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. 

Putting Their Lives on the Line

I was at home enjoying some family time when it happened. But just hours after the horrendous incident in north-west London that left four police officers with serious injuries after being stabbed, I was back on duty, and this time, not a million miles away from the scene.

At a totally unrelated call, an RTC, the police had to block the road for a few minutes so that we could treat our patient safely. A driver caught up in the traffic approached one of the officers, stood toe-to-toe, and through gritted teeth and a with a horrible snarl commented: "It's no wonder you lot get stabbed."

I'm not sure I would have been as restrained as this officer was.

The police have to put up with a lot more abuse than we do, and take greater risks too. If there's a call that sounds a little suspect, we'll ask for police attendance and hide around the corner until we know it's safe. Yesterday's incident proves once again how big that risk often is. I have a great deal of respect and admiration for the police, what they do, and what they sometimes have to put up with, especially as they've saved me from a serious pounding on numerous occasions.

I hope and pray that those injured make a full and speedy recovery, both of body and soul. They deserve it.

And as far as the idiot driver who had been inconvenienced for a few minutes, well, I can't really tell you what I hope and pray for him. But I'm sure you can well imagine.

Lives

Some, over the years, have been badly hurt. 

Some, over the years, have been only lightly grazed. 

I guess they're the lucky ones. 

Assuming it's lucky to be stabbed.

Some had a wound so deep, they needed surgery right away. 

Some had a wound so shallow, the hospital sent them straight home, 

with a stitch or two and a warning. 

Some, bravado and ego getting the better of them, 

refused any treatment at all and ran off.

Two died. In front of me. 

When there was nothing I could do.

Others may have died later, but I'll never know.

Drop the damned knives, people. 

Stop destroying lives, people. 

Go live your lives, people, 

and stop tearing those lives apart. 

Nothing

He was covered in blood, so much of it that even his socks were soaked through. The engine roared as the ambulance sped towards hospital, the wailing siren pleading with the early evening traffic to clear the way. As each wound was bandaged, trying to stem the flow of blood, a police sergeant needed some answers. There was no time for questions on scene.

"What's your name?"

His answer's slightly muffled by the oxygen mask. "None of your business." 

"Where do you live?"

"Nowhere."

"What happened?"

His breathing quickening, he managed a single word. "Nothing." 

"Was it a knife? A bottle?" 

"It was nothing. I fell." 

A needle is placed in his arm without so much as a flinch. Fluids are run into his body, a poor replacement for the blood he was losing. 

"You don't get holes in you like this from falling." 

"I told you. Nothing happened." 

His lips were turning blue, his breathing more rapid and shallow.

"You've got wounds all over you, it would help if you told us how you got them." 

"Nothing. Happened." 

"Did anyone see what happened? Was there anyone with you?" The officer knew he wouldn't get an answer, but he tried anyway.

He turned his face away, closed his eyes, and refused to say anything else.

Minutes later, at hospital, a man with no name, of no fixed abode, full of unreal holes, died from nothing whatsoever. 

Sisters

At the risk of having posts on my blog that are better than my own, this is a guest post from PenguinEMT - one of the people at the top of my list of friends whom I've never met. Yet.

_____________________

She lay in a barren field, the blood from her face and knees mixing with the dirt and grime to hold her together as a sheath of discolored glue. I heard no sound, save that of the vehicles racing by. As I came closer, I heard some slight gurgling and moaning. The officers stood back as we surveyed what has become a scene that haunts my dreams.

I spoke to her softly, trying to encourage a response. Nothing. Once in the ambulance she roused, shielding her face with her hands, screaming in absolute terror. My voice calm, I assured her we were there to help. With every procedure, every move we made, she recoiled and screamed, her voice hoarse. 

We weren't to touch her, she said. She belonged to her husband. Only he could touch her. 

We couldn't. 

He would be angry. 

*****

He lay curled up on the basement floor, the blood soaking the carpet. A crimson mist coated the walls. From upstairs I could hear the sounds of anger. Downstairs, however, it was eerily quiet. 

A faint pulse, but no response. Four occlusive dressings and two packs of gauze. I spoke loudly, attempting to garner a reaction. Any reaction. Finally, at the hospital, I heard a faint whisper. 

"Thank you," he mouthed, eyes still closed. 

*****

She stood in the kitchen, a mere wisp of a thing. The anger was palpable, her face mottled with tears. The knife block was empty, its contents scattered on the counter-tops and in the sink. All of them covered in blood. 

My exhausted mind traveled back in time, just an hour. 

Sisters. 

Central Locking

Before the old ambulances could be completely replaced, we were treated to a smattering of new vehicles. Shiny yellow, with a trendy battenberg design all the way round, and as an extra confusion, diesel engines rather than the lawn-mower type petrol ones. Many a medic would be caught out in the first few months by feeding the engines with the wrong fuel.

They were hardly loved, those old LDV's. Nothing more than vans that had been given blue flashing lights for the roof and the front grill. Meat wagons. Loud, growling engines that would wake an entire street at three in the morning, but which you had no choice sometimes but to leave running, just to make sure that you still had some battery power by the time the patient had been recovered from the scene and placed on board. The three battery lights on the front would give the cab a disco feeling as they would all start off a tired red, change through slumbering amber and on their way to eager green, each individually, each moving backwards and forwards through the sequences depending on what the driver tried to get out of the engine.

At least the temperature control was reliable. The heating would completely fail in the winter, and work whether you liked it or not on the hottest days of summer. The air-conditioning never worked - there simply wasn't any. Anything that broke, fell apart or went missing was fixed with tape, a staple of any medic's armoury, along with all the medical stuff, and in fact probably higher on the priority list than most of the real kit.

In their final days, as they sensed the day of judgement and their own demise, they mounted a rebellion. They had a knack for trying to poison the occupants by filling the cab with noxious gases that would leave crews needing oxygen therapy themselves. Finally, not so long ago, and at least five years past their best, the last of the old fleet were mothballed.

In the early days of the new Mercedes ambulances there would be fights as to which crew would have the privilege of owning it for the shift. Those on the longest shift thought they were entitled to it, or those who were taking the longest transfer. The lure of the softer suspension, gentler ride, and most importantly the ability to control the internal temperature were cause for more than one disagreement. Yet, as the younger members of staff would argue over the newest, shiniest ambulances, the old guard would reminisce about the wondrous days of sliding doors, scoop-and-run, and were often mocked about their memories of the horse-and-cart. Finally, after several weeks of watching others enjoy the pleasures of the new arrival, it was my turn, and as I tried to climb in the passenger side door, I discovered one more novelty that the old trucks lacked - central locking.

Dean took the keys and control of the vehicle for the day, I never even got a look-in, not that I minded particularly. Even from the earliest days in this job I've preferred to attend rather than drive. Dean, however, was like a kid in a sweet shop who'd been given free run of the shelves, and loved every minute of finally driving a vehicle that responded as an emergency ambulance should. After a few routine calls, we were tasked to a call given as a man with a serious laceration to his arm caused by broken glass.

Arriving at the call a few minutes later, we took out the normal bags, as well as an extra bag of bandages. A trail of blood stretched across the pavement by where we'd parked, down the paved driveway and into the house that was about thirty metres away. Dean locked the ambulance. We started to walk towards the house and as we opened the porch door, a figure started to run towards us and stopped us in our tracks. As he came nearer, we saw that he wasn't alone, but carrying what looked to be a knife behind his back. We could just see the handle and a glint of metal, but that was enough. 

We stepped back out, backpedalling at speed, and Dean had the presence of mind to slide the porch door shut in a hurry. Still carrying all our kit, we ran back to the ambulance, and tried to climb back in, only to find that the doors, for the first time ever, were locked. Our "patient" had almost caught up with us, and now all I saw was the knife, which turned out to be a samurai sword being waved menacingly above his head and coming ever closer. I dropped the bags.

"Open the doors!" I screamed to Dean. 

"I can't! The bloody things won't open!"

"IT'S THE CENTRAL LOCKING!!! USE THE KEY!!!" 

Dean fumbled in his pocket for the unfamiliar key, whilst we both ran round and round the ambulance trying to avoid being sliced in half. Dean yelled to a neighbour to call the police, as this was before the days when we had personal radios, and our only means of communication were, like our safe haven, locked inside the ambulance. Eventually there was a standoff, where we stood at 180 degrees to each other - us on one side - and a sword wielding maniac on the other, but all three of us standing by doors. If we unlocked the ambulance, he could get inside just as quickly as we could. We worked out a plan where we could hold him away from an access for just long enough to unlock the doors, climb inside and re-lock the ambulance before he'd climb in. Another couple of circuits of the ambulance and we'd finally positioned ourselves as per the plan, and miraculously managed to pull it off. 

"Control, this is Z321, we need urgent police assistance!"

"Z321, received. Can you tell us what's happening?" 

As I tried to catch my breath, I told them in half sentences what had happened and they promised to arrange for the police to attend. Our sword-swinging friend had finally realised he couldn't get in, and instead took to trying to smash the windscreen, which thankfully held fast. Any interested bystanders had quickly seen sense and fled back into the safety of their own homes, and as he turned away to pick up one of our discarded pieces of kit, we had just enough time for Dean to beat a hasty retreat, far enough to be safe, but close enough to still see the scene. Ninety seconds later, the first of the police units arrived, closely followed by several more. 

We watched from afar as our patient was quickly bundled to the ground by half a dozen officers, the sword wrenched from his grip, and he was placed in the back of a police car. Not without a struggle, but it wasn't a very long one. Slowly, Dean turned the ambulance round and we headed back to the scene, safe in the knowledge that neither assailant nor weapon were now of any threat. Stopping alongside one of the officers, I wound down the window and briefly explained again what had happened. 

"We'll need a full statement," said the officer, "we can do it here or back at the nick." 

"Might as well do it here. At least we've got air-conditioning." I climbed through the door between the cab and the back of the ambulance as the officer tried to open the back door from the outside. 

"Can't open it!" he said, "Must be jammed!" 

"Oh. Yeah. That'll be the central locking..." 

Dean pressed the button that magically unlocked every door to the ambulance. 

"Must remember not to lock these in future, especially on samurai-sword calls. Too bloody dangerous!" 

Stabbed

Needle Thoracocentesis.

Try saying that half way through your fourth night shift.

Worse still - try doing it when you've only had 10 hours sleep in the last four days.

And worst of all, despite being a paramedic for over four years - it's the first one you've ever done.

It's not the sort of skill that is either required or used very often. Even by trauma magnets such as yours truly. The problem is, that when you do need to use it, it's always deadly serious.

In the simplest terms, it involves sticking a large needle straight through the chest wall and into a collapsed lung. Counter-intuitively this will re-inflate the lung. Collapsed lungs (or pneumothorax in medicspeak) can be caused in various ways, such as severe asthma, sometimes spontaneously (especially in young, tall, fit people), and most commonly in ambulance terms by severe trauma. This can range from bad RTAs, to stabbings, shootings and other traumatic chest injuries.

The most dangerous sort, a tension pneumothorax, if left untreated, will kill. No questions. It will compress the lung, stop oxygen getting into the blood stream and round the body, and eventually compress the heart and stop that working too.

No oxygen + no heart = certain death.

It works, at the risk of telling fellow medics what they already know, a little as follows: the normal lung is a little like two balloons inflated one inside the other, with a tiny lubricated space in between, to make lung movements effective and painless.

In the case of a tension pneumothorax, the inner balloon has a leak. Every time you take a breath in, air enters the inner balloon. Normally, each time you breath out, the air leaves, but with a tension, the air moves from the inner balloon only as far as the outer balloon. That stretches, puts more pressure on the inner one, collapses it, and stops it working. It's also how the heart gets squashed, as well as eventually the other lung too. All in all, very nasty, and very, very deadly.

This is where the needle comes in. The needle goes into the large space that has now been created between the two balloons, lets out all the trapped air, allows the inner balloon to reinflate, releases the pressure on the heart, and allows the business of breathing to resume. It's only a very short-term solution, but gives the patient instant relief, and some vital extra time to get to hospital and definitive treatment.

In short - if you decompress the lung - you save a life.

Last night, for the first time ever, I stabbed someone in the chest.

Despite the 200 or so witnesses, and a police officer watching my every move, I got away with it.

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.