Some you win !

29 degrees C,  it's hot hot hot and a clear blue sky.  The ambulance's air-conditioning had packed up. Not good for us in the cab, and the back where the patients are treated and transported? It was like a cavernous oven. Adding at least 5 degrees onto the outside ambient air temperature.

With my crew mate doing a magnificent impression of the "Wicked witch" in the wizard of Oz being splashed with water, "I'm melting, I'm melting, they whined every five seconds.  Enough was enough, for the sake of my sanity and our patients, we took the truck off the road to get the air conditioning fixed.

One hour later we back up and running, in a cool refreshing ambulance, the air conditioning recharged and ready for our first job of the day. We headed back to our base about 30 minutes away. Not that we thought we'd get there.

With the sun blazing high in the sky, music playing, and sucking on recently purchased ice lollies, the familiar siren of the MDT sounded in the cab. 

Pre - alert 

Respiratory arrest 

Address

57 year old patient.

I was driving, I popped the blue lights on and gently pressed the accelerator to the floor while pointing the ambulance in the direction of the housing estate some 5 minutes away. Knowing full well that unless some miracle happened or the 999 caller performed rescue breaths or patient would be in full cardiac arrest by the time we got there.

Skilfully, my driver training being tested to it's limit, we navigated our way through the afternoon traffic,  racing through red traffic signals,  my crew mate reading the information on the MDT as it came through. 

No action plan was needed, we were going to an arrest where seconds counted.  I rounded the corner, tyres protesting and threatening to lose cohesion at any moment.  I braked hard to a stop. Engine running and lights still strobing, we grabbed the kit we needed. The defib, drugs and primary response kit. the intubation kit pulled from it's stowage to accompany us into the house.  

At a trot like walk, we entered the front door and straight into the lounge, the scene laid out in front of us was one of total mayhem. The patients partner performing ineffective chest compressions on  the patient, who was bouncing up and down on the sofa, as if on an  inflatable bouncy castle.  A large chocolate coloured dog barking and bouncing up and down in unison with their very unwell owner, it's tail wagging at hypersonic speed. 

The patient was grey, with more than a tinge of blue and agonal breathing, ineffective breathing often called the last gasps of life. We needed to take control of the situation before it deteriorated into complete chaos.

We dropped our kit on the thread bare, dog hair covered carpet. I took one look at my crew mate, without words we pulled the now over excited dog and hysterical partner away from the patient, orders barking out at the relatives that rivalled the canine's excited yelps. We dragged the now unresponsive patient onto the floor, with a swift movement, I cut off the sweat soaked T shirt from our charge and used it to dry off the skin. 

As my crew mate set up the cardiac monitor and defib. I started chest compressions at the rate of 100 per minute with 2 assisted breaths with BMV* every 30 compressions, our patient went into VF,  ventricular fibrillation, a severely abnormal and chaotic arrhythmia in which the heart is unable to pump blood around the body and importantly the brain.  We had a fighting chance, this was a rhythm we could shock, stopping the heart to give it a chance for it's natural pacemaker to take control.

                                       
                                                           Ventricular fibrillation ECG

We shock after we've primed the heart with 200 chest compressions, which, by the time my crew mate had attached the defib pads I had completed.  

"Charging"

"Stand Clear"

"Oxygen away'

"Off the chest"

"Shocking now"

My crew mate delivered the first shock as I briefly lifted my hand of the chest.

Rhythm check, still in VF

200 more chest compressions, sweat dripping off my nose in the 30 degree heat, vaguely aware of the partner, their gulping sobs penitrating our efforts to revive our patient. 

CPR or Cardio pulmonary resuscitation is a violent act, a last ditch attempt to save a life. In the ambulance service we quickly get used to it, but the by stander or relative is not. It must look terrible and brutal, the sound of ribs detaching from the sternum penetrating the charged atmosphere, as our actions compressed the chest.

"Charging"

"Stand Clear"

"Oxygen away'

"Off the chest"

"Shocking now"

As the crescendo penetrated my thoughts, the defib charged. I found my self silently willing the patient to return to a regular heart rhythm.  "Stand clear, shocking now" I shouted, with a quick safety check, I pressed the shock button. 

A dull thud, coupled with the lifeless body flexing, as electricity charged through their chest and heart.  "Rhythm check", We both studied the  ECG on the defib screen. I felt for a pulse. It felt like the world was waiting for the result. I held my breath.

We had a pulse and a heart rhythm with PQRST waves. The patient was making respiratory effort although not good enough to sustain life, it was a start.  With continued assisted ventilations it would sustain life.  

We printed an ECG which revealed just why the the patients heart had gone into VF, a massive STEMI*. With in seconds my crew mate had transmitted the ECG to the nearest PPCI* lab some 30 minutes away.

The danger time post arrest and ROSC* is in the first ten minutes, where moving the patient could cause a further arrest. We packed our kit as we waited the obligatory 10 minutes. The patient being ventilated at 12 breaths a minute. 

We literally draged the patient along the floor, dog hair platting beneath him. We scooped them onto the stretcher and bundled them into the back of the ambulance, checking for a pulse all they way.

On the back of the ambulance, with the kit put away, well thrown in the back of the ambulance, we set off for hospital.  I was seated at the head end of the stretcher, continually ventilating our patient, who's vital sighs were getting stronger BP up to 115/67, pulse a bit bradycardic at 55, but better than we could have ever hoped for.  I knew I was successfully breathing for the patient, who had turned from a grey death colour to a pink fluffy colour. There were no signs of cyanosis either peripherally or centrally.

We were wining this one

At this point I'm travelling backwards at speeds of up to 70 mph, inside what can only be described as a metal box on wheels, as it wobbled and wallowed through the lunchtime traffic, the sad wail of the siren warning other road users of our presence, the bull horn,  a distant foghorn wailing through the mist of traffic as our destination grew ever nearer.  It was 30 miles to our receiving hospital in the city north of the patients home. As we neared the hospital the city traffic was becoming heavier. Although I couldn't see out of the tinted windows, I could tell from the style of driving my crew mate was having a hard time weaving in and out of the traffic. Drivers not noticing the very big yellow truck with all bells and whistles going, lights flashing and bull horn sounding. It was as if they were in their own cocoon, where sensory deficit was the norm and the outside world didn't exist.  

The ambulance turned it's last corner in to the hospital, screeching to a stand still, audible and visual warnings switched off.  The back door opened and my crew mate simply said "alright" to which I numbly nodded,  feeling a little more than green around the gills. The ramp was down and still ventilating the patient we headed off to the PPCI lab.

The dog and relative induce chaos we'd left behind was replaced by a calm and serene filled room of the PPCI lab.  And relax.

We'd done our job, we'd successfully brought someone back from the brink of life extinct, our interventions meant out patient could have more years with their loved ones and demented chocolate coloured dog.

A few days later I had an opportunity to be back in the same hospital, I casually enquired about our patient.  They were being discharged back to their family and friends, the prognosis? With a few life style changed and daily medication our patient is expected to make a full recovery !!

RESULT !!

* BVM = Bag, valve, mask. a mask that fits over the the mouth and nose with a squeezable chamber to force air into the lungs of a patient in respiratory arrest.
* STEMI , ST elevated myocardial infarction, the flat line between the S and T wave starts to elevate from the base line.
*PPCI, the operating theatre where stents are used to open and clear coronary arteries.
*ROSC, Return of spontaneous Circulation.

Critical

At a stand by point in the county, just chatting with my crew mate, probably about office politics and the ambulance service. The MDT* fired into life, the whoo, whaa siren within the cab signalled a new job. Initially a pre alert, letting us know the address of the pending job. At that point we set out  to the address some 10 miles away, which we should have made in about 8 minutes on lights and sirens.

My crew mate was driving, so we'd be there is 7 minutes, at times I start the paper work on the way just so I don't need to look at the road and traffic ahead. I digress.

As we made our way through the morning rush hour traffic with full blue lights, sirens and bull horns going, the red brake lights of traffic parting, as if commanded by Moses at the shores of the Red Sea, we picked our way through the traffic.

Within 3 minutes the MDT gave us more information, we were racing towards a rural cottage, to a patient, 59 years of age with crushing central chest pain radiating down the left arm.  The next message made my crew mate push his already lead foot hard to the metal. "patient sounds desperate."

These were classic signs of a heart attack, with a danger of cardiac arrest. My crew mate and I talked through our action plan, preparing for the worse, hoping for the best.

Chest pain isn't always cardiac related, in fact, more often than not, the symptom is from some other  cause. An oesophageal spasm for example, a twisting of the tube that leads from the throat to the stomach can cause similar symptoms to cardiac pain.

It was a long 8 minutes to the address, with up dates coming through thick and fast, telling us the patient was getting worse and increasingly panicked.

Finally we got to the scene, without switching off the engine or lights, my crew mate and I grabed the drugs bag, the ECG* machine, response bag and defibrillator.

As we walked through the door of the cottage, we gave the usual greeting "Hello, the ambulance service" What we got back in response was strangulated with pain, "in here." A quick look in a couple of rooms , we found our quarry, a youngish looking patient, their face contorted with pain, dysponea (difficulty in breathing) was obvious. although the cardiogenic grey pallor that gave the game away.

Without touching the distressed patient or further examination, the first glimpse of them told us this was serious.  Quickly and calmly my crew mate did basic obs, blood pressure, blood oxygen saturation, heart rate, while I attached the the ECG machine to take a reading. Already 99% sure this was a cardiac event, the ECG would confirm what we and the patient already suspected.

Three minutes after our arrival, it was confirmed, our distressed patient was having, in layman's terms "a massive heart attack."   Or as we call it, a anterior and inferior MI, known in the ambulance service as a barn door MI. It used to be known as a tomb stone MI but this was viewed as being less than appropriate. (The description refers to the shape the electrical activity of the heart makes on the ECG rhythm print out.)

On the example above you can see the rounded arch in most lines or leads that look like a barn doors or tomb stones.



Even as the rhythm strip came out of the ECG machine, I knew we had to get a move on. The patient was seriously ill.
With in seconds, I'd transmitted the ECG to the cardiac unit at hospital via 3G  and was on the phone to them to see if they'd accept the patient. They did, we now had to get the patient out the ambulance and get on our way.

One of the golden rules about cardiac pain is to never walk the patient or put more pressure on the heart other than when absolutely necessary.  With the patient chewing 300mg of aspirin to prevent further clotting,  a quick check of their blood pressure and a quick squirt of GTN spray to open the blood vessels. My crew mate cannulated to get morphine access to relieve the pain. This calms the patient and calms the bodies physiological reaction to the pain. Which in turn makes the patient more comfortable.

We carried our kit and the patient out to the ambulance. A quick check of vital signs and obs, which remained ok, my crew mate jumped in the front and we left  the scene.

Those of you who live in cities will find it hard to believe, but our running time to the receiving hospital was 45 minutes. It was going to be a long journey both for me and our patient.

One of the side effects of cardiac pain is vomiting, we gave a drug to try and stop the vomiting. About half way to hospital it became apparent the anti emetic drug hadn't done it's job. The poor patient, who was in considerable discomfort, scared they may die, started to vomit.  How anyone could produce so much and at supersonic speed is beyond me. Hopelessly , I tried to catch the half digested porridge in several vomit bowls. Not easy in the back of an ambulance hurtling towards hospital sirens blaring and blue lights strobing. Unfortunately, most of the vomit hit the floor of the ambulance, adding further danger to me. I could easily slip on the vomit as the ambulance careered round an unexpected corner.

We finally arrived at the hospital, the ambulance interior, the patient and I covered in partially digested porridge. As my crew mate opened the back door, vomit poured over the ramp onto the ambulance bay. With our job almost done, unusually, we were met by the cardiac team as we dragged the stretcher containing our patient and the equipment still hooked up to them out of the ambulance, they must have been concerned about our patient. At a quick pace (almost a run) while giving a brief over view to the cardiac consultant we headed up five floors to the cath lab.

The breathless  handover while running through the hospital, "This is (name), 59 years old, sudden and acute onset of crushing chest pain approximately an hour ago, pain score 9/10 on scene, now 4/10. GCS of 15 throughout. we've given 300mg aspirin, 10 of morphine, GTN and oxygen @ 15ltrs.

While we watched, two metal tubes called stents where placed in the patients anterior and inferior descending coronary arteries.  A couple of days later, all being well, our patient will be able to return to normal life.

It was just one hour and 5 minutes from the initial 999 emergency call to the life saving treatment being delivered.

A good interesting job and a fantastic outcome for our patient.


*MDT is the computer screen that relays information about jobs and is where the information like destination and address.

*ECG, Electrocardiogram, reads the electrical activity in the heart.