by Stuart Gray
The crew had done a stunning job and before I had completed cannulating and readied my drugs, the patient had a pulse and was breathing, albeit with support. We now had a solid chance of saving this guy’s life. It was time to get going; the quicker the better. We deputised a few of the blokes in the bar and they helped us transfer the patient on to a trolley bed and out to the ambulance.
I took the man’s brother in the car with me and we sped off to the nearest hospital. He was taken straight into Resus where the good work continued. When I left to green up, he was breathing for himself and he had fairly stable vital signs.
Our performance as ambulance personnel has led to the incredible success of CPR for more and more patients, young and old. Survival outcomes statistics continue to rise and I go to more recoveries than losses now. There still remains the high probability of failure, but that should have more to do with the predisposing clinical condition of the patient, rather than the sterling efforts of ambulance staff.
CLOSE CALLS
THE WORST CLOSE CALLS you get involve sick children. The heaviest of all weights, I think, is the one you bear when you hold the life of someone else’s child in your hands. My colleagues will testify to this, especially those who have experienced the stress of working alone with a dying child until help arrived.
I sped through rush hour traffic on the way to a ‘6-year-old fitting’. Then the information was updated to state that he was no longer having a seizure and was simply ‘hot’. As I hurried to get there, my instinct was that this would be a fairly run-of-the-mill infection and temperature-related fit; in other words, non-epileptic and likely to end with me assessing a conscious and lively (albeit warm) child.
Despite this, I tried not to be complacent: it was my first call of the night shift, and there’s a tendency - for some unknown reason - for the first and last calls to be bad. I got out at the given address and headed towards a door which was open and being guarded by a little girl. She had been sent to ensure I went to the correct house. She looked up at me with big brown eyes and said nothing as I walked past her and into the flat.
Inside, a woman was kneeling on the floor, phone to her ear, looking down at a little boy who was on his side, writhing and shaking. He was clearly having difficulty breathing properly and his airway was very noisy. The woman handed me the phone as I put my bags down and assessed the situation. The call-taker from EOC was on the other end and, as I unpacked what I needed, she confirmed my presence on scene and I asked her when I could expect an ambulance. I made it clear that I needed it quickly. She told me that one was on its way but I didn’t get an ETA, and nor did I remember to ask her not to have the call downgraded or over-ridden by a higher priority whilst the crew were en-route. I knew they would have been thinking the same as I had after the information update, and I hoped that the tone of my voice had carried enough weight for an experienced call-taker to recognise that I was actually dealing with something serious.
The boy’s sats - his oxygen saturation level - was extremely poor, his pulse was racing and he was hot to touch. He was in spasm, especially around the diaphragm, and was completely non-responsive. I gave him rectal diazepam to try and stop the seizure and then I got on with re-establishing his obs.
SATS: Saturation levels – specifically, oxygen saturation levels. We use a device called an oximeter to determine the amount of oxygen that has bonded to the haemoglobin. A normal, healthy person would be expected to have between 95% and 100% saturation – in other words, their haemoglobin is attracting a full complement of oxygen molecules. If the level falls below 95%, something may be amiss. Levels below 90% are becoming critical. Asthmatics may have low sats during an attack – say 93% – and will need supplemental oxygen to boost their haemoglobin levels. People with chronic breathing problems usually have permanently low sats.
His status didn’t change, and his breathing was now causing me great concern. He was becoming flaccid, except for his phrenic spasms, and he wasn’t getting anywhere near normal. I knew I had to get him to hospital without delay. His mother told me that he had been like this for 20 minutes and that she had been considering taking a taxi to hospital before I’d arrived.
PHRENIC SPASMS. These are spasms in the diaphragm, with many causes. They can be very minor – a hiccup is a phrenic spasm – or life-threatening. In this case, it was caused by seizure.
After what seemed a lifetime, the crew arrived and I wasted no time in getting the little boy into the back of the ambulance. I cannulated him and considered another dose of diazepam, but something wasn’t right with this. We set off on blue lights and I asked the attendant to put a nasal tube in. The child’s breathing had now become much noisier and he was clenching his teeth - this could mean there was a problem with his brain.
His breathing began to deteriorate, despite his airway being improved by the nasal tube. He wasn’t breathing adequately enough and so we ‘bagged’ him and prepared to resuscitate. All the time, I was reaching over to the mother, who was travelling with her daughter, to comfort her and reassure her as best I could.
When we arrived at hospital, the boy’s condition had deteriorated significantly. The attendant carried him whilst the other EMT continually ventilated him. A colleague from my base station helped with the oxygen and that freed me up to begin the hand-over in Resus. I stood and related the history and my findings, including drugs given and other treatment carried out, whilst the Resus team and a paediatric registrar worked on the little boy. His mother and sister stood in isolation at the end of the room, distressed and overwhelmed.
Before I left, the team had intubated the boy and had him on a ventilator whilst they worked out what could be wrong with him. I spoke to his mother, gave her a little hug and reassured her daughter, who burst out crying from a state of staring silence. I sat with the crew who had been with me throughout this and had a cup of tea. I was shaken up inside.
Then I got a lift back to my car, which had been left on scene. I said thanks and goodbye to the crew and off I went, back to base to reset my head and complete my VDI, not knowing whether we had saved the little boy or not.
A few days later, thanks to a colleague, I received a telephone call telling me that he had survived and was back at home awaiting the results of a brain scan. A massive relief. His life had been hanging in the balance, for sure.
VDI: Vehicle Daily Inspection. Drivers of all vehicles in the Service are required to check the safety and roadworthiness of any vehicle they use. The check includes all equipment on board.
Working with sick children when you are part of an ambulance crew isn’t any less stressful, but the reassurance of backup and the availability of more expert hands is valuable. We were called to a house in a quiet street for a ‘two-year-old child with difficulty breathing’. Often we can expect to find nothing more than a kid with the sniffles; a lot of parents who call us with this description have misunderstood the nature of the questions asked by the call-taker, or are simply panicking because they are inexperienced or ignorant.
This time was not like that. We walked in to find the mum holding a very exhausted-looking child. He had been suffering an asthma attack for the past hour or so and, despite the fact that there was an inhaler and ‘spacer’ device for administering relief, both were sitting on the window ledge, unused. It turned out that the parents, who were both non-English speaking, didn’t know what it was for - their GP had diagnosed asthma and given them the inhaler, but they had been none the wiser about either the diagnosis or the treatment.
There were now three of us at the house, including an FRU paramedic who had arrived first. It was clear the kid was in trouble - his breathing had become so weak that he was giving up altogether, and he needed to get to hospital quickly if he was not to die. We took him from his mother and ran to the ambulance, mum and dad running alongside. As we got going, he was treated with a nebuliser, though we knew this would do little good at this stage because he could hardly breathe the drug he needed into his
lungs. As we weaved through the London traffic, sirens blaring, he looked very close to suspending, and the necessary equipment to keep him alive was made ready just in case. It wasn’t needed: we got him into Resus without further deterioration and the team there began the work of stabilising him. But it looked grim. I left them fighting for his life, walking past the parents on the way out. They looked in a state of shock, completely bewildered; if only they’d understood what the inhaler was for. As is so often the case, I never found out what the outcome was.
A similar emergency for an asthmatic child in the middle of the night reinforced how important it is for us not to be complacent about ‘child with DIB’ calls.
DIB: Difficulty in breathing. The term should only be used for those who are genuinely having trouble breathing in or out, or are having to struggle to breathe. Unfortunately, because the system we use prompts the call-taker to ask if someone has difficulty breathing the answer, especially for the frequent fliers and the inebriated, will invariably be YES… and that starts a whole emergency cycle, costing you (the tax payer) millions of pounds each year. The flip side is that not to ask the question may mean that somebody with genuine DIB will slip through the net and possibly die – although the chances of that happening are much less than someone answering YES to get an ambulance quicker (and someone else who really needs it dying instead).
My crewmate and I arrived to find the FRU on scene and a little crowd of neighbours standing outside the address. There was an anxious look on each of their faces as they glanced at us.
We went into the house and the FRU paramedic was already on her way out with a very floppy child. She was running towards us, in fact. We took the hint and turned ourselves around so that we could get the ambulance ready. He was a little boy and he was hardly breathing. He was being nebulised, but it was having little effect as far as we could see. He was only four or five years old and had suffered asthma since birth. He had a history of acute severe attacks and had been hospitalised on many occasions, but his mother, worryingly, told us that this was the worst she had seen.
We took him into the ambulance and the care continued. Our drugs weren’t having much effect - mild, at best - but at least they were keeping him stable. I looked at him lying in the artificial light of the vehicle; he looked as if he wanted to sleep forever, which is precisely what he was going to do if we didn’t get him to hospital quickly. The neighbours moved out of the way and someone stood in the road to halt any traffic as we turned our vehicles around for the ‘blue light’ run to the nearest Accident and Emergency department. He was going to make it by the skin of his teeth. I had the necessary resuscitation equipment ready and strategically hidden from mum, but it would all have to come out if this child decided not to hang on any longer. Luckily, we got him to hospital in good time. He was still fighting for breath but his condition hadn’t deteriorated as rapidly as it had been before treatment began and his vital signs had even improved a little. An upward curve in anyone’s condition is always good news.
He survived his ordeal and was eventually discharged, but we all know that one of us will see him again and that, one day, his luck may run out.
Some close calls occur because the patient has been living with an acute problem for days, or even weeks, and has only just decided to call an ambulance. These individuals tend to be strong-willed, stubborn or just plain old-fashioned and believe in the principle of only calling an ambulance if you are at death’s door. (I only wish some of our regular callers were more like that.) Unfortunately, many of them have got death’s door half open by the time they, or their relatives or friends, decide enough is enough and call us out.
We went to the house of a 63-year-old man who had been complaining of problems urinating. This was a low priority call because no details of anything untoward had been given. As far as we were concerned he probably had a urinary tract infection and that was why he couldn’t pee properly. Inside the house, his family gathered to explain that the man was in the toilet at that moment.
‘He’s having a pee now,’ said his wife. ‘He loses a lot of blood every time he goes.’
That didn’t sound good. ‘What do you mean, “loses a lot of blood?”’ I asked.
‘Well, he goes to the toilet every ten minutes and it’s just blood that he passes.’
This concerned us greatly; we waited until another family member had got him out of the toilet and brought him to us in the front room. He was walking slowly, as if he had wet himself, and we could see a red stain on his pyjama trousers.
‘I’ve left it there for you,’ he said.
‘OK,’ I said. ‘I’ll go and have a look, but let my colleague check you out first.’
We sat him down and my crewmate checked his obs while I went to the toilet and looked at what he had passed into the bowl. It was frank blood. I mean, the toilet bowl looked like it had been badly injured and was bleeding into itself.
I went back into the living room, where my colleague was chatting to the man. He’d had some pain but not a lot and he had been like this for days, apparently. The family had thought nothing of it, at first, because he’d often had urinary problems and, in the first day or two, he’d passed only a small amount of blood each time he went to the toilet. But now his visits were much more urgent, more frequent and, as I’d seen, very bloody. He had no significant medical history to explain this development, and he was normally healthy. Now, however, he looked ill; very pale and drawn. He was also very weak on his legs. We got him into the ambulance and prepared to set off, but he insisted on sitting in the chair rather than lying on the bed, which would have been preferable.
‘I’ll need to go again soon,’ he said, ‘so I can’t lie down. When I need to pee I can’t help myself so it’ll be difficult for me unless I’m upright.’
We relented and drove off with him sitting upright. So far, his obs were stable, but we were concerned about his blood pressure, considering the amount of blood he must have passed over recent days. We’d already decided that if it fell significantly he was going to have to lie on the bed, regardless of his urgency to go. During the journey, which was supposed to be an emergency run, he had to pass fluid, so we had to stop and he stood up in the ambulance and peed blood into a vomit bowl. He passed about a cupful and it took him a couple of minutes to complete the exercise because he found it hard to put enough pressure on his bladder to allow a full flow. The task exhausted him. We set off once more, but only a couple of minutes had passed before he needed to go again. Another stop and another cup of blood later, we carried on.
Our lights were on and the siren was being used but we were travelling at 10 mph because he repeated his stand up and pee blood routine again and again. The vomit bowl was quickly starting to fill, but we made it to the hospital just as it looked like we were going to have a bloody floor. It took us three times as long to get there as it should have - it was one of the most bizarre journeys I have taken with an emergency patient. We handed him over and left him; he was a nice old chap and I hope they got him sorted.
Doctors often call ambulances for patients who have come into the surgery with acute problems, like chest pain. They’ll dial 999 without hesitation if the person they are treating suddenly becomes worse, arrives with obviously serious illnesses or injuries, needs immediate hospital care or simply presents too complex an issue for the GP to solve at that location.
A call to an ‘unwell baby’ at a doctor’s surgery in east London had my crewmate and me, once again, preparing for the worst. The child was so obviously ‘going off’ that I was surprised the doctor was so laid back about it when we went to get him. His mother had no idea just how sick the child was.
‘His breathing is shallow and he’s not responding much,’ the doctor told us.
‘How long has he been like this?’ I asked.
‘It started about twenty minutes ago,’ she replied. ‘Then he was fine, then a few minutes ago he went back to being like this.’
I was feeli
ng a little under pressure here. The child was not doing well and could suspend on us at any time. We grabbed our stuff and took him and his mother to the ambulance. I opened up the red paediatric bag that contains the specialised emergency equipment I would need if the baby stopped breathing on the way and sat down with him in my arms while the mother looked on anxiously. I supported his breathing and continually tried to stimulate a response from him, but I got very little. Mum kept asking me what was wrong with him. I didn’t have a clue; neither had the doctor. All I knew was that he was in trouble.
I discovered a week or so later that the child had a serious neurological condition and was undergoing tests to see what could be done for him.
Close calls can develop as a direct result of the action, or lack thereof, taken by parents when their child presents with a possible life-threatening condition. In the middle of the night we were sent to a ‘3 year-old male, fitting’. We arrived on scene within a few minutes and made our way up to a second floor flat in a dismal estate. It was raining and cold - the weather had been like that all night and this was our last job of the shift.
Inside the dimly-lit bedsit, we found a mother crouching over her little boy whilst he appeared to be having a major seizure. There was another child in the room, lying on her back in a cot, staring at the ceiling while her brother’s drama unfolded right across from her. She showed no sign of emotion or interest.
My crewmate and I approached the woman - she was African - and asked her what had happened. She didn’t reply. I looked at the boy and saw that he needed help with his airway, so I cleared his mouth and nose of mucus and made to give him oxygen. His mother insisted that it wasn’t necessary and tried to prevent me from putting the mask on his face. I couldn’t believe what she was doing and practically wrestled with her to get the desperately-needed oxygen to her son. Eventually, she relented.
