Frostbite

We have a code for paperwork for every ailment, disease or injury we meet. There are about 100 options for the calls that we are most commonly called to. Ones not covered go under the "other medical problem" code. Every so often the list is updated, something added, something taken away, and the alpha-numeric sequence is shot to pieces again. I've memorized a large number of the codes, and rarely have to look at the crib sheet to remind myself. I'd hazard a guess that every single London Ambulance Service paramedic knows that 62 is the code for Alcohol Intoxication. That one hasn't changed for years. We probably also all know about 75 being a minor head injury. Friday and Saturday nights especially. But our all time number 01? Sitting at the head of the table? Abdominal Pain.

I believe it's number one not just for alphabetical reasons (although I'll admit that AB at the start of a word will give it a pretty good chance in any alphabetically organised list), but also as it's probably the most common complaint that we come across. Abdo pain is a potential minefield. It can be anything from gastroenteritis to food poisoning, from a heavy period to appendicitis, from labour pains to a ruptured placenta. It could be a potentially fatal bowel blockage to a very unlikely to be fatal under-cooked doner kebab making some very unhappy returns. In some patients abdo pain can signify a heart attack, in others it could be a ruptured aortic aneurysm, both potentially lethal. With no CT scanners, ultrasounds, or X-rays available in the back of the ambulance (yet), it can sometimes be a matter of educated guess work, at least initially.

However. I'd like to guess that the patient who's had mild abdominal pain for three (yes, 3) months (yes again, months), probably wasn't in a life threatening condition. In fact, she knew she wasn't. She told me so herself. She was about to go to the GP for a repeat prescription for some regular medication, but realised that the surgery had shut ten minutes earlier. So she called an ambulance to take her to A&E so she could get what she needed.

I had to ask what made her call an ambulance for what was clearly not an accident or an emergency. I'll give her her dues. She was honest. "It doesn't cost anything!", she said. The cab to the hospital would have cost her £5, possibly less. Less than the packet of cigarettes that she was holding in her hand.

As I'm in the FRU, just a car, and not really supposed to transport patients, technically there's a "big" ambulance on its way too. I'd love to be able to say to this person that she doesn't need an ambulance and she should get on a bus, but it's just not worth it. Sometimes I just can't be bothered for the argument, but I'm sure they sense my unease. I cancel the ambulance and inform control that they may as well save it for a worthwhile call. The "patient" wants her friend to go with to the hospital, so I move my luggage out the back seat and sit them there.

The 7 minute drive to hospital was spent in frosty silence, until it was broken by the radio.

"General broadcast all ambulances - ambulances needed for two possibly fatal stabbings in local area. One with multiple stab wounds, one with slashed neck. Anyone available please respond!"

In a moment of Mouth before Brain (unusual for me), I look in the mirror and mutter loudly "Unfortunately this taxi is already in use. Sorry I can't be of any help."

Did I mention the silence? It could have induced frostbite.

Funny Bone?

Children's playgrounds are made for children. For good reason.
Climbing frames are generally built for fun and enjoyment by those same said children.
If you're an adult,
And drunk,
With several other drunk adults egging you on,
And stupid enough to try to play on said climbing frame,
In pitch black,
You're likely to come off second best.
Oops.
Once you're sober, your broken humerus will serve as a good reminder.
Yup. That's the one they call the funny bone.
I wonder why?

Handover again

The latest Handover Carnival has arrived over at Life Under the Lights. It's a collection of hilarious stories entitled Funniest. Call. Ever. Have a read and a good laugh.

*****

When you're done, get your thinking caps on, as next month's Handover is being held by yours truly. The theme is "Kids - Seen but Not Hurt". Any calls, from funny to sad, sombre to heroic, anything child related. Kids are in my eyes the most precious possession we have both as individuals and as a society, and it's our job to protect them. So tell me how you go about it. Don't forget that there is now also an open entry section, for anything EMS related. I'd particularly like to hear from non-EMS personnel who may read this blog with regards any experiences they may have had with Emergency medicine.

Email your entries to benyatzbaz999@gmail.com . I look forward to them all with baited breath.

EDIT: Forgot to write the closing date: Monday, 26th October.

To be published on Friday 30th.

Cen-Tree

I have an ex-crewmate, Jim, who, when frustrated with the job and its ensuing politics, would threaten to go and work for the council as a lawn-mower. No, not as the machine, but as the operator of one. No grief, out in the open air, music blaring. What more could you ask for?

*****

Al, a local-council gardener for several years, loved his job. It wasn't taxing, he loved the open air, loved working at his own pace, loved listening to his music. No managers, no hassles, never home late. Just him, and the flora and fauna of the local area. Today was his turn on Daisy, the industrial-sized ride-on lawn mower. Daisy was used when the big jobs needed doing. Parks, large verges, anywhere that a normal sized machine would take days to complete, Daisy could do the job in a fraction of the time. Daisy's twin, Belle, was also sent out on the mission, piloted by Sue.

The weather forecast had promised a bright sunny day and for once had delivered on its promise. Al and Sue were thrilled. They moved from place to place, leaving behind them the scent of freshly cut grass whenever they journeyed on. Daisy and Belle were in their element. With Sue and Al chatting throughout, the morning flew by, and as the midday sun began beating down, they found a shady area that needed cutting too. A wide grass verge with several large trees dotted around.

Sue went left, and Al, right. He'd just remembered a funny story he was going to tell her and turned round to call out. Two seconds. That's all it took. Two seconds looking in the wrong direction. Sue barely had the time to scream: "AL! LOOK OUT!!!!"

Al turned round to face the front again, just in time to see the huge branch. Most trees would be proud to have that branch as their trunk, but on this tree it was just a branch. Perpendicular to the tree-trunk, parallel to the ground, and about six feet above it. Daisy was about four foot high. Al sitting down another two. He took the full impact straight in the face. Ten miles an hour isn't fast when you're surrounded by a tonne and a half of metal, but it's lightning speed if your face meets a tree and has no protection at all.

When we arrive, Daisy is the other side of the tree, with Al a crumpled heap on the floor. There's blood everywhere. I take a few seconds to assess and work out what's going on, in which time, Jim, my crewmate suggests that immobilisation may be a good idea. I wholeheartedly agree, and curse myself for not thinking of it immediately too. Right, brain back into gear. Trauma. ABCs.

Airway - clear at the moment, but some bleeding in the mouth. Unknown source. Regular reassessment required.

Breathing - yes. At the moment. Clear chest, no funny noises, no missing sounds.

Circulation - yes. At the moment. Several areas of blood loss, none that are obviously too heavy.

Disability - Sue's unsure if he lost consciousness, but thinks that he did. At the moment, he's conscious but very confused and a little agitated.

I'm still worried about Al's airway. We need to immobilise him on a board, with a neck brace, on his back. And there's something bleeding in his mouth. Not at all ideal. Ideally I'd like to have the patient knocked out and intubated. That would ensure that his airway and breathing are secure and I could deal with the other problems.

I ask for HEMS. They're unavailable. (Not once, in my whole career so far, have they come when I've called them. I've done calls with HEMS, when other people have asked for them, but never when I have. Either they've been busy, had no helicopter, or a myriad of other excuses. Once, they even crashed when they were on route to me. Before you scan old newspapers for news of a HEMS chopper crash, they were coming in the car. But still, it must be some sort of conspiracy...)

I ask for a BASICS doctor. The nearest one is at least 40 minutes away.

We're ten minutes at most from the nearest A&E, not one known for its trauma care. The nearest Trauma Centre is an extra twenty minutes drive away. Al has an airway problem, so we don't really have a choice. We package Al, load him into the ambulance, warn the local A&E that we're on the way, and apply diesel. Jim's driving, which is a good thing, as he's a much faster and smoother driver than I am. On route I constantly suction the blood from Al's oral cavity. I have flashbacks to the dental surgery. Not a good thing.

His observations remain stable. A quick look shows that he's lost several teeth, probably fractured his jaw and eye-socket, possibly fractured his skull. As his face took the full force whilst Daisy kept going, we had to suspect a serious spinal injury too. When we arrive at the hospital, there's a full trauma team to meet us. I'm impressed. They obviously understood the significance of the injuries that we'd tried to relate over the radio. Al's handed over to the team, and I never find out what happened to him after that.

Whilst we're cleaning all the blood, mud, and carnage we'd left in the ambulance, Jim mentions that he's not so sure about his alternative career path after all. I'm not surprised.

*****

PS. This is my 100th blog post. My century entry. What started out as a little bit of a trial run, has turned into something that has taken over my life! I'm shocked I've made it this far, and honoured that I seem to have captured the interest of so many people. I hope I keep going for a long while yet, and I hope you keep coming back. But in the meantime - thank you.

First Impressions

The call? 25 years old. Male. Chest Pain.

Go on, fellow medics. Admit it. Doesn't fill you with the joys of spring, does it? Didn't do much for my need for an adrenaline rush either. It's the sort of call that immediately throws up images of drunk and incapables. Or Man Flu. Or a bad takeaway dinner. Or something equally as life-threatening.

We weren't met by the frantic windmill that's the traditional signal either for a very poorly patient or for mass unnecessary panic. Good.

We weren't met by the patient lying in the middle of the street. Very good.

We were met by an open door, a filthy house, and a mixed aroma of alcohol and vomit. Bad.

However, so far, so predictable.

The front door opened straight to a flight of stairs, so nowhere to go but up. As we're climbing the stairs there's a call of "We're up here!". I roll my eyes and wonder to myself where else there is to go. Somewhere sunny, warm, and far removed from self-indulgent, self-harming drunks would be nice.

I'm a bit of a one for first impressions. I make instant, snap judgements on people as soon as I meet them. I try very hard at work not to make these sorts of decisions just by reading the call on the screen, but at times it's a little difficult. And I admit, this time I'd already made my mind up, and it wasn't particularly complimentary. Normally it takes a very long time to convince me of the error of my first impression. In fact, it almost never happens. I'm just too stubborn. Tom, for his part, was going to do everything to prove me wrong.

As soon as I'd set foot in the room, I could see that I was wrong. Tom was indeed about 25. And in pain. Not chest pain, but pain nonetheless. And he looked ill. Very ill. His pulse was well over 100 and climbing. His blood pressure was in his boots. His temperature sky high. His abdomen was very tender and he'd been vomiting, or at least trying to, for days. His partner told us his story.

The cause? A rotten tooth. Antibiotics for an abscess had failed to work. Painkillers had failed to do their duty. The doctor had told him to wait until he felt a little better and then go to the dentist, a thought that would have filled me with dread. And probably make me turn to drink, too.

The thing is, he wasn't feeling any better. He was feeling worse. He was short of breath. He could hardly talk. He couldn't eat. But he could drink. So in an attempt to numb the pain, he drank. And drank. And vomited. And drank. And vomited. And drank. Tom had been drinking constantly for nearly a week, and now his body was finally giving up.

It could be his liver, his kidneys, his pancreas, his bowels. Anything or everything in that region. They could be inflamed, they could be ruptured, they could be failing. Whatever it was, it was possibly killing him. When I put the priority call into the hospital, I didn't really know what to tell them. Not having a mobile CT scanner made it a little difficult. I think that I said something along the lines of "acutely unwell" and just reeled off a set of observations. Hopefully they would give the staff a clue. Once there, they continued our treatment of oxygen and fluids, gave him some IV antibiotics and rapidly handed him over to the surgeons.

The last I heard, Tom was still teaching me a lesson about first impressions. From his bed in the Intensive Care Unit.

Cooking

Forty year old men tend to know if they're allergic to something. Rani did. He knew that there are certain spices that if he so much as touches them, he breaks out in a rash. If he eats them, the rash is followed by his mouth swelling, his tongue doubling in size and his airways constricting. He knows to avoid them, but just in case, he also carries an Epipen wherever he goes. This is a self-administered injection of Adrenaline, used in cases of anaphylaxis. This is such a severe allergic reaction that it can kill in minutes.

Rani knew immediately, mid-evening meal, that something was wrong. All the signs of anaphylaxis were starting to show. He took anti-histamine tablets straight away to try and ward off the allergic reaction, but it was getting worse. He didn't think he needed the Epipen yet, but knew that he needed to get medical attention, so he called an ambulance.

When we arrive, Rani's wheeze can be heard from outside. His face had blown up like a balloon, and he was beginning to drool as his throat tightened. We put him on a nebuliser and gave him an injection of adrenaline. By the time we'd arrived at the hospital, lights and sirens blaring, Rani's condition had improved so much, that the staff wouldn't believe how bad he'd been. He even joked about how his wife might have been putting the spices in the food on purpose. By the time I got back to the same hospital a couple of hours later, he was just being discharged. I wished him well and suggested that maybe he should do the cooking next time. "Maybe", he said. "But I think I'll just keep supervising".

My words couldn't have been more prophetic, as exactly one week later we're back at Rani's house. "I should... have done... the cooking..." he wheezes at me. He looked even more ill this time. We were wheeling him out to the ambulance when he vomited all over the pavement. Later I'd thank him for keeping the ambulance clean. He'd obviously developed an allergy to something new, and this time they'd have to investigate properly. We treated him almost identically to the previous week, but this time his improvement was slower, and the staff at the hospital witnessed first hand what we were talking about. As we left Rani in the hospital bed, he whispers with a smile on his face, "I'm going to learn to cook. It's too dangerous otherwise. The wife's clearly got it in for me!"

*****

Forty year old women tend to know that they've got asthma. They know how to deal with it. Sima did. They get short of breath, they use their inhalers. Either they feel better or they don't. If they do, all well and good. If they don't, they go to hospital. Sima wasn't feeling better. Her boss in the office could see she was struggling, so he called an ambulance. Sima is sitting on the 5th floor, head down, shoulders forwards, using all her chest muscles trying to catch her breath. As we approach, she looks up. And smiles. As I'm putting her on oxygen and a nebuliser, I only have one question.

"Rani's learnt to do the cooking then, has he?"

Pat

The image above may look to the non-medically trained like a road map of the Himalayas. To the medically trained it'll look like something all together different. This is a sick heart. This is a myocardial infarction. Or in plain-speak: a heart attack.

*****

Going to bed after a heavy meal is apparently no good for you, or so Pat claimed. That's why normally he'd have his main meal of the day at lunch time, and only a small dinner. Tonight was different. He'd gone out for a meal, and it would be an otherwise squandered opportunity if he didn't eat well whilst someone else did the cooking and clearing. As Pat and his partner were getting ready to leave, he felt a little discomfort. Indigestion. Must be. One.

They went home, watched some television, and got ready to go to bed. Pat decided that a glass of milk just before bedtime would ease the indigestion that had now been bugging him for the last two hours. Two.

His partner was starting to get a little nervous that the dull burning sensation was still there, so decided that maybe it'd be a good idea to call an ambulance.

Good plan.

*****

Out of the kindness of my heart (as well as the weightlessness of my wallet), I'd decided to do an overtime shift on a real ambulance. Abandon my solo car for the night, and join Lou, the contender for my "Station Insomniac" crown. She's the sort of person who when you first meet seems a little matronly, but is actually just the sort of crewmate you need when it's all going wrong and all your patients turn out to be quite ill. It would be a night full of surprises. Pat was one of them.

When we arrive at his house, we're greeted by another paramedic on a FRU. Nice to be on the other side of the handover for a change. Pat looks well, is calm, not sweating, not feeling sick. He's a fit man in his early 60s, not seen a doctor for years, not on any medication, and the most serious illness he's had was a bad flu about five years back. And the fact that he's a smoker. Three.

His basic observations show a normal pulse, a normal blood sugar, excellent oxygen levels, and a very high blood pressure. Four.

He's still playing down the burning sensation as a bad case of heart burn, although he's a little concerned about the fact that his left arm feels heavy. Five.

Five warnings. Five danger signs.

Eventually he relents to an ECG (or EKG for our friends across the water). What printed out was the one at the top of this post. Lou and I step up a gear and a flurry of activity follows. We tell Pat what's happening. Drugs are administered, cannula inserted, bloods taken, repeat ECGs done, priority message placed to the hospital to make sure that they were all awake and ready to perform the angioplasty that would save Pat's heart from further and potentially fatal damage.

*****

As we open the back of the ambulance at the hospital, before we've said a word to the staff who regularly greet us, I hand the ECG to Al, the cardiologist, and I could swear I see a glint in his eye. Even if it is 3am. This is one of the things they live for. Diagnosing heart attacks and delivering patients directly for emergency angioplasty is probably one of the best innovations in the ambulance service in recent years, and these cardiac experts are clearly a major and enthusiastic part of this innovation.

Al's first words to the patient are praise for us. "They got it right, sir. You're having a heart attack". Now I know that looking at the ECG it'd be hard for any trained medic worth their salt to get it wrong, but it's still nice to hear from another medical professional. Pat's wheeled in to the theatre, attached to the monitors, and prepared for the procedure. Whilst all that's happening the consultant walks in. He turns to Pat, takes one look at the ECG and says "These guys got it spot-on, they said that we need to fix your heart, and they're right". That's twice we've been complimented, which we like, but it had better not happen a third time, or our heads would be too big to fit back in the ambulance...

Pat successfully undergoes the procedure and should be out of hospital within a few days. With a little rest, a few life style changes and the right medications he should be able to get back to normality in a relatively short time. All in all, a good result.

And we got a pat on the back to boot.

Paperwork

Over the past few weeks I've seen a huge increase in the number of patients who I feel are at risk. Adult patients. They've either had no family, no family that cares, no friends who care, or no-one that cares at all. Some live in the most depressing and appalling conditions that, truthfully, I can't believe still exist in a country that claims to be one of the world leaders in social care. Over the years I have come to accept that it happens, to expect to see it twice or three times a year. Over the last few weeks it's been nearer that number every week. It's horrifying, and it's heartbreaking. It shouldn't be allowed to happen, and I wish I could do more about it. It's one of the hidden ills of our supposedly illuminated society.

A few shifts back I met Hetty. She's 85. I can't expand too much more for fear of identifying her, although I can tell you she's spent her entire life caring for others, and now she can cope no more. But now, in her hour of greatest need, all those she's cared for have decided that their lives are too important. She'd been practically left to die in an abandoned wasteland. Whilst waiting for the ambulance to arrive to take her to hospital, she told me of her greatest fear.

She didn't want her children to find her diary if she dies. She told me a little about what's in it, how long she's been writing in it for, why she writes. She refused to tell me what the last entry, the one she's scared they'll find, contains, but sadness and anger were reflected in her eyes in equal measure. I could only go on to imagine.

*****

Dear Diary,

I've confided in you since I was young, many, many years ago.

I told you of growing up, of my many successes and failures there. And of my parents' pride.

I told you of my school life, of my many successes and failures there. And of my eventual triumph.

I told you of my university life, of my many successes and failures there. And of my graduation.

I told you of my early years of marriage, of my many successes and failures there. And of my joy.

I told you of my years of parenting, of my many successes and failures there. And of my immense pride.

Now, Dear Diary, I must tell you a painful truth.

I'm old. And lonely. And a failure.

I've failed to instill my morals.

I've failed to teach my way of life.

I've failed to make them realise that the carer now needs care.

I've failed, and I've been failed.

Must I really end my days in squalor? Alone? Abandoned?


Do I deserve to see out my life neglected by those I have raised? Cherished? Cared for?

Dearest Friend,

Where are they when I need them most?

*****

My care goes as far as the hospital, and only a little further. I can fill in a form. A form to inform Social Services of my concerns. A form to advise them that I think she desperately needs help. A form to call for that help and pray that it arrives in time. Just fill in a form.

And then all that's left for me to do is hope.

Hope that someone sees the form and realises the urgency of it.

Hope that someone sees the form and shares my concerns.

Hope that someone sees the form and feels the same as I do.

Hope that someone sees the form and realises that this isn't just another pile of paperwork.

Grand Rounds

Medic999 has become the first EMS related blogger to host the Grand Rounds blog carnival. This hosts blogs from all fields of medicine, not just our small world of emergency medicine. Yours truly has been added to the list of blogs showcased, but there are many, many more that are well worth a read. Look here for some insights and inspiration into a whole range of topics from the world of medicine, from my favourite topic of sleep to successful resus attempts, and from caring for kids to the safest handshake in this swine flu season. These are just a snapshot. There are many more.

Go.

Read.

Learn.

Enjoy.

Changing Lanes

Highway Code, Rule no. 999
When you see an Emergency Vehicle approaching on lights and sirens, could you please indicate and move over to the right/left*.

____________________

* Please delete as appropriate according to the day of the week.

Clockwork

All the call taker could hear were screams. Terrified, terrifying screams. Without a second thought, an ambulance was dispatched, and the police were requested to also attend. One of the seniors in the Control Room called to explain what was happening. Something was obviously badly wrong, and it may take too long to wait and find out what it was, and only then send the ambulance. The updates would follow, the police were already on route on the highest priority.

The screams, incoherent at first, were starting to form words.
*Blood.
**Baby.
***Help.

*Blood.

**Baby.

***Dead.

****Help.

The words were sent down the computer screen in the FRU in quick succession. With each update, the foot on the accelerator seemed to get a little heavier.

*****

The police sent a message that they were on scene, and requested that we attend Immediately. The word is etched vividly. The police regularly ask for our attendance, regularly ask for an ETA, sometimes ask for our attendance ASAP. Never have I seen the word "Immediately" appear on a police request.

*****

The heavy foot put on some additional weight, the car, understanding the message, lurches forward as if trying to jump five steps at a time. The traffic seems to understand too, and despite the time of day, despite the school run chaos, the cars move aside to let the wailing car through. The scene on arrival is horrifying.

*****

The sea of red everywhere tells the story. It starts with a trickle at the front door, becomes a small stream, and leads all the way to front room and to a pool of blood. If the blood wasn't enough, the shrieks alone would have led the way.

Sitting terrified in the menacing pool is Trina. All she keeps yelling is "The Baby! The Baby!" A quick look around the house by the police finds no baby, and no other blood. The blood must be Trina's. There's too much of it for a baby to have lost it. She won't speak to us. Or can't. Probably the latter. It was initially difficult to tell because of the way she's lying on the floor, but Trina is pregnant. About 32 weeks. The police find a set of ante-natal notes from the local hospital, and a quick glance at the inside front cover tells of Total Placenta Praevia. It's written in huge letters, surrounded by a red marker pen. Potentially life threatening for both mother and baby.

*****

Well, that explains the blood.

The pain.

The fear.

The baby.

*****

The ambulance arrives, and Trina is loaded as quickly but as gently as possible. A blur of activity later and she has a needle in each of her arms with fluids running through. Salty water isn't nearly as good at replacing blood as real blood would be, but it's the best that can be done until Trina and her unborn baby get to the hospital. Hopefully it'll buy her the time she needs to get to theatre. Maybe even save the baby.

*****

For once, things seem to happen like clockwork. A priority call is placed, advising the hospital of Trina's condition, of her vital observations, of the blood loss, of the ETA. The police drive ahead as an escort, the traffic yields again. An anaesthetist, midwife, nurse and surgeon, as well as four units of blood, are waiting as Trina is wheeled out of the lift. Within 15 minutes she was in theatre. Two lives hung in the balance.

*****

Thanks to Clockwork, Trina survived.

Despite it, her Baby didn't.

Trouble

As I work solo on the car, I'm supposed to get to calls first. I try to help the crews locate where the call is quicker by leaving on a flashing light on the car once I have found the location. However, as I work nights, I prefer not to wake up the whole street by leaving on the bright flashing blue/red LEDs, so I use a small orange flashing light on the roof of the car. It's sort of become my trademark around the area. Crews that turn up and see the yellow car with the orange beacon now know it's me. And probably start worrying.

Christine and Ricky who were on duty last night on the ambulance threatened to put in a priority call to the hospital as soon as they see it's my car on scene. They'd tell control that it's "Ben on scene, it's bound to be poorly", with a "details to follow" message... Am I really that much trouble???

Back to the point.

I'd arrived on scene to a patient fitting, who by the time I arrived wasn't. R&C weren't far behind. We loaded the patient into the ambulance as he'd apparently fitted several times, which was unusual for him. As they're checking his basic obs, we hear a knock on the door of the ambulance. Assuming that it was the patient's relative, we open the door and are somewhat surprised to see two police cars and three police officers outside.

We hadn't called for them.

The patient and his family hadn't called for them.

So why had they stopped?

"Well, we saw the orange beacon, and presumed that it means that you must be in distress!"

Clearly my reputation for trouble has moved on from just the Ambulance Service...

One For the Ladies

To the ladies who complain that we men have no idea of pregnancy.
To the ladies who complain that we men have no idea of feelings.
To the ladies who complain that we men have no idea of pain.
You've never caught your foreskin in the zip of your trousers.

Neither have I.

But I know a man who has.
And he was in much pain.
And it was still stuck when the ambulance took him to hospital.
And he needed surgery.

Ouch.

Be Safe

Several of my co-bloggers have posted this recently. I think it's worth watching, and definitely worth being spread by as many people as possible.

A number of points:

1) It's graphic
2) It's real
3) It's pointless if you just watch and then forget it




Be Safe