Right To ‘Load And Go’?

Yesterday we got a call to a 27 year old male, diabetic having a fit. It was only 4-5 miles away, but travelling through Newham on a Saturday afternoon is always slow business – this was compounded by one of the roads which we use as a shortcut being closed for relaying. It took us 14 minutes to travel those 4 miles. Then it was up five flights of stairs into a flat where the first thing we could hear was hysterical sobbing. As I've mentioned before it's one of those sounds you know means trouble.
Squeezing past a large bed we entered the bedroom to find a first responder 'bagging' the young man who was laying motionless on the floor – sitting on the bed wailing, was a young woman who we discovered later to be his fiancée. The patient was connected to one of our cardiac monitors and it was showing sinus rhythm. Kneeling on the floor I did a quick pulse check – beat, beat, beat…then nothing, no pulse for ten seconds. During the pulse check I was getting a history – apparently the patient was an insulin dependant diabetic, who had possibly been neglecting to take his insulin injections – he had become more agitated during the morning until he collapsed and started fitting after having an argument with his fiancée

With a monitor showing an apparent sinus rhythm the patient was in 'pulseless electrical activity' – we can't 'shock' this rhythm so I started CPR. From out of his mouth flew some bloody saliva, straight towards my face, luckily impacting on my forehead rather than ending up being swallowed (I don't want to make that a habit). One round of CPR later (3 minutes) and we got a pulse – the patient started 'cramping up' all his muscles had gone into spasm. A very quick blood sugar measurement reading showed 'HI' – a reading of over 32.0 mmols of sugar – the normal is 4-7 mmols. Immediately I started thinking of DKA – a condition that occurs when blood sugar goes too high, a life threatening condition that could explain his cardiac arrest. There was little that we could do on-scene as he needed immediate medical treatment beyond what we could provide.

With a 'Load and Go' order my crewmate set up the chair and the three of us dead-lifted him over the bed blocking the door and into the chair – I felt the familiar trickle of urine down my leg and looking at the patient he seemed to lose all colour. Another pulse check followed – his heart had stopped again.

I had to make a decision then – would we start CPR again only for him to continue this cycle of pulse/arrest, or do we make a run for the ambulance all the time starving his brain of oxygenated blood so that we could get him into hospital to correct the cause of his arrest.

I decided that we should 'run for it', if we got a pulse back it would be a purely temporary measure until his high blood sugar could be corrected. It was a very difficult removal – my back was spasming as we carried him down the five narrow, dark, winding flights of stairs and ran him across the 100 meters of pavement to our ambulance. Throwing him and his fiancée in the back of the ambulance we started the long run back to the nearest hospital. For ten minutes I did CPR in the back of the ambulance while my crewmate tried his best to get through the exceptionally busy traffic – stopping and starting, swerving across the road, over pavements – he drove to the limit.

Throughout transport the only rhythm we had was 'asystole' which is when the heart isn't beating at all – with our first responder 'bagging' him and myself doing CPR we we doing all we could to support his life. During the transport the fiancée told us that he had had a previous arrest when he had stopped taking his insulin, but that he had, obviously, recovered.

Rolling up to the hospital we were met by the 'Arrest Team' – senior doctors from across the hospital. They descended on the patient, trying to get IV access, a secure airway and running diagnostic checks. It seemed however that the team leader didn't want to listen to our handover. I was later told that he was concerned about getting the audit times right. The first thing he said was 'the patient is biting on the airway' suggesting that the patient wasn't actually in cardiac arrest – because he hadn't listened to my handover he didn't know about the cramping episode earlier. The hospital staff did their own 'pulse check' and were confused about feeling a pulse (in a stressful situation doctors often feel their own pulse rather than the patients) It was only after some time that I could actually give the team leader a complete handover that he paid attention to.

The team worked on him for over an hour – blood tests showed that his potassium was sky-high 7.5; this was probably the main cause of his arrest. It transpired that the patient had renal failure and the high potassium and high blood sugar probably meant that the normal biochemical reactions in the body were being interfered with leading to his fitting and cardiac arrest.

One hour later the patient was declared dead.

His fiancée was distraught, the patients parents had to travel 170 miles to the hospital and so it was necessary to tell them what had happened over the telephone – I can only imagine the drive down to London. The fiancée was convincing herself that it was her fault – that it was the argument that killed him, or that she should have recognised his symptoms of a high blood sugar before they became fatal. Both myself and the nursing staff tried to console her – to tell her that it wasn't her fault; but would the parents blame her?

I was thinking, would he have survived if we had remained on scene longer? Was making a run for it the right decision, given that I knew we had to carry him down the stairs? Would he now be alive if he had lived in a house rather than a flat? Did he die because he was an 'angry young diabetic' who didn't want to comply with this treatment? He did have a history of taking an insulin overdose two weeks before.

It was a bad job, travel time was longer than it should have been, the flat was awkward to reach, it was difficult to remove the patient and the return journey to hospital was too long. It could have gone so much better – although the patient may still have died it would have made us feel better. In all that job has left my crewmate and I a little depressed. Two deaths in as many days, one a 'victory' the other a real loss. I have today off so I'm going to relax and prepare for the joys of a night shift tomorrow.

One question for my medical readers – In the same situation would you 'Stay and Play', or would you 'Load and Go'?

7 thoughts on “Right To ‘Load And Go’?”

  1. None of us were paramedics so we couldn't start an IV line (I could due to my nursing experience, but have been explicitly told that I would get into serious trouble if I did). Because there was no way of getting fluids into him, which is probably what he needed to start moving his blood metabolites in the right direction, I decided to transport.His pottasium of 7.5 is probably what killed him in the end – and there is nothing we could have done on scene to alter those levels. One of those 'correctable causes' that we can't correct on the street.

    We'll see what the coroners court has to say.

  2. I wasn't around in his era but all rave about the potential for improvement, vision and leadership. Sadly he was our loss and your gain! Maybe I should move to London?!?I personally prefer residential courses rather than SDL extramural courses (Self Directed Learning), but you are right, it is often hard to get the work life balance (especially when you are single) in ambulance. I don't think I'm even remotely close to the right balance 🙁

  3. You did the best you could: with ARF and K7.5 +/- DKA the cards were stacked against you all. Load and go was absolutely the right thing to do. It may have taken longer to reach the hospital than it should, but it you needed the lab data to do the right things. A miserable business however you look at it. I hope your account is widely read: it is very moving and illustrates the real world better than any fiction. Thank you for sharing it.

  4. Yes, that truly does suck…and whilst I have never attended a hyperglycaemic in extremis to that extent I think we would have been expected to have initiated an IV line as per the protocol (above 20mmol and lowered GCS) and resuscitated at scene…possible transporting under emergency conditions depending on the response to the CPR/IV fluids.We are lucky that most of our dwellings are single/double storey structures, not the five flights of stairs you mention. In our situation the LATER concept would have applied i.e. Load And Treat EnRoute. In yours…I don't know how I would have managed that. I presume there was no Amb Para around for IV access/fluids etc.

    Who knows what the outcome would have been had you stayed? Yes…living in a house probably would have helped (egress wise)…and yes had the patient better managed his medical problems the situation might have been avoidable. But lets face it, a large proportion of our work is derived from people who are unable to (or choose to) not manage their health – I'm grateful for the employment!

  5. Thanks for the reply. Just intrigued about the lack of an EMT-I equivalent in your service. I am surprised that your CEO (the ex CAO of our service here in Auckland as it happens) has not considered attempting to implement this level? You must get extremely frustrated at times not being able to initiate some basic skills that you have already been trained in. What RPL (recognition of prior learning) is possible as an RN migrating into ambulance?Cheers – CraigP

  6. We all like our chief exec. he is a top bloke who still does work on the road occasionally – he's also the government advisor on all the ambulance servies across the country.There are only two levels of training (soon to be expanded) – Technicians and Paramedics – the joke is that Paramedics can do more to dead people given the restrictions on intubation and the increased number of cardiac arrest drugs available to them.

    Traditionally prior learning has meant nothing – to become a Paramedic you need to do a year at 80% pay, then a year 'post Millers', then you can apply for the course. Places are limited, and there is a lot of disappointment over this.

    However…We've just (this month) started RPL for people – this includes RGN's and in this months 'house journal' they are publicising it. Basically a charge nurse has gone straight onto a modified paramedic course after getting his 'Millers exam'.

    I've always been a bit quiet about my nursing experience – people know but I don't make a big song or dance about it, but given this last job where an IV may well have helped – it might just give me that push to go for it.

    The only thing, is that I feel like I'm 'living' my work at the moment, and do I really want to go on a residential course? I'll have to do it at some time, so perhaps it'll be good to get it out the way…

    Cheers for the comments – they _are_ appreciated

  7. Hey Tom, obviously i'm not a para or even a tech, but i'd have to agree with the previous commenters you were a little screwed. Not sure what the of state of paras there are, but could you have stayed, doing the cpr dance while a para could get on the scene and maybe stabilized the guy a little?Still, like someone mentioned – if a patient won't look after themselves, there is little you can do – diabetes especially, where your body can be shutting down and you don't entirely know about it…

    Definitely consider the para course – i'm sure you have the skills, so why not use them ? 🙂

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