No Answer

Driving back towards the station after yet another routine call, a set of traffic lights on red sees me pull up alongside another car, a brand new convertible. Warm sunny days are a rarity in this part of the world, and those with convertible cars make the most of them. As soon as the sun is out, the lids come off the car, be it thirty degrees above, or be it ten below.

The car has two occupants, the driver and his passenger, both young, both wearing the uniform of a local bank, and both with no seat belt. I can't help but wonder, somewhat cruelly and not for the first time, whether an unrestrained driver in a convertible flies over or through the windscreen when the car crashes.

Being stopped at the lights gives me the opportunity to have a quick word with the guys in the car. "Seat belts might be a good idea gentlemen!" I was all ready for a comment to the effect of "mind your own business" or just to be completely ignored. Instead, the driver looked over to his passenger, back at me and they both put on their seat belts.

"Thanks".

"Well, we couldn't really say no to you could we? If you'd've been a copper, I'd ignore 'em. But you're not looking to give me a a hard time and a fine. You're only asking 'cos you actually just want us to put the belts on."

"True enough", I said, "I'm just trying not to find the answer to a question I've had for ages."

"You don't want the answer?" Confusion covered his face like a rash.

"No thanks. Not today."

With that, the lights turned green, and we drove our separate ways, confused and pleased in equal measures.

And still, thankfully, with no answer.

Fishmedic

Blogsphere is an amazing place.

First, I started reading blogs.

Then I started following them.

Then, twice, I started writing them.

After a while I made contact with some other writers.

Whilst some of these writers decided to meet each other on opposite sides of the Atlantic.

Finally, this week, I had my own meeting with an overseas blogger/paramedic.

Fishmedic, AKA Sam, a paramedic and blogger from Germany, decided that on his short visit to London, he'd like to see a little of the whats, whys, wherefores and hows of the London Ambulance Service, at least as I see and experience them.

Through the wonders of social media and other forms of communication, a meeting at station was arranged.

So he came, he saw, he took photos (thankfully not with me in them), we talked.

And we drank coffee. When he asked for cream with his coffee, (in English that is better than most English people I know) I muttered something about this being the NHS, and that we can only afford milk.

Anyway, we compared notes and systems and were each shocked about things we see as lacking, and inspired by ideas we liked. It was entertaining, educational, eye-opening, and lots of other things beginning with the letter 'E'.

Chronicles of EMS - see what trouble you've caused!

Hmmmm, maybe that's an idea for the byline competition...

Simon Says

Go back to this post about a waste-of-time-but-can't-do-anything-about-it call. I received a scathing comment on it, a couple of weeks after the post was written, which reads as follows:

*****

I just hope that it wasn't a member of my family having a cardiac arrest in the 15 minutes or so it took you to get her to hospital. Quite simply, you shouldn't have took her. The RRV isn't a taxi service.If Paramedic's want to be paid a professional wage, then they need to act professionally. This means assessing your patient and perhaps deciding they don't need to be taken to hospital by ambulance. If ambulance staff are doing to fit the "stretcher monkey" sterotype and just do exactly what the patient tells them to do, then they deserve to get paid the going rate as a taxi driver. (sic)

*****

The first thought that, cynically, came to mind, was that I wouldn't mind being paid as a taxi driver. I'm sure they earn more than I do.

Then I sat and criticised the spelling and grammatical errors in the comment, as though I'm some sort of linguistic expert.

Then, and only then, did I really think about it, and reply to it. Go look at the post again. My reply is there.

I still question both my actions with the patient, as well as my reply to the comment. Ultimately, I feel that I really didn't have a choice. I had no chance of being a "professional" paramedic, as professionalism could equal job-loss.

I was incensed at the time. Called control, asked them to listen back to the call and find out how this was given a high-priority status, only to find that the "patient" knew all the tricks in the book, and answered all the questions to lead the system down the path of a life-threatening emergency.

The call taker had no choice.

The computer system had no choice.

I had no choice.

Sometimes we're all stuck in a big game of Simon Says.

And whatever Simon says, whether it's right or wrong, goes.

Every so often I just wish my name was Simon.

Take Away

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

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

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

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

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

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

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

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

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

We don't get enough training.

We don't do enough refreshers.

We don't use the skill enough.

We're not good enough at doing it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Stride

Each one of us has a system.

A line of questioning that we follow each and every time to get the answers we need.

Following the same method for each patient ensures not only consistency in our history-taking, but also in our treatment of the patients.

Personally, it guarantees that I have asked all the questions, at least the basic ones, to know where to start and which line of treatment is the most likely.

History taking involves everything from past medical problems, to current drug treatments, from the time of the last meal to bowel opening patterns, from sleeping patterns *ahem* to the actual current reason for calling the ambulance.

And then, there's pain related questions. Where is it?

How bad is it?

When did it start?

Does it move?

What were you doing when it started?

Does anything make it worse? Or better?

All in order. Need to keep my stride.

It's especially important towards the end of a night shift, and even more so towards the end of a set of nights.

My favourite pain-related question, probably because the answer is invariably "No", is "Have you taken anything for the pain?"

You know, any analgesia or anti-inflammatory stuff? Anything that might have helped you get the night's sleep that you're complaining you didn't get? I'm always a little bemused by people who go from having a pain that they can cope with straight through to excruciating-ambulance-required-immediately pain without going through the lets-take-some-tablets-and-see pain in the middle.

I digress. Must try to keep my stride.

The following is a true, if slightly shortened, recording of a recent conversation with a patient in pain.

InsomniacMedic: "When did the pain start?"

Patient in Pain: "About 12 hours ago". That would have been at the more tolerant and alert part of my shift.

IM: "And you haven't slept at all?"

PIP: "Not a minute."

IM: "Did you take anything for the pain?"

PIP: "Yes."

IM: "Can I see the tablets that you took?"

PIP: "It wasn't a tablet." Assuming that this patient can't swallow tablets, I presume it must be a liquid. Exasperation is slowly setting in.

IM: "Can I see the bottle then?"

PIP: "It wasn't a bottle." Exasperation is slowly being followed by the loss of will to live.

IM: "So what did you take for the pain then?"

PIP: "Coffee."

IM: "....................................."

All the training, all the working on a system, all the pre-planned questions, all down the toilet.

I mean, with answers like that, how is a guy supposed to keep his stride???

I think I need a drink.

And not necessarily a coffee.

The Name Game

The story so far:

You know all about 999Medic and his journey to San Francisco.

You know all about HappyMedic and his return journey to the UK.

And you know all about the Chronicles of EMS and their efforts to bring this (ad)venture to the masses.

Well, now that you know all about it, how about becoming part of it?

Become part of the evolving world of EMS.

Join one of the productions.

Anywhere in the world.

The Reality Series at Chronicle of EMS needs a new by-line. Something catchy. Something exciting. Something that will tell the world all about it. And you could be the one to choose it. If you do, you'll win a MASSIVE prize. All you need to do, is join the Chronicles site, and follow the instructions from there.

Trust me, it's worth a look, and definitely worth having a go.

I will be.

Suit of Armour

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

King Arthur's knights donned them before battle.

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

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

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

*****

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

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

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

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

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

*

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

*

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

We don our Suit of Armour.

We put on our uniform, and become someone else.

The mindset is different.

The thought processes are different.

The coping mechanisms are different.

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

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

It may not be an immediate breach of the defences.

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

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

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

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

*

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

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

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

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

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

We are human.

With a very special Suit of Armour.

Everyday Decisions

Everyday decisions.


What to have for breakfast.

What to pack for lunch.

What to wear for work, and how to get there.

Whether not to bother going at all.

*

Everyday decisions.

Cook dinner, or take-away.

Football or soap on TV.

Early to bed, or a late night out.

*

Everyday decisions.

Bridge.

Or Building.

Or Drugs.

Or a combination thereof.

*

Everyday decisions.

To Jump.

Or not.

*

He did.

And no-one will ever know why.

No-one will ever understand.

Nor explain his tragic, irreversible,

Everyday Decision.

Defeat

After my election manifesto of a little while ago, I received some feedback and suggestions of improvements and additions. I nominated members of the Cabinet in the comments section, and prepared for my move to the seat of power.

It would seem however, that not everyone liked my proposals. I was sent the following copy of the minutes from a secret meeting of medical specialists:

*****

The Allergists voted to scratch it, but the Dermatologists advised not to make any rash moves.

The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve.

The Obstetricians felt they were all labouring under a misconception.

Ophthalmologists considered the ideas short-sighted.

Pathologists yelled, "Over my dead body!" while the Paediatricians said, "Oh, Grow up!"

The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it.

Surgeons decided to wash their hands of the whole thing.

The Internists thought it was a bitter pill to swallow, and the Plastic Surgeons said, "This puts a whole new face on the matter...."

The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea.

The Anaesthetists thought the whole idea was a gas, and the Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the arseholes in Government.

*****

In light of the above, I concede defeat.

Thanks to my secret souRCe. You know who you are...

Stabbed

Needle Thoracocentesis.

Try saying that half way through your fourth night shift.

Worse still - try doing it when you've only had 10 hours sleep in the last four days.

And worst of all, despite being a paramedic for over four years - it's the first one you've ever done.

It's not the sort of skill that is either required or used very often. Even by trauma magnets such as yours truly. The problem is, that when you do need to use it, it's always deadly serious.

In the simplest terms, it involves sticking a large needle straight through the chest wall and into a collapsed lung. Counter-intuitively this will re-inflate the lung. Collapsed lungs (or pneumothorax in medicspeak) can be caused in various ways, such as severe asthma, sometimes spontaneously (especially in young, tall, fit people), and most commonly in ambulance terms by severe trauma. This can range from bad RTAs, to stabbings, shootings and other traumatic chest injuries.

The most dangerous sort, a tension pneumothorax, if left untreated, will kill. No questions. It will compress the lung, stop oxygen getting into the blood stream and round the body, and eventually compress the heart and stop that working too.

No oxygen + no heart = certain death.

It works, at the risk of telling fellow medics what they already know, a little as follows: the normal lung is a little like two balloons inflated one inside the other, with a tiny lubricated space in between, to make lung movements effective and painless.

In the case of a tension pneumothorax, the inner balloon has a leak. Every time you take a breath in, air enters the inner balloon. Normally, each time you breath out, the air leaves, but with a tension, the air moves from the inner balloon only as far as the outer balloon. That stretches, puts more pressure on the inner one, collapses it, and stops it working. It's also how the heart gets squashed, as well as eventually the other lung too. All in all, very nasty, and very, very deadly.

This is where the needle comes in. The needle goes into the large space that has now been created between the two balloons, lets out all the trapped air, allows the inner balloon to reinflate, releases the pressure on the heart, and allows the business of breathing to resume. It's only a very short-term solution, but gives the patient instant relief, and some vital extra time to get to hospital and definitive treatment.

In short - if you decompress the lung - you save a life.

Last night, for the first time ever, I stabbed someone in the chest.

Despite the 200 or so witnesses, and a police officer watching my every move, I got away with it.

The Missus

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

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

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

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

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

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

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

I change track.

"How long's it been happening for?"

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Technophobia

Well, fellow technophobes, I may just have cracked it. However, I'll only know once I've posted this. There is the distinct possibility that I have finally, and not without personal danger, overcome the technological problem that has plagued me for ages.
The personal danger bit was me being on the verge of pulling out what is left of my ever-receding hairline.
All I hope, is that from now on, if you like a post on here, you'll be able to link to it (and hopefully recommend it) directly on Facebook, Twitter, MySpace and a host of other social-networking sites and the like. If the one you want doesn't immediately appear, click on the "Share" button, and your choice will be somewhere on the list.
I shall be eternally grateful if you were to do so.
You'll know this works because you'll be able to read this post. If this post isn't here, I've failed.
Again.
But then, you'll never know.

Count to Ten

Chest Pain.

Category A.

Immediately Life Threatening.

The FRU wails and worms its way through the early evening traffic, scattering cars and pedestrians alike. Arriving in just a few minutes at the address, where the door is opened by a woman in her 30's. I wait for her to show me in and direct me to the patient. Instead, she blocks my way in and waves a piece of paper in front of my face.

"Are you taking me to the hospital?" The look of expectation is matched by a stare of disdain.

"Can you please tell me what the problem is? Maybe you don't need hospital!"

"I've told you I need to go to hospital. Your job is to take me."

Count to ten.

I ask to see the piece of paper that was thrust in my face, and find that it's a hospital prescription for some medication that is just as readily bought over-the-counter.

"The local pharmacy says they can't fill this - only the hospital can. So now I need to get to the hospital."

Count to ten.

It's a ten minute walk at the most.

In the traffic, it'll probably be a ten minute drive too.

I ask a question I already know the answer to. "Then there's no-one with chest pain?"

"Just take me to hospital. I need to be home in half an hour."

Count to ten. Again.

I'm in no mood for a fight, so point to the back seat of the car, make sure she puts her seat belt on, and shut the door. On the walk back round the car to the driver's side, I call control and cancel the big taxi. The small taxi will suffice.

On route to the hospital she tells me to wait while she gets the prescription and then take her home.

I didn't wait.

But I did count to ten.

Thousand.

Out of Depth

On days like today, warm, sunny aberrations from the norm, being ankle deep in water isn't so bad. Just the thought of it conjures up images of sitting by a pool, a lake, or even at a stretch, sitting on the beach, feet dangling in the cool blue waters.

Ankle deep in water would probably be a blessing for those affected not so long ago by torrential rain and devastating floods all over the world. Sure beats being knee or waist deep in the stuff.

Ankle deep really isn't all that bad, unless you're ankle deep in blood.

*

A call to the local bus garage isn't unusual, more regularly to patients whose blood alcohol volume is a little high and who are looking for somewhere warm and dry to sleep it off. So when the call came in as a young adult male unconscious, it sounded like business as usual.

The car had its hazard lights on, just as we'd been told it would. Abandoned rather than parked between two buses, with Rami stood at the back of the car, frantically flagging us down. Something about his demeanour said it was serious, but as we stepped out of the ambulance, there was no patient.

"What are you waiting for?" screamed Rami. "He's in the front seat!"

Didn't expect that.

And there, in the front passenger seat, was our unconscious man. 20-something years old. Ankle-deep in blood. And dying in front of us.

"What happened?" The question was more to keep Rami out the way and his mind occupied, so that he'd keep out the way and let us do our job.

Airway - clear.

"We were in the park and got attacked. They came out of nowhere, about six of them. They hit us with all sorts. He had blood all over him but we managed to run away. I didn't see where the blood was coming from. I thought it'd be better if I just took him to the hospital, but I got lost. Now I don't think he's breathing! I stopped to call you guys! I didn't know what else to do!"

Breathing - present, but laboured.

We reassured Rami that his friend was breathing, but was unconscious. His shirt was crimson red, his breathing laboured and his pulse rapid. We didn't need to check his blood pressure to know that it would be dangerously low - the amount of blood on the floor of the car told us what we needed to know. He needs fluids, preferably blood, and in a hurry. Out in the real world, pre-hospital, the only fluids we have are basically salty water. Better than nothing, and enough hopefully to get him at least as far as hospital.

Circulation - problematic.

We found the source of the bleeding, multiple stab wounds in his lower back and abdomen. Too many holes to plug, and not enough time to do it. We'd asked for assistance from HEMS, but as it was night and they weren't flying they would be coming in the car. Luckily, they'd been on a call not too far away, and even though they're normally based the other side of London from where we are, they wouldn't be more than 10 minutes away. Just as we were getting him into the ambulance, we were given an update that HEMS weren't coming. Apparently they'd crashed, and although it was only very minor, they were now tied up with paperwork.

With no assistance on the way and no way for us to give him anything more than fluids, we opted not to delay any longer, made him as comfortable as we could in the ambulance, and began the mad dash to hospital.

Police were with us.

Rami was with us.

Time was very much against us.

And we were back where our patient started.

Ankle deep in blood.

Weekend Plans

I'm glad it's the weekend.

It's been a tough week at the office.

No particularly traumatic calls to deal with.
No particularly difficult decisions to make.

I've had some good calls that have made me think and learn.

I've treated all my patients the same as any other week - with respect, courtesy and professionalism.

But along with all that - this week, the system repeatedly let me down.

*

The frustration of feeling let down by the system that I serve, is compounded and even exceeded by the feeling that the system has also let my patients down.

*

And therefore, by extension, so have I.

And that's a feeling I don't like.

*

I'm glad it's the weekend, and I'm glad I'm not working it.

I need this weekend to regroup, rethink, re-energise.

When I return next week, I hope to be back to my normal self.

Rats

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

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

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

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

Rats.

Elections

Chaos reigns in this country at the moment. We've had a General Election and have managed to elect precisely no new government. Nor did the old one win either. The electorate, all full of fire and brimstone due to various misdemeanors allegedly undertaken by the lawmakers in Parliament, threatened to sack the lot. Anger, fury and threats turned out to be a damp squib, full of talk but devoid of real action, and the vast majority voted for no majority at all. Welcome to limbo-land.

I, however, have a manifesto of two policies only, both of which will hopefully guarantee me the vote of the entire front-line ambulance community. I'm sure that not a single other person would vote for me, but at least I'd be assured of tens of thousands of green-uniformed votes.

THE GREEN-UNIFORMED INSOMNIAC'S PARTY - A MANIFESTO

Item 1: The Law of Visibility

This law defines the rules relating to the ability of ambulance crews to easily identify the location of their patients.

- All properties are required, by law, to have their property number and/or name displayed in such a manner that it can be seen clearly, using the naked eye, from the road.

- The number should be visible by all emergency vehicles whilst driving past, day or night, at speeds of up to 70 miles per hour without blurring.

- If necessary, a flag-pole must be erected and a flag bearing the number of the house flown at full-mast.

- All streets must number their houses sequentially, odds on one side, evens on the other. Any streets already otherwise numbered must display a 10 foot high neon sign at the top and bottom of the street to indicate the irregularity.

Item 2: The Law of Sod

This law relates to the tendency of patients to collapse in the most difficult surroundings possible.

- All toilet doors must be built with doors that open outwards.

- All toilet doors must be built with the ability to unlock from the outside.

- All toilets must have enough room to allow for one occupant and two rescuers to enter simultaneously and not involve either stepping on the occupant, sitting on the toilet seat instead of the occupant, or partially hanging out of the window whilst rescuing said occupant.

- All toilet rescues are to be carried out without the relative of the collapsed occupant having already gained access first, but by so doing prevented other rescuers getting in without having to sit on their lap.

THUS ENDETH THE MANIFESTO OF THE GREEN-UNIFORMED INSOMNIAC'S PARTY.

So, are you going to vote for change?

Vote for stability?

Vote for the sane?

Or are you going to vote for me?

Possibly, Probably

I had to be honest. "Possibly not", was the best answer I could come up with.

How do they do it? How do kids always know to pick that one moment? The split second sometimes when the adult's gaze is averted, their attention diverted, is the exact moment that their child decides to do something dangerous.

*

A year and a half is a long time in the life of a toddler. Long enough to fill them with a sense of adventure, a love of excitement, a curious wonder, and no fear of danger whatsoever. Milly was a typical 18-month-old girl, waddling and toddling from one new find to the next. This time, the next find happened to be a marble. Well, a bag of marbles, but one marble in particular was to be the cause of all the excitement over the next few minutes.

The bedtime routine was more or less adhered to. Milly and her big brother Dan, had dinner at six, bath time at half past, story at seven, lights out at quarter past. Their parents split their nights, taking it in turns to make sure that both of them read to each of their elder children on different nights. Milly and Dan's baby sister, only two months old, didn't yet believe in timekeeping and routines, and during this one bedtime decided to scream, just after bath time. Milly was left in pyjamas and ready for bed, whilst mum went to tend to her sister. Her dad was just sorting Dan out upstairs. It was a perfect time for Milly to go discovering her big brother's collection of marbles.

As mum was dealing with baby and dad was settling Dan, Milly started to cough. A strange cough, one like Milly's mum and her intuition had never heard before. She rushed back in, baby in arms, and saw Milly struggling to breath.

"Tony! Tony, get in here now!"

Dad ran downstairs, saw what was happening, picked Milly up and looked in her mouth, hooked a finger in to see what he could find, and then tipped her upside down to see if he could dislodge whatever it was.

Mum was on the phone to the Ambulance Service.

Milly continued to struggle for breath.

Parents were frantic, Dan was scared to the point of tears, when all of a sudden, after a lifetime of being held upside down and patted harshly on her back, Milly coughed once more, screamed, and cried.

At that point, we walked in. Ninety-nine times out of a hundred, when called to a choking, the call will downgrade whilst we're on the way. What will start as a call to a non-breathing patient will often, through the wonders of the human body and its capacity to fix itself, turn into a post-choking, now breathing normally call. This time, it didn't happen, and until the second we walked into the house, we were on the way to a child still choking. Five minutes from the start of the call until the second we clambered over the building site of a driveway and into the house.

As I stepped across the threshold, I heard her scream, and breathed a sigh of relief. You can't choke and scream at the same time. It's physically impossible, so I knew Milly was no longer choking. The look in Milly's parents' eyes told the story. There was a mix of fear and panic, along with tears of relief welling up, threatening to burst their banks.

"She must have picked up a marble when we weren't looking. That's all I can guess, because they weren't all over the floor before".

I left Milly in dad's hands whilst I listened to her lungs, and checked that her breathing was completely back to normal.

Dad started to tell me what he did. "I just picked her up and stuck my finger in her mouth to see if I could find anything, but there was nothing there!"

Alarm bells rang. "I don't mean to tell you off, and I certainly don't want to scare you, but please don't do that again. If you blindly put your finger in, you could push whatever is there in the wrong direction, which could be the worst thing to do". He looked shocked.

"And then I tipped her upside down, and patted her on the back, and then you came in and saw what happened." Now, that's a better idea.

"Can I ask you a question?" said mum. Questions always welcomed, I just hoped I had the answer.

"If she'd have kept choking, and you'd have been another couple of minutes, would you have been here in time?"

I had to be honest. "Possibly not", was the best answer I could come up with. "But that's where you come in. That's why control give you the instructions, to give us the extra time to get here. You need to be able to help us to help you".

On the way to hospital, we talked about how kids are there to scare us as parents, how, even with all my training as a paramedic, I still hate it when it's one of my kids that's unwell or injured, and how MrsInsomniac has the luxury of panicking whilst I deal with whatever crisis may arise. Except, obviously, when I'm not there.

"So what can I do?" Milly's mum asked.

"Well, a first aid course would be a great start". It's something I strongly believe every parent should be offered and something I recommend regularly to all parents I meet in the line of duty.

It's true. First aid courses can't prepare you for every eventuality, but they can give you the confidence to know that what you're doing is definitely going to help, at least until the ambulance arrives. Whether it be CPR, how to deal with burns, with injuries, or, just like in this case, with a choking baby. Those few minutes of immediate care can make all the difference. They could change the outcome, they could improve survival chances, and they could even change my answer to Milly's mum's question, and in fact, the question itself.

Instead of saying "probably not" to the question she asked, she could ask a different one, a question with a very different answer.

"Could I be the one to make the difference?"

With just a little bit of training, even of the very basic kind, very probably.

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.