It’s a cold, clear night, the tower block is almost completely in darkness, save for a few bedroom lights high up and the twinkling of someone’s obscenely premature Christmas decorations in a window at the top. We’re headed for the eleventh floor for a thirty five year old male who’s slit his wrists.

We’ve not even pressed the button on the entry system when a metallic voices barks from the speaker.

“He’s no here.”

Ummmm….?

“He’s the other block, tenth floor.”

Bag on the shoulder and O2 under an arm we tromp across the carpark to the neighbouring building, where the same nippy-robot-woman shouts at us from the entry phone. I idly envisage her in her volcano lair at the centre of Arthur’s Seat, peering at CCTV footage of emergency workers across the city and cackling to herself.

She buzzes us in and the lift hauls us to the tenth floor.

Which is deserted.

“Eleven?”

My partner nods and up we walk, up towards raised voices and tears. There’s a police car in the carpark downstairs, so everything should be hunky dory.

Out of the stairwell and we find ourselves on a communal landing with two people, one a screaming woman in a flat’s doorway and a youngish man lying on the floor. His a laceration on his throat bleeds steadily, his wrists are red from their own wounds.

Neither of these people appear to be the police, or at least, if they are, they’re mightily undercover.

Awww crap.

The patient isn’t actively bleeding, although the polka-dots of blood on the floor are comically bright, the friendly primary shade of blood that comes from arteries, his clothes are wet with it, it’s smeared across his face and down his hand. The hand that’s still holding the smashed neck of a beer bottle.

I step closer and his grip tightens on it, drunkenly waving the shard back and forth.

“Don’t touch me! Don’t come near me!”

Muttering platitudes I take another step forwards, letting him know that nobody’s going to hurt him, that everything’s cool, just put it down. He relaxes slightly, allowing me to get close enough to place the toe of my boot on the back of his wrist, lean over and flick the glass out of his fingers, tossing it across the landing into a far corner.

He leans back against the wall - check me out, I’m the Radge Whisperer.

A quick pat down of his pockets to ensure he’s not carrying a knife or needles, the woman at the door jumps in -

“He’d not hurt you, he isn’t like that.”

Call me Cynical Susan, but he’s obviously had no qualms about sticking himself with a big sharp pointy thing…I can’t see him thinking long and hard before carving a lump off me.

Despite his injuries, he’s not actually that sick, his pulse and blood pressure are more than acceptable and despite being a tad on the emotional side, there’s not much else wrong with him.

We roll him down to the ambulance and pop him on the stretcher where he leans back, wet eyes staring at the ceiling.

“I always fuck this up…I’ll do it properly next time, take tablets or something.”

“Don’t do that, mate.”

“I want to die.”

“I know.”

“So why shouldn’t I take tablets?”

“Because it’s very hard to get right, you’ll end up permanently sick, but you’re highly unlikely to die.”

“So what do I do?”

“Now THAT I’m not allowed to tell you.”

“So what use are you?”

To a suicidal person?

Not much.

We’re clear.

That’s good.

We’ve got an emergency.

That’s bad.

It’s close by.

That’s good.

It looks like it’s at my friend’s house.

That’s bad.

The patient is male, my friend is female.

That’s good.

The patient is 1 year old.

That’s bad

The patient is floppy.

That’s bad.

The patient has “laboured breathing.”

Oh fuck.

The call has come from NHS24 who have hyped the job up massively, making our happy, engaged and fully concious patient “floppy and dyspnoeic.”

NHS24?

That’s bad.

FriedBanana slumps down next to me in what is laughably called the “Internet Café” at the station.

“You owe me.”
“Oh?”
“You nicked Chop’s name…I was calling Chop Chop when he started, and you’re using it on the blog.”
“Aye…but it suits him.”
“Do I get a co-writer’s fee?”
“Nup…but I’ll let you choose your own nickname.”

And so he did, hence the horrendous new moniker.

(I suggested “Jump-Suit” or “PBJ”, he wanted “King”.  We compromised.)

I can neither confirm nor deny that an emergency call was made reporting the cardiac arrest of a patient who the caller had been video conferencing with and “Hadn’t seen move for ages.”

Nor can I confirm or deny that that patient had just fallen asleep.

No confirmation or denial at all.

I may have made it all up.

Maybe.

*still laughing*

I’m not into football, so the Scotland/Italy game was little more than a passing interest for me. Through conversations before the day I managed to work out who had to win/draw against who to ensure that we got through…though I was never completely clear as to what were getting through to or why it was important.

I was working day shift, so had to rely on catching updates from excited radio listeners at the hospital while the match was played, but it was the atmosphere of the city that I enjoyed most of all, cars with saltires from their windows, hordes of drinkers in the pubs with scarves and strips and not a shred of aggression or animosity that I could see.

What interests me far more is the photography of Neil Milton from that day, a great montage that sums up the anticipation beforehand and crushed hopes afterwards.

Go see.

!Edit! Link should work now.

Not appropriate at all.

But funny as fuck.

I’d been warned he was end stage cancer en route, I knew he was short of breath, the computer in the cab had told us that, flashing red until we punched buttons to silence it.

But I wasn’t prepared for the sight of him when I walked in.

A cold sliver of a man, his skin so tight on his bones that they shone white in the window’s November sunshine. His family by his bed as if suspended from the roof, bobbing from foot to foot, stepping forwards and back, unable to find a place to stand that made any difference to their loved one’s distress.

His shoulders lurch as he clutches at each breath, the flesh between his clavicles and ribs sinking into his chest with each inhalation, blue lips, scared eyes.

If it weren’t for his mortice grip on my fingers, I’d assume he was in cardiac arrest.

He’s not far off.

I turn to the family and ask about a DNR, the son pulls it from its place behind the clock on the mantlepiece amongst bills and postcards while his mother runs to the kitchen before bursting into tears.

I imagine she’s been looking after her husband all night, hearing the ambulanceman ask about letting him die must be unbearable.

Cluedo and I slide the patient over the sheets, his portable morphine pump in a neoprene bag tucked into his trousers.

Nobody’s treating him any more, there’s nothing to do but make him comfortable.

Just as we’re about to strap him to the chair he takes a deep breath and a sound like dull chains makes the room look up, his lungs are packed full of fluid.

He’s drowning.

Down the stairs fast and into the vehicle, I barely feel his weight in my arms as we lift him onto the bed, concentrating instead on wiring him to the defib, upping his oxygen levels, pouring drugs into a nebuliser to try and open his throat.

He’s grossly hypoxic, his hands are everywhere, they grab my shirt, my collar, my face and fingers; between gasps he speaks.

“Help me.”

“I’ve got you, mate.”

“Can’t breathe…help me…please.”

In his oxygen starved state he can’t think or reason, he scrabbles at the nebuliser mask, rips it off his face, I gently replace it, but he repeats the trick.

I compromise for popping the mask apart and aiming the gas at his mouth and nose, it’s better than nothing.

He’s dying in front of me, his DNR is in my pocket.

If his heart stops and he stops breathing, I’ll do nothing but confirm the fact and pull the blanket over his face.

But he’s not there yet, right now he’s dying and scared.

His wife stretches across the aisle of the ambulance and squeezes his hand, it’s in my way, but I let it stay. It’s probably doing more good for him right now than I can.

He’s calmer now, quieter, though his breathing is just as laboured. Are his oxygen levels up? Is he recovering, or deteriorating? It’s a moot point, through the bulkhead of the vehicle I see we’re pulling into the ambulance bay at hospital.

I switch his O2 to a portable tank and begin to unclip his ECG when his eyes roll up in his skull, his neck relaxes and his head drops backwards like a rock.

His wife wails in her seat, wrestling with her seat belt to stand up and be closer to him.

Shit.

We’re not meant to use sternal rubs as painful stimuli anymore, they’re no longer considered to be gold standard; but my instincts are forgetful and powerful and, unbidden, my fingers are digging at his chest immediately.

Fast and mean and sore I shove my digits against his sternum, yelling his name.

He gasps, pushes my hand away and opens his eyes, glaring at me, utterly betrayed, as though he’s not having a bad enough day without me hurting him to wake him up.

“You alright mate?”

He nods, slowly.”

No more of that, ok? Stay with me.”

A nod.

He’s with me all the way into resus where they pour him full of drugs to ease his breathing and discuss transport home.

He didn’t want to die in the hospice, there’s no reason for him to die in a hospital bed.

When the time comes, I hope it’s peaceful.

I’m working with Cluedo this weekend and it reminded me of this story, a case I wrote up for the following case study.

Despatched to emergency call at 1722 for “67yof collapsed, recent diagnosis brain tumour”, arriving at locus (patient’s home) at 1732.

On arrival, the patient (a small, frail woman) was found to be sitting on toilet, GCS15, warm, dry, agitated and uncooperative, she was protecting her own airway, breathing with no effort or distress and appeared reasonably perfused.  Her husband stated that he had helped her to the toilet and stepped outside the bathroom.  He then heard a “bang” and returned to the bathroom, finding her unconcious in a seated position, with her head resting against the cistern.  The patient had a long standing history of dementia, was registered blind and had recently been diagnosed with a terminal brain tumour.

With assistance from the crew, the patient was dressed and moved into the living room.  The patient denied pain but complained of feeling dizzy,.

On examination she was found to be tachycardic at 111bpm and somewhat hypotensive (107/62).  Her BM was adequate at 10.1mmol.  The husband reported that the patient was usually hypotensive and that her GP was aware of and investigating the cause of this.

On further examination of the scene a large stool was found in the toilet pan and it was surmised that the patient had overstimulated her vagus nerve while straining to pass this and in combination with her existing hypotension had suffered a faint.

The crew informed the patient that it would be wise to attend A&E for further investigations as it could not be said conclusively that this was the cause for her black-out.  The patient refused transport, vehemently repeating that she did “Not want to go to hospital.”  No amount of encouragement or discussion appeared to make any difference to her decision, so an NHS24 GP was called to attend the house within the hour.

While awaiting the attendance of the GP the crew completed further observations and found the patient to be in sinus rhythm with a capillary refill of <2 seconds.  Her SpO2 levels were found to read “<50%” (a reading which the crew were loathe to accept, the patient being adequately perfused and in no apparent respiratory distress).  By checking the SpO2 probe on their own fingers the crew were able to confirm that the reading was accurate and as a result Oxygen was administered via a Trauma Mask at 15lpm.

Despite denying pain, a head to toe examination was carried out whereupon a large and pulsatile mass was found to the left of the patient’s abdominal midline.  Recognising a possible AAA (Abdominal Aortic Aneurysm) the double technician crew made a Priority call to the EMDC requesting immediate Paramedic assistance.  The patient continued to refuse to travel to hospital, despite the severity of her condition being thoroughly explained to her.

On the Paramedic’s arrival, the patient was cannulated and 500mls of normal saline were administered through this IV access at a slow rate.  The Paramedic took this opportunity to discuss with the attending crew the aim of this fluid therapy, that being to maintain the patient’s perfusion whilst avoiding the risk of rupturing the walls of the stretching aorta and causing/increasing any internal bleed.

At this point the NHS24 GP arrived, as requested, and the crew and Paramedic discussed the situation with her.  It was agreed that the patient had to attend A&E, regardless of her wishes and after a period of questioning where it became apparent that the patient, while vocal and oriented in her immediate surroundings was unable to tell the GP the correct day, date or month and was unaware of major events in the press that week.  It was agreed that the patient was unable to make an informed decision as to her care and that the most appropriate measure would be to have a Mental Health Worker attend from the Royal Edinburgh Hospital’s Psychiatric Evaluation Team with a view to ’sectioning’ the patient.

Once the MHW had attended and sectioned the patient, she was removed from the locus by the crew in a carry chair and transported to the Edinburgh New Royal Infirmary’s A&E Department, a standby being passed en-route to alert them to the patient’s impending arrival.

The receiving medical team at A&E found the patient to be distressed and aggressive.  Her notes showed a similar admission in the past which was thought to be an overdose of her prescribed Nitrazepam.

On arrival she was found to be peripherally cold and cyanosed with O2 saturation levels at 75%.  They queried existing Chronic Obstructive Pulmonary Disorder and noted that the patient was a heavy smoker.  They found her abdomen to be soft and, while the aorta was palpable, ruled out any aneurysm or organomegaly.  Femoral pulses were also found to be equal.

Four hours after admission the patient’s blood paracetamol levels (which at such a point should be zero) were found to be 19, while testing her arterial blood gases showed metabolic alkalosis.  A diagnosis of respiratory failure was arrived at, secondary to a possible OD.  The patient was moved to a ward for further observation.

The patient died four days later, cause of death was listed as respiratory failure and worsening existing meningioma.

PMH  - Meningioma, COPD, dementia.

Meds - Quetiaprin (anti-psychotic), haloperidol (anti-psychotic), nitrazepam(sedative), paracetamol (analgesic).

Learning points - From attending to this call and researching/writing the subsequent case study, learning has occurred in the areas of: AAA, fluid therapy, paracetamol/nitrazepam OD, COPD, emergency procedures in the care of the mentally unstable or incompetent, particularly when working in a multi-agency environment.

Sir, I realise that as a diabetic, a hypo may sneak up on you from nowhere.

But we have to force your door open against the sea of VHS tapes on your bedroom floor.

We’re picking our way over the rubbish and dirty laundry that cover the stinking carpet, sweeping the piles of dirty needles aside with our boots, bending our backs double because we’re too scared to kneel down on your mattress.

And next time you need an ambulance?

Put the shitty dildo and the copy of “British Bondage Bitches V” away, yeah?

From the wonderful Jaffa.

1.  You cannot touch all of your teeth with your tongue.
2. All idiots, after reading the first truth, try it.
3. The first truth is a lie.
4. You’re smiling now, because you’re an idiot.
5. You soon will forward this to another idiot.
6. There’s still a stupid smile on your face.