Paula O'Sullivan
Until 2018, I spent most of my career working with critically ill children and eventually progressed to becoming a clinical educator with the resuscitation team at a well-known London children's hospital. My role included teaching advanced resuscitation skills to all levels of professionals, ensuring that their skills were of the highest standard when dealing with the deteriorating patient and the patient in cardiac arrest. On my non-teaching days, I was part of the resuscitation team, and would be called out in the event of a clinical emergency.
I began my medical aesthetics business 6 months prior to leaving my role as a resuscitation officer, as being a busy parent to my two young daughters and simultaneously working this fast-paced role proved challenging, both physically and mentally. Since leaving the role, I have kept up to date with my resuscitation training, with my most recent update being in February 2021, when I enrolled with the vaccination team as an ad-hoc clinical supervisor.
Clinical emergency
It was the beginning of a busy day in my clinic. Since I began my business in 2018, I have always worked alone, apart from having a virtual assistant who deals with the daily tasks of administration and bookings. My first patient arrived at 10am for her anti-wrinkle treatment and cheek enhancement. I had met the patient the week before for her consultation, at which point any medical history and previous aesthetic treatments were discussed. She spoke about having her thyroid removed a few years prior, for which she was taking throxine, as well as removal of a melanoma just 12 months earlier. Thankfully, the patient was well. In the past, she had regular toxin treatments, with the last treatment being 18 months ago.
During the patient's appointment, we spoke at ease about work, children and plans for the summer. Her anti-wrinkle treatment was uneventful. Soon after, I began to treat the patient's cheeks using a cannula, with the plan of using 1 ml Restylane Lyft per cheek. The right cheek made a marked difference to her appearance. I offered her the chance to sit up and review the result of her right cheek in the handheld mirror, which she was keen to do. She was pleased with the result so far and sat back in the chair while I started on the left cheek.
The pilot needle was introduced ready for the insertion of the cannula when the patient asked if she could lay back, as she felt ‘unusual’. The procedure was halted immediately, and I made her comfortable by reclining the chair and raising her feet, to improve her suspected hypotension. I reassured the patient and continued to talk to her for the following few minutes, while continually observing her and reassuring her with my presence. I opened the windows within reach and turned my back on her to open my clinic room door.
Within seconds, the patient became unresponsive and was displaying seizure-like activity. I continued to reassure her, while shouting for assistance. I suddenly felt very vulnerable and afraid. I could see a patient and her friend had arrived for a review, although they could not hear me due to their car radio playing. A workman was approximately 100 feet away but, due to the background noise of his building tools, he was also unable to hear me.
The patient became cyanotic as the seizure-like movements continued. Help was needed urgently; however, I was afraid of stepping away in case she endangered herself. I located my mobile phone and called an ambulance. During my assessment, it was evident that the patient was making no respiratory effort. Her tonic movements started to settle; she had been incontinent of urine; she was peripherally shut down; and I felt seconds away from initiating resus. I was able to communicate my fears to the 999 operators, requesting help immediately. With the operator on loudspeaker, I recited what I already knew and what had been engrained in my brain for so long: the basics of safety, stimulate, shout, airway, breathing and circulation (SSSABC). The first steps of ‘SSS’ had been initiated, and the next stage was airway: the patient was mechanically blocking her own airway due to her poor neurological state. With a head tilt and chin lift, her respiratory effort slowly returned, as did her colour. At this time, the paramedics arrived, and the patient began to regain consciousness, albeit slowly. Thankfully, when the paramedics arrived, I was able to hand over her care and talk through the events with them. I needed their reassurance that my practice was safe and was open to discuss areas which I could improve.
Reflection and moving forward
On reflection, I managed the situation quickly and effectively, but that did not take away the fear and shock of what I had experienced in my isolated environment. I was solely accountable for my patient, and this suddenly became daunting. Shouting for help was the challenge when I was desperate for support, raising the question of how I could improve this moving forward, for the safety of my patients and my practice. I strongly believe that, if a plan to call for help is in place before any procedure, this vital stage of any clinical emergency would be seamless.
I have now created a smart clinic, meaning that I can now instruct my Amazon Alexa to call emergency services in the rare event of this happening again. Since the incident, I very quickly run through a mental safety checklist before each patient, making sure that my mobile phone is on its stand and my Amazon Alexa gadgets are switched on. Through my time and experience as an intensive care nurse and resuscitation educator, I believe that preparation is key to delivering prompt, systematic care, regardless of the setting.