Tuesday, 25 November 2008


Day shift: Eight calls; three declined; five by ambulance.

Stats: 1 Head injury; 1 Abdo pain; 2 Chest pains; 1 ?GI bleed; 1 ?EP fit; 1 Palpitations; 1 COPD with DIB.

A 59 year-old lady tumbled as she left a bus and hit her head on railings, causing a large swelling. Police were on scene and the crew was with me in five minutes, so all I had to do was gather my obs and hand her over for hospital.

Then I went to a local call and found a 19 year-old female sitting on a step inside her University Campus building, crying and nursing her painful abdomen. The security guy, who was just outside the entrance, took no notice of her and people practically stepped over her as she sobbed at the bottom of the stairs. She was on her period and its possible she was suffering a particularly painful episode but that doesn’t reduce the reality of her pain and it was a shame that nobody wanted to stop and ask her if she was okay. Maybe they were used to girls crying on those stairs.

A call given as a 42 year-old male was a female in fact and because I was looking for a man I almost drove past her as she waited outside a train station for help. She had chest pain and kept rubbing her breast to soothe it, something I haven’t seen done in this context. Again, she was on her own and nobody seemed to care. It was rush hour, so I guess there is a time and a place for caring.

After that I went to see a regular patient for whom a doctor had called an ambulance, stating she possibly had a GI bleed. When I arrived at the flat, she told me she didn’t have any problems and that her doctor ‘worried too much’ about her. In spite of her denials and because of the low blood pressure I was recording, I decided to call the GP myself and get the facts. The crew was on scene as I made the call and her own GP told me that she hadn’t been contacted at all. Then I tried the on-call doctor and this time the story became clear. She had been visited the night before when she became unwell and the doctor had told her that she was concerned about the low blood pressure and recent spate of malaena. She was advised to go to hospital but refused, thus the call to us the next day.

The patient spoke to the doctor on the ‘phone while I was there and pulled faces and made gestures that intimated her feelings for the professional on the other end of the line. Then she hung up on her.

She flatly refused to go and even though she had been warned that she could be found dead sometime soon (by her GP and us), she still said no. We had no choice but to leave her where she was and get the paperwork signed. No doubt I will see her again – dead or alive.

Another patient to refuse a trip to hospital had suffered a fit, according to witnesses. The school teacher was six months pregnant and had passed out but the description of the incident given by her colleagues in the Staff Room was closer to an absence (this used to be called petit mal). She felt fine when I arrived and insisted that she should carry on with her day.

The kids outside were extremely interested in what was going on and asked me if I was delivering her baby. On my way back to the car I told them it was a boy and it was to be called Brian. This caused a sudden upsurge of excitement and the rumour spread like wildfire before I’d reached the gate.

It was turning out to be an odd day with the third refusal in a row. A 40 year-old man with chest pain decided he wanted to continue his coach journey to Poland, despite collapsing and causing great concern among his fellow passengers. His father had died a few days earlier and he was on his way home for the funeral. His chest pain could have been the result of anxiety but there were changes on his ECG and he was strongly advised to go and get it checked out, rather than risk a long journey by road. I understood him though – I would want to be at my dad’s funeral if I had been away when he died. The poor man was working in the UK and sending every penny home to his mother so now he had no cash and no means of taking the trip later on.

He signed the PRF and was allowed to go on his way – he just about caught the coach as it pulled out of the station. I hope he made it without any drama.

A 27 year-old Soho prostitute suffering palpitations took 45mg of Valium to try and calm her heart down. She already had an anxiety problem and worried that she’d taken too many. I reassured her as she sat on the step of her bed-sit home and the crew took her for an ECG which, apart from the tachycardia, was normal.

I almost made it home but I got a late job and was off to see a 57 year-old man with COPD which had suddenly become exacerbated. I knew the man and I knew he was very fragile, so I tried to give him more oxygen but he didn’t want the mask on his face. His nasal cannula was only delivering 2lpm and that wasn’t enough. I couldn’t nebulise him either because, again, he refused the mask. I cranked up his oxygen to 4lpm on his home cylinder and hoped the crew would be there quick because his sats were very low and his condition was deteriorating. He was panicking. ‘I’m going to die’ he said repeatedly.

As his anxious family stood round I tried to calm him and prepared to do what was necessary if he stopped breathing – a strong possibility in these cases. The crew arrived and he was taken to the ambulance where he relented and allowed a nebuliser to be put on him. His condition improved slightly but he was still using accessory muscles to breathe and looked ready to give up, so he was taken to hospital for further treatment.

I take people with real breathing problems seriously; the look of a person, they way they posture and behave will indicate the severity of their condition, whether we gauge that through our instruments to be serious or not depends on how we see the human being that is trapped in the desperate fight to catch a breath. Until you have been there yourself, it’s dangerous to assume that a high saturation means they are ok.

Be safe.


Lottie said...

Did he refuse to use the mask at all or did he just not want it hooked over his face?

I work on a coronary care unit and we have sooo many patients who will only wear a mask if they can hold it. Its better if they'll keep it on but if its hold it or nothing, I'd say its a reasonable compromise.

*shrug* just a thought.

VA FireMedic said...

and from my experience, when the patient says they're gonna die, they're usually right...

Anonymous said...

Quick question. What does it mean when someone uses their accessory muscles? I often get in from you guys in the blue calls and have always wondered what it means medically and for the patient. And along those lines, what is a tracheal tug?

Lottie said...

@beaker when someone breathes normally they use their intercostal muscles (between your ribs) and diaphragm. If someone is using their accessory muscles they're using other muscles as well as their intercostal muscles and diaphragm to help them breathe.

It can look as though the person is using their entire body to breathe - they tend to tense their shoulders and neck when they inhale and force air out during exhalation with their abdominal muscles.

From a patients point of view its incredibly hard work and not very comfortable. I imagine its also quite frightening to be in that position.

From a clinical point of view, it signifies either increased work of breathing (usually with chronic things like emphysema or COPD) or respiratory distress (with acute asthma or exacerbations of COPD etc).

I hope this helps!