Sam’s Blog- A final year medical student elective in Aix en Provence. Week 7 – some challenging experiences with SMUR

I’ve just woken up from an afternoon nap, following a 24hr shift with the SMUR team and I am knackered! It was a very full on 24 hours and I could probably write a book about it… Our first call out was to a lady with COPD (BPCO in French) at a pulmonary rehabilitation centre who was unconscious, with a suspected hypercapnic coma. After a pretty long drive we arrived and found her  a bit more responsive (GCS ~12 compared to 9/10 previously). The rehab centre had a ABG machine which was very useful. Initially her pH was 7.17, improving to 7.19 about 30 minutes later with the help of some non-invasive ventilation. Both ABGs showed a huge respiratory acidosis (normal range 7.35 – 7.45) due to a lot of retained CO2, which was about 68mmHg (normal 35 – 45 mmHg).  We transferred her to small hospital in Aubagne (~40km south of Aix), where she was known by the respiratory team. Enroute giving her some nebulised salbutamol, then struggling to get the BiPAP mask back on properly but succeeding eventually.

On our way back we were sent a call to a patient at a psychiatric hospital who had lost consciousness and fallen down ~3 stairs. He was aphasic and unable to move his left arm, with no sign of any pupil asymmetry. Initially, it was easy to discard this presentation as a medication overdose or psychiatric behaviour but was important to carry out a thorough examination. Later on that day when at the hospital we discovered he had had a primary intracranial bleed and a likely a secondary one after falling, but was stable.

After a quick nap following lunch we were called to a patient with chest pain at the prison in Aix. I’ve never been in a prison before (and hopefully wont be going back any time soon), but it wasn’t a pleasant experience. The number of huge doors and barbed wire we drove through made it feel like we were going into Jurassic park. Fortunately for us the patient was already in the medical wing, and not in his cell as walking past all the cells can be a particularly unpleasant experience I was told (probably even more so for the female doctor and nurse I was with). The patient was 60 and had been discharged from hospital a few days previously following investigation for chest pain; there was a slight change on the ECG so he was admitted to hospital. The exit procedure was even more time consuming than entering as he had any of his personal belongings removed and was restrained in hand and ankle cuffs – not a particularly comfortable transfer for him. I have no idea why he was in prison and I think it was probably better that way.

After eating that evening we were called to the middle of nowhere to a man with extensive cardiac history (5 previous heart attacks) and chest pain, as it had taken a while to find the house we didn’t receive the warmest welcome (“oh it’s just women that have arrived”). However, the patient was adamant that he wasn’t experiencing any chest pain. The first couple of ECGs scared me, as it looked very much like a ventricular tachycardia (I think at this point the family were asked to wait downstairs), and I was asked to draw up the drugs that would be needed to sedate him if we were going to shock him. The experience and calmness of the doctor allowed her to perform a few more ECGs – on which the rhythm started to look more irregular, so she was thinking of an atrial fibrillation with fast ventricular response. Finally they wound up looking like atrial flutter (~150bpm). Managing to avoid shocking the patient, a dose of diltiazem reverted the rhythm to a sinus rhythm before going to cardiac intensive care in Aix.

After another call, we got to bed at about midnight and were called out again at 4am to a cardiac arrest of an 81 year old man. We arrived and he was slumped in a chair in front of the TV in a very cluttered room, not responsive and not breathing. After clearing some space and getting him to the floor CPR was started. He was resuscitated for 10-15 minutes, with the rhythm never reverting to the shockable side of the algorithm (VT or VF) but remaining in asystole, and had unfortunately died. His wife was there throughout, which must have been a hugely traumatic experience for her. One of their daughters was there and another 4 arrived by the time he we had stopped trying to resuscitate him, their grief was inconsolable, understandably. From my limited experience with cardiac arrests I can control my emotions throughout, but the relatives’ grief really upsets me. At least I’m still human.

After returning to the base and a short hour break we received another call out to a patient in Gardenne for a patient with chest pain (~12km south of Aix). Once we were pretty much there we were rerouted to a patient back in Aix (~15mins). A 37-year-old lady with a cardiac arrest. No previous medical problems at all apart from that she had had a miscarriage in March and had opted for a natural abortion, but had had curettage and evacuation yesterday. She had woken up breathless at around 6:15 and next thing her partner found her unconscious at 7:20, all pointing towards a pulmonary embolism. On arrival the pompiers were performing CPR. We continued to resuscitate her, using everything we had with us (she was intubated and ventilated, had adrenaline, IV fluids, atropine, amiodarone and even a huge IV bolus of heparin to try to break down the suspected pulmonary emboli) but unfortunately to no avail. Her partner watched from the door as his world fell apart, quietly sobbing through the fear, dismay and anxiety as we tried to resuscitate her. After around half an hour of resuscitation we stopped, having been unable to revert her to a shockable rhythm. She lay there motionless, the childlike innocent part of my mind was just willing her to splutter back into life as I took off the ECG electrodes, but she didn’t.  There was an audible silence as all the beeping of the equipment and all the motion and commotion stopped and we started detaching all of the monitoring. We cleaned her where she had vomited from CPR and bled following the trauma of CPR and cannulas combined with heparin, and placed her back in her bed.

 Whilst I appreciate that death is very much a part of life, I think it is something that in this day and age we are so sheltered from. When confronted with death in such a frank manner it certainly affects me, and these experiences are something I will never forget. It makes me grateful for what I have, but definitely starts a certain amount of existential thoughts.

 On a happier note, when in the department earlier in the week there was a 49 year old lady whose tyre had exploded on the auto route at 130kph, she was largely unscathed apart from a broken ankle (which I was able to plaster!) and some burns from the airbag which was pretty miraculous.