Luckily I was just around the corner when I got called to this one. Traffic police were driving by on their way to curry night at the local police station. They saw a young man on the ground just inside the grounds of a park. They pulled up to investigate and saw that he was injured and losing a lot of blood from a leg wound. Springing into action one of the cops put a huge battle dressing on the wound; he pressed firmly on it and elevated the leg. He established that the young man – Alex – had been taking a short cut by climbing over the railings when he slipped and impaled himself by the lower leg onto one of the spikes. Unbelievably he managed to pull himself off and stagger only a few steps before he could go no further.

The policeman said he had to climb over the railings by using the police car as a step up, but that it was very tricky so the other cop hadn’t even attempted it. He told me that the fire brigade were on the way to break the lock on the gate. However, I ADORE climbing things and do so at any opportunity, so I decided to attempt to scale the railings. I threw my bags over first then used the car to give me a step up, then clambered over the spikes. Landing safely and dare I say, gracefully perhaps, on the grass on other side, I assessed Alex’s condition. He was very quiet, pale and sweaty, his blood pressure was ‘in his boots’ so I put a cannula into a vein in his arm and gave him some fluids to boost it a little, and then I gave him some painkiller. We cut away his blood soaked jeans to assess the wound and check for other injuries. On the surface it was quite a wide laceration and there was no way at this point of knowing how deep it was or what the damage was like underneath.

Three fire engines arrived next and even though all we needed were some bolt cutters I never complain about having them there! At least we could move in and out of the park with the equipment now.

An ambulance arrived and we prepared to get Alex on board for his journey to hospital. We lifted him on to the trolley bed and kept him lying down with his legs elevated; we needed to monitor his blood pressure constantly as it remained a little low but at least the bleeding was now under control.

So Alex went in the ambulance to hospital for further assessment of his injuries, the police went off to enjoy their curry, and after a quick clean up and restock I was ready for my not so eventful next call.

Image courtesy Matt from London, on Flickr

This is part 2 of a 2 part article. If you missed it, read part 1.

The next morning I met another anaesthetist who was willing to let me assist her, this time with cannulation.  I wasn’t expecting this to go very well as I don’t really like needles, especially when I have to have a blood test, so I didn’t know how I would get on doing this procedure on somebody else.  The anaesthetist was really patient and supportive, talking me through each step, but to say I fluffed it is an understatement.  I got the needle into the vein, but as I was trying to coordinate pulling the needle back and advancing the plastic part further into the vein, I managed to point the needle upwards and puncture the vein, spurting blood everywhere.  I felt so silly and really sorry for the man I was practicing on, but he was ever so sweet and said how he understood that everybody had to learn sometime!  Needless to say that particular anaesthetist was reluctant to let me try her next cannulation, but she did let me do 2 intubations in the afternoon which were both successful.

By the middle of the week I had tracked down the lady I had worked with on my first day, and together we conquered my cannulation problems.  By the time I was finished working with her, the only veins I was missing were the patients who were so dehydrated from not being allowed food or drink before their surgery, or the patients who knew from previous experience that they had difficult veins.  It was still useful to have a practice on such patients though, as not every cannulation out on the road is going to be easy.  In fact, as the majority of cannulations we do are in life threatening conditions, they are more likely to be difficult as the venous network goes into shutdown, so I needed all the practice I could get.  It was reassuring to know that if I was unable to cannulate in hospital, there was somebody else there with more experience who would probably be successful.  This will be the same for me during my sandwich year out on the road starting in September, but very soon after that I will be going it alone.

As well as experiencing some difficult cannulations, there also seemed to be an abundance of difficult intubations sent to try me.  On my second to last day of placement, one of the anaesthetists told me that he had 3 intubations I was welcome to try; all 3 of them turned out to be difficult.  I had a go at getting a view of the vocal cords but just couldn’t see a thing in any case.  The anaesthetist told me to put the tube in blind as it had a 50/50 chance of going in the right direction, but this technique failed me each time.  It was reassuring that the anaesthetist found all of these patients difficult when he tried them, and it wasn’t just a bad technique preventing me getting a view.  This particular day was a very positive learning experience as I experienced the frustration of difficult intubations and got an idea of how the anatomy varies to dictate whether the task is going to be easy or not.  It also highlighted that even though intubation is considered the gold standard of airway management, time must not be wasted trying to achieve it.  If it looks like it isn’t going to be successful, emphasis must be on adequate oxygenation, and then it is possible to consider other forms of airway management such as LMAs.

As a whole, my time in theatres flew by.  On days with short surgical lists up in the main operating theatres, I was allowed to go down to day surgery.  I found this particularly useful as I was exposed to a completely different way of working, with different types of operations.  The biggest bonus for me in trying to achieve as many of each skill as possible was the fact that these operations were generally shorter than those performed in main surgery, so the turnaround time was quicker resulting in more patients being seen each day.

Despite imagining the worst, everybody I met and worked with was really lovely.  They were all very supportive and eager to help me practice and learn, and many of them complimented the career I’m entering into.  I found this particularly touching, as sometimes it can feel like hospital staff don’t understand what our job entails or the challenges we can face on a daily basis.  On completion of my placement, I felt a lot more confident with the emergency skills to help me appropriately deal with some of these challenges.

Image courtesy Johnathan Beard, on Flickr

Despite finishing my university time for year 2 back in June, it wasn’t time to kick back and relax for the summer holiday until last week.  On successful completion of all the academic components of the second year, each of us had to complete a fortnight’s placement in a hospital operating theatre, followed by the remaining 2 weeks of the driving course.

The aim of this hospital placement was practical consolidation of the skills we had learnt in our second year skills module, most notably cannulation and intubation, but also placement of LMAs (another type of airway, generally easier to insert than the tube used during intubation), and the running through of fluids if we hadn’t done many of these during our placements on the ambulance throughout the year.  We needed to do the cannulations and intubations in hospital before we are given the opportunity to do them with our PPEds out on the road next year.  Paramedics used to have to achieve a specific number of each skill before they could be let loose on the public on their own, but this wasn’t the case for us.  Our LAS tutors recognised that when in theatre, lots of the patients are candidates for LMAs as opposed to being intubated, which dramatically decreases the number of ‘tubes’ (intubations) available for us to try.  Furthermore, in many hospitals, there are medical students competing for the same skills as we are, and preference is generally given to them.

The night before my placement started I was really nervous; the thought of going to a place completely different to anywhere I had ever worked before, with a whole set of new people I had never met before was incredibly daunting.  Our year group had also heard horror stories of scary anaesthetists at other hospitals who shouted at students for no reason and didn’t let them assist with the procedures they were there to do.  I decided to get an early night rather than ponder on such thoughts; I had been informed I needed to get there early on my first day anyway so I could be shown around and told where to work, so the sleep would do me good.

When I arrived on the Monday morning I introduced myself to the staff on reception and told them why I was there.  It wasn’t difficult to guess who I was as I stood in front of them in my obvious green uniform.  They directed me to the changing room and showed me where the scrubs were that I would need to wear.  It took me ages to find a size that fitted me, they were all either too small or ridiculously big and baggy, making me look like a bit of a clown.  As if I didn’t feel silly enough, I also had to wear a surgical cap!  Once I was all dressed up, I got a guided tour of the department, invaluable to me as my sense of direction is generally pretty poor.  The lady showing me around pointed out each operating theatre and advised I go round to meet the Operating Department Practitioners to find out which patients would need intubating that day, or whether I could assist with the cannulations.  All patients required this skill as the intravenous route was used to give the drugs to put them to sleep.

I spent most of my first day trying to be in the right place at the right time.  I kept going from theatre to theatre to see if there was anything I could do, but I had either just missed an opportunity or the patient wasn’t appropriate for my skill level for one reason or another.  It wasn’t until very late in the afternoon that I finally got the chance to do something; one of the anaesthetists had seen my wandering around the department and said she had two intubations coming up next.  There was a medical student who needed the practice too, so she said we could do one  intubation each.  I asked to watch the other student’s attempt; unfortunately for him he the intubated the oesophagus rather than the trachea, and rather than give him another chance, the anaesthetist took over.  I was really nervous about having a go as the other student asked to watch my attempt, but I was lucky enough to get a very good view of the vocal cords, ideally where we want to be able to watch the tube passing through, and intubated the trachea correctly.  I got this first skill signed off in my paperwork and decided to go home for the day, leaving on a high.

Come back next week to read part 2 of my summer theatre placement.

Recently I had one such call. An elderly lady had been given a diagnosis of cancer a few weeks earlier. Plans were being made and a package of care was being put in to place that would support her through the inevitable decline that would ultimately lead to her death. However, her condition suddenly took a down turn and the desperately worried family, not knowing where else to turn, dialled 999. Despite her diagnosis of terminal cancer there was no ‘Do not resuscitate’ (DNR) order in place and we were obliged to attempt to resuscitate her. This means compressing her chest to squeeze oxygen around the body, placing a tube into her throat to allow ventilation of the lungs and placing a cannula into a large vein in her arm to provide a route for drugs. We moved her from her home to the ambulance during this procedure and her family were in a state of flux as they prepared themselves to follow us to the hospital.  It all proved futile (as we knew it would) and efforts were finally stopped shortly after arrival at hospital.

Sadly, I have been called to many patients in the last stages of cancer, emphysema or other long-term or terminal conditions who have suffered a cardiac arrest. Usually the family’s expectation is that we begin cardio-respiratory resuscitation (CPR). Shocked and distressed, they want the best for their relative; they want them brought back to life and so we commence CPR. Sadly their expectations are often misguided and unrealistic.

CPR is definitely not a panacea for all. It should be considered a targeted treatment to be reserved for those for whom there is a reasonable expectation of survival. Importantly age should not be an influencing factor when deciding who receives CPR because the elderly can do just as well as the younger population – provided that there are no co-existing serious diseases. CPR is unlikely to be successful in those patients who already have a disease such as emphysema, advanced cancer or pneumonia.  Even if we do bring them back to life, they will still have the disease that caused the cardiac arrest and quite possible they will now additionally have brain damage through the lack of oxygen as a result of the episode.

Personally I blame television for much of the problem when it comes to expectations. On a weekly basis we see CPR used in hospital soaps.  One after another sick patient is resurrected, still miraculously in full possession of their faculties. They then skip off into the sunset with their grateful families in tow. This inaccurate portrayal does little to give a balanced perspective to families or aid reasonable and honest discussion on the matter.

The British Medical Association, Age Concern and The Royal College of Nursing all advise discussion between the patient, families and health care practitioners as the disease progresses to the terminal stage.

I believe that it is important that we actually start to have a transparent dialogue about the appropriateness of resuscitation much earlier on in the disease process rather than waiting until the terminal stage before we even begin to talk about it. Or perhaps we should encourage it long before that. I have previously discussed the importance of letting your family know your wishes regarding organ donation in the event of an untimely death.

While many of us understandably shy away from discussing death and dying it is important to do so long before we reach a crisis point and only then can we hold out some hope that our final wishes regarding how and where we die may be taken into consideration.

A £224 million government database holding the records of all 11 million children in England has been scrapped.  [source]

What a wasted opportunity to assist professionals to protect vulnerable children and young people. So much developmental work had already been undertaken on ContactPoint, an important and much needed project which would have improved communication between all those who come in to contact with children. Everyone who works with vulnerable families holds a piece of the puzzle but unless these are placed together somewhere, no-one ever gets to see the complete picture.

Historically, poor communication has been cited as a contributory factor in all investigations into child death due to abuse. Therefore logic suggests that anything that improves the sharing of information between social services, schools, police and health – including the ambulance service – will go a long way in the challenge to keep children safe and protect them from unnecessary suffering. There may very well be a ‘Plan B’ in the pipeline but sadly I suspect the process will be lengthy and dogged by delays and bureaucracy. In the meantime children will continue to suffer and the list of child victims of abuse will continue to grow.

Image by laughlin on flickr

Like many of my colleagues who work in a range of health care roles, I have got used to and don’t usually mind, being asked for medical advice by family, friends or occasionally even relative strangers when off duty.

We get used to the unexpected knocks on the front door or approaches at social events. They are part and parcel of life for us. In fact have lost count of the number of times that someone has pitched up on my doorstep in a state of panic following some incident or another take these real examples;

• An hysterical young mum whose baby had been covered, head to toe with the entire contents of a tin of gloss paint by her toddler – Dulux Bright White – in case you were interested. Only his little eyes and tongue remained pink, cute!
• A plumber – cut to the head when a frying pan fell on him while working in my neighbour’s house! That’s what they said and I believe them!
• A neighbour called me to help her friend, a man definitely old enough to know better, who had been enjoying a bevy or three at her party and then decided to have a cheeky bounce on the trampoline – dangerous combination by any standards – he had fractured a vertebra during a failed somersault attempt!
• And not forgetting a very young lad who had panicked when he cut himself practicing some premature shaving – bless him!

I didn’t mind any of these; I’m a good natured soul, but then there are also the numerous phone calls and generally speaking, I don’t even mind any of these either. One such call even came while I was on holiday feeling slightly tipsy on the local vino “Lysa i’ve been in a fight and I got hit on the head with a bottle, there’s blood everywhere, can you come?” Clearly not!

But it’s not just my altruistic tendencies coming in to play here; it is also the hope is in the back of my mind, that when I need to call on these friends and neighbours – they will be there for me. And indeed, so far this has always proved to be the case. It’s a win-win situation.

BUT –what I do object to is being disturbed and then having my professional advice ignored. Take this example;

“Hi Lysa it’s only me sorry to bother you, but I have this dreadful central crushing chest pain, I’m sweating like a pig and feel sick, and I’m not sure what to do”

“You should hang up and dial 999 immediately, it may be that you are having a heart attack” I reply.

“Oh no! I have to be somewhere in an hour, can I just call the doctor in the morning do you think?”

“No – my advice to you is to call for help right away”

“Ok well thanks for that – I’ll probably leave it for a bit though sorry if I disturbed you”

Then there is the call during the early hours of the morning. At first I thought I was the victim of a dirty phone call as a breathless voice gasped;

“ I can’t breathe” wheeze “What shall I do?” wheeze.

“Take your medications and call for help straight away” I replied once I had woken up enough and established what was going on.

“But it’s very late now“ wheeze “I’ll  see how” wheeze ” I go” wheeze “ for now” wheeeeeze!

And this is when I really object – Do not wake me at three in the morning to ask my opinion on what action you should take next and then IGNORE IT!  Now you have made me aware of the problem I shall have a sleepless night wondering what has become of you and that just isn’t fair! If you simply want to find out what you should be doing during your health crisis, try calling NHS Direct (0845 46 47) and if you chose to ignore their good advice, well that is your prerogative because a) they are being paid to be awake at three in the morning dishing out advice and b) I will be none the wiser and can sleep soundly in my bed!

Image by Dplanet on Flickr

On my way to work one day I approached a busy junction. I could see that the lights weren’t working so I stopped and pulled on the handbrake. I noticed with horror that a motorcyclist and car approaching the junction from different roads were on a course for collision. As the vehicles impacted, suddenly the body of the motorcyclist was catapulted through the air like a rag doll and landed hard on the road in front of my car.

Forgetting I was in my own car I instinctively I reached for the radio to call the control room, then remembering myself I switched off the car engine and pulled my Hi-Viz coat from the passenger seat. I grabbed my paramedic bag from the boot and made my way to where the body lay. In my mind I was convinced that I had just seen someone killed – so I was very surprised to see the ’body’ start to move. I was grateful that at least she was conscious and breathing. I told her to lay still and knelt at her head and held it still to keep her from moving and possibly damaging her neck further.

At this time I remember someone approaching me. They told me that they had called an ambulance; and so I waited for it to arrive and in the meantime I tried to comfort my patient – it felt like an eternity.

The next thing that happened was a milkman parked up his float and marched over to me. He then started to yell and swear at me, blaming me for the fact that the lights hadn’t been working for two days. He shouted in my face telling me to get ‘her ‘out of the road and out of the way. I asked him, fairly politely, to go about his business and crossed my fingers that help would soon arrive. Things were getting rapidly out of hand!

Luckily, a couple of off-duty police officers passed by and stopped to help with the traffic  – little did they know at the time that my patient was in fact one of their colleagues on her way home from work. Their presence at least had the beneficial effect of making the horrible shouting milkman leave us in peace!

Next an off-duty paramedic stopped and together we safely removed her helmet (the removal of a crash helmet in this situation requires two people and special training so as not to cause any further damage to the spine). We then checked her over to determine her injuries.

When the ambulance arrived we all worked together. We placed a stiff neck collar on her and moved her on to the back of the ambulance using a spinal board, then gave her pain-killers to help her cope with her injuries.

Amazingly despite her flight through the air, it transpired that she had only sustained a very severe fracture of one of her lower legs (I found out afterwards that she went to theatre for pins and plates to be fixed to the broken bones while they healed).

This experience brought home to me how very different actually witnessing an accident is compared to arriving in an ambulance some minutes after the event; and while the actions of the milkman saddened me it was reassuring to see that even when off-duty you can always rely on the emergency service to stop and help when they can!

I must say i’m partial to kitsch items that are somehow related to anatomy or medicine. I’m not afraid to admit it. I thought i’d share a few i’ve seen that have caught my eye (and some that i’ve bought!).  All prices correct at time of writing.

Dr Jam’s Man Flu Stress Ball

A large tablet shaped stress reliever, I bought it the first day I saw it. It’s a little bit strange to squeeze as it tends to bend in the middle along the centre groove, but this really caught my eye and is currently sitting on my desk.  An absolute steal at £1.99 from Play.com.

Blood Bath Shower Gel

Not managed to buy one of these yet, because they sell out so quickly!  This cherry scented shower gel is in a bag that looks like IV fluid (commonly referred to as a ‘drip’). Available from Spinning Hat (when it’s not sold out).

Dr Cool/Dr Hot Bags

While we’re on the subject of things looking like drip bags, Suck UK sell these two items.  The Dr Cool bag is filled with Gel that you chill in the fridge, while the Dr Hot bag is one of those hand warmer items that warms up when you click the little silver disc inside it.

Giant Microbes

If you’re into plush, then these are the plush for you!  The problem is deciding which one to get. You can get them in the shape of the flu virus (including the swine flu variant), the Common cold, MRSA, red blood cells, or even the microbe responsible for bad breath! Get them from Firebox.com.

Bonus: Some recommended reading

If you’ve liked this post you might want to add the following sites to your reading list:

• Street Anatomy
• I Heart Guts

Image by dno1967 on Flickr

It was the last shift before I was due to go on my holidays. It was also a very hot and sunny day. The last thing that I wanted was any jobs that were going to give me any stress or cause me to break in to a sweat. I was simply intent on winding down in anticipation of my trip to Italy.

Then the first job came down to my screen in the car: ‘Male – Stabbing – please give a report for HEMS’. Oh great – just what I needed! I hurtled down there and arrived at about the same time as an ambulance and the police. We all got out and grouped together before we went in to the house. There was no answer at the front door and the police were weighing up all the options with regard to breaking in to the property when some of the immediate neighbours approached us.

Well, if their stories were to be believed it sounded unnervingly more like an episode of Holby City than downtown suburbia. They told us that one of them had apparently had a heart attack just last week and another had been shot only a few days earlier (although she looked quite well for it), and now a fatal stabbing. I could only guess at what the insurance rates would be in this particular road!

It soon became clear to us all that this was nothing more than a hoax call. Thankfully, no one had actually been stabbed, shot or had a heart attack and in fact it was all down to a single caller who had nothing better to do with their day but waste the time of the emergency services.

Charlotte and I were on the car recently and we had a call to go to an elderly lady believed collapsed behind locked doors. She had had a blood test a few days earlier and the pathologist (a doctor who specialises in the scientific study of the nature of disease and its causes and processes) was very concerned about the results because they were extremely abnormal.

The pathologist informed the GP practice who rang the lady to advise her that he was arranging an ambulance to come to her and bring her into hospital ASAP. When he got no answer he feared the worst and called for the ambulance service and police to go to her address, break down the door if needed, treat her and then bring her into hospital.

So we were all there – two police vehicles, an ambulance crew and Charlotte and I in the car – it must have appeared as if there was a major incident going on in Croydon at the time! We got no answer from persistently knocking and ringing at the door. A neighbour approached us and insisted that we must have the wrong address because the lady was seen to be alive and well only an hour before.  After lots of phone calls and a fair bit of detective work we established a mobile phone number for the patient. I spoke to her on the phone and told her the situation.

Very calmly the lady told me that she felt perfectly well; despite her advancing years she had walked the two miles to the pub and was quite happily watching the football – until I had disturbed her. She politely added that she would prefer it if we would all leave her in peace to continue to do so!

Well, we did as requested! Obviously we ensured that she would speak to her GP and make arrangements to be admitted to hospital first thing the following morning – but I was in admiration,  I can only hope that I have some of her spirit and determination when I am in my eighties!!!