Memoirs of an Emergency Nurse (8 page)

At o
ne of
the
hospital
s
I
worked at, the medical assessment unit took
patients
straight from GP referrals
,
bypassing
the
emergency
department.
We had
a
protocol for asthmatics, whose condition has meant that their asthma attacks have caused them to be ventilated in the Intensive Care Unit
.
The protocol for people on this
ICU asthma
-
at
-
risk list was to be brought into emergency to
stabilise
their condition before moving them to the medical assessment unit for further treatment.

Due to the severity of the
ir
asthma
,
these patients
can easily and quickly deteriorate into having a respiratory arrest, where they become so
acutely
unwell
,
their airways block and they are so exhausted from struggling to breath
e,
they no longer have
the strength
to continue without invasive treatment such as
intubation.

I
cannot imagine the feeling of gasping for air and not getting any, lungs tightening and blocking the air getting in, the inability to speak because of gasping for oxygen
and
the progressive dangerous
exhaustion
that take
s
so much energy out of the patient they are just too tired to carry on breathing and fighting the foreboding feeling that they might die
.

With many things in
e
mergency
,
a change in the weather means a change in the
number
of patients
.
It was
a rainy morning in
spring but really
muggy
too
after a few days of sunshine
.
Anna was an
asthmatic and
in her late
twenties
.
She was brought into emergency by paramedics
.
Her
breathlessness was clearly audible over the noise of people talking
, with a raspy wheeze on expiration and inspiration
,
every breath she took. The paramedics had given
her
several nebulisers on
the
way in
. The nebulisers were
sachets
of liquid
S
albutamol
put into a collection pot running through a set of oxygen tubing.

The
S
albutamol opens the lungs to allow for more oxygen to be used, however
,
it doesn’t reduc
e
the
constricted swelling in the airway
,
which is the main cause of asthma and has a side effect of tachycardia.
T
he nebuliser
was
steaming loudly as high flow oxygen went through the drugs
,
making it bubble
in the collection pot and steam out of the face mask
.
Anna was a large lady with long brown hair
and she was in
her nightdres
s
.
S
he had been woken with an asthma attack and had little time or energy to get dressed prior to the paramedics arriving
.
She was red face
d
and clammy, her whole upper body moved with every strained breath she took, clearly using all her accessory muscles to help suck air into her lungs
.
Strands of her long hair were plastered over her forehead and she made no effort to move it away from her eyes,
indicating
a lack of energy to do anything but concentrate on breathing
.

We transferred Anna onto the trolley
, keeping her in as upright a position as possible to assist her breathing
, and then we
unhooked the portable oxygen to the oxygen on the wall
.
She was so out of breath she couldn’t move her legs over onto the bed next to her and
so
we use
d
the pat slide to quickly get her across
.
We had
had
a warning telephone call from the paramedics
so
Anna was expected and we all knew the possible outcomes
.
She
had stopped breathing on many occasions because of her asthma and was well known by the medical teams
.
She was a regular for being intubated in intensive care and that is probably why she called the ambulance as soon as the attack had started
.

She
was literally gasping for breath
;
it was a slow controlled breath in and
a slow breath
out with a loud wheeze
.
A
s I listened to her chest with the
stethoscope
,
it sounded like she was breathing through a loud speaker
.
H
er airway was so tight
I
could hear
what sounded like
a large gentleman snoring with a whistle at the end of each breath
. The
air
desperately trying
to get through her narrow airway
caus
ed
the
whistle
.
T
here was no way we could attempt a peak flow measurement as she needed every breath
.

We could tell Anna was bad and we didn’t need a measurement for that. She was extremely anxious. I’d measured her oxygen saturations via a probe on her finger and it measured something in the eighties. The average measurement of a normal reading in a non-smoker would be above ninety six percent. The doctor had asked for back-to-back nebulisers and we continued giving the drugs to open up her lungs so that oxygen could get to them.

Anna was sat nearly bolt upright and her whole chest was moving, trying to get air. Her belly rose and fell with each big gasp and her chest muscles expanded with each inspiration. She was scared. She was well aware of how bad her asthma was and of her past experiences of being intubated and waking up in intensive care, wondering if she would survive. She took hold of my hand. Between the breaths was a loud moan and I tried to reassure her. I was talking close to her ear, steady and slow, reassuring words. While she was struggling for breath, doctors around her poked and prodded her arms to try to find a vein so drugs could be given. She had been stabbed a few times as the doctor couldn’t find a vein and she was now sweaty and couldn’t keep still.

She was given steroids to stop the inflammatory process and blood was taken. She was talked through the process but she already knew what the routine was, she needed support.  I talked to her to calm her down. I don’t think Anna was listening but calming words produce less distress so I talked her through what we were doing, and told her that the doctors were looking at her blood results.

Asthmatics can retain carbon dioxide in the lungs which doesn’t help matters, because they essentially aren’t clearing their lungs properly. Oxygen struggles to get in and carbon dioxide struggles to get out and usually a blood gas sample is taken to determine if this is occurring. It is a painful experience to get blood from the artery and is usually taken from the wrist. This caused Anna to panic even more and my reassuring words were wasted. As the doctor took the sample, she squeezed my hand. The sample was taken and the syringe with blood in it enclosed in ice and staff ran upstairs to ICU for the reading from the blood gas machine.

Anna was becoming tired, she lay back on the pillow with her flopped sideways from exhaustion. The high flow oxygen continued. I let go of her hand to get a wet cloth to wipe her sweaty forehead and she woke up immediately as if her support had left her. I reassured her again and her eyes told me that she had confidence in me and my comforting words and didn’t want me to go. Her breathing remained laboured, her respirations per minute were now twenty seven down from thirty four. Normal adults would be approximately twelve breaths per minute, so she was still breathing really fast.

The medical team had the results back and it concluded that Anna was retaining carbon dioxide and despite the drugs we’d given to dilate her lungs, her condition wasn’t improving as we’d hoped it would..  Radiology was paged and they came to give Anna a chest x-ray in the resuscitation room. Her medical case notes were huge and tied with stretching elastic bands.  Three sets were brought for this twenty three year old woman; her notes told me she’d had numerous medical admissions and treatment for her asthma.

She became agitated with the oxygen mask around her mouth. I’d put on a nasal cannula around her nose and calmed her down so that she kept the mask on her face. The medical registrar had organised a high dependency bed on Intensive Care and I told Anna I was going to get her ready. I fastened an ID band around her wrist making sure it was loose enough if they wanted to take more arterial gases or put more lines in.

I’d called one of her relatives and they were on their way. We got the go ahead that the bed was ready in ICU and, after photocopying her notes and making the machinery portable, we were on the move upstairs. I’d measured Anna for an airway and slipped it onto my pocket. I knew from other transfers it always pays to be prepared. Onetime we were transferring a patient to the medical assessment unit and
the patient
stopped breathing. The three quarter mile journey to the other side of the hospital was isolated and I just said “Run.” It
was too far to go back. Luckily, the rush of cold air hitting the patient and a quick sternal rub from me
started
the patient
breathing again.  The staff back in the ward were oblivious to my need in the long corridor and were surprised when I told them what happened.

Anna continued to breathe on her own, but at a rate that was still worrying. I was glad to transfer her off our trauma bed and onto the ICU bed. She was hooked up to their monitors and again sat up right but she still looked incredibly scared.  I handed over the patient to the ICU nurse and wished Anna all the best.  I hoped she would be alright, but I understood that she was still struggling to breath and was tiring and more technical interventions may be made. I called ICU the next day to see how she was doing and they told me she hadn’t been intubated and had stabilised overnight. She was being moved to the medical ward that day for further investigations.

During my days as a student nurse, part of my emergency department placement was the opportunity to experience a day with the paramedics. It is usually a foregone conclusion that they would get no call outs the day that I am there and that I would sit in an ambulance all day with nothing to do. I hoped this would not be the case.

  I made my way enthusiastically to the ambulance base that morning and was greeted with faces full of smiles. I am a petite 5 ft 6 and they gave me a bright yellow luminous jacket which happened to be a large male size which hung over the ends of my hands.  Nevertheless, I folded the sleeves over and was happy that I would stand out at any accident scenes, even if I looked like a kid wearing her dad’s jacket. My first job was to get a tour of the ambulance and check everything was in working order with my paramedics.

I had never seen inside an ambulance before and it was so neatly packed, with cupboards full of securely fastened equipment. Each space had something in it. The ambulance was cold from spending the night in the ambulance garage and I thought of how different this working environment was from the emergency department. I became familiar with where the oxygen cylinder was and masks and tubing, syringes and medication; all the same equipment I had seen in emergency but hidden from display. No sooner had we finished checking the equipment and restocking, than the phone rang and our number was called and put into action.

As a learner, I didn’t know exactly what I was meant to do and what would happen next but I was indicated to sit down and buckle up in the back in the one seat facing front next to the trolley. The two paramedics climbed in the front and within thirty seconds, we were on the road. It was definitely a case of phone rings, seatbelts on, and on the road without delay. I found the back of the ambulance was very noisy and rattled a lot. We had packed the back with everything that we would need and every available space was cramped with something. It was all securely fastened, but at the speed we were going, I thought everything was bound to fall out and roll around on the floor. The paramedics discussed the route they needed to go and they decided the back roads were quicker or they would have to double back on the motorway. I couldn’t believe how fast the ambulance went. The passenger paramedic had a clipboard and was writing notes. I couldn’t see exactly what he was doing but he shouted back, asking if I was ok and I said “yes.” The sirens were very loud, it amazes me how people cannot hear them a mile off.

We were going to attend a person with chest pain, so making progress was essential. Any delay and there was the risk his condition would deteriorate into cardiac arrest. The ambulance hurtled along the back roads, the height allowed visual clearance over the short cut hedges and the blue lights and the yellow and white flash made cars stop in plenty of time. I was being bounced around in the back with every bump in the road we went over and being pulled right and left around every corner. I was very pleased to be belted in.

At one point, we were about to go over a narrow bridge and a Volvo driver was coming the other way, not leaving any room for us to get past.  The dead weight of the ambulance just about stood on its nose as it was pulled to a stop by the skilled paramedic driver. We all looked at each other and breathed a sigh of relief that the ambulance had good brakes.

We were getting nearer to the location we had been given and up ahead, we could see the fast response paramedic car had beaten us to the scene. Not surprisingly the paramedic car can go faster than the tonne weight of the ambulance and it manoeuvres much better. The car has only one paramedic in it and is usually first on scene to give immediate treatment until the ambulance can transport the patient to hospital. It is usually deployed if it can reach a scene within 8 minutes, but it cannot take passengers as the lone paramedic is the driver and cannot do both jobs at once.

The patient had taken children with learning difficulties to school and on the way back, stopped the car after experiencing chest pain. The initial tracing of his heart showed no cardiac changes and the fact the pain had resolved was good. The paramedics directed him to the ambulance trolley and further assessed him there. They administered oxygen via a face mask at 10 litres per minute and took a thorough medical history while gaining IV access. The drive back to emergency was much slower and I was able to watch the paramedic in the back calmly monitor the patient. The pain had resolved prior to the first paramedic arriving but nevertheless, the patient was very shaken and we took him to hospital for further assessment and treatment.

Once in emergency, the paramedic handed over the patient to the triage nurse and he was transferred onto an emergency trolley. I said hello to my supervisors on placement, restocked the equipment we had used such as oxygen mask and tubing, bed linen and cannula and repacked the ambulance. As we were out and about, we drove to a parking space near a bridge over the motorway to wait for further emergency calls. No calls were received and the morning dragged into the afternoon. Both paramedics got in the back and taught me how to attached ECG pads and let me practice taking blood pressure on them both. It was really great that they were keeping me interested and assisting my learning.

That afternoon, I had an experience that would direct me into trauma nursing. The paramedics had a call out and we were despatched to an area of road not far away from the ambulance station. The roads that day were slimy wet, it hadn’t rained but the roads just hadn’t dried up from the previous night’s rain. The information we got was that a driver was trapped inside a car. Fire engines and police had been called for. I remember looking out of the window at the hedges flying past and my eyes rapidly moving from side to side. I saw the fast response paramedic car racing past us like we were stood still when we were doing about seventy mph. We had barely enough time to write down departure and arrival times on the paramedic chart and put gloves on before we had arrived at the accident scene.

From the skid marks on the road, it looked like the car had lost control somehow and veered across the road,  stopping on the other side of the road in a hedge. The car had taken most of the impact on the driver’s side.  The door was crumpled in and glass window smashed, but it was the right side up at least. We assessed the situation. The lone paramedic was alongside the driver, fitting an oxygen mask over his face. The ambulance paramedic carried his orange equipment bag with him to the scene and I followed behind with the driver. The car was down a grassy wet embankment next to a hedge so we had to carefully walk down the embankment to reach his driver’s side door.

The patient was in pain and confused, his dark denim jeans were a sodden red colour over the left thigh and blood was running down the back of his neck. The car door was jammed and there was no way he could get out from the driver’s side. It appears there was no airbag in the car and the patient clearly had a head injury which was indicative of serious impact and potential neck injuries. The paramedic quickly measured and fitted a C spine collar around the patient’s neck while he was sat up in the car seat and continued to assess him for other injuries. The patient was conscious and began to indicate where he hurt. It looked like he had a compound fracture of his femur.  As he was in intense pain and bleeding, we were unable to move his leg. The patient indicated that he had been driving at the speed limit when he lost control, so essentially that meant an impact of 60mph.

He looked pale and clammy and due to his positioning, it was hard to get access him and assess his vital signs. The paramedic measured his pulse at his own risk and estimated his blood pressure also. He padded him down to see if any other areas were injured and the man said his chest hurt from the steering wheel impact. The car was so smashed up all the paramedic could do was lean in through the window and try to get a cannula in his
vein. The paramedic used his scissors and cut up the length of the driver’s right arm to get access to his brachial vein, a large vein in the arm that can take a large cannula, which is used to give fluid quickly. The patients hadn’t gone into shock yet and his veins were easily accessed.

The patient was given a prefilled syringe of morphine for the pain. Fluids were primed through an IV line and attached to the patient’s vein. I assisted by holding the fluid up high so it would drain in easily. How different it was, being outside when giving medical treatment; no drip stand here. We could see that the patient was losing blood from his head and leg and so we gave him a pad to hold over his bleeding thigh.

The police had stopped all traffic and I saw cars until I could see no further, over the hills on either side of the accident. The fire brigade had arrived and asked what we wanted them to do. The patient had already taken off his seatbelt but because of his probable fractured femur, couldn’t get out of the car. He had hit his head pretty badly and it was still bleeding through the several wads of gauze placed by the paramedics. The oxygen was running low and I was asked to get our supply from our ambulance. I passed the IV bag to another paramedic and brought back our oxygen cylinder. The paramedic thanked me and, looking at my size, suggested that I apply pressure to the patient’s bleeding head, because no one else could fit inside the car. I stuck on a helmet and leaned in the car through the window. I didn’t think about my safety or if anyone had turned the engine off. I just reached in as comfortably as I could.

I automatically began talking to the patient trapped in the car. He had glass cuts all over his face and a bloody nose. While the fire fighters tore away pieces of metal from the passenger’s side door, the patient told me that he was just starting up an outdoor adventure holiday business. The foot and mouth disease outbreak had deterred all the tourists from coming to the area and he was at a loss. The car accident was just another thing he didn’t need. Time was getting on and although the patient was talking coherently, we needed to get him out and to hospital. The bleeding had slowed down and someone passed me some tape so I could tape the gauze to his head without moving his neck in the C spine collar. I stopped leaning through the window.

The fire fighters carried what looked like a big metal claw out of the fire engine. The paramedics explained to the patient what was going to happen and partially covered him with a blanket. They removed the head rest from the seat and put a hard hat over his head for protection. Two fire-fighters removed the front and passenger window from the inside and then another placed the ‘claw’ around the door frame. The hydraulic cutter was extremely loud but spilt open the metal in a matter of seconds. The passenger’s side door was removed and then the top of the car ripped off like it was tin foil. The fast response paramedic had called for a helicopter to come to the scene as the patient had been trapped in the car for over an hour. It felt like twenty minutes to me.

Once the roof was removed and the driver’s side metal trimmed, the paramedics lowered the patient’s seat back as far as it would go and, with one paramedic holding his head and neck stable, we slid the spinal board underneath him. It seemed easily done to me; the paramedics and fire officers worked very well together. The helicopter could be heard but not seen. The patient was belted onto the spinal board and carried up the grass embankment to a waiting paramedic trolley. There his shoe was removed from this injured leg to assess for circulation and his trousers were cut to reveal a large wound with white bone piercing through the skin. More gauze padding was applied.

The grand yellow helicopter had arrived and was hovering effortlessly in the sky, above the empty road and waiting traffic. The police waved for it to land on the road and as it hovered, great gusts of wind made everyone stand solid near the ambulances to give about 10 meters distance; I held onto my hard hat. The helicopter landed and the engine was cut
and s
ilence followed and trees swayed back to their original position. A
helicopter paramedic in an orange flight suit emerged from the sliding door at the side to meet the paramedics with the patient. He wore a large flying helmet equipped with a microphone
.

After a quick interlude, a gathering of paramedics and I wheeled the trolley to the chopper. The chopper was cramped inside and smaller than it looked from the outside. It was difficult to get two people inside in order to slide the patient across on the spinal board. The patient was loaded feet first into a cramped area, snug as a torpedo launcher. The pilot stayed at his controls in the helicopter while the activity occurred in the back.  I was amazed how calm and in control all the paramedics had been. There was just enough space to have the air paramedic work from one side of the patient and lean over to reach his other arm. I was on such a high as the helicopter blades began to whirl and the machine went straight up in the air, then turned around and flew off into the distance.

I looked at my colleagues, one of the paramedics had blood wiped on the side of his face and another was picking up swabs and fluid bags from the surrounding area. I looked at my hands and the cream plastic gloves were covered in both blood and black oil and dirt from the scene. We left the fire officers to remove their equipment from the car and after doing a final check to see we hadn’t dropped anything, we packed up our ambulance. We borrowed some equipment form the fast response paramedic to stock up and he called to us that he was going back to base to stock up.

We were on the road again, ready and waiting for the next call out.