It was a gentle summer day. The occasional cloud breezed overhead as we chugged along, chatting away, heading out on an ‘urgent’ call for a gentleman with abdominal pain. Nothing unusual or sinister about the job; just a straight forward transfer from the patient’s home to the local A&E department. Normal road speed; no great hurry.
We pulled up outside the address, I hopped out to go and meet Stan whilst my colleague turned the ambulance around. I rang the doorbell and Stan appeared almost immediately (no hollering through the letterbox this time). He was ready ‘to roll’ and had a small suitcase packed with some overnight bits and bobs waiting by the door. He seemed in good spirits and certainly didn’t appear to be unwell. I took his bag; he locked the door.
“Did the doctor leave you a letter for us to take to the hospital?”
“No, he said he’d fax something through.”
“So, you’ve got a bit of an upset tummy or something have you?” I asked as we walked back down the drive.”
“Not really, its all a bit odd. Here look.”
Aaarrrggghhh! Help! Ohmygod!, Don’tpanic!, WotdoIdo?! WotdoIdo?! Ohmyfirandwhiskers! Staycalm! Yikes! Ohdear! Goodnessme! Thinkstraight! Youraprofessional! Stayclam! Staycalm! Help!
Stan had lifted up his T-shirt to reveal a wonderful pulsating mass just above his navel. Oh goodness. A triple-A and its probably gonna blow any second!!*
“So, how long has your tummy been like that then?” Trying to get my brain to clam down a bit.
“Oh about 3 days now, but its starting to make me feel a little unwell” I’m not bleedin’ surprised!
I’ve only come across a few patients with diagnosed abdominal aortic aneurysms but never one with such a blindingly obvious pulsating mass. Ideally you don’t make them walk. Well that part of the protocol’s already out the window. This is an emergency surgical admission. The only thing we can do, realistically, is get the patient to hospital alive. If the aneurysm bursts we’ve practically no chance; so it should be large bore cannulas in both arms; fluids up; ready to pump everything we’ve got into him. Now Stan was looking good and feeling relatively OK; with obviously no idea of the seriousness of his condition. I’ve got to prepare for the worst whilst maintaining an air of calm.
“Make yourself comfortable on the stretcher Stan. That’s it, pop your feet up. We just want to do a few observations before we set off; blood pressure and stuff. Can you just show my colleague your tummy?” Stan lifted his T-shirt again and I watched the look of horror on my colleagues face. At least he knew the seriousness of the situation.
“I think we should avoid the traffic.” Our euphemism for blues and twos and put your bloody foot down mate!
Stan’s pulse and BP were fine; the ECG looked normal(ish). I lied a bit.
“Stan, your blood pressure’s just a touch low, would you mind if I popped a needle in your arm so I can give you some fluids to help it along; might make you feel a bit better.”
He agreed. I sweated a bit, trying to get a size 14 gauge in first time. Don’t want to be ‘faffing‘ about tryng to get cannulas in and I don’t want miss this one! I only did the one arm, partially because I couldn’t think of any reasonable excuse to give Stan as to why I would need to cannulate him in both arms, but also because we didn’t take bloods (not at that time at any rate) so I was leaving an arm free for the hospital – at least that was my justification to myself. I got the line in without mishap, and set up a drip just on tick-over (i.e. barely running) I needed to avoid circulatory overload but I wanted everything in place – just in case.
Off we set. Stan happily chatting away, me sweating profusely and trying, desperately, to not keep staring at his abdomen. I gave the hospital a courtesy call.
“Hello, its C472 here, can I just give you some details about a patient we’re bringing in?” I was stilling trying to maintain an air of calmness. I gave Stan what I hoped was a reassuring smile. “72 year old gentleman, should be on your board as a surgical expected.” a slight pause while the nurse checked. “Good. I wonder if you’d mind letting the surgeons know he’s got an observable pulsating mass in his epigastrium; all vital signs normal; cannulated with fluids on tick-over. We’ll be with you in about 10 minutes.”
The journey was uneventful apart from my pulse racing up to well over a 100 and a lose of about 4 pounds in body weight (well, it was a warm summer day). Stan continued his breezy conversation all the way. Everyone one was waiting as we rushed into resus. I think Stan got a bit of a shock to find so many doctors and nurses, all wearing aprons, waiting just for him. They were great and everything went smoothly. I heard sometime later that he’d gone up for surgery but I’ve no idea what the outcome was.
For me the outcome was a very, very big sigh of relief and a large cuppa.
If you want to know what treating a triple-A is like from a surgical point of view, read Barbados Butterfly’s account.
*As BB points out; Abdominal Aortic Aneurysm – the main artery in the abdomen. If it ruptures you bleed to death, unless a surgeon stops the bleeding quick smart.