More on Change

Following on from my previous post - here's one of the changes that are going to be trialled in London in the very near future. The Evening Standard, a London daily newspaper, has titled it "UK paramedics sent to emergency calls without ambulances". Slight newspaper sensationalisation is evident in the title and may scare the public a little, so briefly - here's the plan and how it'll work. Single responders will be sent in FRUs (fast response units) to the calls that are deemed as appropriate. Having recently completed an 18-month secondment on such a vehicle, I see no problem with that.

As a single responder, you are in an emergency vehicle that carries pretty much everything that an ambulance does, except the transport devices such as trolley, carry chair, spinal boards and the like. FRUs up until now have been tasked to respond quickly, start treating the patient, and then hand over to a crew that is sent to back them up. The thinking behind it is that the FRU paramedic/EMT is then free to attend another call. Whereas a call turnaround time for an ambulance is somewhere around the hour mark, on the FRU it was often less than half that.

The difference with the new model is that a transporting vehicle will not be automatically dispatched at the same time (in theory) as the FRU, except in the most serious cases, but that those in control will wait for instructions from the FRU paramedic on scene who can give a better assessment as to what sort of further response is needed. This, to me, is a small admission that the dispatch system we use is somewhat flawed. Having said that, the system can only go by what the call-taker inputs, and the call-taker in turn can only go by what they are being told over the phone.

There are other flaws. Calls to serious RTCs and other traumatic injuries are very often not categorised in the highest banding, and could in theory leave a lone paramedic dealing with a multi-casualty incident. I understand that any intelligent dispatcher will take one look and send the ambulance anyway, but in an era where there is more and more intention to rely on computer systems, turning around and asking for human input smacks of a contradiction.

Despite all my reservations at this point, I'd be glad to be one of the first paramedics to trial it had it have been trialled in the area in which I work. I would, however, have certain conditions that I'd like to ensure were adhered to. The main one would be that if I turned up on scene and requested immediate back-up, that it'd be on the way there and then. Too many times as an FRU paramedic I've had to wait for the transport to arrive despite repeatedly pleading with the control centre to find me someone to take the patient.

It's not a lack of confidence in my skills or treatment abilities. It's not that I'm desperate to "get rid" of the patient and hand responsibility to somebody else. I like and accept the responsibility, I enjoy treating patients, and I thrive on the extra challenge that is often presented when dealing with a critical patient on your own. But I recognise when the patient needs more care than I can give them.

Equally, if I decided that a patient didn't need transport to A&E, I'd like to know that the system was in place whereby other medical professionals would recognise and accept any diagnoses or referrals, and I'd like the public to be aware that I'm trained and qualified enough to make those decisions. This was the idea of the Emergency Care Practitioner (ECP) role that has been running in London for the last few years, but was never fully put into successful operation. The staff that took on the role were and still are dedicated, motivated paramedics who undertook a large amount of extra study and training, and are now being left high and dry as the role is phased out. It just never had the understanding and backing that it needed, and was never fully accepted by external agencies.

I'd love to think that this trial is being undertaken at least partially from a clinical point of view. I suspect economics has had more of a say. I may be an optimist, but I'm not naive. I have my reservations about this trial, but am more than happy to give it a go. No-one yet knows a full job description or scope of practice for this new role (probably entitled Advanced Paramedic), or whether there will be extra training involved, more pay, or any other details. But we know it's coming. This is one of those things where front-line crews need to be involved in the decision making process, and as far as I know, they haven't been, certainly not to any great extent.

More communication between the sides might surprise us all. The front-line staff might find that they want to be a part of the changes, even pioneer them, and management might find that they have willing partners, rather than unwilling subordinates.

Overall, change is a necessary thing for an evolving profession such as the one of a paramedic. Change breeds teething problems. These will exist at every level, public understanding, call taking, dispatch, front-line and external agencies. The trick will be to iron out these problems and turn them into a viable, working model, that will ultimately benefit not only the target-setters and finance department, but also the most important people.

Our patients.

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?

Guide Dog

A woman was flying from Seattle to San Francisco. Unexpectedly, the plane was diverted to Sacramento along the way. The flight attendant explained that there would be a delay, and if the passengers wanted to get off the aircraft the plane would re-board in 50 minutes. Everybody got off the plane except one lady who was blind.

The man had noticed her as he walked by and could tell the lady was blind because her guide- dog lay quietly underneath the seats in front of her throughout the entire flight. He could also tell she had flown this very flight before because the pilot approached her, and calling her by name, said, 'Kathy, we are in Sacramento for almost an hour. Would you like to get off and stretch your legs?' The blind lady replied, 'No thanks, but maybe Buddy would like to stretch his legs.'

The pilot took the dog with him off the plane so they could both spend a few minutes out of the cramped environment.

*

Picture this: All the people in the gate area came to a complete standstill when they looked up and saw the pilot walk off the plane with a guide-dog!

The pilot was even wearing sunglasses.

People scattered. They not only tried to change planes, but they were trying to change airlines!

*****

Another call to a man, almost incoherent to the call taker, stating that he's in a park but doesn't know where. I can almost hear the call.

"I'm by the big tree, near the lake."

Not very helpful. The lake has a three mile circumference and there must be thousands of trees along those miles. I drive in circles around the park, trying to get updates, clues, general directions so that this lost man can be found. Not even sure I want to find him. He's probably one of the local NFAs. A person of No Fixed Abode. Probably drunk. Probably filthy. Probably very unpleasant in his appearance, manner and demeanor. In fact, chances are that the only thing more filthy than his attire will be his language. It's not a call that leaves me wanting for more of the same.

I drive in circles, following instructions from control, who in turn were getting directions from what may as well have been the Sahara desert. "Take the third sand-dune on the left and keep going for three days. You'll see a sand-dune. Turn right there, and just in front of you will be a row of sand-dunes. I'll be there".

Sand-dunes in a desert. Trees in a forest. Same thing really. This is slowly becoming a futile task for one car and its driver. It's pointless driving round in circles with no idea of where to look. Instead, I stick the blue lights back on to see if that attracts the attention of the caller, or at least gives him a point of reference.

Clearly not. That'd be too easy.

"I'm walking to the edge of the tree-line", he tells the call-taker, "and I'll just sit down. If they find me - good. If they don't - well, whatever".

I'm about to give it up as a lost cause. Maybe even a hoax call. It's the dead of night, what chance is there that he couldn't see, even if it was at a distance, dozens of flashing blue LEDs? Driving over the brow of a small hill, and round one final corner. Been there already, and there's plenty of light there to be able to complete the pointless paperwork.

Pulling up under the beam of a street light, I suddenly see an outline of a man in a pool of darkness, sitting by the edge of the road, swaying back and forth as if trying to shake the weight of the world off his shoulders.

"Control, believe it or not, I've found him".

As I get out the car, my initial fears are realised. The smell hits me as I open the car door. Even the clear night air seems suddenly infected. His clothes are grimy and in parts torn. His hands and face the colour of a cloudy sky, his entire worldly possessions scrunched up into a couple of plastic bags. Two things are missing from the picture. Two things that are out of place for the normal, run-of-the-mill homeless drunk.

He has no half-empty alcoholic beverage containers.

And he's crying.

Not the drunken cry of the teenager who's overstepped his boundaries and is trying to save face by claiming that his drink must have been spiked.

Not the hysterical cry of the girl who's gone to drown her sorrows after her 3-week-long relationship has gone sour and who's world suddenly and irreversibly seems too dark to cope with.

This was the cry of a grown man. A stone-cold sober man, a man who at one time had everything, and then lost it all.

He told me his story, and left me feeling powerless to help. He's an educated man sent to this country by his company to continue his work and expand the company's reach. Until the company folded. He'd lost his job, his family are overseas, he can't get back there, and he has no other support here. The flat he lived in was rented by the company, and it disappeared along with his wages. The park had eventually become his home. He'd tried all avenues for help, but received none. "You'll get a job", they'd tell him. "Just be patient". Initially he'd sneak into hotels to shower, then the lake sufficed. After a while and multiple rejections from work interviews and social-care agencies, he'd just stopped. Didn't see the point any more.

At first he could afford the calls back home, or plead and beg with someone at one of the interviews to let him make just one phone call. Now even that infrequent contact was lost. It had been several weeks since he'd spoken to them.

I had no idea what to say to this man. No idea how to help him. I just put a blanket around his shoulders.

The call-taker in control said he was incomprehensible. He wasn't. He was inconsolable.

I'd assumed he'd be another regular, drunk, unpleasant, NFA. He wasn't. He was sober, and pleasant. But he was a man who'd lost everything, including hope.

The ambulance arrived, and as the man sat on the edge of the road, wrapped in both our blanket and his grief, I told the crew his story. They invited him into the ambulance, and after a few minutes drove him away.

I sat back in the car and just for a couple of minutes reflected on what had just happened. On how I'd assumed everything and got it all wrong. On how I'd jumped to a conclusion before even setting eyes on the man.

On how sometimes a man with a guide-dog isn't blind at all, and how sometimes people with eyes wide open, have their minds tightly shut.

Simon Says

Go back to this post about a waste-of-time-but-can't-do-anything-about-it call. I received a scathing comment on it, a couple of weeks after the post was written, which reads as follows:

*****

I just hope that it wasn't a member of my family having a cardiac arrest in the 15 minutes or so it took you to get her to hospital. Quite simply, you shouldn't have took her. The RRV isn't a taxi service.If Paramedic's want to be paid a professional wage, then they need to act professionally. This means assessing your patient and perhaps deciding they don't need to be taken to hospital by ambulance. If ambulance staff are doing to fit the "stretcher monkey" sterotype and just do exactly what the patient tells them to do, then they deserve to get paid the going rate as a taxi driver. (sic)

*****

The first thought that, cynically, came to mind, was that I wouldn't mind being paid as a taxi driver. I'm sure they earn more than I do.

Then I sat and criticised the spelling and grammatical errors in the comment, as though I'm some sort of linguistic expert.

Then, and only then, did I really think about it, and reply to it. Go look at the post again. My reply is there.

I still question both my actions with the patient, as well as my reply to the comment. Ultimately, I feel that I really didn't have a choice. I had no chance of being a "professional" paramedic, as professionalism could equal job-loss.

I was incensed at the time. Called control, asked them to listen back to the call and find out how this was given a high-priority status, only to find that the "patient" knew all the tricks in the book, and answered all the questions to lead the system down the path of a life-threatening emergency.

The call taker had no choice.

The computer system had no choice.

I had no choice.

Sometimes we're all stuck in a big game of Simon Says.

And whatever Simon says, whether it's right or wrong, goes.

Every so often I just wish my name was Simon.