Distorted

Honestly. You write one post about thoracotomies and sudden it’s the only reason anyone ever visits.

Ambulancing again

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.

BLS ABC AED LMA HFD

I made that last one up, it stands for ‘Harder Faster Deeper’, which obviously refers to chest compressions! We do love our abbreviations don’t we?

Last night I went up to the medical school for another Grampian Immediate Care Scheme (GICS) education evening. The subject was the new 2010 resuscitation guidelines. Although more for GPs and first responders, I enjoy going along to ‘have a play’, learn something and meet people who work in the pre-hospital care environment in my area.

I got to practice my BLS skills with 3 excellent tutors, all medically trained aircrew from RAF Lossiemouth. The manikin we were using could be hooked up to a practice AED, something I’d not used before, so it was good to see how they worked. I also got a shot sticking an LMA in the dummy, again not something I’d done before. It’s not a skill I could justify using on a real person in an emergency, limits of my competencies and all that, but then neither is intubation or central line placement, and I’ve done them on plastic heads before.

Most importantly though, I got talking to a paramedic who works in Stonehaven. He foolishly said if I ever wanted to come out on a shift to just ask. So obviously he’s going to text me at the weekend, after he’s spoken to his team leader, and we can organize a day. I did warn him not to offer unless he was serious! I’m looking forward to it, I want to find out what he thinks about paramedic intubation, the gradual move away from EMTs and all the other contentious issues of the moment. All things I meant to ask when I was observing in Aberdeen, but the time never seemed right…

Unfortunately it’s not going to count as my new medical experience for March, cause I’ve done it before. My goal is to do something different every month. January was the emergency medicine conference and February was the National Undergraduate General Surgery conference, both in London. March isn’t looking good, exams until the middle of it then away to Nepal. Nepal itself obviously counts as an experience, but it’s April. My plan is to cram as much into the two weeks before I leave as I can. I’ve already got a rock climbing partner sorted, I’m off for a weekend with the Wilderness Medical Society and then there’s the bonfire birthday party on the shore of Loch Ness. Just got to pass these damn exams first.

MRI

Today’s MRI was far more traumatic than the last one I had. This time they stuck ECG electrodes to me, wrapped a pulse oximeter too tightly round my finger, velcroed plastic discs round my chest and made me listen to James Blunt. I was also prodded with a plastic stick at one point, however I was in the tube and had ear plugs in when she did it so I couldn’t hear what she was saying about why it was necessary. Nor could I really see very well, so I suppose she may not have poking me with it deliberately. Of course, she may just have not liked me. On the plus side, the whole scan was much quieter than last time. Less crashing and and strobing noises.

I spent most of my time looking at the roof of the scanner thinking, “I wonder how many people have lain here and though ‘well they didn’t do a very neat job on that edge did they’.” I asked the radiographer about scanning hearts, she said they gate the scans so they only collect data in diastole, hence the ECG electrodes. She then went on to explain what diastole was, but hey, she didn’t know I was a medical student.

You have to pass through the x-ray department to get to the MRI centre, as I was walking out I saw a lad handcuffed to a security guard coming in. I guess those held as Her Majesty’s pleasure need x-rays occasionally just like the rest of us, but it was a first time sighting for me and it was difficult not to look like I was staring. Having said that, I’ve seen a couple of blokes under the supervision of a PC down in A&E on a Saturday night.

Sleep Cycle

My current holiday sleep cycle has me going to sleep about 3am and getting up at about midday. Which is fine for now because there’s nothing I need to be doing that requires me to be up at the same time as the rest of the world. However, I have an MRI scan at 9am tomorrow. I’m not sure how I’m going to be up. I said to the guy that anytime on Friday morning, indeed up to 1pm, would be fine. But Sod’s law, I get an early scan.

They’re doing a heart scan. I still don’t understand how they can do cardiac MRI. How can they build up a picture of my heart if it’s moving all the time? One to ask the radiographer. There’s nothing wrong with my heart (well, not my physical one at any rate). All the medical students were sent an email asking for “healthy male volunteers with no existing cardiac problems to undertake a study validating a type of cardiac magnetic resonance that investigates heart metabolism.”

Only trouble is, the amount of coffee I’m going to have to consume to get me to the hospital for 9am may well flip me into SVT.

Ambulancing

I rode along as an observer with crews from Aberdeen ambulance station a few nights ago. It was good fun and, although I didn’t get to see any really exciting jobs, I learnt quite a lot.

First job of the night was an urgent transfer from the helipad, a diver destined for the hyperbaric chamber brought in by Helimed. We were there in plenty of time so I was lucky enough to be in position to get a video of the helicopter coming in to land. Apologies for the quality, I need to get an iPhone 4 so I can shoot hi-def videos from the back of an ambulance when I don’t have my video camera with me.

As the rotors spun down and everyone decamped from the helo, I was struck by how small and cramped it looked. I’ve never had the chance to see one of these Eurocopter EC 135s up close before, but from a distance they definitely look bigger.

The patient was ambulatory and therefore able to walk to the ambulance, we didn’t have to faff about with the trolley. As everyone was piling into the back of the ambulance after them, one of the flight medics glanced down at my ID badge. Only the bottom strip, reading ‘NHS Grampian’, was showing, the bit reading ‘Medical Student’ was hidden. He turned and asked, “are you from the Hyperbaric Centre?”
“No,” I replied hastily, anxious to dispel any notion that I was important or had any responsibility for patient care, “I’m just a medical student.” Obviously some of the raw panic I was feeling must have shown in my eyes, because he chortled at that. We drove round the corner to the Hyperbaric Centre where we were quickly dismissed by the medical team. Not in a disrespectful way, our initial handover was obviously so detailed they simply didn’t have any questions. However, we were destined to return in short order.

As soon as we cleared from the hyperbaric unit we were tasked to an urgent transfer. A gentleman had taken a tumble at a nursing home and, although unhurt, he had become uncommunicative and apparently less aware of his surroundings since. We took him to the geriatric assessment unit at Woodend for triage and further treatment.

Then, in a move that surprised us all, we were tasked back to the hyperbaric centre, not for a transfer, but as an emergency. The details came though and sure enough it was the same patient we had dropped of earlier and they wanted us to… “transfer her to A&E for an x-ray”. What? Why did this warrant a blue light response? Alas, that is not for us mere mortals to decide, so we trundled back and sure enough they were waiting for us. Apparently the patient had previously had a thoracotomy so the doctor wanted a chest x-ray before putting them in the chamber. I have since discovered that what I had always thought of as a ‘thoracotomy’; a clamshell incision or ‘bilateral anterolateral thoracotomy’, is actually just one kind of thoracotomy. You could also describe more minor incisions like a median sternotomy as a thoracotomy, not that cutting your sternum in half with an oscillating saw is exactly minor, but it’s more minor that this:

Best avoid one of these if you can!

I am yet to be enlightened as to why a simple transfer required a blue light response in the first place. Anyway we got everyone safely to A&E, everyone being: the patient, the consultant, a nurse, a paramedic, an EMT and me, the medical student. 6 people and one ambulance to take one patient 500m, and back again (after the doctor jumped the queue), for an x-ray. Surely there are some potential efficiency savings to be made there.

I’ll be honest, the rest of my night was so unremarkable I won’t even bother telling you about it. The rest of what I saw was evidence of what people can do to themselves when they have too much to drink and:

• Ride bikes into cars on Union Street.
• Collapse at the side of the road where concerned members of the public with mobile phones can call us and run off.
• Collapse in the road and attract the attentions of a disproportionate number of coppers and ‘Street Pastors’.
• Collapse outside a restaurant and cause the owner to call us because they are concerned for the image of their establishment patient’s welfare.

We ended the night with a classic ‘nan down’ call. Little old lady fell out of bed in the night and her daughter couldn’t get her up on her own. All the friends, family and neighbours who normally help were unavailable (it was about 3am), so we didn’t mind scooping her up off the floor and depositing her back in bed. She was unhurt, so we left them to get a few more hours kip.

So there it is; a shift of transfers and drunks. Quite good fun really.

Shift Prep

I’m getting excited about my ambulance shift on Saturday night. Now I have a date and time and know who I’m going to be observing with it seems much more real. I’ve been claiming that the reason I’m going to bed later and later (about 2am now) each night is because I’m preping myself for the 6pm to 6am shift. In truth of course, I’ve just been playing lots of Neverwinter Nights, a Dungeons and Dragons rules RPG. What I have been doing is mentally preparing myself.

The thing that sticks with me is something that Ambulance Driver says again and again about ambulance work, “the more competent you are, the less exciting it is.” Or, as Samuel Shem put it, “at a cardiac arrest, the first procedure is to take your own pulse.” So let me take you back, if you will, to my last ambulance shift, which incidentally was also my first ambulance shift. Picture the scene…

It’s about 8pm, a couple of hours into a 12 hour night shift, and we’ve had no jobs so far. We’re just back on station after a very important run however, from the Chinese take away down the road. The timing could, literally, not have been more perfect. I have just plated up (Szechuan beef, fried rice) and the first fork full of steaming hot, tasty Chinese was half way to my mouth; when the phone rang. I’ll admit, I was actually happy we had a job, not disappointed that my food would have to wait. This was despite the fact that I hadn’t even had a chance to grab a snack on my way out the door; a girl had put what turned out to be a £2000 dent in the side of my new car only 3 hours previously, effectively ending whatever hope I’d had of getting a bite to eat.

But it wasn’t just any call, it sounded exciting too, a proper trauma job with a really juicy mechanism of injury: fall from height. So I did what any painfully keen medical student with a fascination for trauma would do on his first shout. I gleefully dropped my fork, grabbed my HiViz from the back of the chair and walked quickly, perhaps a little too quickly, out to the ambulance. In fact, gleeful doesn’t even begin to describe it. Stepping through the automatic doors out into the cool night, striding the three steps to the ambulance, sliding back the door to the patient compartment (no front seat rides for the observer), I damn near wet myself with excitement. You know what I’m like, this was a dream come true for me. It brings a massive grin to my face even thinking about it even now. Then the blue light drive! Well obviously we weren’t absolutely tanking it, I know Rob could have gone a lot faster, but even so.

Then I became useful for the first time. The housing estate we were sent to was new, the SatNav appeared to be sending us into the middle of an empty field, but at least it knew where we were going… sort of. It deposited us at a junction in the middle of the estate at what was clearly not our destination. My keen young eyes (*cough*) spotted one of those horrendously small signs that Tom Reynolds always used to complain about. “Even numbers that way,” I pointed. So there it was, the first use I was to an ambulance crew was giving directions.

It didn’t end there however. I tried to make myself as useful as I could, but I was Just. Too. Damn. Excited. Don’t get me wrong, on the outside I was perfectly calm, I wasn’t fluttering about being irritating or anything. In fact I think I didn’t do a bad job of maintaining c-spine control, despite the patient’s best efforts to impersonate one of those bobbing head dogs you see on the parcel shelf of cars. When it was time to go I helped push the trolley and heft the patient onto a spinal board (there can be no other way to describe it; the patient wasn’t big, but it was never going to be an elegant maneuver from where they had landed). I moved wheelie bins and garden hoses, I opened ambulance doors and explained to family member number three exactly what the paramedic had already explained to the patient, family member number one and family member number two, each on three separate occasions of course. The trouble is, although I was doing, I wasn’t thinking. I was far too caught up in the moment to think about the patient. I wasn’t considering all the things I should have been, and indeed would have been, had the same patient been presented to me in a calm, well lit A&E, and not on a dark patio in the rain.

I did mention that, right? That we were outside, it was raining, and we got wet. Well, Rob (the EMT) and I did. There was quite a funny moment when, in the back of the ambulance, Paula, the paramedic, looked up from the patient, saw me dripping wet and said “Is it raining? I never noticed.” Rob and I, who were both having trouble seeing though the rain running off our hair and over our glasses commented that, yes, it might have been drizzling. Just slightly. (The patient had been up against the back of the house and clearly the direction of the lashing rain had meant it wasn’t falling on Paula kneeling over the patient. But for Rob and I, who had to run round to the front of the house to get things from the ambulance, it most definitely was raining.)

Clearly, since my status as observer is roughly equivalent to ‘equipment fetcher’, it didn’t matter that I wasn’t thinking about the patient. It wouldn’t have made the slightest bit of difference to anyone but myself if I had been thinking. But I want to learn. The history I take in A&E is very different from the one I take on the wards, and I know that the history we take in the pre-hospital arena is different again, but if I’m not paying attention to what’s going on then I’m never going to learn exactly how it’s different. I want to feel confident dealing with patients in these situations. I’m not going to need to be able to deal with these situations because it’s not my job, but it’s another learning experience.

And so we come back to my next shift. My goal is to pay attention. Be excited on the inside, calm on the outside, just like last time, but take a moment to let some of the external tranquility sink a little deeper. And bloody well pay attention!

Cardiac arrest

I was walking back to my car in the dark and the rain at about 8:30pm this evening, and my mind was wandering, as it tends to do. The hospital entranceway and surrounds are quiet at that time of night, no one really around, and it got me wondering. Say I see someone collapse just outside the main doors. No body else sees, and I can’t see anyone to shout for help. I run up and check the collapsed patient, find them to be unresponsive, not breathing, and not displaying any signs of life/pulse. And no, this is not turning into another discussion about whether I go for a pulse or rely on the ‘signs of life’ for state of heart function. Basically, I establish this person is in cardiac arrest and I’m the only one immediately available. Now, I expect someone to be along relatively shortly (and even if I wasn’t), so I go straight in for ABCs, rather than going for the phone. I start compressions, but now I’m stuck. What this person needs right now is uninterrupted CPR. What this person needs very very quickly is a defibrillator. And a definitive airway. And IV access. And cardiac drugs. None of which I can really do by myself, in the dark and the rain. None of which I can do at all actually, but that’s beside the point.

So the first question my wandering mind asked was, “how soon do I go for the phone?” I know how long the medical school tells us to carry on CPR before going to fetch help, but I’m at the entrance to a hospital not too late at night. Surely if I’m shouting, someone will come along eventually? I have just timed myself, yes I got on the floor and did it, to see how long it takes me to go from giving compressions to have my phone out and dialled 999 (I skipped pressing the call button). 15 seconds, and that’s me calm and thinking carefully about what I’m doing. I reckon I would be hands off for at least 20 seconds in a real situation, which isn’t that much, but if someone comes round the corner just moments after I do it, I’m going to feel I’ve made the wrong decision.

The next question I wondered was, “who to call?” Really, the ambulance station is so close that I’d just dial 999 in the situation I described, but that got me thinking about who I’d call in a slightly different situation. What if it was actually in the hospital, in some dark corridor with a similar lack of other people around. When I was down in Newcastle at the heart-lung hospital there was a sticker on every internal phone that read:

CARDIAC ARREST DIAL 2222

Relatively self explanatory, if you witness an arrest in the hospital dial 2222 to summon the crash team. So what’s the number in Aberdeen hospitals? I have no idea, and I think that’s a really bad thing. Fair enough, we got some very rudimentary BLS training before we went onto wards, but nothing else. And I know we should never be unsupervised on wards and the situation should never really arise, but if there’s an unexpected arrest, the least I should be able to do is call for help. It’s a really basic thing that we could do. A nurse is going to be a far more useful pair of hands in the first minute or two of an arrest that a medical student is. If we could call the crash team, it would free up those hands for an extra few seconds.

I mean, all theoretical situations aside, it’s just something we should know. Maybe I’m over thinking it a bit, but I guess I’m a bit concerned about witnessing my first arrest. It’s something I expect myself to handle well. When I was down in A&E resus and we got word that a suspended was coming in, I was excited. I didn’t want the person to be that ill, but if you’re going to perform CPR on a real person for the first time, I can’t think if a place I’d rather do it. As it happens, the paramedics got return of spontaneous circulation in the ambulance (I know! In an 70-odd year old woman, how often does that happen??).When I come on to a ward, I usually clock where the crash cart is. Just because if something does happen, the last thing I want to do is freeze, and knowledge helps make that less likely. I know, chances are I’ll be thrust out the way, but in the event there is something useful I could do, I’d like to be able to do it well. So, I’m going to find out what the number is next chance I get.

Update: It is 2222 here as well.

IMPACT

So at lunch we were accosted by a registrar looking for some willing volunteers to act as patients for a course they were running at the hospital today. It’s called the IMPACT course (ill medical patient’s acute care and treatment). It aims to improve junior hospital doctors’ treatment of severely unwell treatment before senior help (if necessary) arrives. So for a few hours this afternoon I was a 67 year old man who was brought in to the A&E department with intermittent severe abdominal pain. I was tachycardic, tachypnoeic, slightly confused and experiencing rigors. I was really interesting to see the varying standard of care each of the 4 groups provided. I appreciate there’s a great deal of difference between trying to talk you’re way through a clinical scenario and actually having the patient in front of you, but I would not be happy being treated by the first group. The other three groups all did things slightly differently but got everything done and correctly diagnosed my intra-abdominal sepsis. Really the most important part was the fact I needed ITU now, because my SIRS score gave me a mortality of about 50% (apparently). Now, I guess I had an unfair advantage because for the Special Study Module we just completed I had to research sepsis and SIRS, but during the first group I was screaming inside for someone, anyone, please, give me fluids!

During the scenarios I was trying to act it out properly, although I must admit I did stop hyperventilating when my extremities started tingling. I did the whole ‘rip the oxygen mask off my face’ thing that confused patients seem so fond of doing, and had some rigors and rolled around a bit. Although I did have a bit of trouble trying to only expand one side of my chest when I developed a tension pneumothorax, tricky thing to do. Overall it was a bit of fun and I got to see exactly how an acutely ill patient who presents to A&E should be managed… and how they should not be managed.

Pwned

By text message

Friend:

Did you know cardiac arrest is a chaotic system?

Me:

Well, cardiac arrest relates to the lack of muscle contraction in the heart. The electrical states capable of inducing this are varied. So while ventricular fibrillation is indeed a chaotic system, asystole is actually very calm and not chaotic at all; both are still “cardiac arrest”

Friend:

Ssh, i was trying to know more about medicine than you.