Honour

There is no honour in a so-called "honour killing." 

These horrendous pieces of news reach our eyes and ears all too often, streaming in from media the world over, yet for as many of these horrendous news items that make it to the front pages, there are so many others stories that never see the light of day. The trauma affects only those closely connected to the victim and the world can't share the pain, even if only for a brief, fleeting moment of reading a hastily clicked-away internet screen. 

I know these cases exist. I have seen them, or at least their results. A woman lies dead in the street. A man she chose to live her life with was found not far away. Their families, disapproving of their relationship, made an unholy union in order to sever theirs. Calm is restored. At least until the next victim in the cycle finds themselves at the wrong end of a knife or gun or blunt instrument; harbingers of doom; revokers of life; restorers of so-called honour. 

The cycle continued. One death led to another, each family seeking the upper hand, the glory. There would be news of a shooting, or a stabbing, or an inexplicable car accident. Then there would be quiet. Sometimes days, sometimes weeks or longer, but still the air was filled with the constant threat of the next retaliation. 

We were traveling through one of the tougher parts of town. The roads have more holes and fewer rules, housing is a mish-mash of prefabricated buildings and run-down apartment blocks, street signs and street lights are almost non-existent and the numbering system no better than guesswork. 

Only a few days had passed since the last honour killing. The latest in the neverending cycle of deaths that proved nothing except that yet another gun had tried to restore its owner's pride, yet at the same time now made him, or those closest to him, the next likely target. In the darkness, we could see the hazard lights of a car parked a few hundred metres ahead. The driver's door and the rear door directly behind it were both open, and all we could see was a pair of legs sticking out. As he heard us approach, he jumped out. 

He was wearing nothing but a pair of boxer shorts. No shoes, no trousers, no shirt, nothing. As we pulled up behind the car, the first thing we noticed was that he was covered in blood. 

"She's in here! I don't know if she's breathing!" It seemed as though the latest victim of honour was in the back of an almost-naked man's car. 

We jumped out of the ambulance, grabbed the bed so that we could at least move her into the ambulance and be able to see to start treating whatever gruesome injury was about to reveal itself to us. The man who greeted us jumped over the clots of blood that were lying on the floor by the passenger door and looked as though he was about to faint. He sat back down in the driver's seat with his head between his knees and his hands on his face. 

"Just help her. Please. Just help her." 

Two steps later, we could see that our victim was no victim at all, sitting as she was, cradling the baby boy that she had just delivered. 

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. 

Bad Weather

Heading through the terrible weather towards the scene at right angles to the accident, the level of carnage looks all the more brutal. We're the third ambulance to arrive, adding to the sea of flashing lights. Rain drops look like tiny blue specks of light, reflecting the LEDs from all the emergency vehicles. Police cordon off each end of the street as fire crews start to cut through the mangled remains of what used to be a private car. The two occupants of the first car have managed to escape their wrecked former mode of transport and walked away with nothing but scratched arms and, for the driver at least, a bruised ego.

The other driver wasn't so lucky. Trapped in his seat by the crumpled front of the car, his head pinned back by the first paramedic on scene, all Terry wanted to do was move. One quick glance and I realised that it wasn't going to be a simple question of taking the roof off and dragging him out. There would have to be pieces of metal bent against their natural direction, some cut away all together, before we could even begin to think about getting him out of the car. 

And all the while, the rain continues to fall. 

"You must be getting soaked out there!" said Terry, talking through a misty oxygen mask. 

"Drenched to my core, but I'll worry about that later." 

At least he was in fairly good spirits. 

"Have you got any pain anywhere?" 

"Just my legs, but that's probably because they're wearing part of the engine." 

"No pins and needles, no pain anywhere else?"

"Nope. Nothing at all." 

"That's good. Can you move your toes for me?" 

Terry tells me that he's following my instructions, but his toes don't seem to move. Maybe I just can't see properly, but in any case, there's not much I can do about it.

"OK, we'll check on you a bit more once we've got you out of there." 

It took almost two hours of the fire brigade cutting, stretching and bending metal to get Terry free. In the meantime, we did what we could; gave him fluids and pain relief to keep him stable and comfortable. He finally appeared, borne out of his car on a flat, rigid rescue board. One look at his legs was all it took to see that they were both broken below the knee. 

"Can I just see the car before you take me away?" 

"Well, not really. It's the other side of the ambulance and you're now joining the wet-suit brigade. Besides, I think you need to get to hospital." 

Terry looked disappointed. 

"I'll tell you what - let's get you inside and out of this tropical downpour, and I'll go and take a photo for you on my phone." 

"Sounds like a plan to me!" 

We moved the trolley inside, turn the heating onto the highest level and my crew mate checked him out from top to toe again. I ran outside into the pouring rain, took a photograph as promised, and ran back inside into the dry.

"So, you sure you want to see this?" 

"You bet. Might as well have nightmares about something I've seen, rather than something I've imagined." 

"Alright then, here you go." 

With his head strapped to the board and stuck between two head-blocks, only his eyes moved. 

"Well, it's taken me twenty years!"

"First accident in twenty years?" 

"No. Third actually." 

"So what's taken you twenty years?" 

"Well, I've always wanted a convertible. I just thought I'd pick better weather to put the roof down." 

Two Feet

The rain is pouring down and I can't help but step across some muddy grass to get to the front door. I ring the doorbell and am thankful when it only takes a few seconds for Wendy to open the door - a torrential downpour is not my favourite choice of climate. As she pushes the door outwards, she looks back into the house and shouts. 

"They're here!" 

I wipe my feet and as I walk in I accidentally catch the strap of the bag on the door handle. 

"Can't your mate help you carry any of that?" 

"It's just me for now. There'll be another ambulance along soon enough." 

"Well, I don't know how you're going to get him off the floor on your own! I mean, he's been there for hours, and I've tried all I can do. He just keeps shouting at me that it hurts!" 

"Let's have a look and see. If I can help him on my own, then we'll do that. If not, I'll make sure he's comfortable, and we'll wait for a couple more pairs of hands." 

Clive's lying flat on his back, his legs in the kitchen, whilst his head and torso are out in the narrow corridor. It's rarely that these falls occur somewhere simple, and I have no choice but to step over him repeatedly, assessing for injuries and vital signs. 

"As long as I lie still," Clive's voice has a sing-song quality to it, "I really don't feel that ill. But if I try to get up or move, well, that's a different kettle of fish altogether." 

"Where's the pain?"

"In my left hip. I've already had the right one replaced, and I expect I've got the same treatment coming up now on the other side." There's no way I can move him on my own, and I've just been helpfully advised that the nearest crew may as well be in France. 

"The boss tells me you've been down here for hours. What time did you fall?"

"Oh, no. I only fell about ten minutes before she called you. She gets a little confused at times." He whispers the last bit, hoping not to upset his wife of more than fifty years. 

"I heard that!" She yells, out of sight, but clearly not out of earshot. "I don't get confused, thank you. Just forgetful!" 

Clive beckons me nearer. "Forgetful then, but selectively good hearing too."

"OY!"

"Told you!"

The crew arrive over half an hour later. In the meantime Clive's had all the pain relief I can safely give him, any minor wounds have been bandaged and I've strapped his legs together to try to take some of the strain off his hips. It takes about the same time again to manoeuvre a scoop stretcher into place to try to get him out the house. 

We split the scoop in two, separating the hinges at each end and gently move each side underneath him. We need to keep him as straight as possible to avoid moving his hip, but there's no way the now rigid stretcher will make the turn around the tight corner and into the narrow corridor. We try moving further into the kitchen to get a different angle, then try again to move in the opposite direction. The only success we have is in leaving dark footprints on the cream carpet. 

"I'm sorry, Clive, but there's nothing for it. We're going to have to stand you up. But don't worry, we'll keep you on this stretcher, strapped in, so you won't actually be standing at all. Is that all alright with you?" 

"No problem. Just do what you have to do." 

We add some extra straps for support, forming a "figure-8" around his feet and the bottom of the scoop, ensuring that when we stand him up, he won't move anywhere. 

"You can close your eyes if you like, it's probably a bit of weird sensation rising like a zombie." 

"With all that stuff you've given me, I feel like a zombie anyway!"

"Ah. That'll be the morphine. Told you it was good stuff." 

"You weren't kidding!"

After more to-ing and fro-ing, furniture moving and a few more wet, muddy footprints on the carpet, we finally manage to get Clive out to the ambulance and make sure he's as comfortable as possible for the journey. His wife joins him, and just before I shut the doors, I apologise. 

"Sorry about the footprints. If there's a next time, which I hope there isn't, I'll come in barefoot. Failing that, you could try calling when it's sunny instead." 

"Don't worry about it," says Clive. "Hopefully the next set of mucky footprints on there will be when I'm back on my own two feet." 

You Know You're in EMS When...

So this is the tweet I posted that started it all off: You know you're in EMS when you sit eating breakfast whilst watching amputations and impalements on TV.

After that, I thought it'd be good to hear what some other people think too, and the snowball started it's journey. These are the others that were posted. Read all the way to the end if you want to see my absolute favourite. Actually, there were two that I couldn't choose between. Having said that, I can identify with almost every single one of these!

Enjoy, and feel free to add some more in the comments...

You know you're in EMS when...

... you call a bunch of friends to meet up only to realise that they're all working because it's a weekday. Ah shift work. @flobach

... you're more unconscious than your "unconscious" patient at 3am. @goforfink

... a great sense of humour and no sense of smell are essential. @thesmurse

... you have extra gloves in your car, house, everywhere. @texaschef

... you consider asking your partner to start a line on you after a night at the bar. @texaschef

... you decide which hospital to transport minor calls to based on the food choice in the EMS room. @texaschef

... you somehow you manage to treat the patient with toe pain with the same respect as the patient with the genuine emergency. @justmyblog

... you've had to wait for hours in the emergency department for hours, without being a patient. @goforfink

... bed is a missed friend. @seanhfitz

... you've responded to back pain that's getting better, but they still call at 3am. @texaschef

... you have no shame taking the ambulance through a drive-through, and expect a discount! @justmyblog

... 2 hours sleep is considered a full night. @texaschef

... your crew mate takes the bumpy route when you're in the back. @ambulance_999

... you watch "Trauma" and wonder when your service is going to get stretchers like that. *drool* @goforfink

... you drive up to a width restriction and think "will I fit?" @MadMedic1

... you identify random places around town by the call you attended there. @seanhfitz

... you don't remember working a cardiac arrest at the end of your shift because you were asleep. @seanhfitz

... townspeople and ER nurses only recognize you when you're in uniform. @justmyblog

... you drive by an MVA (RTC) and not look at it, because you've seen worse. @texaschef

... you can eat, use the restroom and sleep, all in 20 minutes. @texaschef

... Friday and Saturday become the worst nights of the week. @goforfink

... you can work a 17 hour shift, running all night, and still find the power to go to the pub. @grindermedic

... you look at a person in the street and think "5 loops and call it!" @MadMedic1

... you can live off two hours sleep per night - as long as you have coffee. @justmyblog

... when you get ideas for your lunch from your patient's vomiting. @seanhfitz

... you tell patients "the gloves are for your protection". @ambulance_999

... you drive a Mercedes all day, then get in your car and try to indicate with the windscreen wipers. @goforfink

... you become a dustbin for everyone's poo. @christopher_mcg

... you've mastered the art of getting dressed whilst still dripping from the shower and still looking somewhat ok. @justmyblog

... you drive home after a night shift and realise you've treated the last three red lights as give-way signs. @999donkey

... you're looking for a friend's house at night and reach for the centre console to turn on the floods. @flobach

... when you use all your sympathy at work, and leave none for your family. @mrsinsomniacmed *ahem*

... when the flight attendant asks if any medical people are on board and you try to become invisible. @seanhfitz

... for you to have a good, challenging day at work, someone has to have a really bad one. @ColdGh0stR1der

... when your house is always an organised mess, and your rig looks like something out of Martha Stewart Home. @justmyblog

... you can judge exactly 350 yards, with or without the satnav. @MrTom_Abbott

... you can smell what's wrong with your patient before you can see them. @ambulance_999

... you eat every meal like it's your last, because you know the alerter will go off any second. @ambulance_999

... hot girls walk past you and you notice they have a curvaceous body, slender arms, and beautiful... veins. @flobach

... you utter the phrase "that's not that much vomit!". @510medic

... you turn off the radio to hear the sirens. @EMTDani

... you never have a wardrobe malfunction at work. @flobach

... you can pick the type of vehicle responding by hearing a far away and faint wail of the siren. @flobach.

... even at home, when the phone rings, without thinking you answer it "Ambulance". @multistar

...you know the streets of your patch like the inside of your pocket, but are hopeless outside. @flobach

... you walk into the messroom at 1900, and bid everyone "Good Morning". @insomniacmedic1

... you're off duty and hear sirens, and for a second think they're your sirens. @texaschef

... you go to grab a pen from your breast pocket... but you're off duty and in a T-shirt. @flobach

... you see a trauma in a movie, and immediately run through your assessment. @texaschef

... your wardrobe has a disproportionate amount of green in it. @saintpara

... you refer to you mirrors as whiskers for judging gaps in traffic. @idle_paramedic

... your life is ruled by three-letter abbreviations and complex terminology. @christopher_mcg

... you categorise people by what you think they'll die from. @saintpara

... you can't watch a medical drama without screaming at the TV every time some actor does something wrong. @multistar

... you've answered your personal mobile phone with your callsign. @thesmurse

... you have to stop yourself waving at ambulances / police cars when not at work. @saintpara

... you're constantly tired, over-worked, and under-paid. @multistar

... you're a passenger in any car and out of habit you say "clear left". @thesmurse

... you look on YouTube for car crash vids, and wonder how you'd extricate them. @yellowspanner

... you discuss decapitated bodies at the dinner table. @UKmedic999

 And my two favourites? These two laugh out loud moments of pure genius:

... you have too much blood in your caffeine stream. @theroaddoctor

and

... when anything over 8 minutes is just too long. @saintpara

Light Bulb

"You have a scratch on your cheek."

"The dog did it."

"Where's the dog?"

"It's in the back room."

"Can we see it?"

Door opens, and rat-sized dog appears.

"That's it?"

"Yup. That's it."

"And you called an ambulance for...?"

"Well, it scratched my face and I was bleeding."

"You had a scratch on your face and you called an ambulance?"

Friends and family all laugh.

"Ever cut yourself shaving?"

"Yup."

"I see. Ever call an ambulance for it?"

"Nope."

A look of understanding registers on his face. You can imagine how the rest of the conversation went.

It's like a light bulb suddenly came on in a dark, dark room.

Brick Walls

A short observation:

Children's heads do not do well in collisions with brick walls.

Ask any of the kids I had to treat during my so-called days off...

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.

A Conversation

On the 100 metre walk to where the patient lay in the middle of the makeshift football pitch:

"I've put a bandage on his leg".

"Great. What happened?"

"He was playing football, stepped on the ball, and fell over. There was a wicked crack."

"Have you moved him?"

"No. I just put a bandage on his leg."

"Is there lots of bleeding?"

"Well, no. Not really. The bone is sticking out of his leg, but not a lot of blood."

"Hm. Sounds broken to me".

"Don't think it's broken. The bone's sticking out, but there wasn't a lot of blood, so it can't be. Yeah. Pretty sure it isn't broken."

"..................."

Tug of War

Cigarettes litter the hallway.

The floors filthy with the wanton abandon of morals, respect and self esteem.

Walls are stained by smoke, the floors covered in grime.

The room is filled with it all, smothered by the air of neglect.

She's there, In the midst of it all, there, her eyes open, staring.

Empty. Void of joy, of life.

Her last will and testament to the world stuck up with gum.

"You won't even know I'm gone".

The ceiling fights against gravity, the rope torn between the two.

A tug of war.

Of Life.

Of Death.

Suit of Armour

Armies, thousands of years ago, would wear them as they invaded another land.

King Arthur's knights donned them before battle.

Modern-day soldiers protect themselves in modern-day versions.

And we, as Emergency Services workers, have our very own models too.

There's no other way to explain why we do what we do, whilst knowing that what we do is sometimes a little bit crazy.

*****

It's the sort of news that makes people in the UK mutter about becoming too much like America. Random shootings, killing sprees, mass murder and then suicide. The horrendous events in Cumbria, in the north of England, sent shock waves not only through the usually quiet villages and towns where the killings took place, but all the way through the land.

It's happened here before. Dunblane, in Scotland, was the site of one such atrocity in 1996, where the victims were young school children and their teacher. Hungerford, in 1987, was the other infamous occasion where firearms, legally held, were used for such appalling, random, senseless killings. But look at the dates. One is more than 10 years ago, the other more than 20.

Crime is an everyday occurrence, wherever you are. There is violence on the streets, robberies, muggings, murders.

These sorts of crimes, the mass murders, however, are rare, which makes them, if that's at all possible, all that more traumatic for those involved.

The dust hasn't yet even started to settle on this story. The families of those killed and injured are still asking questions to which there are, at least for now, and possibly for ever, no answers. The grieving has started, the injured are being cared for, friends and relatives supporting each other, helping each other through a process that will take many many months, even years. From afar, I feel for them, I'm shocked with them, I try to hold them in my thoughts and prayers.

*

And then, there are the others. The unseen. Those involved who will not be given a second thought. They won't be part of the grieving process or the recovery. They won't make the news talking about their experiences and feelings. Because they are the professionals. They're one step removed, and they can cope. Those members of the Emergency Services, police, ambulance crews, air-ambulance staff, fire-brigade. The front line. Front-line, yet hidden from view. Exposed to sights that should never be seen. Shouldn't be seen ever, yet we are exposed to them on a regular, if not daily basis.

*

I believe that when we get ready for work, one of the things we do, is put on what all those armies and Knights of Yore used to do.

We don our Suit of Armour.

We put on our uniform, and become someone else.

The mindset is different.

The thought processes are different.

The coping mechanisms are different.

The Suit protects us from what Chris over at Life Under the Lights called "Splashed Sadness". Briefly (and not as eloquently as Chris - you MUST go read his post), Splashed Sadness refers to the exposure we all have to emotions on a regular basis, and how we each cope with them. How a family standing in front of us will be grieving the loss of a loved one, and how we'll be sympathetic, empathetic, sometimes look on the call as a "good job", and then without pause for thought, discuss what we're going to have for lunch.

In truth, however, every Suit of Armour has a chink. And each of us is vulnerable to it. We'll cope on scene, because we have to. We'll not even give it a second thought sometimes. But every so often, there'll be the call that gets through that chink.

It may not be an immediate breach of the defences.

It may not be a total loss of the coping mechanism.

It may not even cause any sort of diversion from the normal flow of our thought processes.

Sometimes you just need a break, someone to talk to over a cup of coffee.

It might just be your co-workers on base, it could be your nearest and dearest, sometimes, even if rarely, it may well need to be a professional. We need to know when each of those times is.

*

We don our Suit, and face a world of sadness. A world of illness, of grief, of trauma.

We don our Suit, and become rescuers, therapists, saviours, even heroes to some.

We don our Suit, yet underneath we are the same as everyone else.

At the end of our shift, when we go home, we take off the Armour and are no different from anyone else.

We are partners, husbands, wives, parents, children.

We are human.

With a very special Suit of Armour.

Everyday Decisions

Everyday decisions.


What to have for breakfast.

What to pack for lunch.

What to wear for work, and how to get there.

Whether not to bother going at all.

*

Everyday decisions.

Cook dinner, or take-away.

Football or soap on TV.

Early to bed, or a late night out.

*

Everyday decisions.

Bridge.

Or Building.

Or Drugs.

Or a combination thereof.

*

Everyday decisions.

To Jump.

Or not.

*

He did.

And no-one will ever know why.

No-one will ever understand.

Nor explain his tragic, irreversible,

Everyday Decision.

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.

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".

Happy to Help

Public education should really be at the forefront of the campaign against misuse of the ambulance service. Huge posters, TV and radio ads, even, as far as I'm concerned, parliamentary debates.

Even the occasional blog post.

There's a relatively new law that could see a person fined, and potentially jailed, for obstructing an emergency ambulance in its duties. From the news that I've seen, this has been used precisely once in London since it became law over a year ago. This is probably because being deliberately obstructive, whilst potentially lethal and exceptionally obnoxious, is a very rare thing. More often than not, the obstruction is caused elsewhere, when an ambulance is called unnecessarily, whilst somebody else, in desperate need, lies waiting nearby.

*****

The call was to an industrial site, a plastics factory, for a hand injury. The call taker has been told that there is serious bleeding. As per normal on these sites, the front gate security sent me the wrong way, but the array of white-overall-clad windmills soon had me turning 180 degrees and heading for the right factory. After grabbing the kit out the back of the car, I'm shown into the main office that doubles as the first-aid room. My tour-guide is walking double-time, and speaking twice as fast.

"I'm sorry we've had to call you. It's Stefan. He was slicing some plastic sheeting with a Stanley knife and it slipped. He's cut his hand. It's really bad! I've put some bandages on and tied them tight, but it's leaking through, so I've made him sit with his hand on his head!"

A first-aider with some knowledge, and putting it to good use. I'm impressed.

I find Stefan sitting on the office chair, feet up on the table, his right arm bandaged and resting on his head. Blood trickles out and drips down the side of his face, giving the impression that he's bleeding from his ear. He's paler than the overalls he's wearing, clammy and scared. I have to see the injury, so warn Stefan that I need to remove the bandages and he may want to look away. There's a definite reverse shuffle of feet heading for the door as I say that, as the few people who'd come to see what was wrong realised that they'd seen enough. With the bleeding still seeping through the bandage I presume an arterial bleed, and remove the bandages with some care to ensure I don't get covered in case of any spurting blood vessels.

The injury is serious. He has a deep laceration from the back of his hand by his little finger almost as far as his elbow, all along the top of his arm. It's like having a lesson in the anatomy of an arm - muscles, blood vessels, bone, all on view. The force being used on the blade to cut through thick plastic made easy work of Stefan's arm, as the knife slipped off its intended target and took out its venom on the next available one. With his arm re-bandaged even tighter than before, elevated in a sling, Stefan was blue-lighted to hospital for what would initially be an attempt to salvage his arm and its motor functions, and later on for the plastic surgeons to work their magic too.

As the back doors of the ambulance were shutting, Stefan looked up and said a drowsy "thank you".

"No worries Stefan. Happy to help."

*****

One week later, almost to the minute, and I'm called to a private home, for a man with an arm injury, again with serious bleeding. These sorts of things tend to happen in blocks. There'll be a few people all having heart attacks around the same time, then I'll attend RTCs as though they are going out of fashion, and obviously now a few days of people slicing their arms.

Kev meets me at the door himself. His hand and arm are wrapped in a colourful array of tea-towels. He starts telling me how the accident happened, and only half listening (big mistake), waiting to see another anatomy lesson, I start unravelling the towels that seem to have stemmed the serious bleed. Four towels later I can see his arm, but no sign of any bleeding. I ask him once more what happened, and he tells me again of the new DVD player and cutting his hand on the box as he opened it. For a moment, I'm lost for words.

There's no cut, no blood, at a stretch there's a small scratch. A paper cut. That's why he called the ambulance. For a paper cut. Sometimes, most times in fact, if I'm on route to a call that I think isn't either an Accident or Emergency requiring an ambulance, I'll rant, rave, threaten to scream and shout, but invariably, as soon as the door opens, I'm polite, professional and calm. I'll politely suggest that if there is a "next time" other alternatives, a GP appointment, a visit to a minor injuries unit, even self-conveyance to the A&E department are all possibilities.

This was a grown man, in his late 40's, with a supposedly responsible job, runs his own home, and seemingly has at least a normal level of intelligence. His justification for calling an ambulance for his paper cut was because he was on Warfarin - blood thinning medication - and was concerned that he wasn't going to be able to stop any bleeding. I tried to point out, gently at first, the fact that he needed to have been bleeding in the first place to be worried about it not stopping. I tried to tell him, calmly at first, that despite the fact that he was on Warfarin, he was at no greater risk than the rest of the general population of dying from a paper cut. None of this was being taken on board. Kev kept repeating the same mantra over and over. "I'm on Warfarin. I deserve an ambulance. I know my rights and that means that you have to take me to hospital, otherwise I might bleed so much that I'll die!"

In one final attempt to explain who we are, what we do, and when is the right circumstance to call us, I asked Kev if he had any family in the area. "Sure. My parents live not far from here."

"And if one of them was to have a heart attack, what would you do?"

"I'd call an ambulance."

"Well, sir, you wouldn't get one."

He looked incredulous. "Why the hell not?"

"Because, sir", I tried to answer with all the composure I could muster, "I'm here dealing with your paper cut!!"

Finally, the penny seemed to drop.

"Ummm... Errr... Maybe I over-reacted a little."

I sighed.

"Maybe you did, sir. Just a little."

*****

Fears allayed, Kev decided that he didn't really need to spend several hours in hospital for a paper cut, and after a short time and the traditional paperwork, he decided to stay home. We parted as friends, and he promised to think long and hard if he really needed to call an ambulance in future. I, on the other hand, after doing my little bit for public education, promised that if he did ever need us again, either for himself, his family or his friends, we'd be only too happy to help.

The Curse

The curse is well known. You can be busy as anything for days before, then on the day itself, nothing happens. Closely followed by something happening, but it'll be very mundane, dull, even boring. It is the Curse of the Observer. I've had many observers out with me over the past few years, some on a Vanbulance, and some on the Carbulance, but the vast majority have been the same. Cursed. Not every shift with an observer is so, but it does seem to be more often than not.

In fact, just as an illustration, I once had a very eager young lady join me for a shift. She worked for one of the big medical supplies companies, and had travelled from overseas, sent by her bosses, to see first hand how one of their new pieces of kit worked out on the front line. I was one of six people in London trialling it. She spent eight of the twelve hours of my shift hours with me and we did nothing. I mean nothing. We didn't see a single patient for the whole eight hours. Later that afternoon she had a flight to catch, so I dropped her off at a train station, and off she went. Moments later I was called to a hanging, and she missed exactly what it was she had come to see. I also had another few calls before the end of the shift, all of which requiring proper intervention. She missed them all. See what I mean? Cursed.

Having an observer has its positives too. It gives me the chance to learn from these people. Often they are medical students, nurses, or doctors. All cleverer than me, and will instantly fall into the trap of being asked a million questions about one of the many things I don't know or understand.

More importantly, however, is that it gives me the chance to show off. Not necessarily my skills per se, but to show off the world of Prehospital Emergency Medicine. To show how far the Ambulance Service has come in the last few years. To show how we are able to deal with situations that even the best doctor would find challenging. To show off what happens before the patient arrives in the hospital and is presented packaged, 4 foot high, and horizontal. And I love doing it.

Now, whereas I do my little bit in this promotion of EMS to the non-ambulance world, there are those out there who have gone above and beyond the call of duty, and have started a small revolution. This weekend coming, is the premiere of a production called the "Chronicles of EMS". What started as a trans-Atlantic, glorified shift swap between two of my fellow bloggers, 999Medic from England, and HappyMedic in San Francisco, has turned into a huge project that promises to try to change the Ambulance world forever. The initial idea of sharing and swapping thoughts and working practises between two people, has now got thousands involved through all sorts of media, social and otherwise.

The whole concept has taken off in ways that no-one had envisaged. It'll give us all a chance to pool ideas and ideals, to highlight what separates us and, more importantly what we share, and to make us all think about how we can go about improving what we do, as well as how we do it.

So as I go on entertaining observers and their curse, really and truly, I should count myself lucky. More than that. I'm not really cursed at all. In fact, I'm anything but.

GD

Chaos.
Smashed glass.
Fuel all over the place.
Unconscious, probably drunk driver.
Lots and lots of bystanders who all come rushing out.

*****
I'm always amused by the fact that when attending the scene of a serious RTA, as this one was, there are people who still insist on waving frantically to show the ambulance where to go. I mean, do you really think I can't see the upside down car with the steam pouring out of it? I know, I know they're only trying to help, so I shouldn't really complain, but still. It's weird.
One of the bystanders, we'll call him GD (the reasons will become clear shortly), comes over to tell me proudly that he and one other person dragged / assisted the driver out of the upside-down car, and after a few seconds of drunken yelling and thrashing about, he collapsed into an unconscious heap, where I found him.

GD then stands watching me and talking to me as if I'm his best friend. I complete an initial assessment, sort out a collar, some oxygen, do some basic obs, and assess for any immediately life-threatening injuries. None are apparent. Had he not have been drunk, this would never have happened, but the fact that he was, probably saved his life. Ironic really.

The whole of the local fire department turn up, and look sorely disappointed when the car wasn't on fire as had been originally reported. Apparently. They're closely followed by the ambulance. We package our drunk friend, who's starting to come round a little. Frankly, it was easier when he was unconscious and wasn't claiming to be one of several Hollywood heroes whilst fighting everybody off.

The ambulance leaves, and as I start my paperwork, I'm left watching the fire brigade turn the car back onto its wheels and then sweep up the mess. A voice behind me startles me a little, and I turn round to see GD standing there, proud as a peacock. "You don't remember me, do you?," he says. "You were at my house six weeks ago!"

I search the recesses of my brain but in the chaos can't place him at all. He must have seen the blank look on my face. "You were at my house", he adds, "for something completely different. Just as messy, though. Don't you remember? You delivered my... "

"Grandson!" we both said, simultaneously.

I'd delivered his grandson not two months previous, in the house right by the scene of the crash. I knew the house looked familiar.

"Don't you remember? I floated round the house yelling to everyone on the street: I'm a GrandDad! I'm a GrandDad!"

Cue huge grin.

Oh yes, GD. I do remember.

Handover Carnival 9

Well folks, here it is, the latest monthly Handover Carnival. The theme for this month is all about the small people we deal with, so without further ado, allow me to introduce:

Kids - Seen and not Hurt

I'm going to start this month's with a post from the Grumpy Dispatcher, who suggests a list of kit that is not part of our emergency stocks, but will probably help even more with our treatment. Remember that you're not only treating a condition. You're treating a person. Read it here.

*****

Read it? Good. Our next post is from Mack505 and tells how calls dealing with kids have the potential of turning a sleepy medic into a sleepless one.

*****

Epijunky, drawing on her experiences as both a mom (or mum in these shores...) and a medic, reminds us that we are all human, with human feelings and emotions, and that it's OK to let them get to us sometimes.

*****

Over at Rescuing Providence, you can read about the way kids capture the hearts and minds of even the toughest EMS and Fire crews, and that even the Bullies on the block are reduced to baby babble.

*****

Back in the UK and up in the Welsh mountains, Hypoxic Witterings gives us two views of the same emergency. One from the rescue team, and one from a bystander who watched helplessly as the drama unfolded.

*****

BasicsDoc, who I've personally had the honour of working alongside, has sent in a post about a call that's both haunting and heartbreaking, showing how families often cling to the smallest details in their despair.

*****

I've also had a couple of entries from blogs that I had not heard of or come across before. This is partly the reason for the Carnival, so I was pleased that it was serving its purpose. The first came from Dispatches From the Street. It shows the internal conflict we often have with a very sick child asking very pertinent questions. Do you lie or do you tell the whole truth?

*****

The next blog I've been introduced to is one called Just My Blog. Here I read about children getting hurt due to the laziness or otherwise of the so-called responsible adults. Sometimes we're no better than the kids.

*****

Lumo tells a story on a similar theme that's not really theirs, and gives an insight into what happens in an A&E department when they don't have the "luxury" of being forewarned of the horrors about to be unleashed, and how it doesn't always have to be personal experience that leaves a lasting impression.

*****

Almost last but most certainly not least, I'd like to give the floor to Mark over at 999Medic, the originator of the Handover Carnival. This is all his fault.

Mark's view is one of mixed memories, from how children leave us all traumatised, to the small people who steal our hearts. From the calls we hope never to attend, to kids who are nothing but sheer inspiration for all the adults around them. We all have much to learn.

*****

The next Handover Carnival is to be held over at The Happy Medic, who whilst planning for his edition, sent in his entry for this one. Sounds like his fire skills as well as EMS ones were going to be required, or maybe not...

The theme for the next Carnival is "Close Call", stories of a time when you or your patient cheated death, which left you with a reinforced idea of how life is precious, just in time for Thanksgiving. Entries by the 23rd of November, to be published on the 27th.

*****

Thus closes this month's Handover Carnival. It has left me with much to think about, a great deal to be inspired by, and a huge amount to be thankful for. I hope you feel the same.

Frostbite

We have a code for paperwork for every ailment, disease or injury we meet. There are about 100 options for the calls that we are most commonly called to. Ones not covered go under the "other medical problem" code. Every so often the list is updated, something added, something taken away, and the alpha-numeric sequence is shot to pieces again. I've memorized a large number of the codes, and rarely have to look at the crib sheet to remind myself. I'd hazard a guess that every single London Ambulance Service paramedic knows that 62 is the code for Alcohol Intoxication. That one hasn't changed for years. We probably also all know about 75 being a minor head injury. Friday and Saturday nights especially. But our all time number 01? Sitting at the head of the table? Abdominal Pain.

I believe it's number one not just for alphabetical reasons (although I'll admit that AB at the start of a word will give it a pretty good chance in any alphabetically organised list), but also as it's probably the most common complaint that we come across. Abdo pain is a potential minefield. It can be anything from gastroenteritis to food poisoning, from a heavy period to appendicitis, from labour pains to a ruptured placenta. It could be a potentially fatal bowel blockage to a very unlikely to be fatal under-cooked doner kebab making some very unhappy returns. In some patients abdo pain can signify a heart attack, in others it could be a ruptured aortic aneurysm, both potentially lethal. With no CT scanners, ultrasounds, or X-rays available in the back of the ambulance (yet), it can sometimes be a matter of educated guess work, at least initially.

However. I'd like to guess that the patient who's had mild abdominal pain for three (yes, 3) months (yes again, months), probably wasn't in a life threatening condition. In fact, she knew she wasn't. She told me so herself. She was about to go to the GP for a repeat prescription for some regular medication, but realised that the surgery had shut ten minutes earlier. So she called an ambulance to take her to A&E so she could get what she needed.

I had to ask what made her call an ambulance for what was clearly not an accident or an emergency. I'll give her her dues. She was honest. "It doesn't cost anything!", she said. The cab to the hospital would have cost her £5, possibly less. Less than the packet of cigarettes that she was holding in her hand.

As I'm in the FRU, just a car, and not really supposed to transport patients, technically there's a "big" ambulance on its way too. I'd love to be able to say to this person that she doesn't need an ambulance and she should get on a bus, but it's just not worth it. Sometimes I just can't be bothered for the argument, but I'm sure they sense my unease. I cancel the ambulance and inform control that they may as well save it for a worthwhile call. The "patient" wants her friend to go with to the hospital, so I move my luggage out the back seat and sit them there.

The 7 minute drive to hospital was spent in frosty silence, until it was broken by the radio.

"General broadcast all ambulances - ambulances needed for two possibly fatal stabbings in local area. One with multiple stab wounds, one with slashed neck. Anyone available please respond!"

In a moment of Mouth before Brain (unusual for me), I look in the mirror and mutter loudly "Unfortunately this taxi is already in use. Sorry I can't be of any help."

Did I mention the silence? It could have induced frostbite.

Cen-Tree

I have an ex-crewmate, Jim, who, when frustrated with the job and its ensuing politics, would threaten to go and work for the council as a lawn-mower. No, not as the machine, but as the operator of one. No grief, out in the open air, music blaring. What more could you ask for?

*****

Al, a local-council gardener for several years, loved his job. It wasn't taxing, he loved the open air, loved working at his own pace, loved listening to his music. No managers, no hassles, never home late. Just him, and the flora and fauna of the local area. Today was his turn on Daisy, the industrial-sized ride-on lawn mower. Daisy was used when the big jobs needed doing. Parks, large verges, anywhere that a normal sized machine would take days to complete, Daisy could do the job in a fraction of the time. Daisy's twin, Belle, was also sent out on the mission, piloted by Sue.

The weather forecast had promised a bright sunny day and for once had delivered on its promise. Al and Sue were thrilled. They moved from place to place, leaving behind them the scent of freshly cut grass whenever they journeyed on. Daisy and Belle were in their element. With Sue and Al chatting throughout, the morning flew by, and as the midday sun began beating down, they found a shady area that needed cutting too. A wide grass verge with several large trees dotted around.

Sue went left, and Al, right. He'd just remembered a funny story he was going to tell her and turned round to call out. Two seconds. That's all it took. Two seconds looking in the wrong direction. Sue barely had the time to scream: "AL! LOOK OUT!!!!"

Al turned round to face the front again, just in time to see the huge branch. Most trees would be proud to have that branch as their trunk, but on this tree it was just a branch. Perpendicular to the tree-trunk, parallel to the ground, and about six feet above it. Daisy was about four foot high. Al sitting down another two. He took the full impact straight in the face. Ten miles an hour isn't fast when you're surrounded by a tonne and a half of metal, but it's lightning speed if your face meets a tree and has no protection at all.

When we arrive, Daisy is the other side of the tree, with Al a crumpled heap on the floor. There's blood everywhere. I take a few seconds to assess and work out what's going on, in which time, Jim, my crewmate suggests that immobilisation may be a good idea. I wholeheartedly agree, and curse myself for not thinking of it immediately too. Right, brain back into gear. Trauma. ABCs.

Airway - clear at the moment, but some bleeding in the mouth. Unknown source. Regular reassessment required.

Breathing - yes. At the moment. Clear chest, no funny noises, no missing sounds.

Circulation - yes. At the moment. Several areas of blood loss, none that are obviously too heavy.

Disability - Sue's unsure if he lost consciousness, but thinks that he did. At the moment, he's conscious but very confused and a little agitated.

I'm still worried about Al's airway. We need to immobilise him on a board, with a neck brace, on his back. And there's something bleeding in his mouth. Not at all ideal. Ideally I'd like to have the patient knocked out and intubated. That would ensure that his airway and breathing are secure and I could deal with the other problems.

I ask for HEMS. They're unavailable. (Not once, in my whole career so far, have they come when I've called them. I've done calls with HEMS, when other people have asked for them, but never when I have. Either they've been busy, had no helicopter, or a myriad of other excuses. Once, they even crashed when they were on route to me. Before you scan old newspapers for news of a HEMS chopper crash, they were coming in the car. But still, it must be some sort of conspiracy...)

I ask for a BASICS doctor. The nearest one is at least 40 minutes away.

We're ten minutes at most from the nearest A&E, not one known for its trauma care. The nearest Trauma Centre is an extra twenty minutes drive away. Al has an airway problem, so we don't really have a choice. We package Al, load him into the ambulance, warn the local A&E that we're on the way, and apply diesel. Jim's driving, which is a good thing, as he's a much faster and smoother driver than I am. On route I constantly suction the blood from Al's oral cavity. I have flashbacks to the dental surgery. Not a good thing.

His observations remain stable. A quick look shows that he's lost several teeth, probably fractured his jaw and eye-socket, possibly fractured his skull. As his face took the full force whilst Daisy kept going, we had to suspect a serious spinal injury too. When we arrive at the hospital, there's a full trauma team to meet us. I'm impressed. They obviously understood the significance of the injuries that we'd tried to relate over the radio. Al's handed over to the team, and I never find out what happened to him after that.

Whilst we're cleaning all the blood, mud, and carnage we'd left in the ambulance, Jim mentions that he's not so sure about his alternative career path after all. I'm not surprised.

*****

PS. This is my 100th blog post. My century entry. What started out as a little bit of a trial run, has turned into something that has taken over my life! I'm shocked I've made it this far, and honoured that I seem to have captured the interest of so many people. I hope I keep going for a long while yet, and I hope you keep coming back. But in the meantime - thank you.