The Other Leg

Late evening in the city, where another weekend heads to a close as the world prepares to face another Monday morning. There's a definite chill in the air, a disappointing summer fizzling out as the nights begin to draw in, yet all around people are spilling out of pubs and clubs wearing no more than the bare essentials. The street sweepers are out in force, one of them earning a torrent of verbal abuse for daring to complain to yet another youth for throwing an empty cup on the floor.

Rash and his friends walk away laughing, alcohol and bravado fueling yet more antics until, suddenly, he loses his footing on the edge of the kerb. His leg twists, snaps and gives way, and he crumples in a heap on the floor. The street sweeper sees it happen, yells something about karma and walks away to continue his never-ending litter hunt. 

We're dealing with a drunk no more than ten paces away, another victim of just having a good time and she doesn't usually get like this. Each of us, Dean and I, has one eye on our patient making sure we don't get covered in vomit, and another on the altercation, looking for signs of a fight breaking out. When Rash falls, we're close enough that we see his leg change direction and clearly hear the crack in the bone. 

"Stay there!" I shout. "We're coming." Dean calls for help, asking for a second ambulance.

Unable to move even if he wanted to, Rash lies on the ground screaming in pain. Two police officers patrolling the area hear the noise, which even in the bustling surroundings was out of the ordinary, and come to investigate. The bad timing on their part means they get to stay with the vomiting drunk and her overly exuberant friend.

Dean brings the trolley bed and a splint over, the need to see the injury first seeming superfluous having witnessed the noise it made. Nevertheless, a pair of shears always beats a pair of jeans in the trauma version of "rock, paper, scissors" (where the rock or paper are any item of clothing which may be hiding any part of the anatomy that needs to be viewed directly, in a hurry and with a minimum of movement), and seconds later Rash sees his leg for the first time since getting dressed earlier in the evening. He looks down at his ankle, and instantly looks away.

"Do you think it's broken?" It's more of a last gasp attempt at denying what he already knows than a real question.

"Well, I think the fact that your foot is facing the wrong way and there are two bones sticking out of your ankle would probably confirm that." Ten paces away, as if on cue, our drunken patient vomits for the umpteenth time. One of the police officers sends us a grateful stare, all the more grateful now that another ambulance has arrived to deal with her.

We load Rash into the ambulance, dose him up with some pain relief, and straighten his leg out as much as possible before heading to the nearest hospital. The screams of pain as we pull his leg straight subside once his foots faces front again, entonox and morphine leaving him a little dazed. When I ask his date of birth, he hesitates, looking at his friend for guidance. A shrug of the shoulders was the only reply.

"How old are you Rash?"

"Nineteen."

"And what's your date of birth?"

He tells me a day and a month without hesitation, but when it comes to the year, all he could say was "Ummm..."

"OK, so how old are you really?"

"Sixteen. And a half." And a half. Of course. That makes all the difference.

"And why didn't you want us to know that?"

"I didn't want those coppers to arrest me again. You know, for being drunk under age and all that."

"What do you mean arrest you again?"

"Well, I've already been arrested five times before. I was twelve the first time!" He high-fives his friend, seemingly proud of his criminal record.

"Twelve? What were you arrested for at twelve?"

"Fighting!" Another laugh, and another high-five.

"And you were twelve?"

"Yeah man. I've still got the scars now!"

"And you're proud of that?"

"Well, yeah, why not? But not as proud as I am of something else." He shoots his friend a knowing look, and they both smile.

"What's that, Rash?"

He pulls up his other trouser leg and proudly shows off his electronic tag. "Got this last month, didn't I! All my mates want one now, it's, like, so cool!"

"You know that you'll probably get nicked now anyway, out after what I presume is your curfew time?"

"Oh what? Even if I'm in hospital? Pull the other one, yeah?"

"I already did." 

No Answers

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

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

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

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

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

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

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

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

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

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

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

Smokers with emphysema? Charge.

Footballers with broken legs? Charge.

Diabetics with high blood-sugars? Charge.

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

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

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

I just wish I had some decent answers.

What do you think?

A Conversation

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

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

"Great. What happened?"

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

"Have you moved him?"

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

"Is there lots of bleeding?"

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

"Hm. Sounds broken to me".

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

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