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.
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.
Not a corpse.
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.
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.”
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.
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?”
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.
“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.
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.
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.”
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?”