Monday, August 18, 2008

In At The Deep End

There's nothing like being thrown in at the deep end to see if you'll sink or swim.

That's pretty much what happened to me today on my first job in my new role.
The call was given as a 58 year old male who'd fallen over twice and now had rapid breathing.

On arrival, the man was sitting on his bed. He was alert, and breathing far too fast. He was also complaining of some back pain over his right kidney. I coached his breathing and calmed him down, and after questioning both him and his carer, discovered that he had a tumour on his right kidney, and was waiting to go into hospital for an operation to remove the kidney. He'd also had his medication changed in the last couple of days, and seemed to be confused as to what he should be taking and when. I couldn't rule out the possibility of an accidental overdose.

Although he didn't look acutely unwell, there was something about him that niggled my mind, but I couldn't put a finger on what it was. I asked my crewmate to go and fetch the chair - I didn't want to walk him down to the ambulance.

At the patient's request, I fetched his trousers for him, and he put them on. He stood up and fastened them up. It was then it happened.

He seemed to throw himself backwards across his bed. My immediate thought was perhaps he'd had a jolt of pain which had made him faint. However as I leaned over him to reassess him, I realised his rapid breathing had become slow, gasping and irregular - known as Agonal Breathing. This is seen when a patient goes into cardiac arrest. I quickly attached the defibrillator. If he was in ventricular fibrillation - a shockable heart rhythm - a rapid shock may get his heart beating again. He wasn't - he was in PEA, which looks like a normal heart rhythm on the screen but there's no pulse.
"Is he alright?" asked the carer.
"Err...not really," I replied as my crewmate appeared with the chair.
"Give me a hand to get him on the floor," I said to my puzzled looking crewmate. "He's suspended."

One of the rules for a cardiac arrest is the first paramedic on scene runs the resuscitation, regardless of who else turns up, unless it's a doctor that arrives of course. As he'd arrested in front of me, it was down to me to run the job.
So we got him off the bed, and as I started CPR, my crewmate rang control and asked for a second crew.
"What do you want out of your bag?" he asked.
"The intubation roll. I've set it up so it's got everything you'd need for a cardiac arrest," I replied.
My crewmate attempted to get IV access, but blew the vein as the patient had "shut down", which means his veins had contracted and were difficult to find.
It was quite a small room, and space was tight. At the head end, I was right up against the bed - no way I'd get low enough to see the vocal cords to intubate, so I grabbed an LMA, and put that in instead, and attached the automatic ventilator while my crewmate took over chest compressions.

Next, I got IV access in the neck - the External Jugular Vein (EJV). This went in, and I gave adrenaline to try and stimulate the heart back into action.
One of the paramedics on the second crew helped me to secure the cannula in place, but in doing so, I must have knocked the cannula either out or through the vein, because it blew. I muttered a few naughty words, and set about getting a cannula in another vein. At one point, there were three paramedics attempting to cannulate whilst the fourth did chest compressions. I finally got access in a vein in the back of the hand, and wasted no time in securing it down and ensuring it was working.
More adrenaline, and as the rate of the electrical impulses had slowed down, I gave Atropine, which blocks the part of the nervous system that slows the heart rate, and so should cause the rate to speed up again. It did, which was good. I set up and connected a bag of fluid.

We got the patient downstairs and onto the back of the ambulance. One of the paramedics from the second vehicle jumped in the back to give me a hand.
"Right, let's reassess everything," I said. I rechecked the airway to make sure the LMA hadn't been dislodged as we'd brought him out. It hadn't, we were getting a good CO2 reading, which meant that good ventilation was being achieved, and I could hear the air entering his lungs when I listened to his chest with the stethoscope. As I listened, I also heard something else - was that the heart beating?
"Check the pulse!"
The other paramedic didn't think he could feel one, but could see the neck veins pulsing which proved the heart was beating. I felt for the pulse - and found it. We'd got him back!
He still wasn't breathing for himself, so we left him on the ventilator. My crewmate jumped in the driving seat and picked up the microphone to put in the blue call to alert the hospital we were coming. "I'll put it in as a cardiac arrest yeah?" he said.
"No, post cardiac arrest - we've got him back!" I said.
"Stop messing about." Clearly, he didn't believe me, despite the fact I was just getting a blood pressure.
"No, we've got a pulse - put it in as post cardiac arrest."
"It won't matter if I just say cardiac arrest," he said.
"Yes it will - if he arrests again on the way to hospital, they won't stop the resus as soon as we get him there - they'll work a bit longer"
So the call was put in as post cardiac arrest.
He did lose his pulse again on the way to hospital, so more adrenaline, more fluid, and more CPR.

Putting the call in as post cardiac arrest did make a difference. As we got to the hospital, the patient was starting to show signs of having suffered an internal bleed, so the doctors tried giving blood to see if the bleeding was the cause of the cardiac arrest.

Shortly after, the electrical activity in the patient's heart stopped altogether. He was in Asystole.

Resuscitation was terminated - he'd died. I was disappointed, but not unduly upset. You can't let yourself get upset when a patient dies. You simply cannot save them all.
My colleagues reminded me of this, and reassured me the resus had been a good one that I had run really well.
"After all, you did get him back at one point," said one.
"We got him back you mean - it was a team effort," I said.
"But you ran the team. It was your decisions that we followed, so technically you got him back. And you got an EJV in - it doesn't matter that it was lost for whatever reason, you still got it."

I felt better. Then I looked at my new paramedic bag. It was completely trashed. My intubation roll had bits strewn all over, my cannulation roll had been opened and trashed when three of us were trying to cannulate, and my drugs pack had only three adrenalines left.

"We need to get your bag restocked," said my crewmate. I nodded, and booked us off the road to go back to station to put my bag back together.

It had been a good job, and when thrown in at the deep end - I'd swum. It was a good feeling.

Sunday, August 17, 2008

Title Changed

Yep - it's finally happened. I've finished my hospital placement, and can now apply for my registration with the Health Professions Council.

I start my mentoring tomorrow, which means although I'm not yet registered, I can use my new paramedic skills as long as I'm being supervised by a registered paramedic. As it's gonna cost me £86 to register, it's gonna have to wait until pay day in 10 days time before I can apply.

So the blog name has changed, although the web address remains the same for simplicity.