I was going to post about how much I hate Christmas, but Bill Sticker (an always readable and enjoyable blog) has beaten me to it.

We in the LAS will soon have a new drug to play with.

Morphine.

Morphine is an excellent painkiller, in our case it will be given through an injection straight into a vein causing nearly instant relief of pain. It's a pretty safe drug in that few people are allergic to it, and even if we make a huge mistake and overdose someone, it is really easy to reverse using another drug (Narcan) that we have been using for years.

But all is not perfect with this drug. It's potency, and the ability to get people 'high' means that it is a 'Controlled Drug', with whole books of legislation covering it. It should be stored in a double locked wall safe, every usage must be well recorded and every use should be witnessed by two professionals.

This is a bit of a problem for the ambulance service. While we have double locked wall safes on station to keep the stock on, the ambulances are a bit short on these. Instead we have come up with a plan, that for reasons that will are obvious, I won't be mentioning here.

Why won't I mention where we are keeping it? Let me put it this way, junkies love morphine, especially the nice pure, safe stuff that we will be carrying. Junkies also have a habit of turning to crime to get their 'fix'. We don't want junkies stealing our Morphine, if only because it will mean filling in a tree-load of paperwork.

So the Morphine is safely padlocked and hidden away. Although to be honest, the security is all in the hiding, rather than in the padlock...

Even though Morphine is a paramedic only drug, meaning us poor lowly EMTs can't give it, we all have to undergo the additional training. The reasoning behind this isn't because we can't trust the Paramedics not to muck it all up and give the wrong dose, but because we have to sign our name to a bit of paperwork every time Morphine is given to say that the patient got the right dose, and that our Paramedic crewmate isn't shooting up in the carpark/selling it on the street.

So we have all had a look at the drug information sheet, we had a laugh at one of the contraindications (reasons when not to give the drug) as being described as 'rare as rocking horse shite'. You wouldn't get that in a nursing memo.

The issue I have with the use of this drug is in its dosage and administration. For the medical people out there, the dosage is 2.5mg over two minutes, repeated every 5 minutes (I may have to amend this later, I've left the information chart at home). For the non-medical people, this is a dosage that seems almost homeopathic in nature. It is a tiny dose. I'm considering all the times in hospital we'd give 8mg immediately, and another 2mg to 'top up'. While I understand that too much can cause you to stop breathing, we do have the 'antidote' sitting right next to it.

While I understand the concerns of our Clinical director, I hope that this will get reviewed at some point in the near future.

What has been done right is that the drug comes in pre-filled syringes. We won't have to faff around with needles, bottles of water, and shaking up bottles of powder. Instead it is a simple process to pull out a syringe, flip off the top and give the patient some pain relief.

So we are moving forward with our pain relief treatments, which can only be a good thing.

Although I don't think we will be getting paid any more for our new skills...

Well, extended licensing laws are in, which I’m afraid will mean more disorder on the streets, couple that with the seasonal increase in illness, and the ice on the roads that means I can’t drive as fast as I normally can and what you get is an increasing failure to reach our government’s benchmark time.

Remember the Great and Powerful God ORCON?  Where we have to reach most high priority calls within 8 minutes?

We aren’t on target for it this year, and unlike other years I don’t think that “extra effort”, as our management call it, will save us.  There is a shortage of ‘flu vaccinations, so more at risk people will get ill, we’ll be going to more alcohol fueled violence because of the new licensing laws.  It is thought that there will be a colder than average winter, so, because of ice, our vehicles won’t be able to drive as quickly and as safely as normal.  And Agenda for Change has hit morale hard especially given the uncertainty of payment for overtime shifts (which are needed to cover staff shortfalls).  Oh and more people are calling us for more crap reasons every day.

We are doomed.

But worry not, patients won’t be doomed, remember, this eight minute ORCON time has absolutely no basis in health, or prevention of death.  If your heart stops then you have, at best, five minutes to get it going again, after eight minutes, I’m afraid you are more than likely dead, and are going to stay that way.  Most calls clinically either need a “faster than five minutes”, “faster than half an hour” or “Sometime in the next couple of hours” response.  Eight minutes is some figure plucked out the air.

So don’t worry, all it means is that the best Chief Executive the LAS has ever had will lose his job, and we won’t get given as much money to fund the service.  After all you wouldn’t want to fund a failing service would you?

Stupid $&%*£^&*!!! government.

All I can do?  Get there as quickly and safely as possible, and make sure the patient doesn’t get any worse.  I can only do what I can do…

Absolutely nothing of interest last night, the most interesting job being someone with a two month history of muscular back pain that had been getting worse that day.

“So”, I asked all innocently, knowing full well the answer I would get, “Have you taken any painkillers as the pain got worse?”

I wasn’t surprised by the answer she gave.

Then two calls to two regulars, one of which had only been discharged from hospital three hours previously.  Then finally to a patient who was actually sick, but that would only be because he earlier discharged himself from hospital against medical advice.

There is nothing more disheartening than to attend to a patient, and to see them clutching a little pink slip of paper.  “Why so?”, I hear you ask.

When you visit the local hospital, and the doctors and nurses are finished poking and prodding you they decide if you need to be admitted to hospital, or if you can safely be sent home with treatment.  If you are to be sent home they give you one or two bottles of pills, explain how the pills work, and then write a letter to give to your GP (family doctor).  The letter tells your GP exactly what tests they have done, and the treatment that they have prescribed.

This letter is on a pink bit of paper.

All too often I get called to a patient who has been seen with a minor condition earlier in the day, but after one dose the medicine hasn’t cured them, this is most common in the case of antibiotics, but you will also find people who tell me that the pain has gotten worse, and that they don’t like to take the painkillers the doctor has prescribed.

Inevitably they still have the discharge letter with them.

In these cases all we can do is take them back to the hospital they were seen in just hours ago, so that the doctors and nurses can repeat all the tests they ran the first time.

Sometimes this happens three of four times.  And each time they call an ambulance.

Don’t get me wrong, sometimes things do indeed get worse, and in that case a return trip to hospital is warranted.  But in most cases I come across it is simply the inability of a single dose of a tablet to make your symptoms disappear instantly and permanently.  Still on the up side, it makes diagnosis really easy, all you have to do is determine if the symptoms are the same as the last time they were in hospital, or if they have gotten worse or changed in any way.  If the symptoms are the same, then they are unlikely to drop dead in the back of the ambulance (thus causing a lot of unnecessary paperwork).

I have two or three days off now (don’t ask me how many, I need sleep before doing any serious thinking), so I may raid my ‘Ideas File’.

It is, to put it bluntly, cold enough to freeze the balls off a brass monkey, which is really cold. No matter, it keeps the drunks off the street...well, mainly it keeps the drunks off the street...

I got sent to a '50 year old man, fallen in street. blood from ear'. The location was given as 'Outside Red Lion Public House'. I could guess what had happened.

I pulled up, leaving the headlights pointed at the patient who was laying on the ground covered by a blanket borrowed from the pub. surrounding him were:

A lot of police (about five or six officers).
Two sons, both of which were crying and worrying about their dad dying.
Some bystanders, most of them had come from the pub, and...
One off duty fireman, who was clutching the patient's hand.

"Fair enough", I thought, "best get to work".

The lighting in the street was bad, but my headlights, and some police torches made that a little better. The patient had been celebrating in the pub and had tripped over a kerb while trying to walk home. He had possibly been knocked out, and there was some blood coming out of his left ear.

The first thing that you think of when someone who has fallen has blood coming out their ear is that they may have fractured their skull. With a fractured skull you will sometimes get cerebro-spinal fluid coming from their ear. Cerebro-spinal fluid is the liquid that your brain and spinal column float in, and should not be outside the body at all.

The standard test is that blood and C.S. fluid don't mix, so you'll see yellow streaks in the blood. Given the poor light it was hard to see, so I fell back on an old trick. You stick your (gloved) finger in the blood and if there is C.S fluid in it, the blood will feel 'slick'.

The side effect is that your gloves get covered in blood. It was cold. I wanted to wipe my nose. My gloves were right out, and I wouldn't like to wipe my nose on the cuff of my jacket because it's a disgusting thing to do, and also (mainly) because my jacket is horribly unclean.

The patient also had a large swelling to the back of his head, and because of the way that he had fallen, I couldn't rule out an injury to his neck. In a perfect world I would have liked to have put a cervical collar on him to immobilise his neck, but this is far from a perfect world. A cervical collar only really immobilises a patient if they want to be immobilised, in a drunken or combative patient this will often make them thrash around trying to get it off. So often a better course of action is to tell them to lay nice and still and leave the collar until you need to move them.

The off duty fireman had obviously had a bit of first aid training, because he was keeping the patient constantly talking. This was fine, as it meant I didn't have to talk to the patient too much, apart from assessing him, and getting his details.

The crowd were pretty well behaved, I kept hearing one of them moaning that the disabled ramp to the kerb was the reason behind the fall, and that they were 'bloody dangerous'. I didn't want to mention that walking while drunk was perhaps more of a contributing factor...

I threw another blanket over the patient because there was little else I could do until the ambulance turned up. Unfortunately I'd been waiting a long time for ambulances all night, and I suspected that this would be the same.

My nose still threatened to drip on the patient.

Suddenly behind me was a flash of a high-visibility jacket, "Excellent", I thought, "the ambulance has turned up".

But, no, it was one of our duty managers come to see how I was doing. They knew the ambulance would be some time, and wanted to make sure I was alright.

"Ah", he said, "I can see you have everything under control", and left.

He could have wiped my nose for me...

By now I was losing sensation in various small, but important bit of my anatomy. I looked at my watch and saw that I'd been with the patient for over thirty minutes, I was cold, but at least I wasn't laying on the cold wet floor.

Finally the ambulance arrived, they had travelled from out of their area to attend this call, and I was very grateful for them turning up when they did. We put the collar on the patient, strapped him to a stretcher and loaded him into the back of the ambulance where it was much warmer, and I could remove my gloves and wipe my nose.

Can you see what was uppermost on my mind?

The patient was swiftly taken to hospital, and as I prepared to face the crowd of people and explain exactly why the ambulance took so long to arrive, I was instead mobbed by people who wanted to shake my hand and thank me. None of them were bothered by the forty minutes it had taken the ambulance took to arrive, and they were actually happy that we had done our jobs, accepting that as it was a Friday night we might be a bit busy.

It was only later that I found out that there had been another shooting in the area (some drunk men had been apparently been thrown out of a pub, they then returned and fired a pistol through the pub windows, hitting a barman).

First off, my sympathies for everyone concerned in the murder of the West Yorkshire policewoman. I heard about it when I was sitting in the FRU listening to the news on the radio. We work with the police a lot, and most of them are really good people. I couldn't do their job, as at least most of the time people are happy to see us.

Bit of a busy night, partly I think due to the frost on the roads. I know that I wasn't able to drive too fast, as I was occasionally fishtailing across the road.The first job, aptly enough, was a man who had driven his car into a bus. The car was an utter mess, and I would have wanted to immobilise him in the car and have the fire service cut him out. I say would have wanted because once the crash was over, he'd run off...

So I'm guessing that the car was either stolen, or more likely he just didn't have any insurance, road tax, or a driving license.

A couple of 'nothing' jobs, then another car accident. Some bright spark had decided to borrow his friend's car, and then lose control of it on our main 'A' road. The car, yet again was a write-off, and the driver kept telling me that he was going to 'get done', because he didn't have any insurance... or a driving license.

Can you see a pattern?

I then had to go to a 13 year old child with a progressive and ultimately fatal disease. He was having difficulty in breathing due to a chest infection, and when I got there his breathing was incredibly irregular, and his oxygen levels were only 67% of what they should be. Even with high flow oxygen his oxygen levels were only just adequate.

There was a bit of worry about what I was going to do if he stopped breathing, as he had a 'Do not resuscitate' order, but it was a year out of date.

Thankfully it never came to it, and I was very happy when the crew arrived to take the child to hospital.

My final job was a bit of a nasty one. A young man (a cleaner) was found not breathing in a local supermarket. The call woke me from a light sleep, and as I mentioned, I couldn't drive too quickly to the call. I got there as the ambulance crew arrived, and we were led through the warrens of the supermarket by the cleaning supervisor.

The patient was large, covered in blood and vomit, and wasn't breathing. We attached our heart monitor, and it showed no activity in the heart at all.In the process of doing CPR, everything got covered in bloody vomit. As I type this, my jacket is in a plastic bag, waiting to be taken home and washed.

We got him to hospital, but they were unable to save him.

Once more it was a patient where no-one seemed to know him (no-one there knew his name, although they had been working with him for a couple of days), and I don't think he had any identification on him.

A tricky job for the police.

A busy night, but as my mum would say, "At least it made the time go fast".

The ambulance was only a few minutes away from the hospital, the oxygen had been swapped over for Entonox, and the patient appeared to be stable.

We give Entonox (a painkilling gas that has lots of oxygen in it) to both load up the blood cells with oxygen and to ease the pain, which in turn reduces the strain on the heart.  The other pain relief that we have is Tramadol, or Numbain, both of which can only be given via the vein, and so are a Paramedic drug only.  Both of which are…well…less than effective as the doses we are allowed to give are quite small.

Paramedic in London will soon be getting Morphine, but that is a topic for another post.

Joan was feeling a little better, although the pain was still there, it didn’t seem to bother her as much, and she was sure she was in safe hands.  She felt the ambulance pull to a stop, and the back doors flew open.  Standing outside were two young women in blue pyjamas.

“I wonder where the doctor is”, thought Joan.

The ambulance crew did something complicated to the underside of the trolley that she was laying on, and it slid out into the air.

Joan was trying to listen to what the ambulance people were saying, something like ‘Anterior’ and ‘GTN not given’, strange jargon like ‘BeeEmm’, she didn’t have a clue what they were talking about, she hoped that the nurses knew.

“Hello”, said one of the young women in the pyjamas, “I’m Doctor Rushkov, I’ll be looking after you”.

Joan thought that the woman was too young to be a doctor.

She was wheeled on the trolley into a big white room, chock full of strange equipment.  Nothing seemed to make sense as she was physically dragged from the ambulance trolley to the hospital trolley.  The people around her continued to talk over her head, reeling off numbers and phrases that Joan had no chance of understanding.

“I’m just going to put a little needle in your hand”, said one of the women.

There was a sharp scratch and the doctor started to talk to Joan.

It’s one of the things that we tend to be not that good at – when we have a seriously sick patient, we are concentrating so much on what their ‘numbers’ are doing (blood pressure, pulse, oxygen levels), and on our treatment, that we can sometimes treat them like lumps of meat.

Ambulance crews however have a solution to this.  We talk utter rubbish.  I don’t meant that we lie to our patients, but instead we have a number of stock phrases that are used to reassure, and explain things to patients.  It works pretty well.  It’s not that we don’t want to have a serious conversation with you, just that our minds are concentrating on more serious things.

Of course the seriously ill patients tend not to listen to us anyway, as they are often very frightened.

The doctor, young enough to be Joan’s granddaughter was talking about the treatment she was going to give.  She’d started off by saying that she was too unstable to be moved, Joan wasn’t sure what this meant – why wold she be moved anywhere?  The doctor then mentioned a drug they were going to give her, but that this drug may cause a stroke.  Would Joan give them the go ahead to use it?

Joan just wanted the pain to stop, so she said yes, and within minutes a new bag of fluid had been hung above her head.

There are two main treatments for a heart attack in London.  The first is via a drug called a thrombolytic, this drug is given in a bag of fluid via a vein, it takes around 40 minutes to run* and it ‘breaks down’ the clot that is blocking the artery to the heart.  The only problem with this is that in around 1 in 1,000 patients suffer a serious side effect.  This can range from internal bleeding to a stroke.  For this reason the drug is often given in the safety of a hospital.

Outside of London, some ambulance trusts give these thrombolytic drug to their Paramedics so that they can give them out on the road.  The reasoning behind this is that every minute the artery is blocked, more of the heart dies, and in places where hospitals can often be an hour or more away, it would be better to start the treatment while carrying the patient to hospital.

In London there is another form of treatment, the ‘Angioplasty’.  This is a surgical technique where a device is threaded up through the leg into the heart where it physically clears the blood clot.  This has less chance of a side effect, and works a lot better.  In East London there is one hospital that does this procedure, and because of this ambulance crews are being trusted as better clinicians.

It works like this.  If a patient is having a confirmed heart attack, so you need to be able to read the heart trace ECG.  Then you can bypass hospitals with an emergency department, to go straight to this hospital.  So hopefully more people will survive their heart attack.  It’s a good idea, but a little scary to drive a critically ill patient past a hospital to reach one further down the road.

In Joans case the ambulance crew were so close to the emergency department of their local hospital, and Joan was so unstable, they decided not to go to the specialist hospital, but instead head for the normal emergency department.

Six months later and Joan was still getting out of breath climbing her stairs, she had to take six different types of tablets every day, and often found her ankles swelling at night.  She supposed that at least she was alive, and there were people who had much worse damage done to their hearts.

She had been told that part of her heart had died, and that this is why she was lacking in the strength that she had previous to the heart attack.  Pretty much everyone who had a heart attack felt weaker afterwards, she had been told, but she was weaker than many because of how large a patch of her heart had been damaged..

Every now and then she got a little twinge in her chest, but a squirt of her spray under her tongue, and a little rest soon sorted it out.  She was waiting to have surgery to open up the arteries of her heart, and it couldn’t come soon enough.

And that’s the end of these series of posts, it’s been an interesting thing to write especially as I have just used my normal ‘churn ‘em out’ style of working.  I think it’s worked reasonably well, at least it’s kept the ‘content’ coming while I’ve had my time off.  Tonight I start the first of four night shifts, and with any luck I’ll have some interesting tales of daring-do to relate.

Or maybe a moan about Maternataxis…

*I’m running off my memory of hospital treatment now – things may have changed.

 

The EMT (Emergency Medical Technician – like a Paramedic, only not paid as well…) was very relieved to see the familiar yellow form of an ambulance pull up outside Joan’s house.  He went and opened the door, and mimed pushing a wheelchair to the crew getting out of the vehicle.

There are a couple of ways to lose your job working for the ambulance service, one of these ways is to walk a ‘chest pain’ out to your ambulance.  The patient goes on our carry chair, and straight onto the trolley in the back of the ambulance.

The EMT finished telling the crew all that he had discovered, the crew, not being stupid, also only needed to take one look at Joan to realise that she was seriously ill.

They wheeled her quickly to the ambulance, where they explained that they were going to take a look at what Joan’s heart was doing.  Joan didn’t care that they wanted to put sticky dots on her naked chest, she was feeling too ill to worry about being topless.

One of the things that we in a London Ambulance Service can do is a “12 lead ECG”, this is a detailed electrical reading of the hearts activity.  We need to get the patient topless, then stick a number of electrodes to the front of the patient’s chest.  The machine then prints out a pretty little picture of what is happening with the patient’s heart.  Joan’s looked a little like this.

The real skill comes from understanding what all those squiggly lines mean.  We run a two day ECG reading course, where we are taught to recognise the seriously bad things that can happen to someone’s heart.  When we first trialed the reading of ECGs there was a test between the ambulance crews and the junior accident and emergency doctors.  The ambulance crews got more ECG interpretations right than the doctors.

Twice…

In Joan we are looking for something called the ‘ST Segment’. 

In a normal healthy ECG this part of the line should look like this.

In Joan that part of the ECG looked like this.

         

Can you see how the rightmost part seems raised?  This is one of the signs of a heart attack.  For us it is a ‘red flag’ that tells us to get the patient to hospital in as quick a fashion as possible.

The ECG machine spat out a pink piece of paper.  The ambulance crew both read what it meant immediately.  Joan was having a confirmed heart attack.

The driver went through the cabs dividing door an sat in the driving seat, she started the engine and hit the ‘priority’ button on the radio.

“J201 calling priority, go ahead”, came the voice over the radio.

“Afternoon”, the driver said into the mike, “Can you show us Blue into Newham hospital, we have an eighty two year old woman with confirmed MI via ECG, BP is 88 over 50, pulse is 40, O2 sats are 99 on O2, BM is 5.2 and our ETA is two minutes”.

The radio operator repeated it all back to the driver, and finished with, “that’s being done for you now”.

The ambulance attendant was sitting in the back, keeping a watchful eye on Joan, while explaining that they were going to use the sirens to get Joan to hospital, and that when they got there she was going to be the centre of attention for a lot of doctors and nurses.

The ambulance pulled away, blue lights flashing and the driver gave a quick wave to the Rapid Responder who was finishing up both his paperwork and the cup of tea he had in a travel mug.

Now that ambulance crews can interpret the heart tracing of an ECG we have two options as to which hospital the patient can go to.  We can run them to the nearest hospital, where they will receive a drug to break up the clot in their heart, or we now have the choice of taking the patient to the nearest hospital that provides a primary angioplasty service.  An angioplasty is a medical way of opening up the blocked heart artery.

…but more on that tomorrow…