Monday morning, 2am. The tanoy on station wails a brief two-tone squawk before crackling:
“403, emergency call, Torry; male, collapsed.”
To be honest, I can’t really be bothered. It’s been an interesting enough shift but my second night in a row and, frankly, I’m wiped out. Torry is not, to be p.c. about it, the most affluent area of the city. The chances that this call will be anything worth attending are vanishingly small. Most likely it will be a drunk, fell over or a sore tummy. I’m not generally so cynical, but the memory of last night — drunk after hopeless drunk — combined with a powerful lack of sleep, has created a being who’s sole aim in life at this moment is to make it through to 6am performing only two functions: sleep and running decent jobs. There is a very low chance Torry can offer me either of these things.
I barely even look up as the crew of 403 get up and make for the mess room door. Tonight ABN403 is being manned by a contrasting pair. Mark, a tall, balding paramedic who’s cynicism at any time of the day or night seems to rival my own at this painful hour. With him is Davie, possibly the oldest EMT on staff at Aberdeen and currently working part-time on a job share. His irregular work schedule mean I’ve not worked with him before. As he squeezes past the chair I’m draped over in the over-full lounge, he regards me for a moment.
“You comin’?” I look up, surprised, my brain whirring into life reluctantly.
“It’ll be pish; Torry at this time of night…” it’s half statement, half question. Davie doesn’t say anything more as he reaches the door. It may be sweet-Jesus-o’clock, but even in this state I can’t quite shake off that painfully eager medical student persona that is my hallmark. I leave the chair with agility that surprises even myself and make swiftly for the door. Davie is holding it open for me as a grab my high vis from the wall. I’ve not needed it yet, but I like to have it, just in case. My PPE — helmet, gloves, safety glasses — is in the locker on ABN441. As we reach the garage, Mark’s long legs have already carried him across to the ambulances and he’s squeezing between two of them, heading for the driver’s seat. A comment passes, unbidden, though my head; I’ve no idea how Davie drives, but Mark goes fast and heavy. Deciding I have no time to pick up my PPE bag, I brush past the passenger door and slide open the side door, thanking the gods of dispatch that this is not the old truck with the side door you can’t shut from the inside.
As Davie hops into the passenger seat, I climb over the response bag into the jump seat behind the driver. Thinking back to the nature of Mark’s driving, I pull the seatbelt down and click it home next to the Entonox cylinder beside me. As we pull out of the bay and though the main door, a hand reaches across to the centre console and hits the ’999′ button. The station grounds are illuminated in blue as the emergency lights bring them to strobing, dancing, life. The MDT is ignored momentarily as it beeps an update; all eyes are scanning up and down the road, looking for that motorist. The one changing the radio station; talking on the phone; doing anything other than seeing the mass of light and colour pulling out in front of him. The road is empty, attention returns to the screen. Silently I scan the job details, ‘ 37 year old male collapsed, unresponsive and not breathing, CPR in progress.’
“CPR in progress,” mutters Davie, switching the terminal back to the GPS system.
“Hmm?” Mark questions, eyes darting to the map. There is a flash of understanding between the two of them. I have no doubt he heard.
“Yeah,” comes the reply.
“Right.” The comment is derisive, doubtful, but still there is a subtle change of atmosphere in the cab. Mark, already pushing the ambulance quickly down the middle of the deserted street, squeezes the accelerator a little more. The sensor operated traffic lights ahead of us flick to green at our rapid approach. We fly on, no need to slow or break the silence of the night with the siren. Only the rising and falling pitch of the engine cuts though the air around us. Inside the cab, silence dominates.
The journey is mechanical for the professionals in the front, each junction approached with the same practiced efficiency; gentle braking, look, look, double check, go. For me, twisted round in my seat to see the city rush past, things are a little different. I’m trying not to be to excited, for many reasons. If the job is, as I originally suspected, a load of bollocks, I don’t want to be disappointed. On the other hand, if it is as given, then someone is dead. I also know the more excited I am the more I’m going to get in the way. I focus on what I’m going to do on scene if the shit really has hit the fan. I check my knowledge; CPR technique, ventilation rate. That’s about all I can do, but better not to cock up the simple stuff all the same.
We clear a major junction and Davie turns round to look at me,”what size gloves?”
I look at the dashboard when the boxes of gloves are kept, only seeing large sitting there.”Medium if you got them,” I call back. He opens up the storage bin between the seats and pulls out a pair of mediums, handing then back to me. I start pulling them on, reassured that in addition to this pair I have another two in my pocket, just in case. I watch as our little moving dot on the GPS screen eats up the red line ahead of it, approaching its target. As the ambulance leans around the corner into the estate all eyes look outwards, searching for a light, an open door.
There! Off at the end of the street. An open door, people standing, waving. Before we even reach the flat I’m out my seat, unplugging and unclipping the defib. As the ambulance rolls to a halt, I lean across and throw open the door. Davie appears and grabs the first response bag before turning up the path. Mark arrives at the door a second later. I heft the defib out of its cradle and pass it out to him. A quick,”Thanks,” and he too is jogging up the path. I jump down after him and slam the door closed. Those long legs have got the better of me again and he’s at the door before I can start off after him. I almost run, before remembering the mantra.
“Never run.”
Instead I settle for a brisk jog, catching up and reaching the inner door of the flat just behind him. There are people everywhere, some looking scared, others just relieved we have arrived. Someone is crying in another room. There is some urgent chatter, eastern european, coming from the room at the end of the hall. The one I’ve just seen Davie disappear into. This is starting to feel like the real thing. We reach the door and find our way blocked by broad backs. Mark pushes past, but I wait for a moment. Sure enough, there is suddenly a mass exodus, giving me space to move in and observe in the scene.
Davie is trying to rapidly extract information from the one bystander left in the room. On the floor is a man. Mark dumps the defib down next to him and reaches for the neck.”Nup, no pulse.” He looks around and sees me,”Ross, on the chest please.” I push forward and step on to something that gives beneath me. The man is lying on the floor, but on top of a mattress. I throw my arms out to regain my balance and step over the body. As I move, I scan around me, searching for discarded needles or anything else dangerous. I may have only been doing this job two days, but I’ve read enough blogs over the years to know the scene safety sweep is not an optional extra. Seeing nothing, I kneel down and place my hands on the chest Mark has just exposed with his TuffCuts. On the other side of the small room I can see the final bystander has left, Davie is also kneeling, unzipping the medic bag and throwing it open.
I start compressions. I expect it to be somehow different from the CPR dummies, but it really isn’t. No, that’s not true; there is a different, but it’s the surface I’m working on. Not only is the patient resting on a mattress, now so am I. As I push down, the whole body falls beneath my hands until it hits the floor. We all drop a good 5cm before I can feel the resistance increase sharply and see the cheat compress. As I release, we all bounce back up again. Every compression sends a wave though the mattress, bouncing us back and forth as though on a sailing ship. These waves threaten to unbalance me. I have to fight constantly to compensate for the varying depth of my knees, each moving independently. Maintaining regular compressions becomes an almost impossible challenge.
I count rhythmically in my head. I start with ‘Row, row, row your boat, gently down the stream,’ but find I don’t need to. I can keep a rhythm just as well without it as with on this unstable surface. Mark interrupts me, slapping the pads onto the chest and hitting analyze with a determined,”right, let’s see what we’re dealing with here.”
The defibrillator voice calls out, “analysing.” Fine ventricular fibrillation scrolls across the screen.”Shock advised.”
“Everybody clear?” asks Mark, finger moving for the shock button. Daive stops pulling kit out the bag and drags it off the mattress. I roll back onto my haunches.
“Yup.”
Mark points to the patients arm, lying out at funny angle near my feet. I’m not touching it, but it’s close. I step back further and, finding a bed (without a mattress, that answers that question) behind me, sit on it. He hits the red button. The body between us jerks, muscles contracting violently, and that same arm – that was next to my foot – flys upwards, landing with a loud thump on the underside of the bedside table. With an almost apologetic “oops,” Mark pulls it out the way.
“Continue CPR,” commands the defibrillator. I jump back down from the bed and begin compressions.
“Bag him, I’ll get a tube,” says Mark, standing up and reaching for the kit bag. Davie slides past him and presses the BVM onto the patient’s face. I pause and he squeezes the bag once; twice.
“Go,” he says, nodding at me. I start in ernest once more, counting compressions for the first cycle but loosing track the second time. I carry on for what seems like a reasonable amount of time before randomly counting out loud,
“28 29 30 go.” Davie squeezes the bag a couple more times as Mark steps past us both, laryngoscope and ET tube in hand.
“No fucking space,” he spits, shoving a clothes hamper out the way.”Stop a second,” he commands me, sliding the blade of the laryngoscope into the patients mouth. I rock back off the chest again, thinking about everything I know about intubations and realizing this going to be a difficult one. Short, fat, neck in a cramped and poorly lit room. After repositioning the head a few times, Mark feeds the tube into the patient’s mouth. Discarding the laryngoscope and holding the tube in place with one hand, he pulls the bag off the BVM and attaches it to the ET tube. Davie pulls a stethescope out the response bag and is already listening to the chest as Mark squeezes twice.
“Nope,” Davie shakes his head, a hand now on the abdomen.
“Shit. The crime is not intubating the oesophagus,” Mark almost smiles, pulling out the tube and looking at me, “the crime is…”
“Not noticing,” I finish, regarding that half smile curiously. I get the feeling the he might just be getting as much of a high from this as I am. The defib wails, indicating it wants another shot at the heart. Davie pushes the button automatically, “analysing…” it squeaks.
Fine VF again.
“Shock advised.” I step clear as the body lurches again, thankfully not colliding with any furniture this time. “Continue CPR.”
“Go again a second,” Mark commands, repositioning for another attempt at the tube. I jump back on the chest for 5 or 6 compressions before being told to stop once more. As I sit back again, I notice a head appear around the door. Attached to the head is a body in a green jumpsuit. Lynne is edging into the room, stepping around the bits of kit we’ve left on the floor.
“Alright? Control sent us down to find out what was happening,” Owen’s voice travels into the room, rapidly followed by the man himself.
“Could do wee’ a bit of help, no doubt,” says Davie gruffly.
“Air entry?” queries Mark, looking up from the tube. Davie grabs his stethoscope again.
Owen surveys the scene before him, “got access yet?”
“Air entry bilaterally,” call Davie, to no one in particular.
“Aye, you go that side, I’ll take this one,” Mark says to Owen, pointing to an arm and handing the bag off to Davie. I lean forward again, hands clasped before me. Lynne catches my eye as I move.
“You alright?” she asks.
“Yeah, I’m fine,” I start compressions again.
Owen’s eyebrows head skyward, “you’ve got the medical student doing all the hard work! You getting too old for this job, eh Mark?”
“Far too old,” agrees Mark, smiling once more.
“He’s doing a fine job,” interjects Davie. I can’t help myself, a smile creeps across my face too.
***
We continue working on scene for 5 minutes. Apart from giving some ‘frothy’ amiodarone because it got mixed up incorrectly, everything runs smoothly. A couple of coppers turn up at some point, but I’m too absorbed in continuing compressions to take much notice of what’s going on around me.
After another couple of shocks and the VF deteriorates into asystole. This patient is not heading in the direction we want and a decision is made to make a run for the hospital. So we come on to another problem. The patient is a well built guy and going to be a nightmare to move. I listen to the rapid discussion being held over my head.
“We’ll never get the trolley in here, it’s far too tight.”
“He looks heavy, we can’t carry him outside.”
“Chair job, you think?”
“Yeah, on to a chair in here, wheel him out and move him to the trolley in the ambulance.”
“Ok, I’ll get the chair.”
“We’ll get him on a blanket.”
A flurry of activity begins again. A chest of draws is shoved away from the door and a rolled up blanket placed along side the patient.
“On three. 1..2…3… God he’s heavy!” We all roll the patient and shuffle the blanket underneath him. I feel a wet slickness through my glove and look down. I have put my hand in a puddle of what can only be urine. I look down and notice my knee is in contact with a small run off from the very same puddle. Ah well. Rocking the patient back the other way we manage to get him fully on the blanket.
By this time Lynne has returned with the carry chair. I look on dubiously as everyone grabs a bit of blanket, most of it seems to be at least damp with urine now.
“And again, 1..2…3..lift,” with a massive effort we move the patient onto the chair. I’m conscious that all this time there have been no compressions.
The run to the ambulance is a blur. We don’t actually run, but faces seem to blur past; men, women, police officers. The road is narrow and substantially busier than when we arrived, two ambulances and a police car on site, another pulling up just as we load the patient. The car rolls to a stop just behind us. Owen signals to the officer driving it, using the universal point-at-the-vehical-point-where-we’re-going technique; we’re about to make a swift exit and she just blocked us in. She nods and backs back up the street, pulling in behind the other ambulance, sensibly parked out the way.
I stand in the corner of the ambulance, no longer sure exactly where I’m supposed to go now.
“Do you want a hand in the back?” asks Owen.
“I’ll be alright with Ross, you wanna stay in here with me?” Mark looks over from the head of the stretcher.
“I’m good,” I reply.
“Ok, come take the bag.” I shuffle over to the seat at the head of the stretcher and grab the bag. Again, I’ve never used one on a real patient before, but know the theory well enough.
I start ventilating the patient at a steady 10 breaths per minute, as best as I can guess, counting to 5 between each breath and squeezing the bag over a full second. The journey to the hospital gives me a chance to stop and think for the first time, and the first thing that comes to mind is that you can’t run an arrest properly in the back of an ambulance with less than 3 people. Mark is now doing compressions, balancing in a moving ambulance and giving drugs. Every time we go round a sharp right hand bend, he is pulled back and the depth of compressions drop. Every time he has to give drugs, compressions stop.
I can’t see where we are as the ambulance rocks and sways through the city. I only realize we’ve arrived at the hospital because the lights above the entrance to A&E shine through the window. The rear doors swing open and I see a nurse standing by the doors to resus, waiting. Davie jumps in and takes over the head of the trolley; I don’t think I have the skills to push the patient and bag at the same time. I squeeze out the ambulance and take over compressions again as we wheel the patient down the ramp at the back of the ambulance, up the ramp into the building and through the resus doors. I attempt to maintain a good rate and depth with one hand as me move, but it’s more for show than in the belief that it’s doing any good.
We’re directed to bay 1 where a team are ready for us. I hand over compressions to a nurse and head back to the ambulance while Mark gives the handover. By this point I’m aching at the wrists and shoulders from giving compressions for so long. Davie is already cleaning the ambulance as I step inside and take my usual seat. Mark appears a few minutes later and starts on the paperwork. I’m now a ball of unexpendable energy, the adrenaline still pumping but without any activity to direct it towards.
Mark goes to hand in the paperwork as Davie finishes his cleaning. He turns to me and his expression softens, “You alright?”
“Yeah, I guess.” My reply is noncommittal but honest. I think I’m alright, but then the last of the adrenaline is still working its way through my system.
“You ever worked an arrest before?” he asks?
“No, this was my first one.”
“You did well.”
“Thanks.” I smile at that, content that if nothing else, I did my best.
***
The patient didn’t survive. The team in resus worked for another 10 minutes, but as far as I’m aware his heart never budged from asystole. No reversible causes were found at the time. I don’t know what the results of the autopsy were, assuming one was done. There was no evidence of substance abuse in the flat where we found him.
