More Nights (Oct 27-30)

If only my nights were as exciting as Paramedic Frank Pierce’s

Friday 27th October

Well it didn’t rain and, for me at least, the pissheads stayed out of trouble. Spent the early part of the night out on dynamic cover, which included a trip round to Tesco to get some milk and other provisions for the station. This was followed by being parked up for an hour or so reading a new edition to my ECP library: Minor Injuries – A clinical guide. Written by Quacktitioners for Quacktitoners, which means I can actually understand it. Highly recommended.

First job of the night was to pop round and assess Gladys. Her neighbours, who act as her unofficial carers, were concerned that she was “going down hill” and not coping. A locum GP had been out earlier in the day and, by all accounts, had just given her a cursory examination and told her to eat more and get a bit more exercise. I’m not sure exactly what the neighbours hoped to achieve by dialling 999 but it got classified as a ‘C’ category call. Control often want to save cars for ‘A’ cat calls only, so a crew was dispatched from station. However, as I was also there and got some idea of what the call was about, I managed to persuade the dispatcher to let me go instead and do an assessment.

In the end I was there for nearly 2 hours. Gladys turned out to be a charming lady in her early 90s though the neighbours had warned me she could be “a bit of an old bat“. I turned on the cheeky bedside manner and it seemed to work. She got as thorough an examination as I’m able to offer, at the end of which I’d established that she’d got a UTI and probably has AF, though she wasn’t the easiest patient upon which to carry out an ECG. Her son turned up in the middle of it all so I had to stop and explain to him what was happening. It’s amazing how long all this takes when you’re working on your own and have to explain things two or three times to varies parties.

In the end we all agreed she’d remain at home. Just as well really as the family say she suffers from agrophobia (or agoraphobia) so getting her to a hospital is a nightmare. I left her a 3 day supply of trimethoprim to see her through the weekend and popped a copy of my clinical record form and a letter round to the surgery with a request that her GP call on Monday to see how she is getting on.

Interestingly, her “message in a bottle” notes stated “recurrent episodes of depression”. The only anti-depressant medication she appeared to be on was clomipramine, which I’ve not come across before but which my BNF informs me is used for phobic and obsessional states – (the Wikipedia link says “panic attacks with or without agoraphobia“- so that’s something else I’ve learnt – maybe SHP can tell us more).

The only other job I did was towards the end of the shift for a lady in her mid 70s who’d had a hypoglycaemic event; BM at 1.3 milli moles. A crew was there as well. We gave her glucagon (only partially successful) a tube of her own Glucogel formerly Hypo-stop (still not helping a great deal), sugary milk and a few biscuits. Took her nearly an hour to fully come round. The glucagon made her sick and we were all considering a trip to A&E. All except her husband that is. He’s been dealing with these episodes for the last 40 years. He’s pretty much got things down to a fine art except on those occasions, like last night, when her sugar levels get so low that he can’t get her back. He showed us her daily blood sugar level record. She’s very compliant, taking readings 3 times a day, but the figures are all over the place. It was a bit like looking at lottery numbers; 20 in the morning, 5 at lunch, 14 by evening then down to 4 the next morning and so on. She’s on insulin but it all looks rather poorly controlled to me.

Once we’d got her back to full consciousness the crew departed and I stayed on for another 15 minutes just to see how things developed. Her hubby said he’d couldn’t remember the last time it took this look to “bring her back” and that she “wasn’t usually sick this much afterwards”. She was adamant though, that she wasn’t going to hospital so, in the end, I left them to it with stern instructions to “eat something”

I wouldn’t be surprised if we get called back there later today.

Saturday 28th October

I hadn’t even got my kit on the car before the bat phone was ringing for the first call of the night. “Patient with chest pains at BigTown police station” I’m often a bit cynical about these types of calls as so often it’s a someone trying to avoid spending a night in the cell (and occasionally a deportee trying to avoid a flight home). This time though it was Jim, one of our regular alcoholics. He usually manages to avoid get tangled up with the law; we get called when he and his girlfriend have had another “bust up” and he’s “thrown a wobbly“. Once he’s calmed down we generally leave him at home.
“I’m not drinking anymore” he told me.
Yeah, right!
“How much have you had to drink today then Jim?”
“Nothing. I’ve been in here since yesterday afternoon.”
“OK. How much did you have to drink yesterday?”
“Just a few pints…. I think.”
Ah. So you’ve only given up drinking for today then, and that’s only because you’ve been locked up for the last 24 hours.
We popped him down to A&E as the police were a bit worried. What he probably needed was a large bottle of scotch to get him back to normal.

Next up was a middle aged lady with a PV bleed. Bright red blood with a few clots. She is already under investigation at the hospital for this and is due to have a cystoscopy in a couple of weeks. She was haemodynamically stable (BP, pulse, respiration, all fine). The nearest ambulance was 20 minutes away so the family agreed to pop her in the car and run her up to A&E, which was only 5 minutes drive. Apart from some accompanying paperwork my only contribution was to provide an inco-pad to protect the car seat – just in case.

I got back to station for a vehicle check and a cuppa. Just as I thought about settling down to some serious reading it was off for an assault. “Patient hit over the head with a bottle”. Location: the big green barn on the road to Pretty Village. I kid you not, this is the sort of ‘unhelpful’ location details we get out in the sticks. I was told to “look out for a large crowd of revelers.” Thanks! In the end I got canceled because the police were on scene and felt I wasn’t required.

A quick U-turn and it was back to BigTown for the first pisshead of the night. He’d damaged his foot dancing in one of the local bars. He was, as they say, “giving it large” which means he was a right arrogant little sh*t, rather aggressive young man. With the assistance of two police officers and a very large doorman, he agreed to let me have a look. To be honest, trying to conduct a foot/ankle examination in the market square with hoards of onlookers and an unco-operative patient is not my favourite pastime. His ankle was fine but he had a rather large swelling above the proximal 4th metatarsal which seemed very painful (had nothing to do with me pressing very hard on the spot – honest guv). After much cajoling, with him hugging numerous, scantily clad young ladies (and the doorman- though he was wearing an overcoat) and many tearful recriminations about wasting the evening, I managed to get him over to the car and a quick trot over to A&E.
When last seen he was trying to order a take-away pizza on his mobile, from the waiting room – “coz I’m hungry mate!”

There was a lull in the proceedings after this during which I was able to undertake a serious study of the inside of my eyelids (just checking to see that they hadn’t developed any holes).

After a while I was asked by one of the crews to attend an elderly lady who’d they’d been called to and felt might have vertigo. They thought perhaps I could give her some prochlorperazine. I spent nearly two hours with the lady. The first 20 minutes or so was just getting her to give me a half decent history. Interestingly none of the obvious symptoms of vertigo were mentioned; room spinning, difficulty standing, nausea, vomiting; no earache or recent viral infection. I covered the usual examinations and watched her get up and go to the toilet in the middle of it all – no problems except she worries – a lot – about all sorts of things – including falling over. Her own GP had told her she was just having panic attacks. I’m inclined to agree seeing as I couldn’t find anything else wrong. Her biggest problem, so it seemed to me, was she was spending ever increasing lengths of time in bed. (My niece reliably informs me that if you stay in bed too long your legs fuse together and you become a bed-slug – sounds nasty!). Needless to say she stayed at home.

The final call of the night was to a teenager having a panic attack and hyperventilating; an Academy Award winning performance indeed. He took over an hour to calm down, helped immensely once one of the crew asked all the people in the room to leave. Unsurprisingly, without an audience he started to settle down, though by then he’d lost sensation in his hands and feet. This will go once the O2 and CO2 levels in his blood return to normal. And all this because he’d had a bust up with his boyfriend earlier. When I was his age I was more worried about whether my bike had a flat tyre or who’d nicked my football.

Guess I’m turning into an old fart.

Sunday 29th October

A slow start: vehicle check, 2 cups of tea and a chance to catch up with a crew on the late shift.

The bat phone rang, then the station alarm went off and we all bundled round for a “patient trapped behind locked doors”. These sorts of calls can be almost anything from a patient fallen to a full working cardiac arrest. This time it was for Alf. He’d accidentally hit his alarm pendant and then, because he’s a touch deaf, he hadn’t heard the (we don’t) CareLine controller on the speaker phone. With no response from the patient, Careline had requested the full works. So we pitched up together with the police so they can break in if required. As it happened, after a minute of so of banging (very loudly) on the front door and hollering through the letterbox, Alf appeared, rather perplexed as to what was going on. Thankfully he was fine. He hadn’t fallen or suffered any other mishap; it was all a misunderstanding. We bid him a good evening and he tottered back to watch the TV.

Later I was asked to pop round to visit Eileen, a young lady in her 60s. I called up the paramedic solo at the scene.
“She’s had an asthma attack. I’ve nebulised her with 10mg of salbutamol and her breathing is much improved.”
“What would you like me to do?”
“I was hoping you could come round and maybe give her some anti-biotics or something.”
“Why’s that? Has she got a chest infection then?”
“No, her chest is clear, it’s just that she doesn’t want to go to hospital.”
I couldn’t see much point in arguing the toss, besides, it’s not as if I had anything better to do. So I pootled on round.
Bit of a nothing job really. As he’d said; chest clear, breathing all settled down and her runny nose had cleared up after having the nebuliser.

Salbutamol is a ß-receptor agonist, very similar to the natural compounds epinephrine and noepinephrine, so it acts to relax the muscles of the airways and also (as a side effect) increases the rate and force of heart muscle. Compounds developed to ‘cure‘ runny noses act on alpha-receptors which are also stimulated by epinephrine and noepinephrine, so perhaps (and this is pure speculation) salbutamol will also stimulate alpa-receptors.

I had a good listen to her chest. There was some reduced air entry on one side. We discussed whether to go down the prednisolone route just to tied her over until the morning but she declined. If things got worse she’d ring back. Fine by me.

After this I had a nice break. Tucked into dinner and then continued my investigations into the ability of photons to penetrate eyelids. The night crew were happily curled up in the easy chairs.

Just after 2 o’clock we got a ‘real‘ job. “33 year old female fitting”, and boy, was she: status epilepticus. It was all hands to the deck. It’s amazing how much easier jobs like this can be when there are 3 of you. Two to manage the patient and the other to get all necessary kit. So, while Tommy managed the head end, I chucked in a size 18g cannula and administered the first 5 mg of diazemuls. Not a lot of effect. The patient was fitting for 2 to 3 minutes then having a short postictal state for a minute or so before setting off again. In all I gave 20 mg of diazemuls, the maximum allowed under our protocol and JRCALC guidelines. Getting status epilepticus patients out to the ambulance is always a challenge; how to lift them on to the carry chair, down the stairs and out to the bus while the patient is thrashing about? At least this time we had a window of opportunity between fits. We made it as far as the front door before we had to stop and hold the patient in place while the next seizure passed. No time for mucking about. We alerted the hospital and zoomed off. She was still having full tonic-clonic (grand mal) fits even after we’d cleared up; I think we were up to about number 15 or 16 by the time I left resus.

The final job of the night was a ‘C’ cat call for abdo pains. The lady was distressed but not unduly so. She’d been seen at A&E yesterday and been diagnosed with a UTI and sent home with anti-biotics and pain killers. The doc had told her that if the abdo pain started radiating around to her flank she should re-attend. This morning the pain had radiated. As she was walking about OK I suggested I run her back up to A&E, seeing as she doesn’t drive. Really this was a case of being a ‘blue light’ taxi, but as I would be heading back towards the hospital anyway it didn’t seem a problem.

At A&E they pulled up her ‘caz-card’ from yesterday together with her blood results. Ooooooh dear!!! Her CRP (c-reactive protein) which should be no higher than 10mg/l (so I’m informed) was 143.1 !!!! According to the doctor on duty “this patient should never have been allowed home.” I left them all frantically scanning the notes to see which doctor was due for a major bollocking later.

Monday 30th October

Last night was the last shift of 4, and a very civilised 12 hours it was too. We had a bit of a party atmosphere to start with; both vehicles were on station, there was a visiting crew from one of the smaller stations, a ‘spare’ paramedic who’d been dropped off to pick up an unused response car, the local operations manager and a number of ‘hangers on’ who’d been over at the hospital doing their placements as part of their paramedic course. The mess room was truly packed with not a spare chair in sight. Luckily some mug offered to make tea so it seemed rude not to accept.

Finally a job came in and we played pass-the-parcel. The crew member who took the call passed it to the other crew on the grounds that he and his crew mate were on a ‘meal-break’. One of the second crew managed to palm it off onto the visiting crew as they were just heading out the yard on the way back to their station. They in turn managed to pass it on to me, a little later, as they felt it was an ECP job. And they were right. It was for a ‘loopy-lou’ at the custody suite down at the local nick. One minute she was all sweetness and light, the next a foul mouthed obnoxious bitch. It was an easy job though, I just glued up a self-inflicted laceration on her arm. It’ll leave a bit of a scar but I shouldn’t think she’ll notice it amongst the 200 others she’s already got there.

What should we do with DSHs (deliberate self harmers) like this? Obviously she’s suffering from mental illness and possibly paranoia; first she was telling me that the police were a bunch of sh*ts who put poison in your tea and beat you up (wrapping offenders in a wet blanket and kicking them is apparently the current trend) then she was saying how nice the WPC was and “didn’t they have a tough job”. I left her in full flow, shouting obscenities at the custody sergeant because he had the gall to tell her she couldn’t have a cigarette.

There followed a ‘nothing’ job with one of the crews, for a lad who had “difficulty in breathing.” Apparently that’s what happens when you have a sore throat and Mum panics. Some light hearted banter and a few minutes on nebulised water did the trick.

Next up was a bit of excitement; at least we all thought that’s what it would be. “Overdose on morphine, police in attendance as patient known to be violent”. We all donned our stab vests. First time I’ve ever worn mine which gave everyone a laugh as it still had the manufacture’s label hanging from the lapel. In the end nothing happened. We lined up at the rendez-vous point down the road from the house only to be told that we’d been stood down as the police said we weren’t required. Argh! and I’d been so looking forward to narcing someone. (narcan is a trade name for naloxone which we use for reversing the effects of opiate overdoses)

There followed a long interval of peace. Time for dinner. The night crew came in and the 16 hour vehicle crew went home. All quiet in CrapVille.

At 2 a.m. I assumed my nightly role of ‘blue-light’ taxi. Like last night it was another person with abdo pain. Already been seen at A&E but pain continuing and not being eased with pain killers; morphine tablets and oro-morph this time. Usual excuse “I don’t drive.” Fair enough but isn’t that what the local cab firms are for. Still, I was there, I was going to be headed back to the hospital and the person was obviously in some pain. Free taxi rides on the NHS; you won’t believe it could happen?

The final call of the night was to a young woman in one of the grottiest parts of town who claimed she had tendonitis of the shoulder which was getting worse. Maybe she did, maybe she didn’t but the crew and I all agreed that whatever she had she looked like sh*t and seemed to be going down hill very rapidly. Pneumothorax? PE? still don’t know. We got her up the road – pronto.

Why did I mention that it was one of the grottiest part of town? Well, because her 5 year old daughter came too and she was a little angel; polite, smiling, interactive (she punched in the security code for the hospital doors while I held her up to the keypad, she carried her mum’s coat and bag and helped me push Mum around in the wheelchair) We all commented on how pleasant she was; not the sort of kid you find in that area.

So that ended my set of nights. With a couple of hours left I was able to continue with my studies on sleep disorders. When the day crews arrived the teapot came out and I got ready for that long drive home.

3 days off now – hurrah!

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8 Responses to More Nights (Oct 27-30)

  1. Mart says:

    Whats your services protocol for IV glucose?

  2. Kingmagic says:

    Did my first of three nights last night…two “nan downs” both falls, a psychie O/D, a student with another “spiked” drink-nothing to do with the fact that she had consumed a couple of bottles of wine/various shorts/at least 4 half lagers and all on top of having nought to eat, a miraculous fall from 6 story floor/unco/bleeding from head/? breathing-stood down en route as patient got up and walked away!!!(allegedly), unco in street-pissed and covered in vomit (I mean really covered!!) and a “…questionable life status” for our last job- 20 yr old male asleep in someones doorway!
    Going on shift in 45 mins…oh I cant wait, the joy and excitement….BRING IT ON!!
    Good blog btw Magwitch.

  3. Craig says:

    IV Dextrose or Glucose would be far more preferable than waiting an hour for the patient to recover unless you can’t get a line. Its our first option for hypoglycaemic patients. We almost never transport a simple hypo. Our service allows it at the EMT-Intermediate equivalent level.

  4. Murphy says:

    Hyperventilating. Bike with flat tyre. Could all sort itself out!

  5. kingmagic says:

    Magwitch…just set up my own blog…”purpleplus”.
    Having fun trying to edit the homepage and put boxes at side like yours.
    Any advice would be much appreciated.

    Kingmagic.

  6. ecparamedic says:

    Nice site, good to see another ECP having fun in the rain. Please pop across when you get a sec.

    SD

  7. ecparamedic says:

    Glucose guidelines in our service are IV first where possible, has anyone else noted a delay of up to 15 minutes when using 10%? When we used treacle, sorry… 50% the patient would be sitting up before you had finished squeezing the gloop through the cannula. I’ve seen a few have their measured levels brought up to the patients normal level only to stay sparko for about 15 minutes before the sudden “three … two ..one.. you’re back in the room” effect. Still impressive nontheless and still quicker than stripping their glycogen stores. I hear a rumour that we are withdrawing dextrose gel soon. SD

  8. Magwitch, this is a great blog. Very well written and easy to read. Lovely. I shall be back. xx

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