Password

Asthma had plagued Leanne's life for the past three years. Now, at only five years old, she was having yet another bad attack and as always, it was at bed time. The local crews know her well. They also know that her parents aren't the panicking type. They only call when they've tried to control everything on their own, but failing to do so always means a trip up to the hospital and an inevitable stay for a day or two.

Her little lungs struggle to cope with the narrowed airways, breathing in all the good stuff, but not breathing out the bad. Her shoulders move up and down with each breath, her stomach moves in and out, her chest muscles hurt with every move. Leanne's face is pale and tired, yet she still tries to force a feeble smile. 

We attach the mask with the misting medicine, willing it into her lungs, hoping it will work quicker than we know it really will. 

"You know what happens now Leanne, don't you?" 

She nods a silent reply, conserving her energy for more important things. 

"Good. Who's going to carry you down the stairs this time? It was Daddy last time, wasn't it?" 

Again she nods. She looks around the room at the four adults, two parents and two green giants, finally makes her choice, and points. 

"Well, I'm honoured!" I say, picking up Leanne as if she were one of my own. I hold her up to my shoulder and we can see eye to eye. Each time she breathes out, a little of the mist blows out the sides of the mask and onto my face, making her laugh a little. A strained giggle at best, but at least it's something. 

We double the dose as we settle her on the trolley and get ready to make our way to hospital. 

"Now, you know the drill. We're going straight in to see the nurses and doctors, and they might want to do all the tests they did last time. Do you remember?" 

Finally, she manages just a single word. "Yes." 

"And you know you have to show Mummy and Daddy how you're much braver than they are!" 

Each smile from Leanne paints a slightly brighter picture, her face has a little more colour, her shoulders  and lungs struggle a little less. Each small effort is rewarded with a small step forward and by the time we've slalomed our way through the early evening traffic, parting the cars with sirens and lights, Leanne is able to say a few words at a time. 

Leanne asks me to carry her back out of the ambulance again, but we decide that it might be more fun if she was wheeled in on the trolley. The familiar sliding doors won't open as we approach and she is confused. 

"Why don't the magic doors open?" 

I show her the numbered keypad and explain. "We need to tell it the password. Only special people are allowed through!" 

"Am I special?" 

"Of course you are." All four adults said it at the same time, causing Leanne to laugh again. 

"Do you think you can you guess the password?" 

She thinks for a few seconds and then talks loudly, straight at the keypad. 

"Please?" 

Greg

"GREG?" 

The man looks up, raises an eyebrow, shrugs his shoulders and finally shakes his head. 

As for us, there's still a child with an asthma attack waiting for our attention. 

Greg will have to find help elsewhere. 

Thinking back to the crash, maybe he's already receiving it. 

Missing

We spread out and search a room each. The police broke the door down, leaving the splintered remains of the frame lying all over the carpet, like a giant wooden pile of pick-up-sticks. Greg's worried neighbour had called the police having not seen him all day and seeing that his morning newspaper was still sticking half way out of the letter box. 

"He often goes out for the day, but he's never this late back and never leaves before reading the paper first." He stands behind us as we step into the house, brave and afraid in equal measure. "I just hope he's alright." 

Each door is opened slowly as the fear of what may be found behind it gnaws away at the back of all our minds. The kitchen and main dining room are empty, as are the other two downstairs rooms. One of them looks as if it had been locked in a time-warp for fifty years, with piles of newspapers tidily stored all around the room. 

Some houses give more of an eerie feeling than others and this is one of them. Only half the lights seem to be working, the doors creak and floorboards whine as the small army of police, ambulance staff and worried neighbours walks around fearing the worst, but hoping for the best. The search continues upstairs and follows a similar pattern. A gentle opening of the doors, initial relief at finding nothing and then a move to the next room. A more thorough search of each room, behind beds, in hidden corners, in the toilets and bathrooms reveals nothing. Greg isn't at home. 

Initial relief is soon followed by concern. The police start to take a more detailed report from Greg's neighbours, knocking on a few doors up and down the street to see if anyone could remember the last time they'd seen him, the latest time being the previous afternoon. The lady next door tells us that she's known Greg for over twenty years. 

"He has family, but they all live somewhere in the north of England. Come down for Christmas and his birthdays, but that's about it. He's fiercely independent and very stubborn. Never asks for help or anything. Loves his days out, goes everywhere by bus." 

We ask our control to contact the local hospitals, wondering if Greg had been taken ill in the middle of the night or whilst out and about on one of his gallivants. As they contacted each hospital they called us back to let us know the answer. No hospital within a ten-mile radius was looking after Greg and concern for his welfare was building. The police had called his relatives just to make sure that he hadn't headed north without telling anyone, but he hadn't contacted them either. 

As we were about to leave, a white van pulls into the road, the two men on board had come to fix Greg's front door and make sure the house was safe and secure. "We'd have been here sooner," said the driver as he stepped out of the cab, "but we got stuck behind a crash. Some old bloke knocked over about a mile down the road. They've only just let us through!" 

The coincidence isn't lost on anyone and worried looks cross a number of faces. Yet again, one of the officers gets on the radio and tries to find out the name of the victim of the crash. We all hear the reply. 

"No details yet. He didn't have any ID on him." 

We have no choice other than to leave the scene and leave the police and neighbours to deal with the missing Greg. As we drive up the steep hill towards the main road, we're given another call. A child somewhere is having an asthma attack. It puts an end to our mystery call. We turn left at the top just in time to see an older man walking in the opposite direction. Shopping bags in each hand, he strolls without a care in the world. On a whim, I wind down the window and shout. 

"GREG?" 

Animal Farm

Towering over me, with arms as big as a normal person's torso and wearing a vest that showed off tattoos from his shoulders to finger tips, Tom struck an imposing figure. As he opened the front door to let me in, I could hear barking from somewhere else in the house. 

"Is that dog locked away?" 

"Are you kidding me? He won't do you no harm! He's only a little thing."

"Yeah, the last person to say that to me then suddenly had to apologise and explain that Ooh, he's never done that before!"

"OK," Tom said, a mischievous grin crossing his face, "I'll go get him and lock him in the garden. Mum's in the back room with him, so you can follow me." Tom led the way, making sure to grab the dog as he went. "This is what makes you nervous? And I don't?" Every word dripped with sarcasm, and he had a point. The dog was probably no bigger than a child's football, and looked even smaller in the arms of his giant owner.

"Yes, and no. I can read people, they don't often bite, and I can usually run faster than they do. Dogs on the other hand, I can't read, often bite, and have four legs that are quicker and better than my two." 

Tom was still laughing at me when the crew arrived to take his mum to the hospital, but he did shake my hand and thank me for my help. He took great pleasure in telling the crew, Jill and Rachel, of my nerves, and they joined in the laughter at my expense, Rachel even going as far as asking him to get the dog so they can meet it. 

One-nil to the crew, but revenge is a dish best served cold.

An hour later and another call. This time the only noise I can hear at the front door is the wheeze coming from the lounge. A girl of mid to late teens opens the door. She looks frightened and worried, and practically drags me through the door to see her eight year old brother who's sitting on the couch struggling for breath. I kneel down next to him to start reassuring him and begin his treatment.

"He's got really bad asthma, and his inhalers aren't working. Mum and Dad let me babysit him for the first time tonight, and I didn't know what else to do." 

"You've done just fine, you did absolutely the right thing, so don't worry." Sometimes part of the treatment is treating the family too. "We'll have him sorted in no time at all, but you'll have to go with him to the hospital in the ambulance. Just give your mum a call and let her know what's happening." 

Mum instantly asks to speak to me, and I did all I could to calm her down. I apologised for disturbing their evening out and tried to ascertain a few more details.

"Does he have any allergies?" 

"Well, not to any medicines, but he's allergic to furry animals. You know, cats, dogs, guinea pigs, that sort of thing." I was relieved by that bit. "That's why we eventually let him get a snake." 

"A what?" 

"A snake. It's still quite small, only about five feet long, and he normally leaves it in the tank under the couch." 

Slowly, I lower my head and peek under the couch. There, staring at me from a glass fronted box, is the snake. It makes me jump a little, which probably had more of a therapeutic effect on the little man than any medicine I was throwing at him, making him laugh at my fright. 

"Don't you like snakes?" 

"Don't mind them too much, just didn't expect to be sitting next to one for so long without realising it." 

The room lights up in flashing blue as the ambulance pulls up outside, and two familiar voices are shown into the house.

"Aha! So we meet again." 

"No dogs for you to be afraid of this time then?"

"Well, as it happens, there is. He's terrified of me this time, and won't come out from under the couch. Maybe he knows I don't like animals much." 

They both crumbled at the thought of another tiny dog worrying me, so both knelt down to see if they could entice him out. I gave the brother and sister a quick signal to keep quiet. In an instant, there was a scream in stereo. Jill and Rachel both glared at me as I served up my revenge. 

One-one. And the dish wasn't even cold yet. 

As dawn approached, Jill, Rachel and I met on our third call of the night. We both arrived at the same time, and still just about had the energy to tease each other. 

"I'll tell you what," I said, "we'll make a deal. I'll make sure there are no snakes, if you take care of any dogs." 

"Deal," they replied in unison, as we walked up to the front door. 

A mother introduces us to the patient, her six month old baby, and immediately apologises. She talks in hushed tones, explaining that two other children are sleeping upstairs.

"You'd think I'd know better by now, after three kids, but I think I panicked a bit. She just coughed up a bit of her feed, and couldn't catch her breath for a few seconds. I'm sure she's fine." 

As Rachel checks the baby, Jill and I spot a huge fish tank, an aquarium that was more part of the wall, separating between two rooms. Dozens of beautiful fish swam around, adding colour and calm to the room. 

"Finally," says Jill, "an animal we can all agree not to be nervous of!"

"Well," I said, and Jill looked gleefully forward to me admitting another irrational fear, "I don't mind them if they're swimming, as long as I don't have to eat them!" 

"You don't eat fish?" 

"Can't stand the stuff. Can't eat it, smell it, look at it, or be within a mile radius of the stuff without feeling ill." 

"But you're not actually scared of them then?" 

"No. Not scared. It's just that I'd rather meet a live shark than a fillet of salmon or tuna steak."

At shift's end, I pack up and head for the animal-free sanctuary that is home. No dogs, cats, snakes, fish, or other creatures. Just as I was about to go to bed there's a yell from downstairs.

"Are you asleep yet?"

"Yes!"

"Good. Get up. My dad's had a fall in the high street and is a bit of mess. Can you go get him and see if he needs hospital?"

A grump, stomp and re-clothing later, I was back downstairs and ready to go out.

"Where is he?"

"He was helped up by some people but he didn't want an ambulance, so they helped him into some shop."

"Which shop?"

"The one next to the bank."

"There are two. One each side. Which. One?"

"Um, your favourite."

"My favourite? What's my favourite?"

"Umm, the fishmongers."

At least Jill and Rachel wouldn't find out.

Sppel Chekking

I admit, I'm a pedant. I don't claim to be perfect at it, but to me, spelling matters. 

I have an editor and a sub-editor for this blog who regularly pick up on mistakes I make, as well as using the sppel chekking fasility, because grammatical errors aren't picked up. 

So, in a begging open letter to our call takers, I ask you to please check your spelling. 

I know that if the message on the screen tells me the patient has "palpertayshuns", I can understand what it means. 

I know that if the patient apparently has narrowed "artoreys", he's at risk of heart problems, and not, as would seem at first glance, that he's a high-risk attorney. 

Vomiting. It has one 'T'. Lots of carrots and a dreadful smell, but - Only. One. T. 

Assmah. Really? Or are you just sending coded messages as to what you think of me? 

Stares. As in "The patient fell down the stares." Into my deep, dark, bloodshot eyes? 

And many, many others. Some amusing, some confusing. 

So please, dear call takers. I know it all happens in a hurry, I know the callers aren't always calm, clear and concise. And believe me, I know, that for all the tea in China, I couldn't do your job. But I beg of you; please, please, check your spelling before sending it down the computer to the often baffled crew... 

Anyone else out there got some good ones to share? Feel free to add your comments!

Breathing Again

They came in their masses. Call after call, day after day, week after week, for well over a month. In that whole period I don't think I saw a single person who genuinely needed an ambulance other than a few elderly fallers. Coughs, colds, three-week old ailments that suddenly needed immediate attention at four o'clock in the morning. It was infuriating and demoralising. And to top it all off, in the midst of this lull, before the days when I only worked nights, there was the dreaded "office week". A week of shifts that runs from Monday to Friday, nine in the morning until six in the evening, just like being back in an office.

I used to despise that week. It came round every three months or so. It meant fighting the traffic on the way to work and on the way home. It meant being left with the least suitable vehicle with the least amount of equipment. It meant, more often than not, coming in, taking the ambulance to get fixed, spending hours making sure it was working, ready, stocked and cleaned, seeing one patient, and then going home. Late. It meant always, always finishing late. And it meant that after spending a day making sure that the vehicle was fixed and ready, that someone else would come in and steal it, and you'd have to go and do it all over again the following day.

All in all, it left me frustrated, angry, and burnt out. Office week had finally destroyed the enthusiasm that I'd harboured since the day I joined several years previous. It was just a straw, but the camel's back had been well and truly broken. I had never before taken a sick day when I wasn't actually sick, but I was very close. The end of office week brought, as a reward for surviving its arduous torture, a long weekend. I wasn't due back until the Tuesday morning. Monday night, I picked up the phone and called in sick. Or at least I tried to. Three times I tried, and three times I hung up the phone as soon as someone picked it up. I slept even less than my normal two or three hours that night. Tuesday morning came, I had an ambulance that worked, it was equipped, and there was even a crew mate I was pleased to see.

Although not thrilled to be at work, I was determined to fight through the lull, and go back to enjoying my job. Whatever it may throw at me.

The first call came in seconds after the clock struck seven. The call was more routine. Abdominal pain. A young man with a tummy ache. The MDT updated with more details as we approached the address. A fortnight of pain now culminating in an ambulance being called. My hopes and determination lay in ruins once again. Normally I'm exuberant to the point of irritation. Ask any of my colleagues. Nothing at work really gets me down. Patients who called for inappropriate reasons would be fodder for venom only within the confines of my brain, whilst mostly I'd be all sweetness and light to them, as though they were the most important patient I'd ever had. But now, even I had lost my positive outlook. One minor abdo pain too many, and I was completely and totally fed up and burnt out.

I sat in the front of the ambulance after we'd dropped him off, another one ticked off on the list of the multi-drop delivery van-driver that I'd turned into. As I filled in the paperwork, I wondered how much worse was it going to get. I pressed the green button to tell control we were available and ready for the next call. Barely had we pulled away from the kerb, when the MDT rang again. Just an address appeared, no details as to what was happening. Another waste of time, probably. 

Less than a minute away from the address, and the details popped up on the screen. A lady in her 50s, asthmatic, breathing difficulties. In the extra information it mentioned about the husband who was making the call was difficult to understand as he sounded distressed and that he was possibly crying. We pulled up outside the house, took out the bags of equipment, and as we stepped over the threshold into the lounge where she was lying, she took one last, deep breath, and then stopped.

There was a blur of activity. We requested an extra crew, or at least another pair of hands. We plugged the mask into the oxygen bottle and started breathing for her. We added the kit that produced a cloud of steam containing salbutamol, a drug that would hopefully help to reopen her airways. Needles in, drugs administered, and more and more oxygen pumped into her lungs. Her heart still worked on it's own, whilst her lungs went on strike, but even that wouldn't last much longer if we didn't help it by taking control of the lungs. Another ambulance arrived, making the removal and treatment just that little bit easier and smoother.

Her lungs that were initially silent now had a harsh wheezing sound, a sign that they've opened just a little. Enough for us to be able to push the vital oxygen in just that little bit easier. Once in the ambulance, we warned the hospital we were on the way and a brief outline of what was happening. Half way to hospital things changed.

She took a breath on her own.

Then, after a few long, tortuous seconds, she took another. Still not enough on her own, but a huge leap in the right direction. We kept up our assistance with her breathing, arrived at the hospital, and handed her over to the team. As we stood watching, she took more and more breaths on her own, the regularity returning, the external interventions diminishing.

"Well done, guys", the doctor who'd met us with our patient treated us to a pat on the back. "You've saved another one." Another one maybe, but the first genuine patient in well over a month.

I was beaming as I walked out the department. A patient who not only desperately needed our help, but whose life we'd actually saved. A couple of hours later when we returned to the hospital, I peeked round the door to see that she was sitting up in the bed, a chest drain in place treating a collapsed lung. Her eyes were open and she was talking to her family.  

We breathed life back into her, and gave her another chance to face the world.

She'll never know that she'd already returned the favour.

Jealousy

Red 2, the second highest priority for a call coming in to the ambulance service. In the main determinant - the old favourite - Difficulty in Breathing. In the extra information the screen tells of a 40-year-old with a history of asthma. We race to the scene, find the front door open, and call in to find where the patient is hiding. We take in the oxygen bag, defibrillator, and all manner of equipment to deal with this life-threatening emergency.

A voice calls from the front room, and we follow the noise. The room is one of several in a large house, clearly now divided into several micro-apartments. A shared bathroom and filthy kitchen the only rooms with no external locks on the doors. The patient is sitting comfortably on the bed in the tiny room that is a bedroom, living area and laundry room all rolled into one.

Recently I've been charged with mentoring a student paramedic, (a brave decision by the powers that be...) and for most of this mentorship, he's in charge of the patients.

"Good morning. My name's Sash, what's your name?" Confidence is one of his strong points.

"Adam". A man of few words, obviously.

Adam seems to be having no difficulty in breathing at all, so Sash is a little confused.

"What seems to be the problem this morning?" Morning at this point is just after 5am, after another very long and busy night.

"I can't sleep." The words resonate well with your local friendly insomniac, yet at the same time grate a little.

"How long have you not slept for?"

"Since I woke up yesterday morning."

Whilst Sash is questioning, I'm checking his basic observations. A matter of course, and of course it matters. I think.

"So it's just been tonight that you've not been able to sleep?"

"That's right." I look up, just to make sure I heard correctly.

"Has this ever happened before?" Sash's perseverance is starting to show signs of frustration.

"No."

"So why have you called the ambulance? What would you like us to do?"

"Just take me to hospital. Maybe a doctor can tell me why I can't sleep."

Home remedies were suggested, a visit to the GP was suggested, an attempt to go to back to bed with a cup of cocoa was suggested. And all were rejected out of hand.

"I just want to go to the hospital. You're not doctors. I want to see a doctor."

At a loss for options, Adam was invited into the ambulance, took his seat, and we set off for hospital. We still can't refuse to take people to hospital if they're adamant they want to go.

I stay in the back of the ambulance to keep an eye on Sash and his ambulance aid, whilst our driver for the shift takes her place in the pilot's seat. We all know that there's not much to be said or done, yet I'm keen to see how Sash deals with a call that really shouldn't be.

The hospital is about a fifteen minute journey away. Sash starts to fill in the paperwork, name, address, baseline observations. Adam's not in any mood to talk, Sash has nothing to say, and I sit observing from the sideline.

About two minutes into the journey, I cough quietly. Sash looks up from his scribblings, and I mouth a 'Well done' to him. Confused, he asks me what for. I nod in Adam's direction and congratulate Sash on fixing the patient.

I can only stare at the patient as a strong feeling of jealousy starts to creep over me.

Adam's sitting there, held in place by his seat belt, quietly snoring and sleeping like a baby.

At Home

And so, with no pomp or circumstance whatsoever, it came to an end. A mundane call just before six o'clock in the morning, a simple handover to the crew, and a slightly solemn and very lonely drive back to station. I don't know what I was expecting or hoping for.

Almost five years ago, I started it for the first time. It lasted 6 months, and I hated almost every minute of it. I stuck at it because it was challenging and different, but I still couldn't stand it. At the end of the allocated half-dozen moons, you couldn't see me for dust in my haste to get away. Maybe I was just too young and inexperienced, maybe I was just lacking in confidence. Whatever it was, I was pleased it was over.

Almost two years ago, through lack of choice and with fear and trepidation, I went back to it. Last week it came to a halt, again through no choice of my own. My time on the FRU, the single-manned (personed) Fast Response Unit, has ended. All the things I hated about it the first time round, I loved this time, and I will sorely miss. I guess I'd grown up a little in the interim, and eventually started to feel at home in the FRU.

The most appealing is the challenge of having to think on your own, often for extended periods of time, and sometimes with very ill patients.

Starting a resus on your own and having to carry it out with no back-up for quarter of an hour.

Managing the asthmatic patient who's deteriorating before your very eyes.

Relieving the pain in the elderly patient who's fallen and fractured their hip.

And being unable to transport any of them.

Delivering a baby and praying for it to take its first breath.

Supporting the dislocated shoulder of a brave kid and watching them get drunk on entonox.

Sticking a plaster, or a band-aid, depending on where you are, on an adult who's behaving like a spoilt child.

And telling him so.

Being the first at the scene of a suicide attempt, working hard to save a life, only to see the patient whisked off in the ambulance or the helicopter, and staying at the scene filling in paperwork.

Being the first at the scene of a fatal accident, and having to call it before anyone else even turns up.

Being the first at the scene of a cardiac arrest, a terminally ill cancer patient, and grieving with the family.

And being left alone with your thoughts and a cup of coffee.

Travelling with a crew and them hating you for pulling rank.

Travelling with a crew and them loving you for pulling rank.

Travelling with a crew and the patient thanking you all. Together.

And having to justify it all. To control, to the crew, to the patient, to yourself.

Now, it's back to a mix of real ambulances and a few FRU shifts, but it won't be my car.

It'll be nice to have someone to share with, someone who I can look at over my shoulder when I'm unsure, and hopefully vice versa, someone to sing along to the radio with between and on the way to calls.

They say, whoever they are, that a change is as good as a holiday. Truth is, I could really do with one right now. It's just that I'll miss being at home.

Who'd have thought it?

Driving Skills

At the age of 17, like so many others, I learnt to drive a car. Actually, that's not exactly accurate.

At the age of 17, like so many others, I learnt to pass my driving test.

I learnt about Mirror, Signal, Manoeuvre.

I learnt about road signs.

I learnt to parallel park.

I learnt to drive on slow roads and fast roads.

I learnt to reverse around the corner.

At 17 and a little bit, on a Monday lunchtime, I walked into the staffroom at the school where my mum used to teach, with a dozen pairs of eyes staring at me and my glum-faced expression, none brave enough to ask if I'd passed the test or not. My mum, standing the other end of the room and obviously knowing me better than anyone else there, saw straight through the fake sadness, spotted the glint in the eyes, and without a word spoken, threw her car key across the room to a round of applause.

That was the day I started to learn to drive.

*

At the age of 26, I learnt to be a paramedic. Actually, that's not exactly accurate.

At the age of 26, I learnt to pass the first of many tests to be a paramedic. Yesterday, a patient reminded me of it just by asking a simple question.

"Do you get taught how to stay calm through everything you see, or is it something you naturally have to have before you can join the Ambulance Service?"

To me, that hid an altogether different question: where do you learn how to become a paramedic?

Is it all the sitting in classrooms, bored to death by endless powerpoint presentations?

Is it by spending time in the operating theatres, practising cannulas and intubations?

Is it by listening to lectures on how to treat everybody the same?

Is it by reading through the book about drugs, their actions, their contra-indications and being able to recite them all off by heart?

The answer to all of these are easy. Yes. That's where you learn how to be a paramedic. Or at least, that's where you learn how to pass all the assessments that qualify you as a paramedic.

For me, that's not enough. I don't just want to be able to pass my driving test, I want to learn to be a good driver.

By the same token, I don't just want to be able to say that I have a certificate that says I'm a paramedic, pay my annual dues, and finished. That's the easy bit.

I want to be a good paramedic.

That's what you learn after you get your certificate.

That's when you learn how to use all the skills you've just been handed.

*

You learn to use common sense, you learn empathy, you learn sympathy.

You learn that the technique with which you cannulated your patient in theatre, where all is calm and controlled, won't be the same when you're cannulating a patient in cardiac arrest on his home floor with several family members watching your every move.

You learn that the worst case scenarios which always seem to occur in assessments, are really few and far between. But in the meantime you see cases of domestic violence that you were neither trained nor prepared for.

You learn all about how a heart attack patient might look and feel, you'll know how to treat and transport them, but how do you keep them calm and reassured?

You realise that you're an expert at CPR, yet you were never taught how to tell someone that their loved one has died.

You find that you were given a stab vest to wear, but are never quite ready for the time that a patient or their relative suddenly turns into a threat.

You discover that when you're treating a young child and their asthma attack, when your knowledge of the right drugs is important, that the way you are treating their parents is equally critical.

You find that even if you know theoretically how to treat every patient you see, sometimes you need to treat yourself. The trick you aren't taught is to know when that sometimes is.

Oh, and you learn to reverse around the corner again. This time in a truck.

*

The list is jumbled, just like the real world of the paramedic. A shift can, and often does, range from the sublime to the ridiculous, from the mundane to the life-threatening.

Despite every lecture to the contrary, you find that you can't treat everyone the same, because everyone is different. What you can do, is treat everyone to get the same result.

Most importantly, you learn that you cannot learn it all. Certainly not at once.

It takes time, patience, an open mind and a willingness to learn in order to perfect those driving skills.

Hopefully I'm getting there.

Knowledge

There are certain things in this world that I know I do not, can not, or will not understand.

1) Women. But I think that's the same for any man.

2) Children. But I think that's the same for any parent.

3) Smokers. But I think that's the same for any non-smoker.

Category 3 has a sub-category. Smokers, who are still smoking, despite the fact that it is close to killing them. And they know it.

I know that it was your stressful job that started off the habit in the first place.

I know you can't turn the clock back, and not start smoking.

We both know that that's no excuse.

You know that the inhalers are less effective than they were.

You know that your breathing is getting worse by the day.

We both know that it's killing you.

Your daughter knows that you've called an ambulance, again.

Your daughter knows that she has to spend hours with you in hospital, again.

We all know that each time could be the last time.

Your daughter knows that you should stop.

You know that you could stop.

I know that you won't.

Do you think that your daughter understands?

Who knows...

Dear Doctor

Dear Dr G Practice,

Despite my seemingly, at least in your eyes, lowly position in the world of patient care, I would nevertheless like to raise the following points. This is due to the fact that recently I have repeatedly been met by an attitude which I would not wish on a rabid dog.

1) We are not your get-out-of-the-surgery-on-time assessment, referral, or taxi service. If I get called to a patient two minutes before the end of my day (or more usually, night), I still have to see them, assess them, refer or treat them, transport them too, if necessary. I can't, don't and wouldn't pass them onto somebody else just because I couldn't be bothered, especially without having seen them at all.

2) Just because you have seen your patient and called for an ambulance, does not discharge you of your responsibility towards them. It should not give you the right to dump them back in the waiting room, letter in hand, waiting for the ambulance to turn up. At best, it's unprofessional. At worst, detrimental to the patient. Especially, just as an example, when they are asthmatic, struggling for breath, hypoxic, O2 levels of 68% instead of nearly 100%, and literally climbing the walls, desperately near death.

3) I and all my colleagues, much to your chagrin, are not mere stretcher-monkeys any more. We are emergency medicine experts. We spend years studying, improving on and perfecting our craft. Much as you do with yours. As such, to have the professional courtesy towards a fellow medical professional and to give us a clinical handover would be greatly appreciated. Not to show that courtesy says much more about you than it does about us.

4) I'm fully aware that not ALL GPs are the same. I'm aware that there are plenty who do understand, comprehend and appreciate our role in patient care. I'm aware that there are many who are even pro-active in their dealings with paramedics. But I'm equally, and acutely, aware that there are those who hold us in disdain. So, even though I've said this before, I'll say it again. If what you think about the Ambulance Service and Paramedics hasn't changed in the last 10, 15, even 20 years, then come and spend a shift, maybe two on an ambulance. Relearn all that you thought you knew about us, but has changed so much since your early days as a doctor. You may be pleasantly surprised.

Show us the respect we're due, and once again I can guarantee we'll return the favour.

Lifesaver

The darkness is compounded by the cloudy, moonless sky, the heavens showering down their vicious tears with all the contempt they can muster. At least it helps the house stand out like a beacon. It's the only one in the street with all the lights on, shedding some brightness on the otherwise depressing night. As I approach the house through the overgrown jungle that covers the garden path, the door is already open. Standing on the doorstep is Rita, leaning forwards, hands on her knees, struggling for breath. She can barely get one word out at a time.

Rita's man is there, comforting her, encouraging her, keeping her calm. He's doing a good job of it too. It's especially impressive, as Ryan is only 10 years old, and Rita's his mum.

"I'm used to it", he claims. "She sometimes gets very sick and I have to help her".

"Did you call the ambulance?" I ask him.

"Yup. I've done it before. They always ask me the same questions, so I know what to tell them now".

It's about 4 o'clock in the morning. Ryan is wide awake, dressed, has got all of Rita's medications together, and written down the details that we need. It took me less than 5 minutes to get to the call, so he's obviously well trained and very organised. His little sister is half asleep on the couch, still in pyjamas, but with her coat on, ready to go.

While I prepare the nebuliser for Rita, he tells me that his mum has bad asthma attacks sometimes, and that she always has to go to hospital. He was woken up by the sound of a loud wheeze, and knew immediately what he had to do. He'd got everything ready while he was still talking to the call-taker at control, all the while doing his best to calm his mum's anxieties.

Rita's condition and observations mean that she's going to need some aggressive treatment and to be blue-lighted into hospital, and there's no-one else to look after Ryan and his sister, so I'm left with the babysitting duties. The crew and I decide that it's best if they don't travel in the ambulance, as we don't want to distress them any more, so they watch mum being loaded into the back of the ambulance, stare as the blue lights of the ambulance reflect off the vertical sheets of rain, and then climb into the car and out of the deluge. I've got the duty of transporting them to A&E until another responsible adult can be found to look after them.

On the way there, they both remain calm, although Ryan's sister is a little teary. Ryan tells me all about the schools they go to, how he helps at home, how he looks after his mum. More importantly he tells me about the football team he supports, and laughs when I threaten to throw him out of the car for supporting a team that are the sworn enemies of mine. Although, I have to admit it, they're much better than mine. But then, most teams are...

We arrive just after the ambulance, and the kids say a quick hello to mum and see that she's looking a little better and in good hands. They're happy to find the kids' waiting area and go to find some toys. Ryan keeps up his role of babysitter and looks after his younger sibling, finding toys that he knows are her favourites. I watch from outside and am impressed by all I've seen and heard. At just ten years old, this young man is so much already.

Son, big brother, mini-dad, carer. And, of course, whether he realises it or not - a lifesaver.

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."

Cooking

Forty year old men tend to know if they're allergic to something. Rani did. He knew that there are certain spices that if he so much as touches them, he breaks out in a rash. If he eats them, the rash is followed by his mouth swelling, his tongue doubling in size and his airways constricting. He knows to avoid them, but just in case, he also carries an Epipen wherever he goes. This is a self-administered injection of Adrenaline, used in cases of anaphylaxis. This is such a severe allergic reaction that it can kill in minutes.

Rani knew immediately, mid-evening meal, that something was wrong. All the signs of anaphylaxis were starting to show. He took anti-histamine tablets straight away to try and ward off the allergic reaction, but it was getting worse. He didn't think he needed the Epipen yet, but knew that he needed to get medical attention, so he called an ambulance.

When we arrive, Rani's wheeze can be heard from outside. His face had blown up like a balloon, and he was beginning to drool as his throat tightened. We put him on a nebuliser and gave him an injection of adrenaline. By the time we'd arrived at the hospital, lights and sirens blaring, Rani's condition had improved so much, that the staff wouldn't believe how bad he'd been. He even joked about how his wife might have been putting the spices in the food on purpose. By the time I got back to the same hospital a couple of hours later, he was just being discharged. I wished him well and suggested that maybe he should do the cooking next time. "Maybe", he said. "But I think I'll just keep supervising".

My words couldn't have been more prophetic, as exactly one week later we're back at Rani's house. "I should... have done... the cooking..." he wheezes at me. He looked even more ill this time. We were wheeling him out to the ambulance when he vomited all over the pavement. Later I'd thank him for keeping the ambulance clean. He'd obviously developed an allergy to something new, and this time they'd have to investigate properly. We treated him almost identically to the previous week, but this time his improvement was slower, and the staff at the hospital witnessed first hand what we were talking about. As we left Rani in the hospital bed, he whispers with a smile on his face, "I'm going to learn to cook. It's too dangerous otherwise. The wife's clearly got it in for me!"

*****

Forty year old women tend to know that they've got asthma. They know how to deal with it. Sima did. They get short of breath, they use their inhalers. Either they feel better or they don't. If they do, all well and good. If they don't, they go to hospital. Sima wasn't feeling better. Her boss in the office could see she was struggling, so he called an ambulance. Sima is sitting on the 5th floor, head down, shoulders forwards, using all her chest muscles trying to catch her breath. As we approach, she looks up. And smiles. As I'm putting her on oxygen and a nebuliser, I only have one question.

"Rani's learnt to do the cooking then, has he?"

Reluctant

It's relatively early in the evening, still much nearer the start of my shift than the end of it. I've just seen two patients in a row with exactly the same, quite rare, cardiac problem that I haven't come across for at least the last three years. Two people from completely different backgrounds, different ages, different life styles. Two people who've never met each other, probably never will, joined by a common thread. Weird coincidence. Makes me wonder what other strange things are going to crop up during the night.

I'm brought back to reality with the computer screen yelling at me that there is a patient with the dreaded Swine Flu who's having trouble breathing. My heart sinks at the thought of another unnecessary ambulance call out. I'm starting to think, somewhat cynically, that this whole pandemic has been magnified in this country just to get the government expenses scandal off the front pages for a while.

This time, however, it's different. I must have seen at least fifty patients who've got, or think that they have, Swine Flu. Or, as I've seen and heard it called, Hamthrax. I can genuinely say that this was the first time any of them really needed an ambulance. This time, I could hear the wheeze before the front door was even opened.

Along with probable Swine Flu, Zohara has asthma. She's had it since she was a little girl, and now she has two little ones of her own to worry about. She's done everything right. Stayed home, called the GP, was prescribed the magic cure, taken paracetamol regularly and used her inhaler. In fact, she's used a whole inhaler in just the last few hours. Usually they last weeks. But Zohara has her kids to worry about. No time to be ill.

She lets me in and collapses back onto the couch. Her breathing is rapid, noisy. She sits leaning forward, using all her chest muscles to try and get her lungs to open up just a little bit more. I don't need a stethoscope to determine that she's in real trouble. I put the probe on her finger that tells me her oxygen levels. They should be, at a bare minimum, 94-95%. The numbers read a dozen percentage points lower. Her pulse is double its normal rate, over 150 a minute. In broken sentences she tells me about her kids, how she'll have to get someone over to babysit. The maternal instinct, once again, over-riding everything else. I suggest that I start treating her first, and then I'll help arrange the baby sitter. A little reluctantly she agrees. The nebuliser, a noisy combination of oxygen flowing forcefully through liquid medication, is only just louder than her breathing. She takes some deep breaths on the misty air that presents itself through the mask, and after a few minutes her oxygen levels start to rise. Just a little.

Zohara's stringing a few more words together, enough to make the phone call and get a local family member to come and look after the kids. Ambulance and baby-sitter arrive simultaneously. Zohara is still trying to give instructions as she's taken to the ambulance, but can't yet manage to concentrate on breathing and talking at the same time. Breathing takes precedence, and she's left with no choice but to trust that all will be taken care of.

As the ambulance drives away, I'm left wondering once again, especially in light of my previous post, why? Why did she wait so long? Why did she think that she could do it all on her own? Why is it that a mother's instinct often doesn't stretch to looking after the mother too?

Most incomprehensible of all, why is it that so often, the people who need us the most, are the ones most reluctant to call us out?

Rise of the Machines

With all the technological advances in Emergency Medicine that have happened over the last few years, especially with regards to ambulances, sometimes it's easy to forget that we're treating the patient and not the machine.

Alex is a 55 year old man. Asthmatic since childhood. Heavy smoker since not long after that. Not a good combination.

His breathing today is the worst it's been for a very long time. He's tried all his normal remedies, including oxygen that he now has at home, but has realised that this time he's going to need an ambulance.

I'm back on the FRU again, and turn up first. The smell of smoke hangs heavily in the air, and there's a light fog to go with it. As I walk through the mist, Alex's friend calls through to say that it's OK, he's put out all the cigarettes, and it's safe for me to enter. I don't need to listen to his chest, I can hear the wheeze from the hallway. He's struggling to put 3 words together, and looks very flushed. "I.... Can't.... Breath...."

I put Alex on a nebuliser, and check his observations. His oxygen levels are a little low, his breathing rapid and noisy, and his pulse escalated. After a few minutes on the nebuliser his breathing eases a little, and the oxygen levels begin to improve. The crew turns up as well.

"I still.... Can't breath...."

"Don't worry", says one of the crew, "the machine says you're doing fine, and the machine's never wrong."

"But I can't..... Breath...."

I can't imagine what it must feel like to struggle for breath, but then to be told that the machine says that everything's ok, must just add to the anxiety. Alex's breathing was getting better. Slowly, but definitely improving. Except that he still didn't feel like it, and that needs to be our main concern.

Show some level of empathy.

Treat the patient. Don't just treat the machine.