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Thursday, 18 June 2009
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!
Friday, 12 June 2009
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 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.
Tuesday, 9 June 2009
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...
Sunday, 7 June 2009
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.
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.
Tuesday, 2 June 2009
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!!
Thursday, 28 May 2009
Bang!!! Part 2
So, here I am, at a school many miles from my home, with a dented boot, Sonny Jim having ridden his motorbike into my rear en route. My patient is a 5 year old boy who was hit by a Land Rover. When I say hit, what really happened is that the lad, Tim, had been leaning against a wall when the child sitting in the front seat of the Land Rover had taken the hand-brake off, and the rather large vehicle had pinned Tim against the wall.
I need to act fast here. Children don't act the same as adults: when they get injured they display very few signs of shock until the very end. So, I will have to keep my wits about me. The mechanism of injury tells me a lot - the potential for chest and abdominal trauma is high. I will need all my kit out of the boot.
Oh bum, bum and tripple bum!! I can't get my boot open! The impact with the bike has damaged the locking mechanism. Having an Estate car would be good at this stage - I would have just pulled down the rear seats and grabbed the stuff from there. But I haven't. So I can't.
Quickly, I run over to the ambulance, no kit in hand, and call to one of the fire crew, to appraise them of the boot situation. He calls to his colleagues, and my vision, as I enter the back of the ambulance to deal with a sick 5 year old boy is of 3 burly fire officers attacking my beloved car with some heavy equipment. Oh well, concentrate on the job at hand:
Tim is awake, whimpering in pain. He looks very pale, and is quite drowsy. He has an obviously deformed right thigh. There is bruising across the right side of his chest. Ok, need to get some order into this:
Airway - maintained. He is speaking, and so I can move on to:-
Breathing - looks fast, and the right side isn't moving as well as the left. A count of breaths per minute gives me 30. What's normal for a 5 year old? Can't be more than 25, can it? The EMT agrees with me. Listening to his chest with a stethoscope demonstrates very little air entry in his right side. A pneumothorax? Blood in the chest? I tap on his chest, but cannot decide whether it is dull (blood) or resonant (air). Damn! It's really not as easy when it is a child, nor when we are in the back of an ambulance... Oh well, park that for a moment, and move on to:-
Circulation - pale, weak, thready pulse, blood pressure unrecordable, obvious fracture right femur, probable pelvis fracture. This is not looking good.
Disability - he is conscious, and responsive, with a Glasgow Coma Score of 14/15. He is moving all 4 limbs.
Just then, there is a knock on the ambulance door, and the fire officer hands me my bags from my boot. I'm not even going to think about it...
I start making some decisions: time to any A&E Department is over 20 minutes. Tim is in a bad way, losing blood from a probable pelvis fracture, as well as a femur fracture. He also has a chest injury. If he were 20 not 5 there wouldn't be a choice - he would be put to sleep, and I would decompress his chest. But he's 5 years old!! Giving him a general anaesthetic will be hard enough, what with choosing the correct doses of drugs. And then decompressing his chest! I can't remember the last time I did that in such a small child! No, this one will have to travel awake. In a way this makes the journey much harder, as I will have to be prepared for the worst. I give Tim some ketamine, a sedative used for anaesthetising horses. A much smaller dose for Tim, though, and he is sleeping nicely. Very slow fluids, just to keep his blood pressure stable. Not too much, or he will start to bleed more. Equipment ready to intubate him if he deteriorates en route.
I signal to the ambulance crew, and we make our steady way to hospital. I watch Tim's vitals like a hawk, listening constantly to his chest, my fingers on his pulse all the way. I breathe a sigh of relief when we drive up to the A&E, and I hand him over.
A couple of days later I call to find out how he is: he is still fighting, having had operations to pelvis, femur, chest and abdomen.
I need to act fast here. Children don't act the same as adults: when they get injured they display very few signs of shock until the very end. So, I will have to keep my wits about me. The mechanism of injury tells me a lot - the potential for chest and abdominal trauma is high. I will need all my kit out of the boot.
Oh bum, bum and tripple bum!! I can't get my boot open! The impact with the bike has damaged the locking mechanism. Having an Estate car would be good at this stage - I would have just pulled down the rear seats and grabbed the stuff from there. But I haven't. So I can't.
Quickly, I run over to the ambulance, no kit in hand, and call to one of the fire crew, to appraise them of the boot situation. He calls to his colleagues, and my vision, as I enter the back of the ambulance to deal with a sick 5 year old boy is of 3 burly fire officers attacking my beloved car with some heavy equipment. Oh well, concentrate on the job at hand:
Tim is awake, whimpering in pain. He looks very pale, and is quite drowsy. He has an obviously deformed right thigh. There is bruising across the right side of his chest. Ok, need to get some order into this:
Airway - maintained. He is speaking, and so I can move on to:-
Breathing - looks fast, and the right side isn't moving as well as the left. A count of breaths per minute gives me 30. What's normal for a 5 year old? Can't be more than 25, can it? The EMT agrees with me. Listening to his chest with a stethoscope demonstrates very little air entry in his right side. A pneumothorax? Blood in the chest? I tap on his chest, but cannot decide whether it is dull (blood) or resonant (air). Damn! It's really not as easy when it is a child, nor when we are in the back of an ambulance... Oh well, park that for a moment, and move on to:-
Circulation - pale, weak, thready pulse, blood pressure unrecordable, obvious fracture right femur, probable pelvis fracture. This is not looking good.
Disability - he is conscious, and responsive, with a Glasgow Coma Score of 14/15. He is moving all 4 limbs.
Just then, there is a knock on the ambulance door, and the fire officer hands me my bags from my boot. I'm not even going to think about it...
I start making some decisions: time to any A&E Department is over 20 minutes. Tim is in a bad way, losing blood from a probable pelvis fracture, as well as a femur fracture. He also has a chest injury. If he were 20 not 5 there wouldn't be a choice - he would be put to sleep, and I would decompress his chest. But he's 5 years old!! Giving him a general anaesthetic will be hard enough, what with choosing the correct doses of drugs. And then decompressing his chest! I can't remember the last time I did that in such a small child! No, this one will have to travel awake. In a way this makes the journey much harder, as I will have to be prepared for the worst. I give Tim some ketamine, a sedative used for anaesthetising horses. A much smaller dose for Tim, though, and he is sleeping nicely. Very slow fluids, just to keep his blood pressure stable. Not too much, or he will start to bleed more. Equipment ready to intubate him if he deteriorates en route.
I signal to the ambulance crew, and we make our steady way to hospital. I watch Tim's vitals like a hawk, listening constantly to his chest, my fingers on his pulse all the way. I breathe a sigh of relief when we drive up to the A&E, and I hand him over.
A couple of days later I call to find out how he is: he is still fighting, having had operations to pelvis, femur, chest and abdomen.
Tuesday, 26 May 2009
Handover Carnival
I have been asked to host the June edition of Handover Carnival. For those of you who have not heard of the Carnival, it is an opportunity for bloggers to send in their favourite offering: a post related to EMS, to A&E; to anything emergency. Last month's Carnival was hosted by Rescuing Providence, and was entitled "Partners". Head on over to a great blog, and an excellent selection of posts.
My interest, apart from the obvious, is in communication. We in the emergency world spend our lives communicating; with patients, with family, and with each other. And what is blogging, if not communication. So, for June I am looking for posts that have communication as their basis. Please send your links to: rapidresponsedoc@yahoo.co.uk. The deadline is June 21st, so that I have time to get them all straight and out there in time for month end. I look forward to seeing what you all can come up with.
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