By the rules.

In ambulance, there are rules. Nobody in particular set them.We cannot change them. They simply exist.

It was late at night, and we were called to a rural property: 33 year old female, seizures.

The front yard was overgrown, the house was dark and we wound our way through the narrow hallway passages to the tiny bathroom where a man was calling out for our help.

Inside, we found an obese woman seizing, her legs tangled in the bottom of their toilet and her head jammed up against the wall.

Rule number 1) Sick patients will always be tricky to access.

Asking the man what happened, we received a flurry of answers. A burning pain in the bottom of her neck. A horrendous headache. Next vomiting. Then she fell down and started seizing.

“How much does she weigh?” we queried as we began to draw up the midazolam “146 kilos” was the less than ideal reply.

Rule number 2) Unconscious patients are always overweight, and always hard to extricate.

Having given the first does of midazolam, the seizure activity began to slow. 20mg later when it eventually ceased (in addition to the marijuana and alcohol we’d learned she’d had earlier in the evening) we could finally assess her properly.

Airway was a mess. Trismus, with blood and vomit seeping out the sides. Breathing was a mix of irregular slow snores and ominous gurgles as stomach contents were being aspirated.  Blood pressure was 150/ 72: but there was a disturbingly large gap between our systolic and diastolic. Heart rate around 70, and spO2 at 96% with oxygen. GCS 5 as she intermittently posed in decerebrate posturing. BGL 8.6. Temp 36.1. 3 Lead ecg normal. No obvious head or major injuries.

We called for our intensive care back up: 30 minutes away at least.

Rule number 3) When you really need it, back up is never available.

Forcibly, we moved her into a place where we could try and manage her airway. Between bouts of trismus, we were able to get an OP in. More blood. More vomit.

We begin preparing for extrication. As we find out more about her history and medications we discover more good news: She’s hep C positive.

Rule number 4) When there’s bodily fluids around, there are always nasty things inside them.

Rule number 5) When there’s something important you should know, nobody tells you until long after that it became important.

By the time our back up arrived, we had her cannulated and as close to packaged as we could. The 4 of us managed to get her out on a spineboard.. Reassessing in the truck it was clear she was deteriorating, and likely she had a cerebral bleed. Wider pulse pressure. Bradycardic pulse. Irregular Resps: Cushings Triad, now with decorticate movements.

We pre-notified, and commenced the long drive to hospital, doing our best to handle the increasing vomit and blood being sprayed at us through the OP airway. As we left, the male partner on scene seemed completely indifferent to the health of our patient. After stating the name of our destination and how serious her condition, he simply gave a nonchalant shrug and asked almost absent mindedly, “so I guess I should go up there at some point then?”

I’m still not sure if that woman survived. Having viewed the CT it was clear that there was a significant sub-dural bleed and a marked midline shift of her hemispheres.

What I do know is that it was the first ‘big’ job that I’d run as an intern that I was actually satisfied with my management in.

I’m curious to know though: who thought up these rules and why do patient’s always fell that they have to follow them so closely?



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