I should be working today, but (and I want loads of sympathy here folks) I’m off sick with a work-related injury. Thankfully, it’s nothing too serious, certainly nothing as serious as last time when I swallowed HIV-positive blood.
On Thursday we got called to a big conference centre in town for a (possibly) suspended/dead/fitting male. We rushed over there and were met by their security who had rather cleverly staked out both entrances to this place so that they could lead us to the patient. Parking up we had to climb a couple of flights of stairs carrying nearly all the equipment from the ambulance. Our first-response bag, oxygen and associated kit, defibrillator, suction and carry-chair are quite heavy and, as we were in a rush to get up the stairs, we were a bit out of breath when we reached the patient.
The first thing that we saw (and were very happy about) was that the patient had not suspended, and was instead thrashing around on the floor with some security guards and the centre’s medic sitting on top of him. Approaching closer we saw that he wasn’t fitting, but was instead very combative, trying to fight off the people who were holding him down in a very confused nature. ‘Aha!’ we thought, ‘he’s post-ictal’.
During the post-ictal phase of a seizure, the fitting has stopped, but the patient is often disorientated, sleepy or aggressive. In this case it appeared that the patient was both confused and aggressive – he was not responding to anyone trying to talk to him to calm him down, and he could only make guttural sounds. Normally, these episodes last less than half an hour, so we stay with the patient until we can get them into the ambulance.
Sometimes the aggression can come from physically being held down – the patient is confused and frightened, and all they can feel is people holding them down, so they struggle. I suggested that the security guards let him go, which resulted in the patient trying to stand up, only to fall over again (don’t worry, we caught him) and unfortunately the centre medic got a head butt for his trouble. I managed to get a blood glucose reading, which was normal, and a work colleague phoned the patient’s mother, so I could get a bit of history. The patient is normally fit and healthy, not diagnosed with epilepsy, but has had 2 fits in the past 2 years. All during this phone conversation the mother could hear her son shouting in the background. He had never been violent before.
We resigned ourselves to a bit of a wait, so we managed to get him over to a leather couch, and held him down there. After 10 minutes there was no change in the patient’s condition – normally they get a bit tired or they start to have a change in their condition. So we started to think about other ways in which we could help the patient at the scene. We couldn’t get him to the ambulance while he was so combative, and so we thought he might need some form of sedation. I ran back to the ambulance and asked Control to get us a BASICS doctor, or at least someone who could give some form of sedation.
Instead after about 10–15 minutes we got the PRU (Physician Response Unit), which is a new service where a doctor from the Royal London Hospital covers medical emergency calls – it’s a bit like HEMS, only without the helicopter, and instead of going to trauma they mainly deal with medical emergencies.
The doctor (who is a very nice man) and paramedic crew with him took one look at the patient, listened to the history and decided that sedation was a very good idea.
Cut forward 40 minutes’ worth of trying to sedate the patient with increasing amounts of medication. For the medically trained out there, the patient needed 10 mg haloperidol and 17 mg of midazolam. At one point the doctor was thinking about knocking the patient completely out and intubating him. Luckily the patient was sedated enough for us to get him out of the conference centre and into out ambulance, where we ‘blued’ him into Newham hospital just in time for him to wake up (the sedation lasting only around 15 minutes) where the doctors there did paralyse and intubate him.
We have few ideas why the patient was so violent and so deeply confused – it’s something that will be investigated in hospital. We were considering epilepsy, head trauma (from when his head hit the floor), meningitis (so antibiotics were given on scene) or some form of brain insult. I’m asking my crewmate to find out what happened to the patient.
The reason why I am off sick? Well after holding the patient down for an hour and 10 minutes, I managed to sprain my thumb. Since I can’t be considered safe to carry a patient downstairs, I’m taking today off (plus 2 days of leave) so that my thumb can heal and I can get back to saving lives picking up drunks again on Monday. Oh, and it’s my birthday tomorrow – 33 is such a young age don’t you think?
I did manage to see the patient again … see the next entry.
I went to visit our patient from the last post. This morning I’d put my hand in my pocket and found that I had £2.66 of his money that had spilled out of his pocket during our struggle and I’d put it in my fleece for safe keeping – given the saga of the job, I’d forgotten to hand it in when we reached the hospital. I thought it would be best if I returned it to him, so I had a chat with the lovely receptionists at the hospital, and they told me what ward he was on.
I went to the ward to find him sitting there, seemingly none the worse for wear. He did have a bit of a black eye (not my fault … honest), and when I spoke to him he told me that the doctors suspected that he had fainted, and when he had hit his head had suffered a form of concussion. His CT scan and blood tests were all normal, although I suspect that they will be running EEGs (electroencephalograms) and other more detailed tests a little later. He told me that he was feeling pretty much normal and I suspect that they are keeping him in hospital to continue to run their tests.
He was very pleased to see me, and we had a little chat. I offered him his money but he refused and suggested that I get myself a pint with it.
It’s the first time I’ve actively gone to look for a patient after bringing them into hospital – and it is a weird experience going into a ward to see a patient whom I last saw trying to fight me. Yet another new thing I’ve done because of writing this blog.
I’ve mentioned before how the ambulance service and the A&E department are often seen as a ‘safety net’ by other health-care providers. Both yesterday and today we had perfect examples of this.
Yesterday we were called by a 70-year-old man with a urinary catheter which had blocked. This is a fairly simple thing to solve as it just needs a flush of water up the catheter to clear the blockage. It’s a 5-minute job that we, as ambulance crews, aren’t allowed to do. However it is the sort of job that district nurses are supposed to do.
So why hadn’t a district nurse been to see the patient so that she could flush the catheter and prevent the patient from having to attend A&E? Why was the patient, who had phoned up the nurse himself, and told her exactly what he needed doing, forced to call an ambulance?
Because the nurse didn’t have any water to actually flush the catheter. It’s a bit like if I turned up to someone having an asthma attack, and didn’t have any oxygen to give them.
So the district nurse told the patient to dial 999 for an ambulance. We arrived and found him with a bladder so full it was causing him severe pain. We took him into Newham hospital, who, within minutes, had cleared his catheter, and eased his pain. They gave him a ‘takeaway’ bottle of water so that the district nurse wouldn’t have an excuse the next time she needed to visit him.
Today, we were called to a patient who needed his anti-Parkinson’s disease medication. He had a carer, who was supposed to visit him once a day to clean and arrange his medication. But for the last 2 days, because the ‘carer’ couldn’t get in touch with the patient’s GP, she’d just left him without his medication. We turned up, not knowing what we could do to help. The flat in which the patient was living is brand new, and