Eight Miles

The radio vibrates against my shirt, the phone beeps in my pocket and I run back to the car to see the screen flash up a new call. Eight miles isn't all that far, particularly at night, but even at an average of sixty miles an hour, it will take eight minutes to get there. To average sixty, I need to be going ninety for at least some of it. In London, even at night, it's barely possible and for the most part unsafe. Unsafe for me, unsafe for pedestrians, unsafe for other motorists, unsafe for my patient if I never make it to where they are.

Eight minutes is a long time to wait for an ambulance. I know. I've been there. I've had to make that call, had to wait that wait, watching and worrying. I understand. And I want you to know that when I have to travel that far with the screen shouting at me that someone isn't breathing, or someone is seriously injured, I feel the same as you do.

The trepidation that ninety miles an hour just isn't quick enough. The worry that eight miles is just one mile too far. The feeling that each and every speed bump in the road that's meant to slow me down and as I encounter it makes the patient's chance just a little worse. If I could somehow jump over those bumps, skip around the width restrictions, fly over the cars that block my path, I would. But I can't.

The address is eight miles away, 8.2 to be exact. The junction of two suburban streets is also the meeting point for a car and the bicycle carrying Hayley on her early-morning paper round. At six in the morning, traffic is starting to build and people city-wide are starting to consider their commute to work, just as I start to see the light at the end of the shift.

The caller is the car driver, distraught, distressed, disturbed. Scared not so much of the long term consequences, but more of the immediate danger to Hayley as she lies unconscious in the road. The call-taker gives some basic instructions, to check the airway, the breathing. Not to move the patient, but to wait for the crews to turn up.

We arrive on scene together, two of them in the ambulance and me in the car. 

"Six miles we've had to run for this!" says the frustrated attendant as he grabs another bag out of the side cupboard.

"Tell me about it. I ran eight."

One look at Hayley tells us we're going to need some extra help. She's starting to come round, moaning in pain and confusion. A large, dark patch is slowly spreading across her jeans from just above her knee. Her femur, the thigh bone, is clearly broken, the angle of her leg telling us more than we needed to know.

"I'll get HEMS running. I think we're going to need more pain relief than we can give her."

"Good idea. Bet they have further to run than we did."

During the hours of darkness, HEMS teams travel by car, leaving the helicopter to a better night's rest than most of the people who work on it during the day. It takes them some time to get to us, by which time we've tried to stabilise Hayley as much as possible. I give her a strong dose of Morphine, hoping to reduce the pain at least a little, at least enough to let us straighten her leg. It's not enough. Even doubling the dose to the maximum we're allowed to give doesn't allow us to move Hayley's shattered leg at all. HEMS arrive and the doctor on board gives Hayley some ketamine, finally relaxing her into a state where we can pull the jigsaw-puzzle femur straight enough.

We finally settle her on the stretcher, the minimal warmth of the blood-soaked blankets now assisted by the heater in the back of the ambulance. Hayley is well looked after - a couple of paramedics, a doctor, a mother who ran frantically to the scene when she finally heard what had happened. It leaves me with nothing to do but to clear up the scene as much as I can without upsetting the police.

I sit in the car and watch the clock tick over to the end of the shift. The tail-lift is raised and the back door is shut, the blue lights start to flash and the ambulance pulls away with its injured cargo, leaving me to wonder if we had done all we could, if it would be enough. I start the engine and begin my journey back. 

It's a lonely, subdued eight miles. 

Something

Last night I met one of the HEMS team that was on a recent call I attended.

The one where I performed my first needle-thoracocentesis.

It kept the lungs breathing.

It kept the heart pumping.

It kept the patient alive.

I knew at the time that the patient's chances of survival were very slim.

At last night's chance meeting my fears were confirmed.

The patient died about two days later.

Stabbing them in the chest didn't save their life.

But it did give the family the chance to come and say a final farewell.

And I guess that's something.

Stabbed

Needle Thoracocentesis.

Try saying that half way through your fourth night shift.

Worse still - try doing it when you've only had 10 hours sleep in the last four days.

And worst of all, despite being a paramedic for over four years - it's the first one you've ever done.

It's not the sort of skill that is either required or used very often. Even by trauma magnets such as yours truly. The problem is, that when you do need to use it, it's always deadly serious.

In the simplest terms, it involves sticking a large needle straight through the chest wall and into a collapsed lung. Counter-intuitively this will re-inflate the lung. Collapsed lungs (or pneumothorax in medicspeak) can be caused in various ways, such as severe asthma, sometimes spontaneously (especially in young, tall, fit people), and most commonly in ambulance terms by severe trauma. This can range from bad RTAs, to stabbings, shootings and other traumatic chest injuries.

The most dangerous sort, a tension pneumothorax, if left untreated, will kill. No questions. It will compress the lung, stop oxygen getting into the blood stream and round the body, and eventually compress the heart and stop that working too.

No oxygen + no heart = certain death.

It works, at the risk of telling fellow medics what they already know, a little as follows: the normal lung is a little like two balloons inflated one inside the other, with a tiny lubricated space in between, to make lung movements effective and painless.

In the case of a tension pneumothorax, the inner balloon has a leak. Every time you take a breath in, air enters the inner balloon. Normally, each time you breath out, the air leaves, but with a tension, the air moves from the inner balloon only as far as the outer balloon. That stretches, puts more pressure on the inner one, collapses it, and stops it working. It's also how the heart gets squashed, as well as eventually the other lung too. All in all, very nasty, and very, very deadly.

This is where the needle comes in. The needle goes into the large space that has now been created between the two balloons, lets out all the trapped air, allows the inner balloon to reinflate, releases the pressure on the heart, and allows the business of breathing to resume. It's only a very short-term solution, but gives the patient instant relief, and some vital extra time to get to hospital and definitive treatment.

In short - if you decompress the lung - you save a life.

Last night, for the first time ever, I stabbed someone in the chest.

Despite the 200 or so witnesses, and a police officer watching my every move, I got away with it.

Out of Depth

On days like today, warm, sunny aberrations from the norm, being ankle deep in water isn't so bad. Just the thought of it conjures up images of sitting by a pool, a lake, or even at a stretch, sitting on the beach, feet dangling in the cool blue waters.

Ankle deep in water would probably be a blessing for those affected not so long ago by torrential rain and devastating floods all over the world. Sure beats being knee or waist deep in the stuff.

Ankle deep really isn't all that bad, unless you're ankle deep in blood.

*

A call to the local bus garage isn't unusual, more regularly to patients whose blood alcohol volume is a little high and who are looking for somewhere warm and dry to sleep it off. So when the call came in as a young adult male unconscious, it sounded like business as usual.

The car had its hazard lights on, just as we'd been told it would. Abandoned rather than parked between two buses, with Rami stood at the back of the car, frantically flagging us down. Something about his demeanour said it was serious, but as we stepped out of the ambulance, there was no patient.

"What are you waiting for?" screamed Rami. "He's in the front seat!"

Didn't expect that.

And there, in the front passenger seat, was our unconscious man. 20-something years old. Ankle-deep in blood. And dying in front of us.

"What happened?" The question was more to keep Rami out the way and his mind occupied, so that he'd keep out the way and let us do our job.

Airway - clear.

"We were in the park and got attacked. They came out of nowhere, about six of them. They hit us with all sorts. He had blood all over him but we managed to run away. I didn't see where the blood was coming from. I thought it'd be better if I just took him to the hospital, but I got lost. Now I don't think he's breathing! I stopped to call you guys! I didn't know what else to do!"

Breathing - present, but laboured.

We reassured Rami that his friend was breathing, but was unconscious. His shirt was crimson red, his breathing laboured and his pulse rapid. We didn't need to check his blood pressure to know that it would be dangerously low - the amount of blood on the floor of the car told us what we needed to know. He needs fluids, preferably blood, and in a hurry. Out in the real world, pre-hospital, the only fluids we have are basically salty water. Better than nothing, and enough hopefully to get him at least as far as hospital.

Circulation - problematic.

We found the source of the bleeding, multiple stab wounds in his lower back and abdomen. Too many holes to plug, and not enough time to do it. We'd asked for assistance from HEMS, but as it was night and they weren't flying they would be coming in the car. Luckily, they'd been on a call not too far away, and even though they're normally based the other side of London from where we are, they wouldn't be more than 10 minutes away. Just as we were getting him into the ambulance, we were given an update that HEMS weren't coming. Apparently they'd crashed, and although it was only very minor, they were now tied up with paperwork.

With no assistance on the way and no way for us to give him anything more than fluids, we opted not to delay any longer, made him as comfortable as we could in the ambulance, and began the mad dash to hospital.

Police were with us.

Rami was with us.

Time was very much against us.

And we were back where our patient started.

Ankle deep in blood.

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?

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".