Archive for the ‘medical’ Category

Within our profession (Emergency Medical Services) we have challenging and “head scratching” cases which no amount of education and experience can ever prepare you for.

I have been a degree Advanced Life Support (ALS) Paramedic for 14 out of 20 years, the first 6 years spent as a National Diploma and having recently updated my  Advanced Cardiac Life Support (ACLS) certificate thought I could deal with just about any case thrown at me, until I was faced with that very strange, head scratching situation recently.

I am attempting to explain the case taking into account medical professionals as well as trying to explain the case to the non-medical followers.

I responded to a chest pain case, and upon arrival at the scene, was greeted by fellow ALS Eutimia Garces, who had assessed the patient and requested assistance. She has been qualified over 2 years as an ALS and has experience in excess of 10 years in the industry, but had never encountered a cardiac patient this critical. Her assessment of the patient revealed some interesting information with regards to basic vitals and she had initiated treatment with intravenous cannulation (drip) and oxygen via nasal cannula in an attempt toward maintaining a SPO2 (oxygen saturation) of greater than 90% since the probe was not picking up pulsatile blood flow.

The patient’s vital signs were as follows:

  • Palpable thready carotid pulse at a heart rate of 214 (the ECG “heart” monitor confirmed this rate)
  • Electrical Cardiogram (ECG) presenting a Ventricular Tachycardia (V.Tach) – for the non-medical folk, this is an abnormal heart rhythm that can prove fatal.
  • Non-palpable blood pressure, recorded as 50 mmHg (dangerously low) systolic via a manual sphygmomanometer (blood pressure cuff).
  • Skin condition was grey, pale and clammy.
  • Patient initially was responding to verbal stimulus only, but with a small 50 ml bolus of fluid, became alert and orientated with a blood pressure of 60 mmHg (still dangerously low, but at least his brain was working)
  • The patient presented with severe chest pain throughout the initial interaction prior to sedation.

With regards to history, this proved to be even more interesting:

  • 65 year old male patient with an extensive cardiac history: 10 Acute Myocardial Infarctions (Heart attacks) and 26 minor non-debilitating strokes over the past 6 years.
  • Patient was on an extensive list of medication all specific to chronically managing aberrant heart arrhythmias.

Identifying the severity the condition, we all realised that the only effective method of treatment would be synchronised electrical cardioversion.

For my non-medical followers, allow me to briefly explain a few of the terms used:

  1. Ventricular Tachycardia 
  • A V.Tach is a type of regular and excessively fast heart rate that arises from improper electrical activity in the muscle and electrical pathways of the ventricles of the heart. With a normal heart rate ranging between 60 and 100 beats per minute, I’m sure you can imagine how hectic and dangerous a pulse rate of 214 would be. The ECG for the patient can be seen below

2.  Synchronised Electrical Cardioversion

A synchronised (perfectly timed) electrical shock is delivered through the chest wall to the heart via pads that are applied to the skin of the chest. The goal of the procedure is to disrupt the abnormal electrical activity in the heart and “reset” the heart to allow the natural pacemaker of the heart to restore a normal rhythm. The interruption of the abnormal beat allows the heart’s electrical system to restore a normal heartbeat.

Shocking someone who is conscious is an extremely painful experience and can be mentally traumatic for the patient, which means that some form of sedation is both compassionate and beneficial to the patient.  The dilemma Eutemia was facing, was that the patient clearly needed sedation before the procedure,  but the extremely low blood pressure excluded the use of the only two medications that ALS Paramedics carry for this purpose namely Midazolam (Dormicum) for sedation and Morphine for sedative analgesic effects. Fortunately, as ECP’s we carry a wider range of medications capable of have similar benefits without as significant side effects.

My wife, Nicole de Montille (who was with me at the time is also an ECP and an ACLS Instructor) and I debated the merits of Ketamine or Etomidate (Hypnomidate) to use for the sedation of the patient. These two medications are known in the anaesthetic and emergency environment for their anaesthetic and analgesic benefits.

Being concerned about the cardiac effects Ketamine may produce, it was decided to use half dose Etomidate, which was successful in its sedative qualities, and the patient was sedated without compromising his breathing effort.

With the patient sedated, synchronised  cardioversion was performed .  In my personal capacity I have done this many times during my career. Normally after cardioversion, I have seen a brief period of asystole (flat line) as the heart resets itself, followed by a relatively normal heart rhythm.  What occurred with this patient however left us all feeling more than a little worried and relieved in the space of approximately 15 seconds.

 

Click on image to view in full screen – ECG edited to protect case information

As you will note in the above ECG, the cardioversion successfully shocked on the R-Wave as expected;  What was not expected was that the patient went from V.Tach straight into Ventricular Fibrillation (V.Fib).   This abnormal and erratic twitching of the heart muscle can be likened to a bag of worms all wanting to move in different directions, however the problem is that this situation fails to produce a ventricle contraction which is necessary to keep the patient’s blood flow moving.

I’ve never experienced nor witnessed this happening ……….ever!! Neither Eutimia nor Nicole had ever been exposed to a patient presenting like this either.  Within a matter of seconds the monitor was set to 150J (as recommended by the manufacturer) and defibrillated (shocked the patient without synchronisation) and successfully converted the rhythm to sustainable heart rhythm with contractions and sustainable blood flow.

The patient was transported to the nearby emergency department at a hospital with extensive cardiac facilities, where he woke up a few minutes after arrival, conversing with the staff and looking far better than before sedation and treatment.  As for his vitals, a radial pulse rate of 82 and a blood pressure of 110/70 – both definitely within normal ranges.

Whilst the case was mentally challenging and, to be honest, quite scary, it was one of the most satisfying one.  Witnessing a rapid turn around in the patient condition from life threatening to conversing and looking as if he had experienced a minor “episode” at the hospital.

Thank you Nicole and Eutemia, we made a dynamic team and saved a life that day.

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Today, 10 years ago…

Posted: September 11, 2014 in accident, Keanu, medical

… I was an operational Advanced Life Support Paramedic for one of the national private ambulance companies in Durban.

It was a time for me when I was at a very low point in my life. I was frustrated working in Durban, just moved from one company to another, burnt out after many years of seeing the affects of irresponsible parents when their children have drowned, drunk drivers walking away from the carnage they caused, the savage torture of innocent families during house invasions and the daily violence which has become so common it didn’t make any news stories.

This very night I met a family at their most extreme period of vulnerability, a fateful meeting which I can honestly say changed my life. Even today, looking back on 18 years of operational experience as an ALS Paramedic, I can count on one hand the cases which really effected me.

I have shared much about young Keanu https://carlsstuff.wordpress.com/2010/07/20/that-special-one/ and I can’t believe that his life changing moment which occurred at a mere 3 months old was 10 years ago. It feels like yesterday I arrived on that scene. I can still see the vehicles on the wet ground from the rain earlier in the evening, the reflection of the flashing lights from the police vehicle creating an eery feeling and the all familiar aroma of an accident scene. A distinctive smell which EMS around the world can relate to.

Looking at Keanu now, seeing how he has grown with his ever increasing challenges and the permanent effects of a massive head injury and cerebral bleeds, I’ve often thought why do we as healthcare professionals try so hard to save lives. We study for many years, have the most updated knowledge and skills to perform the impossible in the most difficult situations, only to see the long lasting effects of an injury such as this.

And then, it’s this very miraculous child, that answers my own question. He was for all intensive purposes brain dead, with the family accepting the inevitable of making the most difficult and heartbreaking decision any parent can make, and one pray changed all that.

Those who know me, will know I’m not a very religious person. I believe in a Supreme Being who created all and in salvation, but that’s as far as it goes! But…. I can honestly say, this pray worked !!!…. He woke up and lived.

His injuries has resulted in excessive long term disabilities, the latest being osteoporosis. But through all this, he has brought joy to his parents lives, a happy little boy who thrives on his mom’s love, and knowing nothing else but the love he feels from his family.

Why am I writing all this? Quite simply to assure all EMS practitioners out there, that whilst we save the lives on a daily basis, and ponder as I have as to the validity of our actions, it does make a difference. Always believe that, because despite the long term outcome and how we feel when we see that, we must always be cognitive of the fact that you have performed the ultimate act anyone can provide…. You saved a life, and allowed them to live !

Last night I was browsing through the traffic stats on my blog, and going into some of my older posts which had been viewed, and I realised something…

It felt like a dream going through the posts of Keanu, Brandon and countless others in my “medical, death and accident” categories. The rants I had on child safety after treating countless broken little boys and girls, the emotional posts of terrible cases and the horrors that humans do to each other, and trying to sum it all up in my last post as an operational paramedic https://carlsstuff.wordpress.com/2011/08/26/the-winds-of-change/

I remember every case I have been on in all my years, and yet, having been at EA for 3 years, it feels like a lifetime ago. In fact, almost like it wasn’t me at all, but rather viewing my memories as a 3rd person.

I vowed never to return to the road, and yet I find myself sitting with an emptiness that can’t be filled. Looking back then, and reflecting now, as illogical at it seems, I am a mirror image in a parallel universe that is so different, should we ever meet face to face, we would pass each other without a second glance.

It was a world where my doppelganger found love, experienced sadness, felt pain, witnessed nightmares and dreamt the past. In this world, I have found a passion and purpose in the boardroom which is challenging and rewarding, and ever still, the two worlds threaten to collide and become one.

Perhaps a cosmic collision is required to reduce the black hole. One never knows as we plod on in our diverse altered realities.

a Hero’s prayer

Posted: September 12, 2011 in death, Firefighters, medical, Poem, poetry
Tags: ,

dedicated to the heroes of 9/11

 

Brother when you weep for me
Remember that it was meant to be
Lay me down and when you leave
Remember I’ll be at your sleeve

In every dark and dreary night
I’ll be there as you fight
On every road in driving snow
I’ll hold your coat and you will know

On blackened highways hot with searing heat
At windows where a gate you meet
In darkness where young children hide
You know I’ll be there at your side

The House from which I now respond
Is over staffed with heroes gone
Men who answered one last bell
Did the job and did it well

As Medics we understand
That death’s a card dealt in our hand
A card we hope we never play
But one we hold there anyway

That card is something we ignore
As we push beyond our limits for one call more
For we know that we’re the only prayer
For anyone that might be there

So remember as you wipe your tears
The joy I knew throughout the years
As I did the job I loved to do
I pray that thought will see you through.

Author unknown

 

… are upon us…..well….ME!

Since starting studying, I have worked operationally for 17 years in various roles. I’ve been a paramedic, a Station Officer, an Instructor and course coordinator, a Flight paramedic on helicopters and airplanes, a manager at different private ambulance services and thinking back, I’ve had the privilege of responding at high speeds on the roads in Johannesburg, free state and Durban in  a wide variety of cars.

Ford sierra , opel kadetts, mazda 6, ford telstar, ford mondeo, Toyota camry, audi A4, BMW 328, Golf GTI, Jetta TDI, Toyota RXI, RunX, Colt rodeo, Subaru WRX, Subaru Legacy….hmmm, I could go on, those are the memorable ones.

I have been the the most fortunate person saving many a childs life, seeing the joy in parents eyes when they realise their precious creation has lived through a tragedy.

I have been the unfortunate person, resuscitating countless children due to parents neglect in the form of drownings, car accidents, firearm accidents and abuse. I cant tell you how many small lifeless bodies I held in my arms, after fighting to keep them alive, with tears rolling down my cheeks.

I have delivered many a baby, in shacks, in mansions, in the open veld and inside cars.

I have broken the news to wives that their husbands of 50 years have passed on,seeing the sadness when realisation hits them that for the first time in longer than I have been alive, they are alone now.

I have witnessed the after effects of spousal and child abuse, I have comforted small children after their mommy have been killed by their abusive daddy. I have treated hundreds of gunshot victims, under constant gunfire sometimes, assaults, stabbings, burns…. I’ve seen the savagery of the human race, torture, rape, and other atrocities i’d prefer to forget.

I have responded to thousands of motor vehicle accidents, cut up countless cars,

 

 

 

 

 

 

                                                                                                      witnessed the luckiest people surviving spectacular crashes

                                                                                                                                            seen cars in trees

                                                                                                                            cars in precarious positions

                                                                                                                                      Truck accidents

                                                                                                                       rubbish trucks rolling into gardens

                                                                                                                                Bus and train accidents

                                                                                                           mountain rescues (I even broke my wrist on this one)

                                                                                                                                      even ship rescues

Basically, I have seen every atrocity, experienced sadness and grief, witnessed the worst you can imagine…..

BUT

I have been the most fortunate person around. I have been in a profession that values life, working alongside heroes, men and women who dedicate their lives, their family time to help others, regardless of the pain they experience. And now, its time to hand over the reigns to the younger generation.

its time for me to pack my jumpbag away, hang up the rescue jacket.

I salute all the paramedics, Firefighters, Police officers, and all those involved in the Emergency Services still out there. You guys are doing a fabulous, rewarding job (even though it doesn’t feel like it).

The fire burns hot!

Posted: May 1, 2011 in Firefighters, medical
Tags:

last night I responded to Battery factory that was on fire on the east rand of Johannesburg. When we arrived, it was in one section, and spread rapidly to the rest, completely gutting the entire factory and warehouse.

unfortunately, I didnt have my camera with me, but a  colleague did. Not a photographer himself, he gave me the camera to snap away, and snap away I did, after getting  a crash course on the camera. I use a Nikon, and this was with a Kodak.

…and it all falls down….!

Posted: January 29, 2011 in medical, Photography

A few years ago, I did a short stint in Welkom, a small mining town some 300 km from johannesburg.

One day, i was fortunate enough to watch a demolition of an old building, and I had a perfect birds eye view, as i was standing right next to the dude that had the honour of pushing the button..