Things you might not realise...

We all know there are risks associated with obesity which will seriously impact on your health and quality of life, but something not many people realise is that the problem goes beyond your life and into your death - and our attempts to return life.

I've had a few cardiac arrests now where the patient was morbidly obese and the outcome each time has been a non successful resuscitation. In addition to all of the associated health conditions of morbid obesity leading to an arrest, there are a few points you might wish to ponder...

Many morbidly obese patients are confined to chairs or beds, which is where we usually find them and are forced to try to move them to the ground before effective resuscitation attempts may begin. This can sometimes be an impossible task - anyone who has had to carry a slumped body will know just how heavy and awkward it can be, but when the patient is at an estimated 190-200kg the task becomes almost impossible. While at least 2 ambulances are always dispatched to arrests, it is usually the first ambulance with usually 2 officers who are forced to try to make this move, and while occasionally family, friends or bystanders can assist the danger of injury placed on the officers is sometimes so high that they are forced to wait for more help before the move can be made. Sometimes the patient will already be on the ground, but if the patient is on their side in a confined space or simply has too much mass to effectively roll, the result will be the same - decreased effectiveness of chest compressions which will further reducing the viability of the patient.

Of course, even once the body has been placed in an optimal position a morbidly obese patient may not receive effective chest compressions due to the additional adipose around the chest. With some obese patients chest compressions, although placed correctly with the correct amount of pressure, result in the heart being moved 'side to side' rather than compressed and effectively pumping blood to resume circulation. Sometimes it is simply not possible to achieve the correct amount of chest compression with the chest being significantly thicker.

Airway access is also significantly more difficult and ventilation harder with the bulk of the body decreasing lung inflation. Cannulation becomes more difficult which can delay IV drug administration, and one of the greatest tools of resuscitation - defibrillation - can be less effective with decreased conductivity to the heart due to the additional impedance. While many defibrillators will detect impedance and attempt to adjust the current delivered with each shock, there is only so high the machine can go before the risk of burns and electrocution to other organs becomes too dangerous.

Should resuscitation be effective, or the patient is producing enough of a viable rhythm to be deemed by the paramedics transportable, there are then issues of moving the patient to an ambulance stretcher capable of bearing their weight. In NSW we have stretchers rated to 160kg and 180kg, with patients higher than that requiring the use of a custom built vehicle for bariatric patients. As there are very few of these custom built ambulances, there can be considerable delays from when the initial ambulance arrives to confirm the arrest and to call for the vehicle to when it can arrive on scene with the required equipment. These stretchers also require a large amount of room, and specialised lifting equipment with up to 10 ambulance officers sometimes being required to lift the patient can delay loading times. Once the patient is at hospital there will be issues in transferring the patient to the hospital bed, with resuscitation sometimes continuing on the ambulance stretcher due to necessity. Of course, all of the other issues listed above still continue, with potentially decreased effectiveness of CPR, manual ventilation and defibrillation.


None of this is to say that the efforts made by paramedics, nurses and doctors are any less than for any other patient - regardless of the age, race, gender or size of the patient our efforts are always to the best of our abilities to provide the patient with the best chance of a viable outcome. Every patient deserves compassion, respect and care - every patient and their family will have fear, feel grief and loss. But sometimes we know what the outcome will most likely be, and that the factors involved will decrease the chances of that outcome being positive and we will attempt to prepare the family for this fact.

When people see us arrive at an arrest they gain hope that their loved one might be brought back - that they have another chance of taking another breath.

Sometimes they don't.

The other side of the glass

Day 1:
Had a rough nights sleep, went into work and slogged through a day shift. Transported a Patient with ?Gastro and after a bit was feeling a little under the weather. Got home, made a quick dinner, decided to call in sick for the next shift and went to bed. Woke up 11pm with a general abdominal pain, thought 'damn gastro' spent the next few hours trying to ignore the pain.

Day 2:
Around 4 hours after the abdominal pain started and... other... gastro-like symptoms, I decided I'd better pop into the local hospital for some fluids and maybe an antibiotic to clear the system. Get admitted quickly (thanks friends in triage!), am reviewed and discharged a few hours (and 2 liters of fluids to get back to normotensive!) later feeling a bit better, abdo pain somewhat lessened. Get home, abdo pain gets worse.
General trend continue through day, until I notice it's starting to migrate predominantly lower right quadrant. Uh oh. Rebound pain? Damn. Rovsing's sign? DAMN. It's around 11pm and after a momentary contemplation of calling an ambulance (the people at station would never let me live it down!) I make my way back to hospital... ?appendicitis.
I'm admitted VERY quickly (thanks friends in triage!) given the circumstances where I wait for what I know to come shortly.

Day 3:
Come to think of it, at this point I hadn't slept since Day 1. Am reviewed shortly after midnight by a wonderful ED doctor who confirms my provincial diagnosis (why couldn't she just take my word on the Rovsing's sign? That hurts like F*&%). I'm sent to surgery for an emergency appendectomy. I wake several hours later, a few minor scars and, compared to the abdo pain of appendicitis I'm pain free!

The recovery:
Well I hate being limited by what I can or can't do, but hey... That's life. What I have found invaluable from the whole experience is what it's like going through the system from the patient's perspective. It's completely different from what I had expected and I cannot sing praise for the fantastic work the doctors, nurses and fellow ambo's did for me while I was admitted. As part of the Health system I've known how stuffed up the system is for a long time, but to see the system MADE to work by those inside for the benefit of their patient was incredible and once more I am proud to be a part of it.

I'll keep everyone updated with how I go from here!

EMSPA (NSW) Inc.

Lately I've been caught up working for EMSPA (NSW) Inc., an Assocation of Emergency Medical Service Men and Women fighting for the rights and legal protection of their peers.

Suffice to say this has kept me very busy, but has been a very rewarding and educational experience for me. This experience has also made me VERY grateful for my time spent with the Biomedical Society, which at the time was a fun almost hobby like activity - now many of the same principles and legalities are applying (with of course some alterations), the Association is run by Committee and I feel much more at ease with the way things are done thanks to the previous experiences.

Which makes me glad that I took the time when I was younger to do these sorts of things... I tend to be a real work-a-holic, always trying to keep myself flat out doing SOMETHING - at times the weight has made me tremble but so far I've held steady. I've learned my limits - although I push them from time to time to see if they're still there, and it's only when I look back do I realise that by the age of 23, I've already accomplished things that make me proud of how I've lived my life. And I only plan to achieve more and more before I'm ready to hit the grave.

The biggest lesson I have to learn is to take more time aside from WORK to SOCIAL... But more on that another day.

Smile! EMSPA has your back, Brothers and Sisters - and we're all dedicated as hell to make this work!

All things must change

Months since the lost post here, much has changed.

Firstly, the job has changed. Where I used to wake terrified and excited each morning, wondering what jobs would come down and if I would be able to handle them, I now wake tired, never feeling like I get enough rest and looking forward to the next set of days off, which seem few and far between.

Not to say I don't still love the job - the excitement still gets me and the adrenaline can still get pumped through my system several times a day on the good days, but the bad days are now more monotonous and 'auto-piloted', as if my body and mind lie in wait of 'the next big job'.

Where once I would have a slight tremble in these 'big jobs', despite knowing exactly what to do and be doing it, my hands are now calm, still - my mind sure and planning at least two steps in advance. I've approached major overdoses, CVA's, respiratory distress and cardiac arrests all with the same confident, calm approach that once seemed so comical about the profession but has now become a stable flow of my life.

The wife is frantic, her husband having overdosed on many tablets of tricyclic antidepressants, his ECG shows things are not looking good and his level of consciousness is dropping with each passing second. She runs at him, grabbing him and trying to 'help' move him to our stretcher. I calmly pull her off her husband, force her to face me and not him, tell her how she can help by finding the empty medication wrappers, let us look after him. My partner and I position him laterally, maintain his airway, oxygenate and load him into the Ambulance. The wife has left us, running from room to room as if she can hear the packets calling her, but she cannot quite work out where they are.

Secondly, I have changed. I still make the bad (good) jokes, smile frequently and small talk, but the naievity of my youth is now long gone and I can't help but feel somewhat colder inside. I realise how little of my youth I took advantage of, partying little and studying perhaps too much, and while I know technically I'll still be a youth for several more years I feel older - aged beyond my time. But I am still happy, loved and in love, if anything now appreciating more the sheer preciousness of life, so easily lost, so easily wasted and so easily enjoyed and cherished - made more than just time on this planet, an experience to hold dear and utilise to it's most full. 'On job' I comfort and counsel those who have lost, those who are losing and those who fear for their loved, I show sincerity and understanding and have been told I'm good at it - but it feels as if it comes from someone else, some other source, because in reality I am cold inside to steel myself from the emotional aspect of the daily onslaught of misery we face, and must face.

The wife is crying, sobbing into her hands. We are prepared to leave the scene and she steps up into the Ambulance passenger seat. She was unable to find the medication packets and again feels a failure and powerlessness that only someone watching a loved one dying can ever understand. I tell her that her husband is in a serious condition, but that we are monitoring him closely and will have him at the hospital shortly for definitive care. I comfort her best I can, talk with her to find out more of the details of what had happened, the little facts that at first don't come out but can drastically assist treatment. I weigh our options; try to look myself for the packets, further delaying transport but perhaps having a better idea of what we are up against, or transporting knowing some of the story but getting us to hospital quicker, where many hands make stabilising this patient much easier. On arrival the patient was talking, albeit nonsensically, but now he is only responding to painful stimuli - even then only with much effort. I decide to go with the latter, and we pull out of the driveway.

There is a dangerous balance in this job. Care too much and you can't seperate yourself from your jobs - the misery consumes you and the sheer weight of suffering crushes you. Care too little and you seperate yourself from your jobs completely - you become too cold, burnt out and resenting the patients more and more each day. The balance varies from day to day - sometimes you need to care too much, remind yourself that you are human and the importance of the decisions we make between seconds that can save or damn a human life. Sometimes you need to be cold and untouchable, shield yourself from the onslaught. As long as you can find that middle ground again, survive and endure.

We arrive at hospital and rush him into a Resuscitation suite. A frenzy of bodies, hands, minds and tools check vital signs, draw bloods for analysis and ensure the body stays ventilated,the heart beating sufficiently. The wife is moved to the waiting room for what will be the longest few hours of her life.

The world has changed. Or at least, my understanding of it has. This 'first world' country is far from it. The addage that a person is smart, but people are stupid takes on a greater understanding and the acceptance that people do very strange, often stupid things in 'emergencies' is made. People live in squallor. People live in filth. People live in luxurious mansions with bedcovers that cost more than I make in a month. People have children, children have children. People make mistakes. People get hurt, get sick, get old.

People die.

I always knew about and understood death, but there is a familiarity you make with it after many encounters. There is an essence to it, a feel that cannot be described or conveyed. Sometimes even an anticipation en route to the scene, somehow we know what we will find.

The wife has gone home, although I doubt sleep will find her tonight. Her husbands blood still moves around the body, oxygenated and delivering nutrience to the organs. He is to be transferred to another hospital for acute high dependancy care, although his outcome remains unknown.

We have finished our paperwork, submitted the report to the hospital and move back to the car. We push the little button to make us 'Available' again, and we await the next job. As always we don't have to wait long, and a siren wails off into the night, the previous job cleared from the mind as routines, protocols and plans are laid for the next patient.

All things change, but for now I know where I am in life, where I am going and what roads lie ahead. 

And I am happy.

Morning Mist Part 2

The mist is back this morning... Calm, beautiful, like the last breath of air the earth ever takes.

He lies in the grass, motionless. He's been still for quite some time, and the mist has claimed him as her own. Two dogs - his dogs - bark at the gate a meter away, one excited by this strange new game his master has come up with, the other angry that these two men were probing their master, connecting strange things to him and shaking their heads slowly.

They were young dogs, with many years left in them. Their master, also young, unfortunately did not.

The two men walk back to their van, nodding to the other men, police, that the job was done. Their breath mists in the cool morning, tiny clouds fall and vanish almost before you could acknowledge them...

Two dogs bark, the men drive away, leaving the master in the care of the mist.

Car vs Pole

Pole always wins.

It was towards the end of a day shift, it was becoming dark and we were looking forward to heading home for the night. Dispatch, as usual, had other plans for us.
"We're going to send you down to a MVC, no details at present - unknown patients unknown status".

The Mobile Data Terminal (MDT) flashed with the job and we ran lights and sirens to it. I threw on my fluorescent safety jacket and gloved up - I hate jobs marked 'unknown status'... Even though the descriptions are usually wrong, they put you in the mindset of what to expect. Unknown means you might get there to find a parade of elephants storming through... or maybe not.

We arrived shortly after, a crowd had gathered around a car wedged between a brick wall and a pole - the opposite side of the pole to the road... Now that takes effort. The car was empty, and it took a moment for people to respond when I asked 'Was anyone hurt? Who was in the vehicle?', a young male sheepishly walks forward.

On examination he seemed fine, and although we made numerous offers to take him to hospital he refused - our examinations only go so far, there may have been internal trauma we cannot possibly detect without scanning equipment, found only in hospitals. Still, he was happy enough to make his own way home via his girlfriend - but what really got to me with this job was his attitude.

"Yeah... this'll be the second time I've done this..." he laughs. "No scratches, I'm fine."

A grin on his face, as if he's almost proud of what he's accomplished.

"Lucky there were no pedestrians nearby - this would have killed them. School finished only a little while ago..." My eyes betray my disdain, I care about his welfare but it's obvious it's not about him as a person. People like this who have no regard for others or the impact of their actions make my blood boil. It will take another accident and a life lost before anything will sink into his head.

The smile is wiped off his face, he mumbles something about going to his girlfriend and we head off. It was our last job, and I went home wandering how the story might have unfolded if any one of a million variables were even slightly different and was glad that they weren't.

I doubt he spent the night the same way.

Kids are indestructable... almost

So there we were, two ambo's driving around minding their own business when all of a sudden our terminal flashes.

We have a job!

Usually this would be cause for groaning and mumbling (joking, I swear) - but this call would lead us into a late meal and thus more pleasant pay packet. There's always something to celebrate in life.

We head down for a '?#' - possible fractured limb. The destination is a sporting oval that my TO knows well, and as we head down we see a game of under 12's rugby in play - this is going to be good. Coming from a different state, I never really got into rugby - but from what I've been able to gather the game essentially consists of one team trying their best to kill another team.

We knew then that if this was going to be a fracture, it was going to be done properly - and we weren't disappointed. We pull up at the windmill (otherwise known as a person frantically waving at an ambulance * see note below) and see not too far off a boy around 12 holding his arm and looking rather sorry for himself. His arm shows us why. He'd managed to break both bones of his forearm, the Radius and Ulna, the limb distal to this break flopped painfully with each movement he made.

He still had good circulation and sensation to the hand, something very important to check - because if the break has somehow damaged the vasculature or nerves it's going to be a very speedy trip to hospital for emergency surgery. I gave him some meds for the pain which almost knocked him out. The parents were a little worried about his decreased level of consciousness, but a quick chat convinced them it was for the best - what we had to do next would be something he probably wouldn't want to remember. As gently as possible we maneuvered the arm into a padded cardboard support, the poor boy still let out a semi-conscious groan of pain, and we slung it into a supported position. The meds are fairly quick to wear off, and as we drove off to the hospital we were able to have a bit of a chat and he told me about the game, which for the record ended in a tie.

I'm not sure exactly how many people have been inside a moving ambulance, but I'll give you a hint now that they're bumpy. We kept the poor boy on pain meds but still each pot hole and bump in the road left him a little sore.

We left him with the lovely doctors and nurses who promised to take good care of him, with a promise of ice cream being heard from a nurse as I walked through the exit.

He was going to be just fine...

* Note: To people who insist on waving to an ambulance while the lights and sirens are on - please don't do this unless you're the person we're going to - or at least going to take us to the person we're going to...