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Ambulance: Ambulance or Nurse?

Written by RSS Poster BrianKellett.net

The Independant have an interesting story where, due to the shortage of ambulances the plan is to send community nurses first for patients over the age of 65 who have had a fall.

This is a bad idea.

But first, as a quick update on my career, I went from nursing into the ambulance service, and then returned to nursing. At the moment community nursing. So I’ve done both of the roles that the article is talking about.

The ambulance role is very much different from community nursing. When a community nurse sees a patient, it is not in an emergency situation. If you have a leg ulcer, or cancer, or a surgical wound that’s not healing as it should, then the community nurse is ideally placed to see to your needs. However if you have fallen and either can’t get up by yourself, or have broken your hip, then what you need is an ambulance.
This isn’t to say that comunity nurses don’t already keep people from going into hospital. Community Treatment Teams (CTTs as they are known in my patch, your acronym may vary) work hard to...

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Ambulance: Happy New Year

Written by RSS Poster Medic Scribe

On a private employees’ group Facebook page, an EMT posts a video of a man standing on a street corner, clearly on the nod, asleep on his feet. Another man sneaks up on the nodding man.  He reaches back and then slaps the heroin user hard across the face with an open fist. The victim grabs his head and starts running blindly down the street as if he has been attacked by aliens. The assailant meanwhile has hidden on the other side of the street. The video is captioned:



Ambulance: Post-Bingo NHS

Written by RSS Poster BrianKellett.net

I took a look at my blog the other day. ‘Last post Jan 18 2016’, so nearly a year spent noodling around on Twitter rather than actually writing anything. I’d started a new job and that needed a fair bit of my attention, then there were games to play and food to eat and things to build. Then before you know it you’ve stopped writing and replaced it with reusing other people’s writing by ‘retweeting’ it.

Urgh.

No one reads blogs anymore, or so goes the common consensus, but when I use twitter I’m often redirected to a website, a blog or a whatever you call a Tumblr thing.

I also wasn’t angry. Well, that’s a bit of a lie. I first started writing because I was angry about things and writing about it got it off my chest. I’m still angry but I came to realise that not many people cared about the things I cared about, and so my writing didn’t exactly save the NHS, fix the planet or stop tech people from doing really dumb things.

But, maybe I do have it in me to write again. There are more and more stupid things...

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Ambulance: Angry Snowman: Naloxone Refusals

Written by RSS Poster Medic Scribe

An older man with a cell phone meets us at the door to the apartment lobby. His hands shake. He motions for us to follow toward the stairs.

“What’s going on?” I ask.

“I just went out for ten minutes and I came back and found him.”

“Is he breathing?” I ask.

But he does not answer. I take the stairs two at a time, carrying my house bag over my shoulder and the monitor in my hand. I can barely keep up with him his steps are so quick. I follow him up to the second floor, and then down a long hallway to an apartment whose door opens into the living room. A large man in a sofa chair leans to the left motionless. I can only see him from behind. I come around the side and see he is blue and not breathing. I grab his arm, expecting to find rigor, but the arm is limber and the man emits an agonal gasp. He has a bounding carotid pulse. He has to be two sixty, muscle shirted with tattoos, I’m guessing late thirties. My partner gets out the ambu bag while I get my med kit from the house bag. I quickly screw...

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Ambulance: Chest Wall Rigidity

Written by RSS Poster Medic Scribe

You are called for a seizure in the men’s room at McDonald’s. You arrive to find an approximately thirty-year old man stiff and purple, gurgling.

“Versed?” Your paramedic student says as you break out an ambu-bag.

“Check his pupils.”

“Pinpoint.”

You hand him Naloxone. “Give him 1.2 IM,” you say.

He looks at you like you are testing him.

“Go ahead. “Right in the thigh.”

You normally give Naloxone IN, but when the patient is either in full respiratory arrest or in this seizure like state, you like to go IM because it works quicker.  You toss the ambu-bag to a firefighter who has just arrived. It takes him a moment to get the seal. His first breath is ineffective. You take out an oral airway and slip it in his mouth as the tension seems to go away and the man destiffens. His ETCO2 is 100, but gradually comes down to 70, then 60, then quickly drops to 35. In another moment, the man’s eyes are open, and he is looking around in panic.

“You ODed,” you say. “You are in a public restroom. We just gave...

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Ambulance: Naloxone in Cardiac Arrest

Written by RSS Poster Medic Scribe

 

Case # 1

You find the fifty year old man supine on the floor with the fire department doing CPR. Their AED announces, “No shock advised. Continue CPR.”

You set your monitor by the man’s head and connect the fire department’s pads to your monitor, while your paramedic student quickly places an IO in the man’s tibia. As you approach the two minute mark, you charge the monitor, and then order stop CPR. The patient is in asystole. “Continue CPR,” you say, as you harmlessly dump the charge by hitting the joule button.

Just then the man’s wife announces, “Oh, my God! He was using heroin.” She holds the empty bags she has just found in the trash can. “He used to use. He’s been clean for five years.”

What drug do you give?

***

Epinephrine.

According to the 2010 AHA Guidelines

There is no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose.

Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms

Naloxone has no role in the...

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Ambulance: Surviving Post Naloxone

Written by RSS Poster Medic Scribe

You find the patient – a young man – in respiratory arrest in a Honda with tinted windows behind a service station.  His head is back, his mouth is open, and he is deeply cyanotic.  His skin is warm and despite having no respirations, he has a pounding carotid pulse.  On the floor board you see an orange capped syringe.  On his lap are crumpled heroin bags that say “Soul Survivor.”  The Fire Department has already squirted some naloxone up his nose and while your partner resumes bagging the man, you get the stretcher next to the car and then carefully extricate the man.  Slowly he begins breathing again on his own.  His ETCO2, which initially was 94, has come down to the 50s and then hits 35.  His SAT is 100.  You stop bagging and monitor him.

A minute later he opens his eyes with a start and tries to sit up.  You tell him he overdosed.  He says “What?  I don’t use drugs.”  You carefully explain that he was found not breathing in his car behind the service station.  He had a syringe in the car and empty heroin...

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Ambulance: Wild Wild West

Written by RSS Poster Medic Scribe

There is an anxious crowd on the corner of Hungerford as we come lights and sirens down Park Street.  A woman with tattooed arms waves for us to hurry.   A man is on the ground with a crowd clustered around him.   I can see another man kneeling over his chest. His arms together like he is doing  CPR.  “They hit him twice,”  a bystander says to me.  “Lot of people packing it on this corner.”

“He was just walking along and down he went,” another says.

“He gave him four in the right,” the first man says, and then nodding toward a shorter man wearing a Pittsburgh Pirates hat, “and he gave him two in the left.”  

The man on the ground has his eyes open now and starts looking around as the crowd cheers.

“You oded, man,” a man says to him, still holding the syringe with the atomizer on it.

“I did not,” he says.  “What are you all looking?”

“Man, you were out.  I did CPR on you, man.”

“No, I fine,” he says.  “I just fell out.”

“No, man,” a man with the 4 mg nasal spray in his hand says.  “You...

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Ambulance: Call of Duty

Written by RSS Poster Medic Scribe

“I’m a shit bag,” he says to me.  “I’m supposed to be taking my boy trick or treating tonight.  I can’t fucking believe I did this.  You said I wasn’t breathing?  After all I’ve been through to die like this.  Fuck me.  I’ve got shit for brains.”

The young man got out of jail an hour before.  Thirty days for failure to appear.  He got picked up by some acquaintances, who as a present gave him a bag of heroin to snort (“Just one bag,” he says, “and I snorted it.  I’ve never oded before.  And on top of that I’ve been clean for two months.”

They were going to drop him off at his girlfriend’s house who was going to drive him to his ex-wife’s house, who was going to let him take his son trick or treating.  Instead, when he turned blue and stopped breathing, they dumped him on the sidewalk in front of a hospital – only it wasn’t a hospital with an ED – and took off.  A security guard found him, called 911 and alerted the medical staff inside.

When he came around, I saw the panic in his eyes.  I was...

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Ambulance: Grade A

Written by RSS Poster Medic Scribe

The man kneels in the grass next the pickup truck that has its door open. He vomits.  The fire department is standing over him.  “Citizen Narcan found him in the truck passed out, squirted him with two doses and then took off when we got here,” a firefighter tells me. I see the two 4 mg nasal devices in the grass.

“Thank goodness for community narcan,” I say.

The vomiting man, who looks to be in his early fifties, rouses enough that my partner and our paramedic student are able to get him on our stretcher. I do a quick check of the truck to look for bags, but don’t find any. I do find a used syringe under the center fold down console. I find that odd as the fire department told me they also found a syringe. I do another look in the grass and then I see the bags – three fresh white bags sitting on top of the grass. The brand is a new one. “Grade A” stamped in blue.

On the way to the hospital I learn the man is a house painter. He hurt his back a few years ago when he fell off a ladder. He got hooked on the pain pills. Now he...

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