Angels

Some days I feel like the Angel of Death's right hand man. It's almost as if he's sitting on my shoulder, bidding me to do his work, waiting for me to feed him another soul.

The shift starts with a family member or a carer discovering that their relative or ward has died peacefully during the night. We march in, carrying equipment that we know will be totally redundant. Oxygen, where the tap will remain unopened. A box full of drugs that will number the same when we leave as they did when we entered. A monitor that will do nothing but paint a long, straight, lifeless line on a strip of paper, telling us and the family what we already know. All too often we are still there as the reality of loss strikes home. Sometimes slowly, gently creeping into the minds of those around; sometimes it hits with the full force of a tsunami wave. Before we leave, we comfort the bereaved, we mutter words, platitudes, practicalities, and then go back into the world outside that just carries on as if nothing has happened - unlike the four walls that we have just left, within which the world has suddenly stopped. The Angel has won.

Then there's a call for someone who's dizzy.

Yet another for someone in pain.

And we treat them with care, give them attention, tend to their needs, transport them to the hospital. In the short time it takes me to walk back from the emergency department to the ambulance, all too often I have forgotten their basic details, like a name, or age, or chief complaint. By the end of the day I barely remember these calls at all. And the Angel lurks bored in the background.

And then again there's a call: to someone who has stopped breathing. But this time, someone was watching as they took their last breath. We drive fast, arrive into the confusion and chaos and panic and fright. This time we have a chance. We open the oxygen, we give them the drugs, we beat hard on their chest, we breathe for them, pump blood around the body for them. Try our damndest for them as all around people are crying or screaming or praying or silent. But after a while, twenty minutes, forty minutes, an hour, we are defeated. Death has beaten life, as if the Angel is ironing out the last of the ups and downs on the monitor, leaving that long, flat, lifeless line again.

Then there's a call for someone short of breath. They have nothing more than a cold.

Then there's a call for someone whose blood sugar has fallen so low that they're unconscious, or confused, or violent. We fill their blood stream with dextrose which brings them out of their stupor. All too often they are embarrassed and apologetic. Nine times out of ten we leave on the best of terms, but every so often we need to force a trip to the hospital. All the while, the Angel slumbers.

Then there's a call for someone who's fallen and can't get up. We help them up, dust them down, sometimes make them a tea or coffee. We look at pictures of their grandchildren, or take an interest in their books, or listen to an abridged life story. Often we leave with a smile and a smirk at the Angel. Sometimes, that smile fades in the blink of an eye.

There's a baby turning blue. Can't breathe. Floppy. And we're miles away.

These sorts of journeys happen in an eerie sort of silence. No words are spoken, no thoughts-out-loud. Only the wail of the siren permeates the air, helping us push through traffic as fast as we can, but it never seems quite fast enough. Yet, when we arrive, with the Angel looking over our shoulders, we take hold of the baby.

She's breathing. Shallow, struggling breaths, her shoulders and ribs working twice as hard as they should be, trying to expand her lungs and feed them the oxygen they crave. And the Angel stares, prepares, dares us as he heats his iron, yet all the while we beat him back. We feed her oxygen, drugs, put up defensible borders, give her a fighting chance. We carve our way through the traffic again, to hospital, hand her over to the staff and breathe a sigh of relief when we hear a beautiful noise.

She's crying.

We clear up, tidy the back of the ambulance and prepare it for the next call, and finish the paperwork. Just before we leave, we go back to check on the baby, whose cries have subsided as she finally catches her breath and her face slowly breaks into a wary smile. As we step into the room, her mother finally sees us, as if for the first time, even though she was with us all along. 

"Do you know what you people are?" she asks, as she gently strokes her baby's face. "You're angels. Nothing short of angels."

I look over my shoulder, see no-one there,  and smile. 

Footprints

Bright red footprints, like they'd been painted in a playground, appeared on the steps that we were hurriedly climbing. Not every step, only some. Every second or third stair was marked by a print hastily left by whomever it was that had either caused this horror or, at the very least, discovered it. We would never know whose prints they were, but a clue had been left for the police to use in their hunt. Each mark, no more than half the sole of a shoe or a boot, was as red as the next, each as incriminating as the next, each as foreboding as the next. As we ascended three flights of stairs, the footprints descended at speed. 

The floor and the walls are awash with red; pools and clots and smears and streaks. And footprints. And in the middle of it all, she lies, barely breathing, barely conscious, barely alive. Two police officers search the house as we start to treat her. The scene is no better in the tiny bedroom or bathroom. She had tried to escape and was cornered, prevented from fleeing by the force of a knife, and by her lifeblood draining away. Eventually, she fell by the front door and there she lay, waiting, in a motionless race against time. 

It took time to get her out, as we stepped out of the sea of red, time she didn't have. We couldn't bandage each wound; they were too many, and the minutes too few. We could barely stem the bleeding, although, ominously, it seemed to be slowing of its own accord. Four pairs of hands carried her on the backboard down the stairs, following the footprints and leaving some more, but this time each step was marked. Prints of different sizes, different shapes, but each dipped in the same red paint. 

At the hospital, they're ready for her. Bags of fluids and blood hang at the ready the instant we set foot in the resuscitation room. Oxygen can already be heard hissing out of the tap. Nurses and doctors take over the treatment. Orders are barked, instructions carried out, messages relayed. She's still breathing, still conscious, still alive. 

Outside, as we start to clean up, the police are waiting for us. They want the prints from all our boots. One by one, each police officer who had entered the scene, each paramedic who took part in the call, steps somberly on and off shoe-shaped pieces of card. Each leaving a pair of gruesome footprints - the imprints that would rule them out of the investigation - but would leave a mark in their minds. 

Inside, in the meantime, as the footprints dry, she dies.  

An Insomniac's Guide to the Theatre

If I had to sum up the last week, it can be done in just one word. A word that I have repeated so many times over these past few days, that I'm a little nervous to utter it again. However, there is no better place to start. The word? 

Surreal. 

It all began with a throwaway idea by a friend who asked how I would feel about turning this blog

into a play that would appear at London's Camden Fringe. The throwaway idea began taking shape, delayed not a little by the tough decision of permanently shedding my cloak of anonymity. Take one playwright ready to bare all to anyone who will listen (I mean that in the nicest, most artistically possible way!) and one paramedic who has spent a lifetime building barriers to his innermost thoughts, and you have a potential recipe for disaster. 

Instead of disaster, however, we had a hit on our hands. Hundreds of people from all walks of life - ambulance crews, medical staff, other actors, general members of the public and even a blogger or two - came to see the play, to experience a little of what goes on in our insular world. "An Insomniac's Guide to Ambulances" draws on both my experiences as well as those of writer / producer / director / general dogsbody /chief cook and bottlewasher Rachel Creeger, who in a previous life tackled the world of social work. 

It is a mix of the hideous and hilarious, of the terrific and the terrorising, of the dangerous and the dignified, of the sublime to the (dare I say it again?) surreal. Conflicting emotions battle for room on the stage, work life impacts unintentionally on home life, idealism fights reality, insomnia wards off sleep. All of these are portrayed thanks to Rachel's excellent writing and some fantastic acting by people who, by their own admission, had had little to no contact with the ambulance world prior to taking part in this play. 

Back to where I started - what made it surreal? Well, if you mean something other than the fact that I travelled a round trip of 5,000 miles, just to see a play, the surrealism began by hearing my own words, my own thoughts spoken in somebody else's voice. I had read the script a hundred times, but I was used to seeing words written down. After all, I had written at least some of them. However, hearing them, seeing how they are portrayed, sensing them spoken with an outsider's emotion, was an experience that left me with a chill down my spine, as well as proud and not a little humbled. 

This blog started as nothing more than a figurative notepad for me to voice my thoughts, to tell some stories, to open a porthole into my world, even if no-one else was interested. The fact that it has taken on a life of its own and opened up to a whole new style of audience has left me with a renewed sense not only of pride in my job, but responsibility in its portrayal. 

As for the play itself - it still has two more days (14th/15th August) to run. You can book tickets here if you're quick! The audience feedback has been incredible and the giggles and knowing murmurings I heard from some of my old colleagues must mean that the nail has been well and truly hit on the head. 

I owe my thanks to Rachel and the cast - Dimitri Shaw, Josh Burdett, Stacey Evans, Alex Hall, Buchan Lennon and Laila Pyne - for bringing it all to life. 

Five-a-Day

Progress report: Situation normal.

Well, as normal as it can get in the world of EMS. Several months into my new adventure, treating patients from right to left, filling in electronic patient reports instead of paper ones, on a system that is a combination of awkward, clever, helpful and frustrating all at once, and generally getting back into the swing of things, I have discovered that even if the systems are totally different, the end result is the same. 

The patients don't change. 

There are calls for all the same reasons, some genuine, some not. 

There are drunks. There are assaults. 

There are those who are dying to live and those who are living to die. 

And there is everything in between.

I have been working at a number of different stations, in different towns, separated by distances that in London are probably the equivalent of boroughs and in Australia or the USA I guess it would be just popping by to the neighbours. Still, the people are all the same. 

The arrival of a new baby still brings joy to the parents. 

The passing of an elderly relative brings sadness, grief; sometimes relief. 

The feeling of impending doom of a critically ill cardiac patient is just the same, whatever language may be used to express that feeling. Often, words aren't required; the mere look in the eyes conveys the message all too clearly. 

***

Just a few short years ago, In her early thirties, Leah had a cardiac arrest. She was one of the lucky ones. The stars aligned and she collapsed whilst visiting a relative in hospital. The ward staff reached her in seconds and she was resuscitated, waking up in unfamiliar surrounding a few days later. She heard talk of her heart stopping. She heard talk of having a funny rhythm and could think of nothing but a set of drums, but then talk of electricity in the heart confused her even more. Nothing made sense. 

She heard something about a defibrillator to shock her heart each time it happened. Something about it being there for the rest of her life. A life that had been taken away, returned, and now seemed once again to be slipping through her fingers. 

Leah's deathly pale, beads of sweat covering her face and arms. The fear in her eyes, as if we couldn't see it, was reflecting in her voice, in her pleading. 

"Don't let me die. Not here. Not with my children in the next room." 

The voices of cartoon characters fill the background, muffled by a doorway that separates the innocence of childhood and the harsh reality of life. That reality was monitors, needles, drugs. A battle against time and an unruly heart, beating to its own chaotic rhythm, rather than the regular spike on a screen and the audible lub-dub in the stethoscope. 

A few tense minutes later, Leah's face eases a little. As drugs course through her veins, sending orders to the heart to regroup, we see the rhythm take on a semblance of order. Finally steady enough to move, we carry her down the four flights of stairs to the ambulance and start to head to hospital. A few minutes into the journey, she lifts the oxygen mask from her face and asks a simple question. 

"Do you think it would help if I stopped smoking?"  

"I'm sure you've been told several times prior to today to stop." 

"But I only smoke about five a day." 

"Even those five aren't helping your heart, are they?" 

Leah didn't answer, choosing to sit in silence for the rest of the journey. We wheel her in to the hospital, to be met by an all-hands-on-deck medical team. Leah is transferred to the hospital bed, a nurse detaches our cables so that she could reattach theirs, as all the while Leah appeared deep in thought. 

"They'll take good care of you now," I said as I started to walk away, "just make sure that you do the same."  

Leah called after me. 

"Wait. Just wait a second. I have something for you." She reaches into her handbag, pulls out a box of cigarettes and a lighter, and places them firmly in my hands. 

"Take them. Throw them away. I never want to see them again."

Fringe Benefits

First, there was a diary. Yes, I'm serious. I kept a diary for years. I was still intermittently writing in it well into my twenties. 

Then, in an attempt to join the 21st century, there were a series of blogs. This very blog that you are presently reading is the latest and most successful. It was a natural progression from a hand-written, and now very much destroyed, diary. Anyone who wants to add "of a wimpy kid" to the end of the previous sentence won't be far wrong. 

Now, in a totally unforeseen, unplanned and somewhat unbelievable development, there is a stage play. Yes, you read that right. InsomniacMedic is coming to the stage. Not me personally, for that would be nothing short of foolish, frightening and entirely forgettable, but this blog has become the basis for a play that is to appear for two weeks at this year's Camden Fringe festival. 

That's Camden, London, UK. Not Camden, New Jersey; or Camden, New South Wales. Sorry to disappoint any of you who may be inconvenienced by the distances involved. 

Written by fellow insomniac and long-term friend Rachel Creeger of Time2Shine Productions, "An Insomniac's Guide to Ambulances" was borne out of many late night Facebook chats about our past experiences, mine as a paramedic and hers working with vulnerable families. InsomniacMedic was the starting point for this immersive piece which blends fiction and fact from both our real working lives, much like the blog itself. 

As an added bonus, certainly for me, anyway, despite being several thousands of miles away from London these days, I plan on attending a few of the nights, including one where a Q&A session will follow the play. For all the details, head to the Camden Fringe website, and search for one of two theatres where the play will be showing: Upstairs at the Gatehouse from the 5th-8th of August, or at the LJCC from the 11th-15th of August. The Q&A is on the 12th. 

I, for one, am honoured that this is even happening. I'd be even more so if you came and showed your support. At the very least, I could thank you in person for being a reader of this blog, and by that mere fact alone, making this entire project remotely feasible. 

See you there, but no breaking any legs please. I'm supposed to be on holiday! 

The week that's been

We see things. 

We see things that otherwise are seen only in movies, 

or in overactive imaginations. 

We see things that should never be seen 

and that cannot be unseen. 

We see the amusing, we see the frightening. 

We see things that others can only wish to see,

and that we are privileged to share. 

We see the sublime, the ridiculous, 

and everything in between. 

We see magic at its very best, 

and life at its very worst. 

We see trust and betrayal, belief, 

and the loss of all hope. 

We see acceptance of fate, we see denial. 

We see life end and life begin, 

first breaths and last. 

All in the space of a week. 

Unwritten Rules

The first clue was the fact that the apartment was on the fourth floor. It's the internationally recognised, first unwritten rule of ambulance work that the higher up the patient is in the building, particularly if there's no lift, the more likely they are to need carrying down. A voice hollers out of the window, through the security bars that seem totally unnecessary on a window so high up. 

"Bring some bandages, you're going to need them!" 

We're already carrying a supply, along with oxygen, a defibrillator, a carry chair and all other manner of equipment that we may or may not need. Unwritten rule number two is that whatever piece of kit you leave behind, is exactly the one you're going to need for the patient, so often we carry too much, rather than be stuck with too little. 

The trail of blood that greets us at the front door leads us to Berhanu, an ancient looking Ethiopian man, surrounded by concerned family. Three people start talking to us at once. 

"It happened yesterday too!" 

"He's on all these tablets!" 

"We tried to stop it, but it keeps filling up again!" 

Eventually, we calm the scene and reach Berhanu, finding him chirpy and unconcerned, unwritten rule number three proving yet again that often the family panics a great deal more than the patient. He was sporting a self-made blood collecting device around his foot, proudly showing off the handiwork that we were just about to dismantle. First, we remove the plastic bag, within which must have been a couple of hundred millilitres of blood. Next, we gently removed the DIY bandage that was held in place by sellotape and electrical tape, and that was made up of blood-soaked tissues, cotton wool and torn up pieces of newspaper. Finally we could see the ruptured vein just above the ankle. It was pouring out his blood as though someone had left a tap running. The tourniquet that he'd fashioned out of several elastic bands was doing nothing other than leave nasty marks further up his leg.

Within seconds, we applied a new bandage, lots of pressure and raised his leg, all in an attempt to stem the flow. It took some time, but eventually it slowed to just a trickle and then all but stopped, meaning it was stable enough for us to move Berhanu to hospital. 

"I'll walk!" he says, watching me open the carry chair. 

"I think it's better if you don't. We don't want that to start bleeding again." 

"I have walked every day of my life for the last eighty-five years, and up and down those flights of stairs for the last ten. You're not carrying me!" 

We pleaded with him. His family suggested, begged, shouted, instructed and cried at him. Nothing would convince Berhanu to sit in the carry chair. As a final attempt, my crew mate told him that the rules said that anyone who was bleeding, even a little, had to be carried. 

"Where does it say that?" 

"In my rulebook!" 

"Show me." 

"I don't have it with me. But believe me, it's there." 

"I don't believe you, and I won't be carried. Rules or no rules." 

He stands up, refusing all offers of assistance and takes a step towards the front door. All of a sudden, a trickle of blood appears below the bandage and within seconds it's dripping onto the floor at an ever-increasing rate. Defeated, he sits down again, allowing us to start the process all over; redress the wound, raise the leg and wait until the pressure and some gravity do the job again. 

When we're ready, Berhanu looks up at us and motions towards to the carry chair. 

"Good choice, we don't want to go through that again." 

"It's not really in the rulebook, is it, carrying bleeding people?" 

"Well, not specifically, no." 

"Unwritten rules, I guess. I suppose you have to have them too." 

Then and Now

At a Remembrance Day parade, several hundred war veterans, many of them well into their eighties and nineties, marched past an equal number of supporters who lined the streets of Whitehall, me amongst them. As long as I was in the country, I had attended every single parade for as many years as I could remember, supporting my grandfather, my great-uncle as well as all the other veterans. As they reached the Cenotaph, the cold, grey war memorial reflected the overhead skies. A fine drizzle had fallen all morning, coating the roads and pavements, but in an apparent show of respect had stopped falling as the veterans started to march. The Royal Air Force band escorted the veterans, the mix of young and old stark, but reassuring. A continuation of the generations, a knowledge that freedoms had been bought at huge cost, but that there were still those who would go on paying the price. It is both encouraging and tragic all at once, the knowledge that there are those who will continue to fight, alongside the reality that the need still exists. 

At the sound of the bugle, the flags are lowered and heads are bowed. An air of solemnity replaces the noise as a minute's silence begins, a silence crudely broken by the crackle of a police radio nearby and the words "Possible cardiac arrest on parade, St John Ambulance staff on way." 

When I look up from my place in the crowd, I can see the first shuffling of feet, clearing a path for the medical team and I approach the police officer to offer my help. He immediately pulls the gate aside and allows me through. I arrive at the same time as the team, explain who I am, and they gratefully welcome an extra pair of hands.  

The normal frenzied actions of a full resuscitation attempt are underway, but there is an acute awareness of the moment. Instructions are whispered, actions carried out in silence, even the ambulance arrives with blue lights flashing but the siren mute. The only loud instructions come from the defibrillator, as it advises to all who care to hear "Shock advised! Stand clear!" The orange button lights up and I press the button, wishing that there was another button to be pressed that would silence the instructions too. 

I never found out my patient's name, and the last I saw of him was in the back of the ambulance as he was taken to hospital, his chances of survival in single percentage figures. 

Against the odds, a few months later I found out through the grapevine that he had survived, and at the following year's parade, my grandfather pointed him out as he stood proudly alongside his comrades once more. 

Over a decade has passed since that day. Since then, I have left London, moved countries, and started on a new EMS path with a new organisation. The system may be different, but the patients are the same. They call when they are at a loss for any other options, sometimes they really need us, sometimes they just don't know where else to turn and hope for someone to share the burden and hopefully offload it.

Outside of work, we have made our home in a welcoming community, have made new friends as well as reconnecting with friends from days of yore, have moved nearer to some family whilst leaving others further away than ever. The number of expats is also fairly large, and so there are frequent visitors from overseas. Yesterday, I was introduced to one of the visitors, a friend's mother.

"Oh, so you're the paramedic?"

I'm not sure why I still find that question a little ominous.

"That's me."

"Did my son ever tell you about our story with ambulances?"

"Don't think so!"

"Well, about ten or eleven years ago, my dad was on a Remembrance Day parade and collapsed. St John Ambulance were there, they started doing CPR and they got his heart started again, and..."

I finished the sentence for her.

"And he was on parade the following year."

We both stopped in our tracks; the coincidence incomprehensible. She went on to tell me that her father lived another seven years after that day, long enough to meet his great-grandchildren, to see how the family continued to grow.

It is an occupational hazard, the knowledge that we almost never find out what happens to our patients once they are conveyed to hospital. But every so often, even if it takes a decade, we hear of remarkable stories such as this one.

My first successful resuscitation was on a gentleman whose grandson, years later, became my friend.

Code STEMI

At eighteen, I was the sort of squeamish person that everyone laughed at, as I'd feel faint at the mere smell of alcohol gel at the entrance to a hospital of doctor's surgery. The mere thought of visiting someone in hospital would give me a cold shiver down my spine. The threat of a needle would be enough to tip me over the edge into hysteria. Just a few years later, I joined the world of EMS. I guess you could say I got over my squeamishness. Although I still hate anything to do with teeth, dentists or anything in between. Don't get me wrong, some of my best friends are dentists. But only when I meet them outside of a quarter-mile radius of any dental surgery. 

The London Ambulance Service was my introduction into a world that I could never imagine, and my chance to discover that being squeamish is much the same as any other fear - the best way to overcome it is to face it head on. 

At first, as an EMT, I performed my duties almost by rote. Unthinking actions, following the script that had been drilled into my head throughout the initial weeks of training. But then, after a short while, as my confidence grew, I wanted to actually treat people, not just patients. I wanted to understand more about what I was doing and why I was doing it. And through this, despite the somewhat morbid attraction that many in the world of EMS have to trauma, I grew to love the heart just as much. I would sit and look at ECGs (replace C with K depending on which part of the world you happen to be in), try to delve into their mysteries and unravel the secrets that they held within the squiggly lines. 

Cardiac patients fascinated me. Within a short time of me joining the LAS, a new system was introduced for patients experiencing a heart attack, or STEMI. These patients would be diagnosed by the ambulance crew as having an acute STEMI and immediately conveyed to a cardiac unit for angiogram and angioplasty if required. Many patients have benefited from this life saving procedure, thanks not only to the skill of the doctors in the hospital, but to the skill of EMS providers in the field. More than once, having delivered a STEMI patient into the hands of the cardiac teams, we would stay to watch the procedure itself and get to see how the squiggly lines translated back and forth into what was happening on the inside. 

London became one of the pioneers in the field, leading the way in training all its staff to analyse ECGs and recognise the immediacy of the STEMI. It was exciting to be a part of something innovative and that was proving a great success. 

Recently, a team of paramedics and film-makers joined up, headed across the Atlantic from the USA to London, and joined crews there to see it all in action and share it with the world. Ted Setla and Tom Bouthillet put together a series of short films, taking in EMS systems around the world, with the London Ambulance Service - "The busiest EMS system in the world" - taking pride of place. 

CodeSTEMI (a hashtag with this name is also used on Twitter) is well worth the watch. In just under half an hour, the viewer is introduced into the world of the ambulance service and invited into the lives of people who have survived a threat that just over a decade ago would have meant  a much higher likelihood of death. It concentrates on the patients, on the crews and on the system that has helped raise the chances of survival of a cardiac arrest from single-figure percentages to somewhere over 30 percent in just a few years. 

The film doesn't sugar-coat reality, but it does show the human side of EMS, from the viewpoints of both patient and provider. And in these days where everything seems to depend on what can be done to bring down costs, whatever the cost, it's refreshing to see how people with a passion can still help to make a difference. 

It's been a year, almost to the day, since my last shift with the LAS. I'm proud to have them on my resumé, and smile when I look back, even as I'm still looking forward. It'll be strange to be the new-boy again when I finally wade through the sea of red-tape that is gradually running out (I hope), but at least this time I'll be able to do it with a decade's worth of experience. 

And I'll have all the inspiration I need by just looking back over my shoulder. 

The Story So Far (Or, how to keep the bank manager in suspense)

It’s been a little quiet round these here parts. I mean the blog, not Israel. Below, I explain a little as to why this has been the case. This isn’t really my normal blogging style, it’s just a chance to vent a little, so feel free to skip this one if you so desire. I promise to not be offended.

To say that the last few months have been an education is somewhat of an understatement. Almost ten months since I stopped working in London, I seem to still be some way off from getting my paramedic qualification recognised here. The key word, as you may have gathered either from previous posts or from twitter, is bureaucracy.

Even prior to our arrival, I’d made contact with the right people, presented documents, certificates, qualifications and all manner of related material, and was promptly promised that after a short conversion course of sorts, that I’d be a fully qualified paramedic. There are, like many other places around the world, many roles for a paramedic in Israel, within multiple different organisations and healthcare providers. However, the issue of paramedic qualification belongs to only one – the original (and still main) Israeli ambulance service – Magen David Adom (MDA) – a subsidiary of the International Red Cross. As an organisation, MDA has a pretty good reputation around the world. Many an ambulance service has come to study its mass-casualty treatment system and they lead the way in some of the treatments they provide. Yet at the same time, I'm discovering that it is overly burdened with tape the same colour as its well-known emblem. And I thought that London was bad.

I’m a little wary of accusing anyone of lying, but I think that the phrase “terminological inexactitudes” is a fair one. The information I provided wasn’t passed on. Claims (false or misinformed remains to be determined) were made that they had never had a paramedic who had qualified overseas want to move here, nor that there was even a protocol in place for such an eventuality. The relevant authorities weren’t informed. When they were eventually informed, there was another delay when the head of the right department seemed to leave under something of a cloud. Nothing to do with me, I hasten to add.

Then the plan changed a little and was to become a two-pronged attack on the system. Whilst I was waiting for the right courses and exams to come up that would eventually give me my paramedic license, I’d also work through the other side of the system to be recognised as an EMT and ambulance driver. Unlike the UK, not all road staff need to be able, or required, to drive the ambulances here. The idea was that the driving element should be easier and quicker to complete, the EMT certificate more of a formality, thereby giving me employment, at least as an EMT.

Plans are often foiled, sometimes by man, sometimes by machine. Sometimes the two combine to make life as difficult as possible. It’s meant that whilst I’ve been able to volunteer on the ambulances, I still have no actual employment. Other jobs that I’ve gone to look at, even temporary ones, both related and unrelated in any way to the medical world, have been kiboshed by the fact that someone, somewhere would tell me that there’s no point, as the bureaucracy will be sorted within a matter of days. There are three people particularly upset by this situation. The wife and I are the obvious two. The third is our bank manager.

There have been moments where I have thought about giving up altogether. That the effort I’ve been putting in and the hardship my family is enduring is just not worth the final outcome, assuming we even get there. I have sat through courses, taken exams (one of which, thanks mostly to my own stupidity, but partially to the ambiguity of multiple choice questions, I have to retake next week) and pushed on through the reams of paperwork, often feeling that it is a never-ending cycle leading me to nowhere and back again.

Then I’ll look back at the last decade, think back to the hundreds of shifts both in London and the few that I have here, and remember what it’s all about. What it is that I love about this job, which is so much more than just a job. Think back to the patients where I know I made a difference, or where they made a difference to me. Think back to the simple patients who only wanted someone with whom to talk. Think back to the patients who left no mark on my life, but who years later still remembered the difference we made to theirs, and who took the time and made the effort to come back and tell us so.

I know that I want to continue doing it. I know that I can’t throw it all away. I know, that if only they’d let me finally do it, that I still have so much to give. To give to my patients, to my colleagues, to myself. But for each step forwards, there seems to be at least one step back. Sometimes two. To say that it’s been frustrating is yet another one of those understatements. I have known for a very long time that Israeli bureaucracy is a menace that each person has to fight at one time or another. It’s frustrating that I have the skills and the knowledge, not to mention the experience, just sitting at home and waiting. It was frustrating during the recent war that I’d hear reports of volunteer paramedics arriving from overseas whilst I wasn’t allowed to join them despite sitting on the doorstep.

I am determined to beat the system, even if that then means I become a part of the very same. Perhaps once there, I can do something to prevent the next person crazy enough to want to do the same, from having to go through this chaos. In the meantime, I’m waiting for this chaos to end, just so that I can go and face chaos of another sort altogether; one that I can hopefully do something to treat.

And hopefully make my bank manager a little happier, too. 

Be Smart?

Two calendars run side-by-side in Israel; one religious, one civil. It means that we celebrate New Year twice a year, just to confuse everyone, including ourselves. The change of year on the civil calendar is still marked, celebrated by many just as it is in many parts of the world, although according to a press release issued by Magen David Adom, the national ambulance service, they were called to only fifty (yes, you read that right) alcohol related incidents on New Year's Eve nationwide. The Israeli population roughly numbers around the same as London, so this is a figure that the LAS could only ever dream of; they were averaging some 400 calls per hour for the first few hours of 2013. Admittedly, not all of them were alcohol related, but I can be fairly certain that a large proportion were. 

The end of the civil year also brings with it various annually-published reports, one of which being the traffic fatality report. The headline is nothing less than staggering: 2012 saw the lowest road-traffic fatality rate in half a century and on top of that, the rate is down 25% on the previous year's figures and some 40% lower than 2005. The UK could only hope for such a drastic change. In fact, the figures from 2010 to 2011 actually climbed by 3%, rather than reduced. It is a truly astonishing figure, but the question has to be raised as to how this has happened. 

As a driver on Israel's roads, I still see the shocking driving for which Israel is infamous. Drivers see keeping a distance from the vehicle in front as a mere nicety, perhaps a minor recommendation, rather than a safety measure; lane discipline is non-existent; indicators appear to be optional extras on most vehicles and road-rage is commonplace. We live in a high-paced, high-energy, live-for-the-moment country, where allowing another driver to overtake is seen as weakness and where allowing another car to slot into your lane makes you appear like a pushover. 

Other figures released today show that police have issued 40% fewer tickets for driving violations in the past year, down to 600,000 from over one million. They have concentrated less on minor offences (although the report does not specify what those are) and more on notorious roads, as well as "life-threatening misdemeanors", including dangerous overtaking, running red lights or stop signs, ignoring pedestrian crossings and, in particular, drink-driving. The police can, and do, when dealing with a driver who breaks one of these so-called "life-threatening" laws, revoke a driver's licence on the spot for up to 30 days. They can also impound their vehicle for the same length of time. 

It all sounds like a plan is coming together. 

However, what the reports barely mention is the number of seriously injured. These numbers still seem to be high, and depending on which report one reads, the numbers may still be climbing. The ambulance services here are becoming increasingly skilled at managing severe trauma patients. The times taken to get to definitive care in hospital is decreasing and the treatment options increasing. Tranexamic acid, a drug commonly used in hospital for surgery associated with a high risk of bleeding, has recently been introduced to front-line crews as a pre-hospital treatment and is having, at least according to initial reports, a serious impact on survival figures. 

All these facts and figures are optimistic, but also leave a little confusion in their wake. Clearly, better infrastructure, more intelligent and robust policing, better skilled pre-hospital providers and the obvious ever-improving safety features of the vehicles themselves are helping to save lives. This is a trend that we can only hope will continue to improve. But the fact that the accident rate is still high, that there are still so many seriously injured, is still a cause for concern. 

The human element is one of the toughest to regulate. Emotion will always play a part in a driving, particularly in light of the descriptions of the Israeli driver that I have already mentioned. Actual attitudes need changing too, but that is hard to do when confronted with a seasoned driver who has years of driving experience and picking up of bad habits. Change needs to begin from the ground up, even before a 17-year-old is allowed to start to hold a steering wheel in their hand. It needs to start with the basics, for example teaching that riding a motorbike whilst wearing almost no protective gear is a path to almost certain disaster. 

Attitudes to alcohol need to change. No more the thought process of one drink will be ok. You want to drive? Don't drink. 

Attitudes to other drivers need to change. Understanding that allowing one driver in ahead of you will not only benefit them, but will help the roads run smoother and reduce the aggression on the roads. 

Attitudes to seat belts and appropriate child restraints must change too. Particularly in certain sectors of society. 

It may take another generation, perhaps less, perhaps more, but if we want to reduce fatalities even further, we need the drivers themselves to cooperate. To understand that sometimes there really is a greater, even if unseen, good. 

Years ago, there was an advertising campaign here that promoted the following philosophy: 

"Don't just be right, be smart." 

A combination of the two would be even better.