by Stuart Gray
Messy resus jobs are all too common for us and they present challenges that can test your skills to the limit. I went through a busy period of trial and error before I finally understood my role and how to play it.
The last call I received on one of my Christmas shifts was to a ‘man collapsed, not breathing’. This happened in a large shopping centre, and security had called an ambulance because they thought the man might be dead. They didn’t bother to approach him or start resuscitation, however, and I got a call from Control informing me that he might not be suspended at all and that others had called to say he was simply drunk.
I got on scene and an ambulance arrived simultaneously. The crew had been given a completely different description of the call and I was the only one unloading equipment for the possibility of a suspended. ‘Tell you what,’ I said, doubts filling my mind. ‘Why not bring in your FR2 (defibrillator)?’ I was probably wrong, but there was no harm in being prepared.
As soon as we got into the main entrance of the shopping centre a man came running toward us, waving and shouting that we needed suction. We all looked at each other; clearly, this wasn’t just a drunk. So we ran up the escalator and down a corridor and found a chap lying on the floor. He was being resuscitated by a solo motorcycle paramedic who had arrived minutes earlier and who had also been caught out by the vague call descriptions. Nevertheless, something was now being done for the patient.
When I got closer I noticed a lot of vomit on the floor. This is always a bad sign. If a suspended patient vomits the airway becomes badly compromised and the lungs will take in fluid, a situation made worse when ventilating as it all gets blasted further down the bronchial tree. We pulled the man over (he was a BIG guy) and a lot more vomit poured from his mouth and nose onto the floor. The bike paramedic had not been able to intubate the man because he was working alone and the airway was so full of fluid that nothing could be seen properly (intubating blind is a big risk, for the reasons I’ve explained).
Mistakes. We all make them, and I’m the same as anyone else. I’ve cocked things up, but – fortunately – it hasn’t affected the outcome. Of course, when we get something wrong it can have disastrous consequences. If I put a tube down someone’s throat incorrectly, it will kill them, and I will lose my job and professional registration instantly – there is no such thing as an honest mistake if you screw up when intubating a patient.
So we worked on him: me, the solo, and the paramedic and the EMT from the ambulance. We used our drugs and we tried to intubate him properly. The tube simply wouldn’t go where it was needed and we were stuck with basic airway management and a suction machine that couldn’t cope. We could have ‘stayed and played’ longer to try and change the situation - maybe even stabilise him - but it was looking dire so we got him into a chair, wheeled him out of the place and into the ambulance. CPR continued all the way to hospital. He was handed over in Resus and I didn’t stay long enough to see what the outcome was, but I had no illusions.
A suspended octogenarian won’t have much of a chance. The call had come in as a ‘faint, not breathing at all’ strangely enough - if you’ve fainted, you’re normally breathing, but I guess that’s the kind of confusion that takes over when you are elderly and a loved one has suddenly dropped to the floor. (Personally, I hope that’s how I go.)
I worked on him with a crew and another FRU responder and, I have to say, it was fruitless from the start. His heart had given up and there was no way on earth it was going to pump again. This was a hard-working man who had probably lived a full life. I don’t think he would have appreciated any extra time if he had been given it - the quality of life after delayed CPR is usually very poor if you recover at all; the brain will have been starved of oxygen and significant damage will have occurred. Nevertheless, we spent half an hour trying our best and achieving nothing. The bravest person in the room was his brother, who had to bear the sights and sounds of our efforts, only to be told that there was nothing else we could do. We stopped when inevitability became reality and left him on a sofa, wrapped in a blanket with his eyes closed, waiting for the undertaker. He looked asleep and that was a nice way to leave him, I think.
An early morning call to a 55-year-old female with ‘no heartbeat’ was given as ‘suspended’ by Control. There was already a crew on scene but they always send a few of us to a job like this.
I arrived and pressed the entry button for the flats. A few seconds later I was buzzed in by a crying female. I entered the lift and when I got out I could hear her wailing from all the way down the corridor. Neighbours were flitting in and out of their own flats, wondering what was going on.
I was let into the flat by one of the crew, who guided me upstairs. The paramedic was downstairs with the crying woman, so I knew that nothing was being done for the patient. When I got to the bedroom, I saw that the lady lying on the floor had been dead for some time, probably since the night before - nothing could be done. I went downstairs and joined the crew, who were consoling the young woman, the deceased’s daughter. She was completely beside herself with grief.
She had gone to wake her mum up this morning and had found her. She kept saying, over and over again, that her mother must have been crying out for her in the night but that she hadn’t heard. ‘I must have just slept through while she was dying,’ she said, between sobs. I looked at the stiff, discoloured corpse; the mouth and eyes were wide open and this had given the woman the impression that her mother must have been crying out as she died. This isn’t necessarily true. The last few breaths taken by a dying person are usually taken after consciousness has slipped away - they are the body’s desperate responses to a drop in oxygen levels, and are essentially nervous reflexes. If the last muscular reflex leaves the mouth open, then it will seem as if the person has screamed.
I felt devastated for the daughter; her mum was only 51. I arranged for the police to attend (the daughter was too upset to remember their GP’s details) and left the scene when they turned up a few minutes later. It was a sad way to start the shift.
On an early evening call I was asked to assist with a crew who were working on a suspended alcoholic. He was only 45 and had been found in bed at his hostel, vomiting blood as a result of a massive internal bleed (gastro-intestinal). This brought about a cardiac arrest in front of the key worker who was trying to help him. When I arrived the crew were busily working on him on the floor. It was a pretty awful sight: there was a good deal of blood around, and his airway was a mess. The paramedic was attempting to intubate and I could see it wasn’t an easy job for him, but he got the tube in and secured it while I set about gaining IV access and preparing the drugs that would be needed. There are some jobs you just look at once and decide there is little or no hope. This was one of those jobs.
Still, we frantically ventilated, compressed and drugged him until another crew arrived to help with the removal to hospital. I had been on scene for about ten minutes and there was absolutely no change in the man’s condition. The prognosis was poor. We prepared to move him downstairs (he was a large man and the stairwell, as usual, was very narrow) and tidied up our equipment. I asked the key worker and another member of staff to help carry the bags as we moved the resus effort from upstairs to downstairs and then into the ambulance. The first crew on scene conveyed the man to hospital and I took the key worker in the car so that he could pass on next-of-kin details to the hospital staff.
In the Resus room, work continued and many more people got involved, but it was called by the doctor in charge and the man was pronounced dead. Forty minutes after he had arrested.
I went back to the flat with the key worker because I had forgotten one of my bags and the place looked like it had been raided. The detritus of our effort was everywhere and there was plenty of evidence of recent death; blood on the floor, a crimson pillow on the bed and a little trail of the stuff leading from the flat to the outside world. In the bathroom, the man had prepared his shaving kit for the next day, not knowing that
he wouldn’t live to see it. I always find those innocuous little scenes of seeming normality very poignant.
* * * * *
A few days later I took a call to a collapsed middle-aged woman outside the National Portrait Gallery in St Martin’s Place.
It was Red 1, high priority, but the details were scant. I called in. ‘Can you tell me whether this person is suspended or not?’
They came back and confirmed that it was a suspended - the lady was reportedly not breathing and had no heartbeat - so I put my foot down a bit more. We were there in a couple of minutes. She was a German tourist who had dropped down in the street in sudden cardiac arrest. It was daylight and very busy, but an FRU EMT was on scene and there were a few other helpful people around. I had a training team with me - this was their first ever resus - and while they couldn’t really do very much, they could fetch and carry and help out here and there. The EMT had started CPR; as the first and only paramedic on scene I had to take charge.
‘Right,’ I said. ‘Can everyone just stop what you’re doing for a sec while I check her out?’
Her worried husband was leaning over, watching me, and a crowd was gathering around. Other people were basically walking through the scene, which was shocking - a woman was dying here. I got the trainee crew to disperse everyone and set about trying to cannulate her. I failed - I couldn’t get the needle in properly - so I moved on to securing her airway by intubating her. Another ambulance crew showed up to help and as they parked up I looked over. Right next to me was a man apparently trying to cannulate her. He wasn’t ambulance service, and I didn’t recognise him; he was just a random bloke in shirt and trousers. I said, ‘What are you doing?’
He was a Canadian. He said, ‘I’m a doctor, I thought I’d help out.’
‘No,’ I said. ‘Can you please get away from my patient? I don’t want you touching her.’
I didn’t know whether he was a doctor or not - people claim all sorts of things - but even if he was, this was my patient, I was responsible for her and I didn’t want anyone else working on her except ambulance service people.
But he wasn’t getting the message. In a petulant voice, he said, ‘Do you want me to get a line into her or not?’
‘No,’ I replied. Apart from anything else, I could see that he wasn’t that experienced at it; he was messing around with the vein, getting nowhere.
He didn’t move.
‘I insist,’ I said. So reluctantly he sloped off.
There’s a common misconception, brought about from movies like Flatliners, that we can restart a totally inert heart with a defibrillator. You can’t shock them out of it, it’s usually too late. However, this lady’s heart was in ventricular fibrillation. A heart in VF is not dead, but it’s not pumping - it’s kind of wobbling. The defibrillator shocks it, stops it dead for a split second, and this - we hope - allows the brain to kick it off again, like restarting a stalled car. (In some circumstances, it can convert into something called VT, ventricular tachycardia, which is a fast rhythm; this is also not life-sustainable, and if it appears drugs are usually used to slow the heart and get a proper rhythm back.)
We gave the lady a shot of adrenaline and prepared to shock her. Inevitably, this involves cutting her clothes off. Everything, bra included. There are obviously issues here, particularly for women, and while this patient was completely unaware of what was going on, we still had to respect her. To save her modesty, I asked my trainee crew to fetch blankets from the ambulances and got the police and passers-by to hold them up around her as a screen. Meanwhile, others police shepherded nosey tourists away.
After the first shock her heart got a rhythm back. This was an excellent sign. Another movie fallacy is that people wake up and are almost back to normal immediately. They don’t. The first, often the only, sign you see is electrical evidence that they are back.
She was still unconscious and on the edge of death. We carried on with her breathing and moved her into the ambulance. We needed to get her to the hospital quickly. Our job is to stabilise the patient at the scene; we try not to move them until there is something salvageable, or there is no hope.
In the back of the ambulance, she started gagging, which was amazing. It meant she was coming round and trying to breathe for herself, and the tube was catching in her throat. I had never seen that happen before. Of course, we are trained to extubate, but I’d never had to do it because it’s normally something that happens some time after the patient reaches hospital. I had to remind myself of the process, and as I was mentally working through it she opened her eyes. I told her I was going to take the tube out and I could see from her eyes that she understood.
Once it was out, she began to mouth words and eventually found her voice, which was croaky and weak because her voice box had been damaged by the tube. Another first: I’ve brought someone back and I’m having something of a conversation with her. I couldn’t quite take it in; I’d been giving cardiac drugs and shocks to her just a few minutes before. She had been to the edge of life and looked over the cliff, and we’d brought her back. A magical feeling.
And she survived. After being in VF for 20 or 25 minutes, which is pretty good going. The EMT had got there within three minutes, and we’d been a minute or so later. Someone else - maybe the Canadian doctor - had been working on her before that, with manual CPR. That person actually saved her life because it kept her in a condition that we could work with, but the drugs and the defibrillation made the difference.
I went back up to the intensive care unit two or three days later and met her husband. They had reintubated her and put her back to sleep because her heart was unstable; until it was stable, the doctors wouldn’t let her breathe for herself. She had a long road ahead of her, but she was going to be fine in the long term.
Her husband was obviously grateful to us for what we’d done, but he was reserved in his gratitude, and this was typical: relatives of people you save don’t tend to behave like they do on Casualty, there are no tears or hugs, they’re pretty matter-of-fact. Patients, on the other hand, are effusive if you visit them afterwards.
The greatest sense of satisfaction I got out of it - apart from saving her life - was for my trainees. The fact that their first resus had ended so successfully was sure to inspire them, I felt.
Young people go into cardiac arrest too, but it’s uncommon and when a call comes through for a young chest pain or suspended, unless there’s trauma or a medical link, it’s difficult to believe. Thus, when I received a call to a ‘27-year-old, suspended’ I wasn’t sure it was accurate. I looked again at the age and considered the odds. This was probably not as given but then I heard Control giving details of the job to a motorcycle paramedic and the word suspended was used again, so I adjusted my thinking. I stepped up a gear to get there as fast as I could; if this was genuine the patient had minutes to survive (it wasn’t made clear whether CPR was already being carried out).
I found myself behind an ambulance that was on the way to the same job and armed police guided us into the area. I wondered if this was a shooting because there were armed cops everywhere. Later I realised they had nothing to do with it; the origin of the call was behind an embassy building. A few of the police officers were soon roped in to help us, though.
I went into the house and there were already a number of people dealing - two ambulance crews and one motorcycle paramedic. CPR was underway on a young woman lying on the floor and I offered my help. Most of the people on scene were paramedics, so every skill role was filled, except the drugs. I got my drugs pack out and selected what might be needed for the patient just as a shock was called and delivered. This single shock changed the young woman’s fate - it brought her back. She began gasping and convulsing.
I suggested we load and go because there was nothing else we could do at this stage; she needed to be sorted out in hospital. I brought the trolley bed in with the help of an armed-to-the-teeth police officer and we lifted her onto it and wheeled her out to the a
mbulance. Absolutely no more time was wasted and I travelled with the convoy to the nearest Resus room, where she continued to struggle for survival.
The woman had just collapsed and gone into cardiac arrest without obvious cause. I still don’t know to this day what happened to her. All I know is that she lived.
A ‘routine’ call for a 45-year-old male having an epileptic fit in a pub turned out to be nothing of the sort. The call details changed en-route to ‘unconscious, ? cause’ with information that read ‘caller happy to manage patient’. That was encouraging; it meant the patient was probably conscious and not fitting any more.
When I arrived, there were people standing around outside the pub drinking their pints and chatting; another sign that I took to mean all was well inside. There was an ambulance already on scene, so I thought my role here was just to support or help them if they needed me. I went inside, pushing my way through more drinkers, and as they opened up I saw a crew on the floor working on a suspended patient. He had gone into cardiac arrest almost as soon as they had arrived. They had already delivered one shock and the paramedic was intubating him and his crewmate was compressing the man’s chest.
I looked around and realised the audience of punters were obstructing the exit. Some of them were even attempting to buy more booze as the resus took place below them near the bar.
That moment on the telly when the woman with the paddles shouts ‘Clear!’ is for a reason: that’s a major electric shock you’re delivering to the patient, and anyone touching the patient will get it, too. ‘Can we just clear this area,’ I shouted. ‘Move away please.’ It was for their own safety, but the lack of respect some of them showed for us and the dying man on the floor was shocking. It took me a while to get them, grudgingly, to give us some space.
