Sunday, October 21, 2007

To Go or Not to Go

When we were called to a job at a persons house for a medical complaint there sometimes arose a dilemma deciding whether a patient should actually go to hospital or not. Making the call was often a tough decision.

For example, a person who collapses for no apparent reason and then fully recovers might refuse to go to hospital. The patient may exhibit no apparent irregular signs or symptoms and may well be ok to stay at home. They almost certainly don’t want to be sitting in an A&E waiting room for hours on end to be looked at only to be discharged. We also had to be mindful of unnecessarily taking patients into an already over stretched emergency department. But the fact remains – they collapsed and people don’t normally collapse. So what do you do?

It’s not unheard of to leave a recovered patient at home only to have them collapse again or worse die at a later hour. Certainly some strong questions would be asked why we didn’t transport in the first case.

However we were not the police. We didn’t have the power to insist patients come with us or else! It was always up to each ambulance officers judgement call at the time and to be honest we didn’t always get it right.

Whilst writing this book the ambulance service was in the media for a classic example of this very dilemma.

An ambulance was called to a private residence in the middle of the night where a patient was apparently complaining of symptoms similar to indigestion. The ambo told the patient to go to bed with a Milo to settle his stomach but was called back a short time later after the patient collapsed and suffered a cardiac arrest.

Our official motto was simply ‘if in doubt – transport’ but this didn’t always marry up with the client or their families wishes and that always made the situation a wee bit trickier.

I attended a job involving a mature male patient, who was staying with one of his adult daughters. Despite his age he was a real attention seeker and when we arrived he was sitting up in his bed with his family fussing around him. I can’t quite remember was his complaint was but it did warrant further investigation but he blatantly refused to go with us to hospital.

His stubbornness resulted in more sympathetic appeals from his family who desperately pleaded for him to come with us. I could tell he was enjoying all the attention he was getting and he continued to decline their appeals.

The senior ambo I was working with could also see that he was just seeking attention and said “oh well just sign our patient report book and we will be on our way.” He passed the book to me to get the required signature, picked up our equipment and started walking out the door. Having seen this scenario many times he wasn’t about to join in with this mans mind games.

This immediately spoiled the patient’s attention seeking scam and he quickly changed his tune saying “if we really thought he should go to hospital he will make the effort” and he promptly got out of his bed and accompanied us to the ambulance.

It was a good lesson for me to remember. If patients wanted to refuse transport I decided it was their prerogative and we had better things to do than force people to comply or worse still play mind games.

Another job I attended involved a similar scenario but this time with a patient who really did need to go to hospital but also refused to do so.

The job we were called to was at an attempted homicide in the city.

A female patient had apparently been arguing with her boyfriend when he allegedly pushed her out the second floor window of their apartment. She landed on her bum onto grass and proceeded to crawl back upstairs to her apartment.

We arrived with the police in attendance and found her sitting at the top of her stairs outside her apartment conscious. I carried out a detailed examination and discovered her chief complaint was pain to her coccyx. Naturally, with the height of the fall we thought she may very well have fractured her pelvis which is potentially very serious.

Unfortunately she was completely unco-operative and absolutely refused to come to hospital.

The police were reluctant to enforce her as they wanted her to lay charges against her partner so they could arrest him for attempted murder but she wasn’t co-operating with them either. It was a stale-mate.

The call came through about 7pm and was our first job of the night shift. I hadn’t eaten dinner yet so I was hungry and my blood sugar was low. Now I don’t know about you but when Im hungry and my blood sugar is low I tend to be lot more impatient and my tolerance level dramatically decreases.

After an hour of hanging around with no compromise I was starting to get really pissed off with the situation. I could see no use in sitting around doing nothing when I could be chomping down my dinner. Suddenly the control room called us up. There was a motor vehicle accident in the main St – Queen Street and they had no one to send. Could we attend? We consulted with the police and decided to take a look because we were close. I was relieved we were out of there.

We raced off to the location but found no sign of the accident. It was a hoax. “Oh well” I said, “at least we can go back to station and I can have my food”!

Unfortunately the senior Paramedic I was working with, who had wisely eaten his dinner, insisted we pop back to our previous patient in case she had changed her mind. I held back a string of tyrant language that was on the tip of my tongue and sat sulking as we made our way back to the original job.

An hour and a half later, after more coaxing she finally decided to come with us but only if the police went to a South Auckland suburb first to uplift her sister and bring her to see her.

By this time I had used up all my blood sugar reserves as well as my patience and tolerance reserves. I was irate and getting very angry. I let my offside know in uncertain terms what I thought of the situation. He wasn’t terribly impressed with me and it wasn’t very professional but I was past the point of caring.

Finally her sister arrived in a patrol car and she decided to come with us to the ambulance. As we gently lead her to the back steps of the ambulance she froze and put her hand out to stop going any further. She pointed to the reflective number on the back door of our ambulance (our call sign) and said that the ambulance vehicle number was evil and that she couldn’t go inside.

I almost lost it once again and really had to bite my lip. She was clearly a psychiatric patient and had wasted enough of everyone’s time. I grabbed her arm firmly and with a little persuasion helped her into the vehicle telling her she was coming with us now whether she wanted to or not. Surprisingly the hospital found she had no major injury and after three and a half hours I finally got my dinner!

Thursday, March 29, 2007

Unusual Jobs Continued

Standbys at Airports for crash alerts were fairly common and usually involved several ambulances and fire trucks racing out to the relevant airport and standing by while a plane, typically with some faulty warning light, circled and then landed safely.

Actual Aircraft accidents, on the other hand, were few and far between so when a vehicle was dispatched to an aircraft crash over the radio, everybody wanted to know the details in case they were also called. During my ten years in the service I attended two real aircraft crashes.

One of the incidents involved a shiny new black Squirrel helicopter at a CBD landing pad. The privately possessed helicopter was being piloted by its proud new owner and
was coming in for a landing next to the perimeter fence on the helipad, near the fuel pump so they could re-fuel. Unfortunately he must have mis-judged the distance and he was a little too close to the fence, his main rotor striking the tall petrol tank breather pipe as he landed.

With the powerful and fast moving rotors suddenly coming to an abrupt halt as they collided with the tall metal pipes, the rotational force was transferred to the rest of the machine and it spun violently around throwing off parts across the landing pad as it did so. It was a total wreck when we arrived.

Fortunately the passenger compartment remained fairly intact and the pilot and his passenger were just shaken (but not stirred) and otherwise uninjured. A rather embarrassed pilot declined out offer to take him to hospital for a medical check-up and instead he preferred to stay inside the administration building than face the barrage of fire appliances and media that had also responded to the incident.

The second aircraft accident involved a twin- engine, light, fixed wing aircraft that crashed at a local aerodrome. The young pilot and his mates were off to one of the Gulf Islands for the long weekend.

An apparent engine failure on take off ruined that plan and instead the aircraft nose-dived and cart wheeled along the runway shortly after leaving the ground. The plane was a right-off with bent wings and damaged propellers but the main fuselage remained relatively intact.

Once again the passengers escaped relatively unharmed. Unfotunately the only passenger that was injured was a female who also happened to be the only one of the group that was scared of flying. With a dislocated shoulder, I’m sure the crash only served to reinforce this poor girls fears.

Back on terra firma, many of our medical callouts were to elderly patients in rest homes. The patients typically suffered from shortness of breath, chest pain, fractured hips or even cardiac arrest. One time I was called to an elderly patient who was suffering from shortness of breath.

We responded urgently to the private rest home and were taken into the residents room. The rest home aide had the patient lying down in bed which would have made her breathing harder however she did have an oxygen mask on the patient. The patients’ daughter was also present, giving lots of reassurance to her mum. As we arrived and started getting our gear sorted, the patient suddenly stopped breathing.

I quickly got out the oxygen bag mask from our resus kit to ventilae her and plugged it into the rest homes large oxygen cylinder that was in the room. I was immediately aware that there was no gas coming out so I automatically checked to see if it was turned on and sure enough it had been turned off all this time!

This poor lady was not only short of breath but whatever oxygen she could breath was being denied as the mask restricted air entry. This is what most likely contributed to the respiratory arrest as the patient started breathing spontaneously when the oxygen started flowing. I politely mentioned aloud that the cylinder works better when it is switched on.

The majority of rest homes I visited were notorious places and typically smelt of stale urine. The residents often looked depersonalised, vegetating in reclining chairs and bunched together, vacantly staring into space or disinterestedly staring at some irrelevant Television channel.

The medical care, I found, was also fairly average. On at least two occasions I transported residents with fractured hips, which hadn’t been detected for days meaning the elederly residents had been in unecessary pain and discomfort.

Elderly people, particularly females, in my experience however are the bravest people in the world. it never ceased to amaze me that they were able to tolerate the most amazing amounts of pain as long as they could squeeze your hand. They very rarely complained and were always grateful for our help.

One elderly female patient I attended spent an entire sleepless night in agony with chest pain but didn’t alert the ambulance till the morning because she didn’t want to wake us up! Another tripped over while going to the toilet in the night and fractured her hip. She too spent a long and cold night on the floor before a relative found her. This was a surprisingly common experience before the personal pendant alarms were introduced.

Construction and industrial accidents were another fairly uncommon but usually quite serious type of incident. I went to a few of these including a fatal accident at a bakery, a patient that fell into some machinery and broke his leg, an accidental finger amputation at a factory, and an electrician that fell off his ladder and broke both wrists.

One of the more interesting industrial jobs involved extracting a worker out of a newly constructed storm water drain. The cylindrical concrete drain was large enough to almost stand up in and was about 10m under a central city street.

There was about 20m of the drain that had been laid and two workers were at the end, excavating the rocky earth so more could be laid. One was using a jackhammer to loosen the schist rock and earth and the other was shovelling it into a wheel- barrow. Apparently the man shovelling was bent over picking up a load of rubble when a large piece of rock fell from the roof of the excavation and landed on his back.

I was single crewed in one of our ambulance jeeps at the time and responded to the scene where an ambulance had just pulled up. We were lowered by crane into the large pit in a basket and crawled our way inside the drain.

When we reached our patient we found that he had a painful back but no apparent neurological deficit, which was a good sign and meant that there was probably no nerve damage. We loaded him into a stretcher and proceeded to carry him out.

The other ambo wanted to place him on top of the basket on the portable, foldout, Mk II stretcher and lift him out to the ambulance but I disagreed thinking it wasn’t the safest option. I called up for Fire service assistance and they loaded him into their stokes basket which was a more secure option. He was soon off to hospital and I was off to another job.