Sep 29

Just Add Water

Tag: Ambulance,Thrilling InstallmentKal @ 9:51 pm

Benny and I are in Tesco, choosing salad and cold meat when the phone rings in my breast pocket.

“432, that’s a job in SmallTownOutsideEdinburgh, upgraded urgent for a female with dehydration.”

When a doctor or rapid response paramedic arrives at a patient they sometimes arrange “urgent” transport, an ambulance will respond without lights and siren and ferry the person into hospital. They arrange that this job will be done within a certain time limit, usually one to four hours and that the patient or their family can call back if they take a turn for the worse, in which case the job will become an emergency.

It’s a resource management trick and it works.

But like most tricks, it works both ways.

Nursing homes are exceptionally guilty of calling back for urgents. It’s understandable and, perhaps, not entirely their fault. Picture the scene.

Your elderly relative is not well. The nursing staff in their home call you. You drive over and sit with them while the doctor attends and phones for an ambulance to come and pick them up this afternoon.

“In the next four hours…” they blithely say and head off.

The nursing staff don’t want to intrude on your familial moment, so they leave you all alone.

And you sit and watch your relative.

In bed.

Your relative who, chances are, was pretty sick before they went into the nursing home.

Who is now sick enough to need the doctor to visit.

To get an ambulance.

To go into hospital.

In four hours.

You sit and watch them. Maybe they’re sick. Maybe they have an accident. Maybe it’s your imagination, but perhaps their lips are a little bluer than before? Perhaps they’re a little paler? Are they crying harder? You call the nurse back in.

The three of you stand in the room, patient, nurse, relative. The nurse can’t do anything tangible to improve the patient’s condition, neither can you. An awkward impasse develops between the two of you.

The nurse calls ambulance control.

“They’re worse. Make it an emergency.”

And off we go, lights and sirens, my lunch languishing on the supermarket shelves, Benny and I cursing to ourselves.

We step into the bedroom.

Sure enough. Nurse, care home manager, two worried looking relatives.

And a corpse on the bed, a tiny, dried up little dead woman with the downie pulled to her waist.

No.

Wait.

Not a corpse.

Not quite.

She’s emaciated, dessicated, her head too heavy for her neck lolling on the pillow, her skin hanging in dead sheets between her shoulder blades and ribs. She’s foetal, her mouth hangs open, her eyes are closed.

But she’s breathing. Hauling in handfuls of air with every breath. Her ribs crank up and down, her dusty, dry skin crackling like baking parchment with every inhalation. She looks like a terminal accordion.

Corpses don’t breathe.

Not the last time I checked.

I should know.

Shouldn’t I?

The nurse hustles the family out of the room, come along, come along, let the paramedics do their job, we’ll call you in a moment once she’s ready, nothing to worry about, I’m sure they’ll look after her but there’s very little room and you don’t want to get in the way.

She shuts the door behind her and turns to Benny and me.

“Thank fuck you’re here, she’s totally shut down, I thought she was going to go off on me.”

Wha’?

Who is this woman? With her “shut down” and “go off”. Those are our words, the words of emergency medicine, the words of the ED. They are not the words of nursing home staff, they are not the words of staff who shrug when we ask about medical history, who claim to be “covering a shift for a friend.”

They are words of someone who really, really knows when their ward is really, really sick.

I congratulate her.

“I’ve never met a care home nurse who talks like that.”

Then she hits us with another whammy.

“I’m not a nurse. I’m an auxillary.”

“So how do you know…?”

“I worked in OAPHospital for years. She’s dying, isn’t she?”

I gape at her, switch my head back and forth between her and the patient.

“Oh, she’s completely deaf. And profoundly demented.”

I’m startled by her candour, but recognise a colleague who shares our pragmatic style, I still drop my voice a little.

“In that case, yes. She’s very sick. What’s been going on?”

“She had three coffee ground vomits last night, then this morning five bouts of diarrhoea.”

Coffee ground vomit typically means you’ve either been eating coffee grounds, or your stomach lining is bleeding. Digested blood is black, lumpy and granular.

“I’ve had to change her every time. She’s got pads on, but she’s messing right through them.”

Benny leaves me the defib, bag and oxygen and excuses herself to get the trolley. I loop a tourniquet around one scaly bough of an arm and hang it over the side of the bed. She’s floppy, languid, as her hand swings uselessly I feel at her opposite wrist for a pulse.

Nothing.

My fingers in her throat give me a carotid, but weak and feeble and fast. She’s in “Stage III shock”.

“Stage IV” is an immediate precursor to cardiac arrest.

Shock classically occurs when people lose blood, but any sustained fluid loss will do it. The patient in front of us is literally shitting herself to death. Her gut sucks fluid from its walls and ejects it with every stomach cramp, a system frantically working to expel some invader that it deems more dangerous than self-destruction.

I slide the cannula into one of the stringy veins that crawl across her forearm as Benny reappears with the trolley. The care home manager offers to help us move her across onto the stretcher, but stops, his mouth flapping like a guppy when he realises that we’re taking the pillow she rests on.

“Will it come back?”

“Probably. I think its important that she’s comfortable, though, don’t you?”

“Ummm…”

Benny raises eyebrows at me in response to his hesitation, he notices and backtracks.

“I mean, of course, of course, we should keep her comfortable.”

The auxilliary catches my eye and winks, “Can I carry anything for you?”

Benny nods at the defib on the floor.

“If you could get that, it would help.”

She lifts it with an “oof” and by the end of the corridor she’s resting it on one thigh, bumping it along with the swing of her leg.

“Aye, now run up a flight of tenement stairs with it,” I tease as we roll the trolley outside.

Before we leave I catch up with the manager.

“See her?” I ask, pointing at the auxilliary.

“Yes.”

“She is, with no sense of exaggeration, the best care home staff member I have ever met. If you ever let her go, you’ll be making a grave mistake.”

“She’s very good with the clients.”

“She’s better than that. Keep hold of her.”

I leave him scratching his head as I hop back into the ambulance to join Benny. She’s already hooked the patient up to the monitor. She taps the screen.

“Not good.”

I flash eyes over the data. Sinus tachycardia – her heart working well, but three times faster than normal. BP 72/37 – when the first number dips below 80, the brain shuts down; when it descends past 70, your kidneys abandon their task of filtering poisons from your blood. SpO2 78%, despite high flow O2; despite me shoving oxygen into her as hard as we can, her systems are so trashed they can’t move it around to her hands.

I hang a bag of fluid from the ceiling of the ambulance while Benny radios the hospital, cool and calm as a night time phone in disk jockey she quantifies the plight of the woman in three lines.

“Eightyfour year old female, profoundly shocked, GCS 3, ETA 10″

I hook the fluids to the cannula in the patient’s arm and wrap my fists around the bag, squeezing its walls to force the fluids into her vein as fast as possible. In minutes it’s done and I replace it with a second. I’m swinging from the handles by one hand, crushing the bag with the other while Benny hustles us up the road. Halfway through the second bag, the patient opens her eyes. Looks at me.

“Hello, love!” I greet her, more surprised than I care to admit.

She smiles and replies.

“Hello.”

I drop to one knee, lay my mouth against her ear and yell.

“My name’s Kal. I’m an ambulance man. We’re taking you to see the doctor.”

She fixes me with a stare.

“Rabbits. In the garden.”

Ah.

That’ll be the dementia then.

We’re in resus in minutes, the doctors teasing us. “GCS3, you said, profoundly shocked, you said, what’s this then?”

I wave the empty bags of fluid at them.

“Amazing what a litre of water will do for you, isn’t it?”

“We are nothing but elaborate mechanics. We learn new skills to put air and water into people in increasingly clever ways.

21 Responses to “Just Add Water”

  1. Ross says:

    Once again, a good story. I like that it ends well. Life’s not always like that.

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  2. PA State Cop says:

    Well done.

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  3. Steven Fisher says:

    Very cool to hear your description of the auxillary. And I’m glad the day was put off, but it sounds like maybe not for too long.

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  4. AaronRn says:

    Let me guess, the poor old lady was a DNR with respect to CPR? Perhaps the home staff were thinking, “well looks like her time is finally here”

    I can’t think of any other reason that she wouldn’t have fluids going from the start.

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  5. Heyhoo says:

    Have posted this to my son with the instruction that when the time comes if he puts me in a home where the “manager” is more interested in the return of his ******* pillow to shoot me first, then the “manager”…good post tho x

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  6. Tom says:

    Once again, I have to congratulate Kal on a great narrative.

    We used to live with the old, emergency, urgent and maternity priority system that set our times, providing of course the horse was up to it, and yes I am an old git.

    I have to say that during my service I never encountered a care worker, at a nursing home with that level of skill or commitment. Good on you and your oppo for pointing it out to the stuffed shirt pen pusher.

    However, I must credit you with the distinction of founding my acute and chronic condition of MRBS (must read blog syndrome) to whit I confess I have a terminal case.

    Anyhow, must do that work thingy, and resist the MRBS.

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  7. Cath says:

    “Like a terminal accordion” – that’s just the best I’ve heard in a long time:-)
    Perhaps it would have been better for her to die peacefully in her bed, but the story… beautifully told :-)

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  8. Sarah says:

    The wonders of biology and science – and those who know how to apply them – are pretty amazing.

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  9. Sewmouse says:

    So did the asshat get his fucking pillow back? Congratulations on not decking the jerk. Were I her daughter, and heard that from the manager – I am not sure I wouldn’t have been in the back of a police car for assault and battery and you might have had a 2nd patient.

    And actually, that might have been a good thing – because then he could have seen that remarkable recovery – and maybe been just a teeny, tiny bit less of an asshat when he got back to his job.

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  10. Veronica says:

    Good post. Like Cath I wondered if she might have been better staying there but with s/c fluids running (although that also opens up a whole other debate….) – quick question though – why do some clinical areas and nursing homes appear not to use IV fluids?

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  11. Volley of Oz says:

    Hey Kal,

    Have been a reader of the site for a while. I’ve recently become a volunteer ambo in Western Australia (April) and it’s so great to now be able to understand, more and more, the acronyms you use within your writing. More so to understand your point of view from similar experiences. W.A. is a little different than Edinburgh, outside metro Perth, most country towns are staffed by either paramedics during the day and a paramedic and volunteer during the night or just staffed solely by volunteers for the whole town. The town/city I live in has 2 paramedics during the day and a paramedic and volley during the evening for 45,000 people.

    Really enjoy the stories and your writing skills. Thank you for the excellent reading :)

    W.A. Volley

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  12. Fee says:

    I’m still young enough to have a kid at primary school, but I hope to god we have a better set of euthanasia laws before I get to that stage. The thought of dieing by inches in some stinky nursing home while a pen pusher frets about a ******* pillow, or this months’ bill, or whatever, fills me with utter horror.

    On a lighter note, when I was about 4 my mum took me to see my great-granny in the Western. She “wasn’t long for this world” and was hooked up to goodness knows all-what. I nearly made my mum choke when I pointed to the drip bag and asked, “Is that lemonade? Don’t they have any straws?” Yes, the revolutionary new treatment for whatever ails you – IV Sprite!

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  13. tyro says:

    I’ve seen two of these just in the last two days, gorked initially and flushed with fluid they come back to life. The very old and the very young. Good post. Have to go change a diaper (not mine).

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  14. Win-Stone says:

    I agree with Fee; if I ever reach that state I swear i’ll come back afterwards and haunt somebody!

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  15. Jot says:

    Moving – as always, Kal. So very moving.
    10 minutes left scene to arrive hosp…? wow!
    perchance to dream, mate ;0)

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  16. Morpheus says:

    I *love* your writing style.

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  17. Miss Waz says:

    Awwww. :O)

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  18. Darkside says:

    Shoot the rabbits before they get all the veggies!

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  19. pleb says:

    Good story, I like the way you write.

    Also, I see you know how to eat properly! Can you tell Tom Reynolds of Random Acts of Reality because he insists that he’s forced to eat takeaways all the time. I worry for his health. ;)

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  20. Student Nurse says:

    Hey Veronica i know its a bit late, but nursing homes dont use iv fluids because its more effort for the doctors, to come out and check them daily etc, as the nurses are not qualified to do such a thing, so being the resident of a care home being admitted when they need i.v. Shit i know but tis the way it is.. And i am amazed that the patient was not getting fluids thats usually a top priority within care homes, then again it doesnt matter about the care home, its the shittyness of carers in it and the incompetence of them.

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  21. Melissa says:

    I’m a HCA/Auxillary and i work on a rehab ward which mostly consists of the elderly with dementia/alzheimer’s, CVA’s, Diabetics, amputee’s, UTI’s, falls etc. its always hard to see them suffering, but you do the best you can. I’ve dealt with a few cases of the elderly being dehydrated and with dementia, they are always trying to pull out the I.V lines which can be a nightmare for the nurses when they succeed. our job role is quite huge, which i have recently learnt on training days (I have had the job since may, my previous job was a sales assistant with woolworths, no previous medical experience and i’m 17)we also had a patient who was complaining of pain, i asked where and he said all over and that he felt terrible. So I done some basic obs. his bp was 208/110 which was a little worrying, so i alerted the staff nurse and she told me to do it in 15 mins, which i did. but they were much higher and in the next hour they kept getting higher and higher, the staff nurse just told me to keep an eye on it, i done a BM which read 4.1 a little worrying again. the staff nurse just kept telling me to keep an eye on his obs, which i did but was very worried as he was deteriorating so i asked the staff nurse if she was going to call the doctor and she said she would in a min then went on her break when she got back i asked her again and she said in a min so in the end i asked someone else, they were furious, the patient was then sent down to have a CT scan and i’m not sure what happened to him after as he got sent to a different ward. it annoys me sometimes. I’m hoping to be a paramedic which i hope all this experience helps in the near future.
    keep doing a good job :)

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