Monday, 16 March 2009

Indoor camping

Somebody put these plastic flowers in the ashtray part of this bin. They were either friendly, Greenies or drunk. I'm going for drunk.

Night shift: Eight calls; all by ambulance.

Stats: 1 ? SAH; 1 Abscess; 1 eTOH with head injury; 1 Drug o/d; 1 High temperature; 1 DOAB; 1 Vomiting blood; 1 Thrush infection.

The concept of indoor camping is hilarious to me...not because it is obviously a fun pastime for the kids when they are bored but because (and I am told this by a reliable witness) some patients have been known to indulge in this crazy childish activity as they wait for an ambulance to arrive. Is it possible the indoor arena in which they choose to pitch their tents exacerbates their asthma?


Subarachnoid haemorrhages (SAH) are life-threatening events, with poor prognoses if not detected quickly. The 80 year-old woman I’d been called to attend - whose only complaint was a headache (although it had been given as chest pain) had been healthy all her life and apologised for the call but couldn’t bear the pain any longer. Her son was on scene and he had called us because he was concerned about her.

She had leaned forward to answer the phone when the headache had suddenly struck. Now she felt nauseous and unwell with it. I would normally have left this to the crew but I stuck with it because there was something about her condition that didn’t warrant the usual ‘it’s only a headache’ opinion. She had neck and upper back pain and the history, her demeanour and everything else about it seemed familiar.

I jumped aboard with the crew and we carried out a full set of obs. Her blood pressure was very high and an ECG was on its way when she complained even more loudly about the pain and how sick she felt. She was given a vomit bowl and her head slumped into it as she threw up but I noticed something else; her eyes were glazing over. You can tell when a person’s brain is no longer functioning properly and hers was going - it's like watching a lightbulb become dim. She rapidly lost consciousness and the ECG was abandoned as we suctioned her airway, secured it as best we could against gritted teeth and prepared to resuscitate if necessary. Her respirations dropped and she was ‘bagged’ on oxygen for the blue light journey to hospital. Her son was in the back with us and he remained strangely calm as I explained what we were doing and why.

There was nothing I could give her – I have seen many SAH events before and I was sure this was another. I also knew that time was critical for her, so a cannula was placed en route but nothing else was given until we reached Resus, where her GCS wavered between 3 and 7 at best. Within ten minutes of arriving at hospital she stopped breathing and had to be put on a ventilator. I left the team working on her and spoke to the son (at the doctor’s request). I explained what had happened and reassured him but I felt less sure of the outcome for her than my words may have intimated.


A DIB call for a 46 year-old woman was nothing of the sort. She may have been breathing a little fast but that was because she was overly distressed about a painful looking abscess she had on her neck and the high temperature that accompanied it. She’s already been seen by her GP and advised to call an ambulance if she began to vomit, which she had done, apparently.

The large swelling covering her neck and the area beneath her ear had been drained and she had been given antibiotics and painkillers but nothing was helping her. I sympathised with her pain – if it was indeed an abscess then there was a lot more work to be done on it. If it was more sinister, she’d need to be seen urgently, so off she went to hospital.


In the City, a smartly-dressed man held his drunken wife as she vomited in the street outside the pub they’d both just left. She had leaned forward to get something from her handbag and forgotten completely about gravity, which helped her to the ground and onto her head with a thud. Now she had a bleeding head wound.

‘I’m alright’, she insisted.

They all say that.


A routine looking call to Piccadilly for a 20 year-old female, slumped in a doorway, could have been just another drunk and I was ready to be cancelled when a crew arrived on scene before me but I kept running and no cancellation came through. Just as well because the paramedic and his two brand new trainees were resuscitating the girl in a doorway. She had been found in respiratory arrest after overdosing (probably on heroin). Her belligerent boyfriend interfered with the process of saving her constantly and I called for police support to keep him at bay.

While the crew bagged her I got IV Narcan going. This produced a fully conscious drug addict within five minutes – that stuff’s a real life-saver. Her clothes had been cut away, much to her boyfriend’s annoyance but it didn’t stop him rifling through them to get whatever it was he was after (more than likely the rest of her stash). He may have been looking for something else – something innocuous but I’ve seen addict’s partners behave like this before – the drug is always more important than the life.


If you are a new parent, try to read up on the difference between a fit and a feverish, shaking baby – it will stop you dialling 999 every time the poor child has an infection that can be treated at home. The well-to-do parents of a 1 year-old girl with a temperature of 39.1c and a known illness, couldn’t determine whether she was fitting or not, so called an ambulance. The poor thing was scared enough to have me and a crew around her, never mind ending up in hospital when close supervision, cooling and parental love was all she needed at that point. I have argued this for years and will continue to do so – Calpol is NOT going to make your child better…it will simply make the illness last longer. Personally, I would only use the stuff if the temperature is very high and won’t come down with physical cooling. Paracetamol in any form is not a sweet for kids!


The DOAB of the night was on the back seat of the top deck of a bus with his trousers half way down his backside. He lay face down in slumber until I interrupted his coma and pulled him upright (its one of the effective ways to wake them up but has the drawback of a possible punch in the face if you are not careful). A loud voice is also useful because it alerts them to the fact that you are not the bus driver. This one left without the threat of police but he insisted that his foot was painful and therefore needed to go to hospital. What he wanted was a free bed for the night and he got his wish.

The bus driver smiled and said ‘I don’t know how you guys do it, I really don’t. They’re the scum of the Earth, they are’. I though he was being rather harsh, especially as this DOAB hadn’t threatened me, spat on me or raised his voice at me – he was just drunk and homeless. I guess if you drive a bus and have to call an ambulance every day for a sleeping drunk, you form an opinion of one that tarnishes all of them.


A 56 year-old woman with a history of duodenal ulcer and obstruction lay on the floor of her flat after suffering an acute bout of bloody diarrhoea and vomited blood. Her husband had preserved the evidence for me and, at 4am, I found myself looking into a toilet bowl full of thick red faecal matter and a toilet floor with large pools of clotted blood on it. For those people who call ambulances because they are ‘vomiting blood’ when all they’ve done is thrown up red cabbage, a scene like this would soon shut them up.

The unfortunate lady was very weak, as you can imagine, very pale and very ill. Her blood pressure was initially too low for her to be moved onto the chair, so she was given a few minutes to recover and then gently lifted up and out to the waiting ambulance.


Finally, into a Hell on Earth concrete estate with solid security gates at every entrance and every level on every block (thanks Islington Council) for an 87 year-old man with ‘DIB’. Remarkably, after telling the call-taker that he couldn’t walk to the door and making us wait outside until the sleeping security man arrived to unlock the ‘prison’ gate, the crew and I found the front door open. He’d got up to unlock it, gone back into bed and then told the call-taker that he was too weak to walk.

Despite his DIB, he spoke non-stop, ranting on about that ‘lazy bastard’ security man and how he was always asleep. He lay in his bed, surrounding by rubbish and chocolate as we listened to him go on. Oxygen cylinders littered the hallway and bedroom and he was connected on 4lpm to one of them. Most of the O2 he was breathing was being wasted on expletives.

He recognised me (patients tend to know me or think they know me) and I recognised him. I had been here years before for much the same thing. He was lonely and frail and unwell but there was no cure for his condition. He suffered from Asbestosis and a bad attitude, for which forgiveness from me was instant. As he said in his own oxygen-fuelled words ‘I should just die. What’s the point of living a life like this?’

‘Here, have a look at that’, he said, pulling his pyjama trousers down and exposing his testicles to me. I had asked him why he needed an ambulance today and this was his response.

‘I’ve got really bad thrush’, he declared.

He was right too; his scrotum was suppurating and red. We were all aware of his hands from that moment on and I could hear the familiar sound of gloves being donned in a hurry by one of the crew.

Be safe.

7 comments:

Anonymous said...

I was interested to read what you say about the use of Calpol - I have 2 sons aged 3 & 7. The advice I have always received from the OOH service is 'give him Capol and Ibuprofen', when I've called them. The older child has had some 40 degree temperatures which has led him to halculinate, which is pretty scary.

In what way does the use of Calpol extend, say, a viral illness which leads to a high temp iin a child?

Xf said...

Anonymous

The science of it all is very simple and I'm not the only scientist advocating control of this drug, especially in children.

When you have a virus, one of the first and most effective defences against it is for the body's temperature to rise so that the virus can be killed. It's uncomfortable and can lead to side effects, like fits and hallucinations.

If Calpol is given, the temperature drops and so the virus can continue to breed and multiply inside the body, thus increasing the time it will take for total eradication. You are effectively making your child sicker for longer just to make them comfortable...and their immune system learns nothing.

JB102 said...

One of the same reasons why we do not advocate cooling in infantile convulsions from a dispatch point of view.

I may also have been the one that took the call for the lady with the Subarachnoid, I had a lady give similar symptoms and coded it as chest pain, the neck and shoulder pain will code higher because you go via chest pain.

Sometimes the only symptom that we can actually triage for isn't the most appropriate, but out of interest, would you think that warrants a red or an amber?

Xf said...

JB102

Not sure about the cooling bit because physical cooling does not interfere with the body's process as much as a drug like paracetamol.

As for the SAH, it was actually lucky for her (if she survived) that the call had been given as chest pain. It would have been an amber for a headache with no priority symptoms, right?

As with everything, there is no point in debating call categories in such circumstances because even I felt it was probably nothing until I got there...

JB102 said...

Amber 1 for the sudden onset, same as strokes. But you're right, it could just have been nothing and I'd have been equally guilty, if it was me, of giving a simple headache a red call, sometimes you get lucky.

As for the cooling, it's the main reason given in the principles of emd, however i'd be out of my depth to debate pro's and con's.

Xf said...

JB102

Strange that the principles of EMD advocate the use of Calpol (I guess) and not the natural effect of cooling. Read this article...

http://www.australianprescriber.com/magazine/23/3/60/1/

JB102 said...

I could not say call takers advocate calpol, we're not allowed to advise medication, but we do get dozens of call for high temperatures in children where the advice from other HCP's has been to give them calpol. On the evidence of that article not sound advice.

I'll happily lend you my copy of principles if you're interested in the reasoning behind the triage.