Some Basic Tips

For those of you who aren’t involved in Emergency Medical Services (EMS), there’s loads you can do in a medical emergency. Here are a few tips.

• Learn CPR. That’s the chest compressions and mouth-to-mouth breathing. Ask your local ambulance service, Red Cross or St John Ambulance where you can learn. Your employer may help too.

• Get your family and friends to learn too. It’s great that you know what to do, but what happens if you need it?

• Know the number for your emergency services. In the UK, it’s 999. In the ‘States, it’s 911. What about Slovenia? France? Luxembourg? Within the EU (and some other European countries) 112 will get you through to the emergency services. This applies to the UK too.

• Get your priorities right. St John used to specify the 4 Bs; Beating (heart), Breathing, Blood (loss) & Bones. It’s no good thinking about a fractured shin if the casualty isn’t breathing.

• Bleeding can be stopped or at least slowed down by applying direct pressure to a wound. Sometimes you won’t be able to press on a wound, for instance if it’s got something sticking out of it. DON’T REMOVE THE OBJECT sticking out. It’s partially plugging the hole. Press around it. Don’t be afraid to press hard.

• Pains in the chest always require ambulance attendance. Well, if you know that the casualty has a muscular problem in his/her chest, it’s possible that you don’t need to call an ambulance. However, be aware that people with e.g. pectoral muscle issues can also have a heart attack.

• Burns; get them under cold water immediately. Call an ambulance if the burn is major (i.e. blackened, electrical, more than the area of the palm of the casualty’s hand).

• Sprains and strains do not normally need ambulance attention. However, it’s hard to tell the difference between a badly sprained ankle and a broken one without an X-ray.

• All broken, or suspected broken, bones need to be seen by the hospital.

Serious Condition

Called to a 19yo F with “Difficulty in Breathing and nausea”. I arrived at the address to find out that it’s a house in multiple occupancy. Every resident has their own room but share facilities. It was pleasant and clean.

One of the residents (max age of any <25) pointed me the way to the patient who was in bed with her parents in attendance. I asked the patient what the problem was, as she seemed to have plenty of colour to her face – in fact she was a little flushed.

"I'm dying". "No you're not, other than one day at a time, like the rest of us".

The patient had no DIB. Pulse was 100. She was definitely too hot but kept feeling hot and cold. She had vomited earlier and kept feeling nauseous. She'd been to her GP the previous day and had been prescribed penicillin and an antiemetic. (She'd had a history of tonsilitis so the penicillin was probably prescribed prophylactically.) The antiemetic was obviously not working.

Mum was obviously concerned, but dad kept looking out of the window as if to say "Nowt to do with me, this 'ere".

"Why did you call the ambulance?" "Coz I can't bloody breathe" came the reply, with no lack of breath behind it. I pointed out that she was doing a pretty good job of it so far. Got silence in return.

She was more than likely suffering from a virus that's been doing the rounds hereabouts since before Christmas. I've had a mild dose myself.

The crew arrived. Because local ambulances were all busy, they'd had to come about 12 miles. The attending EMT confirmed my findings and then gave the "patient" a talking-to. He was excellent. Not a word out of place, but all convyed through tone of voice, he must have made the patient feel about that high.

The other EMT had gone to get the paperwork. As I was struggling not to laugh, I thought it best if I went too. I'd swear that I saw a glimmer of satisfaction in dad's eye as he shook my hand and thanked me!

God’s Waiting Room – with people who CARE

Today I went to a residential home (i.e. God’s Waiting Room) to a 90-odd year old patient with “Difficulty in Breathing”. I’d been there before, for different patients, which is hardly surprising.

Arriving just before the crew (and it’s easier to park a car than an ambulance there) I went to the patient. I thought she was cyanosed and my pulseox confirmed that she was short of breath – blood oxygen level between 73-82%. (For the uninitiated, it should be 95%+ for healthy people.) Poor perfusion was probably the cause of the variation.

Putting the patient on full-flow oxygen very quickly, her levels soon reached the low, then mid 90s%. The crew then arrived and did a 3-lead then a 12-lead ECG. Whilst her pulse was regular and at a good rate, the 12-lead showed evidence of an MI. The crew canulated the patient and did a few obs, then took her to the ambulance for a blue light trip to hospital. I’d followed them down the stairs with their Lifepack and the patient’s meds (all one of it), so had to go back for my kit. The patient’s daughter had arrived before I had and she went with the truck.

Going back for my kit, one of the care assistants asked me about the patient’s chances. The patient was nearly 100 after all, so it was a reasonable ask. The staff either thought a lot of our patient or they were damn good actors. I reckon the former.

I thought I owed the staff a few minutes, considering their concern. For the first time ever, I was glad I wasn’t a paramedic. The paramedic possibly could have told them, but wouldn’t have. In my case, I genuinely couldn’t tell them. Sure, the patient was getting close to the ton. However, she was basically well and bearing up as well as could be expected, even for a younger person. Her obs, when on O2, were probably better than mine.

I spent about 15 minutes chatting to the staff. Whilst the patient’s daughter was the person most involved, the staff had an attatchment to the patient. It amused me when they reacted to the fact that I was an unpaid volunteer. (The standard reactions are either “You must be mad!” [True] or “You deserve a medal” [Less true, but some CFR somewhere should deserve an MBE at least.] In this case, I’m pleased that the reaction was the latter.)

Whilst the carers are paid to do what they do, most do actually care about the people they look after. A few minutes of my time (and I was technically off-call when the call came through) is the least we can offer.

One thing that did surprise me was that none of the staff at the home had a first aid qualification. They initially lacked the confidence to call an ambulance. A couple of them said that they would like to learn first aid. Whilst the course is three days and costs £200+, surely there should be someone on duty all the time with a First Aid at Work certificate, or at least the one-day Emergency First Aid at Work ticket.

Q

It’s been very Q for me the last couple of weeks. In fact, tonight I attended my first patient in a week. Usually I do 8-10 in a week.

(Ok professionals, I know you can easily do that many in a shift, but I can’t attend most of the stuff you do.)

Whilst weather and time of year will have an effect, I’d have thought that a cold February would increase, rather than decrease, my calls. When the weather is really bitter, < 0°C, asthmatics may not venture out so much, but it's been above freezing most days, sometimes as "warm" as 4°C.

I'm not against Q shifts (as that means fewer people are sick/injured), but I just find it surprising that I'm running at a lower rate than I would in May.

Family Values

Some say that the concept of family is dead, at least within the indigenous white population. I’m not so sure.

Called to an 80-odd lady “unconscious”. We’ll call her Mrs B. She has a carer who comes in for a couple of hours each morning. The carer had noticed that Mrs B wasn’t her usual self and had called her daughter – one of three.

This daughter came straight round. Whilst she was in the kitchen, with the service hatch open, she noticed a change in Mrs B’s breathing. Looking through the hatch, she saw that Mrs B was still in her chair with her head back. Quickly finding that she couldn’t rouse her mum, she called the ambulance.

She then called her husband and her two sisters.

When the crew arrived, Mrs B had revived and two of her daughters, and two sons-in-law, were with her. The other daughter arrived shortly afterwards.

It was obvious that all of the daughters and husbands were regular visitors.

Mum was on loads of meds (and I had the job of listing them, getting writer’s cramp in the process). The paramedic thought Mrs B had a heart block, previously undiagnosed.

Obviously Mrs B needed to go to the hospital. Unusually, it was one of her sons-in-law who rode the ambulance with her.

This was obviously a close family who knew how to rally round in a time of crisis.

Spinning

Called to a 70-something gentleman who’d had a fit. He was out to the wide, in the kitchen, and his wife let me in. As he was near enough in the recovery position already, I let him be. He started to come round slowly.

Shortly after the crew arrived, he turned on to his back, with eyes open. Still very post-ictal, he was recovering. The paramedic decided to sit him up.

Now, I should explain that Mrs Patient was obviously very houseproud. The kitchen floor was covered in the fancy cushioned lino that had a real good sheen to it. I reckon she must have polished it daily.

The paramedic tried to put the patient into a sitting position by lifting his shoulder. Ah! – mistake. The poor patient ended up spinning 120° on the highly polished floor, pivoting on his bum. If the paramedic had tried a bit harder, I reckon we could have got a really excellent full circle!

I moved (carefully) to his other side so we could balance the forces, and the ECSW braced his feet to prevent us shooting him into the skirting board.

Still, it’s a nice change from the places where your boots stick to the carpet.

Asthma

Is there an asthma epidemic at the moment? Today, I’ve had to deal with three asthmatics whilst at work; one as a First Responder and two as a First Aider. Thank goodness for my pulse oximeter.

The first one was a woman of 30+ years. Somewhat overweight, she also suffers from asthma. A walk to work in cold weather was all it needed to send her into an asthma attack. Checked her out on the pulseox and her sats were 87%.

I asked the switchboard to call 999 and went and got my oxygen, calling the CFR desk at the same time. 30 seconds of O2 brought her breathing back to normal. I tried to reduce the flow, but that reduced her sats.

Very shortly, a paramedic arrived and put her on a nebuliser. That worked really well.

In the meantime, a young lass with a history of asthma turned up. Her chest was feeling tight and she’d left her inhaler at home. No one was in, so we’d need to take her home to pick it up. Whilst waiting, I checked her sats – 99%. She was obviously panicking a bit, being separated from her inhaler. I reassured her and mentioned that we already had a paramedic in the place, who would treat her if she needed it. Thus reassured, her breathing returned to near normal.

Third case was a lad who has BAD asthma. He has a nebuliser at home (much use it was there!) and felt his chest getting tight. Good old pulseox showed that he had good sats. I left it on him as he was really chuffed with what it told him. A bit later, dad came by and took him home to be reuinited with his neb.

Well, that was my morning taken up!

Good Information – Not!

Doncha just hate it when you go to a call and it’s nothing like what you were told? This doesn’t just happen to CFRs, the ambulance or emergency services in general; I bet some plumbers and electricians find exactly the same thing. However, with plumbers and electricians it’s rarely life threatening, as there’s always a stop-cock or an isolator.

From a sheer frustration point of view, I reckon we CFRs get the dirty end of the stick. At least our professional colleagues generally have the means to treat whatever they come across, whereas I will have the resources (maybe) to help the patient if the call is to what control thought it was. But not otherwise.

Mind you, some of these calls do not need immediate attention either.

Let’s look at a few I’ve had recently.

1. A young woman with severe head pains and numbness in her face. She was 20yo and weighed in at about 5½ stones – if she’d soaked in water overnight. No one thought it was a stroke, and it wasn’t – post-op infection, though no one thought to mention the op earlier in the day before we got there.

2 & 3 Two separate calls to blokes with “chest pains” that turned out to be severe abdominal pain. One was ?gallstones and the other had been diagnosed with them. Both were in severe squared pain. As a CFR, all I could do was reassure them that they weren’t dying – and they knew that, but felt as if death would be a great relief.

In all of these three calls, I could have helped if I’d had Entonox (aka “gas and air”). It would have relieved their pain to a greater or lesser extent. I’ve not met a CFR yet who doesn’t think it would be a good idea for us to carry it; I’ve used it as a First Aider and the training is short & easy. Still, we can’t carry the stuff.

4 Call to a patient who had “chest pains”. She actually had a cold, and had been coughing. Her partner had called NHS ReDirect for advice on treating a minor illness and was asked if the patient had any pains in the chest. Well, of course she had – she’d been coughing for the last four days!

5 An 89yo patient “confused”. The poor old bogger had a urinary tract infection. He’d been given the usual antibiotic but it hadn’t worked. He didn’t want to drink much so the toxins were building up in his blood & tissue and he’d started to hallucinate . He wasn’t so much confused as seeing people and things that weren’t there! Nothing a CFR could do; even the paramedic could only arrange transport to hospital for IV antibiotics and rehydration.

I hate standing next to a patient and being completely unable to help, even though sometimes I know what is required. I’m not asking to be able to give morphine – it can be deadly, and I don’t have anything like the training I’d need. I’d just like to be able to help a little rather than standing there like a spare wheel.

So, why was a CFR, with limited skills and equipment, sent to these calls? If you wanted to be really cynical, you could put it down to the Trust needing to make its 8-minute target. However, I believe it’s simpler than that. It’s not the Trust; it’s lack of trust.

Call-takers work to a protocol. Their protocol isn’t bad, but it depends on what the caller tells them. If the caller answers an early question one particular way (and some of these are yes/no), it can lead to a completely incorrect chain of further questions.

NHS ReDirect seem to be even more bound by a protocol, or perhaps the protocol is not as well written. One of their questions, for just about any call, is “Does the patient have any pains in their chest?” An answer of “yes” could mean that the patient has been gardening, coughing, swimming and dived badly, thumped etc etc. It may mean they are having a heart attack. Rather than pass this to a nurse, the protocol insists that the call-taker calls the ambulance service and states that the patient has chest pain.

I accept the need for protocols. I work to them. However, the ones we have at the moment are using up resources that can be ill-afforded.

Surely it is not beyond the wit of man to devise better protocols? It may even free-up resources to save a life or two.

Laughing All The Way

No, it’s not a belated thought about Christmas. It’s about Entonox(R)

Entonox, for the uninitiated, is the BOC Healthcare trade name for a 50:50 mixture of nitrous oxide (N2O, “laughing gas”) and oxygen. Like the word Hoover is for vacuum cleaners, it’s become the common name for this excellent form of pain relief, sometimes called “gas ‘n’ air”.

Please Sir, can we have some…?

A CFR is not normally sent to injuries, trauma. We deal with illness rather than injury. However, there are times when we could do with some pain relief for the patient.

I’ve had two of those times within a week. A patient with severe head pain that was not apparently a CVA. A man with severe abdominal pain who was waiting for a scan to confirrm a tentative diagnosis of gallstones.

In neither of these cases could I give any pain relief, yet I knew that Entonox could have helped.

Giving Entonox is hardly rocket science. I was trained in using it when I was a First Aider at one place where I worked. Essentially, it’s self-administered. The contraindications we’re likely to see in this country mostly revolve around one criterion – has the patient got air in his body where no air should be?

Entonox is now regarded in many cases as part of Basic Life Support. Shouldn’t a CFR, with more than basic training, be allowed to use this stuff?

I get to feeling a bit of a spare wheel when I go to some poor sod who’s in real pain and there is absolutely nothing I can do but wait for the ambulance.

Liars, Damned Liars and Patients!

Honestly, why do it? If you are ill, why try to fib to the people who come to help?

Let’s take a recent example. I was called out to a bloke who was “collapsed” in the street. As this was the middle of the evening and lots of brass monkeys were holding their groins, I was immediately concerned for the patient.

He’s fallen on the ice. Mind you, some discarded chips may also have made a difference between upright and horizontal. He was also dead lucky. A young woman and her partner saw him and got a quilt to put over, and under, him. It was they who’d called us out.

As a CFR, I don’t knowingly get sent to trauma. In this instance, Control didn’t know any better.

Chucking a blanket on top of the quilt, I got the patient’s name and asked about injuries. He told me he’d hurt his back and couldn’t move. Fib 1.

He was slurrring his speech so I asked him if he’d hurt his head. No. I couldn’t smell alcohol, and he was getting agitated, so I left the question of bevvy alone. I simply concentrated on getting him to lie still, and checking some observations.

Sats fine, pulse a little fast but regular. Face cold but the rest of him fairly warm.

As he was in the gutter and the street was narrow I used my car to make him safe from traffic, then called Control to let them know we needed more than a FRV, and waited for the truck.

The paramedic asked the patient if he’d had drink taken. “Oh no” came the reply, “I never touch it”. Fib 2. [Meaningful look from paramedic.]

Eventually, we managed to get him on the trolley, after finding that no, he didn’t have a spinal injury, but that his ribs hurt like hell.

As we were getting him on board the ambulance, a woman came up who obviously recognised him. Instead of sympathising, she launched into a non-stop tirade of what he needed to put his life back on track (essentially kicking the drink and getting a life). This did give us a little more information.

Why, though, tell fibs about your condition? The patient could move, even though it hurt. That’s a big difference. He had partaken of alcohol. That’s not a crime, and I have been known to do so myself (said with a G ‘n’ T beside me).

You may be trying to preserve your dignity by lying, but there’s nothing dignified about lying in the road and being told not to move. If he’d been honest, I may have sat him up and the crew would not have had to think about boarding him. (Luckily for him, the paramedic did a thorough examination.) Not only that, but he was lying to himself. He could, painfully, have sat up. And yes, I DO know how painful broken ribs can be. However, a few seconds pain versus hypothermia is a reasonable trade to me.

It’s daft not to admit you’d had alcohol. Most of us do, and he wasn’t heavily p*ssed. However, it can make your treatment different, let alone your diagnosis.

Ambulance personnel are not the police; not the real ones, nor the thought police, nor the health police. We come to help. Please let us.