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Cardiac Arrest in A&E (I)

Posted Jan 28 2012 9:46am

Placement week. I was posted to Quentin’s hospital for three 12 hour shifts  in A&E. I walked into reception area of Quentin’s at 9.40am. A man who bore an uncanny resemblance to Russell Brand in both appearance and dress was pacing up and down. He wore black women’s pumps, black leggings, and dirty black duffel jacket. His face was unshaven and hair was unkept and matted. Smudged eye-liner framed bleary eyes. Just another day at A&E. He strode up to the receptionists before me and, in a surprisingly well-spoken voice, consulted them on something, I’m not sure what. They spoke to him just as they spoke to me, in a non-judgmental, courteous manner. 

Mouse came through the double doors from Majors. He had started before me at 7am. ‘This way for your scrubs Jeromeo’, an affectionate suffix the cohort’s adopted for me ever since I tried chatting up one of the lecturers during an online assignment admission.
I put a blue scrub shirt on top of my Service issue white T-shirt. This could be dangerous, people might think I was medically trained. We’d been instructed to have scrubs on instead of our shirts because there were issues with the hospital staff thinking we were ambulance crew just passing through rather than here on placement. Bottom down we still wore black Magnum boots and the forest green combat trousers. Or is it more of a bottle green? I’m never sure. 
The advice I’d been given by Esther Lemsip, who was at Quentin’s Hospital yesterday, was to ‘stay in Resus!’ They’d been five nurses down in Majors yesterday and she’s basically been drafted in as an extra pair of hands, changing bedpans, preparing beds etcetera, on the understanding that if anything kicked off in Resus she would be able to observe. This was not the case. She heard about juicy cases from the patients. I checked in with the sister in charge, nodded to her suggestion of spending time in Majors, reception and triage, and walked straight to Resus, where I stayed for eleven out of the twelve hours. ‘There’s a COPD patient in there at the moment, you should check it out’ said Mouse earlier. She was in cubicle seven, lying on her bed like a toad. She had a grossly swollen stomach from oedematous and cellulite. Her mouth was open wide like it trapped in the middle of a giant yawn. She had an oxygen mask on delivering low levels of oxygen. She was unconscious and responded to neither voice or pain. It was extraordinary to see her recovery through the day. She could speak, and in my eyes changed from being a lump of flesh in need of treatment to a human being, complete with son-in-law and basic human needs. The three most pressing of which were a wee, a sandwich and a weak cup of tea, although  in which order she couldn’t decide. ‘E’s nice’, she said pointing at me and nudging the nurse. I didn’t quite know how to react, to I smiled sheepishly. ‘You’ve been pulled!’ Cackled Meesha, the Resus sister. ‘I’ll get your sandwich shall I?’ I said, walking off. This wasn’t the last time during the placement I was to be approached by a swollen, ageing woman with rotting teeth, but that, and the surprising outcome, is another story. Oh well, a compliment’s a compliment!
Things started to get busy in the early afternoon. Sepsis was the order of the day, and it seemed two in every three people coming through Resus doors had this very dangerous infection of the blood. The time I spent the most with was Barton, or Feston, he answered to both. ‘How are you today Barton?’ The doctor bellowed. ‘Oh brilliant, just brilliant, brilliant, brilliant’, he repeated quietly, eyes closed and smiling serenely. He looked as happy as Larry, waving his hands in the air as if he was conducting an unseen orchestra. Sadly his condition deteriorated as the day wore on from mild to severe sepsis. He became confused and agitated and tried ripping out his cannula needles in both arms if he wasn’t restrained. I spent a long time just holding his arms as he struggled silently, eyes firmly closed. It was no mean feet: he had a strength that belied his meagre frame. His nails dug into my gloved fingers – he really didn’t want those needles in! We gave up with the oxygen mask on his face. Gone was the orchestra, the serene look he bore when we first admitted him replaced by a grimace. Eventually, two pretty anaesthetists came down and put him to sleep with an impressive cocktail of drugs. It was a tense time considering his very low blood pressure and cyanosed state, which probably accounted for his confusion and subsequent combativeness. He was intubated, which basically means a tube was inserted into his mouth and down his trachea to secure his airway. We wheeled him upstairs to ITU [Intensive Therapy Unit], where he started to come to.

Just after Barton had been anaesthetised, one of the Emergency Department Doctors poked her head round the corner. ‘Er, Meesha, can I have a hand?’ A look was exchanged between them. Meesha ran round with her. The next thing we heard over the hospital intercom was a crash call for a cardiac arrest in Resus. Within 30 seconds a whole team of doctors and nurses flooded through the double doors. This is the aggressive team approach that Klippity Klop told us about. Everyone previously working on Barton went around as well apart from the anaesthetist, who was still looking after his airway. The patient was an 88 year old male who had been brought in earlier that afternoon with sepsis together with his wife. They had been discovered by their GP who went round after they had failed to turn up for an appointment. The police had forced entry, and ambulances were called straight away. They think his wife fell over, and whilst trying to help her up he fell on top of her. They have no carers either and no relatives to help them. His wife was in the cubicle next to him, separated by a thin partition of surgical blue curtain. She suffers from quite advanced dementia, so one can only hope she was unaware of the terrors next door.

A nurse was already delivering compressions whilst two defib pads were stuck on his chest. Because of the strenuous nature of compressions, we shared the load. This was the second time I was delivering compressions ‘in anger’, but the first time in a hospital environment watched by a team of medical professionals. I had the Beegees ‘staying alive’ running in my head to gauge the speed of the compressions, which should be between 100-120 beats per minute. Thankfully because of all the mannequin training we’ve received in Bethleham, muscle memory takes over and it’s not a matter of thinking but of doing.

We would never try and resuscitate this patient. He is, as we call it in the medical profession, headless
The patient had been intubated to secure his airway. A doctor was at the head end and was suctioning the vomit from his mouth. ‘Oh dear’ he muttered, wincing: what was left of the man’s yellow stumps of teeth were crumbling at the touch of the suction tube. I was giving compressions at the time and was staring into his mouth. Perhaps in any other situation I would turn around and wretch my guts out, but this course and this environment do strange things to your tolerance of such things.
After what seemed like just a few cycles of CPR, 55 minutes had gone by. ‘Okay guys, the patient’s not improving, he’s still in VF [Ventricular Fibrillation], he’s 88 years old, even if he did recover now he’d be severally brain damaged. I think we should give it another five minutes then call it, does everyone agree? The last five minutes felt more symbolic than anything of use. It was a morbid show, going through the motions for the sake of completeness. We felt like a team, 1-0 down in the dying few minutes of a match with absolutely no chance of winning. The lead doctor had one more look at the monitor. Still VF. ‘I’m going to call it. Everyone agreed? He looked around. Some people were nodding slightly, others were just looking at the floor. ‘Time of death, 16.47. Thanks everyone’. The team floated back from whence they came. Resus was quiet once more, the hurried, precise voices replaced by the subdued bleeping of monitors. 
It was up to Mouse, the sister and me to dress the body in a shroud. We cut off what few craps of clothing hadn’t already been chopped already, and put him in the white tissue gown. Whilst turning the body on its side, bright yellow liquid dribbled out of the mouth, dripping into a little puddle on to the floor. The lysosomes in his cells would now start to decompose his body. The heart’s uncoordinated shuddering would become fainter and would eventually stop. A sheet of paper was stuck to its chest before wrapping the body in a white hospital bed cloth and taping it up with surgical tape. It looked like a giant present waiting for some unsuspecting birthday to unwrap. It was my birthday the next day. Happy birthday to me. This all felt so surreal and yet strangely normal.
At 7.15pm A crash call came in over the tannoy. The woman’s voice was remarkably cheerful considering the seriousness of the situation. I wouldn’t have been surprised to hear of reduced price pees in aisle eleven. ‘Cardiac arrest in Resus, Cardiac in Resus, ETA 8 minutes’ she chirped. The room was flooded once more. The pre-alert was of a 35 year old male with no cardiac history collapsing in a shopping centre. Here we go again…

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