Room Service?

So you want to know what sort of calls we attend on a daily basis?

All the gore and guts?

All the mess and misery?

All the sadness and strife?

You sure you're ready for this?

Well, here's a photo of a real call I attended not very long ago.

Take into account that I only work nights.

Room Service, anyone?

Real World

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

And back to the reality of the real world.

Vans

Day or night, mid-week or weekend,

sometimes we see them in action, sometimes all we see is the aftermath.

Sometimes, all too often, we're the intended target.

Fights are a common occurrence. Too common.

Often alcohol-fueled, they invariably end in injured limbs, injured heads, and injured pride.

Oh, and a criminal record.

A gentle reminder to those of you thinking of fighting:

You may well have phoned for an ambulance,

but you're just as likely to leave in a very different kind of van.

Especially if Ambulance staff are the threatened or injured party.

The 492

The 492 bus is standing on top of my patient.

It hasn't run over him.

He fell, and landed underneath it.

A feat of luck, judgement and special effects worthy of Hollywood made sure that the actual wheels missed him.

He's a little dazed and confused, and mostly scared. There are no obvious injuries other than a small lump on the front of his head.

We extricate him, and upset the fire-brigade in so doing. I think they felt we stole their thunder. He's moved to the ambulance and reassessed. As we do so, his phone rings, and "The Boss" appears on the screen.

"That's my wife", he says. "Can you answer it, and tell her I'm OK?"

I open the flip-style phone, say hello, and before I can get another word in, she goes into a gush of announcements.

"I'm gonna be late!" She yells.

"I'm on the 492 bus!" She hollers.

"A man's just gone under the bus and we're not allowed off!" She finally stops.

I whisper to our patient, asking his wife's name. "Lisa", he whispers back.

"Er, Lisa", I begin, "I'm from the ambulance service. We're with your husband at the moment. He's OK, but would like to speak to you in person. He can't talk on the phone right now, but if you get off the bus and walk to the ambulance next to you, you can see him for yourself".

The line goes dead, and an instant later, there's a knock on the ambulance door. I open the door for Lisa to jump in.

The babble starts again, a mix of shock, upset, confusion, and relief.

"You IDIOT!" She shouts at him. "You complete and utter MORON! I was phoning to tell you to go a different way home, the whole place is jammed. And then I find out that you're the one jamming it!"

She bursts into tears, looks at her husband, and as we slowly pull away from the scene, she gently kisses his lumpy forehead.

"I'm never getting the 492 again..."

Tuxedo

Tuxedo hanging on the cupboard door.

Burgundy bow tie hanging off the jacket pocket.

A rose, poking out of the button hole, its colour matching the tie.

The corner of the best man's speech peeks out from under the pillow.

On the floor, right next to the perfectly polished black patent shoes,

and the crimson blood,

lies an empty bottle of pills, with a story to tell,

but there was no-one there to listen.

More on Change

Following on from my previous post - here's one of the changes that are going to be trialled in London in the very near future. The Evening Standard, a London daily newspaper, has titled it "UK paramedics sent to emergency calls without ambulances". Slight newspaper sensationalisation is evident in the title and may scare the public a little, so briefly - here's the plan and how it'll work. Single responders will be sent in FRUs (fast response units) to the calls that are deemed as appropriate. Having recently completed an 18-month secondment on such a vehicle, I see no problem with that.

As a single responder, you are in an emergency vehicle that carries pretty much everything that an ambulance does, except the transport devices such as trolley, carry chair, spinal boards and the like. FRUs up until now have been tasked to respond quickly, start treating the patient, and then hand over to a crew that is sent to back them up. The thinking behind it is that the FRU paramedic/EMT is then free to attend another call. Whereas a call turnaround time for an ambulance is somewhere around the hour mark, on the FRU it was often less than half that.

The difference with the new model is that a transporting vehicle will not be automatically dispatched at the same time (in theory) as the FRU, except in the most serious cases, but that those in control will wait for instructions from the FRU paramedic on scene who can give a better assessment as to what sort of further response is needed. This, to me, is a small admission that the dispatch system we use is somewhat flawed. Having said that, the system can only go by what the call-taker inputs, and the call-taker in turn can only go by what they are being told over the phone.

There are other flaws. Calls to serious RTCs and other traumatic injuries are very often not categorised in the highest banding, and could in theory leave a lone paramedic dealing with a multi-casualty incident. I understand that any intelligent dispatcher will take one look and send the ambulance anyway, but in an era where there is more and more intention to rely on computer systems, turning around and asking for human input smacks of a contradiction.

Despite all my reservations at this point, I'd be glad to be one of the first paramedics to trial it had it have been trialled in the area in which I work. I would, however, have certain conditions that I'd like to ensure were adhered to. The main one would be that if I turned up on scene and requested immediate back-up, that it'd be on the way there and then. Too many times as an FRU paramedic I've had to wait for the transport to arrive despite repeatedly pleading with the control centre to find me someone to take the patient.

It's not a lack of confidence in my skills or treatment abilities. It's not that I'm desperate to "get rid" of the patient and hand responsibility to somebody else. I like and accept the responsibility, I enjoy treating patients, and I thrive on the extra challenge that is often presented when dealing with a critical patient on your own. But I recognise when the patient needs more care than I can give them.

Equally, if I decided that a patient didn't need transport to A&E, I'd like to know that the system was in place whereby other medical professionals would recognise and accept any diagnoses or referrals, and I'd like the public to be aware that I'm trained and qualified enough to make those decisions. This was the idea of the Emergency Care Practitioner (ECP) role that has been running in London for the last few years, but was never fully put into successful operation. The staff that took on the role were and still are dedicated, motivated paramedics who undertook a large amount of extra study and training, and are now being left high and dry as the role is phased out. It just never had the understanding and backing that it needed, and was never fully accepted by external agencies.

I'd love to think that this trial is being undertaken at least partially from a clinical point of view. I suspect economics has had more of a say. I may be an optimist, but I'm not naive. I have my reservations about this trial, but am more than happy to give it a go. No-one yet knows a full job description or scope of practice for this new role (probably entitled Advanced Paramedic), or whether there will be extra training involved, more pay, or any other details. But we know it's coming. This is one of those things where front-line crews need to be involved in the decision making process, and as far as I know, they haven't been, certainly not to any great extent.

More communication between the sides might surprise us all. The front-line staff might find that they want to be a part of the changes, even pioneer them, and management might find that they have willing partners, rather than unwilling subordinates.

Overall, change is a necessary thing for an evolving profession such as the one of a paramedic. Change breeds teething problems. These will exist at every level, public understanding, call taking, dispatch, front-line and external agencies. The trick will be to iron out these problems and turn them into a viable, working model, that will ultimately benefit not only the target-setters and finance department, but also the most important people.

Our patients.

Change is Coming

I've just mentored a student. Four weeks of trying to improve their skills, teach them all I know, and introduce them to the world of ambulancing. And whilst I'm at it, enthuse them about this job of ours. And therein lies the problem.

I love my job. I love everything about it. Everything, except:

The politics.

The lack of decent vehicles.

The lack of equipment.

The lack of training possibilities.

The lack of pay.

The lack of respect from other medical professionals.

And most importantly -

When people, including me, complain about everything that's lacking. Yes, including me.

I'm overly, sickeningly positive about EMS. I can be, because I try my damnedest not to let the things all around me decide how I'm going to treat the people I meet. After all, they're what this job is all about.

There are always frustrations. The recent plethora of them has made me write this post in the first place.

It's wrong that I have to provide some of my own equipment because there are those who are dishonest enough at best to lose the kit and not report it, or at worst, steal it.

It's wrong that we're driving around in some vehicles that are nearly a decade old.

It's wrong that some of the calls we are asked to attend don't even come close to qualifying for something that needs an ambulance.

It's wrong that there is such a strong anti-management culture.

Equally, it's wrong that it seems as though that feeling is mutual.

A recent tweet from someone I follow, someone relatively new to EMS, mentioned that 90% of our calls could be attended by a horse and cart. I don't think that that's even close to being true, but it does show that this negativity is reaching and emanating from all corners, old and new.

Not all our calls are life-threatening emergencies. Not even the majority. From personal experience, and being one who tends to attract trouble when it's around, I'd say that the number of these calls is lower than 15%. But that's not all that our job is about.

There are loud mutterings in the ambulance service that this job isn't what it used to be.

I'm pleased to hear it.

I don't want to go back to the days of being just an ambulance man.

A recent shift with a different student showed me why. Their regular mentor was having a day off, so I was filling the gap. This student was enthusiastic, hungry for knowledge and experience, yet being mentored by someone who repeatedly claimed to be "just an ambulance man". This mentor started this job whilst I was still at school, when ambulances did nothing but pick people up, take them to hospital, and let the doctors there decide what was wrong and how they would treat them. The student, despite their enthusiasm, was being drawn into a world that I just don't want to be a part of. A world of pessimism, of negativity, of apathy.

I was trained by someone who said that our job isn't to diagnose, merely to take a history, treat only what we see, and transport. The Happy Medic has a post about paramedics diagnosing. I'm with him on this one.

We are so much more than we used to be. And we can be so much more.

Change is coming to the ambulance service. There's going to be much more of that stuff we're told that we don't do. You know - diagnosing. There are going to be paramedics trained to a higher level so that they can assess, treat, and refer to a much higher standard, all as necessary. And not necessarily transport. Some of the calls we'll be attending in future, are those that were traditionally seen and treated by GPs. The truth is, we're already attending them. We just don't yet have the system in place to do anything but transport them to hospital. That's changing too.

There are those who see these changes reflect an admission of defeat by the ambulance service. Rather than educate the public about who we are and what our role is in the health-care system, we are adapting to what we think the public would like to use us for.

Personally, I'd like the two ideas to meet in the middle.

I'd like to see more education for the staff, more training, more ability to treat at home and refer if necessary. Who hasn't thought about simply gluing the little kid's head wound back together, or the 90-year-old for that matter. Then they can stay in the comfort of their own home, rather than endure the trauma of several hours of an A&E visit for a ten-minute consultation and treatment.

I'd like to see more back-up from the system when we do leave patients at home, whether it's our decision or theirs.

I'd like to see that ambulances are waiting for calls, not calls waiting for ambulances. Why?

Because I'd love to see that we have time and the resources, like the fire-brigade for example, to go into schools, summer schemes, mother-and-toddler groups, anywhere, to educate the masses. Both about what we do, and about what they can do to help themselves and their loved ones.

I'd love to have all the latest vehicles, fully kitted with the best equipment, and attending calls that truly require our knowledge, our expertise, and our passion.

Until all that happens, I'll work with what I've got, to the best of my ability. And strive for more.

I'll keep enthusing about my work to anyone who'll listen, especially students.

However...

Change is coming.

So are we going to fight it, or are we going to take the lead and steer it in the right direction?

Change is coming.

The question is, are we afraid of it, or are we willing to embrace it, pioneer it, and grow with it?

Far Too Young

The unusual sounding family name on the screen rang bells, but I couldn't remember why. The call was for an inter-hospital transfer, so no clues from the address either. As we walked into the department with the trolley, as requested by the all knowing computer screen, we saw the critical transfer bag sitting innocently near one of the rooms.

She was lying on the bed, barely conscious. Her dad was sat next to her, his eyes filled with sadness. The type of sadness and fear a parent tries to hide from their child, but can't.

As soon as I saw them, the name fell into place. They were an amazing family who I'd met a couple of times before, and she was always there to help with whatever we on the ambulance or her parents asked her to do.

Once, I'd delivered one of her siblings, and she ran around bringing towels and looking after the other little kids.

Calm, unflustered, more mature than her tender years. Far younger than she acted.

Once, I'd taken one of her siblings to hospital after an accident involving a trampoline left their arm in pieces, and she ran around gathering clothes and bottles.

Responsible, obedient, respectful. Far younger than she behaved.

And this time, I was transferring her.

Taking her to where they might be able to do something.

A last, lost hope.

In reality, it'll probably be the place where she'll live out the last few days of her terminal illness.

She'd been diagnosed a week before.

Far too young, at eight years old.

Too Late

I see it... but I don't quite believe it.

Another shift with my new student (can you believe they let me mentor someone new?) and he's getting used to working the night shifts. We discussed things we've seen, things we'd like to see, things we'd never want to see. It's the crazy time in a night shift, the one where the wall of tiredness hits head-on, and where anything can happen. Minor hallucinations are a common thing in the dead of night. The tired mind plays tricks on its owner. I remember thinking once that I was seeing a baby crawling in the road at about 4am, only to realise that it was a plastic bag blowing in the wind.

As we drive over the brow of a hill heading to yet another call during this non-stop run of shifts, I think my brain is up to its old tricks again. We're two hours before the end of the shift, haven't stopped all night, and only eaten bits and pieces on the run. I'm sitting in the back, and looking through the front where the driver for the night and said student sit. Out of the corner of my eye, I see two little kids, probably three, four years old, running towards the road, then back onto the pavement, and then just up and down by the side of the tarmac.

"Stop! STOP!"

It's too late for kids to be up, let alone out on the streets.

The vehicle comes to an abrupt halt, and I jump out the back door. The blue lights of the ambulance illuminate the entire street, and it won't be long before the curtain-twitchers are out in force. The kids see me coming towards them, and head for an open front door. I follow them and as I peer in to the house, I see that there are several supposedly responsible adults there, awake, watching TV or just talking. Cans of beer sit on one of the surfaces, and empty boxes of takeaway food are strewn all over the floor.

"Did you know that your kids are running around on the streets at five in the morning?" The response comes in the form of raucous laughter and does nothing to calm me down.

"It's fine!", starts one of them. "They don't go far!"

"Well, one of them nearly got run over by an ambulance!"

"So we'll sue the ambulance service" they laugh. "They're fine. Leave them alone, and leave us alone."

With that, they slam the door in my face and carry on with their irresponsible parenting. Or partying, if you prefer. Furious, I turn on my heels, walk back to the ambulance, advise control of the cause of the delay and that they might consider informing the police. At least in the mean time, the slammed door might mean the kids stay indoors.

We continue on our way to the original call, not quite comprehending.

Hopefully we saved some lives on the way to that call.

We were too late for the original patient.

Car Crash TV

Edit: For some reason, YouTube has decided to remove this video. I'll keep an eye out and see if I can find it somewhere else. Shame. It was one of the best pieces of public education I'd seen for a very long time.

I've seen this clip in various different places recently, but I first spotted it on Jumblerant.
Mine must be one of the businesses where we'd rather not drum up more business, and this is one way of trying to reduce not only the workload, but the heartache that comes with it.
Watch it.
Learn from it.
Share it.
Warning - this isn't a child-friendly video.
Just in case the video link doesn't work - here's where it can be found: http://tinyurl.com/carcrashtv



Please, please, stay safe out there.
I'd be happy not to have your custom.