Take Away

Take a deep breath. You're gonna need it.

As rumours go, this one has been floating through the ether for some time. When it was officially published the other day, I wasn't at all surprised, but I was, still am, more than a little disappointed.

Intubations are no longer going to be a part of the London paramedic's bag of tricks. The single most useful technique we use, the one used in the most critical of patients, is being taken away from us. Let's start at the very beginning.

Intubation (or colloquially "tubing") is a process by which a plastic tube is placed in a patient's airway to protect it. It's used when we need to breathe for the patient, and when we want to stop all manner of gunk, particularly blood or vomit getting into the lungs, effectively drowning the patient. It's used by paramedics mainly in cases of resuscitation attempts - or CPR. If ever there was a time that a patient is likely to vomit, it's when a paramedic is applying brutal repeated pressure to their chest at 100 times a minute.

It is used at other times such as massive trauma when the patient is unconscious enough to allow the intubation to take place. Yes, there are different levels of unconscious, and there are even different degrees of dead, but these are the subject of a completely different discussion.

Now, however, instead of training new paramedics in the skill of intubation, they are only training them up to use LMAs, or laryngeal mask airways. These are good when you need to breathe for a patient, but totally useless if the patient vomits. So in our case, frequently pointless.

These LMAs, whilst brilliant in the hospital setting, will fail to fulfil their purpose out on the road. The reason is simple. In hospital, when a patient is aware of the fact that they're about to be knocked out for an operation, they are starved beforehand. No food in the stomach equals no chance of vomit. The LMA is perfect. You can breathe for the patient without having to go the full invasive method and intubate them. If, however, someone ends up with an emergency operation, where there was no time to starve them first, guess which method of airway protection is used? Correct - the tube.

The trouble with emergency cases is that they are exactly that. Emergencies. The patient will never have starved themselves prior to collapsing or being run over. They will never be considerate enough to think that they'll hold off on having dinner because there might be the possibility of the cavalry in green charging through their front door on a rescue mission, and would really rather prefer that the patient didn't vomit, thereby endangering their own well being, as well as the ambulance crew's uniform.

The arguments for the de-skilling of paramedics are several-fold.

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

The first two I agree with - up to a point. A study, apparently carried out in the USofA, says that the minimum training requirement is a 90% success rate at 57 intubations. The numbers seem a little random to me - but I'm not arguing them. When I did my training, I had to successfully intubate 100% of 25 patients. At least. I think, if I remember correctly, I intubated 40. The only one I failed at was the first one I ever tried. I told the consultant that I couldn't do it. I couldn't see what I needed to see in order to ensure a successful intubation. He huffed and puffed, muttered something, good-naturedly, about these new paramedics, took one look at the patient's throat and found that it WAS an impossible intubation. Even for a seasoned professional. I'm not saying I'm brilliant. But I am saying that I'm honest enough to admit I can't do something. And that in itself is an important skill.

The problem with getting an intubation wrong, is down to what your mother used to tell you when you were a kid. "Don't talk with your mouth full, or the food'll go down the wrong hole." The trachea (air-pipe), and the oesophagus (food-pipe) are next to each other. Well, actually, one in front of the other. If you put the tube down the wrong "pipe", you pump air into the stomach and do nothing for the lungs. It's lethal. It's not a difficult skill to master, but it does need proper training. Not only in how to do it right, but how to recognise and rectify it if you do it wrong.

Training is apparently becoming a problem due to the increased use of LMAs in hospital. The number of intubations is steadily declining, so there are fewer patients going around for paramedics to train on.

So extend the training. Do blocks of hospital theatre training weeks. If it takes a year to get the prerequisite number of intubations, then so be it. Use all the skills you have, and wait with the intubations. If you're lucky and reach that number in two weeks - then off you go into the field and save lives - along with the tubes.

We definitely don't have enough refreshers. Certainly not on intubations. We have courses reminding us how to do CPR, how many compressions, what drugs, what's changed since the last refresher. But we never go back to theatres to intubate live people. A manequin is one thing. A patient is real and has a different feel and knack to tubing. I'd love the chance to go back, once a year, and intubate under the guidance of a consultant anaesthetist. By the same logic, I shouldn't be allowed to put a patient's arm in a sling either. I know one is not a life-changingly-critical as the other, but the logic is the same.

On average, a paramedic will intubate a 3-4 times a year. A few more if you tend to be a little like me and attract more trouble than the average paramedic. It's not a lot. There are pieces of kit on the ambulance I haven't used more than once in my career. Literally. That doesn't mean that I won't use them if I have to. I have the skill, I know how to use it, and use it I will. I feel it's also important for a paramedic to arrange their own refreshers on less-frequently used equipment. To take out pieces of kit they haven't used for ages and just re-educate themselves in it's purpose and function. Clearly this isn't possible with intubations. However, intubating only a handful of times a year does not mean that I lose the skill. It doesn't mean I don't know what I'm doing, and it certainly doesn't mean I forget how to recognise whether I've done it right or wrong.

We're lucky in London. We're one of the very few services in the country (as far as I have managed to discover) that uses a piece of kit called End Tidal CO2 monitor. I'm not going to go into the ins and outs of how it works, but very simply, when you attach this to the end of a tube, it is an almost guaranteed assurance of the success of the intubation. You get a reading - it's in, you don't get a reading, you've missed. Simple as that. If you get a very high reading, chances are that the patient's started breathing on their own. Good news all round. There are fail-safe methods of ensuring a tube is done right. Any paramedic worth their salt will know them, check them, double check them, and know that if they've done it wrong, that they start again. Or, in the rare cases of seemingly impossible or even very difficult intubations, recognises their own limitations and works with what they can.

I've only once out on the road seen a paramedic miss an intubation.

That one time, it was recognised very quickly and fixed. I don't know where the data comes from that we're not good enough at it. My personal experience, the only one I have to go on, tells me otherwise. There have been tubes that I couldn't get, only two if I remember correctly. I blame my legs for one of them. There was a smaller paramedic on scene who could fit more easily into the restricted area round the patient's head and intubated them with no problem. The other I just couldn't see what I needed to see to ensure the tube was going down in the right place. I stuck with an LMA and prayed the patient didn't vomit. I vaguely remember being lucky. That time.

The cynics amongst us will blame the doctors. They're trying, at least some of them, to regain their superiority and would love to see paramedics bounced back to the stone age where we literally pick a patient up, throw them on the back of a truck and race them into hospital quick enough for super-docs to save their lives.

Those same cynics will also say that it's nothing more than a money-saving exercise. Less training means less spending, both on the training itself and the kit that it entails once qualified.

The establishment will claim that as they cannot guarantee training and proficiency, that they are taking the skill away. Future paramedics therefore won't be trained. Current paramedics will be allowed to go on using it for now, but my suspicion is that the equipment will slowly be used up and never replaced. A de-facto de-skilling.

It's a backwards step for an organisation that aims and claims to be a world-leader.

To me, instead of striving to better at we do, and extend our range of skills, this is a move in the wrong direction, a move to limit our abilities further.

I think it's a mistake. A step towards those who see paramedics as nothing more than World-War-I stretcher bearers, and away from those with a vision of modern, skilled, experts in pre-hospital care.

I hope it will be rethought at some time in the near future.

I hope that lessons will be learnt, and I hope that as a Service, London will rethink it's training strategy.

Most of all, I just hope that this is one take-away that we don't all, patient and paramedic alike, learn to later regret.

Note to Self

You'd think that over the years, and after the previous post, you'd have learnt your lesson.

Don't say out loud what you're thinking.

It's damned likely to happen.

Twice.

So, if you feel the need to say to the The Mrs just before you leave for work that you feel like there's a big job out there tonight, don't. Just don't.

Even if it does mean you get to wake up certain people in the middle of the night.

Thus endeth the Note to Self.

Training School

I was new at the time. Very new. Not even two months out of training school. It was a time when I was keen, eager, and very very scared. I arrived at the station at least half an hour before the shift, which I still do to this day, just to make sure everything that I may need for the shift is available and ready for use on the ambulance. Obviously still keen and eager.

Ten minutes later my crew mate for the day arrived. I introduced myself and told her that I was new, and would need all the help I could get. She asked if there was anything in particular that I was nervous about, anything that I really wanted to see, that she'd see what she could arrange. I didn't really believe it, but I did mention that I'd not yet been to a cardiac arrest call. I'd practised the scenario endlessly in training school. Everyone seemed to die there. All the scenarios seemed to end in cardiac arrest.

Asthma attack scenario? Cardiac arrest.

RTA scenario? Traumatic cardiac arrest.

Pregnancy/Labour scenario? Double cardiac arrest.

Drug overdose scenario? Self inflicted cardiac arrest.

And the scenarios would always be as difficult and unlikely as possible. "Worst Case Scenario" the trainers would call it. We all took it with a pinch of salt, they were just so far-fetched.

In a broken down lift.

A crane at full height.

Stuck behind a toilet.

In the middle of a muddy building site.

On and on it went. Weeks of "people dying". If that was the real world, I wasn't so sure I was ready for it. The real world, however, was anything but constant cardiac arrest calls. Six weeks on the road, and I hadn't seen it or had to deal with it once. So I told Anne about it. She laughed and told me that the chances were slim. It was a day shift, and people tended to die at night.

Those were the days before we had computer dispatch on the ambulances. The calls would come off a printer, and the Control Room would call the station to find out who was to be the next crew out. I can still hear the distinctive whirr of that printer and find that if I ever hear it anywhere else, I instinctively expect to hear a phone ring.

We'd been out on a couple of calls and had managed to get back to station. There was nothing to challenge my knowledge yet. But now, we were the next crew out. I sat anxiously waiting for something to happen. Eventually, the blue piece of paper appeared at the top of the printer, and the phone made me jump half out my skin. This was it. My turn. And for some reason I had butterflies in my stomach. I looked at the piece of paper and saw that we were on our way to a man in his 40s with difficulty breathing. In the special instructions section there was a line about the patient being in a "hard hat" area on a building site. Could be interesting.

Half way there, we get a call on the radio: "ETA request from the scene. Patient deteriorating".

"We're approx 5 minutes away."

"Thanks, we'll let them know."

Anne presses the accelerator a little closer to the floor, the engine screams in response, but the ambulance doesn't seem to move any quicker. Two minutes later, the radio operator calls over the noise of the engine. "Update from the scene. They're on the 3rd floor of a building site. Stairs still unsafe. Ladders in use. Patient turning blue." Leave the important bit until last, why don't you?

"ETA two minutes. Thanks."

Accelerating makes no difference other than the noise, so we will the ambulance to go a little faster.

As we're no more than half a mile away, the radio chirps in once more. "Patient now in cardiac arrest!" I expected panic to set in, for the shakes to take over, for my brain to freeze. None of that happened. It was as if I'd been programmed for just this moment. The adrenaline rush was incredible. In my head I'd made a detailed list of what equipment to take, how we'd get to the patient, how we'd get him down again, and what else needed doing. All this before I'd even got out of the ambulance.

We arrived to find that our patient, had been carried down one floor by the other builders. Now at least we only had stairs to contend with, and no ladders. Two of the builders had started CPR whilst the others looked on anxiously. Anne and I took over and with the oxygen we were giving him his colour started to improve. The defibrillator looked at the chaotic heart rhythm and decided that it needed to be shocked back to life. Shocks, CPR, Shocks, CPR. We were in hard hats, covered up to our knees in mud, on the second floor of a building site, surrounded by exposed beams and electrical cables, with a 100kg patient. A real "worst case scenario".

Moving him to the ambulance was much easier than expected, thanks to several pairs of builders hands helping us carry him. The ambulance visibly sank by several inches and audibly groaned its complaint as the group of 4 ambulance staff, 6 builders and one patient either climbed in or were loaded into the back.

We continued our attempts all the way to hospital where the staff took over. They knew Anne and the other crew, but I was a new face. I overheard one of them ask Anne who the "new guy" was.

"Oh" she said. "He's a bit like this job. Come straight out of Training School."

Pendant

I took one look at the computer screen, took stock of the fact that it was an elderly person fallen at home. A Green call, the lowest priority possible. Doesn't even require lights and sirens. I muttered unthinkingly and quietly to myself. Or so I thought. "Oh Oh...", I said, for some unknown reason.

*****

The lady who opened the door to Grace Court appeared so old that it seemed that if she was to teach history, then Ancient Rome would be her speciality, due to first-hand experience of the era.

"Yes?" Even the monosyllabic required an immense effort.

"Ambulance Service, madam. We're here for one of your neighbours."

"Do you know who?", she asked, polysyllabalism still elusive.

"Yes madam. Thank you." I smile at her question. Even at an age that would put Methuselah to shame, the sense of curiosity hadn't left her.

The building we enter is a warden-controlled residence. The residents, typically elderly, but largely self sufficient, have the benefit of an on-site manager who can be called on for some basic care and assistance, whilst also maintaining the luxury of independence that they would lose if moved to a nursing home. Most of the residents have emergency call buttons worn as pendants around their necks, so help can be summonsed at a moment's notice. Harold had decided otherwise.

*****

It had taken a concerted effort from Harold's family to get him to agree to move here, away from the home he'd lived in for the past 50 years. Harold was a very proud man, an Army Captain who'd seen and survived so much. He still did his own shopping, cooking and cleaning. Only recently he'd agreed to allow his daughter to do his laundry. The man who had rebuffed so many advances of enemy armies, had to make this one concession to the advancing years.

His family would visit every few days, every weekend without fail, and someone would call every other day. Mondays were a quiet day, time for Harold to recover from the grandchildren running riot around his apartment. He hated to admit it, but these days they seemed to exhaust him a little quicker, tire him out for a little longer. He loved having the family visit, but he also treasured his Sunday evenings and Mondays, knowing that the phone or the doorbell wouldn't ring, and he revelled in the calm after the storm. We were called to Harold on Tuesday morning.

*****

Harold's daughter had called him and unusually received no reply. The phone rang continuously. He hated the idea of an answer-phone, his theory of "If it's important, they'll call back" foremost in his thoughts on the matter. He did, however, unlike many of his generation, carry a mobile phone if he ever went out, but it was switched off when he was at home. "I'm currently probably at home", said the message. "If you know my phone number there, please feel free to use it. If you don't, then I probably don't know you either, so don't bother. Thank you". He must have recorded the message with the family around, as there was a great deal of merriment in the background, but no room for leaving messages here either. Sensing trouble, Harold's daughter made the 25 minute journey to visit him. When she arrived, Harold was on the floor. We arrived no more than five minutes later, despite the fact that the call was the lowest on the priority list.

*****

Harold breathed a shallow breath every ten seconds or so, and seemed to have no pulse that we could feel, he was unconscious, but clearly still alive. Listening to his chest I could hear his rapid heartbeat, feebly trying to keep his body fuelled with the oxygen it craved. It was racing at almost 200 beats a minute. Not enough for the heart to refill and pump the blood around the body. He had no recordable blood pressure. We helped with his breathing, and thought that if we tried to move him with almost no blood pressure, we'd probably kill him. He needed more than just salty water in his veins, but it's the best we had to try to stabilise him enough to be moved. After a litre of fluid, Harold's blood pressure was at least readable. Not good, but better. His breathing had also improved a little, and he was conscious enough to mumble a few unclear words. Time being of the essence, we decided that it was best to move. Once we'd handed Harold over to the hospital team, my crewmate told me off. "Next time you think Oh Oh, will you please keep it to yourself! Bloody Jonah!" Obviously I'd not muttered quite as quietly as I'd thought.

*****

Harold was given a blood transfusion, had surgery on his broken hip, and was kept in for several weeks to recover. I kept track of his progress as best I could, and eventually was told that he'd been discharged home. I'd long forgotten about Harold when, several months later I had a call back to Grace Court. The door was opened by a gentleman who still managed to look several years younger than his real age. He walked with no assistance, spoke clearly, knew who we were and why we were there. "I believe you're here to help Alice. She's fallen again. I've tried to make her comfortable, but I just can't get her up off the floor. Not quite as young as I used to be. Anyway, she's just over there".

We walked over to Alice, who this time had just slipped onto the floor and needed help getting up again. Whilst we were helping her, a voice behind me said: "Apparently your chaps were here helping me a few months ago. I don't remember them or indeed what happened, but if you see them, please tell them that the stubborn old fool from flat 42 is still fighting fit!"

"I'll make sure to do that, sir", I said with a grin, noting that he'd finally agreed to wear the emergency pendant.

School's (knocked) out!

It was a grey and overcast day, which was normal.

It was cold, which was normal.

I was waiting to pick up my kids from school, which was normal.

I was asked by one of the mums if I was the paramedic, which was, surprisingly, normal.

She told me that the school had just called an ambulance. This was definitely not normal.

After initially being told by the school admin staff to mind my own business, they did eventually let me in to go and help. Apparently a 10-year-old child was knocked out in the playground. Having been called more times than I can remember to schools to an unconscious child who wasn't, I was a little skeptical. However, as I got to the playground, I saw that this time was different. The child was unconscious. She'd been knocked over by another child as they ran in different directions, and a teacher who saw it happen described how her head hit the floor and nothing happened after that. Slowly she started coming round, and seemed to be in a post-fit daze. She'd been incontinent, which often happens when someone fits. A fit after a head injury can sometimes indicate a serious injury, so I was a little concerned.

With very little kit I felt kind of useless, but luckily I didn't really have to do very much other than to keep her airway clear, keep her calm, and keep her still. I once again had in my mind "So this is what it feels like to wait for an ambulance"... The crew turned up a few minutes later, and I was pleased to see that I knew one of them. It made the hand-over easier, as I didn't have to explain who I was and what I was doing there. They immobilised the patient, and by the time they were ready to go, her mum had turned up as well, so she went with them too. Job done, I went back to picking up my own children.

Kids. Who'd have 'em???

I really shouldn't be let out in public any more. I just seem to attract trouble. Or maybe it just attracts me...

Not so lucky man...

WARNING: NOT FOR THE FAINT HEARTED

I'd been busy all shift on the FRU, and it was beginning to look like I wouldn't get my rest-break. That could mean going home a little early for a change. It did, however, mean that I wasn't getting back to station for my food either... Finally, after calls as varied as an RTA with 6 people and only me to send (admittedly, and luckily, only two needed treatment) to an asthma attack, to a man vomiting blood (probably self inflicted due to alcohol abuse) and various others, I was allowed to have a break. I stopped, had something to eat, and waited...

Just when you thought that Jonah had left the building...

2 minutes after the end of my break, my phone goes, as does the station phone activating one of the ambulances. I yell "see you there" and go to see what the call is. The call is given as a stabbing. Police on scene. Maybe. Control calls me to say "hang back a little until we confirm that the police really are there, but just so you know, we've had reports that it's a lunatic with a machete". Nice... I hide around the corner, until the ambulance pulls along side and says that they've had confirmation that police are there. We arrive on scene together.

There are approximately 8 police cars. That's never a good sign. There are some pale looking police officers. Not a good omen either. There are some other officers making frantic windmill impressions. Definitely bad news. We arrive to find a man lying in the street, unresponsive. There's a bandage on his head and one on his arm. Both just placed on top, not tied down, which makes it a little easier for us to take a look.

Lunatic with a machete is long gone, but his "handiwork" is plain for all to see. There's a massive injury to the face, from the cheek to the temple. Sliced clean through to the bone, in the places where there is bone. And an arterial bleed. From the head. As there are three of us on scene things happen in a bit of blur of activity. There's bandaging to be done, we need to immobilise the patient as we have to suspect a spinal injury as well. We need to check for other injuries, especially to the front and back of his torso. We find none. He needs IV fluids, and he needs to be in hospital.

With trauma calls it's especially important to remember to do things in order. There's no point stopping the bleeding, which is what normally jumps out at you, if the patient can't breath. ABC. Airway, Breathing, Circulation. He was maintaining his own airway, and breathing on his own with no problems. So we could deal with the C problems. We had the head injury bandaged and moved to his arm as well. This also had a large laceration. All through all the skin, fat, muscle. The bone was again clearly visible, but at least no arterial bleed this time. We took him to the nearest trauma centre, and left him in the care of the staff there.

This man was clearly not as lucky as the soldier in Afghanistan. It does make me wonder once again though, which is the country with more problems...

The "Jonah" effect

Apparently, my reputation precedes me. I have a habit of attracting very poorly people to my ambulance. It's known as the Jonah effect. For some reason, last night Jonah went from being my middle name to become my first name...

Many outside of the Ambulance Service will be reading this and thinking that surely that's exactly what should be happening, but let me tell you that it's just not the case. I would hazard a guess that the vast majority of calls that are received by the LAS are calls which could be dealt with in other ways.

But back to the point at hand. When I informed the person who was to be my crew mate for last night's shift that we would be working together, his instant reaction was something along the lines of "Oh oh...I'll make sure everything's properly stocked!" Nice, huh? But evidently wise thinking.

To have the reputation of a Jonah at work is not a good thing. It means that everyone's a little scared of catching the disease with which it seems I've been smitten. I like to look at it another way. I like to think that at least I get to put all my training, experience and expertise to good use.

So to my patients from last night, from the gentleman (and that's not sarcasm) who'd been shot, to the two patients with heart problems, to the lady who ended up in theatre last night, to the ambulance crew involved in the RTA, to the poorly (and sometimes drunk) diabetics, I'm sorry for being such a Jonah. But I hope that you're all the better for the experience...