Carmelo makes a guest appearance and avoids the curse of the observer.
I’ve just finished a run of nights – still catching up on sleep. On Monday night I had the pleasure of Carmelo Alongi who came along as an observer. Normally having an observer means that nothing exciting ever happens and it was great to find that Carmelo managed to avoid the observer’s curse. You can read his report here.
We kicked off with an ‘A’ cat chest pain just around the corner from the station. Goodness knows where ‘chest pain’ came from as the gentleman in question certainly didn’t have chest pain. What he did have was a concerned family. His brother hadn’t seen him for 6 months and now, confronted with a ‘ghost’, he wanted him helped – now! The chap was certainly cachectic (oo, I love that word); emaciated, gaunt, a horrible pale complexion like he’d been hiding in the dark for a few years. He wasn’t eating, smoked roll ups (without filters), claimed a 2 week history of diarrhoea and, to top it all, had decided to self-withdraw from a chronic alcohol addiction about 4 days earlier. Not surprisingly he was suffering the usual symptoms of withdrawal. Was he an emergency admission? No. Could he wait and see his GP in the morning? Certainly, but the family wanted action now and they weren’t the usual scroats demanding the system treat them first; they were genuinely concerned. I rang the DGH and spoke to the med reg; yep he was happy to see the young man. Although he was quite ataxic and his condition didn’t warrant a big white taxi I agreed to pop him over the road in the car. No doubt the hospital will send him home. In my opinion his biggest problem was depression (though what do I know) but what with the history of alcoholism I bet he doens’t get the help he needs.
After this we rolled round for a referral from a colleague. A gentleman with sudden onset neck and shoulder pain. After a thorough assessment I agreed that it was purely muscular – a normal ECP job. I left him with some diazepam tablets to control the muscle spasm and some diclofenac for the pain and reduction in any inflammation. Oddly enough he declined to take suppositories.
After a short break we set for for a child with breathing difficulties. Certainly an upset child but didn’t appear overly unwell. Had an obvious wheeze but not croup and, as far as I could tell over the crying, no chest infection. The crew arrived and we decided to start off with 2.5 mg of salbutamol to see if the wheeze would calm down, needless to say the noise of the nebulizer only appeared to make matters worse. Control rang in the middle of the examination to see if we could be called away for another ‘A’ cat so we left the kiddie with the crew. I heard later that they persuaded the child to inhale some of the salbutamol but the kiddie was getting more distressed so a trip up the road to A&E was in order.
Our next ‘A’ cat was a gentleman in his twenties presenting with chest pain but with none of the associated symptoms of an M.I and no personal or familial history of cardiac problems. I’ve come across this a number of times over the years – stress related cardiac pain; and he had every reason to be stressed: recently lost his job, just moved into a ‘dive’ no bigger than a rabbit hutch and his girl friend had given him the heave-ho. He was tachycardic at around 120. I’ve never got carotid massage to work for SVT (supraventricular tachycardia) so I tried getting him to gently blow the plunger out of a 20ml syringe (no 50ml ones around). It worked after a fashion and got his pulse down to just over a 100 bpm but it rapidly went back up to 120. The ECG showed no abnormalities but his bp was a tad low at 110 systolic (reduced cardiac output?), so what to do? The crew ran him in so the ‘experts’ could sort him out.
Next we ran on yet another ‘A’ cat – given as anaphylactic shock. This could have been a ‘good’ job and I was geared up to administer some 1:1,000 adrenaline. In the event it turned out to be a young lady with a rash to her face; no facial oedema, no swollen tongue or any compromise to her airway. She’s had it before and blames it on an increase in her daily dosage of propylthiouracil for hyperthyroidism. She’s now on the maximum dose of 400mg daily. According to the BNF (British National Formulary) one of the main side-effects is a rash. When the rash occurs she takes piriton and unsurprisingly tonight she’s run out. Luckily, being on an ECP car I carry chlorphenamine, so I dished out some more sweeties and sure enough, before I’d even finished the paperwork the rash was calming down. It was also a great PR exercise for my service as the patient delightedly told us that she was a relative of a senior executive of another service. I hope she relates what excellent treatment she got from Magwitch and Carmelo.
Later in the night we had a call to John. John’s a regular and has advanced Parkinsons but still manages to live at home supported by an extensive care package. Usually John falls over but tonight he had chest pain. He didn’t present as a classic cardiac patient nor did the pain seem to be giving him great distress. The trouble is John’s speech and facial muscle tone have been severly affected by the Parkinsons and communication is extremely difficult, in fact nigh on impossible. With the crew already on scene we all agreed that it was best to let the doctors at A&E check John over – just in case.
This was certainly turning into a busy Monday night – just the way I like it. Next up was another neck pain; almost identical to the earlier call. An assessment suggested a purely muscular problem. The patient’s own pain killers hadn’t sorted things out even though they were as strong as anything I carry. I left a supply of 5mg diazepam tablets and a recommendation that if things hadn’t started to resolve by tomorrow then a trip to the GP would be in order. I’m sure it was really just a case of a bad stiff neck but having had it for the best part of 15 hours, with no relief and being unable to sleep, I think I’d probably be looking for help, though perhaps a call to NHS Re-Direct or the OOH (out of hours) service might have been more appropriate.
We ended the night with a ‘real’ job and a proper ‘A’ cat to boot; a cardiac arrest! It was local and we turned up at the same time as the double EMT crew, within 4 minutes. Carmelo has written a whole post on this. Our newbie EMT inserted an LMA (laryngeal mask airway -a recent article in Ambulance UK by members of the Royal College of Anaesthetists suggested that LMAs are better than ET tubes for cardiac arrests). As I’ve never inserted an LMA ‘in anger’ it made sense for an expert to do it. My other colleague commenced chest compressions while I got a line in and pumped home some adrenaline. We got an output! I felt a good thumping femoral pulse around 60 bpm and the patient was making some respiratory effort albeit at only 4 a minute or so. We carried on with respiratory support while we got things sorted for a rush up to A&E. The patient ‘went off ‘ but we got him back again. Then it all went to rat-sh*t. I’m going to be very un PC here. If the patient is a huge lump at around 18 stone, lying in a small bedroom in a house with a narrow staircase with three 90 degree turns then we’re pretty much on a hiding to nothing. It took 3 of us to lug him down the stairs (thanks for your help Carmelo) while my colleague gallantly attempted to keep bagging while leaning over my shoulder. By the time we managed to dump him on the trolley we were shattered and sweating buckets but more significantly the patient was now noticeably cyanosed around the ears. It was all hands on deck again. We kept going. Did we get a pulse back? I’m not really sure as it’s so hard to tell in the back of a moving ambulance. The monitor still showed a regular pulse though. The team were waiting when we pitched up at A&E. They worked on him for only a few minutes. He remainded in PEA and they soon ‘called it’ on the grounds that he’d been ‘down’ about 30 minutes by that time.
Although the outcome was depressing, from an ambulance point of view it was a job well done. We hit the ‘A’ cat time so the bean counters will be happy. We did everything we could as a team and everyone worked really well. Apart from the nightmare removal it was almost a textbook arrest. Well done everyone.
We had a breather at the hospital and a well earned cup of tea. We even got Carmelo to have a cup – something he’s never done before! We’ll make a real ambulance man of him yet.
All in all a fun night. A fair mixture of jobs, although no trauma, but I went home buzzing which is always a good sign. Thanks to Carmelo for doing all the lumping and humping throughout the shift – it was a pleasure to have you riding along.
Oi Merys! When are you coming out for fun and games then?