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.


Blogger Patrick said...

Well done. You may think about placing a large piece of tape across the tubing as soon as you get the line patent, then work on the dressing. Especially in an arrest when there are so many moving parts.

9:41 pm  
Anonymous Anonymous said...

For exactly this situation, an Australian air ambo doc showed me the technique of "inverse intubation", where the rescuer straddles the patient's torso, and intubates from the opposite end to normal. It's surprisingly straightforward, but not taught much in theatre placements - for obvious reasons!

10:23 pm  
Blogger Chris said...

Well done.

Don't know whether its the same technique as anonymous mentions, but I've heard of a technique that can be used to intubate a sitting casualty, such as a trapped car wreck victim. Probably is the same, just from a different angle

11:18 pm  
Blogger Joe said...

You can't win them all. I'm 100% certain that you all did your best.

Also - a belated congratulations on passing your placement. I'm certain that you'll make an amazing paramedic, who will now have the ability to make that little bit more of a difference to his patient's lives. It's truly a shame that the government would rather spend it's money on lay-abouts, and war than on rewarding what I believe to be societies most valued and overlooked members, the emergency services.
If I didn't turn up to work, then IT systems would go down, if you didn't, people would seriously suffer.
I've been seriously considering training to become a paramedic for quite some time. Your blog, amongst others have convinced me that it is something that I truly want to do, although I want to get rid of the big debt that is called mortgage first! Thank you for writing, and thank you for turning up to work in the freezing cold and the boiling hot, taking risks that nobody else would want to take, going into darkened rooms full of dirty needles, and their owners, and looking after us, the public!
If anyone EVER tells you that they pay your wages, explain that you pay roughly 30% tax too, so you technically only cost the public 30% of your wage! Also, take their photo and send it my way, I'll ermmm change their password or something!

11:58 pm  
Anonymous Anonymous said...

Bravo! You should feel proud of yourself!

5:01 am  
Anonymous Mark Myers said...

Wow - what a call on your first day with the bag! Well done. I actually remember the blue call (I didn't take it but was on the radio shortly afterwards and saw the call) and you going off the road afterwards but I didn't twig that it was you as you weren't at your usual station and I didn't realise you were back yet!

10:30 am  
Anonymous Anonymous said...

well done, it seems that some of your colleagues need the kick up that backside that working with a keen and motivated newly trained para gives them. i think you should have been a medic ages ago and your years as an emt have been a waste for the people of london. with such a positive attitude we can sleep a little safer knowing that you are doing your best to rejuvenate the tired attitudes of some older medics and create a bit of a stink when they roll out the same old excuses.

9:35 pm  
Anonymous Anonymous said...

Fantastic work mate, sounds like to "ran" the arrest well. shame about the outcome, but these things happen, regardless of what you do sometimes they just don't want to stabilise. I had a guy who arrested 3 times with me and he got every drug I had in my bag, but it was his time. You shouldn't put yourself down at all as you still got him back and did everything you could. Well done.

2:31 pm  
Blogger ThePaddlingDoc said...

Well done on a fab job, and belatedly, on getting your bag! :)

12:40 am  
Anonymous Anonymous said...

Congratulations on a good working job.

I hope your colleagues were understanding of your 'newness' to the role and supported you.

Nothing worse than colleagues who think their sh*t doeasn't stink.

Well done you

1:54 pm  
Anonymous Anonymous said...

I'm interested in your opinion on this. As a Christian I believe that God called this person home.

How do you justify going against what God wants? He will punish you.

Surely you are a Christian as you work in a caring profession.

I thought all the Ambulance Service was Christian. I'm so confused about this.

8:53 am  
Anonymous Anonymous said...

wow what a first job!! so many congrats on becoming a's this kind of job that scares the living daylights out of me. I am about to embark on a 3 year course in paramedic science at Uni, it's not my preferred route, some years experience as an EMT I think would have been better but unfortunately that's not an option these days. I am soooooooo scared, nervous but incredibly excited all in one. I can not imagine being in your shoes and lets face it, will never profess to being so - your experience expertise and professionalism are qualities I pray that I too can attain in the future. Good luck in your new career - you deserve every success :)
Maz x
PS to the Christian - I think you will find that God did get what he wants.

8:56 am  
Anonymous Anonymous said...

As a Moslem I find the Christian remark to be most offensive. A follower of Allah would not question a decision of the almighty. We are here to serve and this life is only a transition between now and the afterlife and immortality for Moslems.

I'm an EMT yet I work to save people everyday, even Christians, when I know is it futile as Allah does not seem them worthy of a place at His side. I shall be at His side, in'shallah.

Sometimes you have to put differences aside. Our place is not to judge, that is the will of Allah, not your false prophet

9:57 pm  
Anonymous Anonymous said...

The point is that if God calls someone to Heaven, who are we to accuse him of error? God has his plan for us all and we can't do anything to stop or change that.

Please don't call me 'The Christian' as that is very offensive. I'm not a martyr. This is a Christian, God Fearing country.

9:59 pm  
Anonymous Anonymous said...

I was born and raised a Christian too and have my beliefs. No offense was meant by what I said and I apologize if it did. However, I personally don't think this is the site for us to dispute religion. I am a great believer in all that is 'meant to be' and I reiterate that in this case - yes, it was this chaps 'time'.

Once again, congratulations Steve on an outstanding job.

12:18 pm  
Anonymous Anonymous said...

I am Zoroastrian and I find your Christian bias unforgivable. How can this Blog be neutral if all your readers are Christians and Moslems. These are not recognised religions in my culture.

I love this Blog and check every day for updates. The life of a Paramedic is so exciting. I have so much respect for all of you.

You are all true heroes to me

Bless you

3:02 pm  
Anonymous Anonymous said...

Wow, good job. Thats really got to be a hard situation to be in.

1:35 am  
Anonymous Anonymous said...

You felt the neck veins pulsing?
veins don't pulse ....
and your a paramedic
im only a student at 6th form and i know that.

5:48 pm  
Blogger Steve said...

"but could see the neck veins pulsing"

I suggest as a student you learn to read

8:00 pm  
Blogger Steve said...

and yes, neck veins *do* pulse

8:28 pm  

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