Friday, 19 February 2010

Balancing act

Day shift: Five calls; one refused; four by car.
Stats: 1 EP fit; 1 ? TIA; 1 ? fractured wrist; 1 eTOH; 1 Fractured foot.

During half-term holidays it takes about three hours for London to wake up and start calling ambulances in earnest, so it’s almost always slow for me first thing in the morning. This gives me the chance to wash the car, clean and replenish kit and generally catch up with stuff. At around 9am I can forget about these pauses.

A 20 year-old epileptic had a seizure at a train station and a passing doctor stopped to help. The doc was still with the patient when I arrived and I was given a handover that included a little bit of the history behind the fit. The young lady was very thin and very weak looking – vulnerable and fragile in appearance. She was emotional too and gripped my hand as I took a drop of blood for the BM test. I wondered if there was more to her condition than epilepsy.

When the crew arrived and the doctor left, she changed her mind about medical help and refused to go to hospital. So, she was allowed to get out of the ambulance and carry on with her journey – her health, her choice.

Another choice that had to be made was for the 38 year-old woman who was reportedly having a stroke at work. Her best friend and colleague had noticed slurred speech when she telephoned her after she failed to text in as normal before leaving for work, then when she arrived she seemed to have a facial droop accompanying her speech problem, so the friend dialled 999 and got me out to check.

With no medical history of any significance and a slightly high BP and recent stress in the background, I tried to persuade her to go to hospital by ambulance but she didn’t want to. Her facial droop was resolving and her FAST test arm weakness improved too but I was still convinced that she’d had a TIA and because it had probably happened within the past 6 hours, I wanted her to go directly to the appropriate unit for treatment, so I got her to agree to come with me (and her friend as company) in the car. She agreed to do that and was relaxed and happier for it I think. The journey took 5 minutes and she was seen by a doctor within one minute of arrival. In my book, that was a clinical decision that I had to take otherwise the choice was to drag her to an ambulance, causing further stress and upset... or leave her to make up her own mind with the possibility of another acute TIA or even a full blown stroke later on. These are not good options and so she went with me.

Barclays bank must be erring on the side of caution when it comes to promotion these days. Instead of TV advertising, they sent out four (soon to be out of work again) actors/singers/dancers, dressed in corporate blue costumes (a la marching band) around Soho to sing and dance while showing the bank’s logo prominently on a briefcase they each held. I know this because they stopped at my car as I waited on Frith Street, sipping a Latte, turned in unison, waved, gave me the thumbs up, mimed at me to smile (like banking with them is fun), made a ‘wind down your window’ gesture and then proceeded to sing and dance at me for 30 seconds before shutting down like robots, turning again as if on a parade ground and then stomping off in step (sort of) to unleash the same embarrassing ditty on someone else. Up and down the street they went. I thought I’d driven to Disneyworld by accident. Except in Disneyworld, apart from the prices, they don’t charge you interest and fees for showing up.

Fractures don’t figure highly on our list of priorities – not the common upper limb fractures anyway and so you can expect a Green-type response (in other words, we’ll get there when we can) while, quite possibly, some over-acting person lays on the floor rolling around reporting themselves to be ‘feeling faint’ and the ambulance is sent to him/her/it instead. You can sit on your own with a broken wrist, in quite some pain, while we run around after phantom emergencies. It’s a damned shame that we are driven to this on the basis of fear of getting it wrong and the blasé attitude of a computer coding system. A shame, therefore, that a perfectly lovely 75 year-old lady sat in a train station waiting to be taken to hospital for her (most likely) fractured wrist after she’d taken a tumble on the quite frankly ludicrous sloping surface of the walkway leading to the platform.

She was with her son and I got there a mere 9 minutes after the call was made and in this case all was well because I got her to X-Ray within 39 minutes of her fall, which isn’t bad considering what I have just said about the call category. This was entirely due to a human being looking at the call and deciding that, instead of sitting around on standby doing nothing, I could pop up the road and collect this lady for her inevitable trip to A&E. Otherwise, with our system and the demanding whim of some Londoners, she may well have sat there in the cold, not more than 300 meters from the hospital, for hours before being seen.

Yes, she could have walked or taken a taxi and I always bang on about this too but at that age, unsteady on her feet with pain and a history of high blood pressure, it’s reasonable to send someone like me trundling up to carry out the important clinical checks before things are made worse by moving her inappropriately and I always emphasize when teaching about fractures, the crucial element of pain and complications when deciding to go 999 on a relatively minor broken bone.

Her capillary refill was poor, indicating the fracture may be interfering with her radial circulation, so I made a slight adjustment to the angle of the wrist and placed it in a sling to keep it straight. This worked perfectly and I felt warm and fuzzy about having resolved that more significant issue. With blood now flowing properly to her hand (her thumb mainly), the bone could get on with being repaired by the experts... and her own body.

The police called to ask for assistance with a man who was ‘very drunk’ outside the Ritz (at least he had class). He’d been bothering people as they passed by and now he was just incapable of standing safely, so the officers wanted me to take him to hospital if possible. Now, this is a little tricky because he hadn’t been arrested and hadn’t been sectioned but he was drunk in a public place and a danger to himself if he fell down or walked into the busy road, so I agreed to take him to hospital (a place of safety) and, given that I was told he had a violent history, I asked for an officer to accompany him in the back. No ambulance was required and he was as gentle as a lamb, so no problem.

The female officer accompanied him in the car and her colleague drove behind us in the police vehicle. He had already given up a small bottle of amyl nitrate and confessed to being schizophrenic but whether he was telling the truth about his mental health or not was questionable. Nevertheless, he was going to hospital for assessment in case he’d taken in more than alcohol.

On the way there I was asked if I could take the police officers urgently to help a crew who were trying to deal with an aggressive patient. Other colleagues had gone in support of the ambulance crew at the scene but I had two cops with me and they would be needed, so I diverted and got there in less than 2 minutes. The patient was on a trolley bed, thrashing around and causing real problems for the crew. A few more pairs of hands helped out as motorcycle responders arrived and the two officers with me got into it.

Meanwhile my patient sat quietly in the back seat and I kept an eye on him. I wandered off for a few seconds and returned with the female police officer so that we could continue our original journey and when she got in the back, the patient was wearing her police hat. He’d been very amorous toward her in the car on the way in and had tried to hold her hand a few times, so I think he was getting serious about her with the whole hat thing going on.

After a short journey and an unnecessary dispute about whether he was in a place of safety, according to the law or not, I left to continue my shift. We’d been tied up on this single call for nearly two hours.

Then I had to make another rapid decision and risk egg on my face when I was tasked to deal with a 37 year-old man caught shoplifting who had injured his leg. It was out of my usual area but I wanted to help with this because there were no ambulances available.

When I arrived the police were on scene (and shop security staff) with a very irate man with a hugely swollen foot. I was shown a 20 foot wall and told he’d dropped from it onto the pavement below in a bid to escape. A quick calculation of mechanisms said he needed an ambulance but he had no other injury – no pain other than in his foot and he shouted repeatedly to be taken in the car to hospital because the pain was unbearable for him. With no ambulance available and my colleagues busy on other calls, I decided to take him, as he wished, in the car with, yet again, a police officer to accompany him. I got him in quickly and asked for the hospital to be alerted in case he needed to be seen by a specialist or in Resus but when I got to hospital they had taken it as a ‘blue call’.

His injury was isolated and non-life-threatening but the medics insisted they check him over just in case and I got no real problem from them about the decision to advise them of his arrival but it caused more of a fuss than it should have done and it left me feeling a little like my day was punching me in the face. So, I am thinking harder about my convey decisions. I still want to be able to function and save ambulances wherever possible but after today, it might be easier to pass the buck.

Be safe.


M2MPout said...

Came across your blog via another one.Really enjoyed the few posts I've read so far

Tabs xx

Anonymous said...

I have a son and husband with an inherited epilepsy. Holding a hand after a seizure probably isnt significant of other special need, seizure's aren't very nice really, they make the patient feel awful and you are correct it is an individual's right to carry on their way once they feel better. Both my son and husband are thin and pale and epileptic and further to a seizure quite like a hand to hold. Once they feel better they get back on their feet and carry on, just like she did. Or perhaps you feel she somehow brought her seizures upon herself through a lifestyle decision. Our neurologist says it is common for those with our particular inherited type of epilepsy syndrome to be very thin. As a specialist in his chosen field I have faith that this is true. Although no doubt you know far more about the management of epilepsy than we do.

Xf said...


No, your neurologist will know more about it if it his/her speciality. Epilepsy has many different faces and because it's a brain-related problem, there will be many sub-issues associated with it.

Anonymous said...

Parts of these blogs struck a chord with me. To start with I’m a Thrombophiliac, anticoagulation for 23 years, several thromboses since Cape Town in 86, last one Zurich 2000. 10 years ago in Zurich I had renal failure; Drs kept asking what medications I’d taken. As I’m on OAC I avoid all drugs, Drs didn’t believe me. 10 days in hospital, discharged on Cortisteroids. Fortnight later collapsed in bathroom about 20:00. Ambulance called, Canadian flatmate told ambulance crew "He’s on drugs man" transatlantic English for "he’s taking medication". Paramedic arrived. Several hours in ambulance hooked up to drip whilst crew and ambulance dispatch argued with paramedic that I wasn’t going to be taken to hospital because I’d self-harmed taking recreational drugs (in Schwiez "on drugs"=Druggie). Paramedic won, arrived in A&E about 00:30. I had 2.3 units of blood left in my system; the rest was in my gut. I’d had a Dieulafoy’s arterial lesion in my duodenum. 5 days later I had a second lesion, explosive anal decompression. Had thrombosis when OAC stopped because wasn’t healing. Discharged after 15 days. Drs said was due to cortisteroids, renal professor disagreed. Returned to work after 6 days, no work=no pay=no bills paid. 7 days after that couldn’t get into office cos’ couldn’t find pass. Returned home, forgot why I was there. Tried to go back to work, couldn’t work out how to change train platforms, tried to walk to office across shunting yard. Eventually found myself in main station where my house Doc’s surgery was. One of his partners after examination called him in and I was told to take a taxi directly to A&E. By time I got out of door I had forgotten everything. Half hour later found myself by lake, remembered I was going to hospital. Took taxi to hospital. Forgot to pay driver, had left jacket and papers at surgery. Eventual diagnosis Steroid psychosis, differential diagnosis TIA. TIA later ruled out as flatmates said I’d been weird for several days. After discharge returned to work. Manager’s first question was how were my German lessons progressing, after 3 spells in hospital and two in intensive care!
Month later Uveitis diagnosed, eventual diagnosis TINU syndrome. Renal failure due to infection not drugs and I have severe reaction to Cortisteroids, Atopic, nine allergies and react badly to several other medications.
When I describe this to NHS staff most look at me as if I’m not believable.

Anonymous said...

Does England have Drunk in Public laws?