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. 

Darkness

The instant the doorbell rings, a sharp bark pierces through the biting wind, a pitter-patter of paws runs towards the front door and starts trying to scratch its way out.

"Hold on one minute," calls a male voice, "I'll just put the dog away." Just above the sign warning would-be intruders of the presence of a menacing dog is another, more welcoming sign - Patterson Plaza. We wait outside as we hear the barks fade, and at the sound of a door shutting somewhere in the house, they turn into a distant, sad whimper.

Eventually he returns and opens the door to let us in. "She's in the back room, is Ada. You'd better go ahead of me, I'm a bit slow on the old pegs! Second door on the right. But just be careful, she's right behind the door!"

We peek round to see Ada propped up against a wall, using a glass-fronted unit for support. One of the glass panels is shattered, shards covering the floor and sparkling in the dull amber light. A wound in the back of her head has left her silvery hair tinged with a streak of red.

"I bet I look a right sight!" Ada looks up from her precarious seat on the floor to see two 6-foot plus green aliens in her lounge. The look is almost child-like, a stare upwards that slowly keeps going until reaching the top of the view.

"You look fine Ada, us red-heads must stick together, so we'll make a good job of looking after you." She laughs. "Not much left of your red hair, is there?"

"You noticed, huh?" I kneel down beside her. Apart from the impoliteness of standing bearing over a patient, it also means she no longer has to crane her neck just to speak to us. "Let's get you patched up shall we?"

The shuffling footsteps that had followed us down the corridor finally approached, and Ada's husband joined us in the room. "Mind the luggage, Mr Patterson, it's taken over your lounge a little."

"Oh, I'm alright. And call me Derek! None of this Mr Patterson stuff - you're not my bank manager!" Stern, but friendly and sincere. We check Ada for other injuries and find that she's probably fractured her hip. Derek's warned us that she has a habit of falling, as she uses a zimmer frame to get around, but sometimes gets too frustrated and leaves it behind. When she does, she often tumbles to the floor.

"I've told her she has to use the frame, but will she listen to me? Of course not!" After giving her a glare, he rattles off her list of medications, tells us what each one is for, and how many of each she takes and at what time of the day. "I'll just go get the box and show them all to you, make sure I haven't forgotten any." Derek walks off in the direction of the kitchen.

"He's been looking after me like this for years, ever since the arthritis has stopped me getting around easily," Ada whispers, "but I know he can't go on like this. We're both getting too old. We've been looking into moving into a home together. It's not as simple as it sounds." In the time we've taken to bandage her head and stop it leaking, Derek has returned. Ada stops talking, perhaps not wanting to upset him.

"Right," says Derek, pointing out each of the medications in the box, "this is the one for blood pressure, this one for her heart, this one for the pain from her arthritis, and the big box is full of calcium tablets."

"Thank you, Derek." In the background, the sound of paws clawing away at a door are a constant reminder of the caged animal.

"What dog have you got?" I ask. My knowledge of dogs is limited. I know they have tails, four legs, and bark. And I know that I don't like them particularly. Owners' assurances that "Oh, he's the friendliest dog in the world, you don't need to worry about him," are often followed by a nip on the hand and a now apologetic owner sheepishly mumbling "Well, he's never done that before!" I'd rather not take the risk.

"He's a beautiful Labrador. Wouldn't hurt a fly." At least I know what a Labrador is.

"And who walks him?"

"Mostly I do," Derek answers, a little insulted I fear. "Sometimes, when our son's in town, he'll come and do it for us. But normally I take him to the shops once a day, you know, when I get the paper and a few odds and ends, and he's happy with that." Knowing the area, I realise that the shops are a good quarter of a mile away. "Helps keep me fit, too!"

In the meantime, we've given Ada some pain relief and prepared to move her onto our chair and out to the ambulance. I'd have preferred to keep her laying flat and not moving her hip, but it was an impossible idea, the tiny corridor and curved walls not allowing for a stretcher of any kind. The morphine would hopefully work its magic and prevent her from feeling any more pain.

"She'll want her dressing gown, if that's all right with you? I'll just go get it from upstairs."

"Why don't you give me directions, and I'll go for you. Don't need you running up and down for no reason."

"Right. Well it's up the stairs, first door, right in front of you. It's the light blue one, hanging on the back of the door. The dark blue one's mine, so don't bring that one, or I'll never hear the end of it. But just so you know, it's the room where I put the dog."

Just for once, I decide to be brave. "Don't worry, Derek. I'm sure he won't bite me just for taking a dressing gown. It's probably not his colour anyway!"

"Fine, then. I'll just make sure everything's locked up and switched off downstairs, then I'll join you in the ambulance."

We wheel Ada out wrapped in the ambulance-standard red blanket to keep her warm as well as safe. "Matches my hair now, doesn't it," she muses as she looks down at the crimson cover. Once she's safely on board and as comfortable as possible, I go back into the house, and up the stairs to retrieve the dressing gown. Not before a plea from Ada.

"Make sure you help Derek out when you come back, won't you? He's not so good outside without the dog."

"Of course I will. Don't you worry about anything. That's what we're here for." She relaxes back on the trolley and allows my crew mate to check her blood pressure again.

As I open the bedroom door, the dog is lying on the floor and looks up at me with what seem to be almost contemptuous eyes. "Sorry," I mumble, "we have to look after Ada first." I can't quite believe I'm apologising to a dog. I take the dressing gown, fold it in half over my arm and leave the room with the door slightly ajar. Hopefully if I show the dog a small sign of trust, he'll understand my intentions are only good ones.

I meet Derek at the bottom of the stairs. "Got it!" I tell him.

"You sure it's the light blue one, aren't you?" His question confuses me.

"As you can see, sir, it is indeed! And I got it without being eaten alive!" I try to put on a show of pride.

"Actually, I can't see it. I forget to tell people sometimes, sorry. It's been twenty-five years now." It's then that I see the dog's reins, reflective strips on the straps and bars, and a white cane sitting by the door. I think back to everything he's done. Clear descriptions and directions, knowledge of exactly where everything is, drugs in perfect order, looking after the dog, looking after us, looking after Ada.

And all in darkness.

"Come on Derek, let's get you out to the ambulance. There's a young lady in there asking after you."

His hand holds onto the crook of my arm, and we walk out together, leaving the dog to watch from the top of the stairs.

Real World

In her late 30s, she's barely older than either of us, but her body's betrayed her already. Lying in her bed at home, her face is gaunt and gray, her limbs little more than skin-covered bones. Her breaths shallow, laboured attempts at feeding the cells with the oxygen they crave, whilst sunken eyes share their fear and sadness with all those present.

We're there on a mission of mercy. The call is neither an accident or an emergency, but a penultimate journey that no-one wants to be a part of, one where everyone understands its necessity. A hospice bed awaits at the end of this transfer, a gentle room, surrounded by large windows, the other side of which is a beautiful garden, lovingly tended to by a gardener who clearly realises and appreciates the significance of the nature he maintains.

Kara's cancer had almost beaten her. She'd been given weeks to live, and she, her family and their doctor had agreed that she should spend that time with round-the-clock palliative care on hand. There was nothing left to do, other than make those final hours and days more comfortable, as pain-free as possible. Tony, her partner of three years smiled through his tears, making no attempt to hide them as we moved her as gently as we could onto the trolley. Her parents stood either side of the door, a guard of honour testament to her bravery, and whilst her mother's tears flowed, her father's tear-soaked eyes were held back by a stoic dam, ready to burst at any moment.

We wheeled Kara as slowly as we could, feeling every bump almost as much as she did, whilst she'd reassure us.

"It's fine, I know it's not you. I'll get Tony to sue the council". I'm sure the reassurance should have headed in the opposite direction.

Tony travelled with us in the ambulance and brought with him a large pink, flowery case with a few of Kara's things. Pyjamas, some make-up, her favourite books.

"Not really my colour, is it?", he says, as he drags it up the back steps. Kara smiles, and everyone else forces one too, especially Tony.

A few minutes travel down the road, and we arrive at our destination. A suburban setting, hidden in its very own forest, away from prying eyes and the noise of the real world. It's a truly beautiful place, serene but never sombre. The staff have an amazing talent of making everything seem just right, nothing is ever too much effort, from simply spending as much time as needed to make a pillow just right, to attending to all the medical needs.

We wheel Kara into her room, number 3, and help her settle before handing over to the tender and experienced hands of the hospice nurses.

We turn and leave, saying goodbye to Kara, Tony, and her parents, and they in turn thank us for our kindness. Why is it that it's always the people who don't need to say "thank you" who are the first to do so?

We load the trolley back into the ambulance and sit for a while in silence. The radio blares out a song that seems completely at odds with what we've just done and where we are, and we both reach for the off button at the same time. The comedy of hands slapping each other breaks the tension, and we leave the grounds, back out onto the main road and into the real world.

Two weeks later we were back there, taking another patient to be cared for, just for a while. In her late 80s this time, Lira was going into respite to give her equally elderly husband some time alone, time to care for himself a little.

"It's just a week, Lira", he tells her, "just some time for me to tidy the house properly for you". He looks exhausted, and explains that he'll be living with their son for the week, just as a break, so he can go back to looking after her as soon as she's home.

Elaine, one of the nurses, directs us. "Second room on the left".

"Isn't that room number 3?" I ask.

"That's the one. Beautiful view of the gardens", she adds, turning to Lira as she does so.

"We know it". We look at each other and think back to the previous fortnight.

And back to the reality of the real world.

Shut. Up. Den!

They married the day after he was de-mobbed, seven years to the day after they had become engaged. The day of their engagement was tinged with sadness, as on one hand she placed the ring which betrothed them to each other, and yet with her other she waved him off, not knowing if or when they would finally exchange their vows. They didn't meet again for almost five years, whilst he spent that time at the request of His Majesty fighting in the war that followed the War to end all Wars. They marked their seventh anniversary with a new one, the start of sixty more.

"Sixty years we've been married", he tells us. "Not once has she listened to anything I have to say." His wicked grin was met with a sharp tongue.

"Shut up, Den!"

The pain had kept her up all night. The effects of the tablets she took wearing off before they'd even reached their peak effect. Eventually she could take the pain no more, and reluctantly agreed for the ambulance to be called. When we arrive, she's sitting in an armchair, trying for all the world not to show us that she's suffering. The colour of her face and the fine beads of perspiration on her forehead tell us more than we need to know.

"How long have you been in this much pain?" Seemed like a good place to start.

"Well", starts Den, "It's been getting worse all night. She didn't want me to call, but in the end I don't really think I had a choice!"

She glares at him. "Shut up Den! I can talk myself you know!"

"Oh, I know all right..." He mutters, just loud enough for us all to hear.

I try to hide the smile.

"It's not too bad now. It was much worse before. Keeps coming and going. I think I'll be fine if I just get some sleep."

"You've been like this all night, love, and I can tell it's not getting better. Why don't you let them help you?"

"Shut up Den!" she retorts. There's a clear theme developing.

"Lets have a proper look at you", I suggest, and reluctantly she agrees.

Her observations are mostly unremarkable, just an increased pulse suggesting once again that despite wanting to hide her ailment, the body will always give its secrets away. She can't help but admit it now. The pain is becoming just too much to cope with.

"How about we give you something for that pain then?"

"Good idea", ventures Den. "You could do with something stronger than those tablets!"

"Shut. Up. Den!" she growls at him, rests her head back on the trolley-bed and briefly closes her eyes.

"Maybe I could do with something. It is coming back a bit."

A few moments later, as the morphine courses its way through her veins and works its magic, the relief starts to show. Her whole body relaxes, the colour, so drained before, returns to her face, and the beads of sweat fade away.

"Feeling better?"

"Much better. Thank you."

"We're going to take you to hospital so they can find out a bit more about what's happened. Hopefully stop it from happening again."

"That's fine. Suppose I could do with a check up."

Den shakes his head, one part frustration to ten parts relief.

"One of these days, you'll realise that I do talk sense sometimes!"

"And one of these days", she shoots back, "you might just be right!"

Her voice softens, they smile at each other, and Den reaches across the ambulance to pat her on the hand.

"You know", he starts, "it IS my name on the front door! You would do well sometime to remember that!"

"Oh, do shut up Den!"

She rests her head back on the bed, and for the first couple of minutes of the journey there's a calm silence. I start the paperwork, and they look at each other, holding hands like they were still love-struck teenagers.

"You know what, Den? You're right. It is your name on the front door!" There's a sudden glint in her eye that wasn't there before.

"Just don't forget that the sign with your name on it is on the outside!"

Stride

Each one of us has a system.

A line of questioning that we follow each and every time to get the answers we need.

Following the same method for each patient ensures not only consistency in our history-taking, but also in our treatment of the patients.

Personally, it guarantees that I have asked all the questions, at least the basic ones, to know where to start and which line of treatment is the most likely.

History taking involves everything from past medical problems, to current drug treatments, from the time of the last meal to bowel opening patterns, from sleeping patterns *ahem* to the actual current reason for calling the ambulance.

And then, there's pain related questions. Where is it?

How bad is it?

When did it start?

Does it move?

What were you doing when it started?

Does anything make it worse? Or better?

All in order. Need to keep my stride.

It's especially important towards the end of a night shift, and even more so towards the end of a set of nights.

My favourite pain-related question, probably because the answer is invariably "No", is "Have you taken anything for the pain?"

You know, any analgesia or anti-inflammatory stuff? Anything that might have helped you get the night's sleep that you're complaining you didn't get? I'm always a little bemused by people who go from having a pain that they can cope with straight through to excruciating-ambulance-required-immediately pain without going through the lets-take-some-tablets-and-see pain in the middle.

I digress. Must try to keep my stride.

The following is a true, if slightly shortened, recording of a recent conversation with a patient in pain.

InsomniacMedic: "When did the pain start?"

Patient in Pain: "About 12 hours ago". That would have been at the more tolerant and alert part of my shift.

IM: "And you haven't slept at all?"

PIP: "Not a minute."

IM: "Did you take anything for the pain?"

PIP: "Yes."

IM: "Can I see the tablets that you took?"

PIP: "It wasn't a tablet." Assuming that this patient can't swallow tablets, I presume it must be a liquid. Exasperation is slowly setting in.

IM: "Can I see the bottle then?"

PIP: "It wasn't a bottle." Exasperation is slowly being followed by the loss of will to live.

IM: "So what did you take for the pain then?"

PIP: "Coffee."

IM: "....................................."

All the training, all the working on a system, all the pre-planned questions, all down the toilet.

I mean, with answers like that, how is a guy supposed to keep his stride???

I think I need a drink.

And not necessarily a coffee.