Then and Now

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

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

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

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

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

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

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

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

"Oh, so you're the paramedic?"

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

"That's me."

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

"Don't think so!"

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

I finished the sentence for her.

"And he was on parade the following year."

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

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

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

Code STEMI

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Be Smart?

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

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

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

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

It all sounds like a plan is coming together. 

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

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

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

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

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

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

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

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

"Don't just be right, be smart." 

A combination of the two would be even better. 

Globetrotting

I can hear the murmurings clearly. “He goes and wins the award for Blog of the Year and then promptly stops blogging!” I grant you, it’s a fair whinge. But trust me, the reasons are good ones.

I’m sitting in a room surrounded by suitcases, packing my life into bag after bag, ready to fly off in just a few hours. My London adventure ends here, whilst just over the horizon await a whole new set of challenges. Guesses have been made, since I first mentioned the fact that I had left the London Ambulance Service as to where I was going. Guesses ranged from the south coast of England, to the north coast of Scotland, to the west coast of Australia.

The truth is that I’m heading to the east coast of the Mediterranean – to a little country that punches above its weight in almost every aspect of its existence – Israel.

Let’s start at the beginning: My name’s Aryeh – and I’m an Insomniac. So you see, one of the reasons my blog had to remain anonymous was the fact that with an unusual name like mine, unique in the LAS (in more ways than one, I hear my friends cry), there was no hope of hiding behind a smoke-screen of a more common name such as Adam, or Chris, or Dave. At least in Israel, I can hide amongst the masses of others Aryehs.

It’s a funny old place. Laid back yet highly stressed, open-minded but highly suspicious, and people who are exceptionally friendly or incredibly abrupt – sometimes both at once.

The national ambulance service is completely different from the UK based one. There’s no government funding and it’s privately run as a fee-charging charity. The paramedics and EMT’s who work for them are divided between volunteers who live their normal lives around sporadic shifts and actual paid staff whose day to day life is the ambulance service. Working for them, assuming they accept my paramedic skills as good enough for them, will be a very different experience indeed.

In the meantime, I’ve discovered that I really enjoy teaching first aid to the general public and that might become a new string to add to my bow, either in between ambulance shifts, or, at least at the beginning, instead of them.

It’s a new start for my family and me – but it’s a new start that we’ve been planning for some time, so excitement is, at least for now, overruling the sheer terror of such a big move.

As for the blog, well, I’ll definitely keep writing. What started off as a purely cathartic exercise in creative writing has turned into a project of which I’m exceptionally proud. The writing may be a little sporadic over the next few weeks as we settle into a new reality, but stick around.

We may still have a lot to learn together.

Five Words

Stepping into the office with an envelope in my hand, I was about to take one of the biggest steps in almost a decade.

"Need my signature on an application form, do you?"

It was an obvious question for my boss to ask considering the fact that once again, the coveted places on the air ambulance had been advertised. That, and the fact that he had no idea of my real motives.

"Not quite!" I answered, handing him one of the copies of the letter. He looked down at the piece of paper, the cheap and nasty stuff that the ambulance service has started to use recently in yet another cost-cutting exercise. The confusion on his face said it all.

"You're sure about this are you?"

"Quite sure."

"Can we do anything to change your mind?"

"Not unless you're packing the LAS into a suitcase and sending it with me."

Handing in my notice was a great deal more traumatic than I had ever anticipated. I have loved my job. If not every minute of it, certainly as a career, as a way of life, I have loved it. But the time had come for a change that MrsInsomniac and I had been planning for some time. I'll write more about the change we're making in another post.

I've already had my final shift. It was initially scheduled to be a lonely solo shift on a rapid response unit, but luck had it that there was a student who needed a few extra hours out and about, so she joined me, hoping that my reputation for attracting "real" jobs would prove itself in reality. It didn't, but it gave us time to talk. Time for me to pass on a little of my questionable wisdom and for her to ask questions, question my answers and answer my challenges too.

Towards the end of the shift, she threw me a curve-ball.

"If you had to sum up your career in four words, how would you do it?"

"Four words? I'm not sure I can. Am I allowed five?"

"You can have five. It's my leaving present."

It took me some time. We attended another call, handed another patient to yet another crew and still my mind's rusty cogs whined and creaked to come up with some cohesive thought. Eventually, in a dull flash of panicked inspiration, I had it.

"Tried to make a difference." It really does some it all up.

It speaks of the patients who had no-one else to care for them, it speaks of the families suddenly bereaved, it speaks of the babies brought into the world.

It speaks of the children who were left battered and bruised by their very own flesh and blood, and others who were nothing if not heroes to their families.

It speaks of the people who just needed to hear a voice tell them that help is at hand, and it speaks of those pleading for help for their loved ones.

I hope it speaks of the students I worked with, studied with, taught and learned from.

I hope it speaks of the people who read this blog, those in the know and those who hope that they will become more in the know by reading it.

I tried. Sometimes I succeeded, sometimes I failed, but I tried. In most cases, I'll never really know.

My move takes me away from the London Ambulance Service, but not away from the world of the ambulance. The blog will continue (considering the accolade it has just received, it couldn't really not). For some time it'll be based on the scribbled notes that already sit in my diary, and soon stories will be told from new notes, new patients, whilst looking out over new horizons.

And if nothing else works out, I'm still proud of who I've become, what I've achieved, and the experience that I've gained. I'm proud of this blog. I'm proud to call some of the best ambulance staff out there my friends. And I'm still proud of those five words.

Politics, Strikes and Goodwill

Those of you who read my ramblings on a regular basis, will know that 99% of the time, I try to avoid any of the politics involved in this job, and concentrate on real people and real events. This time, however, the politics are a little bit too big to ignore. 

In under nine hours time, a huge strike by some two million public-sector workers will begin. I wrote about my feelings on this strike in a post at the beginning of the month, and I still stand by what I said then. In fact, I resigned my membership of the union last week, so as not to be in a position where I had to decide at the last minute where my allegiances lay, or leave me any room for second thoughts. 

Over the past few days I have spoken to many of my colleagues, all with differing views on the strike. Some are supporting it wholeheartedly and will down tools, some who are still torn between the patients and the greater cause, some who agree with me that this is the wrong way to go about things. The unions and the ambulance service have been in negotiations as to what sort of cover will be provided, and the agreement that has been reached is that the vast majority of calls that we normally attend will still have an ambulance arrive. At times the response may be slower, but the most serious calls will still hopefully receive the normal fast response. 

This agreement, whilst seen by many as turning the strike into a something of a damp squib rather than a strong statement, did something positive for those who were unsure as to the best course of action. Many, many paramedics (and nurses) felt very uncomfortable with the idea of striking and leaving their patients in need. There was a general uneasiness, something that I think the government (or Government) relied on a little too much, amongst many public servants, particularly those with direct and immediate public contact. An uneasiness that leaving our jobs for a day would impact badly on people who, through no fault of their own, are some of the most vulnerable in our society. 

The uneasiness felt by many, certainly in the health service sector, took yet another battering this afternoon. Just a few hours ago, the Chancellor announced that at the end of the two year public-sector pay freeze, a fiscal policy that still has some time to run, there will now be another two year period of only 1% pay rises. With an annual rate of inflation somewhere around the 5% mark, that pay-cap, in real terms, means a pay cut over four years in the region of some twenty percent. At the same time, tens of thousands of people on benefits, some genuinely, some whose claims range from dubious to outright fraudulent, will enjoy a rise in line with that rate of inflation. I'm no economist, but surely, the best way to get the economy jump-started is to encourage more work, not less. 

Many of those who were left confused and unsure about a strike, and who were going to work through it, are now left battered and bruised by another swipe taken at their goodwill and desire to serve the public. There's a limit to how many times a person can be beaten and bounce back. There's a limit to how much goodwill can be stretched. Every person has their breaking point, even the most public spirited of us. 

I'll be working through the strike, but with a little more personal turmoil than I had anticipated. I will try to tweet throughout tonight and tomorrow night, bringing a selection of sights, sounds and thoughts from the front line. Who knows what lays the other side of the picket lines. 

Natural Wastage

We're in the media... for all the wrong reasons.

The news has hit the mainstream news outlets shortly after we heard about it internally.

Almost nine-hundred jobs are to go at the London Ambulance Service.

Two thirds of them will be front-line.

There are tough times ahead.

Possibly tougher for our patients than for the staff, if the "natural wastage" policy is adhered to.

I just hope I'm wrong.