The call is to a nursing home, well known to us in the Concrete Jungle, by no means the worst I've ever been to but slowly getting there.
The patient apparently has a head wound that the staff are unable to stop bleeding and would like him to visit hospital.
I approach the nurses station where the patient has been sat in a wheel chair ready for us to help him out. His colour is good underneath dried blood which has gatthered on his cheek. The shoulder of his shirt had a crimson stain down to the chest pocket, he fiddles with the pocket trying to get a hankerchief out, when he imagines he has it he slowly raises a hand to his head before starting the process again.
He has a bandage on his head, which looks like its been thrown at the right spot and the person applying it has just hoped it would stick. The nurse informs us patient is called Walter* and he has dementia. He doesn't really communicate but is otherwise fit and well.
"What happened?"
"We don't know. The night shift said he fell this morning when he was trying to get to the toilet. They dressed it and handed over to us."
"Did they give any reason as to why he might of fallen?"
"No, just handed over and left"
"What time was that?"
"7.15"
It was now gone 7.30.
"Any idea at what time it happened?"
"No"
"Did they dress the wound or did you?"
"They dressed it"
"So you haven't seen it?"
"No"
I approach the patient and introduce myself. I get a smile in reply as I explain that I just want to have a look at his head. The grin continues.
I lift the dressing away from his head to find a soaked Elastoplast. The sticking plaster and the dressing are completely soaked through with blood and I can see it is still seeping through the edges.
"Can you pass me a gauze pad? I think this might be a bit messy"
My colleague hands me the pad from the bag. My reasoning is that if it is still actively bleeding then it could be arterial and didn't fancy a squirt of blood in the face so early in the shift.
I hold the gauze as a shield and start to pull back the Elastoplast. I can already see the cut is very deep. As I reach the middle of the manoeuvre I get the expected squirt of claret. I reposition my hands to cover the active bleed while removing the rest of the useless plaster from the his head. I finish off by securing a bandage around his head to apply the pressure that was needed half an hour before.
I ask the nurse for a copy of his medication chart and if there will be an escort. She scurries off as we remove the patient to the ambulance. From what I can make out he is going to need a couple of stitches. I also want to get a full set of observations. The lack of information about the fall the patients inability to communicate concern me slightly. Elderly people can just fall because they loose their balance but they are also much more prone to other more serious causes.
I settle the patient onto the trolley and lower the back, this means if the bleed continues the blood won't run down his face into his eyes. I attach all the relevant monitors and pour some water into a bowl to clean the blood that has dried on his face and around his eyes already.
His vital signs all appear to be in order and his ECG looks normal. Just as we get ready to close the back doors a small figure comes jogging out of the front doors clutching a handbag and a file.
"Are you the escort"
A nod with a heavily accented "yes" has her in the back and strapped in.
"Ok I need some details on the way in. What is Walter's full name?"
A confused look crosses her face as she looks from me to the patient back to me.
"Walter?"
"Yes the patient Walter. What is his second name?"
"Erm" She struggles with her hand full of bags trying to get a better look at the file.
I put my hand out "Just give me the paperwork, I'll get it from that"
Tuesday, 28 April 2009
Friday, 24 April 2009
Repeating Myself!!
Ok! So this is a slightly edited re post as I want to shout about this again. Proper posts coming again very soon promise! In the mean time please help spread the word about this!!
Please check out Michael's website and his amazing story. He sets off in 2 weeks time on this epic journey and with some recent time in the Mountains myself I'm very jealous of the sights he's going to see!
The Cairngorms as seen from just north of Aviemore in March
I'm going briefly off topic to promote a fundraising challenge
As some of you know I am a keen mountain walker, its one of the reasons I moved to Scotland to be closer to the amazing scenery and a choice of thousands of mountains to get my teeth into.
I am also in a couple of online forums where I meet people with a similar interest and love of the Mountains all over the UK.
One of the regular forum members is Michael Tunney. He is undertaking an amazing challenge in May this year to raise money for the Oban and Arrochar Mountain Rescue teams and the Northern Police Treatment Centre.
Michael was in need of all these services after a fall while walking Beinn Achaladair and Beinn a'Chreachain in November 2006. Please visit his website and read his account of the accident and his subsequent recovery.
The medical bods amoung my readers will appreciate the extent of his injuries and the very real possibility that he may not have made it. You will also appreciate the amazing recovery he has made to get to the point he is at now. The hill walkers amoung you will marvel at the work of the MRT'S and Rescue 177 HMS Gannet to get them off the mountain safely. Read the MRT members accounts of the rescue for another perspective.
Michael is going to walk from Aviemore to Fort William over the nine 4,000 ft mountains also taking in another 14 Munros., this is approximately 30,000 ft of ascent, more than a single ascent of Mount Everest. Now I have issues getting up one mountain sometimes so this challenge of physical and mental strength is mind bogglingly hard! He will be camping and using bothy's during the route so will also be carrying his supplies for the trip.
Please visit his site and if possible make a donation via the links. Mountain Rescue is a volunteer organisation who are called out at any hour and any weather to try and help people in trouble and rely mainly on donations from the public.
Ben Nevis from Glencoe
So stick your hand in your pocket, even just for a couple of quid and help the Mountain Rescue teams.
Thank You!!
Tuesday, 14 April 2009
Problem Solving
The driver for the urgent tier motor meets us at the front door.
"She's in some state. Been there for 5 days hasn't moved. She's quite a big lady but she isn't in the position to help herself. The wound from her breast is infected and extends down her side from under her armpit. Its actively bleeding so we can't get under the arms to lift her. The daughter says she apparently isn't aware that she has breast cancer and she won't communicate with us at all. We just can't move her on our own"
We enter the property, which is cramped, extracting her from the house maybe difficult which ever way we do it.
The patient is sat on a sofa which looks to have collapsed under her. The smell of dirt, urine and faeces fills the air. She makes for a sad sight. She's given up.
We have to think of the best way to get her off the sofa and out of the house.
Attempt No 1:
We use a slide sheet as a sling and pass it around her back and under her arms. It'll be soft enough on her wound and give us some leverage. We position the carry chair. Two of us will use the sheet from the front to pull the patient up, one will push the patient from the back and the 4th person will block her feet to stop her sliding in the hope that she will support her own weight long enough to switch her on to the chair.
It is on this last point that the plan fails. It becomes apparent that the patient has totally given up and is not able to support herself in anyway what so ever. The attempt results in us lowering the patient to the floor.
Attempt No 2:
I suggest trying to use the Manger Elk. This is a lifting cushion which assists to raise patient's off the floor without needing to lift them.
We position the equipment and get the patient onto the cushion as best we can. We use the slide sheet to pull her into the Elk.
We position ourselves to try and support her as best we can while the cushion inflates. She slouches and begins to slide off the front of the cushion and no amount of repositioning and support will make this manoeuvre work.
Attempt N0 3:
We lay the patient down on the floor and wrap her in a blanket to try and keep her warm and comfortable.
The orthopaedic stretcher is brought in, measured up and prepared next to the patient. We get the trolley and place it by the front door and then do a walk though the hallway to plan the best way to lift her out. We have to move some clutter to help ease our transition. Its not ideal, we are going to have to bodily lift her over part of the banister at the bottom of the stairs to get around the corner and out the front door. At times like this the 'no lifting' policy goes out the window and you just have to get on with it.
We get the patient on to the ortho stretcher and strap her up tightly. I surprise myself by getting it right first time even though I hadn't had to use this particular technique since the training school.
The lift goes well and we finally get the patient out the front door and in a comfortable position on the trolley. A swift move into the urgent tier vehicle and she is nicely packaged for the doctors and Holy Hospital to begin to deal with her problems.
I remember the application packs for this job saying 'Good at problem solving'. Its jobs like this that make you realise why.
"She's in some state. Been there for 5 days hasn't moved. She's quite a big lady but she isn't in the position to help herself. The wound from her breast is infected and extends down her side from under her armpit. Its actively bleeding so we can't get under the arms to lift her. The daughter says she apparently isn't aware that she has breast cancer and she won't communicate with us at all. We just can't move her on our own"
We enter the property, which is cramped, extracting her from the house maybe difficult which ever way we do it.
The patient is sat on a sofa which looks to have collapsed under her. The smell of dirt, urine and faeces fills the air. She makes for a sad sight. She's given up.
We have to think of the best way to get her off the sofa and out of the house.
Attempt No 1:
We use a slide sheet as a sling and pass it around her back and under her arms. It'll be soft enough on her wound and give us some leverage. We position the carry chair. Two of us will use the sheet from the front to pull the patient up, one will push the patient from the back and the 4th person will block her feet to stop her sliding in the hope that she will support her own weight long enough to switch her on to the chair.
It is on this last point that the plan fails. It becomes apparent that the patient has totally given up and is not able to support herself in anyway what so ever. The attempt results in us lowering the patient to the floor.
Attempt No 2:
I suggest trying to use the Manger Elk. This is a lifting cushion which assists to raise patient's off the floor without needing to lift them.
We position the equipment and get the patient onto the cushion as best we can. We use the slide sheet to pull her into the Elk.
We position ourselves to try and support her as best we can while the cushion inflates. She slouches and begins to slide off the front of the cushion and no amount of repositioning and support will make this manoeuvre work.
Attempt N0 3:
We lay the patient down on the floor and wrap her in a blanket to try and keep her warm and comfortable.
The orthopaedic stretcher is brought in, measured up and prepared next to the patient. We get the trolley and place it by the front door and then do a walk though the hallway to plan the best way to lift her out. We have to move some clutter to help ease our transition. Its not ideal, we are going to have to bodily lift her over part of the banister at the bottom of the stairs to get around the corner and out the front door. At times like this the 'no lifting' policy goes out the window and you just have to get on with it.
We get the patient on to the ortho stretcher and strap her up tightly. I surprise myself by getting it right first time even though I hadn't had to use this particular technique since the training school.
The lift goes well and we finally get the patient out the front door and in a comfortable position on the trolley. A swift move into the urgent tier vehicle and she is nicely packaged for the doctors and Holy Hospital to begin to deal with her problems.
I remember the application packs for this job saying 'Good at problem solving'. Its jobs like this that make you realise why.
Friday, 10 April 2009
So Young
I find the rapid response driver standing outside the front door to the flats.
"I went in and she was in the process of shooting up. I told her to put it down and left so she could finish. I've been to her before she's a long term user."
The call had come through as an urgent call from the GP. The patient was to be admitted for a problem with her hands.
We finally entered the flat, cautiously, picking our way through the dirt and detritus that litters the hallway. We enter a squalid living room crammed with a bed, a sofa, bookcases and a large coffee table in the middle of the room. The patient had finished with her needles and has lit a cigarette causing the room to feel horribly claustrophobic in the thick smoke. Add in 3 ambulance people, 2 police and her friend and things were getting uncomfortable.
She lifts the cigarette to her mouth. Its in slow motion like the concentration of the process is taking all of her clouded mind to complete.
I ask to look at her hands.
One hand is swollen and shiny red. The back of the hand is completely featureless and the fat fingers that protrude from this deformity look out of place on such a small person. The thumb has a black patch indented into the skin. The flesh is rotten but the stale smell of smoke masks any stench from it. A smaller patch is starting on the index finger.
The other hand is also starting to look dead. The red shiny complexion isn't quite as established but its getting there.
She tells me its been like this a while but now she's finding it hard to get sites to shoot up in between her fingers and phoned the doctor.
We gather her and some clothes together. It appears her hit was only a small one and although progress is slow, its progress.
I begin to fill out the patient report form. "How old are you?"
"19"
Shes 19.
19
And she is about to loose at least one hand. Probably both.
Just because of an all consuming habit and desire for a drug that the world knows is bad news and yet it is still produced, sold and taken by people from all walks of life.
Why?
Money. And money makes the world go round.
"I went in and she was in the process of shooting up. I told her to put it down and left so she could finish. I've been to her before she's a long term user."
The call had come through as an urgent call from the GP. The patient was to be admitted for a problem with her hands.
We finally entered the flat, cautiously, picking our way through the dirt and detritus that litters the hallway. We enter a squalid living room crammed with a bed, a sofa, bookcases and a large coffee table in the middle of the room. The patient had finished with her needles and has lit a cigarette causing the room to feel horribly claustrophobic in the thick smoke. Add in 3 ambulance people, 2 police and her friend and things were getting uncomfortable.
She lifts the cigarette to her mouth. Its in slow motion like the concentration of the process is taking all of her clouded mind to complete.
I ask to look at her hands.
One hand is swollen and shiny red. The back of the hand is completely featureless and the fat fingers that protrude from this deformity look out of place on such a small person. The thumb has a black patch indented into the skin. The flesh is rotten but the stale smell of smoke masks any stench from it. A smaller patch is starting on the index finger.
The other hand is also starting to look dead. The red shiny complexion isn't quite as established but its getting there.
She tells me its been like this a while but now she's finding it hard to get sites to shoot up in between her fingers and phoned the doctor.
We gather her and some clothes together. It appears her hit was only a small one and although progress is slow, its progress.
I begin to fill out the patient report form. "How old are you?"
"19"
Shes 19.
19
And she is about to loose at least one hand. Probably both.
Just because of an all consuming habit and desire for a drug that the world knows is bad news and yet it is still produced, sold and taken by people from all walks of life.
Why?
Money. And money makes the world go round.
Monday, 6 April 2009
Compromise
We arrive at the scene carefully picking our way through the traffic to the lay by. There is a lot of activity going on.
2 lorries are sat in the lay by with a large trailer looking out of place in between the two. It looks like it belongs to the truck blocking the road.
The traffic officer in charge leads us to the cabin of one of the lorries. A female driver is sat looking pale and in pain.
"Hi there, whats happened?"
It seems she was sat in the lay by having a well earned rest on her drive down from Inverness when something hit her from behind. That something it turns out was the out of place trailer. It had become detached from the lorry at approximately 40 mph and had slammed into the trailer of the stationary wagon.
My mind wonders to the scene this would have been had the trailer not hit the lorry but taken out some cars on the carriageway.................... I decide it doesn't bear thinking about and should just be thankful for this outcome, although I'm not sure our patient would agree right now.
"Where are you sore?"
"I lurched forward as I'd taken my belt off and hit the bottom of my ribs and breastbone on the steering wheel. Its really sore to breath in too deep."
I can see this is biggest problem she has, wincing every time she tries to take a deep breath. I put some oxygen on her. I want to listen to her chest but there in no point in the cab as its too noisy. It'll have to wait.
"Do you have any pain in your neck or back?"
"A little in my neck, it feels stiff rather than painful"
I look down out the cab and it becomes apparent a manoeuvre to board her in the cab would be far to dangerous for everyone involved. The mechanism of injury and the fact she has neck stiffness dictates I need to immobilise her by the best means possible.
I get a collar on her in the cab, its a quick and simplistic solution for the mean time. The oxygen and collar are taking care of her chief complaints. My main concern is her difficulty breathing.
We manage to bring the ambulance closer to the truck's cabin, I ask SoItIs* to put the board onto the trolley bed. We planned to help the patient down from the cab while controlling any neck movement as much as possible. Its seems to work well, with a few more hands found in the traffic police.
We carefully start to help the patient lower on to the spinal board.
"I can't lay like this, it makes the breathing worse, I can't lay down it hurts too much" I can see its causin her an awful lot of discomfort even trying to lay flat.
Right.
We need to immobilise her painful neck, which she now informs us has pain shooting into her head, but we also need to protect her breathing. Hmmmmm.........?
I come to a decision and move the trolley bed so she is positioned for optimal breathing. ABC's right? Breathing is my priority, the other stuff we can work around. Rolled up blankets are placed either side of her head to keep it in position and taped into place. I ask the patient to try her best to keep looking out the back window to keep her head in line. Its the best compromise I can some up with.
I set about having a look and feel of her lower rib cage, a quick listen doesn't suggest a pneumothorax (punctured lung) but I take a full set of obs and keep a close eye on her condition. The ECG looks normal, if a little fast, but it looks like the strike to her sternum hasn't sent her heart into an odd pattern.
On arrival at Holy Hospital I wheel the patient through to triage delighted to see Smiler* behind the desk (seriously in all my time going there I have not seen her crack a smile once).
She looks up then stands up to look over the desk. The look she gives the immobilisation I've had to improvise says "What have these idiot paramedics done now?" a sigh and a role of the eyes completes the show of distaste for my ingenuity.
"Would you like a hand over to explain why the patient is immobilised in this way or do you just want to make up your own mind that we're stupid now?" I was not in the mood for this kind of attitude today. I'm not usually this cheeky preferring not to rock the boat but sometimes it just niggles at you a little too much.
A raise of the eyebrows and nod of the head tells me to go round to Majors where I hand over to a nurse who patiently listens to my handover and explanation of the patients problems. She gives us a smile and a thank you while busying herself with the patients obs. See its not difficult is it?
I truly think that A&E nurses and doctors should be required to come out on the road with ambulance crews to witness the decisions, compromises and difficult manoeuvres we have to make when dealing with a patient in a non-clinical environment.
Then maybe the minority wouldn't be so quick to dismiss us when we bring in something unusual and not wrapped and packaged for them in the standard way.
2 lorries are sat in the lay by with a large trailer looking out of place in between the two. It looks like it belongs to the truck blocking the road.
The traffic officer in charge leads us to the cabin of one of the lorries. A female driver is sat looking pale and in pain.
"Hi there, whats happened?"
It seems she was sat in the lay by having a well earned rest on her drive down from Inverness when something hit her from behind. That something it turns out was the out of place trailer. It had become detached from the lorry at approximately 40 mph and had slammed into the trailer of the stationary wagon.
My mind wonders to the scene this would have been had the trailer not hit the lorry but taken out some cars on the carriageway.................... I decide it doesn't bear thinking about and should just be thankful for this outcome, although I'm not sure our patient would agree right now.
"Where are you sore?"
"I lurched forward as I'd taken my belt off and hit the bottom of my ribs and breastbone on the steering wheel. Its really sore to breath in too deep."
I can see this is biggest problem she has, wincing every time she tries to take a deep breath. I put some oxygen on her. I want to listen to her chest but there in no point in the cab as its too noisy. It'll have to wait.
"Do you have any pain in your neck or back?"
"A little in my neck, it feels stiff rather than painful"
I look down out the cab and it becomes apparent a manoeuvre to board her in the cab would be far to dangerous for everyone involved. The mechanism of injury and the fact she has neck stiffness dictates I need to immobilise her by the best means possible.
I get a collar on her in the cab, its a quick and simplistic solution for the mean time. The oxygen and collar are taking care of her chief complaints. My main concern is her difficulty breathing.
We manage to bring the ambulance closer to the truck's cabin, I ask SoItIs* to put the board onto the trolley bed. We planned to help the patient down from the cab while controlling any neck movement as much as possible. Its seems to work well, with a few more hands found in the traffic police.
We carefully start to help the patient lower on to the spinal board.
"I can't lay like this, it makes the breathing worse, I can't lay down it hurts too much" I can see its causin her an awful lot of discomfort even trying to lay flat.
Right.
We need to immobilise her painful neck, which she now informs us has pain shooting into her head, but we also need to protect her breathing. Hmmmmm.........?
I come to a decision and move the trolley bed so she is positioned for optimal breathing. ABC's right? Breathing is my priority, the other stuff we can work around. Rolled up blankets are placed either side of her head to keep it in position and taped into place. I ask the patient to try her best to keep looking out the back window to keep her head in line. Its the best compromise I can some up with.
I set about having a look and feel of her lower rib cage, a quick listen doesn't suggest a pneumothorax (punctured lung) but I take a full set of obs and keep a close eye on her condition. The ECG looks normal, if a little fast, but it looks like the strike to her sternum hasn't sent her heart into an odd pattern.
On arrival at Holy Hospital I wheel the patient through to triage delighted to see Smiler* behind the desk (seriously in all my time going there I have not seen her crack a smile once).
She looks up then stands up to look over the desk. The look she gives the immobilisation I've had to improvise says "What have these idiot paramedics done now?" a sigh and a role of the eyes completes the show of distaste for my ingenuity.
"Would you like a hand over to explain why the patient is immobilised in this way or do you just want to make up your own mind that we're stupid now?" I was not in the mood for this kind of attitude today. I'm not usually this cheeky preferring not to rock the boat but sometimes it just niggles at you a little too much.
A raise of the eyebrows and nod of the head tells me to go round to Majors where I hand over to a nurse who patiently listens to my handover and explanation of the patients problems. She gives us a smile and a thank you while busying herself with the patients obs. See its not difficult is it?
I truly think that A&E nurses and doctors should be required to come out on the road with ambulance crews to witness the decisions, compromises and difficult manoeuvres we have to make when dealing with a patient in a non-clinical environment.
Then maybe the minority wouldn't be so quick to dismiss us when we bring in something unusual and not wrapped and packaged for them in the standard way.
Thursday, 2 April 2009
Well Done!
Well Done to the Scottish Ambulance Service.
It was announced today (although I couldn't find a news story on it) that we hit our response time target for last year. We have a a target of 75% for the whole of Scotland and we managed an impressive 77%! Get Us!
I take the same views on the clinical relevance of ORCON targets as Tom Reynolds over on Random Reality (Relevant post are here and here if you are a regular reader of his you'll know the score!).
The clinical significance of the 8 minute target is negligible and based on out dated information for the demand and usage of the ambulance service which we are now seeing throughout the country.
In Scotland we have a different problem.
I have it on the grapevine that the response percentage for my particular area is actually at 97%. I have a feeling that Edinburgh may also have a similar response result. We are heavily populated and built up areas with many stations in a relatively small area. We tend to answer more calls than some of the other divisions however 70% (best guess) of the calls we attend are within a 10 mile radius.
Unfortunately Scotland is a rather big country with big mountains, islands, single roads and has ambulance stations based in strategic positions to facilitate as quick a response as possible.
However strategic you are, and in the vast areas we work in, we are not by any stretch of the imagination (or heaviness of the right foot) going to reach a AS1 call 50 miles away in 8 minutes. Which is what a lot of the out lying stations are up against.
Hence a 97% response time in one area being pulled down to a 77% total overall.
As readers of Random Reality will know, ORCON is not based on any patient outcome or level of care indicators but simply time. It doesn't seem to matter if the patient dies or we are delayed on scene by other factors (e.g. waiting for police assistance, extra crew for a heavy lift) meaning the patients definitive care is delayed. As long as we are at the address within 8 minutes the job is successful.
Tom Reynolds writes much better posts about ORCON and its significance then I can, so if your interested please have a look at his blog..................... not only that, its a bloody good blog!
_________________________________________________________
On a seperate note condolences and thoughts go out the families of the men involved in the recent helicopter crash off the coast of Aberdeen.
Hopefully they can recover the wreckage to discover what has caused the two recent incidents to put a stop to it and bring balance back to the off shore industry which is so vital in North East Scotland.
It was announced today (although I couldn't find a news story on it) that we hit our response time target for last year. We have a a target of 75% for the whole of Scotland and we managed an impressive 77%! Get Us!
I take the same views on the clinical relevance of ORCON targets as Tom Reynolds over on Random Reality (Relevant post are here and here if you are a regular reader of his you'll know the score!).
The clinical significance of the 8 minute target is negligible and based on out dated information for the demand and usage of the ambulance service which we are now seeing throughout the country.
In Scotland we have a different problem.
I have it on the grapevine that the response percentage for my particular area is actually at 97%. I have a feeling that Edinburgh may also have a similar response result. We are heavily populated and built up areas with many stations in a relatively small area. We tend to answer more calls than some of the other divisions however 70% (best guess) of the calls we attend are within a 10 mile radius.
Unfortunately Scotland is a rather big country with big mountains, islands, single roads and has ambulance stations based in strategic positions to facilitate as quick a response as possible.
However strategic you are, and in the vast areas we work in, we are not by any stretch of the imagination (or heaviness of the right foot) going to reach a AS1 call 50 miles away in 8 minutes. Which is what a lot of the out lying stations are up against.
Hence a 97% response time in one area being pulled down to a 77% total overall.
As readers of Random Reality will know, ORCON is not based on any patient outcome or level of care indicators but simply time. It doesn't seem to matter if the patient dies or we are delayed on scene by other factors (e.g. waiting for police assistance, extra crew for a heavy lift) meaning the patients definitive care is delayed. As long as we are at the address within 8 minutes the job is successful.
Tom Reynolds writes much better posts about ORCON and its significance then I can, so if your interested please have a look at his blog..................... not only that, its a bloody good blog!
_________________________________________________________
On a seperate note condolences and thoughts go out the families of the men involved in the recent helicopter crash off the coast of Aberdeen.
Hopefully they can recover the wreckage to discover what has caused the two recent incidents to put a stop to it and bring balance back to the off shore industry which is so vital in North East Scotland.
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