The FRU pulled up outside Joan’s house, the (stunningly good looking, heroic, intelligent, and did I mention GSOH) EMT stumbled out, grabbed his bags and made his way to the front door where he rung the doorbell.

He was met by a woman in her eighties, she was pale, she was sweaty and she really didn’t look too well.

“Sit down luv”, said the EMT, “and tell me why you’ve called me”.

“Well”, she said between breaths, “I’ve got this pain in my chest…”

People who are having a heart attack sometimes look like they are having a heart attack, what I mean by this is that they go into shock.  Shock is defined as a lack of oxygen to the tissues and organs of the body, often this is what happens when you lose a lot of blood, and there isn’t enough blood in you body to adequately keep your organs fed with oxygen.  Sometimes however, you get cardiogenic shock, which is a failure of the heart to pump sufficient amounts of blood to your organs.

Roughly 1 in 10 heart attacks result in cardiogenic shock, they are often heart attacks that affect the large left side of the heart.  The left side of the heart is the part that pumps blood all around you body, so it has quite a lot of work to do.  When the supply of oxygenated blood to that side of the heart is blocked, then the pump starts to falter and die.

This then results in the classic ‘look’ of a heart attack.  The patient is pale and sweaty, they breath rapidly, and look blue around the lips (cyanosis).  Their fingers are often stone cold, and they may be a bit confused.  All this is the bodies response to a lack of oxygen.

The (did I mention heroic?) EMT listened as Joan told him about the pain starting about an hour ago, and that it seemed to travel down her arm.  While he was listening to her he started to assemble an oxygen mask.  Putting it on Joan, he explained that it would make her feel better.

Oxygen is important to the organs, so we want to make sure the patient is getting plenty, this is why we put the patient on oxygen.  It can often make them feel better, although I’m not too sure if this is because of the oxygen, or because someone is ‘doing something’.

While reassuring Joan, the EMT (did I mention he is tall dark and handsome?) checked through her previous medical history, he had a little look at the tablets that she took, and found that she was on a minor treatment for high blood pressure and nothing else.

“Any allergies Joan?”, he asked.

“Only Penicillin”, she replied, “it makes my stomach upset”.

“Alright Joan, I’m going to give you some medicine”.

There are two medicines that we give ‘on the road’ to patients who we think are having a heart attack.  Aspirin and GTN.

Aspirin was discovered to reduce your chances of death from a heart attack by 23%, it works by making the parts of your blood that want to stick together to form a clot (which will then go on to block an artery) less ‘sticky’.  So we give 300mg of aspirin to pretty much anyone we suspect of having pain related to the heart.

So aspirin is given unless the patient is allergic to it, or if they are on a better ‘anti-sticky’ drug.

It is important for me to say, that most patients don’t know what ‘allergic’ means.  An allergic reaction is something life threatening, and will make you incredibly ill.  An allergy is not “it gives me an upset stomach”.  It is really important for the medic on scene to determine if the patient is truly allergic, or just doesn't like taking the drug.

Trust me, 23% reduction in death is worth an upset stomach.

While Joan chewed the aspirin the EMT checked her blood pressure, 88/50, not good.  The other drug that he wanted to give would have to wait.

The other drug we give is GTN (glyceryl trinitrate).  The GTN we give is a little spray bottle, and is again used when we suspect that the pain a patient is feeling is related to their heart.

GTN works by relaxing the blood vessels in the body, it makes then a bit more ‘floppy’ and by extension they get a bit larger.  We are hoping that the blood vessel gets large enough that a bit more blood can flow around the clot, and supply the tissues of the heart with the much needed oxygenated blood.

Unfortunately, the drug has a side effect of dropping a patient’s blood pressure.  so the patient needs to have a fairly good blood pressure to start with, otherwise we might lower their blood pressure so much that the brain wouldn’t receive enough blood and the patient faints (or worse).  In the case of Joan, her blood pressure is too low, so the EMT can’t give the GTN.

The treatment done, all that was left was to wait for the ambulance.  The EMT was getting a bit nervous.  This woman needed to be in hospital, not in her living room.

He breathed a sign of relief, if he listened carefully he could just about hear the familiar sounds of a siren approaching.

Joan was in the garden hanging out the washing, she did the laundry as regular as clockwork.  Her life was normal, and had been so for the last twenty years.  She was looking forward to seeing her grandchildren later that week.  It was a sunny summer afternoon, so the clothing would be dry in no time.

Joan felt a twinge of pain in her chest, it seemed to run down her arm.

“Hmmm”, she thought, “I must have stretched a bit too far”.

Joan, like many of my patients is starting to feel cardiac (or heart) pain, but like a lot of people who get it for the first time, she doesn’t recognise it as such.  Instead she puts it down to overstretching, a touch of indigestion, or something that will go away on it’s own.  Like many of my patients Joan doesn’t consider herself to have any problems with her heart – it has beat healthily for nearly 80 years without a fault, why should it be failing now?

Little does Joan know, but she is going to be one of the 275,000 people in the UK to have a heart attack this year.

But what is a heart attack?  The heart is a muscular pump, that continuously works to pump blood around the body.  All the muscles and other organs of the body need a constant supply of oxygen.  Blood carries the oxygen around the body to the organs, the blood then returns to the heart where it gets pumped to the lungs to pick up more oxygen, before going back to the heart to repeat the process.

Without oxygen, the tissues of the organ die.

As mentioned, the heart is a muscle, and the heart itself needs oxygenated blood.  So as the oxygen carrying blood leaves the heart, some of it is used to bring oxygen to the heart tissue itself.  Should the heart get it’s supply of oxygenated blood cut off, then the heart itself starts to die.

What happens in a heart attack is that one of the arteries carrying oxygen rich blood gets blocked off, and the heart muscle around that artery dies.  The medical term for this is a ‘Myocardial Infarction’.

Myocardial means the muscle of the heart, while Infarction means a reduced blood supply leading to tissue death.

For short we call it an M.I.

We used to think that it was just the lack of oxygen to the tissues that caused the injury, but what actually happens is that the lack of oxygen activates disease fighting white blood cells and these then release a range of toxic substances (mainly free radicals) into the tissue, thus damaging and killing it .

Joan’s pain was getting worse – it was as if someone was sitting on her chest.  She’d had a cup of tea, but that hadn’t helped at all.  She was considering a sip of brandy, the bottle had been untouched since Bill, her husband had died five years ago.  Maybe it would go away if she ignored it.

Perhaps a cigarette would calm her down, she swore she only smoked ‘for her nerves’, so perhaps it would help get her through the pain.

But what causes one of these arteries to get blocked?

Early in life we get small blobs of fat sticking to the inside of our blood vessels, with a healthy diet these don’t get much larger.  With an unhealthy diet these blobs of fat (called Atheroma) get larger and larger, often collecting up different types of material.  These effectively narrow the blood vessels of the body, causing a decrease in oxygenated blood reaching the tissues supplied by the affected blood vessel.

What can happen to cause a heart attack, is that this atheroma plaque can break off the wall of the blood vessel, sending a clot (or thrombus) around the body.  Blood starts to clot around the fatty plaque and the clot gets bigger.  If the clot ends up blocking one of the arteries of the heart, then the blood flow is blocked, the part of the heart supplied by that artery gets no oxygenated blood, and it dies.

Joan is a smoker, which means that she is at least five times more likely to have heart problems caused directly by her smoking.  Smoking reduces the bloods ability to carry oxygen to the organs that need it, partly because the carbon monoxide that is part of cigarette smoke is 400 times more likely to be carried by the blood than the oxygen that the organs of the body crave.

Also, smoking increases the one of the proteins that causes blood to clot, so the blood becomes more ‘sticky’, this helps form the plaques that can burst, sending them floating around the body all ready to cause a heart attack.  Smoking also increases the amount of ‘bad’ cholesterol in the blood.  It is this bad cholesterol that attaches itself to blood vessel walls in the first place to cause the atheroma plaques.

The cigarette wasn’t helping too much.  The pain was still there, and she was finding it hard to breathe.

“Perhaps I better call an ambulance”, she said to herself, reaching for the phone.

…to be continued…

 

 

End of Joan, part 1.  Please let me know what you think, it’s hard to balance heavy medical stuff with making it easy to understand, and there are probably medical people reading this, tearing their hair out at what I’ve just written…

'Two month old child - Not waking up'.

"Shit!", I thought (actually I may have said it).

'Not waking up' could mean that the child was dead. There was something about the way the job was written up on the terminal screen that made me fear the worst.

I raced around there, brakepads burning and swearing loudly at bus drivers who thought that it might be a good idea to pull out in front of me.

Two minutes thirty seconds later I screeched to a halt outside the house, bounding from the car, grabbing my kit and running into the house.

The baby was crying.

The ambulance crew turned up about 30 seconds later.

I was smiling, the crew were smiling, the mother was smiling.

The only person not smiling was the crying baby.

But I was happy at that.





Babies sometimes do strange things like stop responding to stimuli, it's scary, which is why I don't mind going to jobs like that. It's better than the alternative...

Well that's the last time I say that I haven't had an interesting job all shift...

My final job of the day was to a 'collapsed male in the street'. Unfortunately Control were having a bit of a computer failure, so the job was given to me the 'old fashioned' way, by someone at Control telling me where to go.

"Collapsed in the street... he'll be drunk then", I joked.

No matter, I still raced to the scene as quickly as possible (I've mentioned this before, that what I get called for, and what is actually wrong with the patient are often two very different things - so I always try to get to the job as quickly as possible).

The location wasn't exact, so I spent a bit longer than I would have liked peering down dark streets, looking for a man collapsed on the floor. Some people driving towards me told me that the patient was a bit further down the road.

My heart sank when I saw a huge crowd of people standing around a man laying flat on his back. My heart sank even more when I saw a man doing CPR on the patient.

I jumped out of my car, grabbed my bag and trauma shears and started cutting the patient's clothes off. A quick look at his face, and I didn't hold much hope for him.

"He was jogging, and just collapsed", said one of the men who had been performing CPR, "he hit his head, we've been doing CPR at 100 compressions a minutes".

"Are you medically trained?", I asked.

"No", he replied, "I'm a teacher, but I've done a first aid course".

"Well", I said, after glancing at the monitor, and noting that there was no activity in the heart at all,"You were doing really good CPR, so you have given him the best chance he has for survival".

I just wanted them to know that they were doing the right thing. I knew the patient had pretty much no chance of surviving this event, but that these strangers were trying their best renewed a bit of my faith in human nature.

The ambulance arrived only a few moments after I did, and as I looked at the driver, I could see by the expression on his face that he also realised how serious the situation was.

There was no time for any playing around, so we loaded the patient on the back of the ambulance, and took off for the hospital. I was 'bagging' the patient, while the ambulance attendant was continuing the CPR.

We arrived at the hospital, but there was nothing that they could do.

As he was out jogging, he didn't have any identification at all. We had also taken him to a different hospital than you would expect - it wasn't the closest hospital by distance, but it was the hospital that we could get to the quickest.

...So somewhere, there is probably a family wondering why their husband, or their father, or their brother, or their lover hasn't come home. They'll ring the local hospital, and they won't have heard of him, and it will only be when they go to the police that they will find out the truth.

I'm also aware that the bystanders who were doing CPR would probably have this event haunting them - I deal with sudden death a lot, but for these people, it was probably the first time they ever had someone die in front of them. I wish there was some way that I could have stayed and made sure that they were alright, and that I was proud of them and that they should be happy that they did the best that they could.

So, a traumatic event for everyone except for us ambulance and hospital staff. And to think that people ask us how we deal with jobs like this...

The first job of the morning has stayed with me for the rest of the day

*Warning: not for the faint of heart* Herein lays a tale of Scaryduck stylings.

I was sent to a 'Male, 59, fitting - locked in empty bathroom'. I got there quickly, within eight minutes, so already it was a 'successful' job.

As the person who met me opened the door to the flat I was overwhelmed with an intense, and incredibly disgusting smell. At first I thought that it was the person opening the door (he was rather dishevelled, and I've smelt breath that bad before), but no, the smell got stronger as I entered the flat.

There were four people there, all of them looked like the man who opened the door, and the state of the flat made me think that everyone in there was an alcoholic.

Sitting, or rather, propped up on the sofa was the man who had been fitting. His friends had managed to undo the door to the bathroom, and had manhandled him into the living room.

"He's been drinking, we were both drinking heavily yesterday", I was told.

"Fair enough", I said, "Is he epileptic, or does he have alcoholic fits?"

"Both, I think", replied his friend.

Then I looked down.

Something the size of a snooker ball had rolled down the inside of his jeans and was sitting in front of him. It was brown, it was wet, and was rather horrible looking.

A pile of poo. His poo. A poo done after a night of heavy drinking.

Suddenly I realised where the smell was coming from.

I'm sure that most people realise that after a night on the town, the first poo you do can stink to high heaven. This was that epic a poo. I imagine that there was a lot more of it smeared over the inside of his jeans. This is the sort of poo that would issue forth from the arse of Satan himself. It was the sort of poo that shouldn't be flushed away, but instead sealing in a barrel and buried in a place that has lots of warning signs pinned to the barbed wire fence surrounding it.

It really did smell that bad.

His friend (who actually didn't know him that well), picked up the poo with a bit of newspaper and ran it into the toilet.

I could hear him gagging from his new-found proximity to the toxic poo. When he came back into the room his face was an interesting shade of pale green, and there was a thin film of sweat upon his brow.

I treated the patient, actually quite a simple job. Then the ambulance crew turned up, and I pointed out that the patient's shoe was covered in his own sticky poo.

Carrying the patient down the stairs, the poo managed to get transferred from the shoe onto the shirt of one of the crew. He wasn't happy.

I stopped myself from laughing.

...almost.

The only problem is that I can still, several hours later, smell the rank stench of that demonic poo from hell. Actually, I can still taste the poo in the air.

I almost feel sorry for the nurses at the hospital...

The first of my two nights, wasn’t too bad, as I mentioned, I didn’t have to wait too long for an ambulance to turn up. 

Shame about the second night…

My first call was to a 71 year old female with ‘Difficulty in breathing’.  

I turned up, and was met by loads of small children.  Making my way to the patient, she was using her own home medication to try and ease her asthma.

It wasn’t working.

A quick check of her oxygen levels showed 71%.  It should be above 95%, below 85% makes me rather worried.  You might guess that 71% really put the wind up me.

I spoke to the son while preparing my treatment.  He’d obviously seen this before, as he gave as good a description of the patient and her problems as I would have expected from a medical professional.  The patient had been in intensive care twice for her asthma.  If an asthmatic ever ends up in ITU, then it shows how rapidly the patient’s condition can deteriorate.  At the very least, it makes me rather nervous that the patient will ‘go off on me’, and it suddenly turns into a respiratory arrest.

The medication was given to the patient, Salbutamol – a nebulized drug administered straight into the lungs in the form of a gas.  I was also giving her a large amount of pure oxygen in an effort to raise her blood oxygen levels.

Then I turned around and nearly fell over three rows of eight children, quietly sitting cross legged and staring up at me with big brown eyes.

“Don’t mind them”, said the patient’s son, “It’s Eid, so the whole family are celebrating”. 

“She”, he said indicating the patient, “has twenty one grandchildren”.

I nearly suggested that this might be why she was breathless…

So now it was time to wait for the ambulance to take this very sick patient out of my responsibility and off to the hospital.  I could see her getting more and more tired, although her oxygen levels were more normal (if only because I was blasting plenty of oxygen down her face-mask).

“Would you please leave the room”, asked her son after talking to the patient, “she needs to use the commode”.

Now, ask any medical professional when is the most dangerous time for your patient, and I would think that 99% of them would say that it’s when they go to the toilet.

“Hmmm… alright”, I said, “but someone stays with her”.

I was standing right outside the room, waiting for a shout for help and then for me to bound into the room to resuscitate her in front of twenty-one small children.

Luckily for all involved, she survived her encounter with the commode, and we settled down to wait again.

While I was waiting, I was constantly reassessing the patient.  I really wasn’t happy to have her waiting so long because while my treatment was improving her condition somewhat, she needed better care than I could give.

The son offered me a cup of tea.

He knew how serious it was, he knew that the ambulances in the area were probably picking up drunks, and yet he understood my apologies, and offered me a cup of tea.

Thankfully the ambulance arrived, and because of my earlier treatment, the patient had become a little more stable.  She still needed urgent hospital care, but I wasn’t worried that she would die on the back of the ambulance.

It had taken forty-five minutes to get an ambulance to the patient.  Sometimes I like that I’m on the RRU when I can get to a patient in time to actually make a difference.

I also love the drugs I carry, I don’t use them much, but when I need them, they really do come in handy.

I hope everything turned out alright, because as I followed the crew and the patient out to the ambulance, the son shook my hand and said, “Thank you”.

Waiting 45 minutes for his critically ill mum to get a proper ambulance, and still he thanked me.

It’s a Wednesday night shift, which means that hopefully there won’t be too many drunks roaming the streets.  It doesn’t hurt that the weather is, to put it politely, occasionally raining.  I shall be writing what I have been doing every time I get back to station – so if this post seems a little disjointed, it’s because it’s been written over twelve hours.

The first job of the night was just on the edge of my ‘patch’, a woman in her thirties suffering from chest pain.  In people of this age it’s often related to some form of chest infection.  However, when I reached there, the first words out of the relatives mouth was, “She has a heart condition”.

The patient, and her relatives were pleasant to me, but for a person with a serious long-term illness, she didn’t really know a great deal about it.  I asked her what sort of problem she had with her heart, and she couldn’t name it, I asked her about the operation that she was waiting for, and again she didn’t know what it was, or what it was for.  I had to use my knowledge of hospital treatment (“Did they massage your neck the last time you were in hospital?”) in order to work out her previous medical history.

A shame really, patients should be a bit better clued up on what ails them..

My next call was to a location around 200 yards from my first job, unfortunately I’d managed to get back to the station, so I felt like I was on a rubber band.  I was beaten there by the ambulance, so I had little to do apart from making sure that the crew didn’t need my help.  The patient had a pretty standard bellyache coupled with a panic attack.  I did however manage to practice my reading of Polish drug names, translating them into English.

I got back to station, and while writing the first part of this post started shaking uncontrollably.  My legs were weak, and my head was spinning.  What was going on?

I checked my blood sugar…

3.6 mmols!

This is a low blood sugar, our guidelines say that we should give sugar treatment if the blood sugar drops below 4.0 mmols.

I have no idea why my blood sugar was so low – I’d had a big dinner around my mum’s house just four hours earlier.

So I sucked on some sugar, and then got Control to take me off the road for a bit so that a station mate could drive me to the nearest take away shop so I could ‘fill up’ on some longer term sugars.  Chicken chop suey and curry and chips should see me through the night…

I was soon feeling better, so I made myself available for calls.  A few minutes later I got sent to one of our regulars, an alcoholic who had been locked out of his hostel for the night, so he claimed to have chest pain and called for an ambulance.  As this is my first nightshift, I’m fairly ‘chill’ about this sort of job.  There was nothing for me to do apart from chat to him until the ambulance arrived.  It wasn’t raining, and he has always been pleasant towards me, so it was an easy job.

My next job was…Trauma!  A stabbing to be precise.  A young man who had been mugged and stabbed in the leg. Luckily it was a fairly minor wound, and apart from putting a bandage on him, there was little that I could do.  The HEMS doctors turned up in their car, and they were quite happy to leave him in my *cough* capable *cough* hands.  I only had to wait around 15 minutes for the ambulance.

Then I was sent on a ‘chest pain’ job,  but another RRU was there, so it was what we call a ‘duplicate job’, maybe someone up in Control needed a coffee…

A Maternataxi next, she had contractions every 10 or more minutes (and very weak contractions at that) and her membranes were intact.  I was on scene for 50 minutes waiting for an ambulance to turn up.  I was getting so bored that I actually considered reading my ‘Agenda for Change’ booklet.  Apparently there were eight calls in the area waiting for ambulances.

On the way back to station (for a well deserved emptying of my bladder…) I came across one of our ‘make-ready’ people driving an ambulance to the nearby petrol station.

He didn’t realise that he was driving along with both of the back doors open.

As I write this line it is 2am, and I’m conscious that I have 4 and a half hours left to the rest of this shift.  I also fancy a cup of tea…

Forty-five minutes later and I’m racing through the streets to an ‘elderly man, unconscious’.  He is indeed unconscious when I reach him.  Apparently he was asleep with his wife, when he shouted out and became unrousable.  This is the sixth, or seventh time that he has done this, and the hospital are supposedly baffled.  Observing his recovery (looking scared and confused, ‘plucking’ at his clothes), to me he looks like an epileptic who is in the ‘post-ictal’, after-fit state.  The ambulance are thankfully quick to arrive, and he starts to recover as we lift his heavy body down the narrowest flight of stairs I’ve ever seen.

I’m then granted nearly two hours on station, where I have a little doze before being sent out to another elderly man who has been bleeding from his penis for the last 24 hours.  A classic example of the ‘I didn’t want to bother you’ brigade, his house is spotless and he has been married to his wife for nearly 60 years.  It’s nearly 5am and his wife is dressed as if she were going to a Womens Foundation cake sale.  Both are polite and helpful, and more importantly – they laugh at my jokes.

It’s now an hour to go before the end of my shift, and I’m wonder whether to have a cup of tea or not.  I don’t want the caffeine keeping me awake when I go home to sleep, but I am rather thirsty.

Perhaps a glass of water?

It has now reached that time in my shift where the next (hopefully last) job is either going to be someone waking up to their elderly, yet very dead, husband – or another maternataxi…

And as if by magic – 12 minutes after writing that line…

Another bloody maternataxi!  And this one didn’t want to talk to me, refusing to answer any of my questions.  Well, that’s fine, at this time in the morning I don’t particularly want to talk to her…

This time however, the ambulance is a lot quicker to arrive, and I’m left with half an hour until the end of my shift.

Will I get another call?…

The short answer is….No.  Instead the day relief came in quarter of an hour early, and has sent me home.  By the time this has been posted off, I shall be slumbering peacefully in my bed.

Last night is what I would consider a fairly ‘good’ night, a couple of jobs where people were actually ill, a stabbing (although a rather minor one, needing only assessment and a bandage) and with the exception of waiting fifty minutes on the maternataxi, I wasn’t left high and dry by the lack of ‘proper’ ambulances.

And later tonight, I do it all over again.

And while it will be completely different, it will also be the same.