Tuesday, 19 February 2013

Getting back on the horse

I'm going to ease myself back into writing this blog; it's been a long time since I recorded patient-related events in detail, so forgive me if things start off a little slow.

I've been 'third-manning' for the first few shifts on my return to work. I need to be assessed as fit for practice, so I am duty-bound to sit in an ambulance with a crew and 'learn' my trade again. This is standard procedure for any frontline staff member who has been away from patient-care for a length of time.

So, initially I was taking obs and re-learning the layout of an ambulance (not that you forget it but I've been on a car and a desk for a few years now and things change). After the first shift of lifting and listening, I started attending again. I felt as though I'd never left.

My first patient, an 80 year-old lady with a Urinary Tract Infection (UTI), asked me when I was going back to Scotland. She didn't ask me in a 'I am interested in whether you will be returning to your roots at some time in the future' kind of way, but more in a 'why don't you bugger off back to where you came from' kind of way. UTIs have a lot to answer for!

As we drove her to hospital, she chatted and argued with the Hi-Vis jacket that was hanging on a hook in front of her.

A 2 year-old boy was fitting continuously in a non-emergency hospital and we arrived to help. He'd been convulsing for 20 minutes and had already been given Diazepam, with no effect. The nurses were suctioning his airway to keep it clear and he was twitching and arching on a small couch when I first saw him. I can't help thinking of my own little boy when I see things like this now.

It took another dose of Diazepam and a further ten minutes to get him to settle down, but he wasn't breathing for himself and so his ventilations were assisted all the way to hospital. He began to recover and stabilise but he still required support for his breathing, even when we arrived at the Resuscitation room.

An 87 year-old lady fell at home and was found face-down on her kitchen floor by her carer. When we examined her, it was clear she'd fallen many times. She had a fractured wrist as a result of this latest event. A look around her small house gave all the clues needed to suggest this lady needs to live somewhere else; her stairs (which she still used) were extremely steep and the carpeting was worn and sagging, making any ascent or descent a hazardous journey. If she fell from the top of those stairs, she'd be found seriously injured, or dead, next time.

We recorded and reported this, as required, in the hope that something would be done for her.
Unfortunately, jobs like these can come back and haunt you. You can ignore what you see and find yourself on scene again, treating a major head injury, or attempting to resuscitate an avoidable lost cause.

Speaking of head injuries. A 45 year-old female was found laying in the middle of the road by plain-clothes police officers who just happened to drive past. They'd seen a small gathering of people around her and thought, like everyone else, that she'd been hit by a car.

When we arrived, she was sitting with the cops, smoking a cigarette. She'd also obviously been drinking, but when asked how many, she stated 'two glasses of red wine'. She'd also had a free Valium, (courtesy of her friend whom she'd apparently visited prior to her fall), to 'take the edge off'.

She had a nasty cut to her head but no other injury. She denied the possibility of unconsciousness but was vague about certain things… like the date and time of day. She kept telling us that she had a dentist appointment and that she was on her way. She seemed very concerned about her teeth. She'd told us that she'd visited her friend, had a couple of drinks and a Valium, then started making her way to her appointment. As she crossed the road, she tripped and hit her head.

The story was fine but there were a few anomalies. The blood stain in the road was quite far from where she claimed to have tripped, so she either staggered and fell or she flew into the air. She was also hypothermic - something that doesn't just happen rapidly in a mild environment, so she must have been somewhere cold for a while… or she'd been on that road longer than she thought - possibly overnight.

By the time she'd reached hospital with us, she was warmer but still confused, although adamant about the events that led to her being lifted from the road by the police.

Part of the process of a return to practice is re-training in the core skills that are necessary for all frontline personnel, such as advanced life support resuscitation. After covering skills and knowledge in these areas again, one hopes to get straight back into the thick of it as soon as possible, so that rust doesn't settle and spoil the art. My last job gave me the opportunity to save a life, using a lot of the stuff I'd only just revised.

We'd been called to an elderly woman who'd fallen from a wheelchair and was not responding. Initially, this seemed like a perfectly straight-forward call, because 'not responding' can mean anything these days. However, as we pulled up on scene, we were up-dated and informed that it was now a cardiac arrest, so the tone changed and the pace accelerated.

There was already a motorcycle paramedic on scene, carrying out CPR with the help of an off-duty nurse, so I got beside him and asked what he needed. My two colleagues followed immediately with the rest of the necessary equipment.

No matter what you think of us (ambulance drivers, taxis, servants for drunks), we are extremely well drilled in cardiac arrest procedures and within seconds, we will have a team around you, working efficiently and carefully until we stabilise you or lose you, depending on what God decides.

From the outset, there were problems with this patient. She was elderly, she had a recent medical history that gave her less of a chance for survival, and, as we later discovered during the process of resuscitating her, she had leaking lungs. Air was gathering around her lungs so that it caused pressure to build up, thus restricting our ability to help her breathe. It's very likely she had a herniated lung (or lungs) and pneumothoraces caused by her predisposing medical condition... or our chest compressions. We know that this is a possible complication of aggressive CPR - which is the only way to achieve a positive outcome, if there is going to be one at all.

We worked hard for 20 minutes or so before deciding to take her rapidly to hospital. It is quite normal for us to stay and attempt to stabilise a patient before conveying - they have a better chance of survival if we can get the heart to work before moving them. Unfortunately for this lady, despite our very best efforts, we could not stabilise her long enough to justify remaining on scene any longer, and so we continued CPR out to the ambulance and all the way to hospital.

To relieve the pressure building up around her lungs, we inserted two large cannulae into her chest, one either side. This worked, but only very temporarily, as expected.

The hospital team continued to work on her for a little while longer but eventually called it and she was left in peace. I wish it had gone the other way but, as I said, not long into the attempt, it was clear she was in trouble. Still, we get to see some miraculous recoveries, so every mission to save someone is worth the sweat.

And, as I also stated earlier (and please do not think I feel this poor lady was good for practice and no more), her fate allowed me to get back into my skill-set.... inevitably, she will have helped me save a life further on down the line. In all aspects of emergency medicine, this is often the way of it. Someone slips away and exchanges life for life by allowing medics to get better at what they do.

Be safe.