Mood Swings

The gesture is so unexpected, coming from someone clearly suffering as much as Leah is. Lying in her makeshift bed as she has been for two days, a look of pain etched on her face, silently spelling out the words that she refuses to say. Instead, all she does is smile and tell us that everything is alright. 

"It's just a little painful when I move," Leah tells us, except that she can't move at all. The tell-tale sign of one leg appearing shorter than the other leads us to the quick conclusion that she probably has a broken hip - fractured NOF - or neck of femur. I remember wondering in the very early days of my career what a "nekkafeema" was, only summoning up the courage to ask after I could no longer hide my embarrassment at not understanding yet another medical term. 

Leah's son, a tall, sickly looking man of fifty, appears almost as old as his mother and at first I mistook him for her husband. He tells us that she had fallen almost a week ago. Since then, the pain has gradually increased, her mobility slowly becoming more and more limited until eventually she could move no more. 

"It's taken us days to convince her that she needs help!" Leah's son explains. "Every time I've picked up the phone to call you, she screams at me that she'll die if she goes to hospital." 

The smile on Leah's face cracks a little, like an ice-cube in a glass of water, still present but a little changed, and the polished facade she has paraded for her family and initially for us no longer holds strong. "It does hurt, but not too bad. Are you sure I need to go to hospital?" I explain that there may be, in fact probably is, a fracture, but the only way to tell for sure is to have an X-ray done. The old, well-worn joke that I left my X-ray glasses in the other ambulance rejuvenates her smile a little. 

We're lucky. Leah is lying on a strong sheet that we can use to manoeuvre her. She has cushions for support all around and we use all of these to help move her as gently as possible onto the trolley bed. The first couple of attempts catch her off guard, despite my warning that she would feel a little pain when we helped her across. It makes her grab hold of the bed railing and prevents us from carrying her from her bed to ours. On the third attempt, I make her promise that she keeps her hands still and if necessary grabs hold of my arms. That way, at least we'll still be able to keep moving in the right direction. It's a successful move. We're grateful for the lift that means we only have to transfer her once, rather than into a chair and only then on to the bed. Fewer moves means less pain. 

At the hospital, Leah withdraws a little, showing the apprehension that her son had warned us about. "Are you leaving me here now?" 

"As soon as we make sure that you're as comfortable as possible on a hospital bed, then yes. It's the hospital's turn to take care of you." She doesn't seem too keen on the idea, but resigns herself to it nonetheless.

"I have to tell you something," she says once she's calmly lying on the hospital bed. She motions me to stand a little closer, as if she has some state secret to sell. Suddenly, Leah grabs my face and gives me a kiss on the cheek, loud enough for what seemed like the entire department to hear. My crewmate laughs hysterically, sensing and seeing my embarrassment as my face glows a warm shade of red. 

As the first call of the morning, I feel that that one moment sets me up for the day and set off out of the emergency department with a smile firmly planted on my face. 

On our second call, a man dies in front of us with his family all around, and there's nothing we can do. 

Birthdays

Five o'clock in the morning and for the first time all night, we finally arrive back on station. Within seconds, before the engine has had the chance to cool, or the water in the kettle given the chance to boil, the phone rings again, sending us out on our next call. It had been one of those shifts. Job to job, patient to patient, hospital to hospital. With barely the chance for a bite to eat, we had inhaled cups of coffee throughout the night to keep our energies, as well as our hopes, alive and kicking.

Five minutes later we arrive at the address, still with no real details of what awaited us on the second floor of the dilapidated building. The only information we knew was that an elderly lady had pressed an emergency button and there had been no contact with her since then. The three of us grabbed the four bags of equipment and a carry chair between us and started the march up the stairs. Any hopes of there being a lift in the building were dashed the second we pulled up outside and saw its age. 

A tired, but determined voice answered our first knock. "I'm almost there, just give me a minute!" We waited, each silently praying for the clock to tick a little faster, for the end of the shift to arrive, for the calls to end so we could go home. As we did so, a shuffling sound from indoors became louder, like a dog scratching on a door trying to get out. Eventually we heard a key turn and the door opened just enough for us to peer in. 

"You'll have to push the door to get in, I've got no more energy left." Gently we did as were asked, guessing that she was leaning against the door, when after a moment we were able to squeeze in through the gap that had opened. The smile that greeted us was like that of a child seeing its very first snow. Pure delight shone from Eva's face, as if she had stored up ninety years of smiles for just this one freeze-frame. 

"I'm fine, really I am. I just need help to get up off the floor. I've been here for a little while, thought I could manage to get up on my own. Looks like I was wrong." 

"How long have you been there?" 

"Since nine o'clock last night." All three of us do the mental maths. Eight hours on the floor. Eight hours trying to solve the problem by herself that we would now solve in thirty seconds. We checked Eva for any injuries and found that, other than a small graze on her elbow, she seemed to escape unscathed. "I need two things from you please," she asked, almost pleaded. "First, I need you to make sure I'm steady enough to get to and from the bathroom. Eight hours stuck leaves a lady just a little in need of refreshment." 

She smiled her child-like smile again. 

"Second, and more importantly, I'd like five more minutes of your time. Just to have a look at something for me." Presumably a medical issue had been bothering her and now that she had readily available access, she would use the opportunity. 

"We're not going anywhere. Get yourself settled and I'll make you a drink first whilst you do." Once Eva was up on her feet, it took only seconds before she regained her balance, walking around the flat in a manner almost as spritely as a  teenager rather than a nonagenarian. 

"Just a few minutes. I promise. No more." 

When Eva returned, she asked us to follow her into the lounge, where we were greeted to a picture gallery of immense proportions. Every wall was covered, every bookcase had pictures on the shelves, every picture frame hid several pictures within it. Hundreds upon hundreds of pictures, each with smiling faces that crossed ages, generations, and eras.  

"These are my children. And my grandchildren. And my great grandchildren. I should have lost count by now, but I know. I know all their names, I know all their birthdays. Sometimes I might need a small reminder, just that the date is coming up, not that it's their birthday." She stopped just long enough to look once all the way around the room. "It's a birthday today, too, so I'm glad I'm up in time to go and celebrate." 

"Whose birthday? Which generation?" 

"Mine," she said with a wicked grin. "And," as she pulled out a hidden envelope with an old photograph of a young couple at their wedding, "my husband's too." 

I'd had a quick look around when I looked for the kitchen to make her a drink. There was no-one else there. Just Eva and now an ambulance crew. Definitely no husband. 

"Where is he? Your husband?" 

"He's in a home, just a few minutes walk, not far away. When his mind started to wander, his body sometimes followed and he would end up lost, so about five years ago we decided it would be safer to have him move into a home. I see him every day except Tuesdays. That's when I meet with friends for a coffee. Every other day, I always leave the house at six in the morning to get to the home in time to make his coffee and have breakfast with him." 

All three of us looked at our watches. Almost six o'clock. 

"I'm presuming you don't want to go to hospital and get yourself checked after your eventful night on the floor?" 

"Don't be ridiculous. Spend my birthday, my Izzy's birthday in hospital? No way. The only place I'm going is to visit him. And if you people are as kind as you look, you'll help me get down these stairs." 

"We'll carry you down if you like!" 

"Most definitely not. I've still got legs that work, haven't I?" None of us dared argue.

With one of us either side, we slowly walked Eva down the flights of stairs to the entrance of the building. She refused any further offers of help, from us accompanying her on foot, to the offer of a lift in the ambulance. 

"It's only five minutes away, I'll get there the same way I do every day." 

"Happy birthday," the three of us called after her as she started to walk away. 

She stopped, turned around and smiled that smile once more. "Thank you for making it so." 

The Bet

The door is opened by a late middle-aged man holding a wet flannel on his forehead. The call has come in as the lowest category of call, the infamous Green Call that can be anything from a back ache to a dizzy spell, from leg pain to a nose bleed.

"Come in boys, take a seat. I'm just turning the gas off and I'll be with you." 

We follow him in, his shuffling footsteps making a marathon of the short corridor until he points us into the lounge and we take a seat. The room is stuck in a time warp, the furniture and fittings in the enormous semi-detached home harked back to the 1970's and were all immaculately cared for, but dated nonetheless. Greg, my partner for the day, whispers as we're walking in that he'd bet a month's wages that the toilet is avocado green. 

"I can't afford a month's wages. How about a tenner? I reckon it's pink." 

"You're on." 

"How can we help you today, sir?" Greg asks, after the gas is turned off and our patient collapses with much drama into an armchair.

"Well, first, you can call me Ray. None of this sir nonsense. I've been having these stomach aches for a couple of days now. Having to rush off to the loo every few minutes. If it's not one end, it's the other. I just can't take it any more."

"Have you seen your doctor?"

"Went this morning. She told me to sit it out. I complained at the turn of phrase." All three of us rolled our eyes.

"Have you managed to eat anything? Or, more importantly, drink?"

"Water, yes. Food, no. Just can't keep it down. Or up. Depending on which way you're looking at it."

With that, he apologised, told us to make ourselves a tea or coffee, got up and went back to the bathroom under the stairs. I'd noticed it when we came in, a sign on the outside reading "Harry's Room" with a cartoon of a boy flying on a broomstick. Two minutes later, having been left to our devices, we'd decided what we could do to modernise this house, how much it would cost and how much we'd sell it for.

"We'd make a fortune!" Greg announced.

"Just one problem. It isn't ours."

"Well, a man can dream, can't he?"

The second those words left his mouth, he regretted them. We were snapped out of the dream by a crashing noise and a grunting sound that could only mean one thing. Ray had either fallen or collapsed. We both jumped up, tried to open the door and discovered it was, unsurprisingly, locked.  Greg runs out the front door to the side of the house to see if there's any access, only to discover that the window was no bigger than a cat-flap.

"We'll have to kick it in!"

"He'll be right behind the door!"

"Well, what other choice do we have?" 

A muffled voice comes through the door. "Don't kick the door. I'm alright. I'll be up in a second. Just slipped, that's all." 

Greg and I breathe a sigh of relief. Allowing a patient to go to the toilet is always risky, especially if they're already weak or particularly if they're suffering with a heart condition. Hearing Ray's voice put both our minds at ease. Until there was another thud. 

"It's alright lads. It's just me sitting back on the seat again." 

Finally, the door unlocks and Ray tries to walk out. There's a small cut on his eyebrow and some blood on the floor but nothing too worrying. I make sure he's stable as Greg steps back out to the ambulance, both of us noticing the colour of the bathroom before he walks off with a shrug of the shoulders. 

"Stay there Ray. Greg's just going to get the wheelchair. Don't want you walking anywhere else." 

"Probably a good idea, but I don't want you lads going to any trouble."

"Oh, don't worry about that. It's no trouble. Besides, you just won me a tenner!" 

"How'd I do that then?" 

"Your choice of bathroom colour. Pink was my bet." 

"That's only just gone in. It was green until last week. That awful avocado colour. Been like that for years. Couldn't stand it any more, so just went with whatever my sister suggested. She said that pink would be more attractive when I came to sell the place."

"Green, you say?" 

"Avocado green." 

"Do me a favour, Ray. Don't say a word to Greg, will you?" 

The wheels of the chair clatter against the floor as Greg reappears, opens the folding contraption and sets it up. Ray sits in the chair, we wrap him in the hospital blanket and secure the seat belt, keeping him warm and safe.

"Can you wheel me out via the kitchen? I need my keys and phone. Oh, and I've got a present for you Greg." 

Confused, we head backwards before going forwards. Ray picks up his keys and phone from the worktop, then asks Greg to open the fridge. I put my boot on the carry-chair's footplate to stop it from tipping as Greg does as he's asked. 

"What am I looking for?" 

"It's there. In the door. Second shelf down - little shelf with the lid-type thing on it." 

Greg lifts the plastic lid and takes out his prize. 

"Funny, gentlemen. Funny," Greg laughs, as he places the avocado in Ray's lap.

Lost Keys

The door shuts gently behind me, bringing to a close another shift, one that ended at a time normal humans call bedtime. I've left the world of the permanent nights behind, at least for now, choosing instead to pick the shifts I like, while I still can. The times are different, the hours fewer, the system new to me, but the work and the patients remain the same. 

Calls still come in for bad backs, three day old coughs, tight, crushing chest pains and accidents of all types. Cars still fight with each other for a small space on the tarmac, denting bodywork and pride as the space in between goes from narrowed to nothing. Bodies give way to gravity when the ladders beneath them collapse down to earth. Knives and bullets pierce the skin and cause untold, perhaps irreversible damage to the organs hidden from view. 

Here and there a life is saved, a soul is comforted, a child is born. 

Until the door shuts behind me, the shift isn't over and the processing doesn't begin. Most days there is nothing to trouble my thoughts, the patients merging one into the next, each occupying my mind for the duration of our stay with them, or theirs with us. Some leave an impression, a smile, perhaps, maybe a frown. At other times a question mark looms over the lasting imprint of their faces, the tale of their woes, the miracle of their survival. 

Some days, shutting the door behind me, ending the shift with a turn of the key, only signals the start of the process. 

It's bedtime. 

I go in to check on each of my already sleeping children, a habit often repeated several times each night since each was born, thankful that I am able just to stand, and stare, and watch them sleep in peace. I lock the front door, but in so doing, open the door to my own thoughts, trying to process the day. 

That door needs locking too, but all too often I can't find the keys. 

Five Words

Stepping into the office with an envelope in my hand, I was about to take one of the biggest steps in almost a decade.

"Need my signature on an application form, do you?"

It was an obvious question for my boss to ask considering the fact that once again, the coveted places on the air ambulance had been advertised. That, and the fact that he had no idea of my real motives.

"Not quite!" I answered, handing him one of the copies of the letter. He looked down at the piece of paper, the cheap and nasty stuff that the ambulance service has started to use recently in yet another cost-cutting exercise. The confusion on his face said it all.

"You're sure about this are you?"

"Quite sure."

"Can we do anything to change your mind?"

"Not unless you're packing the LAS into a suitcase and sending it with me."

Handing in my notice was a great deal more traumatic than I had ever anticipated. I have loved my job. If not every minute of it, certainly as a career, as a way of life, I have loved it. But the time had come for a change that MrsInsomniac and I had been planning for some time. I'll write more about the change we're making in another post.

I've already had my final shift. It was initially scheduled to be a lonely solo shift on a rapid response unit, but luck had it that there was a student who needed a few extra hours out and about, so she joined me, hoping that my reputation for attracting "real" jobs would prove itself in reality. It didn't, but it gave us time to talk. Time for me to pass on a little of my questionable wisdom and for her to ask questions, question my answers and answer my challenges too.

Towards the end of the shift, she threw me a curve-ball.

"If you had to sum up your career in four words, how would you do it?"

"Four words? I'm not sure I can. Am I allowed five?"

"You can have five. It's my leaving present."

It took me some time. We attended another call, handed another patient to yet another crew and still my mind's rusty cogs whined and creaked to come up with some cohesive thought. Eventually, in a dull flash of panicked inspiration, I had it.

"Tried to make a difference." It really does some it all up.

It speaks of the patients who had no-one else to care for them, it speaks of the families suddenly bereaved, it speaks of the babies brought into the world.

It speaks of the children who were left battered and bruised by their very own flesh and blood, and others who were nothing if not heroes to their families.

It speaks of the people who just needed to hear a voice tell them that help is at hand, and it speaks of those pleading for help for their loved ones.

I hope it speaks of the students I worked with, studied with, taught and learned from.

I hope it speaks of the people who read this blog, those in the know and those who hope that they will become more in the know by reading it.

I tried. Sometimes I succeeded, sometimes I failed, but I tried. In most cases, I'll never really know.

My move takes me away from the London Ambulance Service, but not away from the world of the ambulance. The blog will continue (considering the accolade it has just received, it couldn't really not). For some time it'll be based on the scribbled notes that already sit in my diary, and soon stories will be told from new notes, new patients, whilst looking out over new horizons.

And if nothing else works out, I'm still proud of who I've become, what I've achieved, and the experience that I've gained. I'm proud of this blog. I'm proud to call some of the best ambulance staff out there my friends. And I'm still proud of those five words.

Crisis

The front door is ajar and as I knock and enter, a voice from upstairs directs me to the drama. Two people are in the room; one frantic, one calm. Violet, lying on the floor with a weeping head wound is relaxed and resigned to her fate. Her son, Donovan, tries to sit still and move out of the way all at the same time, causing him to trip and almost fall on top of his mother.

"I'm sorry," he says, "I'll just... Well, I'm... Oh, I'm not much use in a crisis. I'll get out your way now."

"Donovan!" calls his mother. "Will you settle already. I'm alright. They'll look after me now!" The gentle sing-song of her West Indian accent finally seems to have an effect, and he's able to step out of the way and relax a little.

Distraction tactics at the ready, I ask him to find me his mother's medications, write down a few basic details and generally try to keep him out of the way for long enough to assess some basic observations and wrap a bandage round Violet's head.

"Oh, that's better!" he says, returning to the room once some of the mess had been cleaned up and the bandage hid the injury. "Did I mention that I'm not much good in a crisis?" 

"Don't worry. I'd fret too if it was my family." Turning back to Violet, I gently break the news, worried that I was about to have a fight on my hands. "Now, miss, we need to get you off to hospital. There's a hole in your head that needs some proper fixing." 

"I knew you were going to say that. Can you just get me my slippers?" 

Without a word, Donovan turns to find the footwear. 

"And I'll need my keys." 

"Keys, right." 

"And don't forget my handbag."

"Handbag too."

By the time he's half way down the stairs, the list has grown to almost a dozen items, each call from Violet repeated with a resigned sigh from Donovan and an amused smile from the ambulance crew and me. Whilst he runs around the house turning off lights, checking doors and gathering medications, we get Violet as comfortable as possible in the carry chair and move her downstairs and into the ambulance, the crew carrying Violet as I carried the bags. 

After a few minutes, Donovan knocks on the back door of the ambulance and hands a bag through. 

"Did you find everything?" Violet quizzes him.

"It's all in there!"

"Keys, money, tablets, phone?" 

"Yes Mum. Keys, money, tablets, phone."

"Slippers?" 

"They're on your feet, Mum." 

"Oh yes. So they are." 

"What about the lights? Are they off? Did you check the back door's locked?

"Yes, Mum. Off, and locked." 

"Oh, and what about my hairbrush?"

"Hairbrush? What do you need a hairbrush for? You're going to hospital, not a fashion show!"

"Donovan, don't argue with your mother. A woman always needs a hairbrush in her handbag, no matter where she's going!" 

As he runs inside to retrieve the hairbrush, muttering the whole way there and back again, Violet relaxes back on the trolley bed, and allows herself a smile. 

"Kids, you know what they're like, don't you? Even when they're grown up they're hard work sometimes. I mean, look at all of this. Just a simple trip, and he falls to pieces. But he's a good boy really, always looking after his mum. He's just not very good in a crisis." 

Experts and Law Suits

This post over at Rogue Medic reminded me of the day our youngest child was born. Being as stubborn as his older siblings, it was decided that two weeks after his scheduled arrival, it would be a good idea to serve him notice and have him evicted. Bags were packed, plans made, babysitters arranged, and a fortune was spent in the hospital car park. 

As we headed towards the main entrance, a scene so familiar to me, yet alien to a heavily-pregnant-about-to-be-induced MrsIM, played itself out in front of us. A group of people were stood in an almost perfect circle looking down at the ground, as a middle aged lady lay on the floor crying in pain. Much like Rogue Medic's story, the lady probably had a fractured hip. The crowd were a mixed group. Some visitors to the hospital, and several staff, including a few doctors, at least one of whom I knew and several nurses who looked familiar. All told, a group of about twenty people, standing, talking, gesticulating. 

A bed had been wheeled from a nearby ward and stood next to the patient as a discussion took place on the best method of getting the patient from the floor to the trolley. As we neared the actual scene at the rate of a nine-plus-month-pregnant-waddle, I could see six pairs of hands trying to move the patient up to the height of the trolley in a tangled mess that would have any back-injury specialist cringe and cry for their mother.

The upshot of it all was that none of them, not the visitors, or the nurses, or the doctors could work out how to do what comes to any EMT or paramedic as second nature. Having admitted to being a paramedic, I offered my help, and after a couple of "What do you know that the doctors don't?" type questions (from certain nursing staff no less), and using only two pairs of hands, the lady was moved gently, safely and with minimal pain from the floor to the bed.  

I don't claim to know what doctors know, I don't claim to have the skills to nurse a patient either. I do, however, claim to be an expert at what I do for a living. I've said it before - we need to have pride in our profession. We need to know that our skills and expertise are exactly that. We need to know that we are the specialists in our field, and that any doctor or nurse worth their salt would do well to understand and respect that. My remit may end at the entrance to the A&E or ED, but up until that point, the patient is my responsibility. That responsibility extends past mere transport - it can also include extrication, removal from scene, treatment, resuscitation and stabilisation. And just simple pick-ups from the floor.

I would love, one day, to hear news presenters, career advisers and general Joe Bloggs speak about paramedics in the same respectful tone as they do about doctors and nurses. Actually, first of all, I'd like to hear paramedics speak about paramedics in that same respectful tone, instead of doing ourselves a disservice by constantly saying things like "Well, I'm no doctor..."

Whilst the USofA as a whole needs to learn a little more about caring for others, as opposed to staving off law suits (not that the UK is all that much better), paramedics the world over need to learn that we are no less experts than the doctors and nurses to whom we're compared, often in such an unfair light. We need to show that we don't do things just in order to avoid yet another American-style law suit, or just to cover our over-exposed behinds. We do things because they are the right things to do, the expert thing to do, and are in the best interests of our patients. 

The Keys to the Asylum

The council estate is a maze of rat-runs, dead end roads and multi-storey buildings. There's no logic to the numbering, and most of the buildings are unnamed, just to make it all that more exciting. The computer must know something I don't, as I turn into yet another alley and a disembodied voice from the sat-nav announces You have arrived. I drive around in circles, zooming in on the digital map trying to locate the tiny alleyway that was given as the address I was looking for, and try to find the man with the broken leg.

With no luck at finding the patient, I leave the blue lights flashing and give a couple of blasts on the siren. It's not too late at night, but still late enough that some of the neighbours, particularly children, may have been tucked up for the night. A few minutes later the crew follows me in to the multi-tentacled cul-de-sac. 

"No idea where this alley is, and no-one's come to find me." 

"We went up the other way first, no sign there either." 

After a few more minutes of searching up and down the same tiny roads, a figure appears at the top of a fire escape. "Oy! He's up here! Come on! Hurry up! What took you so long?" 

Not lying half dead in an alleyway then, and three flights of stairs up, probably not nursing a broken leg either. Nevertheless, between the three of us, we take all the kit we might need in case the call really is all it was stated to be, including a carry chair. As we reach the top of the stairs, Neil is sitting on a picnic box, his legs intact but his left arm bowed right in the middle of where it should be straight.

"How'd you do that then?"

His first words engulfed us all in a haze of alcoholic breath.

"Fell over, didn't I? Down that stupid alley. I told 'em someone was gonna get hurt, didn' think it'd be me now, did I?!"

We stabilised his arm in a splint and cleaned up a wound that he'd opened up on his eyebrow. It looked like it was an old scab that had opened up again.

"Do you fall often?"

"Nah, not really. Just a bit unlucky the last couple of weeks."

"How much have you had to drink tonight, Neil?"

"Oh, not much. Two, three pints maybe."

"Any other medical problems?"

"Yeah. My liver's knackered. They might have to replace it soon. 'Swhat the docs said, anyway."

"How'd that happen?"

"Well, I used to be an alcoholic. Not any more now though. Now I only have a couple of drinks a night, you know, when I'm at work."

"You used to be an alcoholic, but you're still drinking?" Then it hit me. "Hang on a minute. You drink at work?"

"Yeah. Course! There's got to be some perks to my job."

"Why, what do you do?"

"I'm a mixologist."

Oh. He's got an ology. "A what?"

"A mixologist. I mix all the cocktails at the bar."

"You're an alcoholic, and you work in a bar?"

"You bet. Does it get any better?"

"Well, your arm says it could probably get a lot worse." 

The Other Leg

Late evening in the city, where another weekend heads to a close as the world prepares to face another Monday morning. There's a definite chill in the air, a disappointing summer fizzling out as the nights begin to draw in, yet all around people are spilling out of pubs and clubs wearing no more than the bare essentials. The street sweepers are out in force, one of them earning a torrent of verbal abuse for daring to complain to yet another youth for throwing an empty cup on the floor.

Rash and his friends walk away laughing, alcohol and bravado fueling yet more antics until, suddenly, he loses his footing on the edge of the kerb. His leg twists, snaps and gives way, and he crumples in a heap on the floor. The street sweeper sees it happen, yells something about karma and walks away to continue his never-ending litter hunt. 

We're dealing with a drunk no more than ten paces away, another victim of just having a good time and she doesn't usually get like this. Each of us, Dean and I, has one eye on our patient making sure we don't get covered in vomit, and another on the altercation, looking for signs of a fight breaking out. When Rash falls, we're close enough that we see his leg change direction and clearly hear the crack in the bone. 

"Stay there!" I shout. "We're coming." Dean calls for help, asking for a second ambulance.

Unable to move even if he wanted to, Rash lies on the ground screaming in pain. Two police officers patrolling the area hear the noise, which even in the bustling surroundings was out of the ordinary, and come to investigate. The bad timing on their part means they get to stay with the vomiting drunk and her overly exuberant friend.

Dean brings the trolley bed and a splint over, the need to see the injury first seeming superfluous having witnessed the noise it made. Nevertheless, a pair of shears always beats a pair of jeans in the trauma version of "rock, paper, scissors" (where the rock or paper are any item of clothing which may be hiding any part of the anatomy that needs to be viewed directly, in a hurry and with a minimum of movement), and seconds later Rash sees his leg for the first time since getting dressed earlier in the evening. He looks down at his ankle, and instantly looks away.

"Do you think it's broken?" It's more of a last gasp attempt at denying what he already knows than a real question.

"Well, I think the fact that your foot is facing the wrong way and there are two bones sticking out of your ankle would probably confirm that." Ten paces away, as if on cue, our drunken patient vomits for the umpteenth time. One of the police officers sends us a grateful stare, all the more grateful now that another ambulance has arrived to deal with her.

We load Rash into the ambulance, dose him up with some pain relief, and straighten his leg out as much as possible before heading to the nearest hospital. The screams of pain as we pull his leg straight subside once his foots faces front again, entonox and morphine leaving him a little dazed. When I ask his date of birth, he hesitates, looking at his friend for guidance. A shrug of the shoulders was the only reply.

"How old are you Rash?"

"Nineteen."

"And what's your date of birth?"

He tells me a day and a month without hesitation, but when it comes to the year, all he could say was "Ummm..."

"OK, so how old are you really?"

"Sixteen. And a half." And a half. Of course. That makes all the difference.

"And why didn't you want us to know that?"

"I didn't want those coppers to arrest me again. You know, for being drunk under age and all that."

"What do you mean arrest you again?"

"Well, I've already been arrested five times before. I was twelve the first time!" He high-fives his friend, seemingly proud of his criminal record.

"Twelve? What were you arrested for at twelve?"

"Fighting!" Another laugh, and another high-five.

"And you were twelve?"

"Yeah man. I've still got the scars now!"

"And you're proud of that?"

"Well, yeah, why not? But not as proud as I am of something else." He shoots his friend a knowing look, and they both smile.

"What's that, Rash?"

He pulls up his other trouser leg and proudly shows off his electronic tag. "Got this last month, didn't I! All my mates want one now, it's, like, so cool!"

"You know that you'll probably get nicked now anyway, out after what I presume is your curfew time?"

"Oh what? Even if I'm in hospital? Pull the other one, yeah?"

"I already did." 

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." 

Head Injury

Barely a cupboard under the stairs, the tiny top-floor room in the residential care home had no more than a bed, a two-door bedside cabinet and a tiny sink. The floor space was almost entirely taken up by Jasmine, and she was no bigger than a ten-year-old. As I walked in through the door, the sloped ceiling made me tilt my head to the right a little, just to make sure I walked in unscathed. 

From the look of her, Jasmine looked like she weighed no more than a wet tea-bag, and even then after the water had been squeezed out. Her skin was dry and fragile, veins spidering up arms so thin they seemed as though they would snap like sun-dried twigs. The red tinge to her thinning white hair gave away a secret, as yet unseen, cut to her head. She lay there confused and a little disorientated, but a winning smile crossed her face. 

"I'm not too sure how I ended up here, but I think I'm alright. Just get me up and I'll get right back on that gin that must have floored me in the first place!" 

"Now, Jasmine, if you'd have said whisky, I'm your man, but not gin. Might have to leave you on the floor until you can choose a proper drink."

The care home staff looked horrified, but Jasmine saw the funny side. 

"You'll do as you're told, young man! Now get me up so I can see exactly who I'm telling off." 

With the help of one of the carers, Jasmine was lifted off the floor and helped to a chair. It was the first we saw of the damage she'd done to her head. 

"You're going to need a trip up the hospital, I'm afraid. That's quite a nasty cut you've got on your head." 

"I'm not going anywhere, but back to bed." 

"Jasmine, your scalp looks like you've put a cat-flap in it - it needs sticking back together again. It's that impressive, that I can almost read your thoughts!" 

"I'm NOT going to hospital!" 

"See! I knew you were going to say that!" Jasmine eyed me suspiciously, a small, half-smile giving away her amusement. 

I tried to replace the flap of skin back in place and hold it all together with some bandaging. The carer who helped me lift Jasmine off the floor started to feel faint at the sight of the injury, so I sent him to get something completely irrelevant, allowing him to get some fresh air and maintain some dignity. 

As he left, the ambulance crew arrived, the two-wheeled carry-chair in hand. Having spent a few minutes explaining, cajoling and joking with Jasmine about her injury and the need to have it treated, she finally agreed. We helped her into the wheelchair, wrapped her in a blanket and secured her with the belt.

"At least I managed to arrange a blanket that matches your new hair colour. Anyway, I'll leave you with the  friendly ambulance crew, I'm sure they'll be nicer to you than I was." 

As they turned the chair around, Jasmine said a polite "Thank you", and I turned back to sort out all my bags. 

"I'll check on you a bit later at the hospital if I get the chance, make sure you're behaving yourself." 

"You do that. I look forward to it. And make sure you don't forget that gin!" 

"Whisky!"

"Oh. Alright then. Make it a whisky." 

With that, Jasmine was wheeled into the lift and taken down to the ambulance for the short journey to the hospital. I tidied up the mess of packaging, wrapped some of the blood-stained bandages in an inside-out glove, picked up all my luggage, turned to leave the room, and without looking up properly, walked head-first into the low sloped ceiling.

Milk Bottle

Two bottles of milk by the front door,

A neighbour sensed something was wrong.

"She has one bottle delivered each and every day!"

A light was on,

The television flickered through a sliver of open curtain,

But there was no answer to our calls.

A kick, another kick, and the door splintered open.

In the kitchen, by the table and an upturned chair,

She lay where she fell.

A bowl of dry cereal sat waiting,

For an unopened bottle of milk.

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!

Apologies

This is an open letter to the driver of the car behind me earlier this morning: Stand by for a rant.

Dear Driver of the BMW X5 that was behind me in traffic,

I hope you read this - I gather I owe you an apology.

I'm sorry I stopped in front of you at an inconvenient moment.

I'm sorry I blocked your lane, (even though the other one was clear).

I'm sorry I stopped to help the elderly gent who fell right in front of us.

I'm sorry I took a few minutes to help him and make sure he was OK.

I'm sorry you may have been a little late to your coffee morning or other meaningless task.

But if I ever see you, your car, or the horn you beeped at me repeatedly,

You selfish, arrogant, ignorant, rude and insensitive person,

I may not be responsible for my actions.

Oh, and as for your apology, I shan't hold my breath.

Greenpeace

Once again, we stand, trolley and patient between us, and we wait. The department is manic. Patients in every cubicle, trolleys in the corridors, nurses rushed off their feet, porters running backwards and forwards to x-ray and the wards, reception staff fending off the masses, and doctors sitting down drinking coffee. (Cheap shot, I know. But it made you smile, right? Unless of course, you're a doctor. And I don't mean it really...)

Jenny, one of our favourite sisters is in charge tonight. Even in the heat of a Saturday night A&E battle she remains composed and calm. A tap on the shoulder and a sheepish "Sorry, we've got nothing for a while!" at least acknowledges our presence, and lets us know that we haven't been forgotten. Not that it's easy to ignore us, both six-foot tall and dressed in blood-hiding green. Her only downfall is her gullibility, especially when it's busy.

Derek, our patient, well into his late seventies, must have been a stand-up comedian in a previous life. From the minute we met him and his probably broken hip, we were in fits of laughter, ranging from giggles to full blown hysterics. The added bonus of giving him some entonox and morphine to help relieve the pain only made matters worse. Trying to settle down once we'd stepped inside the hospital was a little like telling a kid who's having a mad half hour in the evening to calm down and go to bed.

As we stood in the middle of the department, we had time to hatch a plan and had the routine rehearsed to perfection. All it would take was a little composure - easier said than done.

"I'm sorry boys, and you sir," Jenny said as she turned to the patient, "but we're just trying to shift some people from here. We should have half a dozen spaces within ten minutes. I'll be back then and we'll sort you out."

"No problem!" I said, "I'm sure Derek won't run off anywhere in the meantime."

Composure? Lost. Awful joke, I know, but when you've already got the giggles, it doesn't take much. 

Jenny eyed us suspiciously, but went back to her duties and clearing the department. We watched as one by one she kept her promise. Some went up to the wards, others sent on their way with boxes of antibiotics or pain killers, and whilst it all happened, I had the chance to finish writing my paperwork.

Calm seemed to return. When a patient leaves A&E, whatever their destination, their entourage leaves with them, so it's not just one person leaving. Six patients sent on their way can easily mean twenty people exiting stage left. The decibel volume drops noticeably and the overall chaos seems to dissipate, if only a little.

Only five minutes later than the promised ten, Jenny comes back to us.

"Right, now where were we?"

"Morning Jenny. This is Derek. He's a Greenpeace activi..."

"You DO KNOW about Greenpeace, don't you?" Derek's interruption was perfectly timed.

Jenny looks momentarily taken aback, but maintains composure.

"I do know about them, yes. Let me find out what the problem is, Derek, and then we can discuss it later."

"OK."

"As I was saying, Derek was on a protest at the local building site. Apparently they're building on what he says should be left as a nature reserve, so he decided he would start a one man protest. Up a huge crane."

"You were where?" Jenny asks.

"Up a crane. They can't use the damn thing if I'm sitting half way up it!" Derek's performance was so convincing, even I was starting to buy it.

"Right."

"Anyway, we were asked by the police to be on standby, should anything go wrong, whilst they sent some climbers up to bring Derek down. As they neared the bottom of the crane, Derek decided to jump about two metres, fell onto the grou..."

"I didn't fall!" He looked genuinely angry. "Those damned coppers brought me down!"

"Either way, he landed quite heavily, and we think he might have broken his hip. The rest of his observations are fine, and he's normally fit as a fiddle."

"Right." Jenny looked a little puzzled, had a quick look at the side of the paperwork that has all the observations but none of the story, and allocated us a bed without any further questions. "I'll help you get him across."

Derek took a few more deep breaths on the entonox as we lay him almost flat in order to slide him onto the hospital bed.

"We'll have you over in seconds, you won't even know it's happening."

"OK, just do it."

I placed the paperwork on the tray at the edge of the bed, and between us we moved Derek onto the slightly more comfortable hospital trolley. We had to take our cylinder of entonox back, so before we did, I went to find a hospital supply rather than leave him without. By the time I came back, Jenny was reading the paperwork. Story side this time, and tapping her foot on the floor.

She read about Derek's fall at home. How he'd been on the way back from the toilet and slipped. How we got him down the flight of stairs, strapped onto a board and dosed up on laughing gas.

"Assaulted by coppers, huh?" She glared.

"Stuck up a crane, huh?" A hint of a smile.

"Greenpeace, huh?" We knew we'd won.

"You sir, shouldn't help these clowns to get away with this!" Jenny shook her head in disbelief. "You two, just you wait! I'll get you back yet! In the meantime," she paused, "thank you for cheering up a mad evening."

We laughed, all of us. Derek and Jenny included.

"Excuse me, nurse. Can I ask you just one question?" Derek suddenly looked serious again.

"Of course you can."

"Do you really know anything about Greenpeace?"

Two green-uniformed men turned and ran, giggling away like school kids.