Leaning on a Lamp Post

It’s been a while since my last post and I feel a bit guilty given I have lots of things to post, just no time to put finger to keyboard.

Here is a true life scenario I had a little while ago. I am currently writing it up as part of my CPD portfolio. I’m interested to see what other people make of it.

History and Presenting Complaint

999 called by a passer-by stating an elderly male was “leaning up against a lampost clutching his chest”

Upon direct questioning, patient either complained of “pain in chest and neck” or “pain all over”.

On Examination

GCS 13/15 (E3,M6,V4)

pulse rate of 72 regular with a good peripheral pulse

SPO2 95% on room air

respiration rate of 20 regular with no signs of difficulty in breathing

hypothermic – temperature  below 34 Celcius

equal air entry and normal chest sounds

bilateral BP raised at 162/122

pupils both 3mm but both reacting slowly

sinus rythum with ocassional isolated PVCs on 12-lead ECG

FAST negative

general weakness

confusion

no signs of trauma

What would you be thinking at this point? How would you manage this patient? What’s your differential diagnosis?

Post answers in comments.

 

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What About Protected Bed Times?

Hospital transfers are for everyone who works in the ambulance service part of the job. Sometimes the patients are very acutely unwell, and sometimes they aren’t.

One thing I hate doing, but sometimes have to, is transfer a patient in the early hours of the morning. Most of the time the transfer will have been booked at a reasonable time, but due to number of more “more important” jobs, these get keep getting pushed to the back of the queue.

Last night we went to transfer a lady in her early 90’s from one hospital to another. The job had been booked at around 8pm but it was gone 2am by the time we had been tasked to it. We got to the ward and one of the staff nurses said she wasn’t prepared for her to be transferred at this hour of the morning. I couldn’t have agreed with her more!

We would have had to wake her up which would have probably woken up the other patients in the same bay in the process. She may have dropped back off to sleep during the journey, but then we would have had to wake her up again only to put her into bed on another ward in another hospital. Madness.

There is no reason why we should be transferring any patients at 2am unless it is medically necessary. Our control shouldn’t be giving out these kind of jobs at these times and hospital wards should involve the ambulance service in the planning of transfers much earlier. This means not just ringing us like you would a taxi to pick-up a patient ASAP.

Patients should only be transferred between the hours of 8am and 8pm. Patients are in hospital for a reason and they need their rest. We shouldn’t be interrupting their sleep to suit our bad planning practices. Patients can expect protected meal times, so what about protected bed times.



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It Could Be Worse. Much Worse.

Recently I’ve had rather a lot on my mind. Much more than usual. I’ve wanted to blog about what’s been going on, but by the time I get around to putting fingers near a keyboard something else has happened. Big things too. It really has been a thought-provoking few weeks for many different reasons.

Most of what’s been going on hasn’t directly involved or affected me. One thing did involve me. I will admit it had me scared, perhaps for selfish reasons.  This was the second time I’ve been hit with this very specific horrifically awful feeling in the pit of my stomach that just would’t go away. I wouldn’t wish it on anyone! I even went to talk to a Priest in an attempt to try and rationalise what was going on inside my head which made me unable to think about almost anything else. Yes it was work related and I will blog about it, but not now. It’s far too fresh.

If your looking for a silver lining, I know I have been. The last few weeks have given me a lot of perspective on my life and problems. It’s made me realise that the situation me and my girlfriend are in is overcome-able and in the grand scheme it could be worse. For many others it is worse, much worse! For this I should be, and am, thankful for. Amen.

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Nightclub [para]medics

This blog post is in reply to and inspired by the BBC Radio 1 Newsbeat article More nightclub paramedics needed say A&E doctors.

I’m sure no one is any doubt alcohol related incidents do place a big drain NHS resources. Many of these incidents would not be occurring if people drank more responsibly and there was less of a binge drinking culture.  This report says that many of these incidents end up going to A&E when they don’t need to, and nightclubs should be employing nightclub [para]medics to take the strain away from the NHS.

Nightclubs do have a legal responsibility for the health and safety for people who come into their clubs in the same way that a business has the same responsibility for visitors to its offices. There is no requirement for night clubs to provide medical staff over and above calling 999 for an ambulance therefore placing the burden onto the NHS. For the nightclubs it’s a win win situation.

Some nightclubs, particularly the bigger ones do have some provision for medical cover, weather that being a member of staff being a first aider, or contracting in a private ambulance service to provide a night club [para]medic. The qualifications of this medic could literally be anything from a couple of days first aid training up to an registered healthcare professional such as a nurse or paramedic however usually it’s closer to the couple of days first aid training, maybe with the title of EMT – which is infinitely ambiguous but still highly converted because of this ambiguity.

The real question is how many people can actually avoid A&E. For many people an NHS ambulance will be called to won’t actually be in need of medical attention, instead they are drunk and incapable. Everyone knows that there are lots of things that present similarly to being intoxicated and therefore can justify in their own minds calling for an ambulance when they can’t deal with them themselves, possibly because they are only slightly less drunk and incapable themselves. Nightclubs simply don’t want the liability to fall onto them, and I would question how much training you get in a first aid course on dealing with someone who is drunk and incapable. Dealing with your drunken friend isn’t something that is even in the first aid manual. Being able to deal with these jobs takes common sense, experience and assertiveness. The challenge with these people is getting them to a safe environment with someone who is capable of watching over them. Sometimes, and as frustrating as this is, this isn’t possible and therefore there is either two options: a police cell or A&E, however usually it ends up being the latter. Maybe if it was universally a police cell in this situation then there would be less desire to go that far with alcohol.

Dealing with someone who is drunk and incapable isn’t something you can do on your own. If they are capable enough to walk unaided or with some assistance so they can get to get to a designated first aid room, otherwise an ambulance would be needed anyway. This would be the same situation on a NHS rapid response car as it would be for a nightclub [para]medic; it has little to do directly with the level the level of training.

There are of course people from night clubs who are in need of medical attention. These patients need to be sifted out from those that are just drunk and incapable. This is something that could go have a bad outcome if the wrong decision is made. The most common will be wounds. Some wounds do not need any more management than cleaning, maybe dressing, and self-care advise. Many however do need further management such as wound closure. There are paramedics who can do this, but it is very unlikely that a night club would have someone who is capable of this level of care. Also a suitably clean environment is needed for wound closure and most of the first aid rooms in night clubs are little more than storage rooms with a sink and a first aid room sign on the door. Also there is the question of those that do need to go to A&E how do they get there. Oh yes, call an ambulance. *sigh*.

Let’s be realistic. Every nightclub having a paramedic is unrealistic and unnecessary. It’s unlikely to have a massive impact on the number of ambulances going to night clubs or how many drunk and incapables end their night on an A&E trolley. Where would all the paramedics come from? The NHS don’t have a surplus to hire out to night clubs. Also I don’t know many paramedics that would want to work in a night club even on overtime. Multi-agency projects such as The Norwhich SOS BUS is a far more suitable, cost effective and successful model.

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The Emotions of Disney & 999 Calls

A few days ago I had two patients that where rather similar. What was wrong with them was very different; however they had some startling similarities. Both patients where in their eighties, living independent self-caring lives with no significant health problems. Both where taking anti-hypertensives, and one had prostate cancer actively managed by hormone therapy. Both had been feeling well and going about life as they would any other day until something quite drastic happened.

The first patient was passed to us as being unresponsive. An FRV arrived first to find a patient who was verbally alert (GCS (4,5,1) = 9).  They were able to grip with one hand but not the other. Suddenly they become unresponsive and started agonal breathing. The FRV started CPR which is when we arrive. The initial rhythm is PEA. We secured the airway by intubating. We also gain IV access and gave adrenaline and atropine. There are no obvious reversible causes for us to treat. Half way to the hospital they’re heart rhythm went into VF which we shocked and it reverted back into PEA. On arrival at hospital CPR was continued for further 10 minutes. However as there was still no signs of spontaneous respiratory effort or circulation after  at least 30 minutes and no improvement in neurological function it was decided that there was no benefit in continuing the resuscitation and they were pronounced dead.

The second call was to a patient with back pain. As soon as I saw this patient I knew something serious was happening. Certainly no MEWS or EWS needed here! They are verbally responsive (GCS (3,5, 6) = 14), very pale, clammy and in obvious severe discomfort. There was no radial pulse, and only a weak slow central pulse. High flow oxygen and rapid extrication to the ambulance was needed where we confirmed his pulse rate being bradycardic at 35bpm. His ECG ruled out any form of heart block. We get large-bore IV access, twice. We give atropine bringing his heart rate up to a more satisfactory 65bpm. We start a steady infusion of intravenous fluids to maintain a radial pulse. We aren’t able to get much out of the patient, but he is able to tell us that the pain is around his kidneys and also in his left iliac/lumbar abdomen starting suddenly about ten minutes before the 999 call whilst watching TV. On assessing his abdomen the only thing of note is increasing tenderness and slight guarding in left lumbar. On arrival at hospital an abdominal ultrasound confirms a AAA of about 7cm in diameter. The consultant radiologist is bleeped and within a few minutes the patient along with an SpR doctor, and two nurses who are rapidly pushing him towards the CT scanner along with a large bag of ALS equipment. This is the last I see of this patient. Hopefully he will survive; ideally he will survive to discharge. He’s beaten the odds by surviving more than most with a rupturing AAA by making it alive into hospital, but all I can think of is that the last AAA I saw was in emergency surgery where the patient needed five anaesthetists to keep them alive. They succeeded, but only just.

Admittedly not all patients are like this. When you do deal with patients like this when there life is literally hanging in the balance it’s hard not to be drawn into the emotions of the situation more than you should; more than it’s safe to for your own sanity and the detachment needed as a healthcare professional. Despite how easy it is, I’m quite good at staying detached. There are memorable jobs though that if they don’t hit you hard then you shouldn’t be in the job. It’s a very fine line.

After finishing this shift, I came home and my housemates where watching a Disney film. Bolt if you’re really interested. Disney films are brilliant, but they all follow a set pattern; the exact opposite of real life. A talking dog, hamster and an anorexic cat are perhaps about as far away from real life as you can get. How is it then that almost without fail that I get drawn into the Disney fabricated emotion provoking script and start shedding tears, when back with real life emotions there wouldn’t be a tear in sight.

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Communicating Through The Iron Curtain

Today has been a good day. I have achieved the following.

  • getting 13 hours sleep
  • watching two classic WWII films (one of which was 3hrs long) that I have never seen before
  • making a home made lasagne
  • planning my meals for next week
  • going food shopping
  • making a bread & butter pudding
  • writing a blog post
  • fixing the house kettle
  • doing a load of washing
  • cleaning the kitchen

Rather productive don’t you think. I certainly think so. It’s even better today because my girlfriend flies back tomorrow after a week with her parents and four siblings. I’ve missed her. It’s not that I can’t cope without her it’s more the lack of contact when she is over in the eastern-bloc. She never phones me, and text messages are very few and far between. During previous visits I would get an email send before she went to bed each night, however this seldom happens now. All i’ve had this time is two brief emails and a couple of text messages.

Maybe it’s that we know we can cope with being apart now. Her usual trips are between two and four weeks. Once she was away for three and a half months. Maybe it’s complacency in the relationship, we’ve been together for two years ten months so you could certainly say the honeymoon is over. Especially as we have gone through quite a lot in this time together and if I’m honest we’ve been trough things that I’m surprised we are still together after this amount of time. I think I would actually prefer it to be complacency in the relationship. If it was then we would do something about it. Instead I feel most of it is to do with her parents and their disliking of me, which is putting it mildly.

However I keep being told and keep telling myself that I just need to persevere. All relationships have their problems. I just need to hang on a few more months until she finishes university and starts working and earning money for herself. Then things will change.  She will finally be able to stand up to her parents and break her mothers dictatorial umbilical cord. I on the other hand am less optimistic of such a dramatic change. I will still remaining hopeful that I am pleasantly surprised…one day.

For me the cold war doesn’t involve the threat of a nuclear holocaust, but it is far from over.

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The Cat Is Out Of The Bag

Tonight I took part in the second episode of the Ambulance Matters podcast.We were discussing the role of the Emergency Care Practitioner (ECP) within the ambulance service. It was a semi-formal chat but we got quite a lot of valid points across. I won’t give anything away you will just have to go and listen to the podcast to find out what was said. At time of posting the podcast isn’t yet available so follow Ambulance Matters on Twitter to find out as soon as it’s released.

I feel quite privileged to have been part of this and right at the beginning. This is the only UK focussed ambulance/pre-hospital/EMS podcast around. There are numerous US based ones but in many ways the profession is very different across the pond; as is healthcare as a whole compared to here in the UK.

I was nervous before, during and now even a little bit after as I have never done anything quite like this before. If we had all been sat in the same room together then I think it would have been easier, but given we had participants from as far apart as Newcastle, London and Michigan then doing the podcast would just not have been possible if we all had to be physically together to be able to record it. Just going on someone’s voice is a bad indicator of their reaction to something you have said. It’s an even worse indicator if you have never met or spoken to them before.

I can now no longer hide behind true anonymity. I used my real first name and my voice wasn’t done by an actor. I said that I was @mralmostbritish and mentioned the name of this blog; which if you Google comes up as the first result. I found this out after doing the recording. As soon as @ukmedic999 releases the podcast to the entirety of the internet then everyone who listens to the Ambulance Matters podcast will know I was part of it and where to find more information about me. Saying that I still don’t think it’s instantly obvious exactly who I am. I don’t think anyone could find out my address or where I went to school. Nevertheless people who know me will more than likely make the connection that it’s me.

Thanks to all those who took part in this weeks episode of Ambulance Matters

@ukmedic999

@Mrs999

@iMedicFF

@TheRoadDoctor

and Sarah.

It really was enjoyable even if a little nerve-racking.

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