Tag Archives: Death

Spice is the spice of life…ish

‘Legal highs’ are becoming a bit of a concern in healthcare circles. They are becoming more and more prevalent, especially among younger children of school/collage age!

For those that don’t know what a legal high is, it is the broad term for a range of drugs that are available legally to purchase over the internet. They pose as a plant fertiliser or similar, and are usually in powder form. They are given unusual names such as ‘whizz’ or ‘spice’, the latter being more popular. Spice is a cannabis derivative mixed with a cocktail of unknown chemicals to bulk it out. It can be smoked with tobacco or sniffed like cocaine.

The trouble with spice is, it kills people. Kills them. It produces a fierce chemical reaction with the bodies own enzymes which increases heart rate, reduces oxygen to the brain which causes respiratory failure, coma and eventually death. But not before a period of psychosis, profuse vomiting, disorientation and symptoms of a heart attack.

Delightful, where can I get some?!

Well, it seems that if you want some spice, all you need to is end up in prison. It is rife!

Cue a flashback to a recent call in the middle of the day to a Category C prison (which is for those who cannot be trusted in an open space) for a 30 year old man who was found unconscious in his cell. He was witnessed to be fitting so the prison nurse was alerted who came and treated him while we were on the way.

Despite there being no packaging for Spice anywhere, the presentation of the man was very similar to someone who had taken it.

When we arrived, we had to pass through 4 double locked gates like a safari park before being signed in to the log in triplicate, then finally being taken to the cell block. After that, we had to grab all our equipment then be escorted into the cell block.

I don’t really get nervous easily with my surroundings. I’m always aware of any danger, but very rarely get scared. I’ve been to drug dens and large fights in small rooms and always managed quite well, but for some reason, I was cacking myself!

As we walked in, every inmate stopped what they were doing and looked at us. The high walls and railings and narrow corridors made it a rather intimidating place to be.

We were shown to the cell to find a male on the floor looking pretty sick. He had a reduced level of consciousness, a racing heart and his colour was pretty poor. We were on the first floor so I needed to get a carry chair, which meant I had to go back to the ambulance and get one! This meant walking along a gangway and down some stairs to the door. Seems simple enough, but I’ve never felt like more of an outsider. Guys stood in the doors of their cells just stared at me as a walked by, people in the gangway didn’t give me much space to pass them and I didn’t really fancy making eye contact.

Anyway, my concerns aside, in the time it had taken me to get the chair and return, my crew mate had got some oxygen on him and gained IV access incase we needed to give him any drugs to stop subsequent seizures. We carried him out to the ambulance, lifted him onto the stretcher and connected our monitoring devizes. By now, he was awake enough to talk to us so we asked if he’d taken any drugs. He denied taking anything so we got driving to hospital.

Back through the security gates to the main gate where they had to find two officers who would escort him to hospital. This meant signing them all out, as well as us and handcuffing them all together. This took quite a while considering he was so unwell, but we didn’t argue – we understood.

So, I got driving to the hospital, which was a good 23 miles away. Nice and steady to start with but then I hear some commotion in the back. There’s only a small hatch between the cab and the back of the ambulance so I couldn’t really see what was happening, but with that, my crew mate popped his head through the hatch and said “keep us moving mate”, which is code for “put the lights and sirens on and don’t stop”. So, I blued the 20 minute drive through the traffic of two small towns and a city until we arrived at the hospital.

It wasn’t until after we’d handed him over to the nurses and doctors I found out what had happened to cause such a stir: He blood pressure and heart rate began rapidly dropping to the point where my colleague believed his heart would stop. He was given various drugs to maintaining a level to keep him alive but he was rapidly deteriorating. He may survive, he may have to be sedated and put into intensive care, he may die, I don’t know. But people take these drugs for a quick ‘high’ and end up critically unwell.

Just to show how commonplace this is in prisons, as we were on the way to hospital, I heard a broadcast over the radio for an emergency in the same prison for another inmate who was fitting after taking Spice…

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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 people 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 get 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 not complaining of any chest pain at all .

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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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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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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Straight into the action! *warning, graphic content*

It’s been a long while since my last post, and with good reason – I’ve been on leave.

Normally during leave when I’m not actually going away, I’ll try to squeeze in some overtime around whatever I’m doing in my time off, but this 2 weeks, I did nothing remotely ‘ambulancey’. It was great!

It’s very easy to get wrapped up in this job, even when you’re not sat in your uniform, you may well be thinking about a job or discussing work with a friend. It’s hard to escape but I managed it (all bar a couple of emails to officers about 1 or 2 important things).

So, back to it yesterday. My favourite crew mate (I have to say that as he reads this blog) at my base station – should be a nice way to return after a relaxing break.

Wrong.

First shout was at a Doctor’s Surgery given as “7 year old, unconscious, fitting”. That gets the adrenaline pumping when you’ve had no exposure to emergencies for a while!

This child had stopped fitting in the 3 minutes it took us to get there, and was being seen to by the GP who had given him Oxygen. The child still had a reduced level of consciousness so my crew mate went immediately to get the stretcher from the ambulance. Once aboard, we gave him a thorough check which revealed a very high temperature (of unknown origin), which could’ve brought on the seizure. Either way, he was going to A&E for assessment.

That job was nice and tame compared to the rest of the day.

Next job was a public cardiac arrest. Cardiac Arrests can be (organised) chaos at the best of times and this was no different.

An elderly male walking to a car and collapsed. His heart had stopped and he was not breathing. We arrived in under 5 minutes to find a member of the public performing good quality CPR as instructed by our 999 Emergency Medical Dispatcher over the phone.

Always a tricky situation this. Protocol dictates a certain order of things that need to happen. CPR was initiated and continued by my crew mate while I cut the man’s clothes off to apply the defibrillator pads to his chest. His heart rhythm was Pulseless Electrical Activity (PEA). This means that the electrical component of his heart was working, but the muscle (the bit that physically pumps the blood around) had failed and stopped. This is not a rhythm we can shock back to life.

From here, the airway should be secured and ventilations should begin to breathe for the patient. However, this was a very public arrest so we needed to get him into the ambulance before any of this could really take place – for dignity more than anything. Also as he was wedged between two parked cars, it was not the ideal location to perform Advanced Life Support (ALS).

My crew mate continued CPR and even managed ventilations while I called for Priority backup on the radio for another pair of hands and grabbed the trolley and a special scoop stretcher that splits into two and allows us to literally ‘scoop’ a patient off the floor keeping them flat.

The patient was large. And heavy. This meant that the lift with just the two of us was a challenge. But at times like this, you draw from the adrenaline and get it done.

As we loaded him onto the ambulance, our backup arrived. Out of public view, and with three of us, we could begin ALS. Gaining IV access to give a cocktail of drugs to try to ‘jumpstart’ the heart, while performing CPR. However, we had a pretty big problem. We struggled to secure his airway (by this I mean maintain an open and clear airway so that we can ‘breathe’ for the patient without occlusion from vomit, blood etc).

He was losing large quantities of blood through his airway. Despite using our suction machine to clear it, it just kept pumping out with every compression off the chest. We have various pieces of equipment to try to secure an airway, and none of them were working. We tried everything in our arsenal but this man had a catastrophic internal bleed which made it very difficult.

We were very close to our local A&E, so a very quick phone call to ensure they were ready for us, and we ‘blued’ him in.

It’s the first time I’ve done CPR in the back of a 5 ton ambulance doing 50mph through a city – it’s not easy!

We arrived at A&E in a little under 10 minutes, continuing ALS the whole time, including while walking into the department.

For another 10 or so minutes, the Doctors and Nurses fought to save this man’s life, but sadly nothing further could be done. With every one’s agreement, life support was ceased. The Doctors thanked everyone for our help and thanked us for our hard work leading up to the patient’s delivery to A&E. There’s always a few seconds of quiet after death is declared. I looked at the man’s eyes, now glazed and fixed, and felt a little sad that we had no idea who he was. Later, the nurses found a wallet with his ID, so his family could be notified.

The mess after a cardiac arrest is substantial. Here’s a photo of the back of the ambulance after the call. Bear in mind that half the kit was still in the hospital. Lots of cleaning after a job like this is needed.

Ambulance Mess

Our very next job (after returning to station and restocking the mountain of kit) was a young lady who’d been found dead by her son. She’d been dead couple of days and was in quite a distressing position. There was nothing we could do, so we contacted the Police to act as coroner (standard practice in an unexpected death). I feel sorry for the son, who lived with his mum, and due to being at work and out with friends, had no idea that his mum was dead. We left him in the care of the Police, as there was nothing further for us to do.

Our final job seemed like a routine backup for a Rapid Response Car on scene with a patient who’d had a seizure. All good, until she started to have another fit in the back of the Ambulance on the way to A&E. “Put the lights on, Stu”, came my crew mate’s voice from the back. I pulled in briefly to give him a hand securing IV access and maintaining her airway then drove under emergency conditions to A&E.

A heck of day, filled with medical emergencies that really made me think and tragedies that also made me think.

I text my mum, and fiancé reminding them that I love them.

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Camaraderie

I’ve spoken a few times about how after dealing with a horrific or difficult job or incident, it’s you colleagues that offer the most support and can help the most to come to terms with stress.

Last week, I was part of the night crew. I arrived on station and found the day crew not yet on station. I stuck the kettle on as my crew mate walked through the door.

“Brew?” I asked.

“Go on then, lad” my crew mate replied.

With that, the day crew walked through the door, both looking a little solemn.

“Evening, everything OK?” my crew mate asked them as I got two more mugs from the cupboard.

“We’ve just been to a ‘one-under’ (an incident where a person is hit by a train – the phrase one-under is mainly used in London Ambulance Service for when someone jumps or is pushed under a tube train).”

“Oh shit, you both alright” we ask.

Our first concern is for that of our work family before asking about the patient. What ever treatment that patient would’ve received would have been first class and in a timely manner, especially by the crew in question, and when hit by a train, their fate is often sealed.

“Did you work on him?”

*shakes head* “The train hit him at 110mph, so no, he was obviously dead.”

I don’t need to reel off the list of injuries the patient had sustained but they were not compatible with life.

And so we managed to sit and have a quick chat and cup of tea before receiving our first emergency. Even though it was only 5 or 6 minutes, it was enough to help them de-stress. There’s some things that you don’t want to tell your family as it’s just too horrific, but your ‘work family’ are always on hand to help.

Best job in the world!

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