Sunday 18 March 2018

Rude health: Pulsus Paradoxus

Having rolled up a sleeve to take the pulse of our ambulance service, Maurice Gueret reveals some stinging truths

A new ambulance HQ opened this summer. Photo: Rui Vieira/PA Wire
A new ambulance HQ opened this summer. Photo: Rui Vieira/PA Wire
Dr Maurice Gueret

A lady cyclist took a nasty tumble outside a train station recently. It happened in a large Irish town with a population of 16,000 and its own general hospital. Passers-by administered to the woman and an ambulance was summoned immediately. Half an hour later, the cyclist was still lying prostrate on the side of the street where she fell.

An ambulance had to be dispatched from a town 40km away, one with no general hospital and a population of 20,000. Now, I attended a motorcyclist in Dublin some time ago when he was knocked from his machine. The first ambulance arrived very quickly, but it had no protective spinal board to place the motorcyclist on. Neither did a second passing ambulance that turned up, so we had to wait for a third ambulance before the injured man could be removed to hospital.

I relate these tales because this summer a spanking new ambulance HQ opened beside The Square shopping centre in Tallaght. Known as NEOC, the National Emergency Operations Centre, it will act as the new nerve centre for our ageing and frankly inadequate ambulance fleet. NEOC will field all 999/112 calls and dispatch emergency teams by road and air. It also hosts the Ambulance College, where technicians and paramedics receive career-long training. Ireland has wonderful personnel in emergency care. The pity is that we let them down with under-resourcing. For a population only slightly bigger than our own, Scotland has twice the ambulance fleet and apparently four times as many crew. It's not easy for whistleblowers to operate in emergency services. They rely on you to do that for them. I worry when a health minister says he wants us to focus on patient outcomes rather than clock times. A wise operator would focus on both. We were promised a world-class ambulance service in return for closing rural casualty departments. The headquarters is now fancy. But the reality on the ground remains a galaxy away.


A reader has been in touch about a bad dose of giant hogweeditis this summer. He wonders if I might dispense any wisdom other than prescription steroids. Well, it so happens that I know more than boastful average about the perils of Heracleum mantegazzianum. You see, it featured as a track in the 1971 Nursery Cryme album by my favourite stadium rock band Genesis. The Return of the Giant Hogweed describes how a Victorian explorer found the plant by a marsh high in the Russian hills. He took it home to London and gifted it to the Royal Gardens at Kew. The plant did not take kindly to this transportation and took its revenge by spreading wildly and threatening the entire human race. The Doomsday bit is a slight exaggeration, but the gist of the song is true. Giant hogweed is a nasty rhubarb-lookalike with a brutish sting. It causes a severe photo-sensitive dermatitis when affected skin is exposed to sunlight. Within a day or two, blistering starts which may leave scarring in its wake. A few years ago in Crumlin hospital, a young lad of 10 needed a skin graft on his shin because of hogweed burns.


I would say straight off that steroids are not to be sniffed at. Not only do they secure the finest Champagne and lobster for consultants, they also counter a veritable array of inflammatory conditions. The trick is to know whether oral or topical ones work best, and how to get best results with the lowest cumulative dose. The word 'steroid' has nasty and, dare I say, undeserved connotations in modern culture. Doctors might rather call them life-savers, but I personally favour the original term, Compound E, or cortisone as it became. Antibiotics are often celebrated as the post-war miracle of modern medicine, but the discovery of cortisone in 1949 deserves equal billing. It was one drug that lived up to its hype. It had two downsides. Some of the conditions it treated returned once it was stopped. And doctors learned that it could be prescribed dangerously as well as safely. But its role today, 65 years on from its Nobel prize, is still that of a rare medicine that helps the body to heal itself.

Physical examination

We began our complete physical examination last week with a dissertation on what doctors might find out about you from your hands. So this week we'll pop open your sleeve to place two fingers on your pulse. The human pulse can be assessed at the neck, elbow, groin and in a few other spots in the leg, but the radial pulse at the wrist is the easiest. As students, we were trained to take it for a full minute, but you wouldn't become a real doctor without knowing how to take shortcuts, so a 15-second pulse multiplied by four seems to be the order of the day now. This is a pity, because it hints that all that matters about a pulse is its rate. Of equal importance is its rhythm. Common causes of a rapid pulse are exercise, anxiety and excitement. More serious causes would be haemorrhage and shock. A slow pulse might indicate an athlete, but an underactive thyroid gland or a rhythm disturbance like heart-block need to be borne in mind. An honours doctor will also know how to diagnose a collapsing water-hammer pulse (signifies leaks), a paradoxical pulse (squeezed heart) and an alternating pulse (heart-muscle damage). On rare occasions, it might be necessary to feel two pulses together in two different body locations, to assess whether there is any delay. Don't forget to wash for next week, as we examine the armpit.

Dr Maurice Gueret is editor of the Irish Medical Directory

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