Sean: As placement beckons…

Seán FlynnBeing a first year Paramedic Science student sometimes has an air of make-believe about it. We dress proudly in uniform for skills classes but we are by and large untested. And sometimes – particularly now, just ahead of placement – the restlessness this generates is practically palpable.

Don’t get me wrong; the scenarios we play out in the skills labs mightn’t exactly be Shakespearean tragedies – they’re usually just ordinary human tragedies but they’re no less gripping for all that. In these urgent clinical dramas, it’s a bit like method acting; the more you commit to your role, the more you tend to learn.

But until we get out on placement, this all seems a little theoretical; at least for those of us who don’t yet have that kind of clinical experience. It’s all been leading up to this and now, after time sometimes seeming to drag, the hour of placement is suddenly almost upon us.

A Monday morning briefing on 20 February for those going with the London Ambulance Service (LAS) brought quite a few issues into sharper focus. The Link Tutor with the LAS, gave us the lay of the land about working life in London town. He didn’t glamorise it and why would he? He did however make us aware of the kind of support services that are available to us in the event of having to deal with any particularly difficult experiences.

Aside from the near certainty of bearing witness to great sadness on a daily basis, the reality of pulling 12-hour shifts and then driving two hours home is beginning to sink in. For body or soul, this won’t be an easy gig by any stretch. And it sure isn’t for the love of money.

As a taster of what might be expected when we do get out on the road, the recent experience of one of our cohort as he made his way home from university is salutary. Having found himself first on the scene of a road traffic collision (RTC), he remained there with his patient until HEMS (Helicopter Emergency Medical Service) arrived. Suffice to say, our classmate’s conduct was extremely professional.

That story is curt, abrupt even, almost like a military despatch but for good reason. Firstly, it needs no dramatisation but more importantly, from a practice point of view; in the interest of anonymity, more granular detail might lead to identification and a breach of patient confidentiality.

But in his actions, I reckon our quick-thinking colleague did what we would all hope to do in a similar situation. The same man would modestly tell you that he only did what he was trained to do and in a way, he’d be right; even if he’s still owed serious kudos for his cool-headedness.

At some point before long, many of us will find ourselves in similar or perhaps even more challenging situations. I wish I had advice to offer but like most of my cohorts, I remain untested and I’m just going to have to trust to my training and the wisdom of my mentor (though not necessarily in that order). All I can do is wish us all well and if it does get hairy, that we’d avail of the appropriate services and (perhaps even more importantly) avail of each other’s support.

So hopefully, in a few months we’ll all be swapping wagon tales like old hands. And in among the black humour and bravado, there’ll be clinical nuggets and I daresay a deeper understanding of the human tragedies we play out in the dressing-up box.

Alex: Returning to university

I have come back to normal university lectures and skills sessions after a successful placement in central London. There’s always post-placement blues as the reality of the course settles in with essays and deadlines here and there. However, a new year means a few steps closer to becoming a registered paramedic and, in fact, I will hopefully be graduating next year.

In January, I submitted an applied anatomy and physiology essay that was 4,500 words, which certainly took a long time to write and reference! I’m glad to say I received a good mark for it and one of the senior lecturers even rang me on a Saturday to talk through the marking! It’s gestures such as this that remind me why I’m studying at Anglia Ruskin University. As well as what seems like essay after essay, we have been learning about Advanced Life Support (ALS) and pharmacology (the study of the effects of drugs in the body) in our practical skills sessions. These have been going really well and we alternate between each other, to take the leadership role in ALS cardiac arrest scenarios in simulated environments on campus.

Alongside my studies at ARU, I have thoroughly been involved in the charitable operations at London’s Air Ambulance, where I volunteer as a photographer and speaker. I have worked for the charity since I started my Paramedic Science degree and just in the last few weeks I have led three evening talks for institutes across London, including the London Freemasons in the City. The London Freemasons have donated a staggering £2 million towards the purchase of a second helicopter (call sign G-LNDN). It was a privilege to stand in front of the head of the Freemasons, but all the more nerve-racking! I am pleased to say that once my presentation was finished they presented myself (representing London’s Air Ambulance) with a £500 cheque for the charity. It’s for this reason why I chose to volunteer in the first place, as every donation really does count.

Alex: End of placement

On a sunny winter’s day in the borough of Brent, a paramedic and myself set about our shift in one of the service’s new Tiguan Fast Response Units (FRU). It was put through its paces as we responded to multiple general broadcasts (GB) throughout the day. One GB was to a drowning in progress at a reservoir where NPAS (National Police Aviation Service)were circling above, and LAS (London Ambulance Service) HART (Hazard Area Response Team) were in attendance alongside the Met Police marine unit. Thankfully the call wasn’t as given: the male psychiatric patient had only been wading through the water and was not submerged. We had to trek 200m along a muddy forest trail to get to the patient, and with the Lifepack 15 and O2 bag it presented as tiring work!

The following two shifts, later in the week, brought me back to familiar territory working on a FRU out of Camden with an Australian paramedic. Since the cars are held back for Red 1’s and Red 2’s primarily we had a lot of green time; meaning we could drive around the West End, visit Big Ben and even be on standby in front of Buckingham Palace! Our car number plate was coincidently ‘CVA’, in which we attended three Cerebral Vascular Accident’s (Strokes) just in one shift, alongside a patient with a Pulmonary Embolism (PE) and others that had fainted at work.

The last three shifts of placement were back with my regular crew on an ambulance out of Islington station for a set of lates (4pm-2am). Friday night proved to be very busy starting off with a young boy who fell off a trampoline at a friend’s house. On arrival it was pitch-black darkness, so scene management was initially difficult until the family kindly held up their phone lights for us. The patient had a severely deformed left arm, which we suspected the injuries to be a dislocated elbow and fractured distal humorous. His pain was well managed with Paracetamol and Entonox and had good neurovascular state distal to the point of injury whilst on scene. However, once splinted and treated, he started complaining of numbness in his affected arm en route to hospital. We exposed the limb to inspect once more to find he was significantly cold to touch distal to the point of injury: a worrying sign of vascular compromise.

At this point we were pulling up to A&E, so we proceeded to wheel the patient in on the trolley bed and called over a senior consultant to give an initial triage. His attention was drawn into the affected limb where he could not find a radial pulse. He instructed us to get back into the ambulance and undertake a critical transfer to the next hospital that specialised in paediatric orthopaedics. Whilst all this was happening around him, our patient was in good spirits talking about all his favourite action figures, probably due to the Entonox…

Following on from that job we greened up at hospital where we instantly got dispatched to a Red 1 just around the corner. Our MDT screen displayed: “29YOM, UNCONSCIOUS, RTC cyclist off bike, blood coming from mouth”. A message popped down to us to say ‘please advice for further assistance on arrival’ which gave the impression we may be on our own here. We arrived to find multiple bystanders surrounding the patient who was wearing many layers of protective cycle clothing, a helmet and a big backpack. He was lying prone on the road, responding to voice and had lots of blood on his face. After conducting the primary survey I held his head whilst my crew prepared the orthopaedic scoop stretcher and trolley bed. He was in no pain but was very confused; constantly asking me what had happened every minute, scoring a GCS of 14 (4,4,6).

Once in the ambulance away from the bystanders we appropriately exposed the patient by cutting off his clothes to assess for any injuries we may have missed. He had bilateral chest rise, globally clear air entry and no pain on palpation of the pelvis and long bones. We decided to convey to the nearest Major Trauma Centre (MTC) that was only a few minutes away from the scene. Once in Resus, I gave the handover to a HEMS doctor, as my crew lifted the patient from our trolley bed to the hospital bed. The consultant had no questions after my handover, which is always a good sign that I included everything necessary and relevant! It was the first major trauma patient I had taken the lead on and I am so happy with how I managed the patient, especially with our on scene time being just 29 minutes!

So that ends placement block one for second year of the BSc Paramedic Science degree. When I am back after the Christmas break we will be studying pharmacology in lectures and have our placements on various hospital wards.

Thank you for reading my blogs up to this point and I hope you have a good new year!

Alex: Too old to die young

This week has undoubtedly been a challenging one on placement with the London Ambulance Service. Alongside many blue calls and time-critical patients we have responded to some very thought-provoking jobs.

A 999 call was made at the start of the week stating a water pipe had burst from underneath the road, causing severe flooding to the surrounding streets. On arrival, there were at least 11+ fire and rescue pumps, two London Fire Brigade command support vehicles and dozens of police cars. A senior police officer gave my crew and me a brief introduction to the scene, which was in Angel, North London. He stated many people had been evacuated to a nearby pub for warmth and shelter as the on scene emergency service workers battle to stop the flow of water. Our Hazardous Area Response Team (HART) followed us into the pub ready to triage any potential patients. When we got there, though, there were no patients at all, just a lot of damp shoes and socks! The Metropolitan Police declared it a major incident so we stayed on scene, with HART, until the Incident Response Officer (IRO) stood us down three hours later.

A whole five minutes after greening up in Angel, the alarm sounded on our Mobile Data Terminal (MDT), which displayed RED1 Cardiac Arrest, was on going just around the corner. With no hesitation we made our way to the address and arrived at the same time as a FRU (Fast Response Units). I entered the property first, but struggled to find anyone inside. My mentor heard noises coming from the kitchen, which was hidden around the corner of the living room. It was an incredibly small space, and she discovered the stepbrother performing CPR on the patient. Unfortunately we found the patient to have rigor mortis; there was nothing we could do for them.

We acquired the 30-second rhythm strip, which showed the patient to be in asystole and declared ROLE (Recognition Of Life Extinct). He was so hypothermic our tympanic thermometer read ‘LOW’ instead of a number, and he had fixed and dilated pupils. His death was completely unexpected, and he only had one common medical condition, which was well controlled by medication. The police were in attendance as standard procedure. It was a heart-breaking situation to be in and we consoled the stepbrother as he began informing the rest of the family. Soon to arrive was the brother of the deceased. We had to tell him that his brother, who was just 29 years old*, had passed away unexpectedly. His reaction was horribly upsetting, and he asked to see the body, to which we said yes. I went into the room with him so he could say his goodbyes. His breakdown and the sound of his cries will stay with me for the rest of my career.

This was a terrible start to the week, but we carried on with the shifts as normal and proceeded to attend an Inferior Segment Elevation Myocardial Infarction (STEMI) as our next job. We followed protocol and blued him into the nearest Cath Lab, which was St Bart’s Hospital in the City. Thankfully the cardiologists deemed her not table worthy, but instead admitted her to the ward for close observation and investigation. The next few days brought us an array of patients including a lady who fell down the stairs and sustained a head injury. I managed to cannulate her and my mentor gave Ondansatron and Paracetamol as treatment.

Sometimes on placement we go to jobs that can be daunting, horrible and emotionally straining, but it’s part of the career I’m going into. This is the reality we live and work in. The brother of the deceased 29 year old* said to me on the balcony of the block of flats: “I guess this is the s*** part of the job you have to deal with?” I was near enough speechless, as I couldn’t begin to imagine what he was going through, but yet he recognised the work we had done and thanked us for our attendance. Not many 19-year-olds have told a family they will never see their brother, stepbrother, son, friend and nephew again. It’s the small things that count in this line of work and it’s the people you meet with genuine gratitude that give you the energy to keep going.

*Not actual age of patient.

Alex: Sepsis Sunday

The second week of placement has seen me and my crew recover from night shifts and move into three 12-hour day shifts. Adjusting your sleeping pattern between days and nights can be a struggle at times and it’s certainly a skill that takes time to master.

Our three-day working weekend gave us a semi-dramatic end on Sunday with four blue calls placed in the shift, which kept us on our toes! Our first job of the shift was to a middle-aged gentleman that a doctor requested LAS (London Ambulance Service) to transport to hospital after an over-the-phone assessment. We arrived five hours after the call had been placed, due to the sheer volume of ‘life-threatening’ calls made throughout the night before. We attended the call and walked through the door to find the patient looking very flushed on the bed. After taking a radial pulse and feeling how ‘hot-to-touch’ he was, I could already predict how critically ill this person was. He was extremely pyrexic at 40.6 degrees, tachypnoeic at 42 breaths per minute, tachycardia of 116 beats per minute and had a SpO2 of 92% on air. This patient was presenting with severe sepsis and we blued him in the to nearest hospital.

After establishing a history of the presenting complaint we found a rash on his left knee where the doctor queried septic arthritis. His wife informed us he recently returned from a Middle Eastern country five days prior to the 999 call being placed. We were quick to establish treatment for sepsis by administering 15L of high flow O2, gaining IV access and administering a 500ml bolus of sodium chloride, 9% and 1g IV paracetamol for the associated pain. Following a swift handover in Resus we left to respond to our next 999 call. This was to an obese patient who has been unable to weight bear and consequently been sat in her armchair for two weeks. She had been incontinent and her legs had swollen a lot according to her full-time carer, who was also her nephew. It was very much a social issue whereby the nephew and neighbour could no longer cope with her healthcare needs, and the patient required more appropriate primary care to be put in place.

We carried out our checks to find she was hypothermic at 31.2 degrees, hypotensive with a systolic blood pressure of 95mmHg, and was bradycardic at a rate of 45 beats per minute. On auscultation of her chest we suspected there to be a build-up of fluid. Her clinical presentation along with the oedema in the legs suggested CCF, otherwise known as heart failure. We requested a bariatric vehicle from St John Ambulance to transport her to hospital, and whilst we were waiting for their arrival we received a phone call from a team leader. The team leader stated that the hospital suspected our previous patient of having MERS (Middle Eastern Respiratory Syndrome). This was very bad news and meant we had to return to base for a deep clean of the ambulance after we had handed over to St John; which blued her into hospital.

The rest of the day also saw another severe sepsis diagnosis and a paediatric patient who had a very high respiratory rate after having a vacant episode in front of her parents. It certainly has been busy, and in fact I slept for 17 hours after the final day shift, I’m not kidding!

This week I am attending a Pre-hospital Care Conference and London HEMS Clinical Governance Day, both beside The Royal London Hospital in Whitechapel. As well as this I will be working hard on my Anatomy and Physiology essay and working at Anglia Ruskin’s Open Day on 3 December; I hope to see many of you there!

Alex: A cold and wet winter weekend

Our first night shift presented two critically ill patients where we ‘blued’ them in to the nearest A&E, including a young child with severe croup and an exacerbation of COPD (Chronic Obstructive Pulmonary Disease). Due to the massive pressure on the ambulance service, general broadcasts (GBs) became a common trend. At one point we responded to a call that was five hours+ old. The last of four night shifts proved to be very productive in terms of PAD sign offs, however we did care for rather ill patients.

We arrived on scene, in the early hours of a wet morning in Central London, to treat an elderly gentleman who experienced two episodes of LOC (Loss of Consciousness). He stated he did not remember collapsing, was complaining of right shoulder tip pain and had significant medical history of two previous heart attacks. Within five minutes of walking through the door we had attached a 12-lead ECG to help us diagnose his condition. I was handed the printout to see he had 2-3mm of ST elevation in leads V1, V2 and V3 which was suggesting an Anterior STEMI (ST Segment Elevation Myocardial Infarction). The patient stated his ECGs can appear abnormal, and the LifePack 15 machine also didn’t detect the elevation to say “MEETS STEMI CRITERIA” like it should have done which was strange. After a very quick consultation with my mentor and crewmate we decided to play it safe and assume the worst-case scenario, as a precautionary measure. Our patient was a really nice man who took the diagnosis in his stride. He was more focused on making sure his wife would look after the dog and cat, which were having a friendly sniff around our response bags, whilst he was in hospital!

After settling down in the ambulance I was tasked with putting in a cannula. I set about doing a mini kit-dump, selected the site as his right Antecubital fossa and proceeded to successfully place an 18g cannula! I was so happy I was able to perform professionally and calmly despite being in a time-critical situation. On arrival at the Cath Lab (dedicated heart attack centre) the team of cardiologists discussed a major symptom that the patient did not complain of: chest pain. Despite the patient not complaining of chest pain they proceeded to run with our initial diagnosis and to put him on the operating table. When they were preparing to anaesthetise him, one of the team discovered an ECG from just under two years ago on the records system. It was identical to our ECG, so the decision was made to not go ahead with the operation, but instead to keep him under close observation on the cardiology ward. It was very interesting to see such a similar tracing, and given the history provided the doctors said we made the right judgement call by transporting him to a specialist centre.

Two jobs later in the shift I managed to cannulate again, this time to let my paramedic mentor administer an anti-sickness drug called Ondansetron. Our final patient of the last night shift certainly challenged our clinical judgement on a diagnosis. He was presenting with multiple abnormalities including reduced mobility, being hypothermic in a hot room, oxygen saturations of 90% on air and being extremely hypertensive. We recognised this elderly man was ‘big sick’ and worked as efficiently as we could on scene before placing a pre-alert to the nearest hospital – we decided to pass it as septicaemia with a source of infection being the respiratory system.

My new mentor, crew mate and I get along really well, I believe our bond was initiated by my offer of chocolate on the first shift and our shared desire for it… My paramedic mentor is international and has been working in London for a few years now. Her emergency ambulance crew mate has an extensive military background and an excellent choice of sweets at 3am. I am really looking forward to our next set of day shifts; hopefully the weather won’t be so harsh on us!

Alex: Call an adult x565.37

Second year of Paramedic Science has been exciting and tough to say the least; we have just completed all of our advanced clinical skills in the run-up to placement. Some of the skills we’ve learnt are Needle Chest Decompression, Needle Cricothyroidotomy, Intubation, IV Cannulation, EZ-IO, External Jugular Vein Cannulation and i-gels.

The good thing about the BSc Paramedic Science course is that it teaches every paramedic skill we are governed to practice. Intubation is a skill we cannot practice as it varies between trusts.

Alongside learning these clinical skills, our theory lectures have focused on applied anatomy and physiology which has proven to be really interesting. To complement our placement Practice Assessment Document (PAD) we have to write a 4,500-word case study review for the Applied Anatomy and Physiology module. I have chosen to write about a patient I went to. He suffered a ruptured abdominal aortic aneurysm (AAA). I was able to recognise he was ‘big sick’ and presented my treatment plan to the crew on scene, who agreed with my diagnosis. As a friend on Twitter said to me after I told him about the job, he simply replied ‘Call an adult x565.37’ which I couldn’t help but find to be very true! I was astonished to hear that he survived to discharge; roughly 90% of patients suffering a ruptured AAA die before they reach to hospital. The kind words and thanks his family sent my way have certainly inspired me to continue to give it 100% on my paramedic degree.