Tag Archives: pain

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 🙂

 

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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The first solo shift…

…turned out to not be solo at all:

 

I arrived on station, alone. Checked the vehicle. Booked out the drugs bag from the safe and logged on for my shift. I radio’d control and asked if they new that a) I’d now qualified and could be used as an EMT (there was a chance I’d still be marked on the manning as a student, and therefor not responsible to anything on my own) and b) if they had a plan for me as apposed to being alone.

“Roger, thanks I’ll update the manning now for you. We do have a plan; a Paramedic in [another town 12 miles away] is also solo on their vehicle. Take your lunch and stuff and head across to crew up with her when you’re ready”.

That’ll do. They told me who I’d be with and I was happy. A very experienced Paramedic of 26 years+ who has always been pleasant when I’ve spoken to her in the past. The last thing you want is a cranky crew mate for a 12 hour shift!

I finished checking my vehicle, made a brew in my travel mug and headed across to meet her. I was available for emergencies the whole drive across, but none came in that I was nearest to, so I arrived uninterrupted.

She, too had checked a vehicle and had her Paramedic kit already loaded, so we used her vehicle. I parked mine in the garage, locked the keys away and added my login to the onboard computer system.

First job, straight away – good timing. 92 year old female, fallen.

We rushed to the address as we always do and were let in by the warden of the sheltered housing site. He told us that he’d found the lady on his morning rounds. She seemed uninjured but he was unable to lift her up. He’d put a pillow under her and a duvet over her to keep her warm, so she was quite comfortable.

We assessed her, found no injuries, so lifted her onto her feet. She was perfectly well so left her at home with a note to the GP to advise of the fall.

We cleared on scene to be sent another job immediately. It was nearby, to an 84 year old man who had also fallen, this time in the garden while watering the tomatoes. He’d tripped over the hose and landed on soft grass. His neighbour saw him over the fence and called us.

He, too was uninjured, but we found some concerning neurological signs. Further investigation revealed that he hadn’t tripped over the hose at all. He had a sudden weakness in his right leg, which was also present in his right arm. He was confused, repetitive and slurring his words. This poor man was having a stroke. I put an IV in his hand incase we needed to give him any drugs (a risk of stroke patients is that they’ll begin fitting uncontrollably and can only be stopped by IV drugs) and rushed him 28 miles to the nearest A&E. That’s the only problem with living in remote picturesque villages – it’s a very long way to hospital! Old people should be made to live near hospitals. In bungalows. With doors wide enough for stretchers 🙂

We did a few more nothing-jobs, all treated at scene then received a call to a 15 year old fallen from a tree “as high as a house”. People calling 999 in a panic are rubbish at estimating hight so we always reserve judgement until we see how far they’ve fallen.

“Hello, we’re from the ambulance service, what’s happened?”

“My mate fell from up there *points to branch*”

“That one?” I also point.

“No, the one above it”

“Ah, the one that’s as high as a house then”

They were right, he’d fallen somewhere near 12-15 meters, hitting several branches on the way down. Somewhat mercifully, he’d landed in a patch of stinging nettles which broke most of his fall. In fact, the only real external injury was a large abrasion on his arse and stings from the nettles.

We scooped him onto an orthopaedic stretcher and applied a hard collar to help protect his neck incase of injury, gave him some pain relief and made a start for A&E.

Despite his remarkable lack of injury, it’s courteous to call the receiving A&E department so they know you’re on the way with a trauma that has potential to be quite nasty. He was perfectly stable and had no other apparent injuries, but he may have had something under the skin that we cannot see without at least a CT scan.

We arrived at hospital to find a full trauma team – 9 doctors and 2 nurses, all with individual roles. My crew mate gave a full clinical handover and the lead doctor said:

“So basically, he’s hurt his bum?”

“Errr, yeah.”

Everyone smiled slightly, including the patient who was high on gas-and-air. The trauma team set to work  while we told the family in the relative’s room what was happening. I’m confident he’ll be fine. The worst bit of it for him was his mates hearing us say that we’d need to see his bum. They took great pleasure in laughing at him. I suspect it’ll take him a while to live that one down!

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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 actually 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 🙂

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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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