Something

Last night I met one of the HEMS team that was on a recent call I attended.

The one where I performed my first needle-thoracocentesis.

It kept the lungs breathing.

It kept the heart pumping.

It kept the patient alive.

I knew at the time that the patient's chances of survival were very slim.

At last night's chance meeting my fears were confirmed.

The patient died about two days later.

Stabbing them in the chest didn't save their life.

But it did give the family the chance to come and say a final farewell.

And I guess that's something.

Cutbacks

Cuts need to be made. We knew they were coming. The NHS, like all other government departments, is facing some major changes to help it through these financially unstable times. Ambulance Driver is using this piece of news to the tunes of "I told you so" in reference to the changes being proposed over in the States - the so-called "ObamaCare".

So whilst over the other side of the pond they're trying to change public health care to be a little more like the UK, we over here are travelling in the opposite direction. Surely there must be some sort of middle ground, although I'm not sure where it is. A socialist health system in a capitalist society are always going to clash.

I don't profess, or pretend for that matter, to understand all the ins and outs of the NHS, but I do know a little about the very tiny corner of it that I occupy. The NHS, to a certain degree, has been a victim of its own success.

People live longer, healthier lives. That costs money.

Chronic conditions are better treated than ever before. Sometimes they are cured, other times merely managed long-term. That costs money.

Some prescriptions, at least in England and Wales, have a minimum charge. The rest of the cost is covered by the state. That costs money.

Trauma victims have a better chance of survival. Then they need rehab. That costs money.

Operations cost money.

Drugs cost money.

Staffing the NHS costs money.

Everything costs money. And slowly but surely, we're running out of it. The promise that there would be no front line cutbacks is proving to be another of the broken promises that has become the norm for any political party seeking to seize or retain power at general elections.

Read that linked article at the top, and have a glance through the threatened cuts. One in particular caught my eye. The one that has most relevance to my little corner. They want to reduce the number of people using Accident and Emergency departments, whether through GP referrals, or at a guess, also by self-admission. Only having the newspaper article to go on, I can't be certain what that means for the ambulance world. I'd love there to have been something in there about reducing the number of inappropriate ambulance calls.

Sometimes, to save money, like the NHS needs to, there's a need to spend some money. Money spent on education, for starters.

Education on when to use the NHS. Can you manage your symptoms at home? Does your child really need to go to the doctor? Do you really need to go to A&E at 3am for something that has been bugging you for a fortnight?

Education on how to use the NHS. How do you access the most appropriate care? How do you ensure that you get the follow up you need? How do you call an ambulance, and what for?

As ambulance staff, we are front-line providers. And also have the chance to be front-line advisors and educators. But to do this effectively, we need back up. From the state, from our employers, from the system. Even from our colleagues. There are too many who opt either for one extreme or the other.

Too many who turn up to calls that are a totally inappropriate use of the NHS in general and the ambulance service in particular, and yet do nothing but transport to A&E. It's an opportunity missed.

Then there are too many who get so angry about that same call, that all they do is rant and rave at the patient. The chances of said patient paying attention to a telling off are slim to none.

We trialled a system of not sending ambulances, but unless the pressure on the ambulance service is so severe that it is on the verge, or possibly past the point of collapse, it's not utilised. So for now, we need to take it down one level, and give that responsibility to the crews on scene. If only we could devise a system where we can legally refuse to transport someone to A&E, and at the same time use our skills and knowledge to educate them about all the things I've mentioned. As things stand, we're not allowed to refuse to send an ambulance, and we're not allowed to refuse to convey to A&E. And that's money we could be saving.

Instead of employing managers at astronomical salaries who are paid for nothing more than concentrating on fictitious targets, spend that money on educating both the public and the front-line staff. There seems to be a culture shift in the ambulance service at the moment of taking decision-making and skills away from the staff, leaving those decisions to faceless, albeit trained, phone operators. There seems to be a train of thought that cost-cutting can only be done by employing lower grade staff for the front-line on lower wages, whilst maintaining staff on high wages just to hold clip boards and tick boxes.

Cost cutting within the NHS has to be brutal, but it has to be honest too.

It cannot be that the top few percent hold on to their precious jobs, whether necessary or not, whilst those at the coal-face have their jobs threatened.

It cannot be that those who most rely on the NHS, bear the full brunt of its savings.

At the same time, the general population must accept that they need to help the system, if they still want the system to be there to help them.

Fiancé

On the steps of the town hall she sits, staring out at the world, looking for something she knows, someone she recognises. The stairs look familiar, but in an unfamiliar world. The pigeons crowd around her, hoping for food, but she harbours nothing but good intentions and lost thoughts.

"Hello! What's your name?"

"Marjorie."

"What are you doing here? You waiting for someone?"

"I'm just having a rest. My legs seem to be tired today. My fiancé should be here somewhere."

The word 'fiancé' catches us off guard. Marjorie must be at least eighty years old.

"Where do you live?"

"Only up the road. Not far at all. I just couldn't seem to make it today."

As we stand there, he turns up, his lungs out of breath and face full of panic.

"Marje! What are you doing here?"

The sound of her own name startles her, and she shies away a little.

"Just having a rest for a few minutes, waiting for my fiancé." The words hit him hard.

"Your fiancé? But we've been married for nearly 50 years!"

We watch through his eyes how his heart breaks, and he explains. He tells of Marjorie's dementia, how she sometimes forgets where she is, where she's going, what she's doing.

But she's never forgotten who he is.

We check to make sure she's not had a fall, we talk to witnesses, to the person who called for the ambulance. Physically she's fine, but lost in a haze of time and memories that she can't quite fit together. She's comforted, reassured, and slowly accepts a muddled reality.

And then she walks off, hand-in-hand, with her fiancé of fifty years.

No Answers

Saturday night, the scourge of all police officers and ambulance crews. These days, all nights are busy, but weekend nights are often like being in a war zone. Trust me. I've done both. Sometimes I think that it was safer in the other one. As I work only nights, my weekend night shifts come round more often than most, and without fail, I regret them.

A list of a weekend night's proceedings often resembles a list of the wives of King Henry VIII. Divorced, Beheaded, Died. Divorced, Beheaded, Survived.

A Saturday night on the street runs something like this: Drunk, Assaulted, Trashed. Drunk, Assaulted, Crashed. The last of these might only appear once a night. If that. If you work in the centre of London, there are probably even fewer. I work out in the suburbs, so there's a chance that once the pubs, clubs and fast food shops have shut, I may actually have to treat someone who genuinely needs an ambulance. By that time, I'm tired, cranky, and struggling to give them my best attention and care. That which they genuinely deserve.

Last night, I tweeted about treating drunks, by asking a simple question. Do you think that people who call ambulances because they've had too much to drink, should be charged?

All dozen or so replies were positive. Some just said "Yes". Someone said "Yes, without a shadow of a doubt". And one even went as far as saying "YES!! YES!!!! A THOUSAND TIMES YES!!!" It seems that I received some support for the idea.

It's a knee-jerk, almost default position by health care professionals, and even some who aren't in the medical field at all: You're drunk. It's of your own doing. You should know your limits, or suffer the consequences. You don't need an ambulance. You don't need to be in A&E. And we most certainly don't want to be the ones who have to clean up all the bodily fluids you emit in your sorry state. Therefore, we all want to charge you. I'm as guilty of it as the next person. Not so much the drunk bit, but the wanting to charge bit. But there's a problem with this thought, once taken to one of its logical conclusions.

We should charge those who overdose on drugs. The heroin addicts who should know their limits, but who take a little more than their normal amount, end up not breathing, and who we administer Naloxone to to get them breathing again, ready for their next hit.

We should charge drunks who wonder out into the middle of a busy road and get hit by the car whose driver had no chance of avoiding them. Or by the same account, charge the drunk driver who's hit the lamp post that's sat on the pavement for years, but suddenly jumped into the middle of the road.

We should charge the wrist-slitters, crying for attention at the age of 18 after being dumped by the love of their lives, and who next week will have another life's love.

We should charge drunks who we convey not for being drunk, but whose drunken state has led to some sort of illness or injury.

We should, therefore, charge anyone who should have had some degree of responsibility for their own presenting condition.

Smokers with emphysema? Charge.

Footballers with broken legs? Charge.

Diabetics with high blood-sugars? Charge.

So how far do we take this knee-jerk reaction, this desire to charge drunks? Is it a question of all or nothing, in which case we charge everyone, or do we continue as we are, charge nobody, and just have to keep putting up with it, whilst we all, as taxpayers, foot the bill? Once upon a time, drunks were taken to police cells, given a mattress to sleep on and sober up, generally ignored, and were then sent home in the morning. Just that cost money.

Now, they get an emergency ambulance, often accompanied by the FRU, as they are frequently supposedly unconscious or not alert. If they're in town, they might get the dedicated "booze bus", a multiple-patient-transporting, baby-sitting service staffed by EMTs and paramedics who are clearly a lot less averse to dealing with alcohol-induced vomit than I am. They get a hospital bed, an overworked nurse, a disinterested doctor, and sometimes a bag of fluids as well. All very often whilst abusing those who are caring for them. And that's if all they have is a serious case of overindulgenceitis. That's a lot more expensive, and a lot more frustrating, which is part of the reason we feel that we want to charge. But is it right? In the overall spirit of the NHS, free to all at the point of treatment, can we really justify it? And if we are going to start charging, who do we charge, what for, and how much?

I have lots of questions when it comes to charging drunks.

I just wish I had some decent answers.

What do you think?

Nosey Neighbours

"40 West St, East Area, Baby crying constantly for last hour".

It's a call that's come directly from the police.

That's an emergency? That's what I spent all that time training for? You need parenting classes, not an emergency ambulance! Nevertheless, it's off to the address to see what's probably a teething baby and convey it needlessly to hospital. One of the residents of number 40 is standing on the doorstep, and we head over towards them. It's about one in the morning, the street's quiet, and other than our voices, there are no other sounds. Not even a crying baby.

"You managed to calm the baby down then?"

"No, the baby's still crying. Follow me please."

We walk up a flight of stairs, and I still don't hear any crying. We're shown into a back room, and finally, a faint cry can be heard. Except that there's no baby in the room, and it's almost as though, judging by the direction of the noise, that the baby's been hidden in the cupboard.

"Where's the baby?"

"We think it's next door. There are no babies in this house, and it's been crying for nearly two hours now."

"If the baby's next door, why did you bring us here?" I can't help thinking that this is a case of nosey-neighbouritis.

"We've tried knocking on the door, ringing the doorbell, and nothing. No-one's answering. They're a really nice couple. He works some weird hours, think he's a copper or detective or something, and she's always home with the little one. Only seems to go out for shopping."

We go back out the house and try to look through the front door and windows. There's a light shining through from the back of the house, and some flickering that suggests the television is on too. Someone's definitely home. An adult. Just like the neighbours, we try the doorbell, we try banging on the door and the windows. When there's still no response, we ask the police to turn up. Just to tug a little harder on the heartstrings in the police control room, and hopefully ensure a more swift response, we tell them that there's possibly an infant in danger.

It works. Less than five minutes later there are two units on scene.

One of the officers goes back into number 40, into the back garden, and scales the fence to see if he can find anyone or anything. A few seconds later, there's a yell.

"She's here, on the ground. The doors are locked, someone get the enforcer!"

The enforcer is affectionately known as the big red door key. It's a single-operator battering ram, made of metal and painted red, weighing several kilos. It opens most front doors with just a few well-placed blows. Hence the key reference. It's not carried in all police vehicles, and sometimes has to be specially requested to scene.

Whilst we wait, and feeling a little more athletic than normal, I decide to scale the fence myself to have a look.

She's lying on the floor of the kitchen, face down and looking away from the door. The only movement is her slow, rhythmical breathing. The television is showing some shopping channel, trying to sell an item for thousands that is probably only worth its weight in paper. As I'm standing next to the police officer, his radio blares back that the enforcer is on its way, but it'll take 15 minutes or so to get there. At a rough estimate, and looking from a distance through the patio door, our patient was breathing no more than 6 times a minute, barely enough to sustain life for any length of time. Back over the fence and through the neighbours' front door, I call out to Kim.

"I need the oxygen bag and a blanket!" My crew mate looks at me confused.

"Have you found a way in?"

"Not yet, but we're about to!"

I take the items round the back of the house, and grab another pair of hands in the form of a tall police officer. The officers take one top corner each of the blanket, and place it over the double-glazed door.

"Wish me luck!" The first tentative strike at the glass meets with stubborn resistance.

The second is more successful. The shattered glass cascades downwards like a shower of hail, the blanket protecting the officers and me from getting covered. The patient is far enough from the door not to be at any risk.

One step into the house and the smell gives away its secret. One officer goes to the front door and opens it. He yells to everyone not to touch any light switches.

I go to the unconscious patient and using a bag and mask, help to pump oxygen into her starved lungs.

The second officer goes straight to the gas hob and turns off the ring that had blown out.

Kim runs upstairs and grabs a baby, no more than six months old.

A torrent of instructions are yelled in all directions, from needing more oxygen and opening all the windows, to getting the carry chair, alerting the fire-brigade, the need to get us all out and both mother and baby to hospital in a hurry. No other crew is available, so we're taking them both. with a 2 metre tall policeman playing nursemaid to the baby, she looks like a miniature doll in his arms.

At hospital, when they're no longer our patients, it's a little easier to reflect. To ask all the what ifs.

What if we'd have been a little longer?

What if the baby hadn't cried so loudly?

What, despite my initial cynicism, if the neighbours hadn't been so nosey?

Luckily, we never found out.

A Conversation

On the 100 metre walk to where the patient lay in the middle of the makeshift football pitch:

"I've put a bandage on his leg".

"Great. What happened?"

"He was playing football, stepped on the ball, and fell over. There was a wicked crack."

"Have you moved him?"

"No. I just put a bandage on his leg."

"Is there lots of bleeding?"

"Well, no. Not really. The bone is sticking out of his leg, but not a lot of blood."

"Hm. Sounds broken to me".

"Don't think it's broken. The bone's sticking out, but there wasn't a lot of blood, so it can't be. Yeah. Pretty sure it isn't broken."

"..................."

Tug of War

Cigarettes litter the hallway.

The floors filthy with the wanton abandon of morals, respect and self esteem.

Walls are stained by smoke, the floors covered in grime.

The room is filled with it all, smothered by the air of neglect.

She's there, In the midst of it all, there, her eyes open, staring.

Empty. Void of joy, of life.

Her last will and testament to the world stuck up with gum.

"You won't even know I'm gone".

The ceiling fights against gravity, the rope torn between the two.

A tug of war.

Of Life.

Of Death.