Thursday, August 03, 2006

Post Cardiac Arrest

I went to a "suspended" patient the other day. It was given as "68 female, ?suspended, looks purple, CPR in progress".

In English, it read "68 year old female, in cardiac arrest, possibly beyond help, but someone's having a go anyway."

It was just round the corner from the hospital we'd just become available at, and we were on scene in 2 minutes, beating the 2nd ambulance and the FRU. We were met by a tearful young lady who led us up two floors to the patient. It's an unwritten law in ambulance work that the poorliest patients will always be on the top floor of a house or block of flats.

A neighbour was knelt in the doorway of the flat, doing good compression-only CPR on our patient. She explained that she checked in on the lady daily, and had opened the door to find her laying on the floor, looking as though she'd collapsed off the toilet - you may be surprised to learn that this is common in older people. I've been to several old folk who've found the strain of going to the toilet just a little too much and virtually dropped dead off it.

I took over CPR, and as I was getting good air entry using our bag and mask resuscitator, Graham decided to cannulate before her veins shut down. The second crew arrived as I was switching on the Defibrillator, which showed the patient's heart had what appeared to be the normal electrical activity, but very very slow, and no pulse. This is known as PEA or Pulseless Electrical Activity. It was vital we got IV access to give Adrenaline to stimulate the heart and to start IV fluids to replace blood volume. The second paramedic started to help Graham gain IV access, while I continued CPR. Then disaster. The patient's airway filled with vomit. Suddenly I was back at "A" in our "ABC of Resuscitation". A=Airway, B=Breathing, C=Circulation.

I suctioned the vomit out, and after making sure the airway was now clear, I started ventilating the patient again. She filled with vomit again. Bugger - I still couldn't get passed "A". As luck would have it, the FRU arrived, with another paramedic on board. He poked his head round the door, and was greeted with me asking him to intubate - put a tube down the trachea to secure the airway. It wouldn't matter if she vomited then - the tube would stop any of it going down into her lungs and drowning her.

It all went well after that - to the point where we were just about to move her when there was a rhythm change on the screen. It showed a good regular electrical rhythm at a good rate. I felt for a pulse at the carotid artery in the neck. I found it! We'd got a cardiac output back. All we had to do now was breathe for her. We connected the automatic ventilator. We then carried the patient head first downstairs to let gravity help keep oxygenated blood going to where it was needed most - the brain. As the others loaded her onto the back of the ambulance, I put in the "blue call". I did it now, because we were a minute - two at the most from the hospital, they'd need time to get the team together, and it would be about 4 or 5 minutes before we were ready to go. I pressed the red priority button on the radio.

"W701 go ahead with your priority," said the dispatcher.
"Thank you, it's a blue call to St Steven's Hospital, 68 year old female, post cardiac arrest, now respiratory arrest. Intubated & cannulated, ETA 5 minutes."
When we put in a "blue call", the radio operator in control reads it back to us to make sure they've got it right. We then either correct anything they've miss-heard, or confirm it's correct.
There's been an influx of new people in control, so we're getting new and nervous voices on the radio, and they're obviously making mistakes along the way as they learn the ropes, but this readback was a blinder.

"Roger, that's blue to St Stevens, ETA 5 minutes, 68 year old female, post cardiac arrest, now severe DIB." I was sorely tempted to say "actually she's not having severe difficulty in breathing - she just isn't breathing", but I knew I was talking to a "newbie".

"Negative, I'll repeat the blue call for you..." and I repeated the whole call. This time it was read back fine, and I confirmed it was correct and thanked the dispatcher. Even so, the information that the patient was intubated and cannulated hadn't been passed on to the hospital, but that was a minor point really. I put it down to the suprise that we were taking in a patient who we had got a pulse back on. It doesn't happen very often, but it is happening more since the new resuscitation guidelines have been introduced.

The patient arrested again just as we were leaving scene, but we'd got an output back again just before we took her off the ambulance at the hospital.

Sadly, the patient lost her pulse again in hospital, and this time they were unable to restore it.


Anonymous Mark Myers said...

Damn, that was *nearly* a happy ending, but well done anyway. I think that on one level the "newbie" radio op was right - the patient obviously was having severe difficulty breathing if she couldn't manage it at all!

7:42 am  
Blogger Spike said...

Bummer that she kicked after all that.

8:22 am  
Blogger rob said...

Mate it sounds like you all gave it a pretty good shot - sometimes it is just someones time to go.

11:41 am  
Anonymous Anonymous said...

A very good read again, as usual!

It's interesting to read different Ambo Trust's ways of doing things. Up here in the North West we speak directly to A+E Triage on the 'red phone' to give info. This cuts out any chance of details not being relayed properly.

That's the theory anyway...!

11:43 am  
Blogger Rosey said...

"It doesn't happen very often, but it is happening more since the new resuscitation guidelines have been introduced"

That is really good to know that it appears to be better, even if even more tiring!

5:09 pm  
Anonymous Ben said...

'It doesn't happen very often, but it is happening more since the new resuscitation guidelines have been introduced'

That's quite interesting. Do you think the new guidelines really do have a noticeable effect then? Presumably that was why they were changed so radically?

Brilliant blog!

3:40 pm  
Blogger Steve said...

There certainly appears to have been a rise in the number of people "blued in" as "post cardiac arrest".
Whether these people have gone on to survive to being discharged from hospital or not I don't know.

Time will tell.

8:12 pm  

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