In the Midst of Life (50 page)

Surely
and slowly, medical progress has been made and many new protocols, policies and procedures have found their way into the ambulance service. Paramedics these days are proficient in 12-lead ECG interpretation, can diagnose and provide definitive treatment for myocardial infarction by administering thrombolytic clot-busting drugs – every minute a coronary artery is occluded depletes life by about eleven days – so our early intervention and treatment in the pre-hospital setting is improving the quality of many patients’ lives, as well as the quantity who survive.

New paramedics, these days, are trained by universities with the emphasis more on education and less on the sort of vocational training that I completed. The new cohorts of paramedics are selected from those who successfully complete a three-year degree course, with the opportunity for all paramedics to extend their training to become paramedic practitioners (PPs) and critical care paramedics (CCPs).

The paramedical degree courses are separated into academic modules covering a range of subjects such as introduction to medical care, trauma care, public health immunology, and foundations of paramedic practice, which covers use of ambulance equipment and clinical skills, and the different sections of anatomy and physiology which are broken down into the various systems of the body – cardiology, neurology etc.

In the first year, the student paramedics cover all the basic education, and by year two they train alongside established paramedics and work as part of an ambulance crew (although they are not allowed to practise autonomously). As the course continues, they learn new practical skills, and complete various hospital and clinical placements to complete their education. Clinical skills are practised under the supervision of experienced paramedics, who have also completed a practice placement educators’ (PPEDs) course.

At the end of three years, all the education, clinical skills and experience from working on the front line allows the students to join the ranks of the rest of us registered as paramedics by the Health Professions Council. Every paramedic has to re-register
every two years and maintain evidence of clinical professional development to remain on the register – failure to do so could result in a paramedic losing their registration and being unable to practise, in the same way as doctors and nurses must show development.

Our PPs and CCPs undergo degree-level education for an additional eighteen months, and, once qualified, have even more developed examination skills, and can provide more comprehensive roadside care to the patients in the community and at home – our PP clinicians can provide catheter care, perform suturing and wound closure, prescribe broad-spectrum antibiotics and, in some areas, are working alongside general practitioners in facilitating diabetic or asthma clinics.

Our CCPs are working alongside doctors and anaesthetists in providing cutting edge front-line care to those patients most critically ill, working on helicopters and specialist ambulances equipped to transfer patients in drug-induced comas safely between hospitals. This reduces the need to use doctors to look after anaesthetised patients.

Our area now encompasses Kent, Surrey and Sussex in the South East Coast Ambulance Service or SECAMB. The newest advances include a FASTrack Stroke Pathway – we work very closely with all our hospitals so that, when we are dispatched to a patient showing a positive test for a stroke, we can deliver them directly to the nearest hospital able to deliver thrombolytic therapy to dissolve the clot. Stroke patients are now being discharged home and are back at work in weeks – a long way from the treatment a few years ago, when a stroke victim was likely to be paralysed for months, years, or worse.

SECAMB is also the first ambulance trust in the UK fully to follow a new cardiac arrest protocol for out-of-hospital cardiac arrest where the first rhythm is ventricular fibrillation.

SECAMB is now delivering resuscitation based on emphasis for effective cardiac compression, which has been championed by our honorary life medical director, the world-renowned cardiologist Professor Douglas Chamberlain, CBE, who has, for many
years, been our greatest advocate, and has worked tirelessly training paramedics.

Our Protocol C resuscitation procedure for patients presenting in ventricular fibrillation is leading the way in pre-hospital resuscitation in the UK. Some of the latest clinical audits published in 2009 for survival following cardiac arrest rate SECAMB as the highest performing ambulance service in the country.

Dying differently

So what exactly does happen when a member of the public dials 999 to a collapsed patient who is terminally ill? Our role is to preserve life, prevent deterioration and promote recovery – but can we always achieve this? What is the dilemma that we, as ambulance paramedics, face when we are called to a patient at the end stage of their illness?

All ambulance service clinicians – technicians, paramedics and advanced paramedics – work within the guidelines of the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). These guidelines are very specific, and state that in the event of being called to a cardiac arrest or near life-threatening event we are obliged to initiate resuscitation unless we have sight of a formal Do Not Attempt Resuscitation (DNAR) order or an Advance Directive to Refuse Treatment.

A patient who is deemed to have mental capacity has the right to refuse treatment, even if not having that treatment leads to deterioration in health and ultimately death. A patient who is unconscious cannot make that decision; it has to be made for them – and in those circumstances, in the absence of any lasting power of attorney by a relative, all steps of active resuscitation would be undertaken unless a DNAR is shown to the ambulance crew.

This formal DNAR must be in writing and given to the crew on arrival at the call. The condition must relate to the condition for which the DNAR is written, so resuscitation should not be withheld for coincidental conditions.

In the case of a known terminally ill patient being transferred to
a palliative care facility, the DNAR can be verbally received and recorded by ambulance control.

In an out-of-hospital emergency environment, there may be situations where there is doubt about the validity of an advance refusal or DNAR order. If the ambulance crew are not satisfied that the patient has made a prior and specific request to refuse treatment, they are obliged to continue all clinical care in the normal way.

I am constantly reminded of how my decisions to provide clinical care for patients I attend can have a lasting effect on quite often distressed and highly emotional relatives, who have witnessed the sudden collapse of a cherished one and act on impulse by calling an ambulance … I have the equipment, the knowledge and the clinical skills to initiate and continue advanced life support and resuscitation, and in the absence of any written order I have to do so … Or is this always the case?

I may be ‘just’ a paramedic, but I have empathy with the suffering of the sick. That’s why I am a paramedic and do the job that I do, surely?

Dealing compassionately with end-of-life patients

Whilst I am very aware that many members of the public urge us to do ‘everything we can’ to save a life, my seventeen years of ambulance service experience have shown me that a good many elderly or terminally ill patients do not require the services of a paramedic; in their time of need, they want peace, or a priest, or, in some cases, both. That is the area that I will now go on to discuss.

About ten years ago I was working on the night shift. It was a little after midnight when the crew received a call to attend a ‘ninety-six-year-old female, breathing difficulty’. We arrived shortly after the call was made and knocked on the door at the address we were given. An elderly man opened the door, and gestured for us to follow him. We traipsed into the house with our equipment and were led into the front room where a very elderly lady lay on a single bed in front of a fireplace.

The
lights were dimmed, but I could see that the lady was dying. Her breathing was bubbly, laboured and intermittent. She was unconscious and her eyes were shut, but she was twitching a little bit. My eye caught an empty ampoule of diamorphine discarded on the mantelpiece.

The man began to tell us his story. The lady in the bed was his ninety-six-year-old sister. He was ninety-four, and had lived with her all of his life. My crewmate and I exchanged nervous glances, and the distress visible in her face was most probably echoed in mine. He continued that she had been diagnosed with cancer a couple of years ago and had fought it bravely, but was now nearing the end and had expressed her wish to die at home – in the comfort of her own bed, in the house where she was born, with her brother for company. He realised that the time was near and was scared. He was terrified of her dying, and wanted to make sure she wasn’t suffering.

The family doctor had visited in the afternoon and given her a pain-killing injection. She had been sleeping peacefully ever since, but in the last hour her breathing had become increasingly worrying to him and she had begun twitching.

He couldn’t get hold of his doctor, and the GP surgery had redirected his enquiry to the out-of-hours doctors; they had simply instructed him to dial 999. That is how we ended up there.

We sat down and reassured the man. ‘We’ll phone the out-of-hours doctor back, ask for the palliative care nurses to come and be with you and get her some more pain relief so she isn’t in any pain.’ He was so grateful; you could see the tension lift from his face.

I made the phone call and explained the situation to the out-of-hours doctor, and said that we required a palliative visit. He refused point blank to attend and ordered me to take that poor dying lady from her nice warm bed to the accident and emergency department. I was nearly speechless, but attempted to reason with him that it was inhumane to suggest such a thing, the lady was dying and nothing we could do could halt the fact. He adamantly refused to consider it. He was the doctor, I was only the ambulance
‘driver’ and was not in a position to disobey his request. ‘Com-passionless’ was my thought, or maybe something stronger, I regret to admit.

How do you explain this to a distressed relative? That you have to drag his dying sister unceremoniously out of her deathbed and cart her off to the local accident and emergency centre, to be poked and prodded, and then breathe her last on a hospital trolley surrounded by the drunks and assaults that frequent A&E during the night shift? But he was understanding; we had no alternative but to obey medical orders.

We went and fetched our carrying chair, two big warmed blankets and a pillow to prop her up. I knelt on the bed behind her, and, as we lifted her into a semi-sitting position before settling her into the chair, she died.

I looked at my teammate and she nodded. We laid the woman straight back down in the bed, still warm from where we had lifted her up, smoothed her eyes over and covered her with the quilt.

I went to fetch her brother from the kitchen, and we all cried. How unprofessional, I hear you say! I knew in my heart it was the best thing for her. I phoned the out-of-hours doctor again, informing him that now the lady had died, he would
have
to visit and confirm death (in those days we did not perform recognition of life extinct).

Having personal experience as a relative also puts a whole new perspective on the whole end-of-life-care issue. This is something that I experienced for myself in 2008 when my own mother died from a chronic lung condition. It was the spiritual epiphany of this event that spurred me on to help our ambulance service develop a better insight into end-of-life care and how we can be of benefit to patients who are dying.

The death of my dear mother was, without a doubt, the most life-altering event of my existence.

She had a condition known as chronic obstructive pulmonary disease (COPD). She had lived with this for many years, but had been particularly unwell for the year preceding her death, and was
being looked after mainly by the respiratory team at home where she had her own oxygen and nebulisers. She had suddenly been admitted to hospital with an exacerbation of the condition. The consultant told my elderly stepfather, Bernard, that there was nothing more they could do for her except ‘keep her comfortable’.

Mum was only sixty, and it was not until I went to visit her in hospital and saw her so ill that the terrible truth dawned on me that she was dying. I gathered the family round.

It was the most numbing and distressing thirty-six hours of my entire forty years. My brother Matthew (also a paramedic) rushed down from his home in East Anglia. We sat beside her all night and had some deeply intriguing conversations during those dark hours.

‘It’s quite ironic, isn’t it?’ mused Matt. ‘If either one of us received an emergency call to a patient of Mum’s age, who was unconscious and breathing like this, we would be intubating her, nebulising drugs, giving intravenous diuretics and rushing her into A&E as fast as we could.’

He had a point, and yet we sat there, helpless, while Mum’s breathing continued to bubble and struggle, the relentless dull sound of the oxygen hissing away, a constant background noise making my head spin. In the small hours of the night she grew distressed and started moaning and twitching. I went to find a nurse for some help. The doctor wrote her up for some morphine which the staff nurse administered. I asked her how long it would be; Mum’s vital signs were all over the place, her breathing and pulse rate were hugely elevated and her oxygen saturations very low. She had a raging temperature of 40.1.I wasn’t used to watching people die – I was meant to stop that sort of thing from happening. I was shivering on the little chair next to her, my hand tightly grasping hers, its heat keeping me warm in the depth of the night. Another doctor popped in to see Mum. I was beginning to panic.