Civilized

Well, this is all very civilized.

It's Sunday morning, and I've been allowed a lie-in by the kids. When I say allowed, I mean I just ignored the noise and chaos that they were creating downstairs, and continued to pretend to be asleep upstairs.

It's very civilized to sit looking out of the window, with a roof over my head, at the thin blanket of snow that covers the street and the cars. It looks all that much colder, from the warm, heated confines of my house.

It's very civilized to sit with a cup of coffee in front of my computer, and be able to communicate my ramblings to the world, whether the world wants to listen or not.

You'd expect that sort of experience in a First World country such as ours.

Housing.

Running water. Electricity.

Heating.

On many occasions throughout my career, meeting patients, as well as their nearest and dearest, has left me with a range of emotions.

I've been at different times;

Amazed by the lengths people go to in order to care for their families, whilst at the same time shocked that there are families who just don't care.

Concerned that people wait to call ambulances until the very last minute, whilst at the same time angry at others who call ambulances for no reason at all.

Inspired that there are parents who give up everything for their children, whilst at the same time saddened by others who would happily throw theirs out on the street.

And I've been encouraged by the way the Welfare State steps in to help many of the needy, whilst at the same time despondent that there are those who can't afford the most basic of life's necessities.

I was asked yesterday by a close family member whether it's really true that there are people who have to forgo these necessities, and how often I meet them. Patients whose houses are dark, unheated and unkempt, whilst often occupied by those who made this country what it is, those whose past created this country's future.

This winter in particular, I've been to several homes, mainly those housing the elderly and infirm, where they sit in one armchair, live, eat and sleep in one freezing room, wrapped in blankets and lost hope. Homes where they have to choose between electricity and water, or between food or heating.

These seem to be the people who are failed regularly.

Their families, neighbours, and friends have failed them.

The Welfare State has failed them.

We, as a society, have failed them.

So whilst I'm having a civilized morning, I'm sometimes left wondering about our civilized society, and whether it truly is all it claims to be.

Happy Birthday Handover!

The latest Handover has been posted over at Gomerville. This is the first anniversary of the Handover Carnival, which has led me to many fantastic blogs all with a different outlook on the world of EMS. The idea of this month's edition was to profile someone who has had an influence on our careers, whether negative, but more importantly, positive.

There is a mix of teachers, partners, family members, even patients who all feature on the list. Go have a read.

There is much to learn from them all.

Operating Table

Several weeks back, I attended the scene of a hit-and-run RTC. The patient was left seriously injured lying in the middle of the road.

He was unconscious. Barely breathing.

A massive head injury.

Every long bone was broken.

Joints were dislocated.

Blood covered the road surface in copious amounts.

I was first on scene. Then a crew, an ambulance officer, and the HEMS team.

We all worked quickly, professionally, silently at times.

If he was to survive, we needed to be at the top of our game, and even then there was barely a hope.

He was intubated, and we breathed for him.

He was cannulated, the fluids replacing the blood he was losing.

Limbs were straightened, some wounds covered with pressure bandages to try to control the worst of the bleeding.

He was loaded into the ambulance, and taken to a trauma centre the other side of town.

I didn't expect him to survive the journey, neither did I expect to ever find out if or how he did.

A couple of weeks ago I met one of the police officers who was there, who told me they still haven't found the driver, but he didn't know anything about the patient.

This morning, just before I left work after another busy night, all I wanted to do was go home and crawl into bed, the ambulance officer who was at the scene was just walking in.

"Morning", he said. I grunted a tired, and I think polite reply.

"Oh. You know that hit-and-run guy? That HEMS job a few weeks back?"

"Yeah. What about it?" I was waiting for him to tell me that the police wanted to take another statement.

"He died on the operating table three hours later".

Nina

Driving past her house for the umpteenth time, I can't help but wonder how she's doing. It's been many months now since I've been called there, and recently I've started to fear the worst. Her house is on one of several routes I can take to and from work, so I could in theory avoid going past it, but sometimes I just can't help it. I need to see some sign of life. Something to tell me that she's still OK. Even if it's just to see an ambulance parked outside again.

*****

We open the key-safe by the front door using the code given to us by control.

"I'm in here! On the floor again". Not even a hint of sadness or despair from the voice. In fact, much the opposite. Like she's pleased as punch to see us again. For me though, it was the first time of many that I'd meet Nina. In an overbalanced (read upside-down) wheelchair, slowly being crippled by Multiple Sclerosis, she somehow manages to remain upbeat and positive, despite her body, and sometimes her mind, betraying her day by day.

That first time, I was working with a paramedic who'd been in the job too long. He was jaded, couldn't give a damn, and refused to accept that the job he was doing was vastly different from the one he joined - changed, but for the better. The only thing I'd learn from him over the few shifts we worked together, was that his was a way I didn't want to learn. Well, that and the fact that I soon found out what it's like to be crewed with someone, yet work the whole shift on your own. I hoped then, still hope now, that I never become that uncaring, that selfish, however long I'm a paramedic for.

Nina, however, had much to teach me. I admitted to her that I was newly qualified, and that I didn't know a great deal about MS. She told me a little about it, how her body was destroying its own nerve fibres, and the more it was doing so, the more she was struggling to cope. It had already taken away most of her mobility.

"I'm sure you'll be back to help me up again soon", she said. "Each time you visit, I'll try to explain a little more." I was being hassled by my jaded friend that we should probably leave, now that Nina was upright and comfortable. I just wanted to stay and learn, but was too scared of being hauled over the coals for being insubordinate, so quickly finished the paperwork, and we left. I'd learn about that too.

I went home that day, and the first thing I did was turn on the computer and read up a little on MS, so that if and when I went back to Nina, I'd be a little more knowledgeable about her condition.

Fate dictated that I would visit Nina about once a month, sometimes once a fortnight, after that for a long time. Every time I went back I learnt a little more from her. And every time, she'd send me out with homework to do. Something else that I hadn't read about, didn't understand, and she'd promised to test me the next time I came back. She kept her promises too. Her memory was amazing. And it wasn't just MS that she'd test me on.

After our third meeting, Nina admitted that she was a senior nurse with 30 years of experience, and clearly had a wealth of knowledge. She'd stopped being able to share and impart her wisdom when the MS confined her to barracks, at least as far as work was concerned. I was to become her latest pupil. I used to look forward to those lessons, despite the fact that I'd often come out of them feeling even more stupid than when I went in. But it gave me the drive to read, to learn, to keep studying. It stopped me becoming complacent. It reminded me constantly that I didn't want to become that old, cynical, jaded paramedic who'd been with me when I first visited Nina.

Nina was always upbeat. Always pleased to see us, polite enough to always offer us a drink, but familiar enough to constantly ridicule me for not knowing something else, and know that she'd get away with it. Despite her physical difficulties, and the fact that whenever we were there it was because she was either stuck in the bathroom, or in an upside-down wheelchair, or some other potentially embarrassing situation, we were always welcomed with a giggle and a joke.

One time when I met Nina, she asked me about the life-expectancy of an MS sufferer. I, in turn, asked her if she was trying to tell me something. She laughed hysterically.

"I'll be driving you nuts for a long time yet. You can't get rid of me that easy!"

I knew the answer to the question too. There is little difference, certainly as far as life-expectancy is concerned, between those who suffer from MS from those who don't. As Nina was in her mid 50s, I knew that she was probably right. She probably would be driving us crazy for ages, and I'd go on being tested by her for some time yet.

I told her I looked forward to it, and joked that next time she's upside down in her wheelchair, I'm going to take her up on that offer of a drink and that I'd like to see how she'd go get it upside down! As always, I left Nina's house grinning, safe in the knowledge that I had another test yet to come. She was just working on the question.

It was the last time I saw her.

Since then, every time I meet something new, a condition I've not heard of, a drug I don't recognise, I write it in my diary, wait until I get five minutes of peace and quiet at home, and go to do some homework.

Just in case I bump into Nina again.

Good Feeling

The address I'm given is wrong. Only by a few doors, but as I stop the car and get out, I'm confused by the young lady 10 houses further up screaming in terror.

"He's in here! His breathing's really noisy! Quick! Help!"

The look of horror on her face tells me that this isn't one of those unnecessary panics, but that it's the real deal. I quickly check with control that they have no other calls on this street, and they confirm that it must have just been a typing error when putting the call on the computer.

I grab my bags and speed upstairs, to find that the noisy breathing's stopped. In fact, the breathing has stopped. Full stop. I place the defib pads on his chest and the screen shows VF. The chaotic, non-rhythmical flutterings of a useless heart.

But there's hope. This is a rhythm that could benefit from a shock. The defib shouts its commands.

"Shock advised. Stand Clear. Charging."

I warn the family that it isn't a pretty sight. Some look away, others watch in fear. I press the button and his lifeless body leaps off the bed. The crew arrive, and we move him to the floor. CPR continues, he's intubated, cannulated, we breath for him, pump his heart for him. The defib, with its disembodied voice speaks again, repeating the sequence of orders. The orange button flashes silently, and as its pressed, discharges another shock. His body jumps again.

Ten compressions later, he takes a breath. We watch, awed by the scene of such a rare sight. This is what we're trained for. This is what we strive for. This is what we hope for. It's just that we so rarely see it actually happen.

We finish dealing with him, tidy up, restock, re-energise. I attend my next call knowing that I've just been part of saving someone's life.

It's a good feeling.

First Day Nerves

I think that I might be alone on this one, so I'm putting my neck on the line a little.

I still clearly remember my first day in this job, my first call, and the bag of nerves that I was as I sat on station waiting for the phone to ring.

BUT... Am I the only person who still gets a kind of "First Day Nerves" when going back to work after a relatively short time off?

I was back this week for a normal set of shifts after having worked only one shift in practically two weeks, and was a little nervous. I kept urging the phone or the MDT to ring and send me on a call, just to get the first one out the way, and reassure me that I hadn't forgotten everything I know.

Once I've done that first call, it's like I've never been away, but it is a little weird that still, several years down the line, I go through that anxiety every single time I come back to work after even a short stint away...

So go on. Tell me.

Am I completely mad? (Anyone who knows me will instantly say "YES" to that one, so behave yourselves!)

Am I the only one who gets nervous coming back to work after only a few days off?

Am I really the only one who gets anxious about coming back to work, in case I've forgotten everything I ever knew?

Answers, as ever, either on a postcard or, if you so wish, in the comments!

Taxi!

Normal thought process:

Pregnant.

9 months.

Got a twinge.

I know.

I'll call an ambulance.

*****

Really?

Had a strange experience recently. Someone I know very well was pregnant. Overdue even. She's young, never been pregnant before, except for the last nine months, so didn't really know what to expect.

She did the strangest thing. She asked her family, several of whom have been through the same thing over the past few years for help, advice, guidance, tips. Anything that may assist her in this weird new world.

Then, finally, what seemed like 2 months late, she went into labour. She wasn't sure it was labour, so she called her family again. They said it sounded very much like she was in labour. So she called the hospital. They said she should come in. It was time.

Except that she has no car.

So she did something even stranger. In the middle of the night, she phoned her nearest relative and asked for a ride to the hospital. She didn't call an ambulance! Can you believe it? What sort of odd behaviour is that?

Said relative took her and remarkably calm hubby to hospital, dropped them off, and waited for news.

Several hours later, still in the middle of the night, the news arrived. As had the baby. And all was well.

And not a maternataxi ambulance in sight!

Amazing.

Who knew???

PS - Congratulations!

Normal Service

Due to technical stupidity and incompetence, as well as some other unwanted problems, I've had to close down my twitter account and start up a new one. You are more than welcome to follow the newly restarted and originally renamed account at @insomniacmedic1. Yup, the 1 makes all the difference. Apologies to those of you who thought that I'd dropped out of the ether, which I kind of had done, but I'm now back.
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Along the same lines, I've had to change my email address as well. So should the spirit take you - feel free to email at insomniacmedic [at] gmail [dot] com.

Oh, and while I'm at it - I now feel that I have finally arrived in the world of blogosphere - I had my first ever spam comment yesterday! Woohoo!

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But for now, normal service is resumed...

SleepTalkinMan

MrsInsomniac sleep-talks.

The MiniInsomniacs also sleep-talk.

But not like this guy!

Adam's behaviour really appeals to me. This sort of behaviour would keep me highly entertained and amused for the hours upon hours that I lie in bed awake while everyone else in the house is sleeping. Assuming, that is, that I'm not at work. My insomnia just means that I don't think I hear what they say, but I actually hear it. Much like Adam's long-suffering wife.

I've put a permanent link on my blogroll to his wife's site, where she chronicles his insane nocturnal jabberings for the perusal, amusement and bemusement of all.

Oh, and I'm not at all jealous of the 4,000+ followers and almost one million hits that they've had. Not at all...

Three Young Guys

Stood outside the station, five minutes pre-shift.
Checking the car, the equipment, the spares.
I feel their car before I even see it.
The booming bass from the stereo pulsates shock waves ahead.
They practically fly by, three young guys, in a suped-up car.
Must be doing sixty in a thirty zone.
"I'll see you guys later" comes to mind.
Along with the hope that I'm wrong.
I'm not. "Later" turns out to be only five minutes.
Three young guys, with one simple need.
The need? Speed.
Three young guys, with one inevitable end.
The end? The end.

Squashed

He lies flat on his stomach in the road, holding her head as still as possible. His dark blue uniform, ballistic vest, highly polished boots and all, normally radiates authority, control and discipline. Right now it portrays none of these, but gives him the courage to see through the job that he's trying to do, and helps him hide his anxiety.

I race to the scene of another RTC. A pedestrian hit by a van. Police on scene requesting urgent attendance of an ambulance. I arrive to see the police vehicle blocking the road, blue lights turning angrily and illuminating the dark surroundings as they spin. It shields the patient on one side, and I drive round to the other, effectively blocking the road completely, and ensuring the further safety of the patient as she lies sprawled and barely conscious in the middle of the road.

As I step out into the road, a smell that hangs in the air almost makes me vomit.

*****

The police officer who was holding the lady's head was shaking as he gave a garbled handover.

"She walked out without looking and got hit. I think she's got a bad head injury".

I ask if he knows if anyone else was involved, and he points to the pavement, where she's sitting, swamped by the same blue, authoritarian uniform, bawling her eyes out. At least she doesn't seem injured. After a few seconds of confusion, I finally grasp the reason the police were there so fast.

They'd hit the patient. Theirs was the van that had hit the pedestrian.

No wonder he was shaking. No surprise that she was crying.

That smell still lingered in the air.

*****

They were on their way to an immediate response call to an ambulance crew calling for police aid after being attacked. Travelling at 60mph, with lights and sirens, they had no chance of stopping as the lady didn't even bother to look or listen before stepping out in front of them. They'd caught her with the wing-mirror.

I leave the officer holding the head whilst I do some basic checks, connect some oxygen, and hope that the ambulance turns up quickly. He's doing a good job of immobilisation, and it helps calm his nerves if he feels he's being useful. Two birds, one stone.

I wish I could find the source of that smell.

*****

The crew turns up, as does an ambulance officer, who I send to check on the sobbing police officer. She's hysterical, but unhurt. It seems she was driving at the time of the accident, and couldn't calm down. Can't say I blame her.

The patient seems to be regaining a little of the awareness that had deserted her since she'd been hit. We move her bags of supermarket shopping away so that we can bring in the bed, the board and other bits and pieces. We've already decided that she has to go to a trauma centre that specialises in head injuries, which is a little further than the nearest hospital, but it's best for the patient. We think she has a fractured skull and she's been unconscious. A bad combination.

As we lift her off the floor, the smell becomes almost unbearable, and I physically heave, but just, and only just, avoid throwing up.

*****

Once she's packaged and in the ambulance, we reassess her, recheck that nothing has changed for the worse, and the crew then get ready to leave. As I jump out, they start the engine, switch on the blue lights, and start moving away. Other police officers are looking after their colleagues, trying to comfort and reassure them. One of them hands me the patient's bags of shopping, including the one that was underneath the patient.

The smell returns.

*****

I look through the bags for anything that will reveal some details on the patient, but all I find is her shopping, a week's worth of groceries. In amongst it all, looking as innocuous as fruit can, was a bunch of over-ripe and very squashed bananas.

I hate bananas.

Lost and Found

Nothing to do with ambulances at all, and unashamedly stolen from my friend over at Jumblerant. Don't worry. I've already warned him... You choose how you look at your life and how you run it. No one else can do it for you. Watch it. All the way through.

Dear Doctor

Dear Dr G Practice,

Despite my seemingly, at least in your eyes, lowly position in the world of patient care, I would nevertheless like to raise the following points. This is due to the fact that recently I have repeatedly been met by an attitude which I would not wish on a rabid dog.

1) We are not your get-out-of-the-surgery-on-time assessment, referral, or taxi service. If I get called to a patient two minutes before the end of my day (or more usually, night), I still have to see them, assess them, refer or treat them, transport them too, if necessary. I can't, don't and wouldn't pass them onto somebody else just because I couldn't be bothered, especially without having seen them at all.

2) Just because you have seen your patient and called for an ambulance, does not discharge you of your responsibility towards them. It should not give you the right to dump them back in the waiting room, letter in hand, waiting for the ambulance to turn up. At best, it's unprofessional. At worst, detrimental to the patient. Especially, just as an example, when they are asthmatic, struggling for breath, hypoxic, O2 levels of 68% instead of nearly 100%, and literally climbing the walls, desperately near death.

3) I and all my colleagues, much to your chagrin, are not mere stretcher-monkeys any more. We are emergency medicine experts. We spend years studying, improving on and perfecting our craft. Much as you do with yours. As such, to have the professional courtesy towards a fellow medical professional and to give us a clinical handover would be greatly appreciated. Not to show that courtesy says much more about you than it does about us.

4) I'm fully aware that not ALL GPs are the same. I'm aware that there are plenty who do understand, comprehend and appreciate our role in patient care. I'm aware that there are many who are even pro-active in their dealings with paramedics. But I'm equally, and acutely, aware that there are those who hold us in disdain. So, even though I've said this before, I'll say it again. If what you think about the Ambulance Service and Paramedics hasn't changed in the last 10, 15, even 20 years, then come and spend a shift, maybe two on an ambulance. Relearn all that you thought you knew about us, but has changed so much since your early days as a doctor. You may be pleasantly surprised.

Show us the respect we're due, and once again I can guarantee we'll return the favour.

Ask the Audience

There are many ways, and many places to fall. For some reason however, fallers often manage to find the MOST awkward of them. I have had patients fall behind toilets, in shop windows, half-in and half-out of truck cabs.

They have fallen on ice, tripped over street furniture, even the apocryphal slipped on a banana skin. With the vast majority of these fallers, whatever their injuries, and sometimes after a little bit of thinking, it's been possible to get to them, treat them, help them up. Transport them if necessary.

What was I supposed to do, however, with the man who fell down a flight of stairs and landed, unconscious, pinned against the front door? The family were trapped inside, having been told, quite rightly, by control not to move him. I was trapped outside.

There was a flight of stairs 3 feet from the front door, the patient had his legs up the first couple of steps - so no room for manoeuvre there. Ground floor windows were only of the very small version, able to fit an underweight supermodel at best. The only part of me that's that thin, is my hairline...

*****

So what would you do?

Scaredy Cat

Oh, for the sake of all that is holy! Man up, man!

Category A.

Immediately Life Threatening.

Lights and Sirens.

16 year old male.

Difficulty in Breathing.

"Do you have asthma?"

"No."

"Do you have any medical conditions?"

"No."

"Do you know why you're breathing quite so quickly?"

"Um, yes..."

Normally, people with breathing problems who are struggling for oxygen have a habit of turning grey, or even blue. They don't tend to turn a tomato-like shade of red, especially their cheeks and ears. I wait until he decides he wants to tell me what happened. His mates are all trying to suppress their laughter. One is laughing so hard, he has tears running down his cheek.

Now, I know that as human beings we have a very nasty (but irresistible) tendency to mock the afflicted, but, other than the fact he was having a panic attack, I couldn't quite work out what he was afflicted by. Eventually, he manages to control his breathing enough to tell me what had really happened. He handed me the box that the latest horror DVD had come in, and with the most embarrassed look, and just the hint of a resigned smile, just said:

"It scared the hell out of me..."

I was glad that just at that point, the ambulance crew turned up. I had to leave the room in a hurry, just before he'd see me join his friends in the fits of laughter.

I really couldn't help it. Sorry.

Switched Off

It's always the little things. The small, almost invisible details, that are most strongly etched in the memory. The daily sights and routines that just blend into the background, and yet give life its real meaning.

*****

Their wedding anniversary was coming up in a couple of months, and since the day they married, he'd gone through the same daily ritual. Every night before he went to bed, he'd set his alarm, place a small chocolate on her pillow, and get the old-fashioned teas-maid machine ready so that the tea would be freshly brewed for the minute they wake up. It'd been exactly the same for more than forty years.

Last night, he'd set the alarm, prepared the tea, and left the chocolate. This morning, his alarm never even had a chance. He was awake a full hour before it was due to go off, woken by a crushing pain in his chest and a desperate inability to catch his breath. When we arrived, he was blue. His face was blue. His hands were blue. His oxygen levels 40% lower than they should have been. His breathing laboured, hardly moving any air at all. He was fighting to stay alive.

She stood there, helpless, terrified, lost. Silently sobbing and wiping away the tears that were flooding her cheeks. We rushed around treating him, willing the oxygen into his body faster than the cylinder could push it in. IV lines were inserted, drugs administered, chairs brought up to the third floor apartment. Everything seemed to her to be happening in a blur. We were hurrying out the flat, when she stopped to take one last look at the room.

She walked back in, stood by his side of the bed, and shedding another tear, turned off the teas-maid.

Resolutions

I couldn't leave this auspicious (suspicious?) date, without at least disturbing your day for a short while, so first, allow me to wish you a happy, healthy, successful and prosperous New Year. And if by prosperous it means that you win a huge amount on the lottery, then please remember who your friends are.

*****

In the days leading up to the end of the year, the London Ambulance Service has been doing one of the things it does best. Counting numbers. Specifically, a very large number. One Million to be precise.

That was the magic number we hit at just after 3am on the last day of the year. One million calls dealt with in a single year. It's a significant rise on the year before, and the year before that, and the ... well, you get the picture. The thing is, I'm not so sure that it's a number to be proud of.

There are no more ambulances out there than there were a year ago.

No more man- (or woman-) hours. There are boasts that there have been hundreds of new recruits, but there have been probably an equal number of people leaving. The front line staff, as well as those in control, are being pushed ever harder to meet targets that are at best dubious and ill-conceived, and at worst downright dangerous. Patient care targets are nothing compared to the national time-based targets set by the government, and this is where we have the danger of falling flat on our faces.

Patients don't want to see just an FRU outside, single-staffed, with no ability to convey a sick patient. They want to see it backed up quickly by an ambulance. More than that, they want those staffing the FRU and the ambulance to be at the top of their game. Well-informed, well-trained, professional staff will do a great deal more for not only our patients, but our image too. Demoralised, despondent and harassed staff will do the opposite.

Partly, the blame needs to be placed on the fact that we are, in a way, victims of our own success. We are too good sometimes. We provide too much for too little, and do not do enough in the way of public education. We provide paramedics with extra training who now do the house-calls that used to be done by GPs. We provide ambulances especially geared for non-life threatening calls. We still attend calls that any level-headed person would look at with disbelief. Stubbed toes, broken finger-nails, a three-week runny nose, and many more of the same ilk. We even provide transport, every weekend of the year, so that the public can drink as much alcohol as possible, take the booze bus, and not face up to their social responsibility. Or their cab fare.

This year, I'd like to see the trend reversed. I'd like to see fewer calls. Not because I'm lazy, but because I think that the priorities need rethinking.

I think we need to educate ourselves and the public. I think we need to concentrate on what's important, and not necessarily what's arbitrary.

I think we need to worry more about serving those who really need us, and ensure that we are always prepared for them.

I think we need to go back to the days where ambulances are waiting for calls, and not calls waiting for ambulances.

I love my job. I am passionate and idealistic about it, probably to a fault. I'm one of those crazy people who actually loves getting up in the morning and going to work (ok, ok, so I work nights and go to bed in the mornings). If I have more than two or three days off, I start getting withdrawal symptoms. I'm inspired by my job, my colleagues, even my patients. I know, it's worrying, but this is why I want to see positive changes.

We all have our New Year's resolutions. The Service's should include more public education, higher expectation of their staff, whilst maintaining high levels of morale. It's a tricky balance.

My resolutions are little changed from last year. Always be ready to learn something new every single day. I owe it to my career, to myself, to the Service. Most of all, I owe it to my patients. I hope I can stick to it, and I hope, whether you're a colleague, a manager, or a patient, that you can help me do that. I promise to return the favour.

*****

Happy New Year to you all.