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I haven’t been terrified at work for a very long time. I remember brand new experiences as a student being ‘scary’; but with time, education, exposure & experience, they became more infrequent
Alas, I can categorically assure you, it still happens!
A thread
/1
Alas, I can categorically assure you, it still happens!
A thread
/1
[Details altered and only the minimal will be discussed. This isn’t theatre and you’ll understand why]
Cat 2: 7yr F - Chest Pain / Breathing Diff (Known Asthmatic)
OA:
Atonic, GCS3, RR10 grunting, minimal chest movment, silent on auscultation
Uncle futilely trying inhaler
/2
Cat 2: 7yr F - Chest Pain / Breathing Diff (Known Asthmatic)
OA:
Atonic, GCS3, RR10 grunting, minimal chest movment, silent on auscultation
Uncle futilely trying inhaler
/2
With those CAD details - the mental rehearsal en route was a “routine” asthma exacerbation
Calm and de-escalate
Peak flow
10 puffs of own
Maybe some nebulisers
...like the hundreds before it
/3
Calm and de-escalate
Peak flow
10 puffs of own
Maybe some nebulisers
...like the hundreds before it
/3
The audible screams of a mother, audible prior to even stepping out of the vehicle
As combat indicators go, this is one of the most powerful
I’ve unfortunately experienced it multiple times before and there are very few contexts when it’s a false alarm
It is not replicable
/4
As combat indicators go, this is one of the most powerful
I’ve unfortunately experienced it multiple times before and there are very few contexts when it’s a false alarm
It is not replicable
/4
The plan did not survive first contact
Little one was in a heap at uncles feet in a tiny bathroom. Desperate ongoing attempts to administer an inhaler
There are tough rooms to walk into and this was definitely one of them
/5
Little one was in a heap at uncles feet in a tiny bathroom. Desperate ongoing attempts to administer an inhaler
There are tough rooms to walk into and this was definitely one of them
/5
Rehearsed contingencies
Rescue as a clinical intervention
360 access
Snatch rescue
Space creation
Environmental manipulation
Whatever you call it in your world, this needs to form part of how you train.
It creates physical AND mental space
It’s control
It’s our terms
/6
Rescue as a clinical intervention
360 access
Snatch rescue
Space creation
Environmental manipulation
Whatever you call it in your world, this needs to form part of how you train.
It creates physical AND mental space
It’s control
It’s our terms
/6
That will be the only bit of gratuitous positive self-reflection
I created space. I optimised position. I ended up knelt with little one lying against my legs & chest - sat up.
Kit to one side allowing me to treat & maintain as best a position for resp function as I could
/7
I created space. I optimised position. I ended up knelt with little one lying against my legs & chest - sat up.
Kit to one side allowing me to treat & maintain as best a position for resp function as I could
/7
This isn’t an overtly clinical thread. If there are queries and discussion that arise from it, fine...
In a nutshell:
Solo paramedic
Optimise position
Enable bronchodilators
Upgrade & req. Critical Care
Try and look after mum
That’s what happened in the first few minutes
/8
In a nutshell:
Solo paramedic
Optimise position
Enable bronchodilators
Upgrade & req. Critical Care
Try and look after mum
That’s what happened in the first few minutes
/8
Other things happened later...
Adrenaline, hydrocortisone & magnesium for example
However that’s not what this is necessarily about
/9
Adrenaline, hydrocortisone & magnesium for example
However that’s not what this is necessarily about
/9
Now we circle back to my initial point
Fear
Up until the second neb, everything was unconscious ‘autopilot’. It was a pre-planned response to a mentally rehearsed scenario
The upper end of stretch, verging into strain.
/10
Fear
Up until the second neb, everything was unconscious ‘autopilot’. It was a pre-planned response to a mentally rehearsed scenario
The upper end of stretch, verging into strain.
/10
During the intial minutes; things were not getting better, perhaps even worse. Everything that could be done was being done...
/10.5
/10.5
I distinctly recall the point where I considered that this child may die in front of me
There had already been a recognition of unwell
There had equally been a recognition of life threatening features
I’d also considered/prepared for a ‘paeds asthmatic cardiac arrest’
/11
There had already been a recognition of unwell
There had equally been a recognition of life threatening features
I’d also considered/prepared for a ‘paeds asthmatic cardiac arrest’
/11
But this was not another clinical consideration...
There was a tangible moment where it all changed. Where the gravity of the human experience became so palpably strong
It was visceral
This was suddenly terrifying
/12
There was a tangible moment where it all changed. Where the gravity of the human experience became so palpably strong
It was visceral
This was suddenly terrifying
/12
This is a good news story. This little human was one of the most incredible fighters I’ve ever had the privilege to meet
But before they managed to quell my fear by fully demonstrating this; other factors played a part - that’s what I’d like to discuss
/13
A second solo paramedic arrived...
The cavalry
Reinforcements
Back-up
I couldn’t have asked for more
It’s important to reflect on what makes this support what it is. How do we best back up that colleague who is overwhelmed or at their limit
/14
The cavalry
Reinforcements
Back-up
I couldn’t have asked for more
It’s important to reflect on what makes this support what it is. How do we best back up that colleague who is overwhelmed or at their limit
/14
My handover over the crowd was “Chris. Asthma. We are properly poorly”
They wouldn’t have had eyes on at this point
He dropped kit outside and navigated the family and small corridor arriving with just the essentials; more oxygen included
/15
They wouldn’t have had eyes on at this point
He dropped kit outside and navigated the family and small corridor arriving with just the essentials; more oxygen included
/15
The full handover was poor. I didn’t know as much as I’d have liked to (I hadn’t had that chance yet)
But this colleague knew that
In the chaos he was calm
Listened to what I knew, asked my plan and where he could help. He promoted suggestions I hadn’t considered
Perfect
/16
But this colleague knew that
In the chaos he was calm
Listened to what I knew, asked my plan and where he could help. He promoted suggestions I hadn’t considered
Perfect
/16
Sounds simple, but arriving at a semi established scene well is an art form & he hit the nail on the head
I was ****ing myself & his positive integration into the incident is was kept my feet on the ground
When it’s all going wrong. Your colleagues need you to ‘be Chris’
/17
I was ****ing myself & his positive integration into the incident is was kept my feet on the ground
When it’s all going wrong. Your colleagues need you to ‘be Chris’
/17
*if he’d turned up and berated me for not checking a blood sugar yet im certain there would be murders
/17.5
/17.5
The crew that arrived after knew the craic
The updates from on scene had made it through
They’d arrived with an extrication plan already. This was huge. It was suggested gently as not to conflict with any solution we’d potentially come up with (we hadn’t thought that far)
/18
The updates from on scene had made it through
They’d arrived with an extrication plan already. This was huge. It was suggested gently as not to conflict with any solution we’d potentially come up with (we hadn’t thought that far)
/18
They arrived with momentum, entering the scene matching the pace of interventions in the room
Don’t arrive to a life threatening asthma attack with your hands in your pockets or carrying paperwork... just don’t be that guy/girl
/19
Don’t arrive to a life threatening asthma attack with your hands in your pockets or carrying paperwork... just don’t be that guy/girl
/19
An advanced paramedic was next through the door. He embodied the role.
Just like Chris he listened.
He quietly agreed with the plan. Reinforced that we were all over it.
He was going to retire to the vehicle to draw up his drugs; he’d meet us there when we were down
/20
Just like Chris he listened.
He quietly agreed with the plan. Reinforced that we were all over it.
He was going to retire to the vehicle to draw up his drugs; he’d meet us there when we were down
/20
I wasn’t terrified anymore
A solo who enabled us to give the full spectrum on scene
A crew who bossed the extrication
An APP who reinforced us, trusted us and encouraged us. A leader
I’m extremely lucky to work with such incredible human beings
/21
A solo who enabled us to give the full spectrum on scene
A crew who bossed the extrication
An APP who reinforced us, trusted us and encouraged us. A leader
I’m extremely lucky to work with such incredible human beings
/21
This reflection is not on the management of life-threatening / near fatal asthma
It’s on these incredible clinicians and colleagues who were my force multipliers
I recognise that I was at my absolute limit - I needed them more than they know
/22
It’s on these incredible clinicians and colleagues who were my force multipliers
I recognise that I was at my absolute limit - I needed them more than they know
/22
Recent events only highlight the attrition of 999 work
It saddens me how often our own systems and cultures make the core clinical work harder
So, where we can; be Chris, be that crew, be that APP
We’re all in it together and when it works we save lives
/end
It saddens me how often our own systems and cultures make the core clinical work harder
So, where we can; be Chris, be that crew, be that APP
We’re all in it together and when it works we save lives
/end
