Tag Archives: Casualty

Critical Haemorrhage

I’ve mentioned before that our ‘Primary Survey’ (i.e your initial assessment of a patient to decide if there’s anything immediately life threatening that needs correcting) differs from that of a first aider, who’s primary survey will be:

D – Danger

R – Response

A- Airway

B – Breathing

and maybe C – Circulation

Our primary survey is:

D – Danger

C – Catastrophic Haemorrhage

R – Response

A – Airway

c (deliberately small) – Cervical Spine injury

B – Breathing

C – Circulation

D – Disability or Neurological signs

E – Everything else

F – Family/Friends for history taking

G – Glucose levels.

So, as you’d expect, it’s a bit different.

When it comes to managing Catastrophic/Critical Haemorrhage (by which I mean an arterial bleed which will bleed a patient dry in mere moments), we don’t piss around. As you can see, we control Catastrophic Bleeding before we even try to get a response from our patient, let alone try managing an airway etc etc.

Most if not all of our critical haemorrhage kits have been developed by the Military. Their ‘bread & butter’ work is dealing with traumatic amputations and massive trauma to the abdomen and chest.

They’ve developed very efficient tourniquets and dressings known as ‘blast dressings’, or to give them their proper name, ‘haemostatic dressings’. These have a chemical in them which promotes clotting to stop bleeding quickly. These dressings are idiot proof, very large and very expensive. They save lives.

I’ve never been unfortunate enough to have to apply a tourniquet, though my regular crew mate was – he was sent to a lady who was trapped under the wheel of a bus!

I have, however, applied a blast dressing to a lady with a catastrophic bleed from the chest. It works very well indeed.

We have a special bag which is a cool, special op’s style black bag with red writing which says ‘Critical Haemorrhage Kit, Trained Personnel Only”. In there we carry tourniquets, various sized blast dressings and haemostatatic gauze.

On my last day shift, we answered a 999 call for a man who’d cut himself shaving, so the bag was left on the Ambulance that day……*sigh*.

Needless to say, we recommended some basic first aid and left him to it. Another life saved 🙂

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Apologies

“Well, well, well”

I hear you say.

“It’s that bloody Ambulance bloke. I remember he used to write regular updates on his day-to-day life on a frontline Ambulance. I’d almost forgotten he existed.”

AHA! I have returned with an apology. It’s been a very long time since my last post but life has been very busy!

I went and got myself married, started my final section of studying for my degree in Paramedic Sciences and re-joined a band I was in many many years ago. I know it doesn’t sound that busy, but trust me, it is!

Anyway straight back into it, eh?!

On the subject of apologies, I did start a post I never finished which was along the lines of this:

On the ambulance, we carry a fairly limited range of pain relief, from Paracetamol tablets, to strong IV Morphine with basically only Entonox (gas & air) in between.

To enable us to give the strong pain relief, we need to get IV access with a cannula. This gives us access directly to a patient’s veins to give morphine or paracetamol in the form of a drip. But what if we can’t get access?

I was working in the city with a different crew mate. As soon as we booked onto the vehicles, the radio goes off:

“Morning chaps, sorry to be so prompt this morning. We have an outstanding call for a concern for welfare.”

“Roger, all received, on our way.”

On go the blue lights, no need for sirens at 0630, there’s no traffic about.

We quickly arrived to find a gathering of people, most in dressing gowns but all with bed hair!

It turns out the neighbour had got up for work and head shouting from the elderly lady next door. He went round but couldn’t get. He heard her shout that she was on the floor so called 999. They had also called the lady’s daughter who had a spare key.

We shouted through the letterbox to reassure her we were there and within a short time, her daughter arrived.

She unlocked the door and we walked in. It wasn’t pretty. The poor lady (who slept downstairs) had got up in the night and fallen forwards. She had scuffed her face down the wall as she fell. She’d landed face down and was unable to get up our to pain in her hip as well as general poor mobility and low strength. And there she stayed, for almost 4 hours until her neighbour heard her calling out for help.

We set to work. Quick ABC assessment revealed nothing immediately life threatening. Then we were concerned about a possible next injury as she’d hit her head. She had no central neck pain reducing the likelihood of a broken neck. We then assessed all the bones top-to-toe.

“Surely, just help the poor lady up” I hear you say. It’s certainly what we hear a lot, but if she’s broken a leg and can’t feel any pain due to nerve damage, then the bone pokes through the skin as we move her, that could prove fatal. So we methodically check top-to-toe.

Her injuries were some nasty facial skin tears, a laceration to her shoulder, a broken left wrist and a probable broken left hip. Unsurprisingly, she was in a lot of pain. We knew that before we moved her, we needed to try to get her pain under control. The best way to do so was with IV drugs.

This is where we got into trouble. My crew mate tried several times to get access, but her veins were so small that he couldn’t find one, when he did find one they just collapsed as soon as he touched them with the needle. While he attempted that, I made a plan to get us out of the house. It involved a second crew and moving most of the furniture into the garden. The plan would be to scoop her, carry her back into her bedroom, onto a vacuum mattress – which has hundreds of polystyrene balls in and we suck the air out of it to cocoon the person safely in – carry her through the house, up the front steps and to the stretcher on the pavement.

But, try and try as well did (the 4 of us) we couldn’t get any IV access. We decided to give her Oramorph (morphine drink) but it’s not as fast acting. We had to roll her onto her back before we could do anything.

We knew it would hurt, and so did she. When she was ready, and as quickly and smoothly as possible, we rolled her. She screamed and all we could to was apologise.

We were sorry that this had happened to her. We were sorry that nobody heard her shouting for 4 hours, we were sorry we couldn’t get into the house for a while and we were sorry we couldn’t get her pain under control before we moved her.

The rest of the plan worked like a dream. We dressed her wounds and drove her to A&E with the daughter.

My crew mate and I spoke about the job afterwards and both agreed that it is horrible when you can’t do what you think is best for a patient. It’s our job to ease pain, but when you can’t do that, you feel a little bit worthless. It may sound silly to you, but it’s true.

We returned to A&E an hour later with another patient and asked how she was doing. An x-ray confirmed a broken wrist and broken hip, but she was comfortable. We popped our head round the curtain and she was led there smiling. “Thank you both so much for helping me” she said.

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Concern for Welfare

*Radio buzzes*

“Go ahead. Over”

“Thanks guys, received your clear status at Hospital. Further emergency call for you in the city; caller states he’s concerned for the welfare of his neighbour as there is no answer at his door. All other details unknown. Over.”

“Roger, all received, on our way. Over”

“Thank you, 21:15, red base out.”

This type of call is quite common. Either a ‘care line’ company will receive an alert as someone has pressed their care pendant but not answered the phone, or a concerned neighbour is unable to get an answer from the door so calls us or the Police to check on them.

There are usually 3 outcomes:

1) They are absolutely fine and probably pressed their pendant accidentally and are quite surprised to see us, or simply didn’t hear the neighbour knocking.

2) They have fallen on the floor or are unwell in someway and very relieved to see us and so were unable to answer the phone or the door and are very relieved to see us.

3) They have died and that’s why there was no answer and we are shocked and saddened to find them.

We didn’t know the details of this call until we pulled up to a small lane, down which we could not fit our ambulance. We were met by a man in his 80’s who was the person whom had called 999.

He explained that “Mr Smith (name changed for confidentiality) always puts his recycling out on a Tuesday afternoon, but this time he hasn’t done it. I tried phoning him and knocking on all of his doors and windows but there’s no answer, so I called you.”

Seems fair enough to me.

“Is it possible he’s gone on holiday?” I ask as we walk down the lane to his bungalow.

“He’s a similar age to me and hasn’t been away for over 40 years!” He replies.

As we approach the bungalow, which is all in darkness, I shoot my crew mate a look that she mirrors. We know that this will either be option 2 or 3 of the above.

We also knock firmly on the front door but there is no answer. There is a key safe outside the porch but our control doesn’t have the code, neither dose the Police control room and neither does the neighbour.

I walk around the perimeter to see if there is a back door or an open window I can squeeze through as my crew mate requests Police attendance to gain access to the property by force.

All the windows are closed and back door is locked shut with security bars.

We decide to send the neighbour home, promising that we will update him as to what the outcome is. We say it is because he can go and have a cup of tea and watch some TV in comfort, when in actual fact, if this man is dead and has been dead some time, we don’t want him to see it.

We wait a little while for the Police, it’s a lower priority call for them and we know it so we don’t mind. All the while we shine our torches around to find a way in.

The Police finally arrive and we fill them in to what’s happened. The too knock on the door and every window. I show one of them around the house to make sure that there is no other way in.

The Police need to justify breaking someone’s door in and also need to do it in a way that is cheap to repair.

Using what they call ‘the big red key’ (see picture):

Enforcer

One of the officers takes a few hard hits at the door. Then we are all pretty bloody startled by what happens next…

“WHAT THE HELL ARE YOU DOING?!” Comes a shout from INSIDE the house!!

We all look at each other, not sure what to say.

“Uuuh, it’s the Police” one officer tries to explain.

“Why are you banging down my door?” He retorts.

“Your neighbour called 999 as he was worried you didn’t answer your door. We’ve been knocking on your door for nearly an hour” I say to try to reassure him. It doesn’t work.

“How do I know you’re not burglars?” Fair point, we all think.

The WPC offers her Police Warrant card through the letter box. He agrees that she is indeed who she says she is and tries to unlock the door. The trouble is, giving an old lock a solid hit with a battering ram throws the lock out of joint, meaning that the poor bloke can’t unlock the door!

“I can’t get out, I shall die in here!” He shouts.

“This is turning into a bloody nightmare” I think to myself. We persuade him to pass his key through the letter box, promising to give it back, to unlock it from the outside.

We unlock and open the door and find the greyest most terrified man I’ve ever seen. He is most surprised to see 2 Ambulance Staff and 2 Police officers stood at his door. Truth be told, we’re most surprised to see him alive! Ever the optimists we are!

It takes us almost 20 minutes to convince him we definitely are who we say we are, and to calm him down. Then he pulls out a notebook and reads this.

“At 21:10 someone rang my doorbell, then knocked on the door and windows (the neighbour). Then 10 minutes later someone did it again, flashing a torch through all my windows (me). For 30 minutes someone knocked on the windows all around my house and shouted something through the letterbox. Then you stated bashing my door in!”

The Police officer says “With all due respect, why didn’t you just answer the door in the first place?”

“I thought it was a burglar.” He replies.

“Your neighbour was worried because you didn’t put your bins out this evening.”

“Bloody hell, he doesn’t know everything! I didn’t put them out because the foxes get to them!”

“That’s fair enough, why don’t you give us the code to your key safe to avoid something like this every happening again?”

“Well, errrm, no I’d rather not”

We tried to convince him that if Police and Ambulance control know what the code is, we can access his property if he’s unwell, but he didn’t want us to have it.

The Police made sure that he could secure his property, and we dutifully informed his neighbour that he was fine, explaining about the foxes.

We shared a laugh with the Police about how ludicrous the whole situation was.

My crew mates final words were : “You couldn’t write this stuff!”

‘I bloody well will’, I thought 🙂

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Broken Leg

Not having had any seriously interesting or ‘out of the ordinary’ shouts for a couple of weeks, I thought I’d write about a routine job that I recently attended.

We were on station when we received a radio transmission from our dispatching instructing us to respond to a Priority 2 backup request for a Rapid Response Vehicle (RRV) Paramedic on scene with an elderly lady who had fallen.

There’s 4 levels of backup that a RRV can request:

P1 – This is for a truly life threatening event. For example, a patient who has stopped breathing, having a stroke, heart attack or is so unwell that they will soon stop breathing. It’s also to be used for life threatening injuries, for example a traumatic amputation with catastrophic haemorrhage or a fall from a hight with massive head trauma. The reason this is only to be used for these types of events, is because no crew will be diverted from this priority backup to another call. We would, in theory, drive past an unconscious patient to arrive at a call this highly prioritised. Respond using blue lights and sirens, of course.

P2 – Not immediately life threatening, but could become so if the patient does not arrive in hospital soon. This could be used for chest pain with no ECG changes, pain that cannot easily be managed with morphine, broken limbs with deformity but no circulatory compromise or non-life threatening incidents where a patient is outside or in the public eye. Also respond using lights and sirens.

P3 – Non-life threatening cases where the patient needs admission to hospital urgently, but not immediately. This could also be used for stable limb fractures, falls where the patient is un-injured but is too heavy to lift with one person and they need assistance from the crew, or abdominal pain with no ‘red flags’. Respond at normal road speed with no lights or sirens.

P4 – Routine admission for a medical case. This is the only priority where an RRV would arrive, assess the patient, request backup and then leave the patient in their house to wait for the crew. The patient must be safe, able to walk or have someone to assist them to walk and not be likely to deteriorate. This is also normal road speed with no lights or sirens.

So, P2 backup to the city for a fall. That’s the only information we ever get. So, blue lights and sirens on and off we roll.

We arrive to find the RRV Paramedic at the top of the stairs with a fairly large lady who had fallen while walking out of the bathroom. She was sat on a small landing holding on to the hand rail, sat on one leg. As we arrived, he was giving her a drug to stop her being sick. He gave a quick history of the event, and told us he suspected a broken hip. So, we worked on a plan to get her up.

We would give her some Morphine for the inevitable pain when moving her then lift her onto a carry chair to carry her down the stairs. We dosed her up and got ready to move.

As I mentioned, she was quite large. And heavy. And old ladies have a lot of soft tissue and not a lot of muscle, meaning she had little strength and we had nothing to really get a hold of. She was sat on a small square landing, I was stood behind her in the bathroom, my crew mate was in front of her on the stairs, 2 or 3 steps down, and the RRV was to her side on the landing.

“On lift? Ready, set, LIFT….hmmmph, arrrrgh, heeeaaaa, oooommph. Lower, lower, LOWER!” Came the cries from all three of us in synch.

Plan a) had failed. If anything, we had moved her nearer to the edge of the stairs and we were all now in a rather precarious position.

I had the idea of using a special inflatable cushion called a Mangar Elk, to raise her to the hight of our carry chair that was with me in the Bathroom, then slide her backwards onto it.

Like this

Like this, but nobody is ever that smiley.

We had encountered a small problem though; after moving her to her new position, we noted the leg she was sat on was grossly swollen at the mid-shaft femur. We had a new diagnosis of a broken leg with a possible hip fracture as well. This meant that one of us would have to manually stabilise the leg before we moved her again.

So, we slid the cushion under her bum (no mean feat, let me tell you!) then began to inflate it. As we did so, she slid further towards the stairs!!!

Between the three of us (two of us really as my crew mate held her leg straight), we somehow slid her onto the carry chair. All three of us took the opportunity to stretch our aching backs before we carried her down the stairs. So narrow were the stairs that only two of us could use our chair.

Comfy, eh? No.

Comfy, eh? No.

So, we heaved and struggled with our lady, all the while, not letting the strain show on our faces so as not to worry the patient or her family – though the red faces and beads of sweat probably gave it away.

In the end, we carried her down the stairs, down the other stairs out the front door and wheeled her to the ambulance. Then one final lift onto the stretcher and that was that.

Hot, sweaty and aching we had done the job. Thanks to the Morphine the patient had hardly felt a thing. We gave her a little more pain relief  before the bumpy drive to hospital and set off to A&E.

Handover to the A&E Nurse, slide patient to hospital bed, clean stretcher and replace linen, clean all reusable equipment, make a list of kit used to replace, wash hands, make cup of tea and make yourself available for another emergency – all in 15 minutes to keep the government happy.

That is a typical job. Heavy lifting, frequent patient reassessment, quick thinking and a well earned brew.

We actually received a thank you letter from the patient’s family for taking such good care of their mum and being so kind to her. It’s always nice to receive a thank you for the job we do, especially when it really is hard graft 🙂

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Heroin Overdose

Much to my Mum’s delight (not!!), we often attend patients who have overdosed on one kind of drug or another. Sometimes accidentally – as in the case of a diabetic lady who mis-read her insulin packaging meaning she’d taken too much., potentially life threatening if left untreated for ay length of time – but mostly intentional.

Many people take overdoses as a cry for help, others as they genuinely want to end their lives. People overdose on a range of drugs: antidepressants, pain killers, sleeping tablets, herbal remedies and once on eucalyptus oil (particularly dangerous believe it or not).

Heroin overdoses (generally) fall into the accidental category.

Heroin is an Opiate based drug and its affect, aside from the ‘high’, is respiratory depression. If one has too much of any opiate, one will eventually stop breathing. If they stop breathing but still have a pulse it’s called ‘respiratory arrest’, if not rapidly and aggressively treated, their heart will stop and they will be in ‘cardiac arrest’.

Today, while in a public toilet in the city, one young man had apparently taken a quantity of heroin. A member of the public was rather surprised to see a man flaked out in a cubicle, quite blue in colour through lack of oxygen, so called 999. Quite right, too!

We arrived within a minute or so (we were really close by) to find him half propped up against the wall unconscious. My regular crew mate and I have a young student paramedic out on placement at the moment and we let him take the lead for a moment.

Our ‘Primary Survey’ is as follows:

D – Danger

C – Catastrophic Haemorrhage

R – Response

A – Airway

c – C-spine protection

B – Breathing

C – Circulation

D – Disability

E – Expose and Examine / Environmental Factors

A little different from DR.ABC taught in First Aid.

There was danger present in the form of used hyperdermic needles, we all spotted them and were careful not to kneel on them (that’s the bit my Mum’s going to hate!). There was no Haemorrhage at all, let alone a Catastrophic one, so the he moved on in his primary survey.

The next bit is ‘Response’. A patient is either fully alert, responsive to voice, responsive to painful stimuli or unresponsive (AVPU). Now, our student is was a little delicate with this bit and his painful stimuli weren’t quite enough to cut through this man’s heroin haze.

Now, you’ll remember I said that we aggressively treat respiratory/cardiac arrest, to prevent death…so, as he was seemingly unresponsive, I grabbed his legs and slid him along the toilet floor to lay him flat with a view to commencing advanced life support. Well, he woke up! He work up and was most annoyed to have been dragged flat onto his back and was rather annoyed that we ruined his high!

He spoke to us clearly enough but was obviously under the influence of something as he was slurring and was wobbling all over the place. He denied the use of anything other than alcohol and asked us politely to leave, which, once we were happy he could walk, we did.

We stood down the Police and the Ambulance Officer that was on his way and cleared from the scene.

Thankfully, this is a fairly rare occurrence, but, does happen. If he wasn’t breathing, we carry a very clever drug which reverses the opiate affects on the respiratory system and brings them ‘back to life’.

Our student learnt not to be so delicate with his primary survey, and I learnt to have a quick check myself before flattening some poor unsuspecting soul to the floor.

Everyday’s a school day!

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ANOTHER public arrest.

Very much on the theme of my post last month, we were sent to another public cardiac arrest.

My crew mate, myself and a University Student on placement had just discharged a patient on scene; a baby who had diarrhoea the day before and her dad called 111. 111 had decided that this was immediately life threatening and actually passed the job to us a an ‘Unresponsive Baby’, which we were very glad to discover she was not.

I digress. We made ourselves available and immediately received details of an emergency in the city about 7 miles away. We were told that an elderly male had collapsed in the street and wasn’t breathing.  This is normally a 20 minute drive with traffic but I got there in 9.

We arrived to find a Rapid Response Vehicle (RRV) Paramedic doing chest compressions and one of our Officers who had also been dispatched, breathing for a patient with a Bag Valve Mask (BVM).

Between the three of us, we had already decided what our plan would be. My crew mate would jump out and help with advanced skills such as IV access or advanced airway management, the Student would take over chest compressions (because he is not allowed to perform any other skills yet, and it’s good experience to do so when the opportunity presents) and I would manage getting the patient off of the pavement and into the relative privacy of our ambulance.

I overheard that they had already delivered 2 defibrillator shocks prior to our arrival, and as I prepared our scoop stretcher, they delivered a third. Between myself and one other, we ‘scooped’ the man onto our stretcher and, while the student continued CPR, wheeled him into the ambulance.

There were Police on scene as well, who had been very proactive and closed the busy road. I was blocking it with my ambulance anyway. Sometimes that’s the only option.

A 4th shock was delivered in the back of the ambulance. For the 4th time, we had been unsuccessful in restarting his heart. But the battle continued.

We were informed that the Air Ambulance had landed in a nearby field and we were to drive round to meet them. I jumped in the front, and with the Police stopping traffic, made my way the half mile or so the the helicopter, where we were met by a Critical Care Doctor and a Critical Care Paramedic.

After a further 25 minutes of quick thinking and hard work, the man regained his pulse – something we call ROSC (Return Of Spontaneous Circulation), however, his heart rhythm was one which would not sustain life and another shock was given to ‘revert’ it back to a normal sinus rhythm. The Doctor, with agreement from all those involved, decided the ‘likely‘ cause – we never really know in these situations – was a Heart Attack which had caused the Cardiac Arrest. There is a specialist hospital that deals with this sort of emergency and it was decided that as the man was too unstable to fly, we would travel by road to this hospital in the next major city.

When everyone was ready, I began the 30 minute blue light drive. It’s a funny feeling up there in the cab on your own. You have a huge responsibility to deliver precious cargo there safely but quickly. The drive must be progressive but smooth. You need to look far into the distance to pick a route through traffic that will cause the least amount of movement in the back of the ambulance and have a 360 degree awareness. It is knackering!

30 minutes later, we arrived and I opened the back doors to lower the tail lift to unload the patient. I’m met by the Doctor who said “that was superb!” High praise indeed! I thanked him and continued to assist with unloading. The patient had maintained ROSC and was making respiratory effort but was unconscious and still very unwell.

We wheeled him in to the resus’ bay and the Doctor handed over to the lead hospital clinician where they set to work attaching leads, taking blood, checking the airway, listening to his chest, arranging scans and a host of other things.

We then were left with the mammoth job of clearing up.

He was alone shopping when he collapsed, but the Officer and I had found his wallet and ID so had his name and address, he also had his next of kin details which we passed to the Police.

I have no idea what happened to the man after we left, but I do hope he survived. If it was not to be, I hope his family were able to come and be by his side before he passed away. Either way, he had been given every chance of survival.

When reflecting on the job, I realised that was the first Cardiac Arrest I had attended where I had not done a single chest compression! Many hands and all that.

The following day, I attended an incident in Bath with my other Crew mate. I don’t like putting city names in my posts but this is important.

We were first on scene at a horrendous incident that made national news on the 9th February 2015 where 4 people were killed in a dreadful accident. I just want you to know that yes, I was there. Yes, it was horrific. And no, I will never be posting it on here.  My trust has been superb in supporting all ambulance staff involved and I have had lots of support from colleagues, friends and of course my beautiful fiancé.

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