Category Archives: Doctor

The first Paramedic shift…

…was actually what it was supposed to be this time; This was my first shift working as a registered Paramedic. I’d been given my shiny new ‘Paramedic’ epaulettes, a personal issue Morphine log book and Morphine pouch and was ready to take the lead on the Ambulance for 12 hours.

My first shift as a Para was with my old mentor. We agreed to meet on station early to go through the daily drug audit process – a lengthy but legally necessary process where the first Paramedic to book in/out controlled drugs after midnight that day, has to perform a full controlled drug count and note it in the log book.

Once that was complete, we grabbed the keys ready to check the vehicle before the start of our shift. Suddenly, somewhere between putting the kettle on and grabbing my hi-vis kit, the station phone rang:

“I’m really sorry to call you early, guys, but I’ve got a Red Call that’s just come in in the next village and the nearest crew is 20 minutes away, can you book on early for me??”

The voice was that of one of our Dispatchers, a particularly efficient and trustworthy Dispatcher who happens to be a close personal friend of mine. I knew she wouldn’t ask us to book on early unless she had to.

“Yeah of course, whats the details?”

“It’s a 19 month old who’s been scalded by boiling water”

An immediate rush of adrenaline rushes across me, along with 100 questions about what had happened; how much water; where are they burnt; was this non-accidental; where were the parents; how in the name of all that is Holy do I manage this patient?!

“Right, send it down, mark us as Mobile to Scene.”

“Will do, thank you so much.”

 

I holler through the garage to my crew mate who responded by firing up the truck, which revved to life after rare 12 hour break. We both jumped in the cab and rushed the 8 or so minutes to the address. The whole way there I was thinking how that after months and months of having nothing but non-injury falls and drunk students, my first shift as a Paramedic commenced with what would be considered a nightmare job! I had to consider assessment strategies, treatment plans, drug protocols, the availability of the air ambulance, our proximity to hospital compared to the regional burns centre, how I would calm the child, how I would calm the parents – all this while my crew mate drove at 60mph through the town centre.

 

We arrived at the three-story Georgian-style new-build to find a very anxious looking Mum at the door. As I jumped out, she said “I’m a Police officer, please don’t report me!” This eased tension quite quickly. Even in dire circumstances, the blue-light team always have a warped sense of humour.

“Where are we going?” I replied while smiling calmly but secretly shitting myself.

Mum pointed upstairs. She needn’t have bothered, I simply followed the screams until I found the bathroom where a stripped naked boy lay in his fully-clothed dad’s arms, both sat in the bath tub, dad spraying him with a cool shower – the absolute best thing to do initially for any burn.

I took a quick history while I opened the burns kit. My crew mate, instinctively knowing that we would be ‘scooping and running’, began preparing the ambulance to transport the patient and parents.

The child had severe scald burns to his lower face, lips, neck, chest, shoulders, arms and back. It was a full, fresh made coffee that he’d grabbed from the kitchen worktop while his mum turned her back for a second that had caused the damage. There were several large blisters that had already burst, and several more forming.

It’s very important that we (pre-hospital clinicians) estimate the total body surface area that has been burned. There are several quick-and-dirty methods to do this, my favourite at the moment is to treat the patient’s whole palm and fingers as 1% and work it from that. I estimated that in this case, the lad had approximately 10% superficial and partial-thickness burns. This is a significant burn % area for a child and it confirmed my suspicions that we would be bypassing the nearest A&E and heading for the regional burns centre.

We gave him some Calpol (liquid paracetamol/Tylenol for those abroad), strong oral pain relief (liquid morphine) and turned off the shower. We placed cling-film over his burns* and placed cooling burns dressings over the top. Mum carried him to the ambulance while dad changed into some dry clothes.

Once aboard, I completed as many clinical observations as you can on a highly distressed 19 month old, then blue-lighted him to the burns centre. I phoned ahead on the red-phone (the priority line) to prepare the team for my patient.

It was an uneventful journey. The pain relief kicked in quite quickly, and cartoons on Dad’s iPhone were a hit, too! At the hospital I handed over to the Consultant Paediatrician who praised the parents for their quick actions in administering first aid. I sensed he could see the guilt in their eyes of having left a hot drink in reach of their child and wanted to try to pacify them. It was clearly an accident and an easy mistake to make. They weren’t the first and certainly won’t be the last parents to do this! The hospital team thanked us and set to work on the boy.

 

It was a very satisfying job. Our total ‘on scene’ time was 11 minutes. And 4 of that was waiting for Dad to get changed. I felt very proud of my actions as lead clinician, and my crew mate and ex-mentor high-fived me and bought me a coffee – the equivalent of a medal in the Ambulance Service šŸ™‚

 

Our very next job was a drunk man on a park bench who said he couldn’t stand up, then, when we wheeled the stretcher to the park bench, promptly stood up and walked to it…….normal service resumed then.

 

 

*Cling film, believe it or not, is excellent for all burns: not only does it reduce infection, it prevents air getting to the exposed nerve endings and actually reduces pain! Definitely don’t be using butter/moisturiser/ice/anything else!

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Blood and bloody idiot

There are a couple of terms used to define bleeding in the medical field;

Capillary – this is when the surface of the skin is scratched, but not deeply, and small spots of blood ooze from the damaged capillaries.

Venous – when a vein is nicked and blood will slowly weep from the wound.

Arterial – Blood will spurt out with every beat of the heart, sometimes spraying large distances depending on the size of the artery.

 

That final one, the arterial bleed, is considered to be a catastrophic haemorrhage. That is, if the bleeding is not quickly stemmed, a person will die within minutes.

 

Today, while working from a different station to normal, we were sent to a 25 year old who had punched through a window in a fit of rage, cutting his forearm. We were told the call had come from Police and they would also be attending.

We arrived after the Police and followed the significant trial of blood to a male laying on the floor, with his girlfriend tightly holding a towel around his arm, blood pouring down through her fingers. Thankfully, we had brought our critical haemorrhage kit in with us, so prepared to uncover, assess and re-dress the wound.

My crew mate wrapped his hands tightly around the arm to slow any bleeding while I prepared some gauze, a trauma dressing (more on that later) and a tourniquet.

*This next section is not for the squeamish!*

I slowly removed the towels to find a large wound which was deep enough to nearly see bone through muscle and tendons. He had two large skin flaps where he had effectively de-gloved his arm, he had some blood clots within the wound from a venous bleed, and a quite noticeable spurting bleed from his Ulnar artery (one of two which run down the forearm). He had lost around 1500ml of blood. The quick actions of his partner prevented him losing any more than that, which would have lead to shock.

We quickly ‘eyeballed’ the wound for any pieces of glass – there was none – and wrapped our trauma dressing around it. The trauma dressing we used has been developed by the military. It is specially designed to apply pressure directly over a section of injury on a limb, without using a tourniquet, which is always the last line of defence in a catastrophic bleed, as the limb may not survive.

While all this was going on, we obtained a quick history of what had happened. An argument with his ‘missus’ caused a fit of rage and he’d punched a window. He was also intoxicated and had been taking cocaine. He was also a bit of a knob head.

He immediately took a dislike to my crew mate (the person applying pressure to his wound to stop him bleeding to death) because he had “one of them faces innit”, calling him a c*nt and saying he would smash his face in. Delightful. Thankfully, I’ve got a knack of getting on with people like that, a trick I learned from an old crew mate of mine. As such, I quickly built up a rapport with him and persuaded him to come to hospital with us. Yes, I had to actuallyĀ persuade him!

During this, he continued to be verbally aggressive to all of us and stood unaided to show us how strong he was. Now, he clearly worked out, but also clearly used steroids. We advised he shouldn’t eat or drink in case he needed surgery, so he drank a pint of water. We recommended a wheelchair due to the blood loss, so he walked upstairs to find his phone, all the while, using the C-bomb like it was punctuation and swearing at us all and being generally aggressive and intimidating. The Police said they would travel with us and called for backup from the PC they had dubbed the ‘man-mountain’. And with good reason. At 6’2″ and 18 stone of muscle, he would certainly be able to contain our almost equally sized patient – owing to the advantage of a working arm. And pepper spray. And a taser.

He eventually walked to the ambulance and sat in a chair because we’d suggested he lay on the stretcher (am I building up a picture of what this bloke is like?). I inserted a cannula into his vein to give some pain relief through a drip. All the while he told me how shit I was at my job. We swiftly left the scene on blue lights heading for A&E. After around 6 minutes of travelling, he decided he had become board of wearing a seatbelt and sitting in a chair while in an ambulance travelling at speed through a town centre, so he undid it – against mine and the PC’s insistence – just as my crew mate had to reduce his speed for traffic ahead. As such, the unrestrained man now hurtled towards the bulkhead, stopping himself on a work surface, pulling his IV line out as he did so. This angered him greatly, and clearly it was my fault so he began swearing at me and saying how I wasn’t fit to do the job etc etc. We had to stop the ambulance, causing traffic chaos, to re-restrain him on the stretcher.There was no way I was going back near him with a needle, so I offered him some gas and air for the pain, which he accepted….

 

…for 3 minutes before throwing the mouthpiece at me and calling me a smug c*nt. The Police officer all the while provided suitable dissuasion from him trying anything. I was glad of the PC’s presence!

This pattern of threatening violence, kicking equipment and behaving like a general tit continued for the long 20 minute drive to A&E. It was one of the most stressful journeys I’ve ever had while attending a patient in an ambulance, and I’ve dealt with some stuff in my time! During the whole trip, I had to keep an eye on the wound to make sure it didn’t start bleeding through the dressing, I had to check that it wasn’t so tight it was cutting circulation off to his hand and somehow get some vital signs. He declined any vital signs and wouldn’t let me near him. All I could do was document it and make sure the built-in CCTV was functioning.

We handed him over to the A&E nurse with an apology, as they’d have to deal with his very unpleasant manner. I feel I should add that he hadn’t lost enough blood to cause severe agitation like that, he was just drunk, high and angry.

Afterwards, I was washed out and a bit teary. It’s very hard to provide life saving treatment to someone, only for them to call you a c*nt 27 times and throw things at you. I can scarcely believe there are people like that out there. But there are, and I’m sure I’ll meet many more during my career.

 

So, I guess….don’t do drugs. Or punch windows. Or be a prick to people who save your life šŸ™‚

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Green cross code

The morning had been a busy one.

We’d attended a lady who’d fallen out of bed, was uninjured so we helped her up, checked her over and left her to her breakfast, we’d taken a 57 year old man with chest pain to hospital with a possible heart attack, and rushed a 60 year old man to hospital who was having a bleed on the brain – what we like to call ‘big sick’! 

We were almost back to our station for a much needed restock and cup of tea when we received another call. 

It came through as a road name in the next city. No house number, just a road name. Usually that means someone has fallen in the street, or there’s been a car crash. 

We received a message which said: “14 year old hit by car – unconscious, massive head injury”

Shit! Pedal to the floor and off we go. My colleague driving as I don my hi-vis jacket and think about how I might treat the patient depending on what we’re presented with. 

We receive another message:

“Ambulanc officer is on scene, he states the patient is GCS5 (which means barely conscious!) and has requested priority 1 backup and the air ambulance as a priority.”

Double shit!

We arrive shortly after to exactly the sort of thing you’d expect to see at an incident like this. An ambulance officer’s car straddling the road, a pickup truck parked awkwardly at the curb, a man sat beside it in tears while members of the public console him, a police car screeching to a halt to block traffic and a lifeless child led in the road with a stream of blood trickling down the Tarmac, our officer colleague at her side rapidly assessing her. 

The clinical handover was brief, it didn’t need to be complicated, we could all see what had happened and all knew what we needed to do. 

Her level of consciousness raised after some oxygen. She was in pain and distressed. 

“Quick ABC; airway clear. Breathing adequately and chest clear on auscultation, radial pulses present, she’s tachycardic (fast heart rate) and pale. Let’s get some IV access and get her off the floor.” 

Another paramedic arrives in a car to assist. I look up and see several more police cars now on scene interviewing witnesses. The patient’s mum arrives in a frenzy! Now we have 2 to look after, the paramedic who’d just arrived set to reassuring mum that we were working hard to save her daughter.

With some volunteers holding up a blanket to make a screen for some dignity, we cut her clothes off to assess her fully. She had a large head wound that we had pressure on, a presumed neck injury, large abrasions on her back and shoulders where she’d rolled down the road like a rag doll. She had wounds to her lower legs but as far as we could tell, no broken bones. We gave her some pain relief, a drip, some anti-sickness medicine as she’d vomited profusely (another concerning sign of head/brain injury). She was a little more ‘with it’ now. The helicopter had landed at a nearby school as the road was too narrow for them to safely land. A police car sped off to collect them. A HEMS paramedic and critical care paramedic arrived just as a critical care doctor arrived by road from another base. We told the story and it was agreed we would take her by road to the nearest children’s major trauma centre under blue lights with the doctor on board. 

We scooped her off the floor and onto our stretcher ready to load onto the ambulance. Another quick ABC check and we were ready to leave. The helicopter left having offered their opinions and assistance and we prepared to leave he scene. 

It was around 40 minutes to the trauma unit, with my crew mate driving and me in the back with the doctor and patient. She was fully immobilised and calmed by the pain killers we’d given via the IV. She vomited twice en-route meaning we had to roll her on the spinal stretcher she was on. Not easy with just two of you while doing 70mph through city streets, but this is the career I chose! 

We arrived to a resus room full of doctors, nurses, surgeons, orthopods, paediatric specialists and porters, around 18 people who would now take over her care. 

There was silence as the critical care doctor gave his handover. As soon as he’d finished, the trauma lead set everyone to work. 

Each was allocated a task from airway and breathing to assessing neurological function of her feet. Every inch rapidly assessed for defecit before whisking her away for a CT scan to see what was happening under the skin level.
Absolutely exhausting and emotionally draining, as dealing with children often can be. The police had driven mum to hospital, leaving us space to work in the back of our cramped ambulance. 

Hoping for a good outcome for her thanks to our interventions, we’ll probably never find out though. 

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Ambulance Crew – A Basic Survival Guide

So, you’re thinking of joining the Ambulance Service. Have a seat, make a cuppa,Ā and I’ll tell you what you need to know to survive being an Ambulance Person.

One of the most important things to realise about working for the Ambulance Service, is that it’sĀ not all blood and guts. In fact, it’s been quite a while since I’ve seen any guts, or brains, or body parts that should be inside the body. A large amount of our work is medical complaints; chest pain; shortness of breath; abdominal pain; strokes; headaches etc. There’s also a very large portion of mental health and social concern cases. Because of that, you need my number one rule:

  • Be able to talk toĀ anyone.

I once heard a Paramedic of 30 years say he could talk to anyone with an asshole. I thought he was joking, but actually, this is a skill you need to have. As you become more experienced and knowledgable, you’ll be able to talk about more specialist medical things, but first, being able to talk and not being scared of you own shadow is a good start. This brings me to point number two.

  • TrustĀ in your training.

You’ll turn up to your first emergency call wearing the uniform of thousands before you and be expected to know what you are doing. Have faith, you won’t be on your own (hopefully) and your basic training will kick in, no matter what the call is. For a newbie, it’s all about A B C and not doing any harm. Increased skills and knowledge will come along in time. You won’t be expected to attend (by which I mean sit in the back of the ambulance and treat on the way to hospital) a very unwell patient, so you’ll be driving the truck more than your crew mate, and so:

  • ALWAYS drive to the condition of your patient.

During your driver training, you’re taught to drive as fast as it is safe to go. In reality, when driving a 6 tonne ambulance through narrow city streets with a seriously unwell patient in the back, speed is the last thing you want. Smoothness is the key! I learnt that very early on after a bollocking from my crew mate who nearly fell to the floor while treating an unwell child in the back of the ambulance while I drove on blues to the hospital. These vehicles do not handle well, they wallow around every corner and feel every bump! You’ll be thankful of this advice when the time comes for your crew mate to driveĀ you to A&E with a patient in the back.

  • Support your crew mate

You’re with them for 12 hours (or likely more) a day in a very small space, during sometimes some very emotionally charged scenes. Unless the clinical decision is dangerous, always support your crew mate. It looks unprofessional to argue on scene and will create a difficult working environment for the two of you. You can always talk it out after you’ve dropped the patient off at A&E. I’ve done shifts with people I really haven’t liked, I’m talking about proper dicks, but when it came to the clinical stuff, you need to work together, especially when time is critical. Which brings me to point 5:

  • Don’t panic!

It will be tempting. You’ll have to stop and take a few deep breaths, you’re ears will be ringing and your vision narrows, you’ll feel your own heart punching you in the chest, your legs will feel weak and your brain will be moving so fast you’ll forget your own name. This will happen the first time you come across something serious like a horrific car crash. And subsequent times after that. Don’t worry about it, but don’t let it affect your care. Even the most experienced medics have that surge of adrenaline during incidents like this. The key is to take your time with things: like a swan – calm and smooth above water, but underneath paddling like fuck!! Your colleagues will be excellent and you’ll fit into the team. You’ll either know what to do, or be told what to do – both are absolutely fine.

  • You’ll have memories, good and bad

No need to elaborate too much here. You’ll see some of the funniest, strangest and most heartwarming things doing this job. You’ll also see things that will steal sleep from you, give you flashbacks and haunt you. You need to be ready for that. Take comfort in the fact that you won’t be alone, and there are support networks in place.

 

 

This list isn’t exhaustive, there are hundreds of survival tips I could throw at you, but that would make a very long post indeed.

Now probably the most important rule of all:

  • Never, I meanĀ NEVER pass up the opportunity to go to the toilet. You might not see another one for 8 hours! (That ‘drive to the patient’s condition’ rule will soon go out the window when driving to hospital with a bladder the size of a small continent fit to burst!!)

This really is the best job in the world. The government won’t ever appreciate what we do, senior managers will alter your terms to make 12 hours seem harder and harder in the name of ‘efficiency’. You’ll miss your family and friends, spend Christmas Day in the houses of strangers and your body clock won’t know what hour of the day it is. But really, this job is like no other – you’re trusted with people’s lives, you offer relief to those who are anxious and ease the pain of those in need.

It’s not for everyone, but if you can stomach it, do it!

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Terrified Out of Hours Service

If you need the Police in an emergency, you call 999. If you need to contact the Police for any other business that isn’t life threatening or dangerous, you can call 101.

Similarly, if you need an Ambulance for a medical life or death emergency, you call 999. If you need non-urgent medical advice, you can call 111.

111 is a private contract that is split into dozens of sectors across the county. So the company that answers a 111 call in Devon will be a different company from the one that answers a call in Birmingham.

The tag line for 111 is that you can ring for medical advice……but we few in the Ambulance Service no this is rubbish!

We know this because we have attended people’s addresses, using blue lights and sirens to get there, when they have rang 111 to ask some advice about medication and they have triaged it as appropriate for an ambulance!

Let me explain. When you call the Ambulance Service on 999, you get through to a non-clinical call taker called an Emergency Medical Dispatcher. There medical knowledge is no better than that of a good first aider, but they use a robust triaging system to quickly and effectively decide if the call is immediately life threatening, or can be given a lower priority in order to allow precious ambulance resources to attend the most serious calls first (if you’ve read my blog, you’ll know that peopleĀ do ring 999 for very un-serious things!).

When you ring 111, you get through to a non-clinical call taker who has in front of them, a screen with a series of questions to ask, your answers to these questions determine what the recommended care pathway is; self care, telephone call with a Nurse, visit and out of hours Doctor, or they can dispatch an ambulance. You don’t get advice when you ring 111, you getĀ triaged!

I should note here, that sometimes, people ring 111 when 999 would have been entirely appropriate – I’ve attended 111 calls where the patient is barely breathing, where a child has a broken leg and a man was having a massive heart attack! My ‘beef’ is when 111 send us to calls that we don’t need to be at:

An elderly man had been suffering a nasty cough for 3 days, his wife thought he had a chest infection, so, one Sunday morning, she rang 111 to speak to a Doctor about getting some antibiotics. She was bombarded with dozens of questions about everything from whether his was bleeding from his anus or if he’d travelled to Africa and may have contracted Ebola. Eventually, 111 told her they would send an Ambulance. This terrified this poor old lady, she thought her husband only had a chest infection, but in fact, he must be seriously ill if they’re sending a blue light ambulance!

-We get the call “85 year old male, Chest Pain and Short of Breath” it’s coded as a Red 2, which is the code for the life threatening calls. So, we do our thing – blue lights, sirens and radio coms – arrive at the address to find our gentleman in bed most definitely not short of breath and notĀ complaining of any chest pain at allĀ .

We get told the story by his wife, and to my ears, it sounds like he has a chest infection and needs to speak to a Doctor about getting some antibiotics. We give him a thorough check over with all the tests to rule out a heart attack, severe infection/blood poisoning, shock or other concerning stuff and it was all fine. So we rang the out of hours Doctors (we have a special number that we can use to directly request a Doctor) to arrange for a home visit.

Time taken for us to drive to the address, assess the patient, complete the paperwork and wait for a callback from a Doctor: 55 minutes.

Time speaking with a Doctor (who agreed with my medical impression): 4 minutes.

That was an hour that an emergency ambulance was unavailable because somehow, that man’s chest infection triaged as an immediate life threat.

This isn’t an isolated incident, sadly. Here’s a list of calls that I’ve been sent on where people have rang 111 and unexpectedly ended up with a blue light ambulance. Ready?

  • Lady wanting to know if she can take Aspirin for a headache
  • Man who hurt his hand three weeks ago and wanted some pain relief
  • Lady with a painful elbow (we were told she was having a stroke)
  • Man who’s back was sore after bending to pick up some laundry (came to us as chest pain)
  • Baby who had a cough and parents wanted some advice
  • Earache

And the absolutely pinnacle in my extensive experience of inappropriate calls:

41 year old man who rang 111 in the middle of the night to see if there was a late night pharmacy anywhere where he could buy some cough syrup. For his cough. This coded as a Red 2 for Chest Pain.

Every single one of those was appropriate for 111. These people did exactly what they should have done, and yet, they each ended up with an ambulance being sent to their houses with blue lights flashing. I didn’t need to take any of these people to hospital,but if you look, that’s at least 7 hours of my time taken up with nonsense. 7 hours during which time someone may be having a stroke, someone may have fallen down the stairs and been found unconscious, there may have been a serious car crash where someone is trapped, someone’s baby may have stopped breathing.

All we can do is report it back, but bare in mind, if you ring the out of hours provider in your area, it may be more than advice that you get!

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