Choice

The other night my partner and I were sent to find a patient who had absconded from hospital during treatment for a life threatening condition. Because she had walked out on her treatment at hospital, and because a doctor believed she needed this treatment to continue living, the doctor had signed papers that turned her into a 'recommended' patient, essentially declaring her unfit to make her own decisions.

I should be fair and say that this is a temporary measure that gives police and ambulance crews the authority to transport a person to a facility for proper assessment by a qualified person and is not a permanent removal of the persons independence. However, I just found it a bit strange that for all intents and purposes this elderly woman was 'rational', had lived with this medical condition for many years and was apparently making an informed personal choice about her treatment. Yet we were directed to take her to hospital, to override her wish not to be treated and utilise police as required to make it happen.

I know some will see this as a passive suicide attempt by this patient, and perhaps it is, but what limits should we set on someone making a personal decision about their treatment? Is it whenever that treatment is likely to cause them detriment? (the medical profession allows people to make dubious health care decisions all the time) or is it whenever that decision may actually cost them their life? I don't know, but it just didn't feel right to me on the night.

Mornin' Rob

Its 4.pm. For the first time in months I've had a decent few hours sleep after night shift. I'm staring at the pile of cereal I've just poured onto the Kambrook sandwich grill and thinking through my cloudy haze that something doesn't look right. The cat circles around my legs trying desperately to get my attention. I know as soon as I feed her she'll give me the question mark (she looks like a ? when she walks away). It's an odd arrangement. All I'm apparently good for is providing food and a heat source on cold nights. Seeing that I'm off working most of the time I'm not brilliant at providing either.

I check the answering machine and listen to my messages - some of them are 3 days old already. Letting out an exaggerated yawn, I put on a big pot of brewed coffee. It usually takes me a few cups to get a clear head. I jam my nose into the only milk carton in the fridge. It fails the sniff test miserably and I recoil cursing. Scratch about for some coins and walk down to the local shop. People are driving home from work and kids are getting off the buses after school - I feel really out of it - a strange disconnected feeling. The cat meets me at the front gate and then follows me inside pleading for attention. Ok ok! Phew... still one can of cat food in the cupboard. She takes one sniff, looks at me and walks away. Great.

I get four days off. I have just slept through my first one and there is less than an hour of daylight left. I will sit watching tv or reading a book for the next few hours before going for a run. Then its dinner and an early night. The real days off start tomorrow.

The missing piece

I just completed my first night shift with a nice bloke who I haven't worked with before. We took over from the day crew and were told it had been a 'reasonable day'. Hmm... was that good? Did that mean it was going to continue to be 'reasonable' or did it mean we were about to have one of those nights?

We had a couple of interesting and challenging jobs fairly early in the night. First up we went on a Signal 1 call to a young girl of about 18 months who was in apparent respiratory distress. We arrived and found a very cute girl with beautiful black curly hair and huge eyes clinging onto her mothers leg in the hallway. I just re-read that and yes, the leg was still attached to her mother.

As with so many of the families where I work - nobody spoke much English. Sometimes there will be a very young family member who has been educated here in Australia who can act as translator for you. This is usually a great way to get answers, although often you need to be very strict with your questions because you will ask "Does your mum have pain in her chest - yes or no?" The kid will turn to mum, there will be a 4 minute long conversation and the answer will come back "she is sick, she doesn't feel well, she doesn't like going to hospital...". Utilising the kids is often your only option and can provide its own curly issues - asking a 7 year old to help ascertain if his mother's waters have broken can require some dexterous verbal gymnastics.

Anyway where was I?... ah the kid and the leg. It turns out she had been "breathing funny" when she was down for sleep. She had been treated with antibiotics about 2 weeks ago for a chest infection but according to family it was gone now. We did a really thorough assessment of the little one and found the only thing amiss was a slightly elevated temperature. She had clear lungs, good heart rate and respiratory rate, she was active, happy and reacting appropriately to mum and everyone around her. But mum was insisting she was sounding strange when she was in bed so we stuck around to observe the girl while my partner did his paperwork. Everything checked out, but as always with kids, we offered mum a trip to hospital for a check up. She declined so we suggested that she take the girl to her local doctor - and she agreed. Hmm... but what were we missing?...

We packed up our stuff and I stopped playing with the kid and helped carry bags out to the car. We were just going through the front gate when there was a single barking sound from the house behind us. Aha! the missing piece of the puzzle. The seal-like barking cough that comes with croup is such a distinctive sound, you only need to hear it once and you have a 99% accurate diagnosis.

We turned around and went back to let mum know what we now thought was going on and to reassure her that croup in its early stages is ok but needs to be watched carefully. Trying to put all the pieces together is one of the things I really enjoy about this job.

officially useless

I've just had a few days off and changed lines on my roster so I earned a couple of extra days away from the ambleeance. I have to say it was rather nice. Back to business today though and it sure was business as usual. We went to Chest pain, leg pain, head pain, vomiting, epistaxis, lacerated (by accident) and last but not least; need a sick certificate for work. Yep, we got called to a guy who has had a pain in his back for 3 years which he has seen a number of doctors about. He said he didn't get to the clinic before it closed and he needs a certificate to say he is unfit for work tomorrow, so he rings '000' and asks for an ambulance.

I tried to explain that we don't provide that particular service and that we'd be happy to run him up to hospital or even arrange for a doctor to come and see him at home. Not good enough apparently - he got all cranky and told us we were useless. Several more offers were made to help him before we wandered back out to the truck to go and be 'useless' elsewhere.

Bedtime Story #2

Prompted by a story over on John Robertson's blog about breaking in to people's houses, I remembered a funny job from last year.

My partner and I got dispatched to do a welfare check on an old lady that hadn't turned up to collect her prescription medicine from a pharmacy for a couple of days. The pharmacist had to contacted the local doctor and found out she'd missed an appointment there too, so after trying to phone her, he contacted the Ambulance service. Nice to see there are still some caring souls out there.

I've done a fair few of these kind of jobs and they can be a little unpleasant - you often have to force a window or a door and go in, sometimes only to find you are too late by a matter of days.

We arrived and went through the process of knocking loudly on the door. All the blinds were drawn and there was no answer. We couldn't get around the back to try the back door because of a big steel fence. I tried to open a sash window and saw it had a small nail holding it closed from the inside. With a bit of huffing and puffing I was able to bend the nail and force the window up. We let our dispatcher know we had gained access and were going in for a look. I stuck my head in the window, parted the lace curtains and called out "hello?"...... silence.

I told my partner he’d better follow me in through the window – we’re a team right? He called me a big chicken and suggested he’d wait out front with all the bags for me to go in and open the front door. I couldn’t come up with any kind of argument that his was a bad idea so in I climbed. I kept calling out hello.. anybody home? Nothing but silence. I really hoped she didn’t own a big hungry dog. The fact that I was getting no answer left me thinking this was probably not going to end well. Whenever you are in somebody’s house like this without being invited – it is a very strange feeling.

I went out of the lounge and into the hall to open the front door. I grabbed the lock and tried to turn it. Nothing happened, it was locked from inside with a key. Damn. I called out to my partner and told him my predicament. He helpfully began laughing while I searched the hall table for a key. I’m searching among the dust and jars of potpourri, when I hear a voice behind me. What are you doing in here!! I whirl around and there is a very, very old lady, in a dressing gown with crazy looking white hair and a walking stick raised ready to brain me. Ahhhh! I think I said a word I would not normally utter in front of an old lady and quickly told her I was from the Ambulance and we were just there to check up on her. She was very deaf and hadn’t heard me calling out. I persuaded her I was not a robber and she put down the stick. Once she finally found the key and let my partner in – who by this stage was wiping away tears from laughing so hard – we found out what had been happening.

The old woman had been feeling ‘poorly’ for the past few days and decided she would go get her tablets when she was good and ready. I told her that people had been trying to call her on the phone and she said “that thing is always ringing... I never answer it anymore”. We checked her over thoroughly and after finding nothing obviously wrong, we contacted some relatives who promised to come over to spend some time looking after her until she was feeling better. I hope they did.

The basic structure

I had a question in another post from Medic who asked what the structure of the ambulance response was here in Melbourne. Basically the system here is probably pretty similar to many others. We have a multi level system that has non-emergency or routine transport cars that might take patients to regular dialysis appointments for example. We also have your normal ambulance (usually a Mercedes Sprinter) which has two paramedics on board. This can be two fully qualified paramedics, one fully qualified paramedic and a student paramedic or two 2nd or 3rd year students. We also have MICA (mobile intensive care) ambulances which have two MICA paramedics on board. These guys have a similar vehicle but carry more drugs and can intubate in the field. There are also MICA single responders and Clinical support officers who often drive around in Subaru Foresters that are very nice to drive. Recently the bike squad was introduced too. I think I wrote about them a while ago.

Oh and I shouldn't forget to mention the boys and girls in the sky - we have fixed wing planes and helicopters too. And..we get assistance from fire brigade first responders and several community first responder teams. Apologies to anyone I left out.

The more serious sounding jobs will get a dual response with a MICA ambulance and a standard ambulance being sent. If it gets crazy busy then there may not be enough cars around to send two, and you are then on your own. We have phone and radio support from a medical clinician if we happen to need it - but you can't call them up and say "um.. what do I do now?" - you need to ring them with a plan of action and a justification for wanting to go outside normal guidelines and protocols.

We have this thing called "the grid" which is the program that is used to dispatch us on Signal 1, 2 or 3 responses depending on the answers given to the call takers. Many jobs are reviewed by a senior clinician after they have been dispatched and upgraded or downgraded accordingly. This method seems to do a fair job of weeding out the jobs that have got an 'overly enthusiastic' response given out by "the grid". We have had the recent introduction of a 'referral service' where a team of specially trained paramedics actually ring many callers back and spend time talking to them to see if another service (such as a locum) might be more appropriate. This works well to eliminate many non emergency calls. And of course occasionally jobs will bounce back through after more info reveals a potentially serious problem.

Yes our dispatch system has major flaws like every other one does, but overall I think it works... most of the time.

Dread

A friend of mine recently asked me what were the worst jobs for me personally. I told her that it was anything involving really sick kids or grieving parents. I still struggle to actually talk about some of these jobs but I told her I'd write something about one of them here.

Driving along, coffee in hand chatting happily to my partner. Bamm. The radio announces that job I had most been dreading. A paediatric arrest. A 2 year old child, put down to sleep and found pulseless and non breathing a short time later. We discussed on the way to the job who was going to do what, and as I had managed the airway at my last (adult) cardiac arrest it was C for circulation for me this time. My partner and I were both secretly praying MICA or another crew would get there first. They didn’t.

We arrived at the same time as an MFB (Fire brigade first responder) crew who were 10 steps behind us on the way in – mum was at the door looking strangely calm as we walked up and were led to a kid’s bedroom. There was dad doing CPR on a tiny little body on the floor. Oh Crap this is a real one. Pucker factor of about 10/10. I felt physically sick. A microsecond pause as we both took in the scene before us and then it began. My partner quickly had airway under control, suction, then in with one of those tiny plastic OP airways you hoped you would never need to use, baby bag-valve-mask and some O₂ flowing in. No pulse could be felt or heard, damn. … one of the fireys was asked to begin CPR. Sit rep to the other cars that were coming… “confirm full arrest”.

I was desperately calculating the joules in my head in case we had to defibrillate her as I cut the Little Mermaid pyjamas off and put the paediatric defibrillation pads on the tiny pale body. Mum and dad are just outside the room and that horrible noise I can hear is a mother in the worst kind of pain I can imagine. I dare not look at her as I’m not sure I’ll be able to hold it together. The monitor shows a sluggish EMD bradycardia at about 15 bpm. This kid looks just like child of a friend …don’t think about that…Concentrate. More CPR, some attempts to get a history of what had happened, a pause …. asystole on the monitor. CPR again… Return of the bradycardia at about 20 bpm.

MICA arrived. Thank god. Tears of relief welled up in my eyes and I had to blink them away and focus on what we were doing. Handover was a blur. Next thing I was prepping a bag of fluid, drawing up some adrenaline and pleased not to be making the hard decisions anymore. Intubation was tricky but the guys did amazingly well with the tiny airway. I notice the MICA guys hands are shaking too. Another ambulance crew appeared and began talking the parents through what was happening. I sent someone out to get more oxygen from the car, then swapped out with the firey and began doing CPR as MICA tried deperately to get IV access.

Drugs, CPR, pause, more CPR, check the monitor… 30 then.. 40 bpm….

Come on -I’m willing the monitor to show more beats. CPR again, I look at my watch… we’ve been at this more than 30 minutes already. More CPR…then suddenly the rate on the monitor begins climbing…A pulse at last....We all work together and get ready to go, I slip my hands under her little back and scoop her up in unison with the other guys. So many hands holding so many tubes, wires and fluid. We all shuffle for the front door. Onto the bed and the heart rate is now 130. Still no sign of any breathing and we quickly load, breathing for her as we go.

We drive the MICA guys, the girl and her almost catatonic parents in to the hospital. Sitting next to her mother in the truck I can’t find any words to say, I feel useless. Come on…say something. I can’t even comprehend what she must be going through. I just try to explain what is happening - I don't know if she is hearing me. Into the trauma room, we give handover and suddenly my part in all this is over. I hear someone in the hallway say they don’t think she’ll make it. I know they are probably right. I head back out to the car to write my case notes, there is a huge lump in my throat and I feel like dropping my bundle – not now, that can wait til I get home.

Over there...we got us a waver

All right I don't quite get it - you or someone you know has called an ambulance - thats good. I would too if I needed one. While waiting for the ambulance to arrive you decide to go out front and wait for it to come. Again - I can understand that, the waiting must be terrible sometimes and we all have our different way of coping.

Most people stand out on the street and when they see the flashing lights come down the road, they'll step out and wave - this can be magic for an ambulance crew who suddenly don't have to be counting houses, squinting for non-existant house numbers and trying to work out where Unit 2A of block 4, 42-45 East-something-court is while driving at a rate of knots. You look up and there is someone doing 'the wave'. This can be a slow one arm "Look, I'm a tree in the wind" impersonation or it can be the double armed "If I do this fast enough, I'll actually take off" method - both will get our attention and I'm usually very grateful.

There is another method which I'm stuggling to get my head around and that is the ESP method. When an emergency services vehicle goes past most people have a look, a few don't but most will stop and stare for a second or two at least - go on, I know you've done it. I still do it! But this other group of 'wavers' will stand out the front of the house and just stare as you go past, obviously sending you powerful ESP messages that you have arrived at the right place....and have in-fact driven past..... and that you should turn around and come back. No wave, no smile, no yell, no raised eyebrow, no nod, nothing. We do a 17 point turn in the tiny street with cars on both sides and finally arrive - where we're often asked; didn't you see me? I always try to answer this question with my mind, but I'm not sure I'm getting through. I'll have to keep working on it.