There are many things in this job that can cause the heart rate to rise and the adrenaline to start flowing, but two scenarios continue to worry me, but have fortunately not presented themselves to me yet.
The first one is the patient who is choking, and I mean really choking, not just got a little something stuck and is struggling to get it out. What I am talking about is the patient that has become unconscious, is turning blue/purple and nothing that you can do is going to help them. We do not have needle cricothyroidotomy in the NEAS as it is one of those skills that is deemed to risky to do due to the lack of practice that we would have to actually perform it, and the rarity that we would actually use it. Imagine the scenario with a child and it becomes even more un-thinkable.
The second one is that patient with life threatening asthma, who no matter what you do, continues to deteriorate and eventually goes into respiratory arrest. If this happens, you will not be able to ventilate the patient and continued ‘bagging’ will likely only hyper inflate their chests and cause a pneumothorax or even tension pneumonthorax. Yes, we have drugs that can work before the patient gets to this stage, but the feeling of helplessness would be truly horrific to have to actually watch someone die through suffocation, and not be able to intervene.
I thought I was going to have to deal with the second one just the other day!
Called to a 42 yr old female, known asthmatic, who was having breathing difficulties. The address was less than 10 minutes away so Tom, my partner for the night, and I make a quick drive through the early morning traffic and arrive at her house.
As I walk round the house to the back door, I see that the door is open and the patient, Julia, is tripoding in the door way. Tripoding is a term that we use to describe the position that asthmatics tend to assume when they are really struggling to shift air. They basically lean forward from the waist, either sitting or standing, with both arms outstretched and holding onto something (shaped like a tripod). This is to maximise the movement f their chests and try to get as much air in and out of their lungs as possible.
As I approach Julia, I get a quick ‘Hiya’ and a smile. She doesn’t actually sound too bad just as I was making my rapid initial assessment. She was able to complete a short sentence, looked a good colour, was obviously having some difficulty, but there wasn’t too much of a wheeze to hear. I get out my stethoscope and have a quick listen in to her chest, where I hear widespread ‘quiet’ wheezes, across both of her lungs. This starts to get me worried, as the only thing worse than a wheezing asthmatic that you can hear as you walk in the door, is a ‘quiet chest’. The wheezing becomes difficult to hear, as the airways have constricted to such a degree that the amount of air moving in and out has decreased to the point where it can be hard to hear through a stethoscope.
Her oxygen sats were surprisingly good at 89% and she was a little tachycardic at 112 beats per minute.
She gave me the history of getting up from bed at 8am and feeling tight chested. She used her own inhaler a number of times but it didn’t seem to be working. Her chest became tighter still, so she decided to call 999. She has had previous admissions to hospital with her asthma, but no intensive care visits and has never had to be ventilated to help her breathe.
Even so, I don’t like how this appears. I start her on a salbutamol and atrovent nebuliser and give the all knowing look to my partner that without any words says ‘Time to get a move on mate! she’s not well’
Tom quickly returns with the carry chair and we move Julia onto it to push her out of the house, thereby minimising any effort that she has to do. What happened next was expected…
As we placed her in the chair, she was asked to sit back so that we can put a belt around her chest to stop her falling out of the chair. The chair then has to be reclined onto its back wheels to push it along the path. However, the LAST thing anyone wants to do who feels as though they are struggling for breath is to be restrained in any which shape or form. As soon as we tried to sit her back, the panic kicked in, and she became really distressed.
Now comes the difficult bit, I have someone who has the potential to very quickly develop from severe asthma to life threatening asthma (an important distinction to make). All I want is her on the back of the ambulance and moving to hospital, but if I try and hurry her too much, it is just going to progress things faster, as she will panic and breath faster. So I giver her a couple of minutes outside in the fresh air, I hold her hand and try and calm her down then we make the decision to let her keep pitched forward and only loosely place the strap around her chest. Tom then proceeded with the difficult task of pushing her to the vehicle whilst Julia was sitting forward on the edge of the chair. Not normal protocol, but you do what you have to in the best interests of the patient.
By the time she is on the tail lift of the ambulance, she starts to become combative and gasping for air. Really not a good sign, and I start to wonder if this is going to be the one who I can do nothing to help with.
Time for gently gently has now past. We get her neck to the stretcher and lift her onto it. I decide the best option is to let her sit with her legs either side of the stretcher and the lap belt around her waist. She should be restrained with the 5 point harness, but she would never tolerate it, so I do what’s best for her.
As I cannulate, Tom gets an I.M injection of adrenaline ready.
Cannula in……500mcg Adrenaline 1:1000 in………Cannula flushed……..200mg Hydrocortisone I.V in..
(On a side note, which scientist developed hydrocortisone to give the side effect of an extremely itchy anus???)
Her O2 sats remain in the high 80`s, but she looks like she is starting to get tired now.
We head off to the A&E department with lights and sirens. The Pre-alert goes in.
Half way up to the hospital (about 7 minutes after she got her adrenaline and hydrocortisone), Julia looks over and tells me that her
“breathing………feels a little………better”
Thank God for that!!
As we continue to the hospital, I can see her starting to relax. She is by no means out of the woods for this episode of her asthma yet, but it looks like she is going the right way. By the time we get her to A&E, she is back to the way she was when I arrived at the house. I hand over to the nurses and doctors and finish my patient report form. As I am about to leave, Julia calls over to me. As I stand by her side, she grabs my hand and kisses the back of it…
“Thank you so much!, I thought that was it tonight…..Thank You”
In my head I say ‘I thought so too!
M999: “No problem Julia, It’s great to see you looking a bit better. Take Care”
I honestly feel that she had a lucky escape that night. If we had been further away, if she had left it a few more minutes to call 999, it may have been a very different ending for her.
But we weren’t, and she didn’t, and she is going to be okay (for now anyway)
So, what’s your worst fear?