step on broken glass. Time to give out plastic 'glasses' in these places then, don't you think?

Xf said...


We did consider this possibility but his family swore that he took nothing more than analgesics.

Xf said...

anon and Sue

Thanks but I'm not sure of the 'be very afraid' bit :-) I'm like a lamb really.