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. 

Plumbing

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

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

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

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

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

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

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

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

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

"So my heart hasn't stopped yet?"

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

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

"Is it safe, this angioplasty thing?"

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

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

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

"Oh."

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

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

"Do you need me to stop?"

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

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

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

His body jerks with yet another shock. 

More compressions. 

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

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

"We're sure." 

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

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

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

"What's that?" 

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

Scars

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

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

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

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

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

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

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

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

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

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

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

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

After-Dinner Mint

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

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

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

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

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

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

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

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

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

In the ambulance, it finally happened.

She took a breath.

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

There were no tricks. She was pulling through.

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

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

Crazily, I wondered what had happened to the mint.

At Home

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

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

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

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

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

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

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

And being unable to transport any of them.

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

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

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

And telling him so.

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

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

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

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

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

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

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

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

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

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

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

Who'd have thought it?

Take Away

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

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

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

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

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

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

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

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

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

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Suit of Armour

Armies, thousands of years ago, would wear them as they invaded another land.

King Arthur's knights donned them before battle.

Modern-day soldiers protect themselves in modern-day versions.

And we, as Emergency Services workers, have our very own models too.

There's no other way to explain why we do what we do, whilst knowing that what we do is sometimes a little bit crazy.

*****

It's the sort of news that makes people in the UK mutter about becoming too much like America. Random shootings, killing sprees, mass murder and then suicide. The horrendous events in Cumbria, in the north of England, sent shock waves not only through the usually quiet villages and towns where the killings took place, but all the way through the land.

It's happened here before. Dunblane, in Scotland, was the site of one such atrocity in 1996, where the victims were young school children and their teacher. Hungerford, in 1987, was the other infamous occasion where firearms, legally held, were used for such appalling, random, senseless killings. But look at the dates. One is more than 10 years ago, the other more than 20.

Crime is an everyday occurrence, wherever you are. There is violence on the streets, robberies, muggings, murders.

These sorts of crimes, the mass murders, however, are rare, which makes them, if that's at all possible, all that more traumatic for those involved.

The dust hasn't yet even started to settle on this story. The families of those killed and injured are still asking questions to which there are, at least for now, and possibly for ever, no answers. The grieving has started, the injured are being cared for, friends and relatives supporting each other, helping each other through a process that will take many many months, even years. From afar, I feel for them, I'm shocked with them, I try to hold them in my thoughts and prayers.

*

And then, there are the others. The unseen. Those involved who will not be given a second thought. They won't be part of the grieving process or the recovery. They won't make the news talking about their experiences and feelings. Because they are the professionals. They're one step removed, and they can cope. Those members of the Emergency Services, police, ambulance crews, air-ambulance staff, fire-brigade. The front line. Front-line, yet hidden from view. Exposed to sights that should never be seen. Shouldn't be seen ever, yet we are exposed to them on a regular, if not daily basis.

*

I believe that when we get ready for work, one of the things we do, is put on what all those armies and Knights of Yore used to do.

We don our Suit of Armour.

We put on our uniform, and become someone else.

The mindset is different.

The thought processes are different.

The coping mechanisms are different.

The Suit protects us from what Chris over at Life Under the Lights called "Splashed Sadness". Briefly (and not as eloquently as Chris - you MUST go read his post), Splashed Sadness refers to the exposure we all have to emotions on a regular basis, and how we each cope with them. How a family standing in front of us will be grieving the loss of a loved one, and how we'll be sympathetic, empathetic, sometimes look on the call as a "good job", and then without pause for thought, discuss what we're going to have for lunch.

In truth, however, every Suit of Armour has a chink. And each of us is vulnerable to it. We'll cope on scene, because we have to. We'll not even give it a second thought sometimes. But every so often, there'll be the call that gets through that chink.

It may not be an immediate breach of the defences.

It may not be a total loss of the coping mechanism.

It may not even cause any sort of diversion from the normal flow of our thought processes.

Sometimes you just need a break, someone to talk to over a cup of coffee.

It might just be your co-workers on base, it could be your nearest and dearest, sometimes, even if rarely, it may well need to be a professional. We need to know when each of those times is.

*

We don our Suit, and face a world of sadness. A world of illness, of grief, of trauma.

We don our Suit, and become rescuers, therapists, saviours, even heroes to some.

We don our Suit, yet underneath we are the same as everyone else.

At the end of our shift, when we go home, we take off the Armour and are no different from anyone else.

We are partners, husbands, wives, parents, children.

We are human.

With a very special Suit of Armour.

The Missus

An apology for calling an ambulance usually indicates one thing. There's no need for the apology. Nine times out of ten, if we're greeted at the door by "I didn't know what else to do, I'm sorry to have called you", it will be a genuine call. That doesn't necessarily mean life-threatening, but calls don't have to be, just to qualify them as a reason to call.

Dennis's wife met us at the door. "He's over there - on the stairs. Your control people told us not to let him move".

"Morning Sir", I start. "How are you feeling?"

"Bloody stupid. I'm sorry we've even called you. I think the Missus has panicked a bit". He looks frustrated and a little embarrassed.

"All it is, is these dizzy spells. They happen a couple of times an hour, and when they do I seem to lose a few seconds and come round a bit fuzzy in the head. The wife says I've blacked out a couple of times too. I just think she's overreacting as always. You know what women are like!"

I tell him that I've been married long enough to know exactly what he means. "You wait til you get to 45 years."

'The Missus' gives me a look that tells me he needs no encouragement.

I change track.

"How long's it been happening for?"

"A couple of weeks. Saw the doc and he gave me some tablets for vertigo. Told me to come back in a month if there was no improvement. Don't know what she's gone and called you lot for. Nothing's changed!"

"Well this Missus disagrees with you!" It was Dennis's turn for a glaring look from his wife. "He's been getting dizzy more often, and keeps going out for longer. It's not really long, mind, just 10 seconds or so, but he's properly out of it! And it happened again, just before I called you, and he was just coming down the stairs."

His vital signs are all normal, he has a strong pulse, a healthy blood pressure, looks a good colour and doesn't feel in any way unwell. When asked why he's sitting on the stairs he just shrugs his shoulders, looks over to his left, turns back to look straight at me and just says "I told you. Blame the Missus".

She seems happy enough to take the blame, but isn't going to let him off lightly. "Just shush and do as you're told for a change". He doesn't have much of a choice. We get him the wheelchair from the ambulance which he tries to refuse.

"I'll walk, thanks. I've got legs haven't I?"

"Well, just in case you get one of your dizzy spells and keel over. My back's not gonna be happy picking you up off the floor again." He relents. Not for his benefit, apparently, but for mine, so I smile and thank him for his consideration. The move to the ambulance is uneventful, and once there he takes a seat on the trolley.

"I'd like to do an ECG, to check your heart. Just in case that's what's making you dizzy". We attach him to the monitor, recheck his pulse and blood pressure, and start putting the sticky ECG dots onto his chest.

"Wouldn't it be better to stick them on my head? It's not my chest that gets dizzy y'know!" He winks at my crew mate and me, and I can't help but laugh out loud.

The Missus gives him another of those looks that even I now cower from. "Will you please be serious! I don't want you dying now that they're here!"

"Well, if I was going to, don't you think it'd be better to do it while they're here and not after they've gone?" I got the distinct feeling that their entire marriage had been this sort of banter. Him the boy that never grew up, she the responsible adult.

The ECG appeared on the screen, and the machine printed off a copy. It all looked almost normal. A first degree heart block, a slightly slowed response between the heart's electrical impulse to beat, and the actual beat happening, was the only irregularity. It's fairly common, and many people live with it for years and never know a thing about it. Nevertheless, I suggested to Dennis that it would be wise for him to be seen at the hospital, if for no other reason than to put his mind at ease and give them a chance to monitor him in case he had another episode.

"And it'll stop The Missus nagging, I s'pose", he added. I didn't dare respond.

Five minutes into the journey, Dennis turned ghostly pale, complained of feeling dizzy, and then passed out. The ECG started making a shrill beeping noise. The kind you expect to hear on TV when a patient's heart stops and they "flatline". Which is exactly what Dennis had done. About twice an hour for the past fortnight, Dennis's heart stopped beating. Just for a few seconds. Just enough to make him dizzy and pass out and not let him remember it.

After those few seconds, he opened his eyes, looked around him, and with a resigned groan muttered "It's happened again, hasn't it?"

"Yes, sir. But at least now we have a clue as to what's causing it. I knew it was a good idea to put those stickers on your chest, and not your head..."

We got Dennis to hospital with no more dizzy spells, handed him over to the staff who stared with some bemusement at the ECG that we'd manage to catch, and were about to go and clear up the ambulance. Catching us just before we left the A&E department, he thanked us both for our help, and apologised for being difficult.

"You know what the worst thing now is don't you?" I ventured the fact that he might have to spend a while in hospital that was worrying him, or that he might have to have some procedure done.

"Oh, it's nothing like that", he grinned.

"It's just that I suppose I'd better thank The Missus too."

Rats

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

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

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

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

Rats.