Sounds of Life

We arrive at the hospital gates
mere seconds apart.
Two ambulances with lights flashing,
Sirens trailing off as we pull up
At the kerb.

They open their doors first,
Exposing their patient to nosey bystanders.
Some look shocked.
Some smile.
Some look away.
Pretend they don't see.
Or hear.
The hiss of the oxygen,
The ping of the monitor,
The instructions of the crew,
All the Sounds of a Life
being saved.

They turn right and disappear,
and as they do,
We turn left.

Our patient is bursting with life, albeit
In pain.
She's Expectant,
Ready,
Anxious.
Scared and excited all at once.
All of a sudden, she screams.
She screams and curses and yells and cries.
And then another noise. A sigh.
And a second cry.
All the Sounds of a Life
being born.

The Trolley

We pull up to the entrance at the back of the hospital, reversing the ambulance into what is no more than a widened alley. Cats roam free, picking food out of overflowing rubbish bins. It's almost as though the levels of cleanliness are saved for the public entrances, leaving areas such as this one neglected and filthy. 

It's always a strange feeling wheeling an empty trolley bed off the back of the ambulance at hospital. There's a sense that we're doing something wrong, backwards, coming to take someone away instead of bringing them in. At this time of the morning, just past the point of no return but not yet quite within sight of the end, conversations are more a series of grunts and confused looks, reinforced by acknowledging nods at the offer of a cup of coffee. 

The hospital corridors are empty, an almost ghostly air circulating through the concrete block. The concrete was supposed to be covered when they built the hospital, years ago, but the money ran out. So now, in amongst the surrounding greenery sits a blob of grey, cold, ugly concrete, as if just waiting for a truck large enough to pick it up and take it away. The hospital looks only marginally better on the inside, but the eerie silence makes it feel just as cold and unwelcoming. The wheels squeak and click-clack over the cracks in the floor and as we reach the entrance to the unit, the doors open as though somebody watched us approach. 

"Morning lads!" Lorraine, a short, bespectacled, red-headed nurse had moved up to the wards from A&E, preferring the gentler nights up in the tower to the hectic unpredictability of the ground floor. She was permanently smiling, always alert, a slight Scottish lilt making her sound as though it was always lunchtime on a bright summer's day and the picnic blanket had just been laid out on the grass in the park. 

"You've come for Mr Sanders I presume?" 

"If he's heading into town for an emergency operation, then yes, we've come for him." 

Lorraine's voice suddenly takes on a serious tone. 

"Seems so unfair. Someone so young. He's my son's age. Early thirties. Don't know how I'd cope if it really was my son." 

We read through the paperwork, Paul and I, meet Dr McKenna, the anaesthetist who's travelling with us and discuss our options and a plan of action. 

"We're just trying to get him stable enough to transfer. Give him the best shot we can," says the doctor. "There's a chance he won't make it through the doors at the other end." 

"Is there any point moving him?" 

"He'll definitely die if we leave him here. He'll probably die if we transfer him. I'll take probably over definitely in this case." 

We walk into the room, the mood suddenly sombre and heavy. Mr Sanders, or Daniel as his mother asks us to call him, is unconscious and ventilated. Machines follow his every vital sign, gentle pings alternating with silence. For a time the only sound is the ventilator, its artificial lungs hissing life into Daniel making his chest rise and fall as though he is no more than asleep. 

Lorraine comes in with another nurse and they start to untangle the lines. Some feed him with life, some with pain relief, others just monitor. One keeps him sedated. The hospital machines will need to be exchanged for more mobile ones, a move filled with inherent risk.

"This'll take a few minutes. Why don't you two go and grab a quick coffee. You look like you need it." 

"I'm not sure whether that's an insult or an attempt at being friendly." I look straight at Mrs Sanders and a hint of a smile crosses her face. I have no idea how she manages even that smallest ray of light as she sits here with her son. 

"Can we get you a drink too, before we go?" 

"No. Thank you. I'd rather just sit here. Hold his hand for a little longer." 

"You hold his hand, we'll get the drink." 

"Thank you. Tea, please. No sugar." 

Standing in the staff room gives us both a chance to reflect, a dangerous thing in the middle of the night. Seeing illness, misery and death so close may be routine in this job, but it's never easy, especially when we're both around the same age as the patient. We hear as the machines are switched over, the wailing alarms of those disconnected being silenced one by one as we head back into the room. Paul hands the steaming mug of tea to Mrs Sanders and she nods a silent thank you as she briefly lets go of her son to take the drink. 

One of the machines runs out of battery power almost instantly. 

"These damned syringe pumps! It's been on charge for the best part of 24 hours!" Lorraine's furious mood is so rare that it's almost funny, except that the setting was wrong. She plugs the pump back into the wall and scurries off to find another. It seems that no transfer happens without at least one of them running out of power on route. 

The monitor screen suddenly flashes red and several different sounding beeps happen all at once. The ventilator seems to be struggling and each time Daniel is moved even a little, his blood pressure and oxygen levels plummet. 

"Let's give him a few minutes to settle," suggests Dr McKenna. "We'll try again in just a bit." 

I call control to let them know that there's a short delay, but that hopefully we'll be on our way soon. When they ask how soon, the best answer I have is that it'll be as soon as it's safe. 

We try twice more to move Daniel across. Each time we do, his vital signs take a hit and we have to stop, wait for his oxygen levels to settle and then try again. Mrs Sanders sits and watches, silence speaking louder than words. On the third attempt, we get him across on to our trolley. The numbers are calm, the machines are quiet, Daniel seems settled and so are we. 

"Let's go, gentle as you can lads." Lorraine looks on, anxiety straining at her permanent smile. We walk the length of the corridor, almost reaching the doors, when the monitor starts it's ominous shriek once again. We wheel Daniel back to the room in a hurry, plug all the machines in to the wall to stop the batteries draining and wait. 

"No more." The voice is quiet. "No more. Please." 

"Mrs Sanders?" 

"Please. I beg of you. This is torture for him. And for me. Please. Just let him be." 

Doctor, nurse and ambulance crew exchange looks, silent, searching looks, hoping for an answer where there is none. Finally, Dr McKenna agrees. 

"OK. No more. Let's get him back to the bed." 

Mrs Sanders sits down, relief and agony etched on her face all at once as we gently move Daniel back on to the hospital bed and reconnect all the machinery. She picks up the mug of still warm tea and takes a sip, then looks down as though embarrassed at what she had done. 

"I'll get you a refill, so you don't have to drink it just warm. Just give us a minute to make sure he's settled." 

"Thank you again. Could I have some sugar this time please? I think I need it." 

"Of course."

The tea is made and handed to a grateful Mrs Sanders, a new sheet placed on the trolley and we're ready to head back on the road. 

"Sheesh," Paul exhales. "I don't think I've ever had such a difficult time not moving a patient." 

The wheels of the trolley squeak, the click-clack noise as they traverse the cracks in the floor, and we head back out the same way we headed in. Through silent, ghostly corridors, trolley in hand, but bereft of a patient. 

Elves

Elves. It must be elves.

We have ECG leads, blood pressure tubing, oxygen piping. We have an oxygen saturation monitor on an electrical lead, charging leads for the machines and a suction unit with a hose that works like a vacuum cleaner.

And no matter how tidy you leave them, no matter how neatly you put them away, no matter which bag, or holder, or drawer you put them in ready for next time, the elves always get in there.

Because the very next time you take out the leads to do an ECG, or whenever you take an oxygen mask out of the packaging, or if you need to check someone's blood pressure, it's all back in a tangled mess. Again.

I keep looking for those elves, but have never spotted them. Somehow, these stowaway menaces appear on every shift, on every vehicle, for every patient. The solution is simple, but probably years away.

Wireless everything - that'll fox the blighters.

Until then, the hunt for the tanglers goes on.

Threatened

I'm not entirely certain what I'd done to offend you, other than come in to help save your mother's life (which would be the last on my list of things to get ticked off about), but as it seems clear that I have upset you in some way, allow me to offer you a little bit of advice. 

If you're going to threaten, in a language other than English, to kill me and my family, maybe you should check one thing first - check that I don't understand what you're saying. 

Otherwise, you will be left with only one of two options: 

Either you leave the house. 

Or I do. 

Seeing as I'm the one with the knowledge, skills and equipment to actually help your ailing relative, I would suggest the first option as the more prudent of the two. Acting all innocent and pretending that you didn't say what I heard, or didn't mean what you said, or, more likely, didn't mean for me to hear and understand it, is all a little bit too late. 

A moment passes, you stand your ground, shout at all those around you. Even your family know you're in the wrong, that you've been rumbled. They want you out as much as I do, but you refuse to leave, or at the very least, apologise. As I stand up to leave, having made sure to leave the oxygen with the patient so that she suffers a little less, you block my path, holding a fist up to my face. 

"I'll kill you if you leave!" 

"A second ago you were threatening to kill me if I stayed. Now make your mind up. Either get out of my way, let me out of the house and you can deal with the consequences, or you can leave and let me treat your mother. Your choice, but the longer we stand here, the worse things get for her." 

You shout some more, a mix of languages. You push your brother out the way, storm out to the street and slam the door behind you. 

After you leave, several sighs of relief can be heard, and amongst them one voice, quiet and muffled by a plastic oxygen mask. 

"Good choice, son." 

The Look

It's that look. The look of someone who knows they're going to die, and very soon. The room is a hive of activity, several people buzzing around trying to help but becoming more of a hindrance, and in the corner, almost hidden from view, is Glenn. His hands clasped at the back of his head, whilst Jana, his girlfriend, tries to comfort him through her own tears.

Glenn's face is tinged with blue, his lips are almost purple. He's breathing, but hardly moving any air. It seems as though his body is going through the motions, the reflex action of the diaphragm shifting up and down to allow the lungs to expand, but the area created turns into a vacuum instead of a lung full of air. The supply to his extremities has practically stopped, the brain electing to feed his core organs first on a starvation diet of rapidly diminishing oxygen. It leaves his finger-nails a deathly shade of white, whilst his pupils are dilated seas of black. The fear in his eyes radiates from head to toe. 

"He's so healthy normally," Jana tells me. "He doesn't take any medicines, not even for a headache!"

She goes on to explain that they'd been out for the evening and had no more than a glass of wine each alongside a meal at a favourite restaurant, one where they had eaten many times before. A minute or two from home, they stopped at a set of lights.

"A friend of ours stopped next to us at the lights, just by chance, and we chatted and waited for the red light to change to green. Then, he threw a piece of chocolate at us, just as a joke. It flew through the window, straight into Glenn's lap. He picked it up, popped it in his mouth, and then we drove off laughing."

The half mile home was uneventful, but as they walked through the front door, Glenn felt his throat starting to tighten.

Jana, worried that Glenn was choking, woke their housemates not knowing what else to do. One of them called for the ambulance, and five or so minutes later I arrived. Glenn is unable to speak, but the signs are classic enough. Textbook cases of anything are rare, but this one was just that. Anaphylaxis kills, and it kills quickly. Glenn's oxygen levels were low, his blood pressure dropping, and the unknown chocolate the final giveaway when Jana remembers he's allergic to nuts. He's carried an Epipen for years, but had never had to use it. The only one he had was ten years out of date.

As I prepare an injection of adrenaline, I place a mask on his face forcing oxygen laced with salbutamol into his lungs, hoping to prise open his airway. He's rapidly becoming less responsive, fighting to keep his eyes open, struggling to stay conscious. The injection into his upper arm is a last gasp attempt, but within seconds it's clear to see that it's working.

Two minutes later, the crew arrive, and as they walk in, Glenn greets them.

"Hey guys, I'm alright now!" His breathing is still a little laboured, and a loud, audible wheeze rasps across the room. It's a much better sound than the total silence of only minutes earlier.

"Don't you EVER do that to me again!" Jana slaps him on the shoulder, and then crumples sobbing into his arms.

Glenn's wheeled out to the ambulance, his oxygen levels vastly improved and his cheeks a flushed rosy colour.   In the ambulance, his blood pressure is up, the wheeze is slowly being replaced by clear breaths, and he's almost able to complete a whole sentence without becoming breathless.

Most importantly, the look in Glenn's eyes has changed. Now he no longer thinks he's going to die - he knows he's going to live. 

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.

Norma

Norma is usually a bundle of laughs, a handful, and was a real joy to meet. Bed-bound she may be, but her physical restraint had left her mind sharp. At least that was the case the last time we met. That first time, she was trying to escape the nursing home that had become her prison. She knew she would never make it past the bed guard. She'd never really recovered from the faint that led to her falling and breaking both hips. No longer able to walk unaided, she'd been forced out of her lifelong house and into the care of the nursing home.

She sat on the floor, refusing to accept in her heart that which her head was already telling her.

"I'll get up and walk. You ain't taking me to no hospital!" That before I'd even opened my mouth to greet her. Something told me that this battle of wits would be good natured rather than nasty, but it looked like it may well be protracted. As we checked Norma's injuries, it was difficult to know whether what we were seeing, and hearing for that matter, was from the previous fall or this one.

"I'm a war veteran y'know!" she said at one point.

"Which war was that then, Norma?"

"The Forty Year War!"

I had to admit that I'd not heard of it, which was a little surprising. You'd think that something that went on for that long would have registered somewhere in my brain during history lessons.

"Enlighten me", was the best I could come up with.

"Forty years it took me to realise that I wanted shot of that man! In the end, I took him for everything he was worth! Now he's got the kids, the grandkids and our house, and all I've got is a prison warden for a nurse!" She laughed the sort of infectious laugh that you can't help joining in.

I looked back on the information sheet that gave all Norma's details and saw that her next of kin was her husband.

"How come it says here that you're married then?"

"I didn't say I got divorced, did I? I just kind of moved out!" Another burst of laughter, but this time it hurt her hip when she moved. I just raised an eyebrow in her direction, and didn't dare say another word for a second or two.

"Alright", she growled, half joking, half serious, "you can take me to hospital. I promise to behave now!"

And behave she did. Before we moved her, I decided that it might be an idea to give her some morphine to help with the pain, and explained about putting a needle in her arm to be able to give her the medication.

"You miss this vein", she threatened, "and I'll pull the needle out myself and jab it in your eye!"

No pressure then.

Soon the needle was in, the morphine coursed through her veins and provided the much needed relief enabling us to get her to hospital as comfortably as possible. After we'd moved her onto the hospital bed, Norma even managed a thank you, put out her hand to shake ours, and gave each of us a kiss on our fingers as if we were each the Pope. At least. "You lot should be treated like royalty, not like bloody cab drivers!"

I smiled and wished her good luck. We left Norma at the hospital, and by the time we came back, she'd already been moved to a ward.

Now, Norma and I were meeting for a second time, this time I was alone, at least initially. There was none of her wit, no sharp tongue to contend with, none of the feistiness that made her such a pain in neck, yet a pleasure to help.

Norma was unconscious. The nursing home staff told me that she was diabetic. They checked her blood sugar which they found to be dangerously low, and so decided to force feed her a sugary drink to try to help.

Not such a great idea with an unconscious patient.

The rest of her basic observations weren't so good either. A pulse and blood pressure so low that they were barely readable, with an ECG that confirmed what I already knew - her heart was really struggling. She was hypothermic as well, her body temperature dangerously cold despite being in a room that was so hot I was sweating from the moment I stepped in.

The crew backing me up turned up after a few minutes. I'd made sure they were updated before they arrived as to what was really happening, and the fact that it wasn't exactly as the call had originally been sent. In fact, it wasn't even close. "Diabetic problems, patient conscious and dizzy" was what I had initially expected, although I'd learnt long ago that not everything the call-taker is told is what is really happening. The patient calling for an ambulance because their own heart had stopped is a real, if a little far-fetched example.

As they came in with the stretcher, Norma's breathing became erratic, the oxygen in the mask now needing some external assistance to make its way into her lungs. We moved her across from the nursing home bed to ours, with the staff complaining that we'd taken their sheet with the patient. If it had been some sort of expensive bedding, I might have had some sympathy, but it was nothing but a regular hospital sheet. We were followed out to the ambulance by two members of staff, one carrying an envelope with the photocopies of Norma's details and drugs, the other empty handed.

"Is one of you coming with Norma? If so, we'll be going in a couple of minutes."

"No. We're not coming. We don't usually send anyone, just the letter."

We load the trolley into the ambulance, and as the hydraulic ramp closes, a voice calls out.

"Can you please make sure you bring that sheet back?"

Incredulous, just as I'm about to shut the other door, I look out the back at the two people charged with the care of so many, but couldn't muster an ounce of understanding between them.

I open the cupboard at the rear of the ambulance, find a spare sheet, and throw it out at them, leaving them fumbling over the cascading linen.

Looking back at Norma, I'm left wondering what her sharp tongue would have replied. I'm sure she'd have found the words at a time when I was fuming, but completely speechless.

Take Away

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

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

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

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

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

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

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

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

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

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Out of Depth

On days like today, warm, sunny aberrations from the norm, being ankle deep in water isn't so bad. Just the thought of it conjures up images of sitting by a pool, a lake, or even at a stretch, sitting on the beach, feet dangling in the cool blue waters.

Ankle deep in water would probably be a blessing for those affected not so long ago by torrential rain and devastating floods all over the world. Sure beats being knee or waist deep in the stuff.

Ankle deep really isn't all that bad, unless you're ankle deep in blood.

*

A call to the local bus garage isn't unusual, more regularly to patients whose blood alcohol volume is a little high and who are looking for somewhere warm and dry to sleep it off. So when the call came in as a young adult male unconscious, it sounded like business as usual.

The car had its hazard lights on, just as we'd been told it would. Abandoned rather than parked between two buses, with Rami stood at the back of the car, frantically flagging us down. Something about his demeanour said it was serious, but as we stepped out of the ambulance, there was no patient.

"What are you waiting for?" screamed Rami. "He's in the front seat!"

Didn't expect that.

And there, in the front passenger seat, was our unconscious man. 20-something years old. Ankle-deep in blood. And dying in front of us.

"What happened?" The question was more to keep Rami out the way and his mind occupied, so that he'd keep out the way and let us do our job.

Airway - clear.

"We were in the park and got attacked. They came out of nowhere, about six of them. They hit us with all sorts. He had blood all over him but we managed to run away. I didn't see where the blood was coming from. I thought it'd be better if I just took him to the hospital, but I got lost. Now I don't think he's breathing! I stopped to call you guys! I didn't know what else to do!"

Breathing - present, but laboured.

We reassured Rami that his friend was breathing, but was unconscious. His shirt was crimson red, his breathing laboured and his pulse rapid. We didn't need to check his blood pressure to know that it would be dangerously low - the amount of blood on the floor of the car told us what we needed to know. He needs fluids, preferably blood, and in a hurry. Out in the real world, pre-hospital, the only fluids we have are basically salty water. Better than nothing, and enough hopefully to get him at least as far as hospital.

Circulation - problematic.

We found the source of the bleeding, multiple stab wounds in his lower back and abdomen. Too many holes to plug, and not enough time to do it. We'd asked for assistance from HEMS, but as it was night and they weren't flying they would be coming in the car. Luckily, they'd been on a call not too far away, and even though they're normally based the other side of London from where we are, they wouldn't be more than 10 minutes away. Just as we were getting him into the ambulance, we were given an update that HEMS weren't coming. Apparently they'd crashed, and although it was only very minor, they were now tied up with paperwork.

With no assistance on the way and no way for us to give him anything more than fluids, we opted not to delay any longer, made him as comfortable as we could in the ambulance, and began the mad dash to hospital.

Police were with us.

Rami was with us.

Time was very much against us.

And we were back where our patient started.

Ankle deep in blood.

Empty

They lie there, piled safely behind the back seat of the car, starting the shift as reassuring, rarely used spares.

It's an uncommon thing to use a single, whole one in a shift, especially on the car. The crews come and whisk the patients away, using their own supply, leaving the car's one barely depleted. That night had been different. A collection was slowly accumulating, with no way of returning the empties to station, relying on the crews to replace them with fulls instead. Half way through the shift, and three of them had already been emptied, each on a separate, critically ill patient.

They lie there, piled safely behind the back seat of the car, spent, empty, used. There's one left in the bag, as yet unstarted, untouched. Enough for just one more, but surely, not tonight. Tonight has been tough enough already.

And yet.

He lies there, unconscious, barely breathing, the machine fighting with him, for him, but it isn't strong enough. Compressing the air and pumping what it can against the odds, all the while making no difference at all. We look at his chest, listen to his breathing, and whilst he's making the movements, no air seems to move. We'll have to breathe it for him.

Out it comes, turned up to full blast, the jet of air blasting out, hissing like an invisible snake, filling up the reservoir bag and mask to capacity. As fast as it fills the bag, we empty it into his lungs, forcing them to work against their wishes. We struggle, full in the knowledge that we're fighting a losing battle, but losing doesn't mean we've lost. Losing doesn't allow us to give up. So we struggle out of the house, into the ambulance, and to the hospital.

It lies there, piled up with the others behind the back seat of the car. Each silently telling its own different story.

And in the front, he sits wondering what's happened, and why. Why so many, why so ill, and the last one, especially the last one, why so young?

Another life in our hands, another battle fought, maybe won, maybe lost, and another whole cylinder now showing empty.