Empty

They lie there, piled safely behind the back seat of the car, starting the shift as reassuring, rarely used spares.

It's an uncommon thing to use a single, whole one in a shift, especially on the car. The crews come and whisk the patients away, using their own supply, leaving the car's one barely depleted. That night had been different. A collection was slowly accumulating, with no way of returning the empties to station, relying on the crews to replace them with fulls instead. Half way through the shift, and three of them had already been emptied, each on a separate, critically ill patient.

They lie there, piled safely behind the back seat of the car, spent, empty, used. There's one left in the bag, as yet unstarted, untouched. Enough for just one more, but surely, not tonight. Tonight has been tough enough already.

And yet.

He lies there, unconscious, barely breathing, the machine fighting with him, for him, but it isn't strong enough. Compressing the air and pumping what it can against the odds, all the while making no difference at all. We look at his chest, listen to his breathing, and whilst he's making the movements, no air seems to move. We'll have to breathe it for him.

Out it comes, turned up to full blast, the jet of air blasting out, hissing like an invisible snake, filling up the reservoir bag and mask to capacity. As fast as it fills the bag, we empty it into his lungs, forcing them to work against their wishes. We struggle, full in the knowledge that we're fighting a losing battle, but losing doesn't mean we've lost. Losing doesn't allow us to give up. So we struggle out of the house, into the ambulance, and to the hospital.

It lies there, piled up with the others behind the back seat of the car. Each silently telling its own different story.

And in the front, he sits wondering what's happened, and why. Why so many, why so ill, and the last one, especially the last one, why so young?

Another life in our hands, another battle fought, maybe won, maybe lost, and another whole cylinder now showing empty.

Ten out of Ten

"Ten, definitely ten". The stock answer of some people when asked how bad their pain is on a scale of 1 to 10. I guess that gives them a genuine reason for having called an ambulance in the first place. The thing is, that they sit in front of you, no wince, not doubled over, just sit calmly and tell you that the pain in their arm or leg, stomach or back, is the worst pain they've ever experienced.

If the patient is a mother, I often ask if this pain is so bad that it's worse than childbirth, a question that regularly has the pain score downgraded, even if only slightly. Either that or they're superwoman. If the patient is a man, I'll compare it to something often involving a gory amputation of one of their limbs, and see what happens then.

These patients, whilst claiming to be in the worst pain known to humankind, then jump sky high as soon as I take a pinprick's worth of blood to test their sugar levels - a procedure that hurts no more than a minor paper cut. And more often than not, haven't bothered to try taking any home-based pain relief such as paracetamol or ibuprofen. The easiest option is to call out an ambulance and discharge the responsibility for their condition and care to somebody else.

Sometimes, I meet the exact opposite. A patient who's pale, sweating buckets and complaining of a slight ache, 2 or 3 at worst on the pain scale. A patient who is so clearly in distress, but denying it, either out of stoicity (if that's even a real word), bravado or genuine fear of the unknown. Regularly these are the sorts of people who wouldn't call an ambulance until they are practically bullied into it by concerned relatives or friends, or have had ambulances called for them without their knowledge.

In both cases, those who overplay their pain, and those who underrate it, I'm left with a dilemma.

On our ambulances, we carry a very limited option of analgesia, or pain relief.

For kids, we have liquid paracetamol to ease pain and reduce fever. To be honest, I don't know why we have it. It should be in the drug cupboard, in plentiful supply, in every child-containing household in the land. There should be no reason for us to give a 4-hourly dose of fever-reducing, pain-easing medication that can easily be bought at any chemist, supermarket or even petrol station. It can be given in the calm, safe and familiar surroundings of the family home by any medically-unqualified parent, rather than in the scary scene of the back of a terrifyingly strange ambulance by unknown, green-attired, martian-looking paramedics. I know which I choose for my kids. If one of them refuses, then just the mere mention of the word doctor or hospital is enough to get them to down the stuff.

We also have Entonox, a mix of oxygen and and nitrous oxide, often referred to as laughing gas. Like any other analgesic, it works well for some people, and not at all for others. Over the last few years I've found that it works particularly well for things like muscular back aches, releasing enough of the tension in the muscles to enable the patient to get on the move again, exercising those tensed backs, instead of leaving them immobile. It also works well enough to enable a dislocated limb to be reduced, enough to allow transport and definitive treatment at hospital.

Then we have Oromorph, and Morphine sulphate. The same thing, but one is swallowed and the other requires IV administration directly into the bloodstream. These are the ones we use for severe pain. Things like heart attacks, nasty fractures, serious burns and other injury or illness-induced agony. There are other options for stronger pre-hospital analgesia, but these require having a doctor on scene, in the form of either HEMS or a Basics doctor.

The dilemma I have is when to use analgesia, and of which sort.

For our first type of patient, the one in such agony as he sits and drinks his cup of coffee in the front room as the caffeine-deprived ambulance crew stand by and watch, do I jump right in and give him some of the heavy stuff? Do I take his answer as gospel, his pain is off the scale, and needs immediate resolution, and so give him the morphine straight away? Is it justified, and is it necessary? Or do I suggest to him to try some paracetamol first (from his own supply, as I don't carry an adult dose)?

And so, on to our second type of patient. Clearly, in my eyes, in severe pain, but refusing to admit it. She declines the offer of either Entonox or morphine, says she's just taken some over-the-counter tablets, and is feeling better already. Both her clinical observations, as well as my observation of her, indicate otherwise. Do I just offer these patients a seat in the ambulance and convey them to hospital, no analgesia, no treatment, no nothing. After all, they've refused any. Doesn't seem right to me.

In both these cases, the question is one of objectivity vs subjectivity.

Is the pain defined by the patient's experience, or by the paramedic's observations and assessment?

Is the treatment decided by the patient's story, or by the paramedic's interpretation of it?

Which of these methods would leave me to treat the patient the best way possible, and afford my treatment, much like their pain, a score of ten out of ten?

Two Hours

Jen's been a little overweight almost all of her life, enough to give the kids at junior school the excuse to tease and bully her, but never really badly enough for her to want to do something drastic about it. Sure, she'd tried diets, fads, exercise, everything, but always ended up back where she'd started. Her parents had, maybe a little tactlessly, nick-named her YoYo thanks to her eternally fluctuating weight. Eventually, at almost 18 years old, she'd learnt to accept who she was and what she looked like and live her life the best way she knew how. She went to a good school, had friends, many of whom had been her tormentors in earlier years, and now saw Jen for who she really was, rather than how she appeared. And she had a boyfriend, Ian, a childhood sweetheart who'd been her partner now for almost four years.

It was Ian who'd called the ambulance. An 18 year old female with abdo pain doesn't fill any ambulance crew with the joys of spring. It's another routine, mundane call, often leading to mutterings of "waste of time", "taxi run", and "bet they haven't taken any pain-killers". Nevertheless, the way the call comes in, we have to run on lights-and-sirens.

As we walk in, Jen looks a little embarrassed, apologises for calling us out, and says that the pain has passed. "He panicked a bit", she starts, "the pain was really bad, and it came back a couple of times, but it's gone now. Really, guys, I don't need an ambulance. I'm sorry".

She's pleasant enough, too nice to be mad at, and clearly concerned as to how ridiculous she seems.

"We'll just do a couple of quick checks, make sure you're really ok, then we'll leave you alone. But if the pain was as bad as Ian described it, maybe you should come with us anyway, just to be on the safe side".

Abdo pain is such a minefield. It can be everything and nothing. Anything from uncomfortable food poisoning from last night's drunken take-away, all the way to a deadly ruptured aorta, the body's trunk-route for blood distribution.

She sat comfortably on the couch, hand on her lower abdomen, the memory of the pain still there, the brain trying to do its usual trick of erasing it. We check her basic observations, her pulse is a little quick, her blood pressure normal. We take her temperature, placing the tympanic thermometer in her ear - a quick and painless way of doing what used to take 3 minutes of sitting still with a piece of glass stuck under your tongue.

Jen suddenly screams. A piercing, terrifying scream that made me jump back, wondering how I could have inflicted such pain by just taking a temperature. She arches her back, holds on to the couch as though she was clutching at life. The pain lasts for no more than 30 seconds, and is gone as if nothing had happened. She looks down at the floor, suddenly refusing to make eye-contact and mutters, barely audibly, "I think I've wet myself".

A minute later, the pain returns again, and it finally dawns on us.

"Jen, how many months pregnant are you?"

"I'M NOT PREGNANT! WHAT ARE YOU TALKING ABOUT?"

"Jen, these pains are contractions. You're about to have a baby! How many months are you?"

Ian and Jen stare at each other.

"I can't be pregnant! I'd know if I was! I've only put on a bit of weight. I'm NOT PREGNANT"

Much as she tried, much as she wanted to, there was no denying it. Jen was in labour. Her waters had just broken, she was having contractions every minute. The baby was about to be born. We asked for a midwife, and another crew, and started preparing for the birth. We have no idea how developed the baby will be, so have to prepare for every eventuality, from a normal delivery to the horrendous thought of having to resuscitate a tiny newborn. There was hardly the time to think.

The baby's head appeared in the very next contraction, and by the one after that, a newborn baby's cry filled the room. The baby girl seemed a good size, a good colour, and there was clearly nothing wrong with her lungs as her voice made her surprise appearance clear to all. We cut the umbilical cord, cleaned her up, and I handed her to the new mum.

"Here she is! Your beautiful baby girl!"

Jen looked away, kept her arms folded, and through stifled tears whispered "I don't want it".

"It", she said. not "her". I was shocked and saddened, trying to understand the turmoil that Jen was going through. An hour ago she had some tummy ache, now she had a daughter. I couldn't get my head round it any more than she could. She couldn't, wouldn't, accept that this baby was hers. To her, the little girl was an "it".

The second crew turned up just after she was born. The midwife was still miles away. We decided to send mother and baby to hospital in separate ambulances, and not wait in the midst of the anger, the confusion and the rejection. Jen came with us, a few minutes after her baby had gone. A few minutes to gather her belongings, gather her lost dignity, and gather her muddled thoughts.

At the hospital, we're shown into a room, and as we walk in, Jen having refused to travel on the trolley bed. There's a small cot already there, and in it a sleeping baby, swaddled in a pink blanket. Jen gets onto the bed and says nothing. One of the midwives asks us for the story, we take her aside and explain all that has happened. Slowly and quietly, the cot is moved nearer and nearer to Jen's bed as she has her blood pressure checked and a midwife reels off a seemingly never-ending list of questions.

Absentmindedly, as she answers the queries about her health, about the pregnancy she never knew she had, and about her personal life, Jen's hand moves to the cot. She sits there, a tiny smile slowly creeping onto her face, as she strokes her daughter's soft, downy hair.

"I want her". As the words escape her lips, she grins, then bursts into tears. "I want to keep her. I want her to be mine".

She seems hardly to believe her own thoughts, as if someone else had spoken them. But she was exceptionally proud of them.

"She is yours, Jen", says one of the midwives. "And there's nothing you can do about it".

She just sits there, uncomfortable on the ancient hospital bed, the initial shock on her face and sadness in her eyes, turned now to relief and happiness like she has never experienced.
Two hours earlier, it had all been so very different.

There

The drops are stopped in their almost perpendicular path by the windows, housed in the walls that has been their home for over sixty years. They continued their gravity-powered journey and soaked the ground below. He sits watching the weather, the tears falling from his eyes mirroring the rain, falling silently off his cheeks to the carpet, soaking in before they could leave any trail.

The door had been left open for us, and we avoided the more usual soaking whilst waiting on the doorstep.

"We're in here", comes the strangled voice from the front room. We went bundling in, four green-suited, adrenaline-driven life-savers. We were overladen with bags full of kit that we already knew, just from looking at the call on the screen, were redundant, and highly-qualified and well-trained with skills that we knew from the outset, would do no good.

We were there to confirm what he already knew, as he sat stroking her hand, her head on his shoulder.

We were there to ease the burden of him having to utter the words he could barely cope to think.

We were there to see to it that he wouldn't be left with no-one by his side, as he kissed her goodnight for the very last time.

Trouble

If you're trying to multi-task,
Doing CPR,
Setting up equipment,
Dealing with relatives, neighbours, nosey passers-by,
Talking to several different agencies,
Informing control on the radio,
All about the traumatic cardiac arrest you're dealing with,
Please -
Don't use the phrase "Kill two birds with one stone".
You're only asking for trouble.

Way Home

"RING RING... RING RING"

It's the simple, old-fashioned ring tone on my mobile. Everyone seems to have their favourite piece of music, some amusing noise, a baby laughing, anything, just not a normal, straightforward "ring-ring" type noise. I guess it makes me a traditional non-conformist. Now there's an oxymoron. I ignore it, as I always do when dealing with a patient. MrsInsomniac will have to wait. I'm sure it's her. She has this amazing knack of only ever calling when I'm with a patient, and never when I'm just sitting around drinking too much coffee.

"RING RING... RING RING"

We climb over the fence and into the field. She sits in the front seat of her battered car, pushed off the road by the force of the impact. The bus had no chance of stopping in time as she came round the blind bend on the wrong side of the road. The weather didn't help either. The road was wet, with the first rain in a few days making it that little bit more oily. She probably lost control as she came round the corner, sending her directly towards the bus.

"RING RING... RING RING"

The windscreen's spider's-web fracture indicating what we'd already guessed. Her head hit the glass leaving her unconscious and with a massive head injury. Her breathing slow and laboured, all other injuries are for now ignored. The scene is now a sea of blue lights, with police and fire brigade joining the frenzied attempts at getting her out of the car. Nothing else mattered for now. The road was closed despite it being a major route for homeward bound commuters, and those stuck in the traffic would be there for some time yet. Most would probably be calling home to let them know of the delay.

"RING RING... RING RING"

The roof is cut off the car, she's removed, along with some of her belongings. Only those critical to identifying who the unresponsive patient was. The rest would have to be salvaged later from the remains of the car. As we finally got her out of her car and into the ambulance, it seemed that the ringing was getting louder. The familiar ring tone rang again, and only sounded clearer as we were away from the generators, running engines, and general noise that surrounds the scene of a serious accident. All in all, the phone rang four or five times whilst we were at the scene. Unusual, I thought, as normally MrsInsomniac would realise that I'm on a call and would wait patiently for me to call back when I was free. If she's tried to call this many times, it can't be good news.

Finally given half a chance, I looked at my phone, only to find that it was switched off. And obviously I hadn't had a single call. Which means that someone else had the same phone, and chosen the same ring tone.

It rang once more, from the direction of the patient's handbag.

The screen was alight, the word HOME flashing with every ring. A police officer answered it, and explained to the patient's frantic husband what had happened. That his wife was in a car crash, where it had happened, that she was with the ambulance, that she'd be OK and was being taken to the local hospital.

"He's distraught", said the officer. "He was trying to call to tell her to go a different way, he'd heard on the news that there'd been an accident on her normal way home".

I wondered how long it would be before she really would be on her way back home again.

It was the end of the shift, and as I sat in the car writing the illegible scrawl that was my paperwork, I switched my phone back on. As it came back to life, a message appeared.

"Can't get through. You must be busy. Let me know when you're on the way home".

Diesel

Three-year-olds are a law entirely unto themselves. Having had two of them over the last 3 years, I'm only just recovering, just in time for them to be four- and five-year-olds. It's not much easier, but at least they can better articulate what it is that they're tantruming about.

So, with all my experience and battle-weariness, I know the following:

Three-year-olds should be active.

Three-year-olds should be vibrant.

Three-year-olds should be very, very good.

Although three-year-olds can be horrid.

Three-year-olds, however, should never, ever, be unconscious.

Or grey.

Or breathing shallow, useless breaths.

The nursery staff look at us with pleading eyes, their gaze shrieking more than their combined voices.

"He just collapsed. Just fell to the floor and stopped. Is he dead?"

I look at Jim, and he at me. There's no need for words between us, we read each other like books.

Oxygen goes on, and we help push it into Tyo's lungs.

Defib pads go on, but, thankfully we don't need to use them. Yet.

We carry Tyo down to the ambulance, Jim jumps into the pilot's seat.

A nursery nurse, tears streaming down her face, sits down in the back, flustered and frustrated at the fact she can't do anything to help.

I feel the same.

Just pumping oxygen in seems so mechanical, so basic, making me feel powerless and useless.

Usually I prefer to sit in the back with the patient, and let someone else do the driving. Seems to me to be the better job.

This time I think it's the other way round.

Jim's got the best job for now.

Whilst I'm force-feeding Tyo the oxygen,

Jim gets to force-feed the ambulance some diesel.

Cul-de-Sac

The cold temperature in the dingy basement flat matched the frost-bitten air outside. Small icicles surrounded the windows, the only light was that of a lone candle, battling to break through the dark of another winter's night. The kitchen, bathroom, living room, even the bedroom, all crammed into a flat no bigger than an average family car.

*

The fire-call seemed straight forward. A ground floor apartment, probably a kitchen fire. There was smoke billowing from the broken windows, but the Fire Brigade seemed to be in control now. The ambulance's occupants enjoying the respite that these types of calls often bring. We're only there "just in case". In case one of the Brigade are hurt, or in case any occupants are found and need treatment.

*

In the middle of it all, surrounded by the barest of bare essentials and wrapped in layers of blankets, sat Ray, looking almost double his middle-aged years. Hardly more than a skeleton wearing a thin layer of skin, with sunken cheeks and saddened eyes, he was clearly embarrassed to let us in. "I don't know where to turn any more", he started. It was tough to work out if his speech was shaky because of the cold, his fear, or a medical condition. "My family have either died or left me to do the same. I have no help. No gas. No electricity. I steal or beg to eat, and only keep warm by wrapping up in layers. I have no light and no heating. I just need to be somewhere warm".

*

The white-helmeted Station Officer had come over to let us know that they didn't think that there were any occupants, but that they'd still like us to stand by. "Hang fire", he says, his grin indicating clearly an intentional pun. "We've still got guys in breathing apparatus. Once they're all out and OK, we'll let you go." We're in no rush. We have chocolate. We have drinks. We have hours left of our shift, and now we have a break. The music's turned up just a little more.

*

Cases such as these are rare, but not as rare as I'd like to think, or hope. In a country famed for its welfare, cases like these have no right to exist, and where they do, they should be easily and quickly solved. Many, too many of them are unknown, shame and fear preventing those suffering from doing anything about it. Ray had had no heating or light for several months. The utility companies seemed just to give up on getting their money, cut off the supplies, and never bothered to check if anyone was still living there. There was wax everywhere from where he'd lit the candles, bags full of rubbish that he said he still had to go through to see if he could find anything worth salvaging for food, and filth all over the space that hardly qualified as a kitchen.

*

One more update from the Station Officer. The last of his crews was now going into the building, to ensure that it was well ventilated and assess when it would be safe for the other residents in the vicinity to return back to their own homes. "A few more minutes guys", he says, talking over the noise of the generators, the pumps and our radio. It's all now a matter of minutes before we'll be back on our way to the reality of ambulance work.
*
One thing was for certain. Ray couldn't stay here any longer. Irrelevant of any medical need - he was going to hospital. At least there he'd be warm, fed, showered possibly, and most importantly there would be time to get the system in place for him to be cared for long-term. It wasn't an ideal solution - just the start of one. He was unsurprisingly hypothermic, his pulse was low, his blood pressure too. It was surprising he was still sat up. We brought the chair in for him, but he refused it, wanting to salvage his last vestige of pride, and chose to walk to the ambulance. He got as far as the door and caved in.

*

Then came the shout. "There's someone here! He's not breathing! Get the paramedics!" We both hear the Brigade's radio over the music channel we're listening to in the ambulance, and jump out of our seats. A Fireman's Lift is given a whole new meaning when you actually see a lifeless body being carried out by a fireman.

*

The journey to hospital was uneventful, we left him in their care, filled in the multitude of forms to get social services involved as quickly as possible. Something must have worked somewhere. Not long after that, I had a call to the same building, to see an estate agent's To Let sign outside. I had a peek through the window and saw that the place had been cleaned up, was brightly painted, and now just waiting for a new resident. Ray was nowhere to be seen.

*

He was placed on our trolley bed, and the resus started in earnest. His face was covered in soot, his skin cracked, his eyes glazed over. Someone started on compressing his chest, trying to beat a rhythm into his arrested heart, whilst I was in charge of using the bag and mask, to breath some oxygen into his burnt lungs. I removed the mask from his face and prepared to intubate him, so that the oxygen we were pushing in to him at random with a mask hit exactly the right spot via a tube.

*

I spoke to the sister in charge to find out what had happened in the interim. She told me that he'd been moved to a ward and would probably spend a few days in hospital. Social services had been contacted and the system's cogs were turning, trying to find the most suitable answer to his problems. For some reason this call bugged me, so I followed up again a few days later to find that he'd been rehoused. I hoped it was clean, warm, and had 1st world utilities, instead of 3rd world conditions. I hoped he was on the road to recovery.

*

One of the bystanders, forced out of their neighbouring apartment by the fire, told us that he'd only moved in a couple of weeks previously, that he seemed pleasant, but kept himself to himself. She didn't really know any more about him. As I took the mask away, I saw a face I couldn't forget. I hadn't noticed in the first moments he'd been thrown at us. Ray's face, covered in smoke and contorted in pain, his eyes, once saddened, now looked back at me again, this time glazed and lifeless. His chance at finding a road to recovery reaching no more than a cul-de-sac.

Opportunity

It's amazing how sometimes your brain will only register what it wants to see, and go on believing what it sees, even if it turns out to be completely wrong.

The house has two cars in the driveway. One an old classic, clearly cherished for many years, the owner one of the old breed of drivers, the tax disc a couple of years out of date now. The rust and dust are building up, but it still takes its pride of place out the front of the house. The other car is a shiny, new-looking car with a private number plate, the pride and joy of someone much younger who probably uses it daily and washes it once a week.

He's eighty-something years old, lovingly cared for by his granddaughter, at a guess in her twenties. She clearly adores him, and the love and admiration flows both ways. He's confused and in pain, having tripped and fallen down a couple of stairs. Whilst we assess his injuries, she's there, wiping his face, stroking his head, doing her best to comfort him. It looks as though he has fractured a hip, and the agony is made just that little bit more bearable by her presence, her reassurance, her love.

We're just the mechanism by which he'll get to the hospital, but she is clearly the power that will pull him through the experience. We give him some analgesia, scoop him up gently, and move him carefully to the ambulance.

She gathers some clothing together, finds his medication, checks the lights, the heating and the locks. Just before she's ready, I ask him a simple question.

"Is your granddaughter joining us in the ambulance, or is she going to drive up in her own car?"

As soon as the words leave my mouth, and I see the look on his face, the penny drops. The penny makes a loud, reverberating noise in my now empty head as I realise my error. Anyone can make that mistake, right?

I shouldn't have assumed. I don't any more.

I should have checked. I always do now.

I should have asked. I always will in future.

"That's not my granddaughter", he practically spits.

"That's my wife!"

There are those who learn from their own mistakes, and there are those who, without having to go through the pain of embarrassment, learn from mistakes made by others.

I hereby present you the opportunity to save yourself the blushes...

Respect is Due

The latest Handover Carnival has been expertly compiled and published by CK over at Life Under the Lights.

As Chris wrote on his site - "Respect can mean many things in EMS. Whether it’s the utmost respect for the sanctity of human life that must be inherent in all medicine, respect for our coworkers, respect for ourselves, respect for our profession, or respect for and from other health care providers and the general public. Almost all of our problems could be said to at least partially stem from a fundamental lack of respect".

So, without any further delay - head over to Life Under the Lights for the latest Handover Carnival - entitled Respect.