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'?