Saturday, 29 November 2008

System failure

Night shift: Eight calls; all by ambulance.

Stats: 1 ?Fit; 1 Hyperventilation; 1 DIB; 1 Fall with multiple injuries; 1 Unwell baby; 2 eTOH; 1 Unconscious.

What a strange Saturday night. Maybe the cold, rainy weather is keeping the drunks at home or maybe everyone’s getting into the Festive Spirit by behaving themselves…or, more than likely, fewer people can now afford to go out and buy unlimited alcohol to poison themselves with. Whatever the reason, I found myself working one of the busiest weekend nights without visiting the West End on a regular basis to help scrape someone off the street.

The first call, given as a fall, was an 86 year-old man who had fitted and was now suffering shortness of breath (SOB). His family told me he had recently suffered diarrhoea and stomach pains and that he was normally fit and well. They had gathered in a posh hotel to remember his wife who passed away a few years ago – they do this every year.

His ECG indicated a left bundle branch block (LBBB) and there were other changes on it too, so he was taken to hospital for further investigation.

Choking provokes a Red1 because of the immediate life-threatening nature of the incident. I was sent to a University library where a 21 year-old was apparently choking to death, so every second counted and I sped there as safely as I possibly could, given the rubbish visibility. I arrived and got lost. Nobody was there to wave me down or direct me and the buildings are sprawled all over the place, so I couldn’t identify the right one. A MRU was arriving on my tail and he couldn’t work out the address either. We might get to your location within a short time but if the address is vague or there’s nobody to meet us, another minute could be wasted; it’s frustrating.

An ambulance pulled up just as I found the correct building, thanks to a passer-by who casually pointed around the corner – it was almost a ‘Yeah, your emergency is over there mate’ type of gesticulation.

So, three vehicles and four LAS bods were on scene – more than enough to cope with a choking person. We could save her life – well, we could if she was choking at all. A gang of students rushed out of the main door to meet me as I approached. One of them was carrying the girl as if she had been wounded by a mortar in a war zone; it was all too dramatic. I took one look at her, asked her to breathe in and out and decided that she wasn't dying. Neither was she choking.

The girl was hyperventilating. She’d collapsed in a heap outside the place and a mob of concerned students with absolutely no knowledge of basic anatomy or physiology decide she must be at death’s door. Obviously, because she was gasping, she must be choking. It all made perfect sense to them I guess.

A district nurse dialled 999 and asked for an ambulance to take a 77 year-old man with diarrhoea and SOB (another one) to hospital. He was in bed and certainly seemed to be having trouble with his breathing. The crew took over once my obs were complete and oxygen was given to help him out. Otherwise, he seemed stable for the moment.

Some calls contain so little factual detail that it’s surprising more people don’t die as a result. Sure, plenty of people exaggerate the information they give (as in the choking call earlier) but some play down the need for an emergency response. We’ll run around on Red3 calls for ‘not alert’ or ‘unconscious’ people who are just drunk and we know it but we fail to grasp the problems associated with mechanisms when we receive calls with scant detail but a high index of possibility for serious injury. It’s not the call-takers who are to blame; they do what the computer tells them to do – it’s the design of the system, the software and the uneducated non-clinical method we employ to associate cause with effect.

For example, I received an amber call for a 72 year-old woman who had fallen down stairs but had ‘no injuries except for a bloody nose’. Right; she’s 72 years-old, so no spring chicken (with respect). She’s gone down stairs (that are made of what?) and landed on something (a floor? A bed of nails?). The call detail also stated that it was a ‘long Fall’ which should sound alarm bells for anyone. When I got there I was shown to the patient by a tall man who is a friend of the family. They are Portuguese and the patient doesn’t speak English at all but the daughter-in-law does and she translates for me.

The flat is a complex of rooms in which there are multiple sets of stairs to negotiate, up and down. The hallway in which the lady landed is tight and narrow, cluttered with stuff, so moving her out of there was going to be a nightmare.

She had fallen from the top of six steps without touching any of them – she’d been launched in fact, landing with a thud that was heard from the back room, according to the daughter-in-law. She was found wedged in a small space at the bottom of the stairs with a head injury. I saw a huge bump on her forehead and good size pool of dark, congealing blood on the floor. She was sitting up now but complaining of neck and arm pain. Further examination revealed a broken nose, broken Humerus and multiple bruises around her limbs. Her neck pain was a concern but she had fair movement and refused to sit still so that I could hold her head in alignment.

I called Control and asked them to upgrade the call so that I could get a faster response but I learned that this wasn’t done and so an ambulance was sent on the amber code with no rush.

I can’t write about calls like this without sounding like I’m having a go at Control staff; I’m not – I’m against a system that ignores the clinical assessment of someone on the front line in favour of a grading system that satisfies ORCON.

When the crew arrived it was decided to take the lady out in a chair and not to board her; it would have been impossible and dangerous to do anyway. She consented to this and refused any sort of restraint in any case.

We need to re-think the way we remotely assess a call, based on the information given using mechanisms and a high index of suspicion. That means using clinically trained personnel to take the calls but call-takers do not receive much, if any training in pre-hospital care. HEMS and the MRU desk use this practice to send additional resources to a call and I use it when I look at calls on the Clinical Support Desk – the computer’s opinion takes second place.

New parents with new babies worry a lot about their offspring – even when they have been told that nothing is wrong with their child. A 3 week-old baby with diarrhoea was brought to my attention and I reassured the young parents that she was okay after a full set of obs. However, they thought she had fitted (she back arched when picked up) and I explained that babies do that when they have wind. Recent trips to hospital where a clean bill of health had been given did nothing to reassure them, however and I was reluctant to leave them at home, so they went to hospital for more support.

Club personnel who carry patients out to us because they are unconscious and drunk risk trouble for themselves if anything goes wrong, so I would recommend they leave the patient where they lie until we get there. I wasn’t surprised when my 18 year-old Portuguese (there’s a lot of them in town) patient was carted out as I arrived but I was annoyed. She had drunk way too much and her sobbing friend couldn’t understand why she’d just collapsed in the toilets. She had vomited and was floppy but conscious. In fact, she still had the sense to speak in full sentences to her friend. Every now and then she’d stop talking and slip into a drunken sleep, from which she was awakened by yours truly.

Off she went, friend in tow, to the nearest A&E.

Early in the morning I was despatched to a 32 year-old male who was unconscious and ‘had a bit to drink’. The word ‘bit’ is often the parody of ‘lots’, I find. Further details explained that the house had recently had a fire and so there was no electricity and that meant no light. This was going to be fun.

I arrived as the crew pulled up and we made our way up the dark, narrow stairway using our penlights to guide us – we do have torches in the vehicles but they rarely work. The smell of smoke was still strong and ironically, when we got into the flat, they were using live candles to light the room.

The man was in the recovery position on the floor and his wife and two friends were present. They had been drinking all night and come back here to party and dance around, as you do. While dancing, the man suddenly collapsed and lost consciousness. He had a fit and then his breathing became noisy and slow. When I assessed him his respirations were too slow for life and we got to work on him with the help of a little torch and one of the friends. I had to ask for the candles around him to be taken away – we were about to turn the oxygen on and this would have become a dangerous farce if we’d ignored the risk.

I’ve worked with one of the crew on several calls like this; we communicate well and things get done. He was bagged and I began the process of gaining as much information as possible about his medical history, drinking habits and possible drug use as I put a line in. He got Narcan even though his wife was sure he didn’t touch strong drugs and only smoked occasionally. I believed her but you never know, do you? His pupils were pinpoint and so going down this route to start was advisable.

We remained on scene for about 30 minutes because we had to wait for help, in the form of proper light, from the London Fire Brigade. They appeared as if by magic in healthy numbers and shone their torches where we wanted them. I’m willing to bet they were the same crew that put the fire out in this place.

His wife cried a lot but was able to keep herself together in order to help us. I think she feared the worst and there were a couple of moments before the LFB arrived when he stopped breathing and our support was the only thing keeping him alive. His pulse rate was dropping, so any interference with his airway, which was manually cleared several times, might have invoked a serious bradycardia.

Narcan didn’t change the situation and Oxygen didn’t make any difference to his state of consciousness, so it was time to get going before we had a bigger problem to deal with. I could imagine how difficult his removal from the place would be if he arrested on us, so it was a good idea to get him in a chair and go while he was drawing some breath for himself.

The LFB helped with light and guidance down the steps and my colleagues creaked and sweated as they carried him away. He was put in the back of the ambulance and everything we had was thrown at him; CO2 monitoring, 12 lead ECG, more oxygen, etc.

The quick journey to the hospital brought no change in him; in fact we had to wrestle with his airway a few more times to keep it clear. We also had to temper the bagging to balance his O2 and CO2…and pulse rate (over-enthusiastic bagging can disrupt the gas balances).

In Resus they worked on him some more, took blood, intubated and hooked him up to their machines but his condition remained the same.

I spoke to his wife as she waited. ‘He was always very difficult to wake up’ she said in an attempt to console herself.

I asked about him later and was told he’d been taken for a scan, which was negative. I was sure he’d been suffering a neurological insult. He was now in ITU and they’d taken two litres of urine out of him. I hadn’t given him fluids; he didn’t need any but the hospital, as part of their own protocol, had pumped a litre into him. I wondered if he had suffered renal failiure, although there are many causes of fluid retention.

I got back to a late job and was late home as a result. I still had two more nights to do, so the overtime wasn’t appreciated. The call was for a 38 year-old man who had walked into a bus. He was very drunk and I found him sitting on the cold, wet ground with a shoe off. The bus driver was annoyed that he’d nearly had to go home after potentially killing someone who was just stupid-drunk – I empathised with him.

The police arrived to help and they checked his immigration status (they are good with hunches like this). The ambulance arrived after 30 minutes and I left him to them (and the police).

Morale is very low in the service and pressure is increasing for all of us. Targets dictated by a lazy Government that believe in a nanny state give us no hope for the job sometimes. It’s made worse when human beings are removed from the exercise in the hope that prediction and submissive supposition can replace a good brain and common sense. I will never claim to be the best at what I do – there are better paramedics out there I’m sure but if you tell me your 20 year-old mate is vomiting in the gutter after drinking and he’s ‘unconscious’, I will replace paternalism with scepticism for the sake of the truly ill and injured out there.

Maybe a good scare is what’s needed for some of them so that they realise the risk they take has potebtial consequences and they stop being dependent on an ambulance service to carry their self-imposed burden all the way to an over-stretched A&E department. Or maybe I’m too harsh and unwilling to accept that people are essentially moulded into this reluctance to take responsibility for their own actions.

Be safe.


Anonymous said...

Unfortunately very few people are willing to take responsibility for their actions these days and the government is just making it easier for them to blame someone else

Feathers said...

But there again the in answer to your last sentence...the government is fighting to reduce drug crime :) so no fear there....(DIP) by giving out £10 vouchers to all drugs addicts to complete a questionnaire,anonymously, a drug addict can take as many friends as they wish they get 10 friends £100 to score or get drunk,as many as they wish, they are sold or can be exchanged at off licenses, major stores......the addicts also get £10 vouchers..not a bad deal for an addict/drunk wishing to get some money courtesy of the government....did not make it up...was there witnessed it. Plus the answers they gave are lies of course, wonder if they will also quote the statistics of the questionnaires.....personally think the help available to addicts once they cross into serious addiction is wishy washy as demonstrated this week by our own government....and ludicrous...where did that money come from??

miss emma said...

A good scare does work formany people. In the case of drunken teenagers... my best friends sister is just recovering from glandular fever and was told not to drink until the new year. She had 3 small glasses of wine at a party a while ago and ended up spending the night on the floor vomitting (although we did not feel the need to call an ambulance as we knew exactly what was wrong with her) and she has been so frightened by the experience that she has not touched any alcohol since then. Also, my dad has recently been diagnosed as being diabetic. He has never listened to our warnings but now he has been shocked into reality as his diabetes is already quite severe.

A good fright really is all that is needed