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." 

Greenpeace

Once again, we stand, trolley and patient between us, and we wait. The department is manic. Patients in every cubicle, trolleys in the corridors, nurses rushed off their feet, porters running backwards and forwards to x-ray and the wards, reception staff fending off the masses, and doctors sitting down drinking coffee. (Cheap shot, I know. But it made you smile, right? Unless of course, you're a doctor. And I don't mean it really...)

Jenny, one of our favourite sisters is in charge tonight. Even in the heat of a Saturday night A&E battle she remains composed and calm. A tap on the shoulder and a sheepish "Sorry, we've got nothing for a while!" at least acknowledges our presence, and lets us know that we haven't been forgotten. Not that it's easy to ignore us, both six-foot tall and dressed in blood-hiding green. Her only downfall is her gullibility, especially when it's busy.

Derek, our patient, well into his late seventies, must have been a stand-up comedian in a previous life. From the minute we met him and his probably broken hip, we were in fits of laughter, ranging from giggles to full blown hysterics. The added bonus of giving him some entonox and morphine to help relieve the pain only made matters worse. Trying to settle down once we'd stepped inside the hospital was a little like telling a kid who's having a mad half hour in the evening to calm down and go to bed.

As we stood in the middle of the department, we had time to hatch a plan and had the routine rehearsed to perfection. All it would take was a little composure - easier said than done.

"I'm sorry boys, and you sir," Jenny said as she turned to the patient, "but we're just trying to shift some people from here. We should have half a dozen spaces within ten minutes. I'll be back then and we'll sort you out."

"No problem!" I said, "I'm sure Derek won't run off anywhere in the meantime."

Composure? Lost. Awful joke, I know, but when you've already got the giggles, it doesn't take much. 

Jenny eyed us suspiciously, but went back to her duties and clearing the department. We watched as one by one she kept her promise. Some went up to the wards, others sent on their way with boxes of antibiotics or pain killers, and whilst it all happened, I had the chance to finish writing my paperwork.

Calm seemed to return. When a patient leaves A&E, whatever their destination, their entourage leaves with them, so it's not just one person leaving. Six patients sent on their way can easily mean twenty people exiting stage left. The decibel volume drops noticeably and the overall chaos seems to dissipate, if only a little.

Only five minutes later than the promised ten, Jenny comes back to us.

"Right, now where were we?"

"Morning Jenny. This is Derek. He's a Greenpeace activi..."

"You DO KNOW about Greenpeace, don't you?" Derek's interruption was perfectly timed.

Jenny looks momentarily taken aback, but maintains composure.

"I do know about them, yes. Let me find out what the problem is, Derek, and then we can discuss it later."

"OK."

"As I was saying, Derek was on a protest at the local building site. Apparently they're building on what he says should be left as a nature reserve, so he decided he would start a one man protest. Up a huge crane."

"You were where?" Jenny asks.

"Up a crane. They can't use the damn thing if I'm sitting half way up it!" Derek's performance was so convincing, even I was starting to buy it.

"Right."

"Anyway, we were asked by the police to be on standby, should anything go wrong, whilst they sent some climbers up to bring Derek down. As they neared the bottom of the crane, Derek decided to jump about two metres, fell onto the grou..."

"I didn't fall!" He looked genuinely angry. "Those damned coppers brought me down!"

"Either way, he landed quite heavily, and we think he might have broken his hip. The rest of his observations are fine, and he's normally fit as a fiddle."

"Right." Jenny looked a little puzzled, had a quick look at the side of the paperwork that has all the observations but none of the story, and allocated us a bed without any further questions. "I'll help you get him across."

Derek took a few more deep breaths on the entonox as we lay him almost flat in order to slide him onto the hospital bed.

"We'll have you over in seconds, you won't even know it's happening."

"OK, just do it."

I placed the paperwork on the tray at the edge of the bed, and between us we moved Derek onto the slightly more comfortable hospital trolley. We had to take our cylinder of entonox back, so before we did, I went to find a hospital supply rather than leave him without. By the time I came back, Jenny was reading the paperwork. Story side this time, and tapping her foot on the floor.

She read about Derek's fall at home. How he'd been on the way back from the toilet and slipped. How we got him down the flight of stairs, strapped onto a board and dosed up on laughing gas.

"Assaulted by coppers, huh?" She glared.

"Stuck up a crane, huh?" A hint of a smile.

"Greenpeace, huh?" We knew we'd won.

"You sir, shouldn't help these clowns to get away with this!" Jenny shook her head in disbelief. "You two, just you wait! I'll get you back yet! In the meantime," she paused, "thank you for cheering up a mad evening."

We laughed, all of us. Derek and Jenny included.

"Excuse me, nurse. Can I ask you just one question?" Derek suddenly looked serious again.

"Of course you can."

"Do you really know anything about Greenpeace?"

Two green-uniformed men turned and ran, giggling away like school kids.

Destiny

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

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

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

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

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

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

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

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

A different person answer from inside. 

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

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

The police stood back, and let us in. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Shortlist

It all seemed so simple. We turned up at the house for what appeared to be yet another "maternataxi". An ambulance being called to a woman in early labour for simple transport, where after nine months of preparation, buying clothes, painting nurseries, and building cots, no-one had thought about how to get to the hospital. Either that, or it's just that we're the cheapest option. Taxis cost money, as does parking, so an ambulance that will deliver you (sorry) to the front door and not cost a penny is a very attractive proposition.

Zara had two days to go according to her notes, but babies rarely arrive exactly when expected unless it's by planned Caesarean. Whoever called the ambulance told the call taker that the contractions were two minutes apart, whereas in reality it was nearly five. Her waters hadn't broken, this was her first pregnancy, and she wasn't too troubled by the contractions even when they did occur. Her husband said he'd make his own way in the car. He could have taken Zara too, but probably feared the mess if she delivered on route. Either that or he panicked. I gave him the benefit of the doubt as it was their first baby.

"Which hospital are you booked into?"

"Faraway hospital," she answered. Not the answer we'd hoped for. There were at least five other maternity units that were nearer in all directions, but if that's where she was booked, that's where we were taking her. It was over half an hour away, if the traffic was bad it could be double that, and the only reason she wanted to go there was because she had heard from friends that it was a good place to go. She never quite took into account the fact that she actually had to get there, and possibly in a hurry.

"Lucky you're not booked into Edinburgh hospital!" I commented, only half joking, trying to hide the nervousness I felt at a long trek with a labouring mother-to-be. Zara's husband stuck his head back in and asked if we would take the luggage as well and then he'd follow us to hospital.

"I'll be right behind you. Don't have the baby without me!" I hoped Zara's husband was right. We told him that if the traffic was particularly bad, we'd cheat and use the lights, and he had to make sure that he got there safely, even if it meant a slight delay.

I was fairly new, with only one delivery under my belt, an easy home birth where the midwife turned up less than five minutes too late. I was working with a partner who'd long ago lost interest in treating patients. He was working out the years until his retirement and spent most of his time driving the ambulance, ignoring both patients and crew mates alike.

"She'll be fine," he said, "we'll make it there with enough time for us to grow the coffee beans and still drink them before she has this baby." With that, he shut me and the patient in the back, and started gently trundling to hospital. Half way there, something about the way she was contracting changed. The look on her face was more anguished, the mix of gas-and-air in the bottle with the chipped blue paint no longer worked its magic quite so effectively. I called through to the front and explained what was happening. My crew mate looked up briefly in the mirror, switched on the lights and pushed the engine a little harder. The engine roared a response, but the actual change in speed was barely perceptible. Zara certainly didn't seem to notice the difference. I placed a maternity kit on the trolley, just by her feet, hoping the clear plastic case would remain sealed.

We called ahead to the hospital and asked them to make sure we were met by the front door, as it was notoriously difficult to get into the unit in a hurry. It involved two doors that required remote access, and a lift in between the floors where the doors were located. Waiting at each stage could easily add ten minutes to the journey. The lights and sirens had no real effect on the speed, but at least we could weave a little easier through the daytime traffic. Fifteen minutes and six or seven sets of strengthening contractions later, we pulled up outside the hospital. As expected, despite our prior warning and plea, there was no one there to meet us.

Zara screamed. She yelled about needing to go to the toilet. Desperately. There are two sets of patients who tell us that. One set is those having some sort of cardiac event, who if allowed to go will probably collapse, or worse. The other set is mothers in labour who are about to deliver their babies. As we lowered the trolley out of the ambulance, I was in a way glad of Zara's panic. It was doing a great job of masking mine. We pressed the button and waited for what seemed like an eternity until someone answered. We didn't need to identify ourselves, Zara once again did it for us.

"Get the lift down here, and get these doors open!" yelled my crew mate. It was the first time I'd seen any sense of urgency about the man.

Dragging the trolley up a slight ramp into the building, I prayed for the lift doors to open, and a midwife to be standing inside. Neither happened. I pressed to call the lift, and the square button lit up, its dim red light stopping us from proceeding. As the lift arrived, the light went off and a bell chimed to announce the blindingly obvious. Another chrome button, this time with a large "2" embossed both as a regular numeral and in braille. Once again I cursed hospitals everywhere for not having all maternity units on the ground floor.

We stopped on the first floor, a frightened looking mother and child taking one look inside and deciding to wait for the next time round. Another delay, another contraction, another scream. I frantically looked for the button that closed the doors again, only to find that there wasn't one. Instead I pressed the number 2 again, willing the lift to move. Zara had practically finished the entonox, and I promised her that there was more on the unit. All she had to do was hold on another minute.

I timed it. Forty-five seconds from when we stopped on the first floor, until we starting rising again, another thirty for the doors to open on the second door. As we landed, Zara contracted once again, and begged us not to move until it was over. We stood, waited, and prayed.

"It's coming!" She yelled. "Now!"

My crew mate got out the lift and pressed the buzzer to ask the staff to let us in. A distance of no more than five metres. As he got out and pushed the button, Zara pushed the baby.

There was a gush of water as the amniotic fluid escaped from the sac, and a scream as the baby's head appeared an instant later. The scream was Zara's, but it might as well have been mine. In the meantime, the unit's doors remained firmly shut, the magnets holding them in place still secured by an electrical circuit. Finally, training took over from panic, and I gently held the babies head as it turned. The next contraction didn't move anything, and in between the pains my crew mate resorted to bashing on the ward doors instead of pressing on the buzzer. But it was too late.

One more contraction, and Zara was able to hold her beautiful baby girl.

"Time of delivery - 13:14. Born in a lift."

She seemed, from my limited experience at the time, to be quite a big baby. Thirty seconds after she made an appearance, a midwife finally came to open the doors.

"What gives you the right to make such a noise? We're very busy in there, and if we don't answer the door, you'll just have to wait!" She emphasised each of the last four words through gritted teeth.

"Unfortunately," I said, somewhat cooler than I'd imagined possible given the circumstances, "this young lady couldn't wait any longer." I pointed to Zara and the little bundle she was cuddling, each wrapped in an appropriately sized ambulance issue blanket.

Instantly, the attitude changed. We were led inside, shown into a delivery room, and assisted Zara to move across from our narrow and uncomfortable trolley onto the hospital bed. There was the small issue of the cord and placenta to deal with, of which the midwives now took charge. The baby was taken to be cleaned and weighed, a shout from across the room announcing that what I'd guessed at being 'quite big' turned out to be well over four kilos, some nine-and-a-half pounds.

Zara was given an injection in her thigh, and with that chemical encouragement, the placenta too was delivered. She was free to hold her baby again now she'd been cleaned, and at that point her husband appeared. He was puffing and panting as if he'd been through the labour himself.

"I thought I told you to wait for me!" he gasped, leaning over to kiss both his girls.

"Have you got a name for her yet?" asked the midwife who'd initially let us in, now suddenly full of smiles.

"Not yet," they answered in unison.

"We've got a shortlist," Zara added, "but we hadn't definitely decided. We had a definite name for a boy, but this little one will have to wait a little while."

"How about Ellie?" I ventured. Zara looked offended.

"You mean short for elephant? Just because she's a big baby?"

"Actually, I meant Ellie as in short for elevator. I didn't think about the weight!"

"She was born in the lift?" asked the new dad, his voice an octave higher than it should have been. "How did I miss out on all that action? I can't believe it!" He sank into the armchair next to the bed, gently stroking his little girl's wispy hair. "What do you think Zara?" he added after a few moments. "It's quite a nice name? And what with all the circumstances, it really fits too..."

"I'm too tired to think about it right now." Zara replied. Single tears from each eye took a gentle stroll down both her cheeks as she gazed lovingly at her newborn daughter. "Why don't we just add it to the shortlist?"

Loco Parentis

The door is opened by a middle aged woman, cigarette hanging off her lips, her attitude delighting us almost as much as the smoke in our faces.

"You take this bag, and I'll bring her out in a minute!" She dumps a pink hold-all in my surprised arms, and shuts the door almost completely, leaving us in the pouring rain. The inch of artificial light shining between the door and the frame means the gap is just wide enough for us to hear our patient and her cries of pain. Our requests to be allowed in to at least see and start to assess the patient are met with defiance.

"You stay out there. I don't want your muddy boots in my house. I told you she'll be down in a minute."

The tirade changes direction and is re-aimed at the patient.

"Come on already. They're here. And you make sure that you don't have any of that gas stuff they're gonna offer you. You don't need it!"

A minute or so later, Mina appears. 18-years-old and a week overdue with her first baby, she looks just about ready to pop. She has a look about her that's a mix of excitement and anticipation, as well as fear of the unknown.

We invite Mina into the back of the ambulance, and ask her whether she'd be more comfortable sitting on the chair or lying on the trolley. She chooses the chair, and as she sits down, another contraction begins. I write the exact time down on my glove, ready to time the frequency and length of each contraction.

Her pregnancy notes suggest that all has been well for the duration, that the health of mother and baby is satisfactory, and even, from just the day before, that the baby was head down and ready to be born. Her vital signs are normal, and contractions now two minutes apart. She seems to be at the stage of labour that makes most ambulance staff nervous about a BBA, a baby Born Before Arrival at hospital, and start to think about the mess they're going to have to clean up.

I offer Mina some entonox, the magic pain relieving gas. She takes the equipment in her hand, only for her mother to snatch it away.

"I told you, you don't need that rubbish. I never had any when you were born, and you're certainly not going to have any with your baby either!"

Mina looks downtrodden.

"I'm sorry", I say to her mother, "but you're not the patient in this case. If Mina decides she wants the gas, then she is more than welcome to use it".

"You. Are not. Her mother", she spits through gritted teeth, "And you're not going to make the decisions. She's MY daughter, MY responsibility, and it's MY decision!"

"You're absolutely right, it's not my decision. But it's not yours either. It's Mina's. She's old enough to make her own decisions. If she wants to use the entonox she uses it. I understand you're almost as anxious as she is, but right now you're not the patient. Mina, would you like the gas?"

She's terrified, struggling with the conflict between the pain she's in and her mother's overbearing presence. She nods an almost imperceptible "yes", and I hand her the entonox once again, just as another contraction starts.

"Well, if she keeps using the gas, then I'm not going with her to the hospital!"

Shocked looks are exchanged between Mina, her mother, and the crew.

"That's your choice! You decide! Yes gas, no mother!"

Another contraction starts, and I tell them both that we're leaving, as this baby wants to make an entrance, sooner rather than later. Mina screams with the contraction, takes another few lungs-full of entonox, and her mother storms out the back door and back into the house.

"You do it on your own then!" she screams, as she slams the door behind her.

Mina's resolute, and tells us to go, as her partner should be at the hospital within the hour anyway.

The transport is relatively uneventful, other than the contractions strengthening and becoming more frequent, causing us to move Mina onto the trolley. Just in case. We arrive at hospital, and Mina moves across onto the delivery suite's bed. As she does so, her waters break, and a baby's head appears.

"Stay with me", she begs the two of us. We do.

A minute later, her baby boy is born, and in loco parentis we witness her joy.

"Thank you, both of you. And don't worry about my mother. She'll be up here apologising soon enough. Stubborn cow that she is."

We congratulate Mina, refuse to have our photo taken with her and the baby, and head back to the ambulance to pack away the trolley.

As we sit back in the front completing the call, a car races into the car park, its driver rushes straight past us and into the department, begging to be allowed to see her daughter.

Laughing Gas

As the nights draw in, the hours of darkness rise as the temperatures fall, and I find myself longing back to the long, warm, days of summer.

*****

A Sunday evening, towards the end of the school holidays, and the kids are making the best of the last of the late sunlight. The park is full of children, some accompanied, some not, and the sounds of the joys of the summer break fill the air. The park is a large expanse of green with a large play area in the middle, a few trees surround it giving sporadic shade, used mainly by the parents enjoying the respite whilst their children soaked up the freedom.

The sound of playing children is shattered by a scream.

A mother runs to her child.

An ambulance is called.

*****

We're greeted at the park gate by an anxious looking man wildly waving his arms. The air conditioning has failed, so the windows are wound down, and as we draw nearer, the sound of a distressed child can be clearly heard. Even from 200 metres away.

"He came down the slide Superman style", he starts, even before we've opened the doors.

"And then he just screamed. Now he can't move his arms." Suddenly the realisation dawns on him that if he wants us to treat the child, he needs to move away and let us get out.

The scream sounds even louder now we're out of the ambulance.

"Well, at least his airway's OK", says my crew mate, pointing out the obvious.

We grab our equipment and start to make our way to the playground.

Harrison sits on his mother's lap, sobbing and screaming intermittently, his pain seeming to make him shrink in his mother's arms to half the size of his nine years.

The description of the event leads us to check his neck first, then his arms, where we find no injury and no pain.

We hand Harrison the entonox and explain how it works. "This is a special gas to help with the pain. It might make you feel dizzy, and it might even make you laugh. That's why they call it laughing gas!"

I try to hand it to him, but he won't move either arm to reach for it, so we ask mum to hold the nozzle for him. After a few short moments, the anxious, pained look on his face eases a little, and he's able to speak for the first time and tell me where it hurts. I feel one collar-bone, and then the other, and find them both to be probably broken. No wonder then that Harrison won't move his arms.

Superman style, head first down the long slide, his arms out in front clearly meeting their Kryptonite in the form of the solid ground.

Harrison starts on the gas, and after about ten minutes, he's calm and relaxed enough to let us put one arm in a sling, as his mum cradles the other one. I check the gauge on the entonox to see that it has just about moved out of the green zone and into the long, colourless middle area. There's a long way to go before he reaches the nearly empty red section, and I doubt he'll ever get anywhere near it. I've never seen anyone other than a labouring woman come anywhere near to using a full cylinder of entonox.

Slowly and very gently we move him to the ambulance, the hiss of the cylinder punctuated by frequent yelps of pain as one or other arm moves even the smallest amount. Thinking about giving him something stronger for the pain, I ask Harrison's mother about any medical conditions he may have, and medications he takes, and any allergies.

"Yeah. He's allergic to morphine! We found that out two years ago when he fell of a trampoline and broke his leg."

Entonox it is then. The only needle for this kid is going to be the one on the cylinder gauge.

A few minutes into the journey, as Harrison drinks the elixir of pain-relief through an overgrown straw, he suddenly giggles.

"You OK, Harrison?"

"Of course I am!"

"Is the gas helping you then?"

He giggles again, on the verge of laughter, but too scared in case it hurts. "It's much better thank you. Can I go home now?"

Mother and medics laugh instead. "Not right now. You need to go to hospital to see what they're going to do to fix you."

"OK", he says, closes his eyes, and goes back to concentrating on the gas. I fill in the paperwork, explain to Harrison's mum what I think has happened and what will possibly happen after we leave them at hospital, and her husband follows behind in the car, refusing to let us out of his sight.

Harrison is relaxed, pain still evident as we hit the unavoidable pot-hole or two, but he seems a lot more care free about it. The cylinder hits the red zone just as we're pulling into the hospital. It'll leave us just enough to get him into the department.

"This may hurt a little as we get you off the ambulance, but we'll be as gentle we can, OK?"

"OK! Let's go!"

We unhook the trolley from its securing clasp on the floor, and get ready to move.

"Happy, Harrison?"

"Very happy", he says. "Can I ask you a question?"

"Sure!"

"Do you know what to do when you're happy?"

"Errr, clap your hands? But I don't think that'll be a good idea for you right now!"

"I know that", he answers back, with a voice that's a kid's way of saying I'm not stupid, y'know!

And so, drunk on a whole bottle of entonox, he sings his way off the ambulance and into the children's department.

"If you're happy and you know it, clap your feet!"

Laughing gas indeed, except it worked on everyone.

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?

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?

Green and Genuine

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

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

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

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

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

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

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

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

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

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

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

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

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