This article previously published on the BMJ’s Doc2Doc forum.
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Is it time we taught our patients how to die?

Death is not an attractive spectacle, a witness at a recent cardiac arrest was most disturbed not by the fact that the women on the floor had died, but by the inhuman colours her face had turned as she did so.

Grey then blue, purple and streaks of black rising around her throat like dry rot.

Similarly, the fountains of vomit and loose stools that poured from both ends of the deceased as everything relaxed and fluids found their own levels were clearly an unpleasant surprise.

We, in the medical profession, are rather blasé about the whole affair; happy enough to come to the end of a cardiac arrest without having to visit the sluice and wipe something ghastly off our clothes.

We’re used to the sound of fluid clattering up and down a trachea, hauled about by agonal gasps. We’ve grown accustomed to the flaccid, chilly flesh and the way that even simple manual movements of limbs become nearly impossible.

We understand the etymology of the phrase “a dead weight”.

We are clinicians. We are professional and cool and sharp-edged. Death and all its paraphernalia does not frighten us. The vanishing of an entire lifetime’s emotions, thoughts and dreams is simply a curiousity to ponder on during one’s break.

It spooks the hell out of the public, though.

The telly is completely to blame. TV and film are desperately keen on portraying birth and death as oh-so-terribly clean affairs. Babies are born, apparently three months old, with an obligatory smear of red goop on them. People either die anonymously in enormous explosions or in protracted quiet scenes where we get to stare at their faces as they shuffle off. Their eyes close and a little dribble of blood trickles over their lips.

Why does everyone who dies slowly in a movie have some form of upper GI bleed?

I digress.

The point is, after any on-screen death, the deceased is looking as clean and sanitised as a made-up corpse in a funeral home. They do not poo in their pants of fill their mouths with Kraft-Cheesey-Pasta-Esque strings of phlegm.

They definitely don’t leave one eye steadfastly stuck open no matter how many times you demurely pass your hands over their face, leaving you with the dilemma of “I wish I could close that lid, it looks bad, but the only way to do it is to poke this dead man in the eye…I’m pretty certain I’m not supposed to do that.”

Nobody on TV gives half an hour of gasps before giving up, or slowly dwindles away into absolute bradycardia, still talking all the way along. You’ve never seen the hero’s plucky, yet ill-fated, sidekick face his demise in a thrashing, babbling hypoxic mania.

The public understand the concept of “dead”.

But not “dying”.

And it’s screwing around with our terminal patients.

Palliative care is a wonderful thing and an area of medicine I know I could never work in. I like my pre-hospital care, thanks. Wham-bam, fast and dirty.

I couldn’t work in a hospice.

“How you doing this morning, Mr Patient?”
“Still dying, thanks, Kal.”

Hum.

I come to cast light on a situation, rather than make light of it.

Some hospices let people home to die without warning their family what dying is really like. They wave the patients off into an ambulance with cardsand flowers, nod a lot and assure each other that “it’ll be nicer for them, he can drift away with his loved ones.”

In what other situation would we trust the pivotal moment of a patient’s care to their family? Neuro? Gynae? Colo-rectal?

“Just punch a hole below the navel and have a rummage about…you’ll get the idea.”

These palliative patients make a final brave stand, they face the transport back home, into a hospital bed that is alien and incongruos in the living room of their own house. They plan to spend their last days with their families.

But we need to be warning these people that it might not be like the movies.

How can we ask laypersons to tell the difference between agonal gasps and the fact that Grandad is choking on his Werthers’ Original and would, in fact, last another week if you’d phoned an ambulance out to clear his airway?

Why aren’t we warning them that, if the call an ambulance in a panic, they’re going to need that DNR in their hand when the crew comes in, lest they have no choice but to commence resuscitation.

(I am eternally grateful to the son of a suspended woman with end-stage cancer who told me “If you touch my Mum, I’ll batter you.” I had no desire to start CPR on a woman who had clearly suffered enough, but had no choice in the absence of a DNR. His threat of physical violence gave me exactly the out we needed to leave the room. I didn’t linger to thank him.)

Who is it that we need to kick in the pants to make sure that the newly-dead corpse of their family member won’t look like a body in a coffin, but a grey, limp version of the man they loved, devoid of any of the sparkle and chatter that made him that great guy everyone’s talking about?

This is not a nice thing to learn.

can’t we warn people before they’re dealing with the death of their loved one as well?

Shouldn’t this be a standard across the board of palliative care?

Shouldn’t we be teaching people how to die?

I’m sitting at lights when the poppa-poppa of a Harley behind me makes me look round. Sitting astride is Squaddie, grinning at me.

“I heard you were out and about. Nice legs…”

The lights change and he rumbles off into the distance, I catch him at the next junction.

“I thought the bike was meant to be fast?”

“Not on the open road, mate!”

“You working Monday day shift?”

“Yup.”

“I’m on the motorbike response unit. Bet you a fiver I beat you to the jobs.”

We shake on it, his leather gloves in my fingerless mitts.

He takes off in a roar of exhaust fumes.

A few days ago a…swarthy man approaches me while I’m doing something really important. I think it involved making an essential clinical decision. My memory is lacking, but I’m pretty certain it was “Americano….or filter?”

Anyway, the swarthy man, who may have been a pirate, approaches me on the bike and doesn’t say “Excuse me?” or “Good morning.”

What he does is grab the handlebars of my bike.

This is akin to reaching in through the window of the ambulance and trying to start the engine.

I believe the swarthy man deserves a medal, it shall be the “Luckiest man alive who did not get smacked full in the face by a paramedic” medal.

Anyway.

I tighten my grip on the handlebars.

“Can I help you, sir?”

He looks at the panniers in an assessy sort of way, its the look that you give a breakfast buffet in a hotel, where you know there is technically no limit to how much food you’re allowed and that you can technically just help yourself, but you think that someone, somehow might object to your MOUNTAIN OF CEREAL, but probably won’t do anything too drastic in foiling your tyrannical breakfast piracy. You are theoreticaly entitled to all that cereal, but you probably shouldn’t just help yourself NO MATTER HOW MUCH YOU WISH.

The swarthy man (probably a pirate, now I think about it…) just states two words.

“Antiseptic cream.”

“Sorry mate, I don’t have any.”

“Are you sure?”

Yes, thankyou, I’m pretty fucking sure. We don’t carry Germolene. It falls somewhat outside our remit. The average “coach full of school children vs circus caravan where the lions haven’t been fed this week cos of the recession, you know?” wouldn’t benefit hugely from a dab of Savlon.

“Yes I’m sure, I don’t have any anti-septic cream.”

“But I need some.”

“Oh, no problem. There’s a chemist down there.”

“I don’t have any money.”

“Well, I’m sorry I can’t help you.”

“Are you sure you don’t have any anti-septic cream?”

“You’ve tried to steal my bike, I think you might be a pirate and now you’re just asking me idiotic questions about the huge fluorescent pack I’m hauling around town for a month. Trust me, cunty-baws, I’m the pre-hospital Sisyphus, I’m pretty fucking familiar with the contents of the fucking bag and I don’t have any fucking anti-septic cream and more to the fucking point what am I? Your fucking free fucking Germolene fucking dispenser? You slack lipped degenerate…”

I fantasized about saying.

Instead I said.

“I’m sure, sir. I don’t have any. I’m sorry I can’t help you.”

And then I cycled away.

Hours pass, I watch a couple of jugglers, I deal with a woman with a smashed in nose, a woman with a smashed in neck and a little boy who was going “Oooh, I’ve been stung by a wasp and now my circulatory system is collapsing and I’m turning purple…I wonder if “dead kid” would help the Fringe’s public image…probably not…Kal? May I have some drugs? Thankyou.”

The sun sets, the Tattoo crowds gather to assault the castle and I’m chatting to a steward when a familiar Rum-And-Parrot themed idiot approaches me.

“Hello…I spoke to you this morning.”

“Yes sir.”

“About the antiseptic cream?”

“Yes sir.”

“Do you have any?”

“No, sir. I didn’t have any this morning and I don’t have any this evening. I’d suggest going to a chemist.”

“Haven’t you bought any?”

I take a huge breath…don’t break every bone in his stupid face…and answer.

“No.”

He stalks off.

I cycled past him on the street yesterday.

He gave me the finger.

I’m trundling through the crowd when I spot him, maybe seven years old, apparently alone, turning slow semi-circles back and forth.

“Are you ok?”

He gives me a nod.

“Yes.”

Fair enough. I catch the eye of the two adults standing next to him and smile. They ignore me and walk away from the kid.

He’s still scanning the crowd for a familiar face.

“Where’s your grown-up, mate?”

He blanks me.

“Because you look like you might be looking for a grown up?”

Nothing. He doesn’t even make eye contact.

Shit. Has he been Stranger Dangered to such an extent that he won’t speak to uniform?

He turns back to me and shrugs.

“None…English?”

Ah. Ok.

(I am going to apologise in advance for what follows. I do not speak French well. My grammar and syntac suck. Also, I write French worse than I speak it. Forgive me.)

“En francais?”

He smiles and nods.

“Oui.”

“D’accord! Tu est ici aved ta Maman? Ton Papa?”

“Oui, Maman et Papa.”

“Et ou est ils?”

“Je ne sais pas.”

Thankyou, finally the crux of the issue.

“Ok. C’est n’est pas une grande probleme. Vous avez le frere ou la soeur?”

“Oui.”

While we’re chatting, he’s still looking about. I find a couple of minutes chat is often all you need to reunite people, folk tend not to travel far from each other before they realise they’ve been seperated and often families will reappear while you’re still talking to the lost person.

However, we’ve been nattering for a bit and there is nary an adult forthcoming. Time to move to stage two “taking the kid to the police station”. This has an extra issue, in that lots of kids will TALK to uniform, but not GO with uniform. Often, I fear, this is due to them not really understanding who the adult is. I always take pains to expain “My name’s Kal and I’m a Paramedic, an Ambulance man, ok?”

Now…in French?

“Comment t’appelle tu?”

He tells me his name, it’s almost comically French.

“Je m’appelle Kal…je suis un…”

Hmmm. What’s the French for Paramedic? “Paramedique”, perhaps? Sod it, I’ll got for literal. If you need an ambulance in France you call the Fire service.

“Je suis un medecin des pompiers.”

Not strictly true, I am neither a doctor, nor a firefighter, but I guess it’ll do in the circumstances.

I am, at this point, feeling pretty chuffed with myself. Check me out, dealing with someone in French. Haw hee haw hee haw, je suis mort internationale, moi, non?

He stares at me.

“Vous etes un pompiers?”

“Oui.”

His face is the very image of “l’incredulous” and he shoots me down from my position on the clouds.

“Sur une bycyclette?!”

Petite croissante mangez merde…..

A cardiac arrest and my first intubation ‘in anger’. The first time I’ve looked down the throat of someone and known that if I fuck this procedure up, they will definitely die.

Nobody warned me that once you’ve intubated someone you start fretting constantly about the tube placement. Is it still in the trachea? Could it have popped out, or slid down into one lung, blocking the other off? Is it still patent?

This is why when we run arrests we have someone on “Airway/Breathing” all the time, there’s plenty to be thinking about.

My mind full of endo-tracheal worries, we pushed more drugs into the patient and glared at the screen.

That heart rhythm COULD support a pulse…let’s check.

I fumble about at her fat, thick neck and can’t get close to her carotid, she’s just too chubby. Without thinking I slide my hands down inside the top of her jogging bottoms and feel for a femoral.

The chattering crowd around me goes quiet, I’m concentrating on the patient’s condition when I hear someone say “It’s ok…you can feel a pulse there, sometimes.”

At that point I realise the surrounding crowd have just watched my push my hands down the pants of a very-very-sick-person-indeed, put two and two together and come up with thirty one.

Really, guys.

Assume a certain level of professional dignity, won’t you?

Nothing much being said on here, on account of being south with Denise and Denephew, doing my summer trip to their place to watch them while my brother and sister in law are working. No stories, thankfully, of horrible trauma or sickness; just hours of Top Trumps and messing about in the park.

In the interim, I received an awesome message from the Fringe Office, the guys who run the bear-garden that is the High Street in Edinburgh during August. It’s been my ‘beat’ on the Parabike for most of this month, though clearly while I’m in England I’m having a few days off.

The staff at the office are brilliant folk, they’ve accepted me as one of their own without question. I’ve cleared sprained ankles and minor head injuries for them, given them advice on their first aid provision and generally worked to keep ambulances out of the middle of town - a major headache for both the ambulance service and for the Fringe.

In return, they’ve greeted me with warm smiles and, on the day I got soaked to the skin and had the cuffs ripped off my expensive waterproof jacket, they plopped me into a chair and fed me tea and jaffa cakes until I felt human again.

This week they twittered:

“Kal is the lovely paramedic who stands on the High Street come rain or shine, 12 hours a day, just waiting for someone to fall off a ladder, set fire to their hair or have a heart attack with excitement when they see Denise Van Outen talking to Anthony Costa. He’s just one of the many brilliant people who make a massive difference to the Fringe experience. If you see him, give him a hug and say thank you.”

Sadly, I was away when they posted this, so I figure I’m due at least a whole day of loving when I get back.

Edit - Lots of people are commenting that they’ve seen me on the street, but not come to say hello. *Please* feel free to do so, I love meeting readers and have already met the lovely Lucy and the friends of the Digitals. Just come on over, I don’t bite.

Well dressed and pale, her stick holding her up…just.

“I was wonder…wondering…if you had anything…for…angina?”

Pally and I get her in the back, the party goers around us melting off, the day’s festivities finished. Her pulse at her wrist is faint, but there. We take a blood pressure and ECG.

That’ll do it then.

Not angina, SVT.

The top half of her heart, her atria, which have steadily been beating at a gentle level for eighty three years, have gone bonkers. Instead of ticking away at 80 beats a minute, their firing off at 180.

The bottom half, the ventricles, are doing their best to keep up. Fat and thick and muscular, they prefer to get a good crack of the whip rather than to rattle along at this speed.

Her whole heart is getting cranky and overtired.

Imagine you’re the ventricles. You like walking along at eighty paces a minute, but you’re pretty shit at keeping the rhythm.

You depend on the atria to shout out like a drill sergeant - left, right, left, right.

Today, he’s gone nuts. Yelling out instructions at more than double my speed, making you run along far faster than you’re used to.

You don’t like this, it’s no fun. You’re getting tired and pissed off and eventually you’ll get just sit down on the floor and give up.

And when you do?

This old lady will die.

There are a range of treatments that one can receive for this condition. A mild electric shock from a defibrillator will often reverse the problem, so will a shot of a drug called adenosine.

The shock from the defib has obvious unpleasant side effects. Even with sedation, being electrocuted is painful. I saw one man get shocked out of SVT in resus and, although he was lying back and giggling from all the midazolam they’d injected him with, he still folded like a deckchair when they zapped him, letting out an involuntary “Oh ya cunt!”

Adenosine, thankfully, doesn’t bend you in half. It does, however, have an unusual and unpleasant side effect.

It makes you brain tell you that you’re dying.

It looks horrible. Personally, I think I’d sooner take the defibrillator, thanks.

Thankfully, in cases of SVT, there is a third option. A little vagus nerve stimulation will sometimes knock the heart back into its standard rhythm.

And we do this through ValSalva manoeuvre.

Funny names or otherwise, you’ve almost certainly experienced the effects of this manoevure already. It’s the act of exhaling hard against a closed airway, or, in the local vernacular, straining to pass a big jobbie.

Remember that funny feeling you get when you’re trying to lay a track, where your head spins and you don’t want to stand up too fast? That’s the Valsalva effect, baby. The forced exhalation stimulates your vagus nerve, which in turn slows your heart rate.

In layman’s terms, it steps between the drill sergeant and you guys, stuffs a sock in the sergeant’s mouth and while he struggles to get it out he realises how stupid he’s been and returns to his old “left, right, left, right” theme.

Pally and I set the woman up with a syringe to blow on, “Try and blow the plunger out of the end…” we tell her.

This is impossible, but it has the required effect.

Watching the ECG, we watch her rate dip by ten, twenty beats per minute and we think we’re getting somewhere, but as soon as she stops blowing she bangs right back up to a hundred and eighty.

Pally gives me a look.

“You ready on the head?”

There’s a second version of the valsava, where you just as the patient is about to stop exhaling and take a big gulp of air, you drop their head down flat and lift their legs above them. It’s basically a grown up version of that game you used to play at school where you hyperventilated and then someone punched you in the chest.

Pally and I nod at each other. The patient blows out, out, out. She pops the syringe out of her mouth and Pally lifts her legs up, while I release the lever on the trolley back and lean her down flat.

I watch her face. Her eyes stare at me, her mouth a silent O.

The ECG slows….slows, the complexes dwindle downwards.

And go flat.

Fuck.

Then, barely half a second later and like a battle-knackered hero, a single, horribly turgid ventricular complex shimmies across the screen. The ventricles don’t like not hearing from the atria for too long and, in the case of radio silence such as we’ve produced, they’ll push out heartbeats all on their own.

Imagine the drill sergeant stops talking…you wait and wait for instructions and on hearing nothing, try to continue marching. But you’re shit at marching on your own, you’re probably taking three steps with your left foot before moving the right.

Remember that bit about getting tired and cranky and not working well and the lady dying?

Yeah.

If survival = marching….can you work out this lady’s chances if you keep marching with one foot?

Yeah.

Fuck.

Thankfully, another half second passes and that single, solitary ventricular complex is pursued along the yellow screen of the ECG by a steady row of calm, disciplined sinus rhythm. Everything fires off in order, everything works well.

The patient sits up. Lays a hand on her chest, smiles at us and says.

“Thankyou boys. That’s much better.”

Pally and I hold her hand, smile pleasantly. She heads up to the ED for a check up.

I retreat behind the vehicle and get my breath back.

Last I checked, the idea of emergency cardiology isn’t to make the medic’s heart rate go through the roof.

Right?

As those of you who follow me on Twitter will be aware, I’ve been busy writing blogs for the BMJ’s Doc2Doc forum over the past few weeks.

Off the back of this I’ve been asked to write a further series of articles for them. In the past I’ve linked to these at Doc2Doc and I intend to continue to do so.

For those of you who aren’t signed up to Doc2Doc, please do! It’s a great forum with lots of health care professionals involved (not just doctors!) and a growing wealth of contributors.

The BMJ posts won’t be published here on TQ until the end of the series, so if you want a headstart on your fellow TQ readers, get on over there!

The latest post is “Fresh-faced and scared“.

Because today, at the Festival Cavalcade, we were approached by a family. Mum, Dad, small male child and smaller femal child.

And Mum and Dad did spout forth on how fond small male child was of emergency vehicles and people and could he say hello?

And we did say yes, and say hello.

And then small male child did ask why we were present in such quantities.

And we did explain the risks of crowds.

And he was satisifed.

And then I did tell him that it was all a load of old bunk, and that we were really there because the very brilliant Oiseaux De Lux were stomping around, as ten foot tall ridden ostriches are wont to do.

And I may have told him that the ostriches hadn’t been fed.

And that at lunchtime they were going to go nuts and eat lots of old people.

And the male child did laugh.

And the smaller female one did believe me.

And she did cry.

Oops.

It makes up for the shortcomings of being poor.

The day before this was filmed Sarge called me up and asked “D’you mind bringing the bike out for some photos for the local rag?”

“No bother.”

Then yesterday morning I’m greeted by a photographer, my boss’s boss’s boss, the Service’s press officer and a film crew from the BBC.

I glared at Sarge.

“You said photos.”

“Did I? Sorry, mate….”

He slunk off into the studi, giggling to himself.

So I got filmed packing my bike, and riding it around the car park, all while Sarge and my other colleagues made faces at me.

Later on the film crew met me up on the Royal Mile and, halfway through the filming, I got a call.

The reporter loved it, I think he thought he was on Police, Camera, Action.

So, since it’s been Tweeted all over my Twitter, here it is.

The sleuth-like amongst you will notice my real name - this isn’t a big deal, you didn’t really think that Trauma Queen was truly anonymous, did you?

Pseudonymous, it will continue as.