Jun 08

Clot-busting I

Tag: Ambulance,Thrilling InstallmentKal @ 6:32 pm

Spring sunshine pulls families from their houses – on a scabby corner of grass at the end of a terrace an extended family flip fatty burgers on a barbecue, smoke spitting in the air, pasty white chests flexing in the sun for the first time in months.
Our patient is round the corner.
Turismo has arrived already, his motorcycle at the kerb on its sidestand. We grab our defib before heading up the stairs, the motorcycle (like my parabike) doesn’t carry a full cardiac monitor. The patient’s called for chest pain, so we’ll need the extra kit to take an ECG

The door carries scrawls of magic marker graffiti and the stairs are dirty, the paint flaking and tired, shreds of carpet clinging to old nails. Dezzy is a few paces ahead of me as we walk into a living room, the curtains drawn against the bright sunshine outside. I can’t see the patient, he’s obscured by Turismo and Dezzys’ backs, coupled with the shadowy conditions.
Turismo machine-guns off a handover – “Pete is forty six, he has no cardiac history and complains of one hour’s crushing retrosternal pain, onset at rest, radiating into left arm, jaw, temple. Described as 10/10. Short of breath, nauseous and dizzy. You can see how sweaty he is…”
Sweat scares me, sweaty chest pains especially so. The gallons of perspiration that pour from people when their circulatory system is shutting down is a huge red flag for us.

Sweaty people are frequently dying.

“Can you go and get me some metoclopramide, mate?” Turismo asks, a syringe of morphine in his hand. No point in giving opiates to an already nauseous patient, we’ll just set him off onto a vomitting cycle, best to give an anti-emetic first.
The patient does not approve, twisting and squirming in his seat he shouts at the three of us

“Please, give me the morphine. Just fucking put it in, I don’t care….please.”
I run down the stairs for the metoclopramide, pulling a vial from my drug pack and slipping the neck of the glass vial between my lips. Before I leave the vehicle I also grab the carry-chair and blanket – I have no doubts that this patient is coming to hospital with us today.
Back up in the living room Dezzy has the ECG connected to the man’s limbs.

We operate two types of ECG, a “four lead” and a “twelve lead”, the first being useful for general cardiac monitoring, the second being a diagnostic tool to examine the heart’s function in detail. A 12-lead ECG is how we check whether or not your chest pain is originating from your heart.

Think of it as the difference between you hearing a funny noise under the bonnet and a mechanic stripping down the gear box to really see.
The thing is, we don’t need a 12 lead here – the four-lead is enough to tell us that the front of his heart has a massive clot forming in it, blocking the blood supply to the surrounding muscle

We transmit a 12 lead ECG to the Coronary Care Unit above the ED for their perusal – a bit like having a cardiologist in your pocket and being pleased to see them.

We have no sooner sent the ECG over the airwaves than the phone is buzzing in my pocket. I listen to the nurse at the other end and she breaks some bad news to me…..

The best treatment for an MI is to breakdown or remove the clot that is forming within the heart as fast as possible. The longer you leave things untreated, the longer the tissue beyond the clot is starved of oxygen and dying.

We have a number of options available to us. We can rush the patient straight to the ED and have a chest pain nurse assess them, though this slows down the patient’s treatment and is far from ideal.

The gold standard treatment is fast angioplasty, where we bypass the ED and transport the patient direct to the operating table in Coronary Care where the surgical team can be bore or drag the clot out.

Assuming the patient can be in hospital within an hour of the diagnosis being made, this is the route we take. The procedure is low risk with minimal anaesthetic and the results are exceptional.

In Edinburgh we’re spoiled. We are never more than an hour’s blue light drive from the hospital and as such whenever we transport to CCU we have little clinical responsiblity other than to give drugs to lessen the risk of the clot growing any larger.

Then we drive the patients super fast to hospital and pass the buck, our hands in the air – “Here he is! He didn’t die in my motor! You fix him!”

We do have an alternative, though.

In all front line vehicles we carry a drug called Tenecteplase. This is a thrombolytic – it dissolves clots to liquid blood. Once the drugs reach the clot in the heart it is immediately broken down and blood flow is restored to the damaged heart muscle beyond.

Tenecteplase is only administered prehospital when it’ll take more than an hour to get the patient to CCU.

For this reason, Tenecteplase is used far more regularly in remote and rural areas than it is in the larger towns and cities and for urban crews it carries a near-mystical quality. Because thrombolysis is not a safe procedure.

Tenecteplase whizzes around your body breaking up any clots it encounters, but it can’t differentiate between a clot in your heart and a clot anywhere else.

So if, for example, you had a nosebleed this morning and we give you thrombolytics? It’ll start up again. If you’re coming to the end of your period, you’ll find it kicks off again with a vengeance.

Or more alarmingly, if you have a small, weakened part of the blood vessels in your head- you’ll develop a brain haemhorrage.

And here’s the humdinger. Because we’ve also given you drugs that stop clots forming in the first place?

You won’t stop bleeding for a very long time.

Bleeding aside, we should also mention the euphemistically titled “reperfusion rhythms”.

Your heart tissues do not like being starved of blood and, just like the agonising burn you feel when you fall asleep on your arm and roll over, the myocardium can get seriously pissed off when blood suddenly rushes back into it.

But it doesn’t burn, or tingle. It frequently goes nuts, shivering and trembling in ventricular fibrillation; the rhythm that we shock with a defibrillator.

The rhythm that kills people.

So in essence, thrombolytic therapy will fix your heart attack. But it might also give you a CVA.

Or make you bleed to death from any orifice you choose.

Or maybe just stop your heart stone dead.

Back to my phone call with the nurse from CCU.

“You’re aware he’s having a massive anterior MI?”

“Yes.”

“How soon can you be with us?”

We’re on the wrong side of town, still in the house, with heavy traffic outside.

“ETA with you, thirty minutes.”

I hear her suck air through her teeth.

“Are you a paramedic crew?”

“Yeee-eees….”

“We already have a patient on the table…he’s proving more complex a procedure than we anticipated…doctor’s not convinced he’ll be free to see your guy. Go ahead and thrombolyse him….

24 Responses to “Clot-busting I”

  1. Win-Stone says:

    OK mate. Do you know what happens to people who write cliff-hangers like that?

    (Muses……… ‘So, where did I leave the pickaxe handle?’)

    On a different note though – I have always maintained that adrenaline really is brown and smelly :-)

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  2. Veronica says:

    GULP! Informative as ever Kal and I’m pinching your illustration of the difference between a 4 lead and a 12 lead ECG. You have a real gift for making the complex simple and memorable. We do ECGs almost constantly on my ward (which is pleuritic in most cases but not all). However, my understanding of them is in it’s infancy – I can only recognise LSL rhythm at the moment….little squiggly lines.

    Quick question though – what is the difference between a four lead ECG and telemetry monitoring or are they one and the same?

    Keep up the good work!
    Veronica

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  3. rjm_cmyk says:

    Telemetry monitoring is simply a method of transmitting an ECG signal from an ambulant patient to a monitoring system via an aerial system i.e no wires.

    Patient has a little box attached to their PJ’s from which the normal ECG leads spring forth and are then attached to the patient. Or they did when I was selling them sometime ago. Aforementioned box like Holter recorders often seemed to end up down the loo.

    Now back to this cliff hanger !!!!

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  4. PA State Cop says:

    I see this ending poorly. Had a guy diaphoretic holding his hands up saying he was gonna die. Was back in the ER an hour later, they were throwing the sheet over him.

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  5. Becca says:

    Egads!

    You do know how to tell’em, Kal.

    This is what almost killed my dad – thankfully he was already in ICU when the clot shifted, and he was successfully resuscitated. Now on Warfarin (and plenty of it) for life, which is not without its own problems.

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  6. Andy says:

    What happened? What happened? Argh!

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  7. Wanderer says:

    Thrombolysis in a a major metro area? Totally different mind-set. I guess we’re spoiled though. Where I live we have 5 hospitals all within 30 minutes (or less) that have PCI equipped cath labs. 30 minutes and you’re still within the 90 minute D2B goals of the ACC/AHA…but if there’s someone on the table already things could get ugly.

    You’re totally right about the sweaty folks…it never bodes well, especially when they’re telling you they’re not going to make it. Can’t wait to hear the thrilling conclusion!

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  8. Patch says:

    Ah, the front line…. They really don’t pay you enough mate.

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  9. Lauren says:

    Aye, they really don’t pay you enough.

    Sweaty, chest painy guys like that phoning me on my wee helpline and kicking up a fuss when I say we’re sending an ambulance scare me quite enough and I don’t even have to see them. Which is probably why we send so many dodgy ambulances for people with “chest pain”, we’re terrified of missing the one who is having a heart attack and just doesn’t want blue lights disturbing his wife/neighbours.

    Beautifully written as always.

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  10. angor animi says:

    This kind of situation does make me wonder how valid their signature at the bottom of your thrombolysis checklist is. Can you provide a valid consent when your body is telling you that death is imminent? What about the 10mg of morphine that an obliging paramedic has just eased into your veins? What does a 1 in 200 chance of haemorrhagic stroke mean to this patient?

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  11. Lucy says:

    Yikes. Hoping the second installment come in double quick time, otherwise the suspense might finish me off.

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  12. Sue says:

    “slipping the neck of the glass vial between my lips”

    You be careful, we don’t want a thrilling instalment that covers the day Kal choked and eneded up in resus!

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  13. karen says:

    oh sh…….

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  14. Cath says:

    I haven’t done the procedure yet, the silly helicopter always beats us to it. But one day, though, there will be a blizzard, and they’ll be stuck. And I’ll be scared to death… Can’t wait, really :-P

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  15. MiniDoc says:

    When I was working in Fife we had to thrombolyse all patients who needed it as we would never get them across the Forth bridge in time. It’s amazing how much treatment depends on geography!

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  16. Katrina says:

    Oooh PLEASE hurry up with part 2, i get really in to your blogs and then BAM… i have to wait for the next part. C’mon Kal.. type type type! ;)

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  17. Michael says:

    Angor – provide the information in a form they can understand as best you can, as far as time allows. If they have capacity, the consent is valid. If they don’t, you go ahead on the rationale it’s in their best interests. Entirely legal either way, provided you make a fair attempt at giving them the information.

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  18. Ian says:

    Hate to be pedantic, but it’s a ‘three lead’, not a ‘four lead’. A ‘lead’ is a view of the heart, not the wire attached to the electrode. You need four electrodes to capture a three-lead view and only ten electrodes for a twelve lead (twelve views – notice that it’s not referred to as a ‘ten lead’). It’s just something that annoys me. Sorry.

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  19. Metamor4sis says:

    ………!!!! KAL!!!!

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  20. Heyho says:

    i enjoy reading about your time scooting about the desert but I absolutely love your “local” stuff…especially if there’s a cliffhanger…

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  21. Dave says:

    There should be a law: if someone wants to leave a cliffhanger they must also provide the date that the next instalment will be released! :P

    Looking forward to it (for the last few days),

    Dave

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  22. Kal says:

    @Ian
    Very much aware of the meaning of “lead”, but the basic version is referred to as a “four lead” in a colloquial manner, rather than an accurate clinical description. In much the same way as I don’t actually make a diagnosis of “fucked”, but it’s how we’d say it on the road!

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  23. Piper says:

    Hah! There are SOME good things to being sans-web for a week while paddling in puddles (and once, the sea) in Cornwall – I don’t have to wait for part 2 :)

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  24. JJ says:

    In response to angor’s comment about validity of consent, I’m interested to know whether paramedics are bound by GMC guidelines or whether you have separate guidelines?? If they’re the same then the following guideline would apply, making treatment without consent permissible:

    “When an emergency arises in a clinical setting and it is not possible to find out a patient’s wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition. The treatment you provide must be the least restrictive of the patient’s future choices.”

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