I'm Angry!

Ok, so I've just got back from a job, and I am so angry with what has just occurred:

He is 43. He has been out for a drink in a pub. Not something to get hit over the head for. He did ask another drinker to apologise for knocking his drink over. Not something that should lead to him lying on the ground with a gaping wound in the back of his head. But it did.

And so, here is James, a rather pleasant chap, according to his mates. He's not being very nice now. He is swearing and snapping at all of us. And when I say snapping, I mean he is trying to use his teeth on us. He can't, but only because there are 4 very strong police officers, holding him down. He needs cuffing, for our safety as well as his. He doesn't like this, and is pulling so hard at his cuffs that his wrists are red raw. Language I am hearing tonight is bluer than on Saturday Night Live. OK, you know the drill by now: the Primary Survey:-

Airway: perfectly maintained, as evidenced by the expletives that emanate from his mouth
Breathing: there's no point trying to listen to his breathing, but he has not received a blow to his chest, so I am happy
Circulation: we can't get a blood pressure, because he won't keep still, but his pulse is regular and strong
Disability: he scores 3 out of 4 for his eyes, as they open if I shout at him. I'll give him 4 out of 5 for voice - I wouldn't say he is orientated, but he certainly knows what he is saying! And he can have 5 out of 6 for motor, because, while he won't obey commands, he is trying his best to do a Houdini with the cuffs.

I do my usual at this stage. I get down close to him and reason with him: "Keep still and we'll take the cuffs off," I tell him, much to the consternation of the rather battered officers. He does quieten, but I don't think getting him out of the cuffs is going to be a winning decision with anyone else.

I know that we are only 3-4 minutes away from NeuroHospital, and, I reason, it's far safer to just go, as opposed to giving him a Rapid Sequence Induction (drugs to put him to sleep so that I can pass a tube into his windpipe and breathe for him.) So, as we are already in the back of the ambulance, I let the team know my plans, and we set off. As we start, one of the team passes the information to NeuroHospital, so that they are ready for us when we arrive: Male, 43, severe open head wound, GCS 12/15, combatative, DA (that's me!) on board.

We arrive, and wheel him in to Resus. We are met by... A nurse and an FY2! A junior doctor, 1 1/2 years post qualification!! At least we have an experienced nurse, but still!! I look around pointedly, and ask, "Where's the Trauma Team? Did you not get our call?" He replied, "Yes, but we didn't think it warranted a Trauma Call." What?? I only didn't tube this chap because I knew we were on the doorstep, and now there's just no-one here to look after my patient. I ask the nurse to put out a call; she just shrugs and goes out the door. Great!! Now we haven't even got a nurse in here!!!

A minute or so later, she returns and tells me the Consultant is in the Department, and will be coming in. Phew!! But no. He wanders in, looks down at me, and talks over me while I am trying to explain what has been occuring. Not interested in the pre-hospital situation, he goes over to the 'phone and tells the radiologist that the scan can be performed with the patient awake. I storm out, muttering under my breath.

The point here is that, despite the fact that the patient is now much calmer, he has had a very significant injury, with very significant pre-hospital features, and the hospital staff are ignoring all we are saying. This has made me angry. My ambulance colleagues are angry. We sit by the vehicle, drinking NHS tea, and bemoaning the difficulties associated with the interface between pre-hospital and in-hospital. As a Consultant, they expect that at least I will be taken seriously, even if they aren't. It's an eye opener for them too.

I have just rung NeuroHospital - he has cerebral contusions and is being intubated as we speak. I'm not a happy RRD.

The Handover Carnival

Well, at long last, here is June's edition of the Carnival. Communication is so important to all of us that I wanted this to be the subject of my edition.

And I am happy to start with a submission from the editor of last month's Carnival, about communication bourne of many years, demonstrating the love between family members:
http://rescuing-providence.blogspot.com/2009/01/communication.html

Peter wants to try and persuade us of the benefits of smoking in his entry:
http://medicscribe.blogspot.com/2006/02/cigarette.html

Our insomniac colleague has some thoughts on 21st Century Britain, that made me sit back and think:
http://insomniacmedic.blogspot.com/2009/04/21st-century-britain.html

A great post from Medic 3, about how sometimes there can be too many words, and no communication:
http://www.medicthree.com/2009/05/here-at-little-ambulance-that-could-we.html

Dani provides us with an insight into how the body can communicate volumes to us, and help us medics do our job properly:
http://medicdani.blogspot.com/2009/05/body-never-lies-how-we-communicate.html

Lumo has something to say, to every patient who has walked into the A&E Department - maybe we should have a biiiiig poster made for the Waiting Room:
http://lumo-wafflings.blogspot.com/2009/05/dear-patient.html

Our HappyMedic has a wonderful post, filled with memories from 1968, and how the communication worked way back when, before mobile phones and pages - possibly better than it does now...:
http://yourhappymedic.blogspot.com/2009/03/pegging-board.html

"It's wern me!" What does this mean? In New Orleans it means something, and to the patient it is important that Sean knows, so that he can help. Read this well-written tale of difficulties with "English" in another language:
http://newburningtiger.blogspot.com/2007/02/ramp-rants-communication.html

Our very own MedigBlog999 has submitted this entry, about Michael, who has is own way of communicating, hopefully not what any of us would subscribe to:
http://medicblog999.wordpress.com/2009/06/08/its-all-about-how-you-say-it/

Here are some tips from Steve about using communication to make a connection with your patient - well worth noting:
http://theemtspot.com/2009/06/09/connections/#more-920

And my final entry, from Kristan:
http://newparamedic.blogspot.com/2009/06/communication.html

This has been a real experience for me, hosting this Carnival. I am looking forward to next month, which is to be hosted by our very own TraumaQueen, whose blog I have followed with interest ever since I started my own. Head on over to his website to see what I mean.

Next month's Carnival is entitled "Pivotal Moment". Entries to kal@traumaqueen.net, by 27th July.

RRD

Handover Carnival

Just a quick reminder to you all out there: there are just 2 more days before I close the Carnival for this month to any more submissions. A bumper crop - do look out for them before the end of the month!

Diogenes - The Man Who Lived In a Tub

A really fascinating, if also very sad, return to BASICS work:

I am called to a man 'stuck in his house.' What on Earth??? I arrive to find a whole heap of ambulance crews and fire crews, milling around an end of terrace house. I approach one of my colleagues and ask what the problem is, and he just shakes his head and points me towards the open front door.

I walk slowly to the door, with trepidation. Peering through into the dark entrance hall, I am struck by the mounds of books, boxes and bottles, stacked floor to ceiling. There is a narrow passageway. "Hello," I call timidly. "Hey, RRD! We're in the front room. Careful as you come in."

I look more closely at the piles of rubbish as I pass - milk cartons from 1987, boxes of cereal and, strangely enough, Mcvites biscuits. Telephone directories by the dozen, a television, numerous radios from way back when. A motherboard. A box of saucepans. I walk slowly and carefully along a corridor which would only fit one person.

As I turn the corner, into the front room, I am stunned by what I see. This is no front room. This is a maze, a twisting, turning passageway through more rubbish; books, more milk cartons, some still full of a brown, evil looking liquid that many years ago was milk, magazines, all piled high to the ceiling. I look down; I am standing on paper and more rubbish. Faintly, I can hear the rustling of other visitors, much more used to this sort of environment than I. I shudder to think what else lives here.
And then I turn the last corner, and see, seated in a chair in the eye of this storm, the king. That's my first thought, as I see him sitting there. The chair, large and ornate, his throne. The space around him cleared of detritis, at least for a few inches, enough for one person to get round him. And the way he sits, upright and proud, as if the scene before him is that of his adoring subjects, not a rat-infested landfill.

I have been called because Jim has become unwell. He has developed a temeperature and a nasty, rattling cough. This isn't very surprising. I am told by the ambulance crew that Jim hasn't moved from the chair in which I now see him sitting for the past 3 years. 3 years, sleeping, eating, everything in that one chair. He has no legs; they were amputated 3 years before, because of gangrene. Yet, he tells me proudly that he walks 2 miles every day, but has been hampered by the chesty cough for the past 2 or 3 days. Not hampered by the lack of legs, nor by the lack of cleanliness.

I am confused: how can someone live in this way? Who cares for him, feeds him? And then I am introduced to his carer! A lady in her early 50s, who looks after Jim, provides him with his daily needs of food and water. She tells me she lives three doors down from him, and comes in three times per day to "look after him."

Who knows what she gains from this symbiosis, this strange relationship. All I know is that Jim is terribly unwell, and needs to be in hospital. But here is the quandry: how do we get him out? The ambulance crew are very worried about moving himm off of the chair - he is so frail that they are concerned even the slightest movement would be the end of him. I don't disagree with them, to be honest! Also, we can't move in the house because of all the rubbish. Everything is so precariously stacked that knocking into any of it might bring the whole lot down on us.

The fire service chief asks to have a chat to me. I make my slow way outside, into the clean, fresh air. I gulp hungrily, not realising until I am outside just how fetid the atmosphere is in the house. "Is he ever coming back here?" he asks me. I'm not sure, and I say so. His idea: to take out the whole front window frame, and get him out that way. "Will you put it back afterwards?" I ask. Of course, the answer is "No." And here is my problem: if we do that, if we make his house uninhabitable, he will spend the rest of his days in a hospital or in a Nursing Home, somewhere he clearly does not want to be. If we don't, he could die as we take him out. I make my decision. We are going to get him off the chair, put him on an ambulance carry chair, and take him out of the front door. I brief the staff, and we prepare.

Jim is lifted off his chair. Well, actually, a lot of the chair comes with him. The fabric adheres to his flesh. He is then carried through the maze of rubbish, of his personal belongings, to the waiting ambulance. His house is intact, ready for him if he ever is able to leave the hospital. His carer is in tears.

And so to the odd title of this post. Jim suffers with Diogenes Syndrome, involuntary self-neglect and hoarding. I have seen only one other in my career, and she died about a week after being admitted to hospital. Diogenes was a Greek philosopher, a beggar who made his home in the streets of Athens, and who made a virtue of extreme poverty. He is said to have lived in a large tub, rather than a house.

Jim died about an hour after arriving at the hospital.

I'm Back!

Yes, folks, I'm back to work. After only 17 days, I had had enough of day-time TV and chocolate-covered cherries, and I returned to work this morning. I was spotted by a number of ambulance crews, and within minutes of my arrival I had a call from Control; "We understand you are back at the A&E. We presume you are also back on BASICS callouts if we need you..." "Only local ones, and not at night", I suggested, knowing full well that, if I'm back, I'm back. Oh well, here's to a full night's sleep tonight...

Mistake

23:45 - "Hi there, it's Ambulance Control. Can I send you on a job in NearTown?" I'm sitting on the couch, my ribs giving me significant problems (I haven't been to work for 2 weeks, and don't feel it's likely that I will be able to go back next week, either.) I am surprised to get the call, as I have signed my self off from BASICS work at the moment.

You know how, after the event, you think of something really clever that you should have said, but too late? Well, in this case, I SHOULD have said, "I'm sorry, but I am off sick with broken ribs, so I can't attend." What I actually said was, "What's happened?" The nice lady in Control then tells me about this serious accident, where a pedestrian has been hit by a car, gone through the windscreen and is seriously injured!

Mrs RRD is frantically gesticulating to me, shaking her head so hard I thought she might need treatment soon. I am not safe to go: I haven't driven my car for two weeks because of the pain, and I'm certainly not going to be of any use at the scene of a serious accident the way I am now. I decline the call, explaining that I am signed off, and why. Control apologises for contacting me.

And then we sit there, the two of us, wondering what is happening. No-one else is going to NearTown - there just aren't any other BASICS doctors close enough. Was this one of those rare occasions when my presence might have meant the difference between life and death? So we sit, and I contemplate the mistake I have made, the questioning of the despatcher, that has done nothing more than fuel my guilt, for not being there.

Bored, bored, bored!!!

Ok, this is quite enough! 10 days off work, 10 days signed off of BOTH Ambulance Services, and 10 days of being unable to get comfortable in bed. I'd go back in to work if it wasn't for the fact that Mrs RRD has hidden my car keys! Also, because I can't stand for extended lengths of time without severe pain. Oh, I hate this!!