Hope

The complex of buildings appears to have been built some time between when asbestos was the latest in safety and avocado green was the height of chic. An impossible maze of apartments, dotted around hidden, narrow side streets all with the same name, or no name, and a numbering system that bears no resemblance to today's recognised linear system. Buildings numbered in the hundreds sit in between buildings number four and six. The GPS always gives up and leaves us with either local knowledge or none. 

We call dispatch, ask them to link us up with the caller with a hope that they can give us directions. It seems like a simple call - a faint - but my gut tells me otherwise. The voice that comes on the other end of the phone is calm, so perhaps my gut is wrong. She gives us exact directions - to a completely different street - and tells us that someone will meet us outside. 

I see them running down the stairs as we enter the dead-end street, three pairs of legs rushing full pelt, one of them skipping the last few steps and landing in a heap at the bottom of the staircase. He gets up and continues rushing towards us, pulling open the door of the ambulance before we've even stopped. One of them is screaming about the fact that it took us so long to get there, all the while blocking me from leaving the ambulance. It's tough not to judge a person in their time of crisis, but this was only making his crisis worse, not better. 

"She's stopped breathing! She won't talk! What are you waiting for?!"

If what he's telling me is true, there is no time for niceties, so I shout back. "You to get out of my way!" 

It seems to snap him back into reality and he takes a step aside, lets me out and bursts into tears. 

Nothing seems to work in the building; the lift is out of order, the hallway lights don't work. The only light in the flight of stairs is that from their open door on the first floor. There's a conflict of unwritten laws in play: the first - seriously ill patients are never on the first floor; the second - if the lift's broken, the patient will be seriously ill. This time, the second rule was stronger. 

As we enter the apartment, we see her sitting by the table, her head slumped awkwardly like it does only in patients who are dying or dead. We move her to the floor, and with little need for words start the attempts to save a life. One person starts compressions, pushing hard on fast on the chest, mimicking the actions of the heart at ten times the effort with less than a third of the effect. I start the ventilations, two breaths for every thirty compressions, finding it easier to conduct the orchestra from the patient's head. Other actions happen all around - a monitor is attached, an IV line is placed ready to give adrenaline. The hands pumping the chest change, allowing time to recover. In between, I look at the monitor. There is no rhythm to shock, but there is a rhythm. A check of the pulse reveals none, and the orchestra continues. Another two minutes, a dose of adrenaline, hands relentlessly pump the heart. 

And a family waits.

The hands change once more and in those few seconds the rhythm does too. A pause, a check for a pulse, feeling for a flicker of hope. 

The miracle occurs. The pulse is strong, fast, effective. It remains so all the way to hospital. 

I have no idea what happened after that. But I saw the family walking around the hospital the following day with cautious smiles on their faces. 

I didn't dare to ask, but I can only hope. 

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.

Plumbing

The first beads of perspiration appear on his forehead as we attach the monitor leads to his limbs and chest.

"I don't think it's a heart attack," he says, more hopeful than certain, "the pain's in my shoulder, not my chest. It can't be a heart attack, can it?"

As the beats begin to dance across the screen, appearing at regular intervals of just over one per second, the picture begins to emerge. A corner of his heart is screaming for blood, for oxygen, as more cardiac muscle dies every second. The strip of paper that spills out the front of the machine, pink paper with tiny red squares all covered in black lines of the ECG, answers his question and leaves no room for niceties.

"You're having a heart attack. It means that one of the blood vessels in your heart is blocked and we need to get you to hospital so that they can unblock it."

"You make it sound like some sort of plumbing job!"

"Well, in a manner of speaking, it is. They'll plumb their way into your heart, remove the blockage and fix your heart."

He has some medication to relieve the pain, some to prevent the blockage from worsening, some to stop him feeling so sick. His blood pressure is a little low for the first part of the journey to hospital, but his pulse remains steady and constant.

"And you're sure this is a heart attack? I thought you die when you have a heart attack?"

"You can blame the media for that. They need to learn the difference between heart attack and cardiac arrest. One is when your heart is sick, the other is when your heart has stopped."

"So my heart hasn't stopped yet?"

"Thankfully not, otherwise we wouldn't be having this conversation."

The dancing heart beats continue on their way crossing the monitor screen from left to right, looking as though each one is holding hands with a beat either side. Speeding our way down country lanes heading for the hospital, he continues to ask some more questions.

"Is it safe, this angioplasty thing?"

"Of course it's safe. They do hundreds of these every year. You'll even get to stay awake whilst they do it."

"And what if I decide I don't want it?"

"That could be one of the last decisions you ever make." I'm not one for dodging answers to serious questions. 

"Oh."

I look back up at the monitor. Suddenly, one strange-looking beat skipped across, the shape and pace very different from all the others. A messy, irregular beat, it's often the precursor to bad news. Quietly and hidden behind his head, I take the shock pads out of their wrapper and have them ready. Just in case. As the ambulance takes a sharp left turn some seven or eight minutes from hospital, his eyes roll back and the beats on the monitor turn from an organised rhythm into an uncoordinated, mangled mess.

"He's arrested!" I shout through to the front.

"Do you need me to stop?"

"No! Keep going and just get us there in a hurry!"

The pounding on his chest keeps the blood pumping round as much as possible, but it's nothing like it should be. The pads are stuck firmly on his chest and the monitor whines as it charges them ready to deliver a shock. I have one pair of hands where ideally I need two, but the other pair of hands is doing work of equally great importance - getting us to hospital. The orange button lights up, flashing away to tell me that the machine is ready. 

His body jolts up, the useless, erratic beats on the machine register the shock and then proceed to go completely flat, just for a few seconds. More compressions on the chest. Just a few more corners and we'll be there, several pairs of hands will be waiting to help, to take over. 

His body jerks with yet another shock. 

More compressions. 

Suddenly, there's resistance, even a groan as he appears to push my hands away. Not unconscious, but not quite conscious either. Breathing on his own and with heart beats that are once again holding hands. We wheel him off the ambulance and into the lab as he slowly seems to regain his faculties. 

"You're sure this is a heart attack, are you?" Totally unaware of the drama of the last few minutes, he still seems reluctant to accept reality. 

"We're sure." 

One of the lab technicians helps us move him across on to their bed, leaving him surrounded by monitors, machines and staff all dressed in x-ray blocking lead outfits. We move behind the clear, lead-lined screen  as the well-oiled machine of the cardiac team gets to work. One of them introduces himself as the cardiologist and explains once again about the procedure, despite our patient's protestations. 

"It's quite simple," explains the doctor, having tried the softly-softly approach but getting nowhere, "you've already died once. If you wish to do so again, but this time stay that way, then I'll be happy not to operate. However, considering the fact that the ambulance crew have worked hard at getting you here alive, I think it might be worthwhile to try to keep you that way." 

"Yeah," said our patient, "that's basically what he said. Go ahead then. But just one thing." 

"What's that?" 

"I just hope you're as good at plumbing as they say you are." 

Playing Dead

Saturday night. 

In fact, it's worse. 

It's a post pay-day Saturday night. 

The calls are coming in faster than the customers can spend their hard-earned cash. Call after call is alcohol related, leading either to faints or fights, pass-outs or punch-ups. Suddenly, in the middle of it all, a genuine call. 

In fact, it's worse. 

It's a genuine call made by a child. 

The call comes in as a mother who isn't breathing. The child is barely able to contain their emotion as they  follow instructions from the call-taker. Luckily, I'm less than a mile away. Under a minute later, as I step across the threshold, a bag on my back and another two balanced on my arms, a young child grabs me by the hand and practically drags me off my feet. 

I walk into the room to see a sight that worries me even more; it's not just one child who's distraught, but four. The oldest is ten years old. All are crying, worried, scared. One begs me to help their mother. 

"She's not breathing! Do something!" 

Another asks me the awful question. "Is she dead?"

All it takes is one look at the mother. Her eyelids flicker like no dead person's can. As I call her name loudly, she jumps a little, but tries to stifle it to keep up the pretence. As a crew arrives, I usher the children out of the room, asking them to let me treat their mother whilst reassuring them that she'll be absolutely fine in a few minutes. 

"Right," I say, "the kids have gone, and it's just us. Now do you want to tell me what this is all about?" It's  rare for me to lose my temper with patients, but I'm close. She opens one eye, then the other and after a moment or two, decides to pretend that she remembers nothing and that she doesn't know where she is.

Leaving the crew to treat the so-called patient, I go to speak to the children. One of them tells me that the two oldest siblings were fighting, their mum shouted at them to stop and when they didn't, she collapsed and stopped breathing.

"She just dropped to the floor?"

"No. She sat on the couch with a bit of a bump, shouted again, and then fell back with her head on the cushions."

"I understand. Just so you know, your mum's going to be absolutely fine. We'll let you in soon so you can see her and talk to her."

"You mean she isn't dead?"

"No, she's not. She's just a little upset."

Back in the room with our now alert patient, I could bite my tongue no more.

"You realise what you've done to your children, don't you?"

"It's their fault. They know how to behave. I just wanted to show them what it would be like if their mother wasn't here. When they fight, they pretend like I'm not here anyway, so I thought I'd show them what it would be really like."

Speechless and angry, we invite the children back into the room. As the youngest runs into her mother's arms, I leave the house, wondering what would force a parent to be so cruel to their own child. 

Storyteller

Elaine stood over my shoulder, watching my every move. She'd been there from the second I knelt down beside her husband Carl. She watched every chest compression, heard every rib as it cracked loudly beneath my hands. And as she watched and listened, she told Carl's life story. 

"He lost his leg last year. Diabetes, you know. Awful disease. But he didn't really look after himself. It was probably his own fault in the end." 

She watched as two more crews entered and made a little room for them and their equipment. Then, as we worked in streamlined silence, she continued her story. 

"We're a rare couple we are. Carl from Jamaica and me, a working-class white girl from the East End. When we got married, back in the sixties, my parents swore to write me out of their lives. They never visited, we never visited them, and eventually we didn't even speak. There was no such thing as racism back then. It was just black and white. And no mixing."

She watched as someone stuck a needle in his arm and started to give him fluids and drugs. 

"When the grand-kids came along, suddenly they wanted to visit. But only if Carl wasn't home. So I told them they could choose. They either accepted our family as it was, or they couldn't be a part of it. It was the toughest decision of my life." 

She watched as a tube went down Carl's throat, allowing us to help him breathe a little more. 

"Our friends stopped being our friends. Blacks and whites each going their own separate ways, all of them turning outwards, away from us, instead of rallying around us and learning from each other. We were left with no family, no friends. It was just us. Carl and me and the kids." 

She watched as the first of the shocks jolted Carl's lifeless body off the floor, the unnatural jerk phasing her just a little, throwing her narrative into a brief silence.

"Is he going to be OK?" 

"We're doing everything we can for him, but at the moment the signs aren't good." 

"He's a fighter you know. He'd have to be, putting up with what we have. We've had to fight for everything. Over the last few years, though, we've finally been winning that fight. Mixed couples are all normal now, aren't they?" 

She watched another shock violently wrack his body and begged him to keep fighting.

"I love seeing them. Walking through the park, doing the shopping, wherever. And those beautiful children. Remind me of my own kids when they were little. Not that my kids aren't beautiful any more!" 

She watched as half an hour later, we stopped. Carl lay where he fell and Elaine knelt next to his head, her story told, muttering in silent prayer.

"Maybe," Elaine said after watching us clear up, "I'll write our story one day. Be good to have it written down once I've gone too, then someone else can tell our story." 

Scars

We're both going to be left with scars, but mine seem unfair. Unfair to you, not to me. I don't have the right to feel this way, to feel the anger, the frustration, the sadness and injustice of it all. After all, he wasn't my child.

My children were safely at home, sharing popcorn and a movie with friends.

Your child was being roughly manhandled by ambulance crews desperately trying and miserably failing to save his life.

We must have seemed so cold to you, so callous, calculated, so damned professional. Sticking tubes down his throat, needles in his scrawny arms, pounding on his delicate, fragile chest. But we're human too. 

At the hospital, after we'd walked back out of your lives, we shed a tear, shared a tear. Some of us outwardly, some torn from the inside out, some showing a passive face, hiding the emotion that was battling to break through the dam. 

As we worked to save his life, nothing else mattered. But afterwards, there are questions, doubts, replays of every single thing that happened go through my mind. Could we have done something differently? Could we have worked faster, better, harder? Would it have made a difference? 

The team at the hospital told us that we did everything that we could. They came out to the ambulance to find a saloon full of sombre faces in green uniforms. They said what they said, and left to go back to talk to you, a conversation so much worse. I know we did all we could. I know that we couldn't have done anything better. I know that nothing we could have done would have saved his life. I don't expect you to feel the same. 

It's never right for a child to die. Not through illness or trauma, neither by accident nor malice. You know that better than I, as you sit and try to come to terms with a tragedy so deep that the scars will never entirely fade, whilst I go home and hold my children closer. 

At home, I tried to leave your child behind. "Just another day at the office," I'd tell myself. I failed at that too. 

Instead, I sat and cried as I polished my boots clean of all the scars of that call, feeling guilty that I'm erasing any physical memory I have of your son. 

I know that you can't erase the memory. Won't erase it. All I can hope is that the memories that linger aren't the ones I have, of a lifeless child, bereft of hope. I can only pray that the memories you keep are the good ones, the happy times, the playful child full of life.

And that in time, your scars heal, if only a little. 

Often, Sometimes

Dozens of times, each time different, yet each time the same.

"I'm sorry. There's nothing else we can do."

Often at home,

Sometimes at hospital.

Often, there are tears,

Sometimes screams.

Often silence.

Sometimes hugs.

Often phone calls.

Sometimes, oddly, smiles.

Often confusion.

Yet always, as we leave, we leave nothing but an empty, dark void.

And questions. Always questions.

Each time may be different, yet each time is the same.

And each time, I'm sorry.

After-Dinner Mint

A midsummer's night, a cool breeze shakes off the last of the day's stifling heat. The trees wave a silent farewell to the day, and usher in the perfect evening. The streets are still aglow in the last moments of the red sunset, and as darkness falls, they step into the restaurant for a quiet birthday dinner. It's still their favourite eatery, the place where they first met, he a waiter in his parents' business, putting his teenage years to good use and saving some money. She was the shy daughter of regular diners. When they married, they took over the business.

They had sold the restaurant several years ago, but it had retained its character under the new ownership, and as it still felt like home, they would always go back for special occasions, and were always treated as royalty each time they did. Her birthday was one of those special occasions.

They sat at their usual table, hidden away in a corner behind a screen. It had been their own private hideaway when they were teenagers, and it remained so well into their adult life. The service was, as always, excellent, the food was top grade, and, most importantly, the company was intimate and loving. They sat and talked about their lives, their jobs, their futures. Their kids, babysat at home by their grandparents, were central to their plans. They talked about school achievements, nursery drawings, friends coming to play, and how they were growing up so fast.

"We have everything we wanted, and everything to live for", he said.

"I know. But if I don't go to the bathroom now, I may explode, and that might ruin our plans!"

They laughed, and as she left the table after their dessert bowls were emptied, she picked up a striped mint sweet and popped it in her mouth.

Less than ten minutes later, there were four of us crowded into that bathroom, as well as her frantic, distraught husband and the restaurant manager looking lost and scared. She lay on the floor, her breathing stopped, her heart firing a useless, chaotic attempt at a rhythm, she was a vision of suspended animation.

Equipment flew in all directions, instructions given, actions undertaken. We would breathe for her, we'd pump her heart for her, forcing the oxygen and the blood to fulfil their duty against their will. The air from the mask was going nowhere. Her lungs wouldn't move, declining the offer of the oxygen that was being forced into them. Something must be sitting in the way and fighting our actions. After another round trying to beat and shock the heart into action, someone took another look at the airway.

It wasn't there the first time we looked, I could swear to it, but now it sat staring innocently back at us, just out of reach. It was the round mint, all along, that had lodged itself in the airway, trying to complete her circle of life, and kill her on her birthday. Five seconds later, a pair of forceps flew across the bathroom and were used to fish the mint out of her throat. We breathed a few more breaths for her, whilst all the while her heart was being operated remotely, from the outside-in.

In the ambulance, it finally happened.

She took a breath.

We all stopped to watch her, to check the monitors, to make sure that our imagination wasn't playing tricks on us.

There were no tricks. She was pulling through.

By the time we reached the hospital, there was nothing left for us to do but hope and pray.

As the adrenaline wore off and the ambulance was being returned to its normal state, I had a weird thought.

Crazily, I wondered what had happened to the mint.

Purple

The streets are lined with market stalls, selling flags, scarves, team-branded items of all sorts. Blues to the right, Reds to the left. Home team advantage to the Blues, but it's a local derby, so feelings are running high, the tension in the air is palpable and threatens to erupt at any moment.

Thousands of fans on the streets walk, talk, shout and sing their way to the match. Some are sucked in by the stall-holders, but most have come prepared. The seasoned professionals in this game are the supporters, not the players. Years, even generations of loyal, unwavering support. The traditions remain strong, even when the reasons behind them can no longer be recalled. The sea of people converge on the ground, Reds from the left, Blues from the right, meeting to create a purple haze as they mingle at the gates.

It's a daunting sight, all the more so if you're trying to find one needle-like patient in a haystack of raucous colour. At least we know he's a Red. Eventually, thanks to the police, stewards and several drunken antics, he's found. Lying face down on a bench, his scarf loosely dangling from around his neck, the back of his shirt proudly displaying the coveted number 10.

Around us are more stalls, this time each plying their trade with an added bonus of advertising by aroma. Food and drink on sale at extortionate prices, yet being bought by hundreds of fans, each allowing themselves one more luxury to complete the day. All the while, there's an added smell in the mix, lavender-like, seemingly, almost impossibly, coming from the comatose patient.

Under the bench we see the can. Lavender air freshener. An officer picks it up and with one shake announces that it's empty. He hands us the can as he reads the warning printed boldly, menacingly on the back.

"Solvent abuse can kill instantly".

A Red fan amongst his own, away at the home of the Blues, gone in a self-inflicted haze of purple.

Bus Stop

Fate sometimes has a strange way of playing with your mind.

After yesterday's post about rarely discovering the outcome of patients, and how it can be the most frustrating part of our job, I had a little closure on one patient.

The last time I saw her, many months ago, she was on a trolley in the resus room.

Unconscious, post resuscitation.

Given a 10% chance to survive the night.

This morning, on my way home, I drove past her address just in time to see her locking her front door, shopping bags slung over her shoulder, and walking to the bus stop just outside her house.

I'll take part of the blame for her shopping bill.

Noise

Opening the door of the ambulance, there's a noise.

An almost feral scream.

Entering the house, there's a noise.

An accusatory shout, querying the delay.

As the kit is prepared, there's a noise.

A low groan, panting, pushing.

As it's being born, there's a noise.

A parent's question, checking the baby's welfare.

Once the baby makes a full appearance, there's no noise.

No noise at all.

As it arrives, it's blue, lifeless. Silent.

We warm it, dry it, breathe for it.

After a few forced breaths, there's a noise.

The noise of a newborn's cry.

As the lungs open up and greet the world, there's a noise.

A loud, high-pitched, life-saving noise.

The most beautiful noise in the world.

At Home

And so, with no pomp or circumstance whatsoever, it came to an end. A mundane call just before six o'clock in the morning, a simple handover to the crew, and a slightly solemn and very lonely drive back to station. I don't know what I was expecting or hoping for.

Almost five years ago, I started it for the first time. It lasted 6 months, and I hated almost every minute of it. I stuck at it because it was challenging and different, but I still couldn't stand it. At the end of the allocated half-dozen moons, you couldn't see me for dust in my haste to get away. Maybe I was just too young and inexperienced, maybe I was just lacking in confidence. Whatever it was, I was pleased it was over.

Almost two years ago, through lack of choice and with fear and trepidation, I went back to it. Last week it came to a halt, again through no choice of my own. My time on the FRU, the single-manned (personed) Fast Response Unit, has ended. All the things I hated about it the first time round, I loved this time, and I will sorely miss. I guess I'd grown up a little in the interim, and eventually started to feel at home in the FRU.

The most appealing is the challenge of having to think on your own, often for extended periods of time, and sometimes with very ill patients.

Starting a resus on your own and having to carry it out with no back-up for quarter of an hour.

Managing the asthmatic patient who's deteriorating before your very eyes.

Relieving the pain in the elderly patient who's fallen and fractured their hip.

And being unable to transport any of them.

Delivering a baby and praying for it to take its first breath.

Supporting the dislocated shoulder of a brave kid and watching them get drunk on entonox.

Sticking a plaster, or a band-aid, depending on where you are, on an adult who's behaving like a spoilt child.

And telling him so.

Being the first at the scene of a suicide attempt, working hard to save a life, only to see the patient whisked off in the ambulance or the helicopter, and staying at the scene filling in paperwork.

Being the first at the scene of a fatal accident, and having to call it before anyone else even turns up.

Being the first at the scene of a cardiac arrest, a terminally ill cancer patient, and grieving with the family.

And being left alone with your thoughts and a cup of coffee.

Travelling with a crew and them hating you for pulling rank.

Travelling with a crew and them loving you for pulling rank.

Travelling with a crew and the patient thanking you all. Together.

And having to justify it all. To control, to the crew, to the patient, to yourself.

Now, it's back to a mix of real ambulances and a few FRU shifts, but it won't be my car.

It'll be nice to have someone to share with, someone who I can look at over my shoulder when I'm unsure, and hopefully vice versa, someone to sing along to the radio with between and on the way to calls.

They say, whoever they are, that a change is as good as a holiday. Truth is, I could really do with one right now. It's just that I'll miss being at home.

Who'd have thought it?

Take Away

Take a deep breath. You're gonna need it.

As rumours go, this one has been floating through the ether for some time. When it was officially published the other day, I wasn't at all surprised, but I was, still am, more than a little disappointed.

Intubations are no longer going to be a part of the London paramedic's bag of tricks. The single most useful technique we use, the one used in the most critical of patients, is being taken away from us. Let's start at the very beginning.

Intubation (or colloquially "tubing") is a process by which a plastic tube is placed in a patient's airway to protect it. It's used when we need to breathe for the patient, and when we want to stop all manner of gunk, particularly blood or vomit getting into the lungs, effectively drowning the patient. It's used by paramedics mainly in cases of resuscitation attempts - or CPR. If ever there was a time that a patient is likely to vomit, it's when a paramedic is applying brutal repeated pressure to their chest at 100 times a minute.

It is used at other times such as massive trauma when the patient is unconscious enough to allow the intubation to take place. Yes, there are different levels of unconscious, and there are even different degrees of dead, but these are the subject of a completely different discussion.

Now, however, instead of training new paramedics in the skill of intubation, they are only training them up to use LMAs, or laryngeal mask airways. These are good when you need to breathe for a patient, but totally useless if the patient vomits. So in our case, frequently pointless.

These LMAs, whilst brilliant in the hospital setting, will fail to fulfil their purpose out on the road. The reason is simple. In hospital, when a patient is aware of the fact that they're about to be knocked out for an operation, they are starved beforehand. No food in the stomach equals no chance of vomit. The LMA is perfect. You can breathe for the patient without having to go the full invasive method and intubate them. If, however, someone ends up with an emergency operation, where there was no time to starve them first, guess which method of airway protection is used? Correct - the tube.

The trouble with emergency cases is that they are exactly that. Emergencies. The patient will never have starved themselves prior to collapsing or being run over. They will never be considerate enough to think that they'll hold off on having dinner because there might be the possibility of the cavalry in green charging through their front door on a rescue mission, and would really rather prefer that the patient didn't vomit, thereby endangering their own well being, as well as the ambulance crew's uniform.

The arguments for the de-skilling of paramedics are several-fold.

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

The first two I agree with - up to a point. A study, apparently carried out in the USofA, says that the minimum training requirement is a 90% success rate at 57 intubations. The numbers seem a little random to me - but I'm not arguing them. When I did my training, I had to successfully intubate 100% of 25 patients. At least. I think, if I remember correctly, I intubated 40. The only one I failed at was the first one I ever tried. I told the consultant that I couldn't do it. I couldn't see what I needed to see in order to ensure a successful intubation. He huffed and puffed, muttered something, good-naturedly, about these new paramedics, took one look at the patient's throat and found that it WAS an impossible intubation. Even for a seasoned professional. I'm not saying I'm brilliant. But I am saying that I'm honest enough to admit I can't do something. And that in itself is an important skill.

The problem with getting an intubation wrong, is down to what your mother used to tell you when you were a kid. "Don't talk with your mouth full, or the food'll go down the wrong hole." The trachea (air-pipe), and the oesophagus (food-pipe) are next to each other. Well, actually, one in front of the other. If you put the tube down the wrong "pipe", you pump air into the stomach and do nothing for the lungs. It's lethal. It's not a difficult skill to master, but it does need proper training. Not only in how to do it right, but how to recognise and rectify it if you do it wrong.

Training is apparently becoming a problem due to the increased use of LMAs in hospital. The number of intubations is steadily declining, so there are fewer patients going around for paramedics to train on.

So extend the training. Do blocks of hospital theatre training weeks. If it takes a year to get the prerequisite number of intubations, then so be it. Use all the skills you have, and wait with the intubations. If you're lucky and reach that number in two weeks - then off you go into the field and save lives - along with the tubes.

We definitely don't have enough refreshers. Certainly not on intubations. We have courses reminding us how to do CPR, how many compressions, what drugs, what's changed since the last refresher. But we never go back to theatres to intubate live people. A manequin is one thing. A patient is real and has a different feel and knack to tubing. I'd love the chance to go back, once a year, and intubate under the guidance of a consultant anaesthetist. By the same logic, I shouldn't be allowed to put a patient's arm in a sling either. I know one is not a life-changingly-critical as the other, but the logic is the same.

On average, a paramedic will intubate a 3-4 times a year. A few more if you tend to be a little like me and attract more trouble than the average paramedic. It's not a lot. There are pieces of kit on the ambulance I haven't used more than once in my career. Literally. That doesn't mean that I won't use them if I have to. I have the skill, I know how to use it, and use it I will. I feel it's also important for a paramedic to arrange their own refreshers on less-frequently used equipment. To take out pieces of kit they haven't used for ages and just re-educate themselves in it's purpose and function. Clearly this isn't possible with intubations. However, intubating only a handful of times a year does not mean that I lose the skill. It doesn't mean I don't know what I'm doing, and it certainly doesn't mean I forget how to recognise whether I've done it right or wrong.

We're lucky in London. We're one of the very few services in the country (as far as I have managed to discover) that uses a piece of kit called End Tidal CO2 monitor. I'm not going to go into the ins and outs of how it works, but very simply, when you attach this to the end of a tube, it is an almost guaranteed assurance of the success of the intubation. You get a reading - it's in, you don't get a reading, you've missed. Simple as that. If you get a very high reading, chances are that the patient's started breathing on their own. Good news all round. There are fail-safe methods of ensuring a tube is done right. Any paramedic worth their salt will know them, check them, double check them, and know that if they've done it wrong, that they start again. Or, in the rare cases of seemingly impossible or even very difficult intubations, recognises their own limitations and works with what they can.

I've only once out on the road seen a paramedic miss an intubation.

That one time, it was recognised very quickly and fixed. I don't know where the data comes from that we're not good enough at it. My personal experience, the only one I have to go on, tells me otherwise. There have been tubes that I couldn't get, only two if I remember correctly. I blame my legs for one of them. There was a smaller paramedic on scene who could fit more easily into the restricted area round the patient's head and intubated them with no problem. The other I just couldn't see what I needed to see to ensure the tube was going down in the right place. I stuck with an LMA and prayed the patient didn't vomit. I vaguely remember being lucky. That time.

The cynics amongst us will blame the doctors. They're trying, at least some of them, to regain their superiority and would love to see paramedics bounced back to the stone age where we literally pick a patient up, throw them on the back of a truck and race them into hospital quick enough for super-docs to save their lives.

Those same cynics will also say that it's nothing more than a money-saving exercise. Less training means less spending, both on the training itself and the kit that it entails once qualified.

The establishment will claim that as they cannot guarantee training and proficiency, that they are taking the skill away. Future paramedics therefore won't be trained. Current paramedics will be allowed to go on using it for now, but my suspicion is that the equipment will slowly be used up and never replaced. A de-facto de-skilling.

It's a backwards step for an organisation that aims and claims to be a world-leader.

To me, instead of striving to better at we do, and extend our range of skills, this is a move in the wrong direction, a move to limit our abilities further.

I think it's a mistake. A step towards those who see paramedics as nothing more than World-War-I stretcher bearers, and away from those with a vision of modern, skilled, experts in pre-hospital care.

I hope it will be rethought at some time in the near future.

I hope that lessons will be learnt, and I hope that as a Service, London will rethink it's training strategy.

Most of all, I just hope that this is one take-away that we don't all, patient and paramedic alike, learn to later regret.

Rats

Below is a screen shot of a recent call. Now I have to say, I can understand the kid for calling. Not sure I'd know what to do if I found one of these lying dead in my lounge. I mean, it's not as if it'd be covered in a normal first-aid course, is it?

What I don't understand, is why the system triaged it as a cardiac arrest call, and despite human protestations, the computer still insisted and sent me on blue lights and sirens.

Not for long though. Human intelligence eventually took over and cancelled the call with some bemused apologies.

I did have to wonder what the ratio of compressions to ventilations on a rat was. I think I may have verbalised that thought slightly too loudly, much to the amusement of several people standing around at the time.

Rats.

Possibly, Probably

I had to be honest. "Possibly not", was the best answer I could come up with.

How do they do it? How do kids always know to pick that one moment? The split second sometimes when the adult's gaze is averted, their attention diverted, is the exact moment that their child decides to do something dangerous.

*

A year and a half is a long time in the life of a toddler. Long enough to fill them with a sense of adventure, a love of excitement, a curious wonder, and no fear of danger whatsoever. Milly was a typical 18-month-old girl, waddling and toddling from one new find to the next. This time, the next find happened to be a marble. Well, a bag of marbles, but one marble in particular was to be the cause of all the excitement over the next few minutes.

The bedtime routine was more or less adhered to. Milly and her big brother Dan, had dinner at six, bath time at half past, story at seven, lights out at quarter past. Their parents split their nights, taking it in turns to make sure that both of them read to each of their elder children on different nights. Milly and Dan's baby sister, only two months old, didn't yet believe in timekeeping and routines, and during this one bedtime decided to scream, just after bath time. Milly was left in pyjamas and ready for bed, whilst mum went to tend to her sister. Her dad was just sorting Dan out upstairs. It was a perfect time for Milly to go discovering her big brother's collection of marbles.

As mum was dealing with baby and dad was settling Dan, Milly started to cough. A strange cough, one like Milly's mum and her intuition had never heard before. She rushed back in, baby in arms, and saw Milly struggling to breath.

"Tony! Tony, get in here now!"

Dad ran downstairs, saw what was happening, picked Milly up and looked in her mouth, hooked a finger in to see what he could find, and then tipped her upside down to see if he could dislodge whatever it was.

Mum was on the phone to the Ambulance Service.

Milly continued to struggle for breath.

Parents were frantic, Dan was scared to the point of tears, when all of a sudden, after a lifetime of being held upside down and patted harshly on her back, Milly coughed once more, screamed, and cried.

At that point, we walked in. Ninety-nine times out of a hundred, when called to a choking, the call will downgrade whilst we're on the way. What will start as a call to a non-breathing patient will often, through the wonders of the human body and its capacity to fix itself, turn into a post-choking, now breathing normally call. This time, it didn't happen, and until the second we walked into the house, we were on the way to a child still choking. Five minutes from the start of the call until the second we clambered over the building site of a driveway and into the house.

As I stepped across the threshold, I heard her scream, and breathed a sigh of relief. You can't choke and scream at the same time. It's physically impossible, so I knew Milly was no longer choking. The look in Milly's parents' eyes told the story. There was a mix of fear and panic, along with tears of relief welling up, threatening to burst their banks.

"She must have picked up a marble when we weren't looking. That's all I can guess, because they weren't all over the floor before".

I left Milly in dad's hands whilst I listened to her lungs, and checked that her breathing was completely back to normal.

Dad started to tell me what he did. "I just picked her up and stuck my finger in her mouth to see if I could find anything, but there was nothing there!"

Alarm bells rang. "I don't mean to tell you off, and I certainly don't want to scare you, but please don't do that again. If you blindly put your finger in, you could push whatever is there in the wrong direction, which could be the worst thing to do". He looked shocked.

"And then I tipped her upside down, and patted her on the back, and then you came in and saw what happened." Now, that's a better idea.

"Can I ask you a question?" said mum. Questions always welcomed, I just hoped I had the answer.

"If she'd have kept choking, and you'd have been another couple of minutes, would you have been here in time?"

I had to be honest. "Possibly not", was the best answer I could come up with. "But that's where you come in. That's why control give you the instructions, to give us the extra time to get here. You need to be able to help us to help you".

On the way to hospital, we talked about how kids are there to scare us as parents, how, even with all my training as a paramedic, I still hate it when it's one of my kids that's unwell or injured, and how MrsInsomniac has the luxury of panicking whilst I deal with whatever crisis may arise. Except, obviously, when I'm not there.

"So what can I do?" Milly's mum asked.

"Well, a first aid course would be a great start". It's something I strongly believe every parent should be offered and something I recommend regularly to all parents I meet in the line of duty.

It's true. First aid courses can't prepare you for every eventuality, but they can give you the confidence to know that what you're doing is definitely going to help, at least until the ambulance arrives. Whether it be CPR, how to deal with burns, with injuries, or, just like in this case, with a choking baby. Those few minutes of immediate care can make all the difference. They could change the outcome, they could improve survival chances, and they could even change my answer to Milly's mum's question, and in fact, the question itself.

Instead of saying "probably not" to the question she asked, she could ask a different one, a question with a very different answer.

"Could I be the one to make the difference?"

With just a little bit of training, even of the very basic kind, very probably.

Driving Skills

At the age of 17, like so many others, I learnt to drive a car. Actually, that's not exactly accurate.

At the age of 17, like so many others, I learnt to pass my driving test.

I learnt about Mirror, Signal, Manoeuvre.

I learnt about road signs.

I learnt to parallel park.

I learnt to drive on slow roads and fast roads.

I learnt to reverse around the corner.

At 17 and a little bit, on a Monday lunchtime, I walked into the staffroom at the school where my mum used to teach, with a dozen pairs of eyes staring at me and my glum-faced expression, none brave enough to ask if I'd passed the test or not. My mum, standing the other end of the room and obviously knowing me better than anyone else there, saw straight through the fake sadness, spotted the glint in the eyes, and without a word spoken, threw her car key across the room to a round of applause.

That was the day I started to learn to drive.

*

At the age of 26, I learnt to be a paramedic. Actually, that's not exactly accurate.

At the age of 26, I learnt to pass the first of many tests to be a paramedic. Yesterday, a patient reminded me of it just by asking a simple question.

"Do you get taught how to stay calm through everything you see, or is it something you naturally have to have before you can join the Ambulance Service?"

To me, that hid an altogether different question: where do you learn how to become a paramedic?

Is it all the sitting in classrooms, bored to death by endless powerpoint presentations?

Is it by spending time in the operating theatres, practising cannulas and intubations?

Is it by listening to lectures on how to treat everybody the same?

Is it by reading through the book about drugs, their actions, their contra-indications and being able to recite them all off by heart?

The answer to all of these are easy. Yes. That's where you learn how to be a paramedic. Or at least, that's where you learn how to pass all the assessments that qualify you as a paramedic.

For me, that's not enough. I don't just want to be able to pass my driving test, I want to learn to be a good driver.

By the same token, I don't just want to be able to say that I have a certificate that says I'm a paramedic, pay my annual dues, and finished. That's the easy bit.

I want to be a good paramedic.

That's what you learn after you get your certificate.

That's when you learn how to use all the skills you've just been handed.

*

You learn to use common sense, you learn empathy, you learn sympathy.

You learn that the technique with which you cannulated your patient in theatre, where all is calm and controlled, won't be the same when you're cannulating a patient in cardiac arrest on his home floor with several family members watching your every move.

You learn that the worst case scenarios which always seem to occur in assessments, are really few and far between. But in the meantime you see cases of domestic violence that you were neither trained nor prepared for.

You learn all about how a heart attack patient might look and feel, you'll know how to treat and transport them, but how do you keep them calm and reassured?

You realise that you're an expert at CPR, yet you were never taught how to tell someone that their loved one has died.

You find that you were given a stab vest to wear, but are never quite ready for the time that a patient or their relative suddenly turns into a threat.

You discover that when you're treating a young child and their asthma attack, when your knowledge of the right drugs is important, that the way you are treating their parents is equally critical.

You find that even if you know theoretically how to treat every patient you see, sometimes you need to treat yourself. The trick you aren't taught is to know when that sometimes is.

Oh, and you learn to reverse around the corner again. This time in a truck.

*

The list is jumbled, just like the real world of the paramedic. A shift can, and often does, range from the sublime to the ridiculous, from the mundane to the life-threatening.

Despite every lecture to the contrary, you find that you can't treat everyone the same, because everyone is different. What you can do, is treat everyone to get the same result.

Most importantly, you learn that you cannot learn it all. Certainly not at once.

It takes time, patience, an open mind and a willingness to learn in order to perfect those driving skills.

Hopefully I'm getting there.

There

The drops are stopped in their almost perpendicular path by the windows, housed in the walls that has been their home for over sixty years. They continued their gravity-powered journey and soaked the ground below. He sits watching the weather, the tears falling from his eyes mirroring the rain, falling silently off his cheeks to the carpet, soaking in before they could leave any trail.

The door had been left open for us, and we avoided the more usual soaking whilst waiting on the doorstep.

"We're in here", comes the strangled voice from the front room. We went bundling in, four green-suited, adrenaline-driven life-savers. We were overladen with bags full of kit that we already knew, just from looking at the call on the screen, were redundant, and highly-qualified and well-trained with skills that we knew from the outset, would do no good.

We were there to confirm what he already knew, as he sat stroking her hand, her head on his shoulder.

We were there to ease the burden of him having to utter the words he could barely cope to think.

We were there to see to it that he wouldn't be left with no-one by his side, as he kissed her goodnight for the very last time.

Trouble

If you're trying to multi-task,
Doing CPR,
Setting up equipment,
Dealing with relatives, neighbours, nosey passers-by,
Talking to several different agencies,
Informing control on the radio,
All about the traumatic cardiac arrest you're dealing with,
Please -
Don't use the phrase "Kill two birds with one stone".
You're only asking for trouble.

Cul-de-Sac

The cold temperature in the dingy basement flat matched the frost-bitten air outside. Small icicles surrounded the windows, the only light was that of a lone candle, battling to break through the dark of another winter's night. The kitchen, bathroom, living room, even the bedroom, all crammed into a flat no bigger than an average family car.

*

The fire-call seemed straight forward. A ground floor apartment, probably a kitchen fire. There was smoke billowing from the broken windows, but the Fire Brigade seemed to be in control now. The ambulance's occupants enjoying the respite that these types of calls often bring. We're only there "just in case". In case one of the Brigade are hurt, or in case any occupants are found and need treatment.

*

In the middle of it all, surrounded by the barest of bare essentials and wrapped in layers of blankets, sat Ray, looking almost double his middle-aged years. Hardly more than a skeleton wearing a thin layer of skin, with sunken cheeks and saddened eyes, he was clearly embarrassed to let us in. "I don't know where to turn any more", he started. It was tough to work out if his speech was shaky because of the cold, his fear, or a medical condition. "My family have either died or left me to do the same. I have no help. No gas. No electricity. I steal or beg to eat, and only keep warm by wrapping up in layers. I have no light and no heating. I just need to be somewhere warm".

*

The white-helmeted Station Officer had come over to let us know that they didn't think that there were any occupants, but that they'd still like us to stand by. "Hang fire", he says, his grin indicating clearly an intentional pun. "We've still got guys in breathing apparatus. Once they're all out and OK, we'll let you go." We're in no rush. We have chocolate. We have drinks. We have hours left of our shift, and now we have a break. The music's turned up just a little more.

*

Cases such as these are rare, but not as rare as I'd like to think, or hope. In a country famed for its welfare, cases like these have no right to exist, and where they do, they should be easily and quickly solved. Many, too many of them are unknown, shame and fear preventing those suffering from doing anything about it. Ray had had no heating or light for several months. The utility companies seemed just to give up on getting their money, cut off the supplies, and never bothered to check if anyone was still living there. There was wax everywhere from where he'd lit the candles, bags full of rubbish that he said he still had to go through to see if he could find anything worth salvaging for food, and filth all over the space that hardly qualified as a kitchen.

*

One more update from the Station Officer. The last of his crews was now going into the building, to ensure that it was well ventilated and assess when it would be safe for the other residents in the vicinity to return back to their own homes. "A few more minutes guys", he says, talking over the noise of the generators, the pumps and our radio. It's all now a matter of minutes before we'll be back on our way to the reality of ambulance work.
*
One thing was for certain. Ray couldn't stay here any longer. Irrelevant of any medical need - he was going to hospital. At least there he'd be warm, fed, showered possibly, and most importantly there would be time to get the system in place for him to be cared for long-term. It wasn't an ideal solution - just the start of one. He was unsurprisingly hypothermic, his pulse was low, his blood pressure too. It was surprising he was still sat up. We brought the chair in for him, but he refused it, wanting to salvage his last vestige of pride, and chose to walk to the ambulance. He got as far as the door and caved in.

*

Then came the shout. "There's someone here! He's not breathing! Get the paramedics!" We both hear the Brigade's radio over the music channel we're listening to in the ambulance, and jump out of our seats. A Fireman's Lift is given a whole new meaning when you actually see a lifeless body being carried out by a fireman.

*

The journey to hospital was uneventful, we left him in their care, filled in the multitude of forms to get social services involved as quickly as possible. Something must have worked somewhere. Not long after that, I had a call to the same building, to see an estate agent's To Let sign outside. I had a peek through the window and saw that the place had been cleaned up, was brightly painted, and now just waiting for a new resident. Ray was nowhere to be seen.

*

He was placed on our trolley bed, and the resus started in earnest. His face was covered in soot, his skin cracked, his eyes glazed over. Someone started on compressing his chest, trying to beat a rhythm into his arrested heart, whilst I was in charge of using the bag and mask, to breath some oxygen into his burnt lungs. I removed the mask from his face and prepared to intubate him, so that the oxygen we were pushing in to him at random with a mask hit exactly the right spot via a tube.

*

I spoke to the sister in charge to find out what had happened in the interim. She told me that he'd been moved to a ward and would probably spend a few days in hospital. Social services had been contacted and the system's cogs were turning, trying to find the most suitable answer to his problems. For some reason this call bugged me, so I followed up again a few days later to find that he'd been rehoused. I hoped it was clean, warm, and had 1st world utilities, instead of 3rd world conditions. I hoped he was on the road to recovery.

*

One of the bystanders, forced out of their neighbouring apartment by the fire, told us that he'd only moved in a couple of weeks previously, that he seemed pleasant, but kept himself to himself. She didn't really know any more about him. As I took the mask away, I saw a face I couldn't forget. I hadn't noticed in the first moments he'd been thrown at us. Ray's face, covered in smoke and contorted in pain, his eyes, once saddened, now looked back at me again, this time glazed and lifeless. His chance at finding a road to recovery reaching no more than a cul-de-sac.

Information

Dear Patient,

I'd like to ask for your help. Please.

When I ask if you have any medical history, can you please do me a favour and give me the information I've asked for? It makes my life a little easier, it may change and probably improve your treatment, and, slightly less importantly, makes me feel a little less stupid when you tell the hospital staff something that you never told me...

There are several ways to garner a history. I normally start with a very simple "do you have any medical problems?"

Often the answer is something along the lines of "Not really, I take medicines for those..."

Then begins the sometimes laborious task of locating said tablets, seeing if what's in the boxes is what it really should be, working out which treats what, and when they're due to be taken. Blood pressure, diabetes, cardiac failure and chronic breathing problems, are easily the most common conditions I meet on a regular basis.

Then there are the less common. Things like sickle cell crisis, Addison's disease, lupus, and a myriad of other ailments that I either haven't heard of, or don't know enough about, that then I have to go and read up on. Whatever it is, I need to know about it.

I admit that if you're in your sixties, and are complaining of chest pain, I don't really need to know about the leg you broke when you fell off your bike 50 years ago, or the fact you had appendicitis when you were in your twenties.

However, if you are in your sixties, and are complaining of chest pain, it might be important to tell me other bits of information.

Information such as the three previous heart attacks you've had in the last two years.

Information such as the fact that this pain feels identical to that experienced in those three previous heart attacks.

Information such as the fact that each time, nothing appeared wrong with the ECG, but your blood tests and later angiograms showed otherwise.

And most importantly, information such as the fact that on each of those occasions, your heart actually stopped whilst you were either on your way to hospital or once you were already there.

That's the sort of stuff we need to know. The important stuff. The sort of detail that may actually help us to help you. Please.

By the way, please say hi and thanks to your heart for not stopping this time. It was good news for both of us...

Much appreciated.