The week that's been

We see things. 

We see things that otherwise are seen only in movies, 

or in overactive imaginations. 

We see things that should never be seen 

and that cannot be unseen. 

We see the amusing, we see the frightening. 

We see things that others can only wish to see,

and that we are privileged to share. 

We see the sublime, the ridiculous, 

and everything in between. 

We see magic at its very best, 

and life at its very worst. 

We see trust and betrayal, belief, 

and the loss of all hope. 

We see acceptance of fate, we see denial. 

We see life end and life begin, 

first breaths and last. 

All in the space of a week. 

Unwritten Rules

The first clue was the fact that the apartment was on the fourth floor. It's the internationally recognised, first unwritten rule of ambulance work that the higher up the patient is in the building, particularly if there's no lift, the more likely they are to need carrying down. A voice hollers out of the window, through the security bars that seem totally unnecessary on a window so high up. 

"Bring some bandages, you're going to need them!" 

We're already carrying a supply, along with oxygen, a defibrillator, a carry chair and all other manner of equipment that we may or may not need. Unwritten rule number two is that whatever piece of kit you leave behind, is exactly the one you're going to need for the patient, so often we carry too much, rather than be stuck with too little. 

The trail of blood that greets us at the front door leads us to Berhanu, an ancient looking Ethiopian man, surrounded by concerned family. Three people start talking to us at once. 

"It happened yesterday too!" 

"He's on all these tablets!" 

"We tried to stop it, but it keeps filling up again!" 

Eventually, we calm the scene and reach Berhanu, finding him chirpy and unconcerned, unwritten rule number three proving yet again that often the family panics a great deal more than the patient. He was sporting a self-made blood collecting device around his foot, proudly showing off the handiwork that we were just about to dismantle. First, we remove the plastic bag, within which must have been a couple of hundred millilitres of blood. Next, we gently removed the DIY bandage that was held in place by sellotape and electrical tape, and that was made up of blood-soaked tissues, cotton wool and torn up pieces of newspaper. Finally we could see the ruptured vein just above the ankle. It was pouring out his blood as though someone had left a tap running. The tourniquet that he'd fashioned out of several elastic bands was doing nothing other than leave nasty marks further up his leg.

Within seconds, we applied a new bandage, lots of pressure and raised his leg, all in an attempt to stem the flow. It took some time, but eventually it slowed to just a trickle and then all but stopped, meaning it was stable enough for us to move Berhanu to hospital. 

"I'll walk!" he says, watching me open the carry chair. 

"I think it's better if you don't. We don't want that to start bleeding again." 

"I have walked every day of my life for the last eighty-five years, and up and down those flights of stairs for the last ten. You're not carrying me!" 

We pleaded with him. His family suggested, begged, shouted, instructed and cried at him. Nothing would convince Berhanu to sit in the carry chair. As a final attempt, my crew mate told him that the rules said that anyone who was bleeding, even a little, had to be carried. 

"Where does it say that?" 

"In my rulebook!" 

"Show me." 

"I don't have it with me. But believe me, it's there." 

"I don't believe you, and I won't be carried. Rules or no rules." 

He stands up, refusing all offers of assistance and takes a step towards the front door. All of a sudden, a trickle of blood appears below the bandage and within seconds it's dripping onto the floor at an ever-increasing rate. Defeated, he sits down again, allowing us to start the process all over; redress the wound, raise the leg and wait until the pressure and some gravity do the job again. 

When we're ready, Berhanu looks up at us and motions towards to the carry chair. 

"Good choice, we don't want to go through that again." 

"It's not really in the rulebook, is it, carrying bleeding people?" 

"Well, not specifically, no." 

"Unwritten rules, I guess. I suppose you have to have them too." 

Then and Now

At a Remembrance Day parade, several hundred war veterans, many of them well into their eighties and nineties, marched past an equal number of supporters who lined the streets of Whitehall, me amongst them. As long as I was in the country, I had attended every single parade for as many years as I could remember, supporting my grandfather, my great-uncle as well as all the other veterans. As they reached the Cenotaph, the cold, grey war memorial reflected the overhead skies. A fine drizzle had fallen all morning, coating the roads and pavements, but in an apparent show of respect had stopped falling as the veterans started to march. The Royal Air Force band escorted the veterans, the mix of young and old stark, but reassuring. A continuation of the generations, a knowledge that freedoms had been bought at huge cost, but that there were still those who would go on paying the price. It is both encouraging and tragic all at once, the knowledge that there are those who will continue to fight, alongside the reality that the need still exists. 

At the sound of the bugle, the flags are lowered and heads are bowed. An air of solemnity replaces the noise as a minute's silence begins, a silence crudely broken by the crackle of a police radio nearby and the words "Possible cardiac arrest on parade, St John Ambulance staff on way." 

When I look up from my place in the crowd, I can see the first shuffling of feet, clearing a path for the medical team and I approach the police officer to offer my help. He immediately pulls the gate aside and allows me through. I arrive at the same time as the team, explain who I am, and they gratefully welcome an extra pair of hands.  

The normal frenzied actions of a full resuscitation attempt are underway, but there is an acute awareness of the moment. Instructions are whispered, actions carried out in silence, even the ambulance arrives with blue lights flashing but the siren mute. The only loud instructions come from the defibrillator, as it advises to all who care to hear "Shock advised! Stand clear!" The orange button lights up and I press the button, wishing that there was another button to be pressed that would silence the instructions too. 

I never found out my patient's name, and the last I saw of him was in the back of the ambulance as he was taken to hospital, his chances of survival in single percentage figures. 

Against the odds, a few months later I found out through the grapevine that he had survived, and at the following year's parade, my grandfather pointed him out as he stood proudly alongside his comrades once more. 

Over a decade has passed since that day. Since then, I have left London, moved countries, and started on a new EMS path with a new organisation. The system may be different, but the patients are the same. They call when they are at a loss for any other options, sometimes they really need us, sometimes they just don't know where else to turn and hope for someone to share the burden and hopefully offload it.

Outside of work, we have made our home in a welcoming community, have made new friends as well as reconnecting with friends from days of yore, have moved nearer to some family whilst leaving others further away than ever. The number of expats is also fairly large, and so there are frequent visitors from overseas. Yesterday, I was introduced to one of the visitors, a friend's mother.

"Oh, so you're the paramedic?"

I'm not sure why I still find that question a little ominous.

"That's me."

"Did my son ever tell you about our story with ambulances?"

"Don't think so!"

"Well, about ten or eleven years ago, my dad was on a Remembrance Day parade and collapsed. St John Ambulance were there, they started doing CPR and they got his heart started again, and..."

I finished the sentence for her.

"And he was on parade the following year."

We both stopped in our tracks; the coincidence incomprehensible. She went on to tell me that her father lived another seven years after that day, long enough to meet his great-grandchildren, to see how the family continued to grow.

It is an occupational hazard, the knowledge that we almost never find out what happens to our patients once they are conveyed to hospital. But every so often, even if it takes a decade, we hear of remarkable stories such as this one.

My first successful resuscitation was on a gentleman whose grandson, years later, became my friend.

Code STEMI

At eighteen, I was the sort of squeamish person that everyone laughed at, as I'd feel faint at the mere smell of alcohol gel at the entrance to a hospital of doctor's surgery. The mere thought of visiting someone in hospital would give me a cold shiver down my spine. The threat of a needle would be enough to tip me over the edge into hysteria. Just a few years later, I joined the world of EMS. I guess you could say I got over my squeamishness. Although I still hate anything to do with teeth, dentists or anything in between. Don't get me wrong, some of my best friends are dentists. But only when I meet them outside of a quarter-mile radius of any dental surgery. 

The London Ambulance Service was my introduction into a world that I could never imagine, and my chance to discover that being squeamish is much the same as any other fear - the best way to overcome it is to face it head on. 

At first, as an EMT, I performed my duties almost by rote. Unthinking actions, following the script that had been drilled into my head throughout the initial weeks of training. But then, after a short while, as my confidence grew, I wanted to actually treat people, not just patients. I wanted to understand more about what I was doing and why I was doing it. And through this, despite the somewhat morbid attraction that many in the world of EMS have to trauma, I grew to love the heart just as much. I would sit and look at ECGs (replace C with K depending on which part of the world you happen to be in), try to delve into their mysteries and unravel the secrets that they held within the squiggly lines. 

Cardiac patients fascinated me. Within a short time of me joining the LAS, a new system was introduced for patients experiencing a heart attack, or STEMI. These patients would be diagnosed by the ambulance crew as having an acute STEMI and immediately conveyed to a cardiac unit for angiogram and angioplasty if required. Many patients have benefited from this life saving procedure, thanks not only to the skill of the doctors in the hospital, but to the skill of EMS providers in the field. More than once, having delivered a STEMI patient into the hands of the cardiac teams, we would stay to watch the procedure itself and get to see how the squiggly lines translated back and forth into what was happening on the inside. 

London became one of the pioneers in the field, leading the way in training all its staff to analyse ECGs and recognise the immediacy of the STEMI. It was exciting to be a part of something innovative and that was proving a great success. 

Recently, a team of paramedics and film-makers joined up, headed across the Atlantic from the USA to London, and joined crews there to see it all in action and share it with the world. Ted Setla and Tom Bouthillet put together a series of short films, taking in EMS systems around the world, with the London Ambulance Service - "The busiest EMS system in the world" - taking pride of place. 

CodeSTEMI (a hashtag with this name is also used on Twitter) is well worth the watch. In just under half an hour, the viewer is introduced into the world of the ambulance service and invited into the lives of people who have survived a threat that just over a decade ago would have meant  a much higher likelihood of death. It concentrates on the patients, on the crews and on the system that has helped raise the chances of survival of a cardiac arrest from single-figure percentages to somewhere over 30 percent in just a few years. 

The film doesn't sugar-coat reality, but it does show the human side of EMS, from the viewpoints of both patient and provider. And in these days where everything seems to depend on what can be done to bring down costs, whatever the cost, it's refreshing to see how people with a passion can still help to make a difference. 

It's been a year, almost to the day, since my last shift with the LAS. I'm proud to have them on my resumé, and smile when I look back, even as I'm still looking forward. It'll be strange to be the new-boy again when I finally wade through the sea of red-tape that is gradually running out (I hope), but at least this time I'll be able to do it with a decade's worth of experience. 

And I'll have all the inspiration I need by just looking back over my shoulder. 

The Story So Far (Or, how to keep the bank manager in suspense)

It’s been a little quiet round these here parts. I mean the blog, not Israel. Below, I explain a little as to why this has been the case. This isn’t really my normal blogging style, it’s just a chance to vent a little, so feel free to skip this one if you so desire. I promise to not be offended.

To say that the last few months have been an education is somewhat of an understatement. Almost ten months since I stopped working in London, I seem to still be some way off from getting my paramedic qualification recognised here. The key word, as you may have gathered either from previous posts or from twitter, is bureaucracy.

Even prior to our arrival, I’d made contact with the right people, presented documents, certificates, qualifications and all manner of related material, and was promptly promised that after a short conversion course of sorts, that I’d be a fully qualified paramedic. There are, like many other places around the world, many roles for a paramedic in Israel, within multiple different organisations and healthcare providers. However, the issue of paramedic qualification belongs to only one – the original (and still main) Israeli ambulance service – Magen David Adom (MDA) – a subsidiary of the International Red Cross. As an organisation, MDA has a pretty good reputation around the world. Many an ambulance service has come to study its mass-casualty treatment system and they lead the way in some of the treatments they provide. Yet at the same time, I'm discovering that it is overly burdened with tape the same colour as its well-known emblem. And I thought that London was bad.

I’m a little wary of accusing anyone of lying, but I think that the phrase “terminological inexactitudes” is a fair one. The information I provided wasn’t passed on. Claims (false or misinformed remains to be determined) were made that they had never had a paramedic who had qualified overseas want to move here, nor that there was even a protocol in place for such an eventuality. The relevant authorities weren’t informed. When they were eventually informed, there was another delay when the head of the right department seemed to leave under something of a cloud. Nothing to do with me, I hasten to add.

Then the plan changed a little and was to become a two-pronged attack on the system. Whilst I was waiting for the right courses and exams to come up that would eventually give me my paramedic license, I’d also work through the other side of the system to be recognised as an EMT and ambulance driver. Unlike the UK, not all road staff need to be able, or required, to drive the ambulances here. The idea was that the driving element should be easier and quicker to complete, the EMT certificate more of a formality, thereby giving me employment, at least as an EMT.

Plans are often foiled, sometimes by man, sometimes by machine. Sometimes the two combine to make life as difficult as possible. It’s meant that whilst I’ve been able to volunteer on the ambulances, I still have no actual employment. Other jobs that I’ve gone to look at, even temporary ones, both related and unrelated in any way to the medical world, have been kiboshed by the fact that someone, somewhere would tell me that there’s no point, as the bureaucracy will be sorted within a matter of days. There are three people particularly upset by this situation. The wife and I are the obvious two. The third is our bank manager.

There have been moments where I have thought about giving up altogether. That the effort I’ve been putting in and the hardship my family is enduring is just not worth the final outcome, assuming we even get there. I have sat through courses, taken exams (one of which, thanks mostly to my own stupidity, but partially to the ambiguity of multiple choice questions, I have to retake next week) and pushed on through the reams of paperwork, often feeling that it is a never-ending cycle leading me to nowhere and back again.

Then I’ll look back at the last decade, think back to the hundreds of shifts both in London and the few that I have here, and remember what it’s all about. What it is that I love about this job, which is so much more than just a job. Think back to the patients where I know I made a difference, or where they made a difference to me. Think back to the simple patients who only wanted someone with whom to talk. Think back to the patients who left no mark on my life, but who years later still remembered the difference we made to theirs, and who took the time and made the effort to come back and tell us so.

I know that I want to continue doing it. I know that I can’t throw it all away. I know, that if only they’d let me finally do it, that I still have so much to give. To give to my patients, to my colleagues, to myself. But for each step forwards, there seems to be at least one step back. Sometimes two. To say that it’s been frustrating is yet another one of those understatements. I have known for a very long time that Israeli bureaucracy is a menace that each person has to fight at one time or another. It’s frustrating that I have the skills and the knowledge, not to mention the experience, just sitting at home and waiting. It was frustrating during the recent war that I’d hear reports of volunteer paramedics arriving from overseas whilst I wasn’t allowed to join them despite sitting on the doorstep.

I am determined to beat the system, even if that then means I become a part of the very same. Perhaps once there, I can do something to prevent the next person crazy enough to want to do the same, from having to go through this chaos. In the meantime, I’m waiting for this chaos to end, just so that I can go and face chaos of another sort altogether; one that I can hopefully do something to treat.

And hopefully make my bank manager a little happier, too. 

Be Smart?

Two calendars run side-by-side in Israel; one religious, one civil. It means that we celebrate New Year twice a year, just to confuse everyone, including ourselves. The change of year on the civil calendar is still marked, celebrated by many just as it is in many parts of the world, although according to a press release issued by Magen David Adom, the national ambulance service, they were called to only fifty (yes, you read that right) alcohol related incidents on New Year's Eve nationwide. The Israeli population roughly numbers around the same as London, so this is a figure that the LAS could only ever dream of; they were averaging some 400 calls per hour for the first few hours of 2013. Admittedly, not all of them were alcohol related, but I can be fairly certain that a large proportion were. 

The end of the civil year also brings with it various annually-published reports, one of which being the traffic fatality report. The headline is nothing less than staggering: 2012 saw the lowest road-traffic fatality rate in half a century and on top of that, the rate is down 25% on the previous year's figures and some 40% lower than 2005. The UK could only hope for such a drastic change. In fact, the figures from 2010 to 2011 actually climbed by 3%, rather than reduced. It is a truly astonishing figure, but the question has to be raised as to how this has happened. 

As a driver on Israel's roads, I still see the shocking driving for which Israel is infamous. Drivers see keeping a distance from the vehicle in front as a mere nicety, perhaps a minor recommendation, rather than a safety measure; lane discipline is non-existent; indicators appear to be optional extras on most vehicles and road-rage is commonplace. We live in a high-paced, high-energy, live-for-the-moment country, where allowing another driver to overtake is seen as weakness and where allowing another car to slot into your lane makes you appear like a pushover. 

Other figures released today show that police have issued 40% fewer tickets for driving violations in the past year, down to 600,000 from over one million. They have concentrated less on minor offences (although the report does not specify what those are) and more on notorious roads, as well as "life-threatening misdemeanors", including dangerous overtaking, running red lights or stop signs, ignoring pedestrian crossings and, in particular, drink-driving. The police can, and do, when dealing with a driver who breaks one of these so-called "life-threatening" laws, revoke a driver's licence on the spot for up to 30 days. They can also impound their vehicle for the same length of time. 

It all sounds like a plan is coming together. 

However, what the reports barely mention is the number of seriously injured. These numbers still seem to be high, and depending on which report one reads, the numbers may still be climbing. The ambulance services here are becoming increasingly skilled at managing severe trauma patients. The times taken to get to definitive care in hospital is decreasing and the treatment options increasing. Tranexamic acid, a drug commonly used in hospital for surgery associated with a high risk of bleeding, has recently been introduced to front-line crews as a pre-hospital treatment and is having, at least according to initial reports, a serious impact on survival figures. 

All these facts and figures are optimistic, but also leave a little confusion in their wake. Clearly, better infrastructure, more intelligent and robust policing, better skilled pre-hospital providers and the obvious ever-improving safety features of the vehicles themselves are helping to save lives. This is a trend that we can only hope will continue to improve. But the fact that the accident rate is still high, that there are still so many seriously injured, is still a cause for concern. 

The human element is one of the toughest to regulate. Emotion will always play a part in a driving, particularly in light of the descriptions of the Israeli driver that I have already mentioned. Actual attitudes need changing too, but that is hard to do when confronted with a seasoned driver who has years of driving experience and picking up of bad habits. Change needs to begin from the ground up, even before a 17-year-old is allowed to start to hold a steering wheel in their hand. It needs to start with the basics, for example teaching that riding a motorbike whilst wearing almost no protective gear is a path to almost certain disaster. 

Attitudes to alcohol need to change. No more the thought process of one drink will be ok. You want to drive? Don't drink. 

Attitudes to other drivers need to change. Understanding that allowing one driver in ahead of you will not only benefit them, but will help the roads run smoother and reduce the aggression on the roads. 

Attitudes to seat belts and appropriate child restraints must change too. Particularly in certain sectors of society. 

It may take another generation, perhaps less, perhaps more, but if we want to reduce fatalities even further, we need the drivers themselves to cooperate. To understand that sometimes there really is a greater, even if unseen, good. 

Years ago, there was an advertising campaign here that promoted the following philosophy: 

"Don't just be right, be smart." 

A combination of the two would be even better. 

As the clock strikes 12...

A post by a friend on facebook has started a discussion. Where have you been when the clock struck midnight on New Year's Eve? As members of the emergency services, of whichever variety, the options are endless, and have so far included a padded cell whilst covered in all manner of unpleasantness. Mine have ranged from being mid-resuscitation of a pedestrian hit by a drunk driver, to the far more sedate call of assisting an octogenarian off the floor just in time for him to celebrate with his traditional glass of sherry. 

So, as we head into the new year, and as many of you will be out there protecting and serving the public, let's start the party early: 

Where is the strangest, funniest, weirdest, scariest or any-other-est place that you have been as Cinderella turned back into a pumpkin after attending her New Year's Eve ball? Or something. 

To all of you, whether you're going out with friends or having a quiet time at home, whether partying or protecting, and especially if you happen to be able to manage both at once, stay safe and have a good one! 

The View from the Back Row of the Classroom

Over the past few weeks, I've gone back to school. I've been sitting in the classroom listening to lectures I've heard before, albeit in a different language, surrounded by a group of paramedic students who are just about ready to be unleashed on an unsuspecting but hopefully grateful public. The vast majority of the students are about to start their lives as combat medics which has made for some interesting scenarios, but one or two are heading for civilian roles. And then, there's me. I've sat at the back of the room that is fit to burst, writing bilingual, multi-directional notes, taken a few exams and hopefully come out the other side unscathed and ready for the front line once more. 

It's been a bit of a struggle to get my paramedic licence recognised and accepted here, and has involved two steps backwards of bureaucracy for every one step forward in actual physical achievement. It's been frustrating. I've been on the ambulances, but in a limited capacity. My paramedic skills have been safely tucked away until the piece of paper that I need is finally spat out of the machine, hopefully sometime very soon. 

I don't mind jumping through the relevant hoops. I don't mind sitting in classes I've heard before, because the reminders that they're providing are more than useful. It has been, however, somewhat disheartening that it has taken this long to make the progress that I'm finally making. 

Yet, as always, there is a silver lining to the cloud. Going back to school has given me the opportunity to see another generation of people who are already loving their chosen path. There are those who are looking far into their futures, planning to change the world, or at least their little part of it. There are those who are talking about being a part of something bigger, part of an EMS world that is looking to expand, to improve, to change, to evolve into something better than it already is. I've had the chance to introduce some of these students to forums, to various forms of social media, to blogs, to ideas, to people, at least virtually, who share their vision. 

(In the meantime, I have another day in the classroom tomorrow, and a rather daunting exam, the equivalent of the end of the paramedic course, on Tuesday. No public holiday here. So those of you celebrating Christmas, spare a thought and send some positive vibes just before you tuck into your turkey and mulled wine.)

From my seat at the back of the class, the future is looking good. Hopefully, once I've defeated the monster that is bureaucracy I'm embedded a little more in the system, I'll be able to be a part of that future. I might even tell them that I know the person who writes this blog... 

Rules for EMS

I have, unashamedly, stolen this list verbatim (with permission, I hasten to add). I haven't changed a word, or the order in which these rules appear, although I think that number 18 should be much nearer number 1, if not the top one itself. Rule number 38 I'd consider removing. Scene time is dictated by the scene, not by the rule book. Expediency is important; rushing, isn't. Many of these rules are not just for EMS, so even if you're looking in from the outside, take a moment. Oh, and I have no idea what the last one is trying to say. If someone wishes to enlighten me, feel free! 

(To my UK readers, this was obviously stolen from someone US-based. I haven't corrected fixed changed the spelling.) 

So, EMS providers, which would you remove, which would you change, and what would you add? I have also noticed that social media doesn't make any sort of appearance. That should probably change! 

And as potential patients (although I wish this on no-one), what would you do with this list. The floor, as they say in the classics, is yours! 

1. You are there to solve a problem, not cause one. 

2. The ABCs will save you every time.

3. The scene is not the venue for retraining. 

4. Interview the patient, not the clipboard.

5. The patient should not be the recipient of your problems.

6. Treat the patient to the best of your ability.

7. We are guests in their domain.
8. Look for reasons to transport, not turf.

9. Do not base treatments on lifestyles.

10. Expect no more from others than you can provide.

11. Handle the call you are on, not the one that might happen.

12. The acuity of the situation is due to the patient’s condition, not your anxiety.

13. We do not interrogate over the radio.

14. We do not yell at the family or patient; we explain the problem.

15. Being nice never hurt anyone or cost money.

16. Do not judge lifestyles.

17. A clean ambulance is a happy ambulance.

18. Obey your gut instinct.

19. Being nice does not indicate that you are weak or naïve.

20. Leave tunnel vision for the Amtrak folks.

21. 35 mph is good for patient care.

22. The closest hospital is not always true.

23. Document truthfully; you never know.

24. Know your equipment.

25. Continue to study; dormant minds make Jell-O look smart.

26. Show me what you know, don’t tell me.

27. Level of certification does not guarantee respect.

28. Talk to the patient first, then everyone else—when possible.

29. If nothing else, do the ABCs, treat the problem, use TLC, keep the patient warm, transport.

30. Trouble breathing equals lung sounds.

31. Regardless of whether you are a career or volunteer provider, you are there to do the “JOB.”

32. It takes less energy to be pleasant; anger festers for the whole shift.

33. Each call is a new one.

34. If they can take a tube, they needed one.

35. Be nice to yourself; you have to start somewhere.

36. Scene survey, ABCs, pick a game plan, make a decision.

37. Have people doing things.

38. Ten-minute scene times are a good thing.

39. Certification cards x patches = ????

Sandy Hook

Rivers of ink have raged, almost as the rivers of blood that flowed all too freely have now stilled. I don't know when is, or even if there is, a right time to wade in to a discussion on a tragedy as raw as that of Sandy Hook School, where those killed are only now being buried, where their families have not even begun to really grieve. Parents of children are being forced to come to terms with a reality that none of us should ever have to face. Families of adults who died protecting the innocent battle with conflicting emotions; pride in the bravery displayed by their loved ones fighting for space in amongst the utter sadness at their deaths. 

And in the midst of it all, the all-too-familiar rhetoric begins. Pro-gun versus anti-gun is too simplistic. It's like saying that there are those who wish to live in a constant state of war against an enemy and those who want peace with the very same. In reality, everyone wants peace. It's just a question of how to get to that state. Rhetoric alone will not answer the questions that will race around the minds of a nation, particularly a nation in mourning. 

I have only questions, no answers, but feel the need to raise them here, if only as an outlet. I struggle to understand why this happens. Why it happens in America. Why is it that I live in a country where guns are a part of the daily view, yet we have mercifully been spared the awful scenes that have now been shown all over the world. 

I am torn. Torn between believing that weapons should be available so that it is not only the criminals and terrorists who possess them, and believing that they should be almost impossible to come by. Several times in the past, terrorist incidents in Israel have been halted by a passer-by who happened to be there and happened to be armed. Right place, right time. On the other hand, the readily available weapons allow for easier access to those who would use them to harm the innocent. 

However, one cannot walk into a gun shop here and buy an assault rifle "off-the-rack." The number of civilians carrying weapons is actually surprisingly low. Assault rifles are seen in the streets, but they are carried either by members of the armed forces or by members of response teams in the more volatile parts of the land. They can't just be stored at home as yet another item on a list of fixtures and fittings. Licenses are hard to come by and are enforced by strict regulation.

Arguments will appear on every media outlet, on social media, in conversations between neighbours and friends. Both sides will voice their opinion, all too often based on that cyclical rhetoric, bandied about by populace and politician alike. Slogans don't solve the problem, they just accentuate and polarise it. They certainly do not reunite grieving families with those that they have lost. Falling back on rights is as helpful as quoting often irrelevant statistics. It is, however, clear that something has to change, probably on both sides of the great gun divide. 

I don't have the answers. I may not even be in a position to ask the questions. I do know one thing for sure. I never want to see these scenes again. Not as a parent, not as a news reader, and not as a paramedic. Not on my own doorstep, nor on anybody else's. 

Yet another community will have to rebuild itself, brick-by-brick, one family at a time, united in grief for now, but hopefully in strength in the future. And all the while, the answers must be found to prevent anyone else from facing yet another unspeakable tragedy. 

Fail

All the way back in May (I could turn this into a poem now, but I shan't. I can already hear your sighs of relief) I posted a series of three posts, each suggesting ideas that I would recommend to paramedics new and old, but particularly new. The first, which I suppose is much more London-specific, was to join the BETS team, the second was about learning to read maps and not rely on GPS, and the third was about not only learning, but teaching. 

This is the fourth of my suggested ideas. 

Yesterday, I had to take yet another driving test. It was my tenth driving test. Considering I have never failed a test, it's a little confusing, but still, experience is always invaluable. The driving test involved three hopeful applicants, one driving examiner, and a specially modified ambulance with dual controls. 

You'll be pleased to know that I passed. We each took it in turns, and just like the other two, I had my 20, perhaps 25 minutes where I drove around the busy streets of one of the towns in central Israel, avoided the obstacles, navigated the narrow streets, slowed down for the speed bumps, stopped at red traffic lights, managed not to hit any pedestrians (apparently that's fairly frowned upon, as we were reminded at the start of the test) and talked to the examiner about life as a paramedic in London. It all seemed too easy and for the hour we had to wait between the test and calling back for the results, I fretted a little. 

Although, to be honest, I was more concerned for one of the others. 

No one seemed to tell her that equally as important as not hitting pedestrians, particularly on your ambulance driving test, is not driving on the wrong side of the road. 

Abandoned

I know, I've abandoned you. I'd even abandoned twitter for a few days. Well, at least one of my accounts, anyway.

We've had a hairy few days in Israel (he says, somewhat underplaying it), and whilst this is not the forum for political comment, I just thought I'd let those of you who care (and I know there are some - your messages have been truly appreciated!) know that we're OK. We've been within sight and sound of some missile hits, but luckily no worse. In the meantime, my writing efforts have been spent elsewhere and my so-called spare time has been taken up making sure that my family and friends aren't panicking too much. Particularly the ones who are too far away to go through it with us.

Life in this country is never dull; I had never, for example, had to run an air-raid siren drill with my kids; and whilst we're still technically at war, I am today heading for yet another ambulance driving test, so I can stay on the side of the life-savers.

Hopefully, some normality will return soon.

Stay safe.

Poppy Day

For the last couple of years, around the time of Remembrance Day, I write a post to mark the occasion. Last year was a story about stories. The year before that, I linked to a story, a single, solitary moment in the life of a soldier. One of my favourite posts to date, even if not the most popular.

This year, I apologise, but I want to raise a point that bothers me. 

Despite being thousands of miles now from the UK, we can still watch British television programmes. For the past few weeks, TV hosts, guests, audiences, even bit-part players in so-called reality or talent shows, have appeared with a poppy attached to their clothing. Anyone likely to appear in-shot is also given one to wear. I know for a fact that most of them do not buy the poppies, but are just presented with them in order to ensure that they appear suitably attired.

To my mind, this not only belittles the poppy, but also defeats at least half of its purpose.

The poppy is worn as a reminder. A reminder of those who fell in battle, those who never grew old, those who never returned home to their loved ones. But it is also a fundraiser. Selling poppies is by far the largest revenue generator for the Royal British Legion, a charity that supports those still serving, the ones who came home injured, as well as the families of those who never came home at all. 

Seeing sparkly, show-biz poppies doesn't achieve the desired effect, in fact, it misses the point completely. The poppy isn't a piece of jewelry, it isn't a fashion accessory, it isn't a part of a costume. The poppy is a mark of respect, a symbol of hope as well as remembrance. 

Tomorrow, as many millions around the world pause to reflect and remember at the eleventh hour of the eleventh day of the eleventh month, I will join them. I will wear a poppy. Not because I've been told to do it, or because it looks good on what I'm wearing, but as a simple symbol of respect to those who have served as well as those who continue to do 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.

Unsung Heroes

Heroism is a term bandied about all too lightly. Teenagers describe the latest pop-sensation as their hero. Sports fans describe the latest world-class footballer, baseball-player or sprinter as their hero. And every so often, a short note in the media, or a new internet-based meme will try to portray unlikely people as heroes, including paramedics, nurses and other medical staff. 

Whilst I agree that all are undervalued, the stretch to the point of heroism is a little bit far-fetched. I've written about it before. The fact that EMS finds itself at the bottom of the heap of the medical world is unfortunate and not a little unfair. Yesterday, I saw a tweet that described it thus: "Whether EMS is part of the health system, or public services, it seems as though we will always be treated as the red-headed step-child." From my experience and understanding, through either virtual or actual meetings with EMS providers around the world, the feeling is mutual across the globe. And this is coming from a (albeit balding) red-head. 

Still, I feel that to reach the point of hero-worship, as some seem to feel should be the case, cheapens the meaning of the word as well as the act of heroism. 

Overnight, as the fury of Hurricane Sandy hit the eastern shores of the United States, a hospital in New York City had to be evacuated after both its regular and emergency supplies of electricity were cut off. According to reports, 215 patients, from the youngest to the oldest and in all manner of medical conditions, had to be moved to other hospitals. 

Staff ventilated patients manually, keeping them alive. They changed mains-powered machines to battery-powered back-ups. They climbed down and up flights of stairs to the ninth floor to rescue the tiniest of neonates, as brittle and dependent as it is possible for a human life to be. 

Ambulance crews braved the weather conditions and risked their lives in a manner which the rest of the population had been ordered to avoid. Not just advised - ordered. 

That, to me, is heroism. It isn't the constant calls, it isn't even the life-saving calls. That doesn't make paramedics into heroes; it makes them damn good at their jobs, as they should be. It's the paramedic who, despite everything he has learnt, despite the awareness of the risks he is taking, jumps into a dangerous scene because he knows he can make a difference. It's the hospital staff who, when faced with the most serious possible crisis, don't walk away, but run towards it, armed with knowledge, skills, awareness and, no doubt, no small amount of fear. 

It's occasions like these that show the world the reality, the true meaning of heroism. 

I certainly didn't see any footballers or pop-stars there. 

Stay safe. 

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. 

Drunk-Drivers United

Once again, the morning's UK news included a headline about a top-flight football player being caught drink driving. Ryan Tunnicliffe, who plays for Manchester United, was arrested after a crash on Saturday afternoon involving his Range Rover. In a momentary rage, I tweeted something about footballers having big money, big cars and small brains. Then, I remembered that this is not the first time that a story such as this had broken recently. 

So I dug into the archives. Or, if you prefer, Google. 

September - Guly Du Prado, who plays for Southampton. Charged with and admitted drink driving. Given a small fine and a short driving ban. 

June - Michael Johnson of Manchester City. Arrested on suspicion of drink driving. Convicted in September and given a slightly larger fine and a three-year driving ban. 

April - Jermaine Pennant, a Stoke City player. Handed a suspended sentence and a derisory fine, as well as a three year ban. 

January - Reading FC player Mathieu Manset, fined and banned after failing an initial and then refusing to be retested. 

Four footballers, guilty as charged, all this year. And those are after only a preliminary and brief search. That, along with the controversy surrounding Luke McCormick who killed two children in 2008 whilst driving drunk and recently released from jail, is a fairly damning indictment of the individuals themselves, but also, in my opinion, of the FA itself. The governing body of footballers in the UK have had some real problems on their hands recently - allegations of racism on the pitch as well as off it, in amongst them. 

However, the issue of drink driving doesn't seem to make headlines within the organisation. It isn't a new issue. Finding four in just this year doesn't even begin to look back at the long, miserable association that football in the UK has had with alcohol.

Perhaps it's time that the FA looked deep into its soul, assuming it has one hidden somewhere near its bank accounts, and asked itself what exactly is it giving these footballers that they can't handle.

Perhaps the courts need to realise that fining a player the equivalent of a couple of hours' pay isn't enough of a threat. 

Perhaps the police, the courts and the FA need to team up to deal with what is a very public problem, even if it is committed by private individuals. 

Whether they like it or not, and I presume they do, these individuals spend a lot of time in the public eye. That gives them extra responsibility, an extra burden on their shoulders. One that, I hope, their incredulous salaries helps to lighten the load. I don't begrudge them their salaries. If that's the going rate for a top-class player in their field, then good luck to them. 

Am I jealous? Maybe. I'd love not to have to juggle my priorities at the end of each month, worrying about whether I rob Peter to pay Paul or vice versa. But as well as being jealous, I'm not stupid. It's a simple rule, whether you're a multi-millionaire footballer or a struggling paramedic:

Drinking and driving do not mix. 

As a paramedic, if I was caught drink driving, my career would be over. And rightly so. 

I wonder how many of these all-entitled footballers would continue to act this way, if their career was also under the very same threat? 

Grandpa

A football appears suddenly in the street, flying out from between rows of parked cars, packed tightly in the premium spaces. The houses in this area have driveways the size of small streets, but still, cars are parked along the roads. Commuters perhaps, using the rare free parking to abandon their cars and walk the relatively short distance to the nearest station. 

The chance of a child following that ball are high so I hit the brakes and stop the car. I'd rather have one patient waiting a little longer than have to deal with an extra patient and spend a lifetime asking what-ifs. The ball stops in the middle of road, dancing a jig with the centre-line, playing a game of indecision.  Seconds pass, but no child appears; no-one seems to want to retrieve the lost ball. It's an unusual one too: Pink. I'm sure someone is interested in getting it back, but time being of the essence, I get out of the car, move the ball to the pavement and head back on route to the call which is on the parallel street. 

I pull up to the gates, large, ornate and ostentatious, push the button on the intercom and wait. After a few seconds, the gates swing open like a pair of open arms, welcoming anyone who is granted access. The driveway is smoothly paved, as though it had only been tarmacked today and is lined on both sides by pristine grass that looks as though each blade has been measured with a ruler to ensure that they are all of the exact same height. 

The door, an immense work of art designed to impress as well as intimidate, is opened by a member of staff, perhaps a butler. Stepping in to the house is an exercise in wonder and envy. Every surface is polished, marble floors are scrubbed to perfection. A spotless kitchen the likes of which couldn't even enter my wildest dreams is just within view. 

"This way please." 

He leads me down the corridor, past several reception rooms and to the back door of the house. It's inconsistent with everything else around. Just a simple, double glazed door leading from a corridor to the back garden, but as soon as it's opened, the grandeur returns. There's barely time to take it all in, the huge garden, the beautifully tended hedges and other plants. In the middle of it all there's a young girl lying on the grass quietly crying. 

Honey is six years old and as sweet as her name suggests. She's upset but not hysterical and is being comforted by her grandfather. He, in turn, is holding a wet tea-towel to her head. A crimson mark is starting to appear through the fabric. 

"Can I have a look, just to see what you've done?" 

Honey nods and I gently remove the towel. There's an open wound on her forehead that will need gluing or stitching back together and a quick check shows that there are no other injuries. She lets me bandage the wound without even the hint of a fuss. 

"It doesn't hurt me now," she says. "Grandpa told me that I was being brave. Am I really brave?" 

"You're braver than me! I bet I'd be crying a lot more than you if I got a bump like that on my head!"

"I'm not crying because I bumped my head. I told you. It doesn't really hurt me now." 

"Oh, really? So why are you crying?" 

"I was playing with Grandpa and we were throwing my favourite ball. Then Grandpa kicked it and it went over the wall and into the street!" 

Grandpa looked sheepish. 

"I'm sorry sweetheart! I promise we'll get you another one as soon as they've made your head better." 

"You promise?" 

"I promise. If the shops are still open when we're done, we'll go together." 

"OK. Let's go!" 

Honey jumped off the grass as if nothing was wrong and, with me having cancelled the ambulance, we headed for the car. It was only a mile to the hospital, ambulances were scarce as always, Grandpa was happy to take a booster seat with him and Honey was thrilled at the adventure. 

We walked into paediatrics and waited for a nurse to take a handover. Honey kept asking questions about what was going to happen, who the people in the department were, and if it was going to hurt when they fixed her head.

"Sometimes, it's like the Spanish Inquisition with that one!" Grandpa joked. "Always asking questions, always wanting to know more." 

"Guess she's a healthy six year old then," I said. 

"True, I suppose. Is it going to take long?" 

"I've no idea I'm afraid, but it doesn't look too busy." 

"Good." 

We stood in silence for some time, Honey taking in her new, temporary surroundings with Grandpa holding her hand. 

"Actually," Grandpa suddenly started, his voice quieter than before, "I've got one more question for you too." 

"Ask away." 

"Where on earth am I supposed to buy a pink football?"