A Sense Of Perspective

I read a post by Kal, over at Trauma Queen. His is another 'Emergency Services' Blog I recommend. I personally find it interesting to see the shit these guys have to put up with, even before they get to the Hospital. Just don't call him / them 'AmbulanceMen'.

Anyway, since my Night Shift was relatively uneventful, aside from planning to elope with one of the Nurses to Cambodia, I was struggling to think of something to post. Kal's post struck a cord.

Now, I may have posted about this before... my memory bites, and I do have a habit of repeating myself, as any of Shroom's friends will tell you. But I just can't be arsed to plow thru' my own archives. So, if you've heard it before, I'm sorry. Perhaps someone could discretely let me know I've begun to tell the same tales over and over, before I turn into the old man in the corner, endlessly recycling war stories...

Anyway...

A little while ago, I was at home, visiting Ma and Pa Shroom. An old school friend and I were off out for a few drinks, passing through the collection of shops, restaurants and estate agents that goes to make up the senior Shrooms environs. As we approach one such restaurant (which, trivia fans, used to be a grocers), I see both Police and Ambulance outside. I am almost pathologically nosey, and sidle up to the window.

My gut tightens, then loosens, just a little. On the floor, surrounded by the attendant detritus that goes with it, is a young man being resuscitated. Full CPR. I approach the Copper on the door.
'Any need for a doctor on scene?' I enquire. In my experience, the Police are happy to let yo get involved. I remember him being young, and he looks pale, anxious, unsure.

'In there'; he opens the door, points unnecessarily. I can hear the sound cloud, the aural miasma that goes with an out of hospital resus. The Paramedic's voices, calm, ordered. Other voices, close to hysteria; these will be the patient's friends; we ask people if they want to watch the resus in Hospital, assign them someone to be with them, hold them, answer their questions.

These people have no choice - it's right here, live, interactive. No red button required.

The restaurant is divided into halves, by a low arch in the wall. Where I've entered is in the first half; the action is next door. The restaurant is full, and the patrons don't know what to do. Something dreadful is clearly happening next door; they can't see it, mostly, but they can hear it; they all know what's going on.

They don't know what to do. Most of them are eating, making small talk, desperately telling themselves that 10 feet away a small terrible drama is being played out. It's incredibly bizarre.

I pitch through next door, introduce myself, hoping that I will know this crew. I worked at the local hospital for 18 months, maybe they'll know me, remember me.

They don't.

Now, while the Police are usually happy to let any Tom, Dick or Harry through, the Paramedics and Techs are not. Why should they be? They know what they're doing; they don't need help, especially not from someone who might be a nutter. If I offer to tube the patient, and stick it in his belly, they carry the can.

Somehow, I do enough to convince them I'm on the level. 3 people on the resus makes life easier. They let me do compressions, the AED tells us when to shock the patient. He is young, maybe younger than me, and something terrible has happened to frighten his heart into the violent, spikey rhythm we see on the monitor.

When the drugs are gone, the time has come. Time to run, get him to hospital now; a wider selection of drugs awaits, and maybe, maybe salvation. I see it in their eyes - do they see it in mine? He's been down 20, 30 minutes in total, and while his rhythm is still in turmoil, and he's still having electricity passed through his failing body, his chances are bleak.

Now, and this was the point of this whole thing really, outside the restaurant, the road is narrow, two lanes only, narrow lanes, one already blocked by the DayGlo rig, that we jokingly used to call The London Big White Taxi Service. To get everyone out safely, the Police block the second lane.

Now it seems obvious to me, that when someone is wheeled out of a restaurant, Paramedics clearly engaged in CPR (and surely everyone knows what that looks like? Don't they watch Casualty?), escorted by Police, a crowd of tearful, sometimes screaming people in tow, that this person is not well.

That his situation might be more serious than your dinner / the pint with your mate / whatever else you will know be 10 minutes late for.

But, no.

While the cars further back quietly waited, used to jams around here, those at the front, those with the clearest view of the end of this man's life, begin to hurl a torrent of abuse. I see no point in reprinting it here, but suffice to say some of the invective was strong enough to result in an extra delay to discuss their choice of language with the Police.

5 minutes later and the road is clear. The diners are still eating.

I catch my mate, and we go for a pint, both just a little bit happier to be alive

"Taxi For The Man In The Arseless Gown..."

On dignity and nappies.

A fellow blogger has had a few words to say about how our clients comport themselves. Manners are rarely a big priority. It's just like any job, obviously. With a few more drunks. And wankers.

I apologise if I've done this already. I have a habit of repeating myself...

One evening many moons ago, a young-ish man was rushed to us. His friends had brought him in, from the pub. He had spent his usual Saturday drinking and smoking. His friends figured he'd had at least 15 pints. Not so much, eh? Then, he'd come over 'a bit funny'. And been sick. Everywhere. Then passed out.

And wet himself.

And crapped himself.

His mates had piled him in the back of one of their vans, which was now truly soiled. They told us he'd had a heart attack and a stroke (or brain attack, if you prefer) in the past. This fella was little older than I, and had the co-morbidity of a septuagenarian. Despite all of this, he still lived the life of a teenager.

Anyway, he was presented to us; a blank canvas, albeit one soaked in fresh, warm effluent. We worked him in the usual way, en masse.

Open his airway, check his breathing. All clear. Check the pulses, blood pressure. All good. Get a line in, blood out - precious, precious, oh, yes, my precious... - fluid in.

Run the neuro. Quick GCS, check his pupils. Apart from being flat out, and stinking of... stuff, not much focal to find. Gut instinct? 15 pints, plus grey matter = coma.

But...

Could it be something else? For sure. He's had one stroke, could this be another? The booze coma waiting game ensues.

IF: it's just booze, you can wait without a CT
BUT: if it's NOT just booze, you can't.
SO: you have to wait long enough for doubt to enter the equation, so you can buy a trip to the scanner from the Radiologist.

Wait too long, and you're a doofus. Jump too early, and he wakes up in time to negate the need for the scan, just in time to piss the radiologist off when he realises he's out of bed at two a.m for a scan that's not needed any more.

I decided to jump early with this guy. He seemed too flat for just booze. My team had shrunk by now, just me and a nurse; much more intimate. Me, my partner in crime and our patient. Our own special club. I was just bouncing the idea of the scan of the nurse, and opining that we'd need a catheter, when sleeping beauty stirred.

"No catheter" he slurred, offering us a share in his ethanolic miasma.

"No fucking catheter. Leave me my dignity."

My delight that he was waking, with now sign of stroke, mixed with joy that I had not yet called the Radiologist and sheer incredulity.

Your dignity? You spent the evening drinking heavily, before passing out, vomiting all over yourself and your friends, and their van before soiling yourself. And you're worried that my placing a urinary catheter, in private, with only an highly qualified nurse to witness the event, will impede your dignity?

My apologies.

Re-examination revealed a very drunk, slightly soiled man, with no apparent injury.
Another life saved.

As the fella's clothes were beyond wearing, we furnished him with an hospital gown - the kind that don't quite do up at the back - and pointed him to the nearest taxi rank.

I can't think why his friends didn't want to take him home

Blood On The Tracks

Common sense...

I think we do our best to frighten people out of it. Or are people just afraid of being responsible for their own decisions?

I think a lot depends on the back up they expect to get from their colleagues, or professional body. Or how used they are to making independent decisions. Thus, I expect doctors to be able to make, and justify, their own decisions, even if these run contrary to "usual practice", or "protocol", or "guidelines".

Nurses and Ambos are reluctant to do so. Because they can't? I'm not sure; I'm certain their training is less about the synthesis of a plan based on the available info, than about responding in a set way to pre-defined parameters, but I'm also pretty sure they get bugger all support if they step out of line, even if it's to do the 'right thing'.

An example, which also goes to my post about dignity.

An elderly lady is discovered collapsed in bed at her nursing home. She appears to have had a stroke. She had been physically disabled by a previous stroke, but her mental faculties were in fine fettle. She had previously expressed a firm desire not to be resuscitated in the event of physical deterioration; in fact she had left written instructions expressing her desire not to go to hospital in such an event. These instructions had been communicated to her daughter, who was in complete agreement.

So, when she is found, what happens? An ambulance is called, obviously. Was this right? Was it wrong? Could the GP not have come out?

Either way, when the Ambulance arrives the situation is made clear to them. But, the written request for non-transport is not countersigned. The patient's daughter is present, and re-iterates her mother's wishes.

This is apparently not enough, so into hospital she comes

My assessment was of an intra-cranial catastrophe of such magnitude as to be unsurvivable; intervention might preserve life, but not in a way she would have wanted, as far as I can see. I discussed this with her daughter, and the home. We agreed she would want to be in familiar surroundings, and arranged for transfer back there, priming her GP as to what had happened.

Was I wrong? I can't be certain of my diagnosis, but I can be pretty sure. This was not a response to something easily correctable, the resolution of which would have returned her to her old self.

Should she have come to hospital? I don't think so. The primary reason she did was to cover the Ambos. Is this their fault then? Of course not. If their organisation does not support free thinking, they have no choice.

Is it anyone's fault? I'm not sure. The system failed, despite all this patient's best efforts, she almost did not get the end she wanted.

Now, I know that the whole area around resuscitation, and 'living wills' is hugely contentious, but surely there's still a bit of room for us to use our common sense? Or are we to become so afriad of criticism, of litigation, that medicine will become a series of giant algorithms, with no room for indepndent thought?

Medicine is an art, and art is sometimes ambiguous.

Dignity

Sometimes I think all we can do is help people keep there dignity. Some of our patients do there level best to strip themselves of their own dignity; that's their business.

Those patients who present with a seemingly hopeless condition often have only their dignity left. Whether we let them keep it or not, seems to be related to their age. I don't know if this is right or not;

Example:

Elderly patient, presenting flat, found GCS 3. Exam might reveal an huge aneurysm, slowly leaking the patient's life blood into their belly. Or the telltale signs of an intracranial bleed. Any sort of injury, of insult that is unsurvivable. They cannot be salvaged...
Here, we gather all their nearest and dearest. With solemn faces we pass the dread news on, share our unwelcome burden. Then we leave them be, let them make their own peace, neatly, quietly, calmly.

Young patient, presenting flat, but from trauma. Shot, stabbed, crushed. It doesn't matter, really. You still know. There is no comeback. We half admit it, but we run the case anyway. Full tilt kozmic boogie. It never works; and the patient leaves us in a blur of shouted requests, of bloody gloves and discarded sharps. There is no time to gather their kith and kin; we know they will come later, and maybe it is for them we form ranks for one futile charge; so that we can tell them of the thin red line that wavered and broke.

Is that better than dignity? Or are we afraid of being wrong?