Friday, 9 March 2012

The shopping trip

The second night shift with the Welsh one....

A call to an 82 year-old female who is reported to have a fractured ‘P12’ (soon to be reasoned out as a misheard T12, unless there are new vertebrae I’m unaware of), starts us off. We arrive to find the lady in a lot of pain and a crew on scene. Our task is simply to assist with the transfer of the patient from her sofa to the ambulance down a few flights of stairs.

The poor old lady is unable to move or be moved without a good deal of discomfort and her anxious family stand around us, no doubt wondering how we are going to get her out of there. She’s been given 5mg of morphine but it’s nowhere near enough. The paramedic on scene is balancing the analgesic dose with the lady’s vital signs, but she gets another 5mg because pain is the greatest enemy of sustainable vitals, and the removal, or at least easing, of it can make everything much better; respiration rate, pulse rate, blood pressure.
Once she’s settled, we decide to transfer her onto a scoop stretcher by sliding it underneath her and pulling her gently onto it. Then we place her on the floor, wrap her up to secure her, and lift her all the way down to the ground floor and onto the trolley bed, which has been parked outside the uselessly small lift.

As soon as the lady was inside the ambulance, Naomi and I set off on the next call. The idea for these two shifts, is to clear as many of the waiting and minor calls as quickly as possible by running on them and either transporting the patient ourselves or deciding on an alternative pathway. Additionally, the options for most of the calls we receive are pretty straight-forward. We can leave the patient at home, treated and safe, or we can leave them at home awaiting a GP visit. Our aim is to hit and run, as it were, to reduce the number of calls that are clogging up the system and slowing down an ambulance for those who really need it.

A 49 year-old woman with chest pain in a train station next. She was a known asthmatic and she had a slight wheeze, but you can never tell with chest pain and so it was prudent to have a look at her ECG before making decisions in the direction of a cardiac origin. A crew turned up within minutes of our arrival and so they took this patient for further investigation.

Then a call to a 23 month-old child who’d ingested incense somehow was cancelled, so I did a quick U-turn. The call was reinstated and I did another U-turn.... then it was cancelled again. My U-turns are getting very good.

An aggressive 56 year-old male, with a special liking for harassing female crews, called for an ambulance but we were sent to suss it out because he rarely needs to go to hospital. When we arrived, I knocked on the back door of his house and he shouted for us to go in. I was a bit wary because the little room he stayed in was gloomy and unlit.

He was lying in bed; his island in a sea of debris and rubbish strewn all over the floor and around him. He told me he had high blood sugar and needed a nurse to come and give him insulin. Naomi checked his BM and it was normal – so he didn’t need anything.

He accepted that all his obs were normal and he asked if we could go and buy him some bottled water and a pay-as-you-go card for his mobile phone. He asked politely but routinely. He had clearly done this many times before.

I spotted about a dozen bottles of liquid on the floor and I drew his attention to them.

“What about this water? Why don’t you drink this?” I asked.

“That’s piss”, he answered.

He wasn’t insulting the water per se, he meant what he said. He urinated into bottles and just left them in the middle of his floor. A simple and efficient system I thought.

Naomi did his shopping (the local shop was only about 50 metres away) and returned to report that the shop keeper knew who she was buying the water for. This, indeed, was a regular habit of his.

I accepted the shopping trip this once but when he asked me if I could pop over to the GP surgery, which was in the same location as the shop, to check when the nurse could visit, I told him he’d reached his limit as far as goody-tokens were concerned. We bid our farewells and left before he asked us to spring clean his flat for him.

In an office more centrally located than the last call, a 28 year-old female had a faint, a fit or a panic attack – nobody seemed to know which. The evidence pointed in the direction of a panic attack because she admitted to having them and seemed poised for another if she didn’t get out of her environment quickly. Her colleagues were concerned and this was creating tension, especially when they spoke of her being unconscious and having seizures, none of which she could recall.

So, an ambulance crew took her off to hospital and by the time she’d reached the steps going in to the vehicle, she seemed much better. She’ll have tests done but I doubt they’ll find much wrong with her.

A drunken 70 year-old staggered into a bar, sat down, wet himself and then proceeded to annoy the customers, according to the manager when we met him. This call was literally around the corner from the last one and so we were on scene very quickly. But even our rapid response couldn’t beat the speed at which the tall manager had removed the drunk from his premises.

He was sitting on a chair outside the front door as people came and went and the street began to get busy with nightlife. He was a typical amusing drunk. That is to say, he was harmless but more than a wee bit annoying and clawing. He wouldn’t tell us where he lived or where he was heading. Neither would he admit to drinking much. We’d considered and abandoned a stroke possibility because he reeked of alcohol and his demeanour was of one who’d practised this art of boozy-clowning over the years.

Naomi went to get something she needed and I was left for a few minutes with the man. He pawed at me, grinned at me and then warned me that he was going to wet himself. Then he fulfilled his promise and a stream of urine trickled out from his trouser leg and onto the pavement. The local smoking women standing outside the bar were not impressed.

Luckily the ambulance arrived and I was able, with Naomi’s help, to get the man to his feet and away from the area before his dignity went the way of the meandering liquid he’d deposited. When I informed the manager of the bar that there was a pool of urine just outside the entrance, he was not pleased with me at all. “Stuart, I can’t believe you let him do that”, he chastised.

So, two lessons here: number one; paramedics cannot prevent nature from taking its course when it comes to drunks peeing. Number two; be careful who you give your name to.

The next call initially looked like it would need the assistance of the Fire Service. We arrived to find a 45 year-old man semi-conscious, with his arm trapped in between a railing and a wall, near the top of a flight of steps. It looked tightly stuck. Passers-by had noticed the man behaving strangely and had reported him being unconscious at times. Now he was semi-conscious, semi-standing and possibly risking the loss of a limb.
We carefully bore his weight and attempted to free him by sliding his body up towards the top end of the steps. It looked possible but was very tricky because his arm was being squeezed even tighter at times. Suddenly, however, the man woke up. He reeled around and seemed momentarily confused. He fought against us as we tried to keep him still, then he yanked his arm out of the space. If he’d done that before we’d taken his weight, he’d have ripped it off at the elbow.

Then things became very strange indeed. He didn’t want to go to hospital. He didn’t want to be examined and he denied being drunk. He did admit to smoking a little weed though, but he was very embarrassed. I can’t tell you what he did for a living for obvious reasons, but it’s not the sort of thing you do very long in your life after being caught under the influence of drugs.

An ambulance arrived and I explained the situation. The crew insisted on taking the man inside the vehicle for a chat about what to do next. He couldn’t go directly back into the hotel where he was staying (the hotel that the stairs and railing belonged to) because he’d almost certainly start to behave erratically and things would go bad for him. The idea was to persuade him to go to hospital and ‘dry out’ before going back. A fair proposition I think, don’t you?

A bit of a selfish one next. An encounter with an HiV positive patient who walked out to the car and demanded to be taken to a specific hospital because he’d been banned by the nearest one for ‘aggressive behaviour’. He then demonstrated this by getting angry when I told him we’d be taking him to the nearest. He stormed off but came back and relented.

I looked at the miles between one hospital and the other, and decided to give him a break. I’d take him to the next nearest and hope that would appease him.

He had bleeding open sores on his head and had been picking at them. He put blood on his hands and purposefully wiped them all over the back seat and head rest. I had warned him on several occasions to consider where his blood was going but he didn’t seem to care at all. I could have sat there and dressed each and every separate wound he had but it would have been pointless because he was determined to mess with them.

Eventually, he behaved and allowed me to take him where he needed to go, without further fuss.

Later on, after coffee and a bit of a break, we went to see a 63 year-old man with back pain. His front door was open and after announcing our arrival with a knock and a shout, we entered his flat. It was in darkness, so we tread carefully.

The patient shuffled out from his bedroom to greet us. He was naked except for his underpants, which were worn and freshly soiled. He was clearly not being taken care of and his first complaint was that his door was unlocked. Apparently his carers had been earlier but they’d left his door unsecured – allegedly anyway.
“That door is always locked when they leave”, he told us.

He had chronic back pain and was prone to falls. All he needed was his medication, which had not been given to him by his visiting carers, again allegedly.

I checked his blister pack, called his care team and then, after clarifying that he had been visited but nothing had been done, gave him his Tramadol. I made sure the care team knew that this man had been left exposed, in more ways than one, and that his meds had not been given, as prescribed.

He didn’t want, or need, to go to hospital but he was genuinely upset that he’d been neglected like that. I sympathised with him, as did the red-haired Welsh one. We’ve both seen this time and time again in our business. It’s sickening.

Finally, we get a call to a man who is inside a pink taxi. He’s either drunk or under the influence of drugs. Police are on scene and they want us to check him out because they’ve found a large number of tablets and paraphernalia on him when he was searched.

We arrive to see the pink cab driving away with a furious looking female cabbie behind the wheel. The man is being spoken to by the cops and his tablets – some prescribed, some illicit, are on the roof of the police car.
“He made the cab drive around for a while and he jumped in and out of several clubs, pretending he had business in them”, explained one of the cops. “But he was getting drugs or messing about. We found a crack pipe on him.”

They didn’t find any evidence of hard drugs on him, however. Most of the stuff they asked me to identify was his own or somebody else’s, but nevertheless harmless.

The man himself was unusual. I mean, he didn’t come across as a typical drug addict. Instead, he looked like a lost lamb; somebody with no purpose and the need to find one. He may have had (and I suspect he did) mental health issues.

He had no need of hospital and the police weren’t going to arrest him, so he was told to walk home. He pleaded for a lift but the cop’s order was quite clear.

“You aren’t wasting our time or the LAS’s time tonight. You are going to walk home.”

He only lived around the corner anyway, so it was no big deal.

This man had spent a few hours in that cab apparently. He had the driver take him from place to place in a circle until he’d run up a £100 fare, which he didn’t pay. I’m truly surprised that any cab driver would have allowed that to happen. I would have thought he’d be asked for at least some of it when he stopped for the first time and got out!

Be safe

Thursday, 8 March 2012

How to step from the pavement and survive

Naomi the Welsh visited for more punishment, London-style, and helped me on two shifts on the car. I’m in Wales next month to attend a CPD day and I’m due to ride out with her and her colleague whenever I get the time to do so. I’m hoping to learn why our system is so different from everyone else’s in the UK. Meanwhile, however, Naomi continues to learn why we are so fast and efficient when it comes to patient obs and pathway choices.

We start the shift with a call to a 64 year-old female with exacerbated COPD and a history of two MIs. We don't have to do much for her because an ambulance is on scene fairly quickly.

We left the scene of that call to attend a held call for the police. They have a 28 year old female who has accidentally overdosed on her antidepressant medicine. The call has been held for a while, and I guess the cops got fed up waiting, because as we arrived, the patient was being walked out with them - they were going to take her to hospital in their own car.

I had a quick chat with her and decided to take her in my car instead, with the police vehicle following, less one officer, who was now sitting in the back seat with the patient... just in case.

A 39 year-old man was allegedly assaulted outside a pub. He had a lacerated nose, so he wasn't in dire need of a grown-up ambulance. Instead he got us and the FRU, in which he was conveyed to hospital.

This x-ray (permission given to show it) belongs to our next patient. She was drunk, as were her friends, and she managed to step off the shallow kerb in a drunken, uncoordinated way. She basically tried to take a big step forward where there was none to be had. She landed awkwardly and tumbled, tackling her own leg on a twisted descent, into the road... and that's where we found her.

Her friends were all around her but, as is the norm for drunken 'sensible' people, they became a bit of a nuisance, so I asked them to step away and keep away. I'm pretty sure they'd have hauled her to her feet and got her into a cab if one of them hadn't retained a sense of propriety about the situation. He seemed to know, outside the alcohol, that his female friend had a significant injury.

On inspection it was very clear from the start that she'd broken her leg. In how many places and just how badly would not be known until my attention was drawn to that x-ray when we got to hospital with a later patient. What was obvious, however, was the lump of bone protruding under the skin of her shin.

She was in pain but I think the smog of alcohol was taking the edge off it. She still had enough marbles to use entonox to good effect and that's all she was getting until the ambulance arrived and took her away.

I don't doubt that this 25 year-old lady will reconsider her booze intake the next time she's out with the lads.

We were met by a security guard and an angry girlfriend (soon to be ex I should think) when we got on scene to help a flat-out drunken 22 year-old who'd downed a full bottle of whisky after a tiff with his boss. This seems ludicrous but people do the most idiotic things when they get upset.

"He's normally a light drinker", his girlfriend tells me. "But tonight he drank a whole bottle then called me up to get me to collect him. I had to get out of bed to come down here".

The young man was semi-conscious, so I taught Naomi a trick that is not often used in Wales (as I understand); she put a line in and fluids were given in a bolus. Within a few short minutes, the man was awake and fully aware.

Now, there is no clear scientific evidence that IV fluids clear ethanol rapidly, but the studies that have been carried out tend to be weak and suffer from small sample sizes and questionable methodology and I'd argue that, in my experience and probably that of hundreds of London paramedics, giving fluids to unconscious and semi-conscious drunks who are saturated in ethanol, will flush and dilute the problem, leading to a fairly rapid recovery... at least to consciousness if not sobriety. I've done this dozens of times, and even multiple times in one place with two or more patients on the street. To me, there is enough evidence to propose that IV fluids help. At the very least, it's worth a try.

Naomi doesn't get to see enough stupidly drunk people, so she has never witnessed the miracle of a needle, some tubing and a bag of salt water.

At a police station, a 27 year-old man was giving a statement about his recent assault, in which he'd been grabbed and beaten about the face as his iPhone was ripped from his hand, causing another injury on that part of his body. The poor guy was shocked, as you would be. He wasn't seriously hurt, so we took him in the car to hospital. If I were to give advice about this, it would be don't walk around with your iPhone out in the open, especially at night. Mobile phones are the new wallet and some thieves will stop at nothing to get you to relinquish it - some thieves carry knives to ensure that happens. It's simply not worth it.

Our last job was for an 82 year-old man who had leg pain after falling. He'd waited 4 hours for an ambulance. His GP had asked for one and said it needn't hurry. There were no ambulances to send, so we went and got him. He could walk, so we carefully assisted him down his stairs and out to the car. It was a painfully (more for him than us) slow journey but it was our going home job, so we took our time with him. He was rather tall and getting him into the car felt like a folding job.

That was that for the night. No mishaps and only one error. Naomi thinks there is a time called 22:60. She must do because she wrote that on the PRF. It's probably the tea-time hour in the valleys.

Be safe

Sunday, 4 March 2012

Answers to the BIG post

I ruffled a few feathers with my post on obesity. I knew I would; I expected it. I want to respond to everyone who has commented and emailed to support, criticise or threaten me (yes, there are still a few idiots out there), just because my professional viewpoint doesn't suit them.

First of all, as I clearly stated in that post, I understand that not all obesity is the result of self-abuse and excess. I have crossed comments with individuals who have taken drugs that have fat-gaining side-effects, or those with other significant issues. But I have to stress that gaining weight is a physical thing. Those who pile it on surely know they are getting far too big for their own good. Too may calories and not enough burning.

I watched an episode of Supersize vs Superskinny, in which doctor Jessen exposes some horrific facts when he visits the USA. Statistically, a third of this nation's population is now obese. Click on this link and look at the map as it shows trends for obesity across every state. It is truly shocking.

One woman, weighing 50 stone, that's over 300Kg, complained about how unwell she was and how she hated the way she looked. She bemoaned the fact that her son's life was ruined by her excesses because he now had to take care of her. He fed her, bathed her and helped her get dressed.

This lady was so heavy that she often damaged the lift system on the bus she needed to travel in to get places.

But while she did all this complaining, she still took herself down to the local restaurant, in her over-sized mobility chair, and she still shovelled in more food than most of us could possibly eat in a day, never mind one sitting. She did that and then went home to lie down. She loaded on calories and spent very little energy getting rid of them.

When Dr Jessen exposed her on TV, showing us the crammed contents of her fridge and the snacks and unhealthy food she had been eating, the lady giggled and rolled her eyes like a naughty child. She had just been told that she would die if she did not stop, yet there she was, mocking the very serious nature of what she herself talked about and agreed upon, moments before.

Getting too fat to live is more than just about eating, whatever the excuse. It is about other issues; emotional, psychological, self-esteem, lack of confidence. Sometimes it's about greed and mostly I believe, sheer laziness. It's just too easy to eat rubbish and do no exercsie these days.

We must address this now. We must be frank, open and honest. We need to face the problem and deal with it, without judgment or criticism where possible. But if those who need help simply don't want it, then there is no solution and things will become steadily worse as time goes on.

Go back to the CDC link and look at their map again... and again. Tell yourself I'm a liar and that it isn't happening. Convince yourself that you are different and that it's everyone else who's to blame. And while you watch the map staining red across those states, copy the pattern in your mind and transpose it for the UK and Europe... and in time, the rest of the world.

If a third of the entire adult population of a continent is obese and cannot function fully as a result, what becomes of a nation trying to defend it's borders when, as time goes by and we ignore the problem, more than half of it is populated by fat soldiers?