Tammy

A crescent moon hangs in the sky, fighting for supremacy over the scattered clouds. Street lights and unnecessarily illuminated buildings pollute the atmosphere and hide the stars, but the blue lights twinkle in their stead. The night is drawing to an end, the last night. The last shift. As it heads to a close, I think back to my first day, my first call, my first patient and wonder if my last call is going to be quite as bizarre.

The calls all night have been routine. No major trauma, no critically ill patients.

"What would you like your last call to be?" My observer for the shift had been quizzing me all night on all aspects of my years on the front line. What had I seen, what had I missed, how had I coped with the mundane, the bizarre and the upsetting.

"I'd love to deliver a baby. Bring one more life into the world. I think that would round everything off very nicely."

It's a far cry from my early years. Maternity calls used to terrify me, even the simple transports. The thought that a routine call could go so horribly wrong, the thought that I could suddenly be thrown from caring for a straightforward pregnant woman to suddenly fighting for two lives at once, used to scare me more than any other call.

A healthy dose of reality, six months on the Baby Bus and delivering almost a dozen babies in just one year (I wonder if that's some sort of record?) put paid to that fear. In total, over the years, I delivered sixteen, but none in the last year. Just one more would be a nice way to end.

"I guess it'll be nicer than a resus!"

"Pretty much anything would be nicer than a resus."

The address appeared on the screen but there were still no other details. A minute later, an update gave the patient's age and gender. Forty-eight year old female. There was still some hope that it would be what I'd asked for, although the chances were slim. Eventually, the call was completed and categorised. Red 2, Breathing problems. Delay as caller very distressed. Caller is patient's mother.

It could be anything from a panic attack to an asthma attack, from back pain to a head ache. It might, just might, even be the wished for maternity. Approaching the address in the early hours of the morning whilst watching the horizon start to brighten, the two of us travel the last mile in silence, trying to prepare mentally for what we could be about to see and the fact that at least for one of us, it'll be for the last time.

An elderly lady, presumably the caller, stands outside the property, one hand on a walking stick and the other using a car bonnet for balance.

"Quick, quick! She's just in the lounge. She won't talk to me!"

Between the two of us, we grab all the bags we're likely to need, at least to start with, to deal with anything from a simple faint to a cardiac arrest. At least five decades younger than our host, we overtake her on the way to the patient and find Tammy sitting in an armchair, eyes wide open but unable to speak. Her mum had finally caught up with us, automatically accepting the two strangers in her front room as if she had known and trusted them for years.

"There's been nothing wrong with her. She's always in and out of here making sure that I'm alright, but she doesn't even take paracetamol!"

Tammy's blood pressure is high and her pulse slower than normal. Her speech is slurred and confused, and she seems troubled by her lost faculties. One arm is strong, the other has no power at all. She can move her head with no problems, so we ask questions with yes or no answers. She understands some, appears confused by others, but keeps trying to answer.

The ambulance arrives, a crew I recognise and who both immediately understand two things; the seriousness of the patient's condition and the fact that this will be my last patient. One unfolds the carry chair, the safety rings clattering into place as they rattle metal on metal. Tammy is helped into the chair, wrapped in a blanket to keep her warm and secured with a strap to keep her safe.

Loaded once more with the bags on our backs, my observer and I walk out behind Tammy and the crew and watch as she's loaded into the ambulance. The tail-lift shuts into place with a thump, the hydraulic whine easing as the pressure is taken off. Moments later, the back door closes too, the blue lights are switched on and Tammy is rushed to hospital.

The return journey to station is almost silent. Traffic is starting to build as the world begins to go about its daily business. A thousand thoughts run through my head. A thousand faces, a thousand places, a thousand cases. But as we finally pull in, driving into the garage for one final time, only one face remains. Tammy looking back at me through the open ambulance door and nodding a wordless thank you. 

Crisis

The front door is ajar and as I knock and enter, a voice from upstairs directs me to the drama. Two people are in the room; one frantic, one calm. Violet, lying on the floor with a weeping head wound is relaxed and resigned to her fate. Her son, Donovan, tries to sit still and move out of the way all at the same time, causing him to trip and almost fall on top of his mother.

"I'm sorry," he says, "I'll just... Well, I'm... Oh, I'm not much use in a crisis. I'll get out your way now."

"Donovan!" calls his mother. "Will you settle already. I'm alright. They'll look after me now!" The gentle sing-song of her West Indian accent finally seems to have an effect, and he's able to step out of the way and relax a little.

Distraction tactics at the ready, I ask him to find me his mother's medications, write down a few basic details and generally try to keep him out of the way for long enough to assess some basic observations and wrap a bandage round Violet's head.

"Oh, that's better!" he says, returning to the room once some of the mess had been cleaned up and the bandage hid the injury. "Did I mention that I'm not much good in a crisis?" 

"Don't worry. I'd fret too if it was my family." Turning back to Violet, I gently break the news, worried that I was about to have a fight on my hands. "Now, miss, we need to get you off to hospital. There's a hole in your head that needs some proper fixing." 

"I knew you were going to say that. Can you just get me my slippers?" 

Without a word, Donovan turns to find the footwear. 

"And I'll need my keys." 

"Keys, right." 

"And don't forget my handbag."

"Handbag too."

By the time he's half way down the stairs, the list has grown to almost a dozen items, each call from Violet repeated with a resigned sigh from Donovan and an amused smile from the ambulance crew and me. Whilst he runs around the house turning off lights, checking doors and gathering medications, we get Violet as comfortable as possible in the carry chair and move her downstairs and into the ambulance, the crew carrying Violet as I carried the bags. 

After a few minutes, Donovan knocks on the back door of the ambulance and hands a bag through. 

"Did you find everything?" Violet quizzes him.

"It's all in there!"

"Keys, money, tablets, phone?" 

"Yes Mum. Keys, money, tablets, phone."

"Slippers?" 

"They're on your feet, Mum." 

"Oh yes. So they are." 

"What about the lights? Are they off? Did you check the back door's locked?

"Yes, Mum. Off, and locked." 

"Oh, and what about my hairbrush?"

"Hairbrush? What do you need a hairbrush for? You're going to hospital, not a fashion show!"

"Donovan, don't argue with your mother. A woman always needs a hairbrush in her handbag, no matter where she's going!" 

As he runs inside to retrieve the hairbrush, muttering the whole way there and back again, Violet relaxes back on the trolley bed, and allows herself a smile. 

"Kids, you know what they're like, don't you? Even when they're grown up they're hard work sometimes. I mean, look at all of this. Just a simple trip, and he falls to pieces. But he's a good boy really, always looking after his mum. He's just not very good in a crisis." 

Animal Farm

Towering over me, with arms as big as a normal person's torso and wearing a vest that showed off tattoos from his shoulders to finger tips, Tom struck an imposing figure. As he opened the front door to let me in, I could hear barking from somewhere else in the house. 

"Is that dog locked away?" 

"Are you kidding me? He won't do you no harm! He's only a little thing."

"Yeah, the last person to say that to me then suddenly had to apologise and explain that Ooh, he's never done that before!"

"OK," Tom said, a mischievous grin crossing his face, "I'll go get him and lock him in the garden. Mum's in the back room with him, so you can follow me." Tom led the way, making sure to grab the dog as he went. "This is what makes you nervous? And I don't?" Every word dripped with sarcasm, and he had a point. The dog was probably no bigger than a child's football, and looked even smaller in the arms of his giant owner.

"Yes, and no. I can read people, they don't often bite, and I can usually run faster than they do. Dogs on the other hand, I can't read, often bite, and have four legs that are quicker and better than my two." 

Tom was still laughing at me when the crew arrived to take his mum to the hospital, but he did shake my hand and thank me for my help. He took great pleasure in telling the crew, Jill and Rachel, of my nerves, and they joined in the laughter at my expense, Rachel even going as far as asking him to get the dog so they can meet it. 

One-nil to the crew, but revenge is a dish best served cold.

An hour later and another call. This time the only noise I can hear at the front door is the wheeze coming from the lounge. A girl of mid to late teens opens the door. She looks frightened and worried, and practically drags me through the door to see her eight year old brother who's sitting on the couch struggling for breath. I kneel down next to him to start reassuring him and begin his treatment.

"He's got really bad asthma, and his inhalers aren't working. Mum and Dad let me babysit him for the first time tonight, and I didn't know what else to do." 

"You've done just fine, you did absolutely the right thing, so don't worry." Sometimes part of the treatment is treating the family too. "We'll have him sorted in no time at all, but you'll have to go with him to the hospital in the ambulance. Just give your mum a call and let her know what's happening." 

Mum instantly asks to speak to me, and I did all I could to calm her down. I apologised for disturbing their evening out and tried to ascertain a few more details.

"Does he have any allergies?" 

"Well, not to any medicines, but he's allergic to furry animals. You know, cats, dogs, guinea pigs, that sort of thing." I was relieved by that bit. "That's why we eventually let him get a snake." 

"A what?" 

"A snake. It's still quite small, only about five feet long, and he normally leaves it in the tank under the couch." 

Slowly, I lower my head and peek under the couch. There, staring at me from a glass fronted box, is the snake. It makes me jump a little, which probably had more of a therapeutic effect on the little man than any medicine I was throwing at him, making him laugh at my fright. 

"Don't you like snakes?" 

"Don't mind them too much, just didn't expect to be sitting next to one for so long without realising it." 

The room lights up in flashing blue as the ambulance pulls up outside, and two familiar voices are shown into the house.

"Aha! So we meet again." 

"No dogs for you to be afraid of this time then?"

"Well, as it happens, there is. He's terrified of me this time, and won't come out from under the couch. Maybe he knows I don't like animals much." 

They both crumbled at the thought of another tiny dog worrying me, so both knelt down to see if they could entice him out. I gave the brother and sister a quick signal to keep quiet. In an instant, there was a scream in stereo. Jill and Rachel both glared at me as I served up my revenge. 

One-one. And the dish wasn't even cold yet. 

As dawn approached, Jill, Rachel and I met on our third call of the night. We both arrived at the same time, and still just about had the energy to tease each other. 

"I'll tell you what," I said, "we'll make a deal. I'll make sure there are no snakes, if you take care of any dogs." 

"Deal," they replied in unison, as we walked up to the front door. 

A mother introduces us to the patient, her six month old baby, and immediately apologises. She talks in hushed tones, explaining that two other children are sleeping upstairs.

"You'd think I'd know better by now, after three kids, but I think I panicked a bit. She just coughed up a bit of her feed, and couldn't catch her breath for a few seconds. I'm sure she's fine." 

As Rachel checks the baby, Jill and I spot a huge fish tank, an aquarium that was more part of the wall, separating between two rooms. Dozens of beautiful fish swam around, adding colour and calm to the room. 

"Finally," says Jill, "an animal we can all agree not to be nervous of!"

"Well," I said, and Jill looked gleefully forward to me admitting another irrational fear, "I don't mind them if they're swimming, as long as I don't have to eat them!" 

"You don't eat fish?" 

"Can't stand the stuff. Can't eat it, smell it, look at it, or be within a mile radius of the stuff without feeling ill." 

"But you're not actually scared of them then?" 

"No. Not scared. It's just that I'd rather meet a live shark than a fillet of salmon or tuna steak."

At shift's end, I pack up and head for the animal-free sanctuary that is home. No dogs, cats, snakes, fish, or other creatures. Just as I was about to go to bed there's a yell from downstairs.

"Are you asleep yet?"

"Yes!"

"Good. Get up. My dad's had a fall in the high street and is a bit of mess. Can you go get him and see if he needs hospital?"

A grump, stomp and re-clothing later, I was back downstairs and ready to go out.

"Where is he?"

"He was helped up by some people but he didn't want an ambulance, so they helped him into some shop."

"Which shop?"

"The one next to the bank."

"There are two. One each side. Which. One?"

"Um, your favourite."

"My favourite? What's my favourite?"

"Umm, the fishmongers."

At least Jill and Rachel wouldn't find out.

Oil Spill

Monday morning. 

Early. 

As the world begins its weekly ritual, a few tired night workers are preparing for their midweek weekend. Empty milk floats head back to their depots, their early morning rounds completed, many a front doorstep adorned with their goods. Autumnal sunrise greets the early risers, the sun shedding plenty of light but not yet enough warmth to clear the dew from the grass and the roads. 

Mike is one of the masses, joining the rat-race and heading into work. In an effort to make his journey easier and quicker, he abandoned his car in favour of two wheels. For months, he'd enjoyed the fact that he could cut through London's standstill rush hour, leave home a little later, arrive back a little earlier, adding a few precious extra minutes with his family every day. 

The call on the screen brings back memories, ones that I'm not keen to relive. Motorcycle under a van, status of patient unknown. When the call comes in, I'd just finished dealing with an acute case of probable paediatric schoolitis, a common childhood ailment, regularly apparent on Monday mornings. There were twenty minutes left of the shift. The call was some five miles away, and would take me straight past the front door of the station, frustratingly close, yet so desperately far. My relief was probably already there drinking coffee and awaiting my return. A few minutes later, Mike and I meet for the first time. 

Unlike the call I'd feared, Mike's head was visible, and he was actually sitting up, helmet off, and talking quite happily. His right leg, however, is wedged between the two back wheels of the van. His bike is lying on its side in front of the van, smashed shards of shimmering glass mingling on the road and glistening in the sunlight. Just in front of that is a small pile of powder covering what we presume is some oil on the road. 

"I don't really remember what happened, I just lost it on the wet road I think. Next thing I know, there's a van on top of me!" 

A quick conversation with the van driver gives us a few more clues and leads us to believe that Mike's had his leg run over by both the front and the first of the back wheels, with the van coming to a halt before the third wheel added insult to injury. 

Unsure of the exact circumstances, Mike's neck is immobilised in a collar and he's laid flat. The fire brigade, having arrived a few minutes later, have secured the van and lifted it high enough for us to get to see Mike's leg. His leathers are intact with only a few scuff marks, but his foot is lying at an unnatural angle, giving away the secret hidden beneath the leathers. As we cut the trouser leg away, the damage is obvious. Several breaks, the worst at the ankle. 

As usual, several things happen at once. A cannula is placed in Mike's arm, giving easy access for some pain relief. A scoop stretcher is placed under him, ready to move as soon as he is secured. Some bandages and a splint are applied to his leg. All while someone else checks for any other injuries, and luckily, finds none.

In the ambulance, once Mike was settled and his pain controlled enough, there are a few moments for a quick conversation.  

"I think you might have slipped on some oil, or diesel. There's a patch already covered up with some gravel, just by where you came off your bike!" 

"You talking about the white grit-like stuff?" 

"Yeah, that's it. Someone must have put it there not long before, it still looked quite clean." 

"Ah. That's not grit or gravel." 

"How do you know that?"

"Well, I work for a pet shop." 

"And?" 

"Well, I was on my way to work with a big bag of cat litter hanging off the handlebar..." 

S'pose

"I know you," he says, his knock on the window jolting me out of my nocturnal daydream. "You picked me up when them cops came to my house! S'pose you don't remember." 

"Craig?" 

"Good memory you've got there." 

"What are you doing here at four in the morning?" 

"Oh, you know. This and that. Just hanging around." 

"Outside a hospital?"

"S'pose this is where I live now. Under section, in the nut house round the back. They just let me out for a smoke, but I ran off to get a better spot." 

Craig was dragged away from home a couple of weeks earlier by the police after destroying every piece of furniture in his house and threatening to set fire to the damaged remains. His mother begged us to let him stay at home, claiming it had never happened before, that he was just drunk, and that she'd look after him now. Two facts prevented that from happening. The first was the fact that it was taking the full force of several police officers to restrain him, and the second was the arterial bleed from his arm. 

Craig went back to sitting on the wall where he must have been perched before scaring the life out of me. It was three storeys up from the ground, with nothing between him and the concrete below. 

"You know, I'm pleased you're here. You can be my witness." 

"Witness for what, Craig?" 

"For me jumping off here. You can tell them that I meant it, that I didn't just fall." 

"Jumping? What do you want to do that for?" I sat there, frantically wracking my brain for a way to get some help without alerting him to the idea, but in the meantime I was happy that he just kept talking. 

He took a crumpled cigarette out of his pocket. "I 'spose you don't smoke, do you?"

"Nope. Never have done. Why?"

"Smoked since I was fourteen. Ten years that is. S'pose I knew then already that I wasn't going to have a long life. Twenty a day normally, sometimes thirty, forty. Even had a hundred once in one day, thought it would kill me there and then, but it didn't. Still here, aren't I? Still need my smokes. Still need some fresh air to smoke 'em. Pollute the air with smoke like they tried to pollute my mind. I know what they were doing to me in there!"

"In where, Craig?"

"There! The nut house!"

Craig pulled a lighter out that was tucked into his watch strap, made himself a little more comfortable on the edge of the wall and after a few attempts finally managed to light the cigarette. Two long drags later, he kept talking.

"I'm gonna finish the pack of twenty that I've got, and then that's it. I'm getting out. I've got this one and one more. That's it. No more smokes, no more police, no more hospitals, no more nothing. Glad you're here, anyway. I already told you that, didn't I?"

"You did. But I might be gone in a minute, if I get a call."

"S'pose I'll wait 'til you get back then."

As if on cue, the computer rang and sent me out into the night, heading in the vague direction of a jumbled set of coordinates on a map. Someone had called in from a mobile phone, and before the exact details are confirmed, the system works out which mast the call is routed through, and starts sending me there. The little red triangle on the map showed a point less than a mile away. Now that I finally had the chance, I called up control and let them know about Craig, where he was sitting, and that they need to send someone, anyone, to stop him from carrying out his threat.

A minute or so down the road, the details of the call finally came through.

Location: Nearby Hospital, by the A&E entrance. 


Details: Male, unknown age, threatening to jump off high wall. Ambulance car was on scene, now left. 


By the time I'd turned round and got back to where I started, two members of staff from the Mental Health unit were talking to Craig, as a police officer helped him off the wall. He looks up at me, perhaps confused by my swift return, perhaps amused by it.

"You know what," he says, as a pair of handcuffs are applied, "I'll do it one day, whether you're there, or anyone's there. Or not. S'pose it's back to the nut house. S'pose I'd better get another packet of smokes, though."

The Look

It's that look. The look of someone who knows they're going to die, and very soon. The room is a hive of activity, several people buzzing around trying to help but becoming more of a hindrance, and in the corner, almost hidden from view, is Glenn. His hands clasped at the back of his head, whilst Jana, his girlfriend, tries to comfort him through her own tears.

Glenn's face is tinged with blue, his lips are almost purple. He's breathing, but hardly moving any air. It seems as though his body is going through the motions, the reflex action of the diaphragm shifting up and down to allow the lungs to expand, but the area created turns into a vacuum instead of a lung full of air. The supply to his extremities has practically stopped, the brain electing to feed his core organs first on a starvation diet of rapidly diminishing oxygen. It leaves his finger-nails a deathly shade of white, whilst his pupils are dilated seas of black. The fear in his eyes radiates from head to toe. 

"He's so healthy normally," Jana tells me. "He doesn't take any medicines, not even for a headache!"

She goes on to explain that they'd been out for the evening and had no more than a glass of wine each alongside a meal at a favourite restaurant, one where they had eaten many times before. A minute or two from home, they stopped at a set of lights.

"A friend of ours stopped next to us at the lights, just by chance, and we chatted and waited for the red light to change to green. Then, he threw a piece of chocolate at us, just as a joke. It flew through the window, straight into Glenn's lap. He picked it up, popped it in his mouth, and then we drove off laughing."

The half mile home was uneventful, but as they walked through the front door, Glenn felt his throat starting to tighten.

Jana, worried that Glenn was choking, woke their housemates not knowing what else to do. One of them called for the ambulance, and five or so minutes later I arrived. Glenn is unable to speak, but the signs are classic enough. Textbook cases of anything are rare, but this one was just that. Anaphylaxis kills, and it kills quickly. Glenn's oxygen levels were low, his blood pressure dropping, and the unknown chocolate the final giveaway when Jana remembers he's allergic to nuts. He's carried an Epipen for years, but had never had to use it. The only one he had was ten years out of date.

As I prepare an injection of adrenaline, I place a mask on his face forcing oxygen laced with salbutamol into his lungs, hoping to prise open his airway. He's rapidly becoming less responsive, fighting to keep his eyes open, struggling to stay conscious. The injection into his upper arm is a last gasp attempt, but within seconds it's clear to see that it's working.

Two minutes later, the crew arrive, and as they walk in, Glenn greets them.

"Hey guys, I'm alright now!" His breathing is still a little laboured, and a loud, audible wheeze rasps across the room. It's a much better sound than the total silence of only minutes earlier.

"Don't you EVER do that to me again!" Jana slaps him on the shoulder, and then crumples sobbing into his arms.

Glenn's wheeled out to the ambulance, his oxygen levels vastly improved and his cheeks a flushed rosy colour.   In the ambulance, his blood pressure is up, the wheeze is slowly being replaced by clear breaths, and he's almost able to complete a whole sentence without becoming breathless.

Most importantly, the look in Glenn's eyes has changed. Now he no longer thinks he's going to die - he knows he's going to live. 

Crosswords

Mrs Vine and I could easily be on first name terms by now, except that she's very much old-school. I learnt that very quickly the first time we met on what was supposedly a "Breathing Problems" call. Control called me on the radio and let me know that she'd already called half a dozen times in the past few hours, each time claiming to have a serious problem, each turning out to be nothing of the sort. 

With the key to her front door locked away in a coded key-safe, she never had to leave her room to let anyone in. She would just tell the control room the number we need to crack the safe, and they send it down the computer screen in the car. I'd hardly set foot in the house and was looking for somewhere to put the key so I wouldn't forget to replace it, when a shrill yell cascaded down the stairs. 

"Close that bloody door already! I'm getting cold up here!" An ominous start.

Her voice reflected the night - cold and miserable. I tried to be a little more cheerful. 

"Good morning, Miss. What's made you call the ambulance out tonight?"

"Don't call me Miss. I have a name!" 

I didn't expect to have to ask the question, having been already chastised, but as she seemed to be waiting for it, I obliged. 

"And what is your name?" 

"My name is Mrs Margaret Vine and as we're not related, I'll expect you to address me as Mrs Vine." 

"Right then, Mrs Vine. I understand you've been having some problems with your breathing?" 

"There's nothing wrong with my breathing. It's just what I told that woman on the phone, because she kept banging on with these stupid questions and I just wanted to make sure that I got one of you here." The contempt in her voice almost made me want to leave, or at least explain the reasons behind all the so called stupid questions, but in the end I decided that both plans were futile. In the first instance she'd call again, and in the second, any explanation would probably go in one ear and straight out the other. 

"So how can I help you?"

"Well, first of all, my carer's left me." She was still shouting as if I was stood downstairs by the front door, despite the fact that there was no more than a metre between us. I'm a little ashamed to admit that the idea of her home help abandoning her didn't surprise me in the least. "And then, the cleaners don't come when they're meant to, and my doctor's completely useless and won't do what I tell him to!" 

"I see." I wasn't sure that I did, but I was trying. "And how can I help?" 

"You can pass me the newspaper and a pen, and sort these pillows out for me.Then I'll be able to do the crossword and hopefully fall asleep!"

"You called an ambulance to pass you your newspaper?"

"Yes. And to sort out these pillows. I shan't ask again." 

"And then you're going to sleep?" 

"As soon as I finish the crossword." 

"Fine then." 

As I found the paper and the pen, and fixed the pillows, I thought about offering to help with the missing crossword clues just to hurry the process along, but decided to leave her to it. I found the key, and as I stepped out across the threshold, Mrs Vine's voice once again filled the night air. 

"Close that bloody door already! I'm getting cold up here." 

I left the house and hoped she finished the crossword before I finished my shift.

You Lot

Balancing on the icy pavement, Alfie flags me down and watches the car practically skate down the road towards him. The snow has finally stopped, and what's left on the roads is now compacted into thick sheets of ice. The nights seem brighter, moonlight and streetlamps reflecting off the shimmering surfaces. Abandoning the car in the middle of the road, I step out onto the frozen pavement making doubly sure of each step. Non-slip boots might work on oil, or water, or blood, but they're useless when competing with ice, so I put a bag on each shoulder, hoping for some extra balance.

"She's in here, mate," Alfie yells, already standing back in the front porch. I follow him in, and as I catch up he starts telling me a little about her.

"Mum's got dementia, so you have to take some of what she says with a pinch of salt. Other than that, she's pretty good. Only takes an aspirin every day." He shows me into the bathroom, a favourite haunt for elderly fallers.

"What's her name?"

"Loretta Dent. But just call her Loretta. She's not really one for formalities."

"Hi Loretta," I turn towards the patient, kneeling down beside her, "what are you doing down there?"

"Well, I'm not really sure! I was just on my way back from the loo, about to go to bed I think, and the next thing I know, Alfie's in here with me, a phone plugged to his ear, and he's telling me not to move!" She looks around her, making sure that she really is on the floor, and that she's not going to fall any further.

"Alfie!" She calls. "Alfie dear, be a good boy and pick your school bag off the floor. Your father will be home any minute, and you know how much he hates things in the middle of the lounge!"

Alfie takes me to one side, and explains that his parents divorced when he was twelve years old. He hasn't heard from his dad since, some forty years or more.

"It's alright Mum, everything's clear. Let's get you sorted. This nice gentleman has to come to help you up off the floor." A mock look over my shoulder to locate said nice gentleman fails to do so, and I tell Loretta that I presume he means me.

"Are you a doctor?"

"No. A paramedic. An ambulance man."

"Oh, well you're better than doctors anyway, you lot."

"Must be the dementia!" I say to Alfie, outwardly humble, and inwardly proud. Even a little smug.

"Oh no," he replies, "this time she knows what she's talking about. You lot always have the time for us. When I have to get the doc out for her, they're in and out in five minutes. Hardly bother checking her blood pressure. Sometimes they just guess over the phone, and prescribe something. Think that absolves them of responsibility!"

I don't really know what to answer. I try to defend the doctors, saying that they're on a much tighter schedule than we are and joking that maybe they get paid by the patient, and we get paid by the hour. Alfie just shrugs his shoulders.

The crew turn up a few minutes later, and together we help Loretta off the floor, recheck all the numbers, and prepare to leave her at home so she can get back to sleep. We place her gently back in bed, and Alfie makes sure she's tucked up, the thick duvet covering her up all the way to her chin. I think of how many times I do that for my kids, checking on them several times a night to make sure they're warm enough and all wrapped up, and how many times over the years Loretta must have done the same for him. Years of motherly kindness partially repaid with each gentle gesture. 

"Goodnight, Loretta!"

"Goodnight you lot! Thank you ever so much!"

As we leave, Alfie turns off the light in her room, and walks us to the door.

"Call us again if you need us." I tell him. "If it's before seven in the morning, you might be very unlucky and it'll be us lot again!"

"Careful what you wish for!" Alfie answers. "You never know what she'll get up to in the night. You lot might be back sooner than you think."

Two hours later, we were.

"Oh, am I glad to see you lot again..."

Wings

It was 4:30am, and I was sitting on the relatively comfortable couch on station, during a relatively quiet shift on the car. Ten hours in, two to go, and I'd only seen four patients. It would normally be double, even triple that number, sometimes even more. On the car it's easy to do, especially if the patients aren't too emergent. You attend, assess, and hand over to the crew for transport, then you're ready to go again. 

My phone rang, the controller on the other end asking nicely if I could move from where I was and take up a standby position a few miles down the road. A groan, moan and miserable tone later, I drove to my new spot, parked up, reclined the seat back, and hoped for some peace and quiet. 

A few minutes later I could see a jogger running towards me, his fluorescent jacket reflecting the street lights and a rucksack on his back bouncing with each step. As a recently started runner, I admired his dedication at being up and running at such an early hour. Clearly a man with more self discipline than I could even wish for. 

As he ran past the car, I nodded a "Good Morning" in his direction, which he returned. I rested my head back in the seat, and started counting down the minutes until I could return to station. 

Thirty seconds later there's a knock on the window, and I wind it down as I see the luminous figure standing still. 

"Here," said the jogger, "you look like you need the wings more than I do!"

With that, he threw a can of Red Bull into the car, and jogged back up the road... 

Destiny

The fact that it's a regular occurrence doesn't make it any more comfortable. At least once a month, there's a call into the Custody Suite at one of the local police stations. The word "suite" belies the stark reality of concrete boxes with no more than a tiny window and an open toilet. The stench of both the current resident and all those who had spent miserable hours in the grey, gloomy cells is often overwhelming, sometimes bearable, but never pleasant. Calls to this place are more often than not an attempt to fake an illness or injury in order to end hours claustrophobic hell. Five minutes is more than enough for me. 

This time the call was for leg pain, post fall.

A police van was parked in the middle of the car park, just by the entrance to the cells. There was some yelling from the van, an incoherent babble about police brutality. Threats and promises of revenge, complaints about treatment and talk of lawyers all doing nothing to rattle the officers standing outside. I thought to myself that he'll probably be our next customer, when he also gets bored of the solitude. Between the van and the building is a wire cage, just large enough for a prisoner and two accompanying officers, leading to the heavy blue door with the one-way latch. We step in to the wire cube, the crew and I, and as we are about to enter the building itself, a call from the van spins us round. 

"He's in here!" I'm thankful not to have to step back into the cells. 

We walk back, and a sergeant quickly fills us in on events. 

"We nicked him for shoplifting. He saw us coming, ran for about a mile, and after running down something like forty stairs, he fell over a simple kerb. Ironic really." The sergeant couldn't hide the smile. "He kept going for another hundred yards, then fell to the floor. Once we got hold of him, he walked to the van, assisted by these gentlemen, and only started screaming about his leg as we pulled into here. Probably the usual trick, but he won't let us move him, and every time we try, he screams like a woman in labour!" 

Rob's still in the back of the police van, shut in the cage that will make a custody cell seem like a penthouse. As soon as the van doors open, his rants become louder and he starts to spit at the officers. As well as the metal housing, the cage is surrounded by perspex, so the spit just rolls down the plastic and onto the floor. One of the officers shouts at him. 

"We've got the ambulance here for your leg. Now shut up, calm down, and stop behaving like an idiot, and then we'll let the crew look at you!" 

A different person answer from inside. 

"Yes, sir." His tone was suddenly calm, he sat bolt upright, and waited for the cage door to be opened. Three officers stood by the door, just in case he ran. 

"Where do you think I'm gonna go?" He laughed. "Have you seen my leg?"

The police stood back, and let us in. 

"A word of warning." I said to Rob, taking a wary step forwards. "You spit at me, and police witnesses or not, I'll knock you out!" I've never knocked anyone out, but if anything's likely to bring me close, it'll be a spitter.

"No way, sir. I'd never do that to you guys. I respect you too much!" The alcohol on his breath could have knocked out a rhino at a hundred paces, and I was concerned that intoxicated, he'd soon change his behaviour again. 

"Right, well you make sure you remember that then." 

Rob smiled and rested his head back on the wall of the van. As we tried to remove his boot, Rob screamed in agony, even with all the alcohol on board. A pair of shears, a lot of entonox, a touch of morphine, and some choice words from Rob, and we could finally see the problem. Both bones of his lower leg were visible through the skin, the sharp edges of a traumatic fracture making easy work of the thin flesh. How he walked anywhere after his fall was a miracle. 

Once the pain killers joined the alcohol, Rob was calm enough for us to pull his leg straighter, splint it and move him to the ambulance. I didn't dare risk much more of the morphine, not wanting to take the gamble of stopping Rob's breathing all together, so I handed him back the entonox. 

"The police told me that you were screaming like a woman in labour. So here's the stuff they give them, should you need it." 

"Thanks," he answered, and took a large, deep breath on the gas. 

He refused to give us too many details. He either didn't want to give us an address, or genuinely didn't have one. He gave his date of birth as the 31st of September. 

"There isn't a 31st of September!" said one of the crew. 

"There was in the year I was born. It was a double leap year." After we all laughed, he clammed up completely, until we opened the doors at the hospital, ready to take the trolley off the back. 

"It's not my fault that I steal, you know," he started, "it's my parents'. Just look at the name they gave me! I mean, what do they expect if they call me Rob?" 

"Surely it's short for Robert?" asked the accompanying officer. 

"Well it is, but they've always called me Rob. It's obviously my destiny." 

"Not with that leg it isn't", mumbled the officer as we stepped out of the cold air and into the hospital. 

Irony

You're sending me? To this?

Sleeping Partner

The bed is covered in blood. The floor is too. Apparently there's loads of the stuff in the bathroom as well.

"We left it there, unflushed, just in case you wanted to see it!" I'd seen enough already, without having to go snooping in someone else's toilet bowl.

Another one of my return customers, Greg and I had met on a previous similar occasion, and probably about a year had passed since then. Maybe eighteen months. The alcohol he'd taken on board over years, slowly destroying him from the inside out. He looked pale, gray even, and was sweating as though he'd just run a marathon in the Sahara Desert.

"I'm gonna die, aren't I?" Greg asks. The fear in his voice is only too real. "Not in my ambulance you're not". I think it, but don't say it. Patients who genuinely fear it, and voice that fear, often know.

"No, Greg, you're not. We're going to get you up to the hospital as quick as we can, and get you sorted."

"We? You're the only one here!" And he's right.

"Another ambulance is on its way. They'll be here soon enough!" I hope my prediction is a self-fulfilling one. I need them in a hurry. In the meantime, I start getting some fluids into him. It's another case of salty water replacing blood, but at least it gives the heart something to work with until we can get him the real stuff he needs. The blood that's left inside him will have to work extra hard to pump round the oxygen that's free-flowing into him through the mask on his face. At least he's stopped vomiting for a while. I don't know how much he's lost internally, but just from what I can see in front of me, he must have expelled a third of his blood volume. By the time the crew arrive, he's had about a litre of fluid back in through a thankfully large vein in his arm.

I hear them downstairs and yell: "Bring a chair up with you!" Often crews backing up first responders will come in to see what's going on, and only then decide what extra things they'll need. Usually it works just fine. Luckily the crew recognised my voice, and the urgency in it, to know not to ask questions.

"Last time I needed surgery. And they gave me nearly twenty bags of blood apparently. But I don't really remember anything. They told me if it happened again, if I didn't stop drinking, that I'd probably kill myself."

He started sobbing.

"I have, haven't I? I've killed myself! And now, two days before my son's due to be born!"

A neighbour was with Greg the whole time we were there, but no-one pregnant.

"Where is she Greg? Where's your partner?" I thought that a friendly face might help calm him a little.

"She went up to her mum's last night, up north somewhere. I've got her mobile number, but I don't want to call her now. It's too early!" Barely in control of his own body, he was still worried enough about his partner and unborn child. "I didn't mean to drink so much. I shouldn't have had anything at all. It's the first time in months!"

We moved Greg to the ambulance, a creaking flight of wooden steps leading down to the front door and out into the cold night's air. Dawn was breaking across the horizon, and the traffic was just starting to build as normal people started another working day. Leaving my car on scene, I travelled with Greg, an extra pair of hands always helpful with a particularly ill patient. The siren blared its way, ensuring the cars cleared the way for us to make a smooth but rapid journey to hospital.

"I don't want to hear the sirens! I don't..." He wept again. "I just want to hear my baby cry..."

We arrived at the hospital, a team ready to meet us was standing round the designated bed.

A doctor listened to the handover and asked for some blood almost immediately, as a student nurse hooked him up to the machines. A nurse thanked his luck for finding a decent vein and put a second needle in the arm I'd left alone.

Greg's tears flowed, and he was barely able to catch his breath between sobs. "Just help me see my baby! Just once! Please... Please..."
Another nurse left the cubicle without a word, and hurried to wake his partner.

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.

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?

Count to Ten

Chest Pain.

Category A.

Immediately Life Threatening.

The FRU wails and worms its way through the early evening traffic, scattering cars and pedestrians alike. Arriving in just a few minutes at the address, where the door is opened by a woman in her 30's. I wait for her to show me in and direct me to the patient. Instead, she blocks my way in and waves a piece of paper in front of my face.

"Are you taking me to the hospital?" The look of expectation is matched by a stare of disdain.

"Can you please tell me what the problem is? Maybe you don't need hospital!"

"I've told you I need to go to hospital. Your job is to take me."

Count to ten.

I ask to see the piece of paper that was thrust in my face, and find that it's a hospital prescription for some medication that is just as readily bought over-the-counter.

"The local pharmacy says they can't fill this - only the hospital can. So now I need to get to the hospital."

Count to ten.

It's a ten minute walk at the most.

In the traffic, it'll probably be a ten minute drive too.

I ask a question I already know the answer to. "Then there's no-one with chest pain?"

"Just take me to hospital. I need to be home in half an hour."

Count to ten. Again.

I'm in no mood for a fight, so point to the back seat of the car, make sure she puts her seat belt on, and shut the door. On the walk back round the car to the driver's side, I call control and cancel the big taxi. The small taxi will suffice.

On route to the hospital she tells me to wait while she gets the prescription and then take her home.

I didn't wait.

But I did count to ten.

Thousand.

Weekend Plans

I'm glad it's the weekend.

It's been a tough week at the office.

No particularly traumatic calls to deal with.
No particularly difficult decisions to make.

I've had some good calls that have made me think and learn.

I've treated all my patients the same as any other week - with respect, courtesy and professionalism.

But along with all that - this week, the system repeatedly let me down.

*

The frustration of feeling let down by the system that I serve, is compounded and even exceeded by the feeling that the system has also let my patients down.

*

And therefore, by extension, so have I.

And that's a feeling I don't like.

*

I'm glad it's the weekend, and I'm glad I'm not working it.

I need this weekend to regroup, rethink, re-energise.

When I return next week, I hope to be back to my normal self.

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.

Icing

Recently I've written a couple of posts reflecting disappointment and frustration at the system that guides the job that I do. I love my job, I'd just like to be able to get on and do it. Sometimes I need a reminder that when all else fails, there's someone somewhere, not very far away, who will call on us and we will make all the difference. They'll be relieved, appreciative, sometimes thankful, even if they don't necessarily show it at the time.

Often all it takes is one call. One short-lasting event to remind me why it is I do what I do. Sometimes it's an entire shift. One of the things I most enjoy about my job is the fact that not only are no two days ever the same, but that the huge variety of calls we receive keeps me constantly on my toes. Every time I get just a little too laid back, something jumps out at me and reminds me that there's always something out there that I know nothing about, have never seen, and will really have to think about how to deal with.

Mostly I feel that it's the variety that keeps me here, but sometimes, when the variety is only of the unnecessary sort, the multiple gear changes leave a burnt out clutch.
Sometimes that clutch just needs changing, and all is back to (ab)normal.

And just when I needed it, the clutch that needed fixing was sent the mechanic that it needed. A recent shift, and being in the right place at the right time, brought the following:

I went from dealing with a child who's been on antibiotics for 2 hours and hasn't yet miraculously recovered from their sore throat, to comforting the relatives of a cancer patient who had just succumbed to their illness.

Then from a mild allergic reaction caused probably by new medication, to extricating two people trapped in the mangled remains of the family car.

And last job of the night, I was called to a patient threateningly at death's door, danger lurking both for her and her unborn twins. I was, along with the crew, still in the maternity unit finishing the paperwork as we heard those same babies, abruptly c-sectioned from their mother, cry for the very first time.

I wasn't all that far behind.

I went home that morning once again knowing why I do this job, and why I love it.

That night, I came back to work to be met by one of our managers.

"Do you remember a call you attended a few weeks back?" He went on to describe a call of which I had a vague recollection. It was routine. An unconscious diabetic, hypoglycaemic, sugars too low. We reversed it, he recovered, and stayed at home to be cared for by his family. I feared a complaint coming my way, although I couldn't figure out why. I told the manager that I remembered it, bizarrely more because I remembered the house, than the patient.

At that point, he opened up the back of his car and handed me a box.

"Here. These are from them for you. They gave me 12 bottles of wine, 4 for each of you that were there!"

Very much taken aback, I took my share of the box and, not being much of a wine drinker, later donated the wine to a worthy cause.

This isn't even close to the reason I do what I do.

But after the night before, it was just the icing on the cake.

Green and Genuine

Just for a change, the weather is grim, and my mood along with it. Nine hours into the shift, and I've had nothing but coughs, colds, and kids with fevers to deal with. I was on the last of four long, dreary, cold nights, and all I wanted to do was crawl into bed and hide. As usual, there were different plans for me.

Despite working on my own, as soon as the computer rang with my next call, I sighed out loud, as if hoping for someone, somewhere, to hear me. They must have done, because at that point the phone rang too.

"Hi InsomniacMedic, it's Dave at control. This call we've sent you, we know it's only a low category Green call, but they've been waiting hours, we've got nobody else, and it sounds like they really need some help!"

I look at the screen, and read the details. Green 2, Male, 30s, back pain. Uncomplimentary thoughts instantly enter my mind, a combination of winter, unnecessary calls and sheer exhaustion. Only 6 hours sleep in four days is enough to make anyone lose the plot, even a seasoned insomniac. On route to the call, I can't help thinking that all I'm going to need to do is throw a box of Nurofen at him and tell him to man up and deal with the back ache. Most times, people seem to go from having back pain and not taking pain killers, and jumping straight to "Code Red" and call an ambulance. I often wonder at what point it is that you go from coping to not coping, without trying to help yourself first. Anyway.

I open the car door, and instantly hear the screams. Something tells me that all my prejudice has just been proved wrong. This sounds like real back pain. Not the sort that goes away with a heat pad and some anti-inflams. I take the entonox (an analgesic otherwise colloquially known as laughing gas) with me as a matter of course on any call stating that the patient is in pain, and laden with my prized possessions of kit and analgesia I walk up the driveway. The sound emanating from the house sounds like a woman in labour, which, had I not have been told that the patient was male, would have had me worried. Then again, it's not unheard of for the system to get the sex of the patient wrong.

The door is opened by a most definitely not labouring lady, at a guess late twenties, who looks anxious to the point of real fear. "What took you so long? He's in agony!" I mumbled some sort of apology about it being exceptionally busy, and that I'd been sent as soon as was physically possible. I skipped the bit about having not been to a single patient who actually required an ambulance the whole night.

I'm shown in to the front room and meet Jake for the first time. He's on his hands and knees, his face resting on the couch. He's pale, sweating by the bucket-load, boxes of used pain killers on his right, a half full vomit catcher by his left, and he's literally screaming in pain. Even the slight movement to see who's just walked in racks his body with more spasms.

I take the entonox out of its bag, connect the bits together, and briefly explain to Jake what to do with it. "Breathe in and out through the straw-like gadget, deep, slow breaths, and give it just a few minutes before you start feeling the effects". He follows the instructions to the letter, and drinks the entonox like it's the elixir of life. After five minutes and almost half a cylinder of the laughing gas, Jake was still crying. Time for the big guns.

Morphine is great stuff. I have never used it and had it not do what it's supposed to. I know full well that as soon as Jake gets to the hospital there'll be eyes rolled at another overkill job of using morphine for a simple back ache, but I know that it's the right choice. I need to treat what I'm presented with, and not what the hospital will assume was happening.

Finding a vein to cannulate in a person on all-fours is a little difficult, but by far not the most awkward I've had to contend with. The line goes in smoothly, and I give Jake an anti-emetic to stop the vomiting, closely followed by the magic potion. Moments later, probably no more than 90-seconds, the relief is plain for all to see. Jake's whole being relaxes, the colour comes back to his face, he's not trying to bring up whatever contents are still left in his stomach, and he even manages a smile.

The crew that finally turns up can't understand what all the fuss was about. They were on a "Green Bus", the ambulances crewed by people who have been trained to deal with low priority calls, such as GP referrals, minor injuries, and things like simple back aches. As they are not paramedics, and I have given drugs that they're not licensed to, I'll have to go with them to the hospital.

We get the looks and the tuts that I expected, but by this point I didn't care. I knew what had really happened, and I was safe in the knowledge that I did what was best for my patient. More to the point, my patient knew it, and was grateful too.

So when is a Green call not a Green call? When it's a genuine call.