Whatever next

It's been a bit bleak on the blog front because to be perfectly honest, we've not done any calls worth blogging about as it's all been stuff that could easily have been dealt with by a GP.

I've only ever been in an ambulance as a patient once. It was in Lincolnshire, and I wasn't given the choice by my GP who booked me into hospital on an urgent call. Most of the stuff we've been to this last week or so I wouldn't have dreamed of calling an ambulance for.
For example:

A woman with abdo pain....for 9 months. And no, she wasn't pregnant - not at 68 years old.

A man with penis pain for 3 days and hadn't considered seeing his GP.

Until today, the biggest time-waster of the week was a 23 year old who called because he'd had a cough since the night before. He supposedly had difficulty in breathing. When I suggested he sit up a bit to make his breathing easier if he was finding it difficult, he just curled himself up on the bed and ignored us. We referred him to his GP.

The call that really made me have to bite my lip was a call to a woman who was thirsty!

Still, it goes with the call Mark Myers took for an ingrowing toenail....

One I know the outcome of...

Until this weekend, it had never crossed my mind that having a dental extraction could lead to a nasty complicated fracture of the ankle.

We were working nights this weekend – at 7pm we’d checked the vehicle over, replaced a couple of items and were ready for our first call. When it came, I went out to the vehicle and looked at the screen.

“Dental extraction this afternoon, passed out, injured broken ankle”

I got the dental extraction bit (I’ve got to have a couple extracted myself – NOT looking forward to it as I have a very real fear of dentists), I got the passed out bit, but I didn’t get the broken ankle bit. Did it mean the broken ankle was an old injury, or did it mean that the act of passing out had caused the broken ankle? I pondered the possibilities as my crewmate Graham drove us to the call.

We were met by the patient’s brother. “He’s in the living room, he passed out upstairs and he’s got a very nasty injury to his ankle.”
“Ok.”
Our patient, Al, was sitting on a chair with his right leg crossed over his left. His right foot dangled uselessly in mid-air, a large lump on his ankle was being held in place by his sock through which blood seeped and dripped steadily onto a towel on the floor underneath.
I turned to Graham.
“Vacuum splint, Entonox, and carry chair please.” Graham left to fetch the necessary equipment.

Al explained he’d had a tooth extracted at lunchtime, and since then, he’d been getting large blood clots forming in his gum which when they came away, he was spitting down the toilet upstairs. On the last trip to expel another clot, he’d passed out in his bathroom, and when he woke up, he was on the floor and his right foot lay at ninety degrees to his leg. He was on his own at this point, but knew he had to get help, so he’d somehow managed to come downstairs on his bottom, and phoned his brother who lived just down the road and had a key to get in. His brother had taken one look at the ankle and called us.

I was amazed at how calmly Al was just sitting there with his clearly badly injured ankle, chatting away as though there was nothing wrong. “Al, out of ten, zero being no pain, and ten being the worst pain you’ve ever experienced, how painful is your ankle?”
“Oh, about three out of ten.” I’d have been screaming.

Graham returned, and after starting Al on Entonox (gas and air), we set about removing the shoe and sock from his right ankle. With a bit of care, we were able to remove his shoe without the need to cut it off, but we had to cut his sock. As we peeled the sock away from his ankle, we saw the bottom of the Tibia (shin bone), known as the Medial Malleolus, poking through the skin on the inside of his ankle. He had not only fractured his ankle, but had dislocated it as well.

A steady stream of blood came from the wound. I felt Al’s foot for temperature and for a pulse, checking that the fracture dislocation hadn’t disrupted the blood supply to the foot. The foot was warm, and I found the pulse on the top of his foot. The pulse can be quite difficult to find, so when we do find it, we put a pen mark at the right point. We then gently put a pad and bandage over the wound, and placed his leg in a vacuum splint. As the name suggests, we wrap the splint around the leg, then using the suction unit, we suck the air out, and the splint moulds itself to the injury and sets hard, preventing movement.

Having his leg straight increased the pain in his ankle, so we gave him some morphine, and took him out to the ambulance.

Due to the nature of the injury, we decided to let the hospital know so they could get an orthopaedic specialist down and we took him in on blue lights.

Later when we went back with another patient, Al had had his leg put in plaster. He told us that he was to have an operation the next day to have his ankle pinned back together. The orthopaedic specialist showed me the x-ray.

This is a normal x-ray of a right ankle. The view is from the front, as though the person was standing facing you.


Al’s x-ray showed the Medial Malleolus had moved sideways – to the right as you look at the x-ray. It also showed that he had a Spiral fracture at the lower end of the shaft of his Fibula – if you were to imagine a spiral staircase going up the outside of the shaft of the bone, that’s what it looked like on the x-ray, but without the steps.

In the operation, the Medial Malleolus would be put back in the correct place, and pinned in place to the Talus. Pins would also be placed along the broken shaft of the Fibula to hold it in place to ensure it repaired correctly.

It was nice to get this feedback from the Dr. All too often we take people to hospital and don't get to know the outcome. It's as frustrating for us as it is for you reading ambulance blogs, because we use this feedback to confirm our own provisional diagnosis, and where that doesn't match, as learning points, to help us to recognise injuries and illnesses and give better treatment in future.

7/7 Remembered

On July 7th 2005, I was on a rest day.  I woke at around 8.30am, got up, showered, put the radio on, and settled down with a cup of coffee to check my e-mails.  I was listening to the radio station Heart 106.2.  At 9 o’clock, the breakfast show finished and the Time Tunnel began.  I hummed along to an old favourite of mine, and then they went to the newsroom for a news flash.  There were reports coming in of an incident on the underground.

I immediately switched off the radio, and turned the TV on to BBC News 24.  It’s a habit to go to the BBC – I’d worked freelance for them for 7 years as a broadcast assistant in local radio in Lincolnshire, with an occasional shift at Broadcasting House in London.  Work had dried up as they took on more staff positions, causing me to leave and become a bus driver before finally plucking up the courage to leave home and join the world’s busiest ambulance service.  Despite the criticism the BBC receives, and rightly so in some cases, I know the lengths that are gone to try and verify a story before it is broadcast.  But that’s a whole other post.

The newscaster said that London Underground was reporting a huge power surge which had caused a disruption in the power supply for trains.  However, it soon became clear that it was more than just a power surge.  Three stations were reporting problems, and people were appearing with blackened faces and burns.

I immediately picked up the phone and dialled the local resource centre.
“It’s Steve Gibbs here – I’ve seen what’s happening on the news, tell me where I can go to help.”
“What are you working today Steve?”
“I’m on rest day today, but I’m back in on days tomorrow.”
“We’ll keep you in mind Steve, but we can’t guarantee what time you’ll get back home, so we’re currently trying not to use people who are rostered to work tomorrow so that we have fresh staff ready, but please remain ready to come in if we find we need it.”
“Ok.”

And home is where I stayed.  None of the chores got done – I spent the entire day in front of the TV watching my colleagues work their butts off.  Then the news that a bomb had gone off on a bus.  I expected the phone to ring at any moment asking me to go in to work. The call didn’t come.  I was grateful really.  I wasn’t sure I was prepared for what I might see if I was sent to one of the scenes.  

Then I felt guilty for thinking that.  My colleagues had been thrown into those scenes.  They’d had no warning.  They hadn’t seen what was being broadcast on the TV.

I recall a posting on the Big White Taxi Service forum from the FRU paramedic who came across the Aldgate bombing as a running call – he was driving past when he saw people, again with blackened faces and burns emerging from the station.

He described being the first paramedic on the train.  The carriage was a mess.  There were people laying everywhere – some with limbs missing, many bleeding.  He recalled having to stack bodies on top of one another just to be able to make progress through the carriage.  He could see a man alive further down, but he couldn’t get to him.  He made his way back down the carriage, got out, stumbled along the outside of the train and climbed in through another door.  When he reached the man who’d been trying to get up, he was dead.

Despite the criticism that the service has received in the last year since that awful day, our staff on the ground did an incredibly good job in the most difficult circumstances you could ever imagine.  It was the first time the LAS had to respond to four major incidents simultaneously, but they went about their duties calmly and effectively.

Yes there were mistakes made.  Some hard lessons have been learned, but the efforts of all our staff that day has made me proud to be able to say that I work for the London Ambulance Service.

Busy Saturday

I was offered overtime for Saturday on either the day shift or the night shift on the car. I chose the day shift, thinking that I at least wouldn’t get slaughtered running round after people who’d drunk too much and started fighting after the England match.

So I started at 6.30am, trundling around my area for a while, re-fuelling the car and generally enjoying the gentle start to the shift. Due to the heat, I was expecting a busy day of running around to people who’d collapsed with fainting and other heat-related problems. In the end, I did eleven jobs – my busiest shift on the car yet, and conveyed two patients myself as they were minor problems and because the service was so busy, there weren’t ambulances available to attend.

The most serious was a call to a 40 year old male with breathing difficulties. On the way, I considered it could be an asthma attack brought on by the heat. I walked into the house to find most of the family in the lounge calmly watching TV. The patient’s wife lead me through to the bedroom, where I was confronted with a deathly pale man. I immediately started him on 100% oxygen, as I asked him what had happened.
“I’ve been getting pains in my chest on and off for the last couple of days. I’ve also had pain in my stomach, and I can’t keep anything down.”
“Do you have pain at the moment?”
“No.”
I took his pulse – it was racing along far faster than it should be. His blood pressure scared me – 54/35. It was way too low. I laid him flat, and put his feet up on a box.
Then I got on the phone to control.
“Has an ambulance been assigned yet?” I asked the dispatcher.
“Not yet, nothing to send.”
“Can you ask Sector to GB it please – I need an ambulance here urgently, preferably a paramedic crew.” I gave him the obs I’d taken.
“Ooh blimey, yeah I’ll get sector to GB it.” GB stands for General Broadcast, and is a call to all ambulances asking if anyone is available to attend the call. Any crews that are just about to finish completing paperwork, and are reasonably close to the call will come up available and offer to attend it.

A couple of minutes later, control rang back and told me there was an ambulance on the way, but it was running a fair distance. He told me the call-sign and I breathed a sigh of relief. I knew the crew – one was a brand new paramedic who had just started her mentoring period, and the other I knew to be a bloody good paramedic.

I suspected he was bleeding internally somewhere, so while I waited, I felt his abdomen for any signs of bleeding and tenderness. If there’s bleeding in the belly, the abdominal muscles tense up to protect the internal organs. This is known as “boarding”. If there is tenderness, the patient tends to push your hands off his abdomen to stop it hurting. This is known as “guarding”. There was neither. I also felt for a pulsatile mass that could indicate an Abdominal Aortic Aneurysm but didn’t find one. (Click here for more information and a couple of diagrams)

When the crew arrived, I handed over, and stayed to help. This was going to be a difficult removal. The first choice for getting him out was going to be on the carry-chair, but we were worried about his blood pressure bottoming out when we sat him up. We decided we’d give it a go. We lifted him onto the chair, and immediately his eyes rolled and he started fitting.
“Quick, back on the bed,” I said and we dumped him unceremoniously back onto the bed. Almost immediately, he came back round.
Plan B. We got the scoop stretcher – a metal stretcher that we can put under a patient with minimal movement – and strapped him to it. We knew he wasn’t heavy from lifting him onto the chair, so we were satisfied we could get him out without asking for another crew to help – besides, we weren’t sure there would be one available.

We got him out without any further problems, and we got some IV fluid running to help restore his blood pressure. The crew took him to hospital on blue lights.

I don’t know the outcome – I’m hoping to be able to find out from the crew sometime this week. I’ll let you know.

**UPDATE**

Apparently, my suspicions of an internal bleed were confirmed. They found a Gastro-intestinal (G.I.) bleed. He will make a full recovery.