Saturday, 23 January 2010

Wet Footed StuFru

Night shift: Seven calls; one left on scene; two by car; four by ambulance.

Stats: 1 Cold homeless person; 2 eTOH; 1 EP fit; 1 Tachycardic; 1 AF.



I have plastic bags over my socks inside my boots. Once again, after only a year or so of wear and tear, my work boots are cracked on the sole and are leaking water and whatever else I step in into my socks. I endured the damp, squidgy feeling last night for the entire shift but today, as I inspected my footwear and realised both boots were soaking inside and that I was about to put my nice new, freshly-showered and warmly dried besocked feet into them, I took the radical decision to cover both using the small freezer food bags that we keep at home.


So, first job with dry feet was a false alarm for an angina attack on board an incoming train. The crew was with me and we stood by on the wrong platform until we were moved and then informed that the BTP had decided to have the train stopped at an earlier station. There was no ambulance deployed there, however, so more advice, for the train to be allowed to continue, was given.

We changed location and I got myself and my bag a lift on the little noisy kart (it would have been quicker to walk but it was fun and convenient) but it was all in vain because a crew were despatched to the nearer station and all we got was a ghost train.


Then a 37 year-old man claimed he had a fractured shoulder and demanded to be taken to hospital. A posteriorly photogenic police officer (this is a private joke so don’t worry) was on scene at the time and he informed me that the man was homeless and showing no obvious signs of distress. This was a typical cold homeless person wanting off the streets and I have sympathy for them but his ‘injury’, which was never diagnosed, was two years old and so I felt kind of abused. If he’d told me the truth and levelled with me about getting a free warm, dry place to put his cold feet, then I’d have more respect for him but he preferred to lie.

I drove him to hospital anyway and he valiantly carried most of his fairly heavy bags, despite his painful shoulder. He’d be carrying them back out the exit door of A&E in a few hours I imagine.


Outside a University campus building, lying in the gutter is a 19 year-old girl with thick, smelly vomit in her hair (the shampoo of the new generation). She’s been found by a bunch of students and a security man and they put her into the recovery position and call an ambulance because she’s ‘possibly drunk’. Correct diagnosis but I'd like to expand on it with my extended medical knowledge. She is very drunk. So much so that after telling me she’d just had ‘three drinks’ that night, she commences vomiting again until her face is covered in the stuff and her warbling voice tells me that she is feeling guilty but unrepentant at the same time. They used to say 'never again' but now they just say 'I'm really sorry' or 'I'm disgusting'.

She gets scraped off the road and into an ambulance where fluids help her falling BP to recover, although her dignity never will.


South of the river and a 25 year-old doctor is fitting in a wine bar where a piano-playing jazz singer bellows out a tune as she shakes on the floor for almost five minutes. I struggle to communicate with her as she recovers and the manager finally puts a stop to the cacophony ( sorry, I'm not a great jazz fan), just in time for me to hear that she’s recently been diagnosed after a short history of ‘absences’ and a full-blown seizure weeks ago. The crew persuade her to go to hospital because her BP is high and she has yet to completely get over it. Trying to convince a doctor to go to hospital is almost like trying to prise a live whelk out of its shell.


The Saturday night morons began their onslaught just before 2am when a call came in for a 30 year-old man who was ‘unconscious’ and vomiting outside a gay club. The police were on scene and they made it clear before I got started that the man had been ‘playing dead’ all night. He was flopped dramatically on his back with a large crowd of cat-calling transsexuals around him. They were clearly enjoying the sport and you don't see that very often. Not unless you are a fan of The Rocky Horror Picture Show.

I woke him up with the necessary pain and made him sit upright before establishing certain facts. I discovered that – 1. He was Lithuanian and 2. He was drunk. He was left on scene with no promise of an ambulance.


It is not unusual for young men to have fast heart rates every now and then when Adrenaline rushes through their bodies for no reason whatsoever but when you have high blood pressure and have been through a vivid sex dream, the risks associated with a tachycardia are greater, so I took the Russian patient to hospital in the car after ensuring that his ECG was normalish for his current heart rate (180bpm dropping to 111 after a few careful exercises in reducing it) and that he had no pertinent chest pain.

Interestingly, he seemed keen to stress that he had managed to complete his sexual antics before waking up with what he thought was his first heart attack. I'm not entirely sure which tale he was trying to impress me with.


I don’t get to meet many true ladies in my job (foul mouthed drunken women don’t count) so it was refreshing to be sent to the aid of an Urgent Care crew who needed help in deciding whether or not to leave their patient at home after she’d fallen out of bed. The patient, a titled Lady, had COPD and, at 89 years-old, wasn’t doing very well in the breathing department. Her ECG also showed AF and it was necessary to take her into hospital on the basis of a lack of information from her live-in carer and the confused state of the patient herself. Whether she coped normally with her rasping, heavy breathing and erratically irregular heart beat wasn’t clear and I wasn’t about to take the risk.

Be safe.

6 comments:

WalkingPlasterDispenser said...

'She gets scraped off the road and into an ambulance where fluids help her falling BP to recover, although her dignity never will.'

I see this quite often on campus for the Students' Union events I help cover (thought undoubtably not as often as you do). It made me think: the first impression I get of an alarming number of people I meet for the first time in a professional capacity is one of drink, vomit, undignified and 'He/She's only had a couple'.


And people ask me why I'm Tee-Total...

Anonymous said...

As a frequent visitor to your blog I was somewhat surprised and a little concerned at this latest entry.

I find that fact that you conveyed a patient who had previously been in a cardiac arrythmia and still a high risk patient quite frankly, irresponsible. Not to mention dangerous and certainly not in the best interests of the patient.

You say that his current heart rate (after a few careful excersises - valsaver? Did you listen for bruits of the carotids?) had reduced to 111 bpm and he had no pertinent chest pain. However, the fact that this patient has hypertension and a potential heart problem appears to go unnoticed. Incidentally, it IS unusual for ANY person to have a heart rate that hits 180 bpm regardless of cause.

As a paramedic/emergency care practioner I would not leave myself open to loss of registration or the patient open to innapropriate care by conveying such a high risk patient in a car regardless of how close the hospital is.

I don't wish this comment to be a slight on your clinical judgement per se. I'm just surprised that you left yourself wide open to all sorts of potential aggro.

Meanwhile, keep up the blog - makes for great reading :)

SLM

Xf said...

SLM

I don't mind criticism but your opinion on whether or not a professional clinician is irresponsible or not should be tempered with a broader picture of what went on at the time, most of which I cannot divulge for obvious reasons.

Young people can in fact have very high pulse rates every now and then without a cardiac cause. Overactive thyroid, for example. And if you read what I wrote, you will see that I did not say that 180bpm was USUAL.

No, I did not perform a Carotid Artery Bruits check because it was irrelevant and his exercises involved Valsalva, which worked. He had no chest pain at all and was recovering from a vivid erotic dream when the whole thing started. This is not the first time I have come across such a case but there is a point that you should consider.

There was no ambulance assigned to this. I was it. The hospital was literally 2 minutes away and I would probably have waited more than ten for an ambulance if I could get one. He was more at risk just staying there than coming with me - someone who could deal with any eventuality that occured en route. He got seen by a doctor in less time that way.

As for risk-taking with patients. That doesn't happen with me. I use clinical judgment. I could leave a perfectly healthy person with a cough at home and still find myself in trouble because he died later on of something completely unforseen. Every clinicain...EVERY one of them, takes the same risk every day of their careers. But delaying appropriate hospital treatment with a stable patient is just plain silly and possibly irresponsible.

It's a diary and it should be read without looking too far into the details and numbers I post - remember I am duty bound to conceal ALL patient-relevant facts that could identify them as best I can. That means things get changed, numbers, locations, names and other details get messed with.

Anonymous said...

You should get some Sealskins gore-tex socks!

Anonymous said...

XF

Thank you very much for your reply - I hoped you would.

Just a few points to clarify my comment:

As a clinician I can ONLY comment on what you have divulged. I can appreciate that we as clinicians are duty bound to protect our patients thus I find it slightly odd that you state my "opinion on whether or not a professional clinician is irresponsible or not should be tempered with a broader picture of what went on at the time".

I am not privvy to all information therefore can only comment on what's given!

I mentioned listening for bruits as you did not specify in which way you had reduced the patient's heart rate. Listening for bruits is part of a cardiac assessment.

So, an ambulance was not assigned? Ok, that can often be the nature of the beast so I ask the next question - Why were you so keen for a "stable" patient to be seen by a Dr so quickly? What difference would 10 minutes have made to a "stable" patient? The very fact that the patient had, a short time before, a heart rate that even if he was recovering from an erotic dream, was still, lets admit, a little too high to have been caused by an erotic dream alone? At the same time you cannot exclude the fact that it may have been cardiac related (despite a 12 lead ECG) or hyperthyroidism or something else. Despite the hospital only being 2 minutes away ( aren't they all?) by conveying in your car this still leaves you unable to deal with the patient in a safe environment, appropriately, adequately and dare I say it, quickly enough. I also ask if you cannulated the patient?

There are calculated risks and there are silly risks. You and I know what would happen to you if that patient arrested in the back of your car and subsequently died. Your feet would not have touched the floor - this is a totally different risk from that of a non conveyed.

I appreciate that as a diary it should be read without looking too far into the details however, I will reiterate to you again I can only comment on what you put in your diary and base my opinion as such.

I did not mean this in any way to be a personal attack on your clinical decision making skills. I was concerned and intrigued about your treatment of that patient. I am merely trying to protect a fellow clinician.

I will add as a final point that your diary is a public domain and therefore your diary is open to critique or opinion.


SLM

Xf said...

SLM

I am indeed in the public domain and, whether negative or not, I always appreciate candid opinions if they are not just personal attacks.I also appreciate that you are a fellow clinician who is offering a viewpoint but I am old enough and ugly enough to take responsibility for myself and this is what drives me to respond in a somewhat defensive manner, for which I apologise because it can often be misinterpreted as reactive.

My remit on the car is to convey whenever possible; that's how it works here. Not every sector shares this belief and I have had discussions with other FRU medics who tell me that what I do is 'unsafe' or 'risky'. I am NOT careless and blase about my job, career or patients and am well aware of the consequences of my actions should I get something wrong. This is what gives me clinical autonomy and the capacity to make decisions.

Now, if this patient was diaphoretic, weak, had an irregular pulse or an arrythmia (he was tachycardic, he did not have a rhythm problem)then I would have waited for an ambulance. If he was at risk of stroke or I thought that stenosis was likely, I would have checked for bruits (possibly but as a paramedic and not an ECP, unlikely).

His pulse was 180 transiently and my probe isn't the most accurate in the world, so on palpation and with a secondary check I could tell that he was settling.

He was stable so that meant I could reasonably predict that he would remain so for the journey and not be detained unnecessarily waiting for an ambulance. And here's my point - you would have seen a few jobs where someone has died for lack of an ambulance because none were available as the direct result of being tied up on non-emergent calls - calls that were not immediately life-threatening. A tachycardia that resolves and settles is NOT immediately life-threatenng. Only those who believe that we should cover our backs so much that every call goes by ambulance would stick to the notion that my actions were problematic.

A Red3 drunk person is probably not life-threatened, you'd agree but the whole 'they might choke on their vomit and die' argument forces us into a corner and we have to run on them as if they are having a coronary. We therefore take the same level of clinical risk when we simply pop them into the back of an ambulance without a routine ECG to check for a possible cardiac problem we just couldn't predict.

And no, he didn't get a cannula because (and you can check this) we are now being told that KVO cannulae are not to be sited unless absolutely necessary.

This young man's clinical presentation was benign. He was calm and without pain. His hypertension was not a diagnosed condition - he just assumed he was because he'd been told by someone else.

I make clinical judgments that are calculated risks, some of which are close calls in others' opinions but I strive not to make 'silly' risks. I do NOT think I am always right but I always think of the patient first. If you are an ECP, you are expected to decide on the correct pathway for a patient. Your judgment will be tested too and what you see as high risk may not be to someone else. It depends on age, experience and capacity. Of all the calls I attend that I have written about, how many would you say were as 'risky' as you assume this one was? This is all about perception. I can see your point of view but I am not you and I don't live like that; I use MY on scene judgment when I am working alone and I trust my judgment.

Finally, and hopefully to end this discussion. Every patient that I convey in such circumstances is asked at least THREE times if they agree to my taking them in the car when there is no ambulance available and I have explained the pros and cons of it. If they are not happy or in doubt, then I will wait. My PRF always includes a note about me conveying patients and why I did it. The devil is in the detail.