Catching Up

Dear Reader,

I'm slowly catching up. I'm a bit of a technophobe, (actually, more of a techno-incompetent), but still I'm trying to catch up. There is now an "Insomniac's Guide" page on Facebook. I plan to use it to let fans know when there is a new post on the blog, but also for many other things. For example, other blogs that I read and make an impact, ambulance news, new ideas that are out there across the world for EMS providers and all manner of things interesting, amusing, thought provoking, and generally related to ambulance work and possibly Insomnia too.

As a special offer to the first 100,000 people to join, you will be allowed free daily access to the blog...

Driving Skills

At the age of 17, like so many others, I learnt to drive a car. Actually, that's not exactly accurate.

At the age of 17, like so many others, I learnt to pass my driving test.

I learnt about Mirror, Signal, Manoeuvre.

I learnt about road signs.

I learnt to parallel park.

I learnt to drive on slow roads and fast roads.

I learnt to reverse around the corner.

At 17 and a little bit, on a Monday lunchtime, I walked into the staffroom at the school where my mum used to teach, with a dozen pairs of eyes staring at me and my glum-faced expression, none brave enough to ask if I'd passed the test or not. My mum, standing the other end of the room and obviously knowing me better than anyone else there, saw straight through the fake sadness, spotted the glint in the eyes, and without a word spoken, threw her car key across the room to a round of applause.

That was the day I started to learn to drive.

*

At the age of 26, I learnt to be a paramedic. Actually, that's not exactly accurate.

At the age of 26, I learnt to pass the first of many tests to be a paramedic. Yesterday, a patient reminded me of it just by asking a simple question.

"Do you get taught how to stay calm through everything you see, or is it something you naturally have to have before you can join the Ambulance Service?"

To me, that hid an altogether different question: where do you learn how to become a paramedic?

Is it all the sitting in classrooms, bored to death by endless powerpoint presentations?

Is it by spending time in the operating theatres, practising cannulas and intubations?

Is it by listening to lectures on how to treat everybody the same?

Is it by reading through the book about drugs, their actions, their contra-indications and being able to recite them all off by heart?

The answer to all of these are easy. Yes. That's where you learn how to be a paramedic. Or at least, that's where you learn how to pass all the assessments that qualify you as a paramedic.

For me, that's not enough. I don't just want to be able to pass my driving test, I want to learn to be a good driver.

By the same token, I don't just want to be able to say that I have a certificate that says I'm a paramedic, pay my annual dues, and finished. That's the easy bit.

I want to be a good paramedic.

That's what you learn after you get your certificate.

That's when you learn how to use all the skills you've just been handed.

*

You learn to use common sense, you learn empathy, you learn sympathy.

You learn that the technique with which you cannulated your patient in theatre, where all is calm and controlled, won't be the same when you're cannulating a patient in cardiac arrest on his home floor with several family members watching your every move.

You learn that the worst case scenarios which always seem to occur in assessments, are really few and far between. But in the meantime you see cases of domestic violence that you were neither trained nor prepared for.

You learn all about how a heart attack patient might look and feel, you'll know how to treat and transport them, but how do you keep them calm and reassured?

You realise that you're an expert at CPR, yet you were never taught how to tell someone that their loved one has died.

You find that you were given a stab vest to wear, but are never quite ready for the time that a patient or their relative suddenly turns into a threat.

You discover that when you're treating a young child and their asthma attack, when your knowledge of the right drugs is important, that the way you are treating their parents is equally critical.

You find that even if you know theoretically how to treat every patient you see, sometimes you need to treat yourself. The trick you aren't taught is to know when that sometimes is.

Oh, and you learn to reverse around the corner again. This time in a truck.

*

The list is jumbled, just like the real world of the paramedic. A shift can, and often does, range from the sublime to the ridiculous, from the mundane to the life-threatening.

Despite every lecture to the contrary, you find that you can't treat everyone the same, because everyone is different. What you can do, is treat everyone to get the same result.

Most importantly, you learn that you cannot learn it all. Certainly not at once.

It takes time, patience, an open mind and a willingness to learn in order to perfect those driving skills.

Hopefully I'm getting there.

Empty

They lie there, piled safely behind the back seat of the car, starting the shift as reassuring, rarely used spares.

It's an uncommon thing to use a single, whole one in a shift, especially on the car. The crews come and whisk the patients away, using their own supply, leaving the car's one barely depleted. That night had been different. A collection was slowly accumulating, with no way of returning the empties to station, relying on the crews to replace them with fulls instead. Half way through the shift, and three of them had already been emptied, each on a separate, critically ill patient.

They lie there, piled safely behind the back seat of the car, spent, empty, used. There's one left in the bag, as yet unstarted, untouched. Enough for just one more, but surely, not tonight. Tonight has been tough enough already.

And yet.

He lies there, unconscious, barely breathing, the machine fighting with him, for him, but it isn't strong enough. Compressing the air and pumping what it can against the odds, all the while making no difference at all. We look at his chest, listen to his breathing, and whilst he's making the movements, no air seems to move. We'll have to breathe it for him.

Out it comes, turned up to full blast, the jet of air blasting out, hissing like an invisible snake, filling up the reservoir bag and mask to capacity. As fast as it fills the bag, we empty it into his lungs, forcing them to work against their wishes. We struggle, full in the knowledge that we're fighting a losing battle, but losing doesn't mean we've lost. Losing doesn't allow us to give up. So we struggle out of the house, into the ambulance, and to the hospital.

It lies there, piled up with the others behind the back seat of the car. Each silently telling its own different story.

And in the front, he sits wondering what's happened, and why. Why so many, why so ill, and the last one, especially the last one, why so young?

Another life in our hands, another battle fought, maybe won, maybe lost, and another whole cylinder now showing empty.

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?

Two Hours

Jen's been a little overweight almost all of her life, enough to give the kids at junior school the excuse to tease and bully her, but never really badly enough for her to want to do something drastic about it. Sure, she'd tried diets, fads, exercise, everything, but always ended up back where she'd started. Her parents had, maybe a little tactlessly, nick-named her YoYo thanks to her eternally fluctuating weight. Eventually, at almost 18 years old, she'd learnt to accept who she was and what she looked like and live her life the best way she knew how. She went to a good school, had friends, many of whom had been her tormentors in earlier years, and now saw Jen for who she really was, rather than how she appeared. And she had a boyfriend, Ian, a childhood sweetheart who'd been her partner now for almost four years.

It was Ian who'd called the ambulance. An 18 year old female with abdo pain doesn't fill any ambulance crew with the joys of spring. It's another routine, mundane call, often leading to mutterings of "waste of time", "taxi run", and "bet they haven't taken any pain-killers". Nevertheless, the way the call comes in, we have to run on lights-and-sirens.

As we walk in, Jen looks a little embarrassed, apologises for calling us out, and says that the pain has passed. "He panicked a bit", she starts, "the pain was really bad, and it came back a couple of times, but it's gone now. Really, guys, I don't need an ambulance. I'm sorry".

She's pleasant enough, too nice to be mad at, and clearly concerned as to how ridiculous she seems.

"We'll just do a couple of quick checks, make sure you're really ok, then we'll leave you alone. But if the pain was as bad as Ian described it, maybe you should come with us anyway, just to be on the safe side".

Abdo pain is such a minefield. It can be everything and nothing. Anything from uncomfortable food poisoning from last night's drunken take-away, all the way to a deadly ruptured aorta, the body's trunk-route for blood distribution.

She sat comfortably on the couch, hand on her lower abdomen, the memory of the pain still there, the brain trying to do its usual trick of erasing it. We check her basic observations, her pulse is a little quick, her blood pressure normal. We take her temperature, placing the tympanic thermometer in her ear - a quick and painless way of doing what used to take 3 minutes of sitting still with a piece of glass stuck under your tongue.

Jen suddenly screams. A piercing, terrifying scream that made me jump back, wondering how I could have inflicted such pain by just taking a temperature. She arches her back, holds on to the couch as though she was clutching at life. The pain lasts for no more than 30 seconds, and is gone as if nothing had happened. She looks down at the floor, suddenly refusing to make eye-contact and mutters, barely audibly, "I think I've wet myself".

A minute later, the pain returns again, and it finally dawns on us.

"Jen, how many months pregnant are you?"

"I'M NOT PREGNANT! WHAT ARE YOU TALKING ABOUT?"

"Jen, these pains are contractions. You're about to have a baby! How many months are you?"

Ian and Jen stare at each other.

"I can't be pregnant! I'd know if I was! I've only put on a bit of weight. I'm NOT PREGNANT"

Much as she tried, much as she wanted to, there was no denying it. Jen was in labour. Her waters had just broken, she was having contractions every minute. The baby was about to be born. We asked for a midwife, and another crew, and started preparing for the birth. We have no idea how developed the baby will be, so have to prepare for every eventuality, from a normal delivery to the horrendous thought of having to resuscitate a tiny newborn. There was hardly the time to think.

The baby's head appeared in the very next contraction, and by the one after that, a newborn baby's cry filled the room. The baby girl seemed a good size, a good colour, and there was clearly nothing wrong with her lungs as her voice made her surprise appearance clear to all. We cut the umbilical cord, cleaned her up, and I handed her to the new mum.

"Here she is! Your beautiful baby girl!"

Jen looked away, kept her arms folded, and through stifled tears whispered "I don't want it".

"It", she said. not "her". I was shocked and saddened, trying to understand the turmoil that Jen was going through. An hour ago she had some tummy ache, now she had a daughter. I couldn't get my head round it any more than she could. She couldn't, wouldn't, accept that this baby was hers. To her, the little girl was an "it".

The second crew turned up just after she was born. The midwife was still miles away. We decided to send mother and baby to hospital in separate ambulances, and not wait in the midst of the anger, the confusion and the rejection. Jen came with us, a few minutes after her baby had gone. A few minutes to gather her belongings, gather her lost dignity, and gather her muddled thoughts.

At the hospital, we're shown into a room, and as we walk in, Jen having refused to travel on the trolley bed. There's a small cot already there, and in it a sleeping baby, swaddled in a pink blanket. Jen gets onto the bed and says nothing. One of the midwives asks us for the story, we take her aside and explain all that has happened. Slowly and quietly, the cot is moved nearer and nearer to Jen's bed as she has her blood pressure checked and a midwife reels off a seemingly never-ending list of questions.

Absentmindedly, as she answers the queries about her health, about the pregnancy she never knew she had, and about her personal life, Jen's hand moves to the cot. She sits there, a tiny smile slowly creeping onto her face, as she strokes her daughter's soft, downy hair.

"I want her". As the words escape her lips, she grins, then bursts into tears. "I want to keep her. I want her to be mine".

She seems hardly to believe her own thoughts, as if someone else had spoken them. But she was exceptionally proud of them.

"She is yours, Jen", says one of the midwives. "And there's nothing you can do about it".

She just sits there, uncomfortable on the ancient hospital bed, the initial shock on her face and sadness in her eyes, turned now to relief and happiness like she has never experienced.
Two hours earlier, it had all been so very different.

There

The drops are stopped in their almost perpendicular path by the windows, housed in the walls that has been their home for over sixty years. They continued their gravity-powered journey and soaked the ground below. He sits watching the weather, the tears falling from his eyes mirroring the rain, falling silently off his cheeks to the carpet, soaking in before they could leave any trail.

The door had been left open for us, and we avoided the more usual soaking whilst waiting on the doorstep.

"We're in here", comes the strangled voice from the front room. We went bundling in, four green-suited, adrenaline-driven life-savers. We were overladen with bags full of kit that we already knew, just from looking at the call on the screen, were redundant, and highly-qualified and well-trained with skills that we knew from the outset, would do no good.

We were there to confirm what he already knew, as he sat stroking her hand, her head on his shoulder.

We were there to ease the burden of him having to utter the words he could barely cope to think.

We were there to see to it that he wouldn't be left with no-one by his side, as he kissed her goodnight for the very last time.

Trouble

If you're trying to multi-task,
Doing CPR,
Setting up equipment,
Dealing with relatives, neighbours, nosey passers-by,
Talking to several different agencies,
Informing control on the radio,
All about the traumatic cardiac arrest you're dealing with,
Please -
Don't use the phrase "Kill two birds with one stone".
You're only asking for trouble.

Way Home

"RING RING... RING RING"

It's the simple, old-fashioned ring tone on my mobile. Everyone seems to have their favourite piece of music, some amusing noise, a baby laughing, anything, just not a normal, straightforward "ring-ring" type noise. I guess it makes me a traditional non-conformist. Now there's an oxymoron. I ignore it, as I always do when dealing with a patient. MrsInsomniac will have to wait. I'm sure it's her. She has this amazing knack of only ever calling when I'm with a patient, and never when I'm just sitting around drinking too much coffee.

"RING RING... RING RING"

We climb over the fence and into the field. She sits in the front seat of her battered car, pushed off the road by the force of the impact. The bus had no chance of stopping in time as she came round the blind bend on the wrong side of the road. The weather didn't help either. The road was wet, with the first rain in a few days making it that little bit more oily. She probably lost control as she came round the corner, sending her directly towards the bus.

"RING RING... RING RING"

The windscreen's spider's-web fracture indicating what we'd already guessed. Her head hit the glass leaving her unconscious and with a massive head injury. Her breathing slow and laboured, all other injuries are for now ignored. The scene is now a sea of blue lights, with police and fire brigade joining the frenzied attempts at getting her out of the car. Nothing else mattered for now. The road was closed despite it being a major route for homeward bound commuters, and those stuck in the traffic would be there for some time yet. Most would probably be calling home to let them know of the delay.

"RING RING... RING RING"

The roof is cut off the car, she's removed, along with some of her belongings. Only those critical to identifying who the unresponsive patient was. The rest would have to be salvaged later from the remains of the car. As we finally got her out of her car and into the ambulance, it seemed that the ringing was getting louder. The familiar ring tone rang again, and only sounded clearer as we were away from the generators, running engines, and general noise that surrounds the scene of a serious accident. All in all, the phone rang four or five times whilst we were at the scene. Unusual, I thought, as normally MrsInsomniac would realise that I'm on a call and would wait patiently for me to call back when I was free. If she's tried to call this many times, it can't be good news.

Finally given half a chance, I looked at my phone, only to find that it was switched off. And obviously I hadn't had a single call. Which means that someone else had the same phone, and chosen the same ring tone.

It rang once more, from the direction of the patient's handbag.

The screen was alight, the word HOME flashing with every ring. A police officer answered it, and explained to the patient's frantic husband what had happened. That his wife was in a car crash, where it had happened, that she was with the ambulance, that she'd be OK and was being taken to the local hospital.

"He's distraught", said the officer. "He was trying to call to tell her to go a different way, he'd heard on the news that there'd been an accident on her normal way home".

I wondered how long it would be before she really would be on her way back home again.

It was the end of the shift, and as I sat in the car writing the illegible scrawl that was my paperwork, I switched my phone back on. As it came back to life, a message appeared.

"Can't get through. You must be busy. Let me know when you're on the way home".

Diesel

Three-year-olds are a law entirely unto themselves. Having had two of them over the last 3 years, I'm only just recovering, just in time for them to be four- and five-year-olds. It's not much easier, but at least they can better articulate what it is that they're tantruming about.

So, with all my experience and battle-weariness, I know the following:

Three-year-olds should be active.

Three-year-olds should be vibrant.

Three-year-olds should be very, very good.

Although three-year-olds can be horrid.

Three-year-olds, however, should never, ever, be unconscious.

Or grey.

Or breathing shallow, useless breaths.

The nursery staff look at us with pleading eyes, their gaze shrieking more than their combined voices.

"He just collapsed. Just fell to the floor and stopped. Is he dead?"

I look at Jim, and he at me. There's no need for words between us, we read each other like books.

Oxygen goes on, and we help push it into Tyo's lungs.

Defib pads go on, but, thankfully we don't need to use them. Yet.

We carry Tyo down to the ambulance, Jim jumps into the pilot's seat.

A nursery nurse, tears streaming down her face, sits down in the back, flustered and frustrated at the fact she can't do anything to help.

I feel the same.

Just pumping oxygen in seems so mechanical, so basic, making me feel powerless and useless.

Usually I prefer to sit in the back with the patient, and let someone else do the driving. Seems to me to be the better job.

This time I think it's the other way round.

Jim's got the best job for now.

Whilst I'm force-feeding Tyo the oxygen,

Jim gets to force-feed the ambulance some diesel.

Cul-de-Sac

The cold temperature in the dingy basement flat matched the frost-bitten air outside. Small icicles surrounded the windows, the only light was that of a lone candle, battling to break through the dark of another winter's night. The kitchen, bathroom, living room, even the bedroom, all crammed into a flat no bigger than an average family car.

*

The fire-call seemed straight forward. A ground floor apartment, probably a kitchen fire. There was smoke billowing from the broken windows, but the Fire Brigade seemed to be in control now. The ambulance's occupants enjoying the respite that these types of calls often bring. We're only there "just in case". In case one of the Brigade are hurt, or in case any occupants are found and need treatment.

*

In the middle of it all, surrounded by the barest of bare essentials and wrapped in layers of blankets, sat Ray, looking almost double his middle-aged years. Hardly more than a skeleton wearing a thin layer of skin, with sunken cheeks and saddened eyes, he was clearly embarrassed to let us in. "I don't know where to turn any more", he started. It was tough to work out if his speech was shaky because of the cold, his fear, or a medical condition. "My family have either died or left me to do the same. I have no help. No gas. No electricity. I steal or beg to eat, and only keep warm by wrapping up in layers. I have no light and no heating. I just need to be somewhere warm".

*

The white-helmeted Station Officer had come over to let us know that they didn't think that there were any occupants, but that they'd still like us to stand by. "Hang fire", he says, his grin indicating clearly an intentional pun. "We've still got guys in breathing apparatus. Once they're all out and OK, we'll let you go." We're in no rush. We have chocolate. We have drinks. We have hours left of our shift, and now we have a break. The music's turned up just a little more.

*

Cases such as these are rare, but not as rare as I'd like to think, or hope. In a country famed for its welfare, cases like these have no right to exist, and where they do, they should be easily and quickly solved. Many, too many of them are unknown, shame and fear preventing those suffering from doing anything about it. Ray had had no heating or light for several months. The utility companies seemed just to give up on getting their money, cut off the supplies, and never bothered to check if anyone was still living there. There was wax everywhere from where he'd lit the candles, bags full of rubbish that he said he still had to go through to see if he could find anything worth salvaging for food, and filth all over the space that hardly qualified as a kitchen.

*

One more update from the Station Officer. The last of his crews was now going into the building, to ensure that it was well ventilated and assess when it would be safe for the other residents in the vicinity to return back to their own homes. "A few more minutes guys", he says, talking over the noise of the generators, the pumps and our radio. It's all now a matter of minutes before we'll be back on our way to the reality of ambulance work.
*
One thing was for certain. Ray couldn't stay here any longer. Irrelevant of any medical need - he was going to hospital. At least there he'd be warm, fed, showered possibly, and most importantly there would be time to get the system in place for him to be cared for long-term. It wasn't an ideal solution - just the start of one. He was unsurprisingly hypothermic, his pulse was low, his blood pressure too. It was surprising he was still sat up. We brought the chair in for him, but he refused it, wanting to salvage his last vestige of pride, and chose to walk to the ambulance. He got as far as the door and caved in.

*

Then came the shout. "There's someone here! He's not breathing! Get the paramedics!" We both hear the Brigade's radio over the music channel we're listening to in the ambulance, and jump out of our seats. A Fireman's Lift is given a whole new meaning when you actually see a lifeless body being carried out by a fireman.

*

The journey to hospital was uneventful, we left him in their care, filled in the multitude of forms to get social services involved as quickly as possible. Something must have worked somewhere. Not long after that, I had a call to the same building, to see an estate agent's To Let sign outside. I had a peek through the window and saw that the place had been cleaned up, was brightly painted, and now just waiting for a new resident. Ray was nowhere to be seen.

*

He was placed on our trolley bed, and the resus started in earnest. His face was covered in soot, his skin cracked, his eyes glazed over. Someone started on compressing his chest, trying to beat a rhythm into his arrested heart, whilst I was in charge of using the bag and mask, to breath some oxygen into his burnt lungs. I removed the mask from his face and prepared to intubate him, so that the oxygen we were pushing in to him at random with a mask hit exactly the right spot via a tube.

*

I spoke to the sister in charge to find out what had happened in the interim. She told me that he'd been moved to a ward and would probably spend a few days in hospital. Social services had been contacted and the system's cogs were turning, trying to find the most suitable answer to his problems. For some reason this call bugged me, so I followed up again a few days later to find that he'd been rehoused. I hoped it was clean, warm, and had 1st world utilities, instead of 3rd world conditions. I hoped he was on the road to recovery.

*

One of the bystanders, forced out of their neighbouring apartment by the fire, told us that he'd only moved in a couple of weeks previously, that he seemed pleasant, but kept himself to himself. She didn't really know any more about him. As I took the mask away, I saw a face I couldn't forget. I hadn't noticed in the first moments he'd been thrown at us. Ray's face, covered in smoke and contorted in pain, his eyes, once saddened, now looked back at me again, this time glazed and lifeless. His chance at finding a road to recovery reaching no more than a cul-de-sac.

Opportunity

It's amazing how sometimes your brain will only register what it wants to see, and go on believing what it sees, even if it turns out to be completely wrong.

The house has two cars in the driveway. One an old classic, clearly cherished for many years, the owner one of the old breed of drivers, the tax disc a couple of years out of date now. The rust and dust are building up, but it still takes its pride of place out the front of the house. The other car is a shiny, new-looking car with a private number plate, the pride and joy of someone much younger who probably uses it daily and washes it once a week.

He's eighty-something years old, lovingly cared for by his granddaughter, at a guess in her twenties. She clearly adores him, and the love and admiration flows both ways. He's confused and in pain, having tripped and fallen down a couple of stairs. Whilst we assess his injuries, she's there, wiping his face, stroking his head, doing her best to comfort him. It looks as though he has fractured a hip, and the agony is made just that little bit more bearable by her presence, her reassurance, her love.

We're just the mechanism by which he'll get to the hospital, but she is clearly the power that will pull him through the experience. We give him some analgesia, scoop him up gently, and move him carefully to the ambulance.

She gathers some clothing together, finds his medication, checks the lights, the heating and the locks. Just before she's ready, I ask him a simple question.

"Is your granddaughter joining us in the ambulance, or is she going to drive up in her own car?"

As soon as the words leave my mouth, and I see the look on his face, the penny drops. The penny makes a loud, reverberating noise in my now empty head as I realise my error. Anyone can make that mistake, right?

I shouldn't have assumed. I don't any more.

I should have checked. I always do now.

I should have asked. I always will in future.

"That's not my granddaughter", he practically spits.

"That's my wife!"

There are those who learn from their own mistakes, and there are those who, without having to go through the pain of embarrassment, learn from mistakes made by others.

I hereby present you the opportunity to save yourself the blushes...

Respect is Due

The latest Handover Carnival has been expertly compiled and published by CK over at Life Under the Lights.

As Chris wrote on his site - "Respect can mean many things in EMS. Whether it’s the utmost respect for the sanctity of human life that must be inherent in all medicine, respect for our coworkers, respect for ourselves, respect for our profession, or respect for and from other health care providers and the general public. Almost all of our problems could be said to at least partially stem from a fundamental lack of respect".

So, without any further delay - head over to Life Under the Lights for the latest Handover Carnival - entitled Respect.

Happy to Help

Public education should really be at the forefront of the campaign against misuse of the ambulance service. Huge posters, TV and radio ads, even, as far as I'm concerned, parliamentary debates.

Even the occasional blog post.

There's a relatively new law that could see a person fined, and potentially jailed, for obstructing an emergency ambulance in its duties. From the news that I've seen, this has been used precisely once in London since it became law over a year ago. This is probably because being deliberately obstructive, whilst potentially lethal and exceptionally obnoxious, is a very rare thing. More often than not, the obstruction is caused elsewhere, when an ambulance is called unnecessarily, whilst somebody else, in desperate need, lies waiting nearby.

*****

The call was to an industrial site, a plastics factory, for a hand injury. The call taker has been told that there is serious bleeding. As per normal on these sites, the front gate security sent me the wrong way, but the array of white-overall-clad windmills soon had me turning 180 degrees and heading for the right factory. After grabbing the kit out the back of the car, I'm shown into the main office that doubles as the first-aid room. My tour-guide is walking double-time, and speaking twice as fast.

"I'm sorry we've had to call you. It's Stefan. He was slicing some plastic sheeting with a Stanley knife and it slipped. He's cut his hand. It's really bad! I've put some bandages on and tied them tight, but it's leaking through, so I've made him sit with his hand on his head!"

A first-aider with some knowledge, and putting it to good use. I'm impressed.

I find Stefan sitting on the office chair, feet up on the table, his right arm bandaged and resting on his head. Blood trickles out and drips down the side of his face, giving the impression that he's bleeding from his ear. He's paler than the overalls he's wearing, clammy and scared. I have to see the injury, so warn Stefan that I need to remove the bandages and he may want to look away. There's a definite reverse shuffle of feet heading for the door as I say that, as the few people who'd come to see what was wrong realised that they'd seen enough. With the bleeding still seeping through the bandage I presume an arterial bleed, and remove the bandages with some care to ensure I don't get covered in case of any spurting blood vessels.

The injury is serious. He has a deep laceration from the back of his hand by his little finger almost as far as his elbow, all along the top of his arm. It's like having a lesson in the anatomy of an arm - muscles, blood vessels, bone, all on view. The force being used on the blade to cut through thick plastic made easy work of Stefan's arm, as the knife slipped off its intended target and took out its venom on the next available one. With his arm re-bandaged even tighter than before, elevated in a sling, Stefan was blue-lighted to hospital for what would initially be an attempt to salvage his arm and its motor functions, and later on for the plastic surgeons to work their magic too.

As the back doors of the ambulance were shutting, Stefan looked up and said a drowsy "thank you".

"No worries Stefan. Happy to help."

*****

One week later, almost to the minute, and I'm called to a private home, for a man with an arm injury, again with serious bleeding. These sorts of things tend to happen in blocks. There'll be a few people all having heart attacks around the same time, then I'll attend RTCs as though they are going out of fashion, and obviously now a few days of people slicing their arms.

Kev meets me at the door himself. His hand and arm are wrapped in a colourful array of tea-towels. He starts telling me how the accident happened, and only half listening (big mistake), waiting to see another anatomy lesson, I start unravelling the towels that seem to have stemmed the serious bleed. Four towels later I can see his arm, but no sign of any bleeding. I ask him once more what happened, and he tells me again of the new DVD player and cutting his hand on the box as he opened it. For a moment, I'm lost for words.

There's no cut, no blood, at a stretch there's a small scratch. A paper cut. That's why he called the ambulance. For a paper cut. Sometimes, most times in fact, if I'm on route to a call that I think isn't either an Accident or Emergency requiring an ambulance, I'll rant, rave, threaten to scream and shout, but invariably, as soon as the door opens, I'm polite, professional and calm. I'll politely suggest that if there is a "next time" other alternatives, a GP appointment, a visit to a minor injuries unit, even self-conveyance to the A&E department are all possibilities.

This was a grown man, in his late 40's, with a supposedly responsible job, runs his own home, and seemingly has at least a normal level of intelligence. His justification for calling an ambulance for his paper cut was because he was on Warfarin - blood thinning medication - and was concerned that he wasn't going to be able to stop any bleeding. I tried to point out, gently at first, the fact that he needed to have been bleeding in the first place to be worried about it not stopping. I tried to tell him, calmly at first, that despite the fact that he was on Warfarin, he was at no greater risk than the rest of the general population of dying from a paper cut. None of this was being taken on board. Kev kept repeating the same mantra over and over. "I'm on Warfarin. I deserve an ambulance. I know my rights and that means that you have to take me to hospital, otherwise I might bleed so much that I'll die!"

In one final attempt to explain who we are, what we do, and when is the right circumstance to call us, I asked Kev if he had any family in the area. "Sure. My parents live not far from here."

"And if one of them was to have a heart attack, what would you do?"

"I'd call an ambulance."

"Well, sir, you wouldn't get one."

He looked incredulous. "Why the hell not?"

"Because, sir", I tried to answer with all the composure I could muster, "I'm here dealing with your paper cut!!"

Finally, the penny seemed to drop.

"Ummm... Errr... Maybe I over-reacted a little."

I sighed.

"Maybe you did, sir. Just a little."

*****

Fears allayed, Kev decided that he didn't really need to spend several hours in hospital for a paper cut, and after a short time and the traditional paperwork, he decided to stay home. We parted as friends, and he promised to think long and hard if he really needed to call an ambulance in future. I, on the other hand, after doing my little bit for public education, promised that if he did ever need us again, either for himself, his family or his friends, we'd be only too happy to help.

Trick up the Sleeve

Once upon a time, in a land not far from here at all, there was a brand new EMT. So new, that he'd only been let loose on the public a matter of a month earlier. He was a nervous, quiet, shy character, not yet quite at ease with his new surroundings, but loving them nonetheless. He wanted to see everything, do everything, know everything, all in the quickest time possible, but for now was always happy that there was someone there wiser, more knowledgeable and more experienced than he to rely on.

One fine day, along with female crewmate, he was sent to an RTC. A lady had fallen off the back of a bus. 'Twas one of the olde worlde, London icon type Routemaster buses, with no door at the rear, and said lady jumped off whilst the vehicle was still in motion. "Stupid", I hear you chorus, with a "serves her right" to boot, but with these buses, jumping on and off at low speed was part of their charm. This time, however, she landed awkwardly and had hurt her arm.

She sat on a wall with her friend, cradling her arm, obviously in pain. As brand new EMT and partner approached the lady, a comment was passed between the patient and friend in a language other than English. A derogatory comment, even a racist one. Said EMT ignored seeing and hearing the comment, registered it and stored it in the back of his mind, and went about attempting to treat the patient. The middle of the patient's lower arm had a shape to it that even to a brand new EMT said "Broken". No question about that one.

Patient wouldn't, couldn't, or didn't make eye contact, and just said, in perfectly good English, "I can't come in your ambulance". Brand new EMT wasn't too shocked, and played dumb.

"If you'd rather be treated by my colleague, that is fine with me. I understand you might wish to be treated by a female".

"No, no. I just can't come in your ambulance".

"Well, if that's the case, I'll just inform our control that you are refusing our aid, despite the fact that you clearly need it. They won't send another ambulance, just because you don't like the look of this one!"

"Oh", she said, and jabbered away in her vernacular to her friend. Clearly they were discussing their next move.

Brand new EMT's patience was wearing a little thin, but he maintained his composure as he asked "Are you refusing to be treated because of who I'm not, or because of who I am? Because you can't choose the crew that get sent to help you!"

Ruse possibly rumbled, patient and friend eventually agreed that they would travel with us and even allowed the brand new EMT to treat the patient. He gave her some entonox to ease the pain, explained that despite the fact that he had not yet been allowed X-Ray glasses that he was fairly certain that the arm was broken, and placed the arm in a splint.

All the while they talked between them about the fact that they'd had to travel in an ambulance with this brand new EMT, how they wished they didn't, how they hated him and his type, and how they'd have to make sure that their friends and family didn't find out about who it was that treated and transported them.

And all the while the brand new EMT sat and with a blank look on his face. Well, wouldn't you if everything around you was in a foreign language?

As they all arrived at the hospital, the back doors opened, and brand new EMT asked the patient how she was feeling now, and if she was ready to leave the ambulance.

Asked, not in English, but in their own language. One which I can't speak fluently, but can understand to a great extent, and speak just enough.

Two faces fell and became instantly beet red, and the two voices became instantly silent.

My face just had on it a small, wry smile.

I could have been angry, furious even. I could have complained, reported them. I could have even refused to treat and transport them.

Instead, I was just glad to have been the bigger person, and have a trick up my sleeve that left me with the last laugh.

A Giggle

I know I've not written for a few days - apologies, the world has gone a little nuts.
Depending on my insomnia, I may get something posted tonight.
In the meantime - have a laugh.
Head over to Flobach Republic's blog and have a read of his latest post. I'm still smiling.
And when you've only had 6 hours sleep in the last week, a smile looks a little manic, but still.
Go.
Read.
Enjoy.

Good Afternoon

So when is a Police Constable not PC? When the police force has issued even more guidelines of how to address people, or how to refer to the time of day. Or not, as the case may be - apparently it may cause confusion for "different cultural backgrounds" if you bid someone a "Good Afternoon".

Codswallop, Tishposh, Baloney and Tripe. I'm sorry. But it is. And I know that the beginning of this sentence sounds like some American legal firm. Sorry for that too.

I can understand not asking for a Christian name. I'm not Christian, and I wouldn't be upset if someone asked me for my Christian name, but I can, just about, understand that rule. I don't necessarily agree with it, but I can understand it. We don't need rules and regulations for every single little thing. There should still be some room for common sense.

The one thing that I have been left thinking about is names in general, and in particular, what do you call your patients?

Do you call all male patients "sir"? Really? Even the six year olds?

Do you call all female patients "madam" or "ma'am" or "miss"? Really? Even the really scared ones?

I know that if someone calls me "sir" it means one of the following. Either I've been knighted by Her Majesty, no-one told me about it and I've missed the Investiture, or someone is trying to sell me double glazing. I hate it. Don't call me sir.

If you call me Mr. M, I am equally as uncomfortable. Either I'm talking to one of my kids' teachers, who are trying to balance the tightrope of officialdom, distance and the personal touch, or I'm meeting the bank manager for another review of my ever-growing overdraft.

My parents were kind enough to give me a first name, so please use it.

I know that this isn't the case for everyone. I know there are many people who prefer to be addressed as Mr. SoAndSo, or Mrs. WhatsHerName, and they are entitled to that courtesy. The Rules say that this is how everyone should be addressed.

No room for manoeuvre, no room for the personal touch.

I think that this is what aggravates me the most. I disagree that calling people by their first names is unprofessional. Sometimes I find that it's just what they need to hear. Admittedly not ALL (ahem) our calls are life-threatening, and not at every given moment is either the patient or their relative in great distress, but if they are, then I think that addressing them by their first name, or whatever other name they choose, has a calming effect.

It portrays that we can walk that tightrope. Be professional at all times, and yet have the personal touch that shows you can empathise, sympathise and treat as necessary.

If, for example, Jill Greaves, was trapped in an upside down car after a high speed RTC, I'm sure she'd rather hear the strange multitude of voices saying "Don't worry, Jill, we'll have you out of the car and in the warm as soon as we can", rather than "Mrs. Greaves, we understand your concerns and are aware of your predicament, so we are undertaking your rapid extrication from the vehicle".

So what do YOU call your patients?

I vote for common sense.

I vote for asking your patient how they would like to addressed.

And I vote for bidding your patients Good Afternoon. But only if it really is.

Oscars Night

I know you're not unconscious.
You know you're not unconscious.
Even the non-medically trained police officers know you're not unconscious.
We all know you're faking because you don't really like the idea of being locked in a police cell for the night.
Your acting is poor.
Your eyelid-flickering, arm-not-falling, half-peeking-in-the-hope-we're-not-looking performance convinces no-one.
But I guess we have to play the game.
It's just that you'll get no sympathy from any of us.
We'll get the trolley-bed and place your pseudo-unconscious carcass on it.
We'll take you up to the hospital for them to know that you're not unconscious too.
We know you're probably going to try to run, so some police officers come with us.
Doors are unlocked, opened, and you feel the fresh breeze on your face.
Miraculously, the act over, you wake up, and try to jump off the bed and run.
Except that in your unconscious state, you failed to notice the obvious.
The thing about handcuffs, is that there are two halves.
One is attached to your hand.
The other is securely fastened to the trolley-bed.
For a moment you seem to bounce back as if on an elastic band.
We snigger.
The officers barely suppress their giggles.
The custody sergeant laughs out loud.
"You ain't going anywhere sunshine", he bellows.
"Well, except maybe to the Oscars".

Confidentially Yours?

CK over at Life Under the Lights has written a motivational post for all EMS staff, worth not only reading, but also acting on. Are you the best that you can be at what you do? Are you the sort of paramedic that you would want called for you or your nearest and dearest? If not, what are you going to do about it? Go read his post, and come back when you're done. His is definitely a worthwhile read.

For me, Chris's post raised a completely different subject, and took me back to a major dilemma I had quite a while back. I know this sounds a little strange, but it all started when I was 14 years old.

Back then, I had just changed schools, and on my first day I was marched into a classroom, told to take the one empty seat and just get on with it. The person I sat next to that day became my friend for life. He'd only been at the school a few months longer than I had, so was also finding his feet, and yet he always made certain that I wasn't left out of whatever was happening, knew where I was going, which classes were where, and most importantly where the nearest shop supplied with chocolate was. "KitKats", said the owner every single time we walked in. "33p each, but special offer for you guys, 3 KitKats for £1". Happy days.

Our lives have since taken very different paths, in totally separate parts of the world, and yet we always make sure to keep in touch. Life sometimes gets in the way, and we don't communicate as much as we'd both like to, but anytime there's any major news in my life, he's one of the first to know about it, and vice versa.

When he moved to the USA, his parents stayed here in the UK. After a while I got to see him again, when he had to return for his father's funeral. These were not the circumstances under which I'd envisaged seeing him again, but despite the tough times, it was still a great feeling to be in the same place at the same time, if only for a short while.

Not long after he returned home to the States, I had a call to a very familiar address. My face told my crewmate more than my voice did. The address, one where I had spent so many happy hours pretending to do homework, practising our different martial arts and generally beating each other up, eating, drinking, watching TV, being teenage boys, now appeared on our MDT screen, alongside "Female, fallen, ? conscious, ? injury". I wasn't sure I could face it, and briefly considered asking one of the other crews to take the call. However, I decided that if anyone deserved my help, it was the person who'd looked after me, welcomed me into her house and regularly force-fed me all those years ago.

We arrived to find that she was conscious, but confused and injured, and would require transport to hospital. As anxious as I was about attending this call, she was just as pleased to see me emerging through the front door again, albeit in a different capacity altogether, and she wasn't entirely certain why I was there. This time, I had to do the looking after. We transported her to hospital for them to tend to her injuries, and I made a mental note that at the end of the shift I'd call my friend and tell him what had happened.

This is where I had a problem. I have treated several people over the years who either know who I am, know my family, or have some other connection to people I know. I have never, will never, divulge even the hint of the fact that I've met someone like that to my family or friends. If the patient wants people to know that they've met me, that's their prerogative and they can tell as many stories about themselves as they like. Often I'll be met with "You didn't tell MrsInsomniac that you treated me???" and other such expressions of surprise. Where I come from, it's gossip first, worry later, then gossip again anyway. I'm just not like that, not in general, and definitely not at work. My patient's privacy is first and foremost, whether they know me by my first name or not.

This time, however, it was my childhood friend. And his mum. People I have known for so many years, who I am very close to, and who are very much part of my life. How do I now go about calling him and telling him that his mum's in hospital, not in any state to talk to him or to tell me to do so, after I was the one who treated her.

Do I wait for the hospital to contact him, and hope that he puts two and two together?

Do I make the initial contact, breaking every rule in the protocol book?

Or do I go to my next call as if the person I just treated meant the same to as any of my other patients that day?

Which option would mean that I had treated the patient to the best of my ability, and in the best interests of the patient?

Friendship versus Confidentiality.

What would you do?

Icing

Recently I've written a couple of posts reflecting disappointment and frustration at the system that guides the job that I do. I love my job, I'd just like to be able to get on and do it. Sometimes I need a reminder that when all else fails, there's someone somewhere, not very far away, who will call on us and we will make all the difference. They'll be relieved, appreciative, sometimes thankful, even if they don't necessarily show it at the time.

Often all it takes is one call. One short-lasting event to remind me why it is I do what I do. Sometimes it's an entire shift. One of the things I most enjoy about my job is the fact that not only are no two days ever the same, but that the huge variety of calls we receive keeps me constantly on my toes. Every time I get just a little too laid back, something jumps out at me and reminds me that there's always something out there that I know nothing about, have never seen, and will really have to think about how to deal with.

Mostly I feel that it's the variety that keeps me here, but sometimes, when the variety is only of the unnecessary sort, the multiple gear changes leave a burnt out clutch.
Sometimes that clutch just needs changing, and all is back to (ab)normal.

And just when I needed it, the clutch that needed fixing was sent the mechanic that it needed. A recent shift, and being in the right place at the right time, brought the following:

I went from dealing with a child who's been on antibiotics for 2 hours and hasn't yet miraculously recovered from their sore throat, to comforting the relatives of a cancer patient who had just succumbed to their illness.

Then from a mild allergic reaction caused probably by new medication, to extricating two people trapped in the mangled remains of the family car.

And last job of the night, I was called to a patient threateningly at death's door, danger lurking both for her and her unborn twins. I was, along with the crew, still in the maternity unit finishing the paperwork as we heard those same babies, abruptly c-sectioned from their mother, cry for the very first time.

I wasn't all that far behind.

I went home that morning once again knowing why I do this job, and why I love it.

That night, I came back to work to be met by one of our managers.

"Do you remember a call you attended a few weeks back?" He went on to describe a call of which I had a vague recollection. It was routine. An unconscious diabetic, hypoglycaemic, sugars too low. We reversed it, he recovered, and stayed at home to be cared for by his family. I feared a complaint coming my way, although I couldn't figure out why. I told the manager that I remembered it, bizarrely more because I remembered the house, than the patient.

At that point, he opened up the back of his car and handed me a box.

"Here. These are from them for you. They gave me 12 bottles of wine, 4 for each of you that were there!"

Very much taken aback, I took my share of the box and, not being much of a wine drinker, later donated the wine to a worthy cause.

This isn't even close to the reason I do what I do.

But after the night before, it was just the icing on the cake.

Excuses, excuses

Chronic insomnia is not an excuse for stupidity, but I'm going to try to use it anyway.

*****

It's been a long, busy night. At 0500, you are starting to see the light at the end of the tunnel, and are just getting hit by that end-of-night-shift-itis.

The patients, just for a change, have all, every single one of them, been in genuine need of an ambulance. You have treated some, stabilised some, resuscitated others, even transported them or travelled with them.

You've finally got back to base, and debate the pros of a cup of coffee in keeping you awake just until the end of the shift, and the cons of same-said coffee stopping you from sleeping when you finally get home.

The decision is made for you by the phone pinging its SMS Morse code sound, frighteningly similar to that of the SOS. The coffee will have to wait. The police have called for you this time, for an RTC. Possible arm injury. That's all the details you have, other than a general location.

As you approach the scene, there are several police cars with their lights illuminating the surroundings, the staccato of their lights reflecting off the buildings.

You park up behind the police cars, and walk to the front of the line, assuming that there might be a pedestrian on the ground in front of them with the arm at a funny angle. No one is there. Not even a police officer.

You look around, and see a couple of other cars a bit further up, but both seem to be parked rather than crashed. No sign of anything. You are confused. You are about to get on the radio and ask control to speak to the police and find out exactly where they, and the patient, are hiding.

And then you stop looking around, and for the first time in the 30 seconds (yes, all this in less than half a minute) since you arrived, you see it. The officers are on the other side of the road, by the block of flats.

The patient is standing talking to the officers. You guess he's the patient as he's standing there rubbing what must be a sore shoulder, and trying to move his arm. There is however, no car. There's a good reason for that too.

The RTC involved a truck.

A big truck.

One of those with 12 sets of wheels, 4 axles, 36 gears type of truck. Don't pick on me about the numbers - I've just made 'em up. Just take if from me, it was one of those huge delivery trucks, the ones you don't mess with on the roads, whether or not you have blue lights on the roof.

And it was parked in the side wall of the apartment block.

Rudely awakening the occupants of the ground floor flat as it appeared in their bedroom uninvited.

SO HOW IN THE WORLD DID I MISS THAT WHEN I FIRST GOT THERE???

*****

Chronic insomnia is not an excuse for stupidity, but if it was, it'd be the best excuse in the world!