Splash back in my eye

I tried to avoid it, it wasn’t the patient’s fault but last week I managed to get splash back in my eye.

The pitiable patient was suffering from an intense chronic stomach pain and his agony was being exhibited through what appeared to be manic yoga techniques mixed with swimming strokes.  All the while he would compliment this majestic display with a barrage of screams, groans and multi directional explosive episodes of cough-vomit.  I think we will abbreviate this wondrous substance to ‘cough-vom’.

And it was from one of these random explosions that the single droplet of cough-vom dispersed itself from the contents of the patient’s stomach and arched its flight through our ambulance air space to land perfectly in my eyeball.

After dropping off the patient at the hospital I started the long and politically painful process of checking whether I would be at risk or not.  The junior doctors were all liberal with their dismissive advice.

“You should be fine”  said one.  “The risk is really low”  said another.  A thoughtful looking one with a trendy beard offered his wisdom, “Yeh, there’s not been any recorded incidents of anyone contracting something from splash back”

Everyone nodded slowly as if the doctor had just said something worthy of the Nobel Peace Prize.

“That’s nice,”  I smiled, “however, I’d like that risk to be ‘no risk’ and in response to you . . .” I looked at trendy beard doctor, “as far as I’m aware there’s no recorded incidents of someone suffering a heart attack whilst doing a parachute jump – but you know what, it doesn’t mean it can’t happen!”

I was eventually forwarded on to Occupational Health who, after a few hours worth of bureaucratic procedures and phone calls were able to conclude with the following results:

    • That my Hep B was up to date
    • That the risk is indeed low
    • That they would try and find out “whether or not the patient was a high risk and see if they were able to give a sample blood check”
    • That they would “let me know”

A sample of my blood was also taken . . . they never said why and I can only imagine it was to mix as a drink afterwards!  Who knows . . . but, needless to say, I haven’t heard anything since – so maybe I should be getting in touch again . . .

Binder

 

I suggest you speak to your manager about appropriate training

(This is a post re-visiting the issues attached to a previous post – apologies if I’m repeating myself).

Jobs where patients have capacity issues really are difficult situations to be in.  It is so hard to make what you think is the right choice for the patient.  The worst of these positions to be in is where the patient is ill enough that they warrant a visit to hospital yet choose not to go and that there is a question mark over their mental capacity to make that decision.

In January I posted a blog entry entitled Mental Capacity and received a reply to it from Dorian – whom I suspect is very qualified in the subject.  This is what he wrote . . .

Hello. Interesting story with many positive aspects, notably your persistence and the eventual outcome. That said, I am surprised by the description of your attempt to assess the patient’s mental capacity. Without being there I can’t contradict your decision that the patient had capacity to make her own decision about accepting treatment but I am very concerned by your assessment. You seem to base yiur judgement abiut the patient,s capacity on her responses to a few random “orientation in time and place” questions lifted from the mini mental state examination. Does the London Ambulance Service not train paramedics in the use of the Mental Capacity Act decision-specific test of mental capacity? Use of that tool would provide a far more accurate assessment of the patient’s capacity, which in turn would inform your subsequent decision-making. I suggest that you speak to your manager about accessing appropriate training.

I’ve put this up as a proper entry.  Not just because I thought Dorian was being an obtuse ‘kill-joy’ with his apparent head strong attack on what I believe should be seen as nothing more than a light hearted blog – but because I wanted to highlight his point of view as an interesting challenge to all of us working on the front line of the ambulance service.

With just one post, a highly qualified person in the field of Mental Capacity has started questioning our entire processes in the field.  To me this simply emphasizes how hard it is for us to attempt to do the right thing in these awful situations, with little more than a green uniform and a keen sense of morals.  But it also stresses how important it is for us to continue to cover all bases and avenues before making a decision which can ultimately effect, in one way or another, the liberty and freedom of another human being’s right to choose for them self.

So, my reply to Dorian was this . . .

Thanks for the comments Dorian

Its good to get outside experience on these matters and your thoughts are greatly appreciated. I understand you are quite qualified and experienced in your field so it is useful to receive such positive thoughts.

However, it is difficult to express the full workings of what happened that day all in one small article – and, in a similar vain it is equally difficult to maintain its “light heartedness” for the blog – which, incidentally, is what I originally set out to do. So, albeit in the article it appears we only asked a few random questions, this is by far not the case. In reality they weren’t just a few random questions – I in fact asked at least three more questions which would make it “a lot” not a “few”. And they were intelligent ones based around things like the weather, colour of her wall paper, my chronic back problem (she was a nurse after all!) and what type of ugly breed her dog was.

The training on Mental Capacity has always been a tricky one but we do have certain guidelines to help and when these matters arise we tend to use a “Capacity Tool” to help the situation. This has a list of points and questions that are designed to help us make the right decision over the patient’s capacity. Things like, “does the patient fully understand the implications of their actions” or “is the patient REALLY happy with the colour of their wall paper” etc. If all the head questions are answered “Yes” then we can assume the patient has capacity to make their own decisions. However, unless it is clear cut, it can all end up being very subjective. And also, when you’re presented with a person who doesn’t even want to entertain your approach or system, inevitably you are left with only simple factors to base your decision on – namely your gut instincts. Don’t get me wrong, we’d love to just “mug” patients like Cassandra, by picking them up and carting them off to hospital to “help” them. But ultimately, if their choice is not to go, what else can you do. As far as I’m aware, its not against the law to kill yourself in this country.

Here’s a rather random example – if someone were to approach you (as a random individual), just as you are about to cross a busy (and potentially dangerous) road, and question your thought processes on why you’re crossing at such a dangerous section, would you even entertain their interjection? Lets say you didn’t (maybe because you were in a hurry to get across and buy a little chihuahua puppy and this person, dressed in a lime green Kappa tracksuit looked slightly odd and frightening – who knows, you choose), would that person be within their rights to question your mental capacity over you choosing to put your life at risk? After all, you could, at a very high probability, get maimed or killed in your attempt. Would your refusal to entertain their bombardment of inquisitive questioning also go in favour of proof of your capacity? Or would the individual be within their rights to say you’ve lost the plot and then forcibly remove you from the situation – with the aid of the police?

Now, I know this is a ridiculous analogy and in fairness Cassandra’s case is a lot different (our tracksuits are a darker green and not sponsored by Kappa). We tried to explain the implications of her decision and by all accounts she fully understood this and accepted it. Which is somewhat a bit better than fully ignoring Kappa man trying to stop you crossing the dangerous road. But, if we have exhausted all avenues in our approach as to a patient’s mental capacity we are left with only two options Dorian – to leave them there or forcibly remove them. We, as pre-hospital clinical practitioners, would rather not choose the former. But as professionals, we will always respect a person’s right as a human being to make their own choices – no matter how crazy they seem to us.

Putting all this aside I think our Capacity Tool is what you meant. So yes we did use it – as best we could . . . and as best we could in similar positions. But a lot of our work, at the end of the day, comes down to our professional decision making at that moment in time. And rest assured we always want to do what’s best for the patient.

I have however, taken your advice and approached my manager on accessing appropriate training. Amongst asking for the two year pay freeze to be lifted I’ve also asked whether I can be trained up on the FRU, HEMS, Emergency Care Practitioning and Paediatric Advanced Life Support. After a ten second bout of negotiations he’s finally agreed to send me on the inevitable Core Skills Training – which we all have to do. Still, if you don’t ask you won’t get.

I hope this in some way answers your concerns. I hope also, you are enjoying the posts – but please remember, the blog is supposed to be light hearted – nothing more.

Binder

 

 

Open Your Legs My Dear

Waters broken, contractions less than two minutes apart and the urge to push are three big warning signs for an inevitable birth.  If just two out of those three are presented to us with a pregnant patient then we are indicated to “stay and play” – and get ready to catch!

A couple of days ago I was driving as part of a training crew.  This meant there were three of us as opposed to the normal two and the student was attending.

We had just parked in the hospital bay with a very heavily pregnant woman.  It was decided that because she had all three of the above, we were going to stay put and see what was going on – for the time being at least.  The mentor paramenace was frantically trying to arrange for a midwife to come down to us . . . but was not having much success.

So there we stood, myself and the student, staring at the woman’s private parts as she lay on our trolley bed.  Her husband stood at her head stroking her hand.

Student:     Nope.  Doesn’t look like there’s any crowning.
Binder:       Wait for the contraction first

Cue contraction . . .

Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Student:     Ah yes . . . right.

Baby was starting to .

With each contraction the mother screamed the place down and baby’s head would almost poke through.  But when the contraction stopped it would disappear again.  So, to help, I held the mother’s legs right back and motioned the student to hold a pad against the her anus.  It took a few explanations for him to fully understand what it was I was trying to get him to do.

Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH! 
Binder:
       You’re effectively just trying to reduce the amount she poos as baby comes out.  But because your hand’s there, you’re ready to catch too.
Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Student:     . . . right . . .
Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Student:     Won’t mum mind that I’m doing this though?
Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Binder:       Dunno, lets ask  **turns to patient**
Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Binder:       **turns back to student**  I think she’ll be fine with it mate.

Baby’s head eventually ‘sprung loose’ and we calmed the mother to a normal breathing pattern again.  But within seconds she was off again . . .

Patient:      **deep breath** AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAGH!
Binder:       Open your legs my dear
Student:     Here we go . . .

. . . And then baby came out into his waiting hands.  The student quickly and calmly unwrapped the chord from around baby’s neck and body and with the help of the other paramenace started to clear all the body fluids from them.  It was a boy – and as they cleaned him his lungs burst into song and the distinctive wail of a new born child was heard everywhere.

Both mother and father were jubilant and emotional.  As births go this was by far the cleanest I’d ever seen – no vaginal tearing, no follow on bleeding and practically no poo!  This bode well for when we had to clean the ambulance afterwards.

I handed the student the chord clamps and then turned to the father with the special chord cutting scissors and beamed.

Binder:       Here you go dad – would you like to do the honours?

With a horrified expression he backed away.  But, with lots of persuasion we ushered him forward and helped him cut the chord.  He then quickly retreated back to behind the mother’s head.  Baby was wrapped up in clean towels and handed to mother and they had their first bonding hugs.

At that moment an A&E Doctor knocked at the door and gingerly poked his head in.  No one had been able to get hold of any midwives so Control had got us a doctor instead.  He looked as terrified as the Father did cutting the chord and didn’t hide his relief to see that it was all over.

Still, giving him his due, he followed us all up to the Maternity ward where the student handed mother and baby over to the midwives.

Back at the ambulance we quickly cleaned up and congratulated the student for his calm temperament throughout the delivery.  And as we sipped our cups of tea other crews gathered in and laughed as they told us how the mother’s screams could be heard right down the street.

This was a good day.

Binder

For those of you who don’t know what crowning is – or have an inbuilt denial button that gets pressed in your brain when certain baby words like this are uttered – crowning is quite simply when the baby’s head starts to protrude from the mother’s vagina . . . nice.

Get some lights!

London really is an fantastically interesting place.  It never ceases to amaze me how blinkered the self perpetuating public can be.

I was driving home at night after a long shift and was waiting to pull out of a junction.  Thinking my way was clear I started pulling out and then slammed on the anchors as a black woman, dressed in clack clothes on a black push bike with no lights and using a mobile phone cycled past.  The lights of other cars had made her practically invisible to view.

As she rode past I caught her attention and pointed at her bike mouthing the words, “Get some lights!”

She moved the hand holding the phone down to the handle bars and with the other stuck her middle finger up at me and shouted back, “FUCK OFF!” . . . and promptly swerved into the traffic trying to avoid her.  Oblivious to the beeping horns around her she continued on her way.

. . . wonder if we’ll meet up some time.

Binder

 

He’s dead Jen

During my mentoring period when I first qualified as a Paramenace we went to a cardiac arrest – which really didn’t go that well.  I remember talking with my mentor Jenny* about it a few days afterwards and empathetically she told me of her very first cardiac arrest . . .

She was working with an old-school paramenace (as her mentor) and they’d just walked into a room to find the patient on the floor . . . dead.

This was Jen’s moment so her mentor stepped aside and allowed her to take control.  She marched over and knelt beside the patient.

Jenny is a very methodical worker and always uses a systematic approach.  Having come straight out of technician school the processes in dealing with basic life support were fresh in her head.  Jenny said that upon seeing the ‘sick’ patient she became very nervous and reverted back to her basic training . . . . and her  methods of passing exams.

Jenny:          OK, I’m checking for a response!

She spoke the words vehemently at no one in particular and then proceeded with shaking the patient’s shoulders.  Bending down so she was level with the patient’s ear she continued – even louder.

Jenny:          HELLO SIR!  CAN YOU HEAR ME!  **shake shake shake**  THIS IS THE AMBULANCE SERVICE!  **shake shake shake**  CAN YOU OPEN YOUR EYES PLEASE!  **shake shake shake**

Her mentor, with a placid expression and his hands behind his back, leant over her slightly.

Mentor:        He’s dead Jen
Jenny:          OK, I’m checking the airway for any obstruction!
Mentor:        He’s still dead Jen
Jenny:          OK, now I’m checking for breathing and a pulse!  **whispers**  one . . two . . three . . .
Mentor:        Nothing’s changed Jen
Jenny:          . . five . . six . .seven . .
Mentor:        He’s still very much dead Jen
Jenny:          . . nine . . ten.  OK!  No pulse and no breathing . . . um . . . chest compressions
Mentor:        That would be a good idea Jen
Jenny:          OK.  I’m now commencing CPR!  **starts singing to self** . . . Nellie the elephant packed his trunk and said goodbye to the . . . .

Her mentor rolled his eyes, smiling slightly, and moved forward to join her.

They worked on the patient for a long while but the outcome was not good.  The patient had been down too long prior to them arriving.

After telling me this we had a good chuckle.  It was comforting to hear that other medics, whom you regard with such high esteem, also suffer the same ridiculously surreal situations as yourself.

Binder

*not her real name of course

 

 

Objective Structured Clinical Examination.  This is a practical exam based around the topics that have been learnt.  OSCEs in the paramenace world will cover all primary and secondary surveys, basic and advanced life support, trauma, paediatrics and many more.  It is customary to “verbalise” your actions during an OSCE!

Don’t use that, it’s shit!

When people get on with each other in this line of work, the jobs can go well.  If however, the patient ultimately dies it can be argued that it doesn’t matter how you all got on, the result was still the same.  No matter what the outcome is though, as ambulance clinicians, we need to be able to move on, learn positively from the things we do so that we can attend future jobs with (at least) the same skill and determination as before.  By working with a person you don’t get on with its easy to have that review process clouded by the single thought that the job might just of gone a bit better if only you weren’t working with such a dick head.

__________________      __________________      __________________

I sat munching on a piece of toast in the mess room.  A partly completed PRF lay in front of me.  To my right was a mug of tea, to my left a plate of toast and in front were several sheets of kitchen roll upon which were two used rubber gloves encased in congealed blood.  Partly obscured by the this, hieroglyphical pen scrawls were strewn over them providing important data from the last job.

The mess room was alive with the banter that follows interesting jobs and the topic at this stage was how my crew mate had brought an egotistical power mad medic down to earth mid job . . .

The job had come down as “20 year old female – bike vs vehicle” – Amber 2″.  Most of time this is usually a benign incident with scratches and bruises but today was going to be a little more than that.  As we approached the scene in our truck we could suddenly sense the tension and panic in the air.  There’s no easy way of describing that funny sensation of how you can just tell something is bad . . . very bad.

A traffic cop was first on scene and his face said it all before he even opened his mouth.  He was terrified.

Traffic Cop:     “She’s stopped breathing!!!”

Before I’d even stopped the ambulance my crew mate had jumped out and was doing chest compressions.  The patient was young, female and had just been run over by a skip lorry.

As I ran over it became very clear that her airway was becoming obstructed as a ‘pink blancmange’ like fountain of fluid started erupting from her mouth and spilling over her face.  Kneeling beside her head I grabbed the manual suction unit from the response bag and started making a futile effort to clear her mouth as it spilled out.  Trying to support her head was like attempting to hold a conker on a length of string, the wrong way up – her neck was irrefutably shattered.

And at that point a motorbike medic arrived.  Charging over he could clearly see what I was doing was pointless and pushed me out of the way.

Bike Medic:    “Don’t use that, its shit!  Go get the proper suction unit – now!!”

I’d only been out a few weeks and was now a bag of gibbering nerves.  So, yanking the suction unit away from the ambulance I ran back and attempted to use it.

Bike Medic:    “NO!  Not like that!  GIVE IT HERE!!!  Get on the airway – now!”

He barked an order at the Policeman to also help with the airway.  There was so much pink blood everywhere it was difficult getting the mask to seal over her face.  Whilst we struggled the Bike Medic continued with the suction.  Not content with that job he moved round and proffered the unit to me.

Bike Medic:    “Move round here and do this!!!  NO!!  Like this!!”

He grabbed my hands to make me do it properly.  None of it was going in – it wasn’t making any sense now and all I wanted to do was curl up underneath the ambulance and disappear.  This was turning out to be an utter nightmare.

Bike Medic:    “Once its clear, get straight back onto bagging!”

He turned to my crew mate, who’d been watching all this quietly.

Bike Medic:    “You!  Get those pads on her chest and – !!”
Crew Mate:     “Please!”
Bike Medic:    ” . . . . . sorry, its the Army talking in m-”
Crew Mate:     “Well, you’re not in the Army now are you!”
Bike Medic:    ” . . . . . . .”

I caught a glance from my crew mate.  She gave me a wink and then suddenly I was back in control.  And from that point forward we started working better as a team.  HEMS eventually arrived a few minutes later and were able to perform advanced techniques like .

But despite all our best efforts the patient was sadly pronounced dead at scene.  Her injuries were just too multiple and severe.  We covered her up with a couple of our blankets and let the police deal with things thereafter.

It was when I was putting things back in the ambulance that I wondered where my crew mate was.  I eventually found her sat in the back of a police car comforting the driver of the lorry.  He was in bits – his demeanour went in a constant circle of moods.  First asking (no one in particular) why the patient did what they did, then getting angry with bikers in general and then building the aggression to a crescendo where he’d finally break down in tears.  Silence would ensue and then he’d repeat it all again.

Witnesses had said it wasn’t his fault.  And by all accounts there wasn’t much we could do for him but take him to hospital to be checked over.  Talking with the driver’s colleagues later they said he’d probably never drive again.

We also checked on the Policeman first on scene.  He was shook up but fine – his superiors stood him down for the rest of the day and sent him home.

As for us – we returned to base to complete our paperwork and grab a cup of tea and some toast.  Our gloves had all the relevant information on them so we placed them on some kitchen roll and cracked on with it all.  The black humour of the mess room reigned supreme and before long we were joking and laughing about how my crew mate rescued me from the nasty evil Bike Medic.  I thanked her personally afterwards too – and typically, she just laughed it off.

Whilst back at station, Control phoned a few times asking if we were ready to accept jobs as they were holding calls.  Eventually we pressed the “Green Mobile” button our MDT and inevitably a job came down straight away – “20 year old male, abdominal pain”.

And as for the Bike Medic? – well, I’d never seen him before and I’ve not seen him since.  Its easy to dismiss his behaviour as bullish and arrogant but I understand he was also quite new and was possibly defecating himself in equal volumes as I was.  And in fairness to him, he calmed down after he was confronted.  So, as I’ve said, when people get on in this line of work, jobs tend to go well – regardless of the outcome.

Binder

bilateral thoracostomies are where an incision into the chest wall either side of the patient is made to gain access to the lungs therein.  Usually done as a ‘prophylactic’ treatment of a tension pneumothorax or a haemothorax  Best performed under clean hospital conditions but done “on the road” in emergencies when the patient has suffered a traumatic cardiac arrest.  This is the time when a doctor to “loses” their keys.