I look up at Turismo and mouth the word “thrombolyse!!!!” at him (my facial expression adding the exclamation marks) and his eyes widen with mine.
We draw masks over our faces, calm and professional, friendly and reassuring as we load the patient onto the chair and begin to roll him down the stairs. Dezzy has the handle at the back, I’m lifting the front wheels, Turismo following behind with the oxygen bottle and tubing snaking over the patient’s shoulder and into his non-rebreather.
Turismo tells me later that he only hears what happens next, that he sees nothing, but hears me shout:
Followed by a thick, fleshy thud as I punch the patient hard in the chest.
Pete’s head swings uselessly at the end of his neck while his limbs stutter for a few seconds as their oxygen reserves run out, his heart having stopped on the way down the steps.
I’m not mathematically minded, in fact I’m practically innumerate, but I’m running lightning calculations in my head – how far are we from the vehicle? Is it more dangerous to delay CPR by rolling him to the ambulance or will the more controlled environment help us to run this arrest most effectively? I reach my conclusion.
“In the motor – go!”
We roll the chair, fast as hell, Pete’s arms and legs flapping in the wind as we go and shove the whole shooting match into the back of the ambulance, slinging the patient onto the bed.
I’m shamed to admit it, but a tiny part of me is relieved that now I won’t have to thrombolyse.
This is just a cardiac arrest – I can do those.
“On chest, Dez.”
He jumps to it while Turismo unpacks me a BVM before ripping open a set of shock pads and slapping them onto Pete’s chest.
We all throw hands in the air as the defib shock bangs Pete up and down on the bed. Dezzy is back on the chest immediately and I’m thinking about what size of ET tube I’m going to stick down the guy when Dez interrupts.
Pete is eyes open, mumbling. As his face grows increasingly pink, he becomes more vocal, ripping the BVM off his mouth and nose, crying, shouting. I shush him, try to calm him, but his brain has been starved of oxygen for too long.
Nothing but time will bring him back and, sure enough, a few minutes of gentle talking and oxygen therapy and he’s back to full consciousness, looking around himself at the three of us.
“Did I black out?”
“Yes, mate.” Turismo begins, before he’s interrupted by the mobile ringing again.
It’s CCU, requesting an update.
We fill them in, the patient is now post-arrest, he’s had a minute of CPR and one shock.
“Ok, go ahead with the Tenecteplase.”
Turismo and I rendezvous at the bulkhead of the vehicle and sotto voce for a minute.
“Have you done this before?”
“Nope. I was hoping you had.”
“I’ve seen it done.”
“Me too. Shit. Right, look. You have the chat, I’ll push it. OK?”
Because we’re not just preparing to inject this guy with a kill-or-cure drug. .
We need to ask his permission to do so.
Put yourself in Pete’s position – he’s suffered crippling chest pain, the worst pain he’s ever experienced. He can’t breathe, he wants to vomit, his brain is telling him that he is going to die. Then he wakes up on an ambulance trolley, two burned patches on his chest, his ribs aching like someone’s been punching him in the sternum a hundred times a minute. The effects of oxygen starvation have him feeling like he’s got the worst hangover of his life.
Then someone leans forward and says “Hey Pete? We can fix this with drugs that might reduce your brain to summer pudding. Fancy your chances?”
Before we go any further, we need to know that he’s fully competent, so I question him as to the date, our location, who he is, who we are and why we’re all in this fix today. He’s a little frustrated by the questioning, but answers correctly everytime.
Fully oriented, person, place, time and situation, or “AOX4” as I’ll later record him.
Turismo crouches by Pete’s bedside and runs him through the situation – how the benefits of this therapy greatly outweigh the risks, but that “it may cause bleeding and that could include bleeding into your brain, causing stroke or death.”
Pete nods along with us as Turismo completes his consent conversation.
“You’ve already had one episode of unconsciousness due to this chest pain.”
The patient looks him in the eye.
“What would you do?”
“I’d take the drugs.”
He mulls this over for a moment, nodding slowly.
“Are you happy for us to go ahead with this procedure?”
Pete delivers his killer line.
“I’m not happy, no. But if you tell me it needs to be done, then we’ll do it.”
Turismo gives me the nod and I rip open the cardboard box of Tenecteplase. The last time I did this was in my paramedic course at a sunshiney desk.
I mix the drugs with water in its handy wee plastic cup and sook the mixture back up into the syringe, lifting it to the light to check that the powder has dissolved properly, that there are no particulates that may lodge in the syringe, or worse, in the vein.
Then I double check the dosage with Turismo. And he double checks it back with me.
The walk from the bulkhead to the patient’s side is two steps, but it feels like it takes an age. I turn his arm and flip open the cap on his cannula, slide the tip of the syringe onto the drug port and give it a half twist, locking them together.
I’m reminded of the course director at my para course when he dressed down an arrogant technician student who asked “Really, what’s the difference between their job and our job?”
He coolly replied – “I teach technicians to use drugs that save lives. I teach paramedics to use drugs that kill people.”
In honestly, I’m also remembering Pally’s thrombolysis story. How he pushed the drugs and watched the woman arrest in front of him, how her husband screamed at him for the journey to hospital, how he didn’t sleep for days afterwards, how he was summoned to CCU to discussion the situation with the consultant.
And I’m also remembering the patients I’ve had arrest in the back and reminding myself, loud and clear, that without this therapy, this man is going to die.
I slip my thumb over the plunger, look Pete in the eye.
He nods, closes his eyes and leans back in the bed.
I push the drugs, twist the syringe from the cannula and call through to the cab.
“CCU, please, Dez. Smooth over fast, but fast as you can, OK?”
He gives me a thumbs up through the bulkhead window.
“Don’t throw us around, mate. We’re working back here.”
The engine starts and the vehicle pulls away from the kerb. I strip my green shirt off and throw it in the corner, my chest and back dripping in sweat already.
Pete remains in position, lying back, eyes closed. I place a hand on his arm.
“How you going?”
He doesn’t open his eyes.
“And your chest pain?”
“Still there, though?”
We reassess his blood pressure and give him another dose of morphine. There’s no need for either of us to be standing, but neither Turismo or I can seem to sit down, preferring to hang from the bars in the roof, hovering around Pete.
At one point the colour drains from his face and he scrambles to sit up straighter – I’m rechecking the monitor for arrythmias, but he instead grabs a sick bowl and fills it to the brim with rancid, watery brown vomit. Turismo and I form a human chain and work an operating line, replacing clean for dirty, stuffing paper towels into the bowl to sop up the puke and shoving the soggy mess into orange rubbish bags. Again and again Pete vomits until he’s left with just dry heaves which eventually subside. He sits back in the bed and I mop the sweat from his face.
I try to start a conversation about his hobbies, his family, his friends, but he denies having any of the above. We ride the rest of the journey in relative silence, only asking Pete relevant clinical questions as we go.
At CCU we’re met by a chest pain nurse, the same lady who taught me most everything I know about acute 12-Lead ECGs. We roll Pete on the trolley into the hospital, the monitor clipped to the side of the bed, one of us always watching him, his rhythm, ready for him to arrest as we go.
Instead we roll into the ward without incident, transfer him to a hospital bed and hand over to the cardiology team – they apologise for not being able to take him into the operating theatre and thank us for thrombolysing – “Now I can go home early!” laughs one nurse.
We head back down to the vehicle to complete paperwork and while Turismo is typing, I go back up to CCU to collect a replacement box of Tenecteplase. A gentleman in shirt and tie buttonholes me as I enter.
“His 12-lead is almost completely normal, now. He’ll be home in a few days.”
“Really? That’s great news, thankyou.”
“Been working hard?”
He nods at the spreading damp stain across my chest and I laugh.
“Oh, no. That’s the first time I’ve thrombolysed in the field – raises the pulse a bit.”
“You should be proud of yourselves, early thrombolysis is better than poor angioplasty and poor angioplasty is delayed angioplasty. You said he arrested on scene?”
“He’d never have made it without the Tenecteplase – you guys saved his life, without question.”
He turns to go and I realise I have no idea who he is.
“Sir, forgive me? I’m afraid I don’t know your name.”
He extends a hand, introduces himself with a name I’ve only heard in conversations.
He runs the entire department.
Remembering Wilco doing the same for Sophia and I in Abu-Dhabi after a shitty job, I grab three ice cold lemonades from a machine in the corridor before meeting Dez and Turismo in the ambulance. We sit together on the trolley and grin at each other, though the can in everyone’s hand trembles just a little.
Dez takes our paperwork back upstairs for us and on his return recounts his conversation with Pete as he sat up in bed, rubbing his chest and frowning.
“When I blacked out, did I stop breathing?”
“And did my heart stop?”
“You guys did CPR on me?”
“And shocked me, too? You shocked me with that machine, didn’t you?”
“I was dead?”
The patient stares at him, wordless. Dez wishes him the best and leaves him to it.
For every pisshead, smackhead and time waster, for every late job or NHS24 – scared-of-your-shadow “meningitis” and “chest pain”, for every snotty GP or adolescent hawking phlegm on the floor, for every “spiked drink”, maternataxi and pseudoseizure.
I will take a thousand of you for this feeling.
You will not dilute why I joined this profession, you will not browbeat me into submission.
All of your shite is eclipsed by knowing that, through the actions of my colleagues and myself, someone is alive who otherwise wouldn’t be.
That’s why we do what we do.
And that’s why we keep doing it.