Joan #4

The ambulance was only a few minutes away from the hospital, the oxygen had been swapped over for Entonox, and the patient appeared to be stable.

We give Entonox (a painkilling gas that has lots of oxygen in it) to both load up the blood cells with oxygen and to ease the pain, which in turn reduces the strain on the heart.  The other pain relief that we have is Tramadol, or Numbain, both of which can only be given via the vein, and so are a Paramedic drug only.  Both of which are…well…less than effective as the doses we are allowed to give are quite small.

Paramedic in London will soon be getting Morphine, but that is a topic for another post.

Joan was feeling a little better, although the pain was still there, it didn’t seem to bother her as much, and she was sure she was in safe hands.  She felt the ambulance pull to a stop, and the back doors flew open.  Standing outside were two young women in blue pyjamas.

I wonder where the doctor is”, thought Joan.

The ambulance crew did something complicated to the underside of the trolley that she was laying on, and it slid out into the air.

Joan was trying to listen to what the ambulance people were saying, something like ‘Anterior’ and ‘GTN not given’, strange jargon like ‘BeeEmm’, she didn’t have a clue what they were talking about, she hoped that the nurses knew.

Hello”, said one of the young women in the pyjamas, “I’m Doctor Rushkov, I’ll be looking after you”.

Joan thought that the woman was too young to be a doctor.

She was wheeled on the trolley into a big white room, chock full of strange equipment.  Nothing seemed to make sense as she was physically dragged from the ambulance trolley to the hospital trolley.  The people around her continued to talk over her head, reeling off numbers and phrases that Joan had no chance of understanding.

I’m just going to put a little needle in your hand”, said one of the women.

There was a sharp scratch and the doctor started to talk to Joan.

It’s one of the things that we tend to be not that good at – when we have a seriously sick patient, we are concentrating so much on what their ‘numbers’ are doing (blood pressure, pulse, oxygen levels), and on our treatment, that we can sometimes treat them like lumps of meat.

Ambulance crews however have a solution to this.  We talk utter rubbish.  I don’t meant that we lie to our patients, but instead we have a number of stock phrases that are used to reassure, and explain things to patients.  It works pretty well.  It’s not that we don’t want to have a serious conversation with you, just that our minds are concentrating on more serious things.

Of course the seriously ill patients tend not to listen to us anyway, as they are often very frightened.

The doctor, young enough to be Joan’s granddaughter was talking about the treatment she was going to give.  She’d started off by saying that she was too unstable to be moved, Joan wasn’t sure what this meant – why wold she be moved anywhere?  The doctor then mentioned a drug they were going to give her, but that this drug may cause a stroke.  Would Joan give them the go ahead to use it?

Joan just wanted the pain to stop, so she said yes, and within minutes a new bag of fluid had been hung above her head.

There are two main treatments for a heart attack in London.  The first is via a drug called a thrombolytic, this drug is given in a bag of fluid via a vein, it takes around 40 minutes to run* and it ‘breaks down’ the clot that is blocking the artery to the heart.  The only problem with this is that in around 1 in 1,000 patients suffer a serious side effect.  This can range from internal bleeding to a stroke.  For this reason the drug is often given in the safety of a hospital.

Outside of London, some ambulance trusts give these thrombolytic drug to their Paramedics so that they can give them out on the road.  The reasoning behind this is that every minute the artery is blocked, more of the heart dies, and in places where hospitals can often be an hour or more away, it would be better to start the treatment while carrying the patient to hospital.

In London there is another form of treatment, the ‘Angioplasty’.  This is a surgical technique where a device is threaded up through the leg into the heart where it physically clears the blood clot.  This has less chance of a side effect, and works a lot better.  In East London there is one hospital that does this procedure, and because of this ambulance crews are being trusted as better clinicians.

It works like this.  If a patient is having a confirmed heart attack, so you need to be able to read the heart trace ECG.  Then you can bypass hospitals with an emergency department, to go straight to this hospital.  So hopefully more people will survive their heart attack.  It’s a good idea, but a little scary to drive a critically ill patient past a hospital to reach one further down the road.

In Joans case the ambulance crew were so close to the emergency department of their local hospital, and Joan was so unstable, they decided not to go to the specialist hospital, but instead head for the normal emergency department.

Six months later and Joan was still getting out of breath climbing her stairs, she had to take six different types of tablets every day, and often found her ankles swelling at night.  She supposed that at least she was alive, and there were people who had much worse damage done to their hearts.

She had been told that part of her heart had died, and that this is why she was lacking in the strength that she had previous to the heart attack.  Pretty much everyone who had a heart attack felt weaker afterwards, she had been told, but she was weaker than many because of how large a patch of her heart had been damaged..

Every now and then she got a little twinge in her chest, but a squirt of her spray under her tongue, and a little rest soon sorted it out.  She was waiting to have surgery to open up the arteries of her heart, and it couldn’t come soon enough.

And that’s the end of these series of posts, it’s been an interesting thing to write especially as I have just used my normal ‘churn ‘em out’ style of working.  I think it’s worked reasonably well, at least it’s kept the ‘content’ coming while I’ve had my time off.  Tonight I start the first of four night shifts, and with any luck I’ll have some interesting tales of daring-do to relate.

Or maybe a moan about Maternataxis…

*I’m running off my memory of hospital treatment now – things may have changed.


17 thoughts on “Joan #4”

  1. Thanks tj,I knew that much, Just SJA where I am doesn't talk about it for Cardiac arrest use that's all. I have ALS, but rarely use it, entonox that is. Were I am, we're fortunate that we might get an arrest every 15 months or so.

  2. I know this comment is two years later than everyone elses but I just found these posts and thought they were really good. I liked the way you turned it more into a story and creating a character rather than just a nameless person who had a heart attack, got ambulance called, went to hospital, had various procedures done, came home. It was very interesting and I have learned alot of medical info. that might be useful one day (I hope!) from it and also from the rest of your blog.

    – sarah

  3. Thanks for the “Joan” postings Tom. Very readable, and the mix of terminology/plain english works very well.Roll on the next set.. !!

    I'm still looking forward to the usual moans and groans of being a London Maternataxi Driver though LOL

  4. Hi Tom,This will probably be an unpopular opinion, but I prefer your usual posts! The reason is that I'm quite a geeky person, and tend to like fact… I rarely read fiction but ravish biographies. I've felt your Joan postings were a bit too story-like for my taste, bringing a touch of Casualty to your blog, if that makes sense. I found the factual bits interesting, such as the treatments you would use and why, but I don't really care about Joan herself.

    The posting of yours which I remember most was about the girl who dropped down and died… that was very sad, but much more effective as a post.

    That said it's your blog and you do what you wish with it! I'm just expressing my feedback.

    But I am very much looking forward to reading your thoughts on paramedics getting morphine.

    Cheers and keep up the good work!

    Flash Wilson –

  5. I just had an idea, you could try dramatising actual cases, perhaps trying to guess at what happened before and after and about the personalities of the people and their situations. This could be quite interesting, and you wouldn't have to worry about the veracity of the medical details, since you'd know them already. I bet you do this anyway: imagining what the people's lives are like and what happened to them.Just an idea.

    Love the blog as usual.


  6. The “Joan” postings worked quite well, especially if their main purpose were to provide a teaching tool for anyone in the medical field (nurses, EMTs, doctors). Much more vivid and memorable than the usual stuff in the books. The only minor critique I'd make is that in Joan#4 you suddenly switch to the patient's point of view. You either didn't do that previously, or did it more smoothly, or with better indications to the readers of whose head they were inside. Something didn't sit quite right there. Alternating between regular and italics for the expository versus “story” parts worked well.

  7. What i found interesting is that Joan felt weak after her heart attack. In my case after the angioplasty and stent, I felt more strength and energy than i ever had before. The doctor says that's because there was more oxygen in my blood than before. My Aunt says that she was weak after hers also and still says she is not up to par. Why could this be in different cases?

  8. Tom,I found your story of Joan to be a very interesting post. Thank you. …Timely

    Though having just treated my first full cardiac arrest in 11 years of volunteering with St John Ambulance. I was interested in your info about the use of Entinox, and would love to know more.

  9. Entonox is a “self-administered” analgesic gas, 50% Oxygen, 50% Nitrous Oxide. Often referred to as “gas and air”.SJA members who have done a medical gases course can give entonox, perhaps you might like to look into it.

  10. I'd guess it's down to the amount of damage caused by the MI and possibly how long it's been building up. I was lucky, in that mine doesn't seem to have done as much damage as it might have and having have angioplasty & stents, I'm back to normal, as far as I can tell.

  11. Hi… You can't give entonox to a *Cardiac Arrest* as it's self administered, and dead people have a bit of a problem following the ambulance crew's instructions on how to use it…

    In a heart attack however, it can provide some relief, and if the patient is concentrating on breathing *right* then that can also only help.

  12. Good series of posts – just somewhat surprised to see that angios are being done in the back of an ambulance or have I drunk too much cider this evening ?

  13. Cheers Mr R,Yes, true, I should be more careful with my language. I was asking about the use in a heart attack, but had cardiac arrest on my mind. *sheepish smile* Sorry.


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