Official Letter

A look of grave concern greets us as we pull up outside the concrete building. Dozens of blue-barred balconies overlook the square, and grey clouds overlook the balconies.

"It's been at least a couple of days, maybe even three or four."

Reg is one of the faces that makes up the character of this estate. His daily walks, regularly picking up his newspaper and a bottle of milk from the traditional corner shop. His cordial greetings to all and sundry were so much part and parcel of the area and had been going on for so long, that it was as if the buildings had been put up around him. Even the kids in the area showed him respect that was rare to find, clearing a path for him to pass, offering to carry his shopping - an offer his pride always forced him to decline. Sometimes he'd just take off on his own for a weekend, visiting some old army friends, but never without telling at least one of the neighbours.

No one had seen or heard from him for days, and he hadn't told anyone he was leaving. Eventually, someone called the police.

The glass panel in the door of the second floor flat was reinforced with wires, as were the only accessible windows. One of us called through the letter box at the bottom of the door, but heard no reply. A neighbour, suddenly remembering she had a spare set of keys, ran home to find them.

"He gave me these years and years ago. Never used them." One word at a time, catching her breath after running down and up six flights of stairs and across the square and back.

The keys wouldn't work.

"Maybe he's changed the locks? It's got to be twenty years that I've had these and never used them!"

Shining a torch through the keyhole, one of the police officers told us he could see the keys in the other side of the door, a sure sign that Reg must be at home, and a probable explanation as to why the spare set wouldn't work.

We contact local hospitals to make sure that he hadn't been taken there already, a task we knew was futile. Another police unit arrives with an enforcer, a heavy metal battering ram, and two forceful swings later, the door swings open. Splinters from the door frame rain down and shards of glass crunch under the heavy boots of the rescue party.

"Police!"

"Ambulance!"

"Reg, can you hear us?"

There's no answer. Each of us heads in a different direction. Bathroom, kitchen, bedroom, lounge. All impossibly empty. An officer decides to look under the bed.

"That's where my kids would hide!" he adds with a shrug of the shoulders, as if trying to convince himself that his idea isn't quite as ridiculous as everyone seems to think. Ten seconds later, as we're preparing to leave and packing up the bags, and with the police already arranging for the door to be fixed, there's a shout from the direction of the bedroom.

"I've found him! Get in here quick!"

In a space big enough for nothing more than a small animal lies Reg, stuck between the bed and the wall. He's unconscious, his breathing noisy and laboured. His leg is burned from lying against the hot water pipe that runs along the skirting and his head cut from where it hit the wall, leaving a dark red-brown smear at the point of impact. There's no reaction from him to any movement, noise or treatment. 

The key-holder, haunted by the thought she'd waited so long, is trying her best to help, but becomes more of a hindrance. A police officer alert to her anxiety as well as Reg's needs, moves her gently away, allowing us to do our job with a little more ease. We move Reg into our wheelchair, carry him down to the ambulance, and rush him to hospital, where we're met by a whole team of people who take over his care. After watching them for a while and helping where we can, we went back outside, prepared the ambulance for the next crew, and left Reg fighting for his life as we prepared to fight the traffic home. 

With the end of the shift came the knowledge that I'd probably never find out the outcome.

Months later, an official-looking letter appeared at work with my name on it. 

The Coroner wanted an account of the day's events. 

Reg had died two days later. 

Ten out of Ten

"Ten, definitely ten". The stock answer of some people when asked how bad their pain is on a scale of 1 to 10. I guess that gives them a genuine reason for having called an ambulance in the first place. The thing is, that they sit in front of you, no wince, not doubled over, just sit calmly and tell you that the pain in their arm or leg, stomach or back, is the worst pain they've ever experienced.

If the patient is a mother, I often ask if this pain is so bad that it's worse than childbirth, a question that regularly has the pain score downgraded, even if only slightly. Either that or they're superwoman. If the patient is a man, I'll compare it to something often involving a gory amputation of one of their limbs, and see what happens then.

These patients, whilst claiming to be in the worst pain known to humankind, then jump sky high as soon as I take a pinprick's worth of blood to test their sugar levels - a procedure that hurts no more than a minor paper cut. And more often than not, haven't bothered to try taking any home-based pain relief such as paracetamol or ibuprofen. The easiest option is to call out an ambulance and discharge the responsibility for their condition and care to somebody else.

Sometimes, I meet the exact opposite. A patient who's pale, sweating buckets and complaining of a slight ache, 2 or 3 at worst on the pain scale. A patient who is so clearly in distress, but denying it, either out of stoicity (if that's even a real word), bravado or genuine fear of the unknown. Regularly these are the sorts of people who wouldn't call an ambulance until they are practically bullied into it by concerned relatives or friends, or have had ambulances called for them without their knowledge.

In both cases, those who overplay their pain, and those who underrate it, I'm left with a dilemma.

On our ambulances, we carry a very limited option of analgesia, or pain relief.

For kids, we have liquid paracetamol to ease pain and reduce fever. To be honest, I don't know why we have it. It should be in the drug cupboard, in plentiful supply, in every child-containing household in the land. There should be no reason for us to give a 4-hourly dose of fever-reducing, pain-easing medication that can easily be bought at any chemist, supermarket or even petrol station. It can be given in the calm, safe and familiar surroundings of the family home by any medically-unqualified parent, rather than in the scary scene of the back of a terrifyingly strange ambulance by unknown, green-attired, martian-looking paramedics. I know which I choose for my kids. If one of them refuses, then just the mere mention of the word doctor or hospital is enough to get them to down the stuff.

We also have Entonox, a mix of oxygen and and nitrous oxide, often referred to as laughing gas. Like any other analgesic, it works well for some people, and not at all for others. Over the last few years I've found that it works particularly well for things like muscular back aches, releasing enough of the tension in the muscles to enable the patient to get on the move again, exercising those tensed backs, instead of leaving them immobile. It also works well enough to enable a dislocated limb to be reduced, enough to allow transport and definitive treatment at hospital.

Then we have Oromorph, and Morphine sulphate. The same thing, but one is swallowed and the other requires IV administration directly into the bloodstream. These are the ones we use for severe pain. Things like heart attacks, nasty fractures, serious burns and other injury or illness-induced agony. There are other options for stronger pre-hospital analgesia, but these require having a doctor on scene, in the form of either HEMS or a Basics doctor.

The dilemma I have is when to use analgesia, and of which sort.

For our first type of patient, the one in such agony as he sits and drinks his cup of coffee in the front room as the caffeine-deprived ambulance crew stand by and watch, do I jump right in and give him some of the heavy stuff? Do I take his answer as gospel, his pain is off the scale, and needs immediate resolution, and so give him the morphine straight away? Is it justified, and is it necessary? Or do I suggest to him to try some paracetamol first (from his own supply, as I don't carry an adult dose)?

And so, on to our second type of patient. Clearly, in my eyes, in severe pain, but refusing to admit it. She declines the offer of either Entonox or morphine, says she's just taken some over-the-counter tablets, and is feeling better already. Both her clinical observations, as well as my observation of her, indicate otherwise. Do I just offer these patients a seat in the ambulance and convey them to hospital, no analgesia, no treatment, no nothing. After all, they've refused any. Doesn't seem right to me.

In both these cases, the question is one of objectivity vs subjectivity.

Is the pain defined by the patient's experience, or by the paramedic's observations and assessment?

Is the treatment decided by the patient's story, or by the paramedic's interpretation of it?

Which of these methods would leave me to treat the patient the best way possible, and afford my treatment, much like their pain, a score of ten out of ten?

Burns Night

It's just gone midnight, I'm listening to the calls on the radio of several people being "blued" into hospital after a bad RTC (or car-crash in normal-speak) that happened not far from me. I can't help but think that this time I'd got away with it. I still seem to be attracting all the big jobs, and somehow instead of dealing with this one, I'd been to an 80 year old with breathing problems. Safe in the knowledge that the RTC was cleared, I headed back to station to grab some much needed coffee. As usual, Control had different ideas. One of these days I'm going to find the hidden cameras that show Control just when we're making a drink...

I took one look at the call and instinct told me to ask for police to attend before I'd even set off. Three men with burns outside a local health centre. A closed health centre, of course, as it was the middle of the night, so no help from them. My sixth sense tells me this isn't some sort of hoax or just minor burns, and I can't work out why they'd be outside in a public place with such injuries.

As I approach, I can hear the screams before I can even see the patients. I pull up outside the health centre to find a shocking scene. The men were clothed in either underwear or nothing at all. They were burnt almost from head to toe. Their skin was peeling, blistered, bleeding, disfigured, and in some places just plain black. They had blackened mouths and noses, an indication that their airways could become a problem. They looked as though they had just walked out of a bombing. Not just the injuries, but the clear state of shock and fear in their faces.

They spoke no English. There were a few others about who spoke their language, but were giving me different stories as to what happened, and I decided that at this point it was fairly irrelevant. I called for back-up and said that I needed 3 ambulances, and needed them in a hurry. I knew that 8 or so had been dealing with the earlier RTC and feared that I'd be stuck for a while with no help. Luckily, there was an Urgent Care ambulance nearby. These ambulances are meant for our Green calls. The calls that don't necessarily need a full A&E emergency ambulance. The people on these are not trained to the same extent as front-line ambulances, but are nevertheless a great asset to the Ambulance Service. I'd started to put burns dressings on the patients, but outnumbered three seriously ill people to one Paramedic, I was struggling. They had a patient on board, yet one of the staff on the UC ambulance came over and offered to help, an offer that was gratefully accepted and that I once again thank them for.

Police arrived and stood there shocked. After a few minutes another FRU and two ambulances arrived. I sent the most seriously injured of the three in the first ambulance, and they headed directly for a specialist burns unit. The other two were taken to nearer hospitals after the third ambulance had arrived a few minutes later still, and then transferred out later to burns units as well. The extra pairs of hands were able to do things like sort out pain relief and fluids which I could never had done on my own. Being a single responder means dealing with the most immediate needs and then working down from there.

It also meant that once the ambulances had left I was left to assess what was almost a surreal scene. The chaos and carnage had been replaced by calm and police questions. There was no evidence of the dozens of burns dressings that I'd used. No sign of the horrific injuries that I'd just witnessed. No reminder of the initial feeling of concern that I'd be unable to cope.

Just time for a quick reflection that, clearly, I'd missed out on the RTC for a reason...

When you read you begin with ABC...

As it happens, tonight (for it is now 05.30 and I'm towards the end of another night shift) is a good time to start composing. I've had a fairly busy night, and for a change most of the people who called for an ambulance tonight, at least those who I was called to, genuinely needed the help.

Admittedly I'm working on a First Response Unit (FRU for future reference) so I'm supposedly called to the most genuine and serious calls, but that logic doesn't always work. A call to someone having a panic attack can easily be categorised as highly as someone having a heart attack. More of this at a later date.

There's been a range of breathing problems, chest pains, poorly children, allergic reactions and one RTC (or RTA or car crash...).

On the subject of poorly children, I'd like to offer some advice. If your child has a fever, please, PLEASE don't put 15 layers of clothing on them. Yes, they will complain it's cold. Yes, they will shiver lots and lots. But at least you'll be helping bring down the temperature and hopefully stop them from having a fit.

Oh, and another thing... Can someone please explain the logic of people putting toothpaste on burns??? Water? Yes! Burns dressings? Yes! Toothpaste? WHY???