Bright Lights, Big City.

Whilst working on a Double Manned Ambulance on a day shift we were dispatched to a bus terminal to reports of an adult male collapsed. I was working with Tom; an Emergency Care Assistant and Mel, a first year Student Paramedic.

On the way to the job I was driving, so I had Mel in the front – a lot of the time students sit in the back so it’s nice to swap this around to get the full experience. It also meant I could ask her questions or run through scenarios on the way to the job – something that challenged the student and kept me focused.

“Talk me through your Primary Survey” I would ask. Mel would reel it off word for word, these algorithms were drilled into the students.

We also designated positions in case the patient was in cardiac arrest –“Mel, I would like you to do the immediate assessment and then if worst comes to worst you start the compressions from the patients side”

Tom” I called through the divider that allowed me to look into the back of the ambulance when driving . “If needed you can get straight onto bagging and sort the airway while I do drugs and get access.”

With everyone prepped, we carried on toward the job. As we pulled up the bus staff were waving us in. As we got closer I looked over and could see a man lying on his back, star-fishing. At his head knelt a lady knelt down, doing mouth to mouth.

I heard Mel take a deep breath. I new the feeling – she was trying to quell the adrenaline that was now surging. I quickly re-iterated the roles I had delegated.

“Mel, make sure you arent distracted by the CPR. You need to quickly pause it, do a pulse check and then start chest compressions if you cant feel one. If your not sure just let me know.”

As I got out the drivers side I could hear the door slide open on the side. Tom jumped out and started handing out all of the kit we would need; the primary bag, the secondary ALS (Advanced Life Support ) bag, the oxygen, suction and monitor.

We approached the patient. As we walked towards the patient I took in the scene around me. This was a busy bus terminal – there were many people stood around. Most were watching. Some were filming. The police had arrived just behind us and were helping the bus station staff to get screens out to give us, and most importantly the patient some dignity.

The patient was lying on his back, his eyes were open and his head was bobbing off of the floor in time with the very effective compressions. Mel kneeled down at the head end and performed a head tilt chin lift to open the airway. All the while I was gaining a history from bystanders.

It turned out the patient had got off of a bus with friends when he looked a bit disorientated and fell to the floor. His friends however, were nowhere to be seen.

Mel quickly stopped the compressions and felt for a pulse.

“I have a pulse” she proclaimed. “No effort of breathing”

“Plan?” I asked her. In my head, I had already made it.

“I think we should start bagging” Mel stated. Excellent.

Without hesitation Tom passed Mel the equipment she needed to do this. It was all prepped. Tom had done the one thing I love in a good ECA. He had pre-empted what would be needed and had it ready. I made sure that Mel was OK with ventilating the patient. She had inserted a basic airway and was getting good chest rise – she was doing great. I told her.

Over the 60 seconds I quickly did a primary survey. I found the cause of the collapse pretty quickly. As soon as I cut the sleeves up the patients arm I found tract marks. He was an intravenous drug user.

I pointed this out quickly and asked Mel what the treatment was.

“Naloxone” She replied. Great.

We drew up a dose and gave it quickly by intranasal administration.

It was effective.

We got the patient onto the ambulance in order to facilitate his transfer to hospital. The patient was coming to a bit more – ideally I wanted to keep him groggy. In my experience, when you reverse the effects of an illicit drug that the patient has taken by administering the life saving medication that prevents the respiratory depressant action of said drug; it can go one of two ways:

A) They are grateful. They apologise for what’s happened and usually come to terms with the fact that they need to be transferred to hospital.

B) They aren’t grateful. They become agitated that you have in effect wasted their money. Despite the fact that in doing so you have saved their life.

This patient was a B.

“GET OFF OF ME” The patient yelled.

We reasoned with him. We attempted to calm him down. For a couple of minutes it worked. The patient explained that he had been on the bus for ages and decided that he would “shoot up” in order to make the trip faster. He had taken some heroin from a new dealer and in his own words:

“It was much stronger”

After this discussion the patient went about refusing treatment. This is often the case with heroin overdoses. Once assessed to have the capacity to make this decision we offered him the alternative, an injection with a loading dose of Naloxone in order to help mitigate any second pass effects of the drug and boost the existing dose. The patient agreed and this was given.

Up until this point the patient had been refusing treatment but had not been particularly aggressive. However, as soon as he looked down. This changed.

“Who cut my F****ing jacket!?” He yelled, looking down at the rags on his arm where the arms of his jacket should have been.

I explained that we had to cut his jacket in order to get to his arms when we tried to look for a vein to cannulate. With this he jumped off of the trolley.

Screaming and shouting incoherently the patient started moving towards Mel. She was between the trolley, monitor and attendant seat. Completely trapped.

Luckily, Tom had already seen this happening and managed to slide the response bag in front of the patient. This gave a bit of distance. Tom then slid open the side door. The door rolled open and to my amazement; there, arms crossed, were a couple of police officers.

The patient was grabbed and dragged off of the ambulance. Kicking and screaming. The police restrained him and he calmed. I explained the situation and the patient was still refusing treatment.

The police reasoned with the patient, took my concerns and communicated these to the patient. The patient still refused. Fortunately, the police had a plan for this – the patient had assaulted one of them in the struggle.

They explained that they would arrest him – and he would be monitored in custody by a clinician there. Although not ideal for the police, the patient would be safe.

Mel was fine. A little shaken, but fine. I realised this as soon as she thrust her portfolio towards me beaming.

“Airway management signatures please”.

I signed the competency. After all. She had earnt it.

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