New Years Day

It was New Years Day and the people of our fine city were not feeling well. I spent most of the day observing the pained expressions on people faces as they struggled with the simplest of tasks, like walking. The previous nights celebrations had clearly taken their toll and as per the norm, the ambulance service were left to pick up the pieces! Here is a rundown of what treats the day gave us! Bear in mind, I too was tired. Like everyone else, I had seen the new year in with friends, had a few drinks, mindful I was on an early it was limited to a few! When my alarm went off at 4am I wasn't amused in the slightest but I got on my bike and headed into the night for my 6am start! 

06:05 - '23 year old male, collapsed. He was drunk and asleep.'

Not collapsed. A good Samaritan had called us. They didn't stick around though. Shocker! Taken to A & E to join the heap of drunken delinquents.

07:00 - '21 year old male, collapsed, head injury.' 

He was drunk. In a skate park. He'd fallen over and cut his head. His friends found the whole affair extremely funny and used words like 'wack', 'nang' and 'rad' with worrying frequency. Bandage on head, a large cannula with fluids and trip to A & E.

08:15 - '23 year old female, vomiting blood.' 

She wasn't. She was vomiting red wine. And 'Purple Rain' which I was assured was an 'aggy' cocktail. Her main problem was a hangover. I gave her 2 x Paracetomol, a glass of water, sound medical advise and a few of my best hangover cures. Left in care of friends.

09:06 - '29 year old male, chest pain.'

He did indeed have chest pain. The cause was the copious amount of cocaine, MDMA and skunk that he had taken with alcohol the night before. Due to the fast heart rate and various other things he was given Diazepam to treat his cocaine toxicity. He was promptly taken to the New Years Eve recovery centre for monitoring and further treatment.

10:32 - '30 year old male collapsed.'

He was indeed collapsed. He'd taken an overdose, presumably of heroin.  He was ventilated, filled with Narcan and then once the effects of his high were reversed we were left with an angry, verbally and physically abusive patient who was arrested and conveyed to hospital. 

11:48 - '24 year old male, chest pain.' 

This one was in a police station. He was claiming to pain to avoid being at the police station. Much to his dissatisfaction, once I'd assessed him, done his ECG and spoken to the duty nurse I told him he could stay in the comfort of his room. He called me a cunt. I left.

12:55 - '14 year old female, intoxicated.' 

This one was in a park. She was smashed, well and truly. He blood pressure was in her boots so she got treated to cannula, fluids and a journey to hospital. Because of her age the police had to attend. She vomited all over the ambulance. And my leg.

*change uniform, clean vehicle*

14:10 - '25 year old male, cardiac arrest. '

Sadly, it was as given. He was dead, nothing we could do for him. His friend found him sat on the sofa. He'd been there 2-3 hours. The nights drink and drugs had stolen a young life. A very sobering affair for all involved. Happy New Year eh? 

15:35 - '26 year old male, severe headache, pains in chest.'

He had a hangover. I told him to take his own paracetomol and drink more water. I told him I had just attended a 25 year who had died. I asked him if he felt us being there was a good use of an ambulance. He apologised. We left.

16:20 - '46 year old male, unconscious on bench.' 

He was drunk, on a bench. He told us to fuck off. We did. The caller hadn't stuck around.

16:40 - '19 year old female, feels weak, chest pain, vomiting.' 

She seemed genuinely shocked that her symptoms were caused by lack of sleep, no food, consumption of weed and too much alcohol the night before. I gave her a dose of health promotion and left her with her proud parents. 

17:25 - '40 year old, collapsed in toilet.' 

Clearly the best had been saved until last. We arrived outside a heaving McDonalds and headed inside. A member of staff met us and took us downstairs to the toilets. Hundreds of pairs of eyes stared at us as if they had never seen an ambulance crew, as they chewed their Big Macs. Despite all watching us head into the toilet, within seconds people were trying to come in and seemed utterly shocked that they couldn't use the facilities! Inside was the wonderment that was our patient.

He was a big man, clearly an alcoholic and was locked in the cubicle. His head was slightly protruding from underneath was wall of the cubicle. He was well and truly unconscious. Oh, and his face was lying in a pool of other peoples urine. It appears McDonalds had fallen foul of their hourly toilet cleaning policy, much to the detriment of the patients big ginger beard and open mouth. We requested a chair to look over the top of the cubicle. 

I climbed on top and peered over. There he was in all his glory, trousers around his ankles, and lying in a pool of his own urine and faeces. He had literally keeled over from sitting on the toilet. It really was a wonderful advert for alcohol!

Unfortunately,  despite the treat waiting for us inside, there was the very real problem of how to get him out. I managed to reach down and unlock the door but we could only force the door open slightly, such was his position. My crew mate was slighter than I was so she begrudgingly agreed to be the one to squeeze through the gap and attempt to move him enough to get the door open. Despite her best efforts, the dead weight drunk man could not be moved and in fairness, such was his condition and covering in bodily fluids, she didn't bear hug him with gusto! Luckily for us he started to wake up of his own accord. His personality was every bit as endearing as his appearance. 

"What the fuck are you doing, get out of my cubicle!"

"You collapsed to the floor sir, we are trying to get you out."

"For fucks sake." he mumbled in a thick Scottish accent. 

"Sir, can you move your legs and sit up, we can't get the door open until you do!"

"Yeah.....I know......I'm not fucking stupid you know!"

It's at times like this I like to freeze frame the moment. Ideally I'd like to take a photo on a Polaroid camera and pass it to the patient for them to digest. I was curious as to which part wasn't stupid. Was it the amount he'd drunk? Or the falling off a toilet? Or the double incontinence? Or his face in puddle of strangers urine? All of the above smacked of stupidity, but who am I to judge?! 

Eventually he was up and out. With every passing moment he became more and more abusive and the smell got more and more offencive. After telling us both to, and I paraphrase, 'go away' he headed out back into the restaurant. After attempting to start a number of fights and verbally abusing everyone he passed he staggered up the stairs and out onto the street. During this short journey he only fell over 4 times so that should be looked at as some kind of achievement. He went off into the distance cursing at all he past. I never got his name. What a treat he was!

So, that was New Years Day! Entirely predictable, totally exhausting and all too familiar. Lives wrecked by alcohol and drugs again. When will people learn?! I could sit and reflect on the 25 year old that died but won't. He isn't the first and sadly won't be the last. Perhaps that's cold of me, perhaps it's just self preservation. I'm sure next weekend will bring similar. 

"It's like gambling somehow. You go out for a night of drinking and you don't know where your going to end up the next day. It could work out good or it could be disastrous. It's like the throw of the dice." Jim Morrison

A Chance - Part 2

continued.......

Moving a patient in cardiac arrest isn't easy. He needed to be put on the spinal board, lifted to the bed and wheeled onto the ambulance. All the while, CPR had to continue, as did ventilations and suctioning. Neighbours were holding up fluids and moving cars to enable the ambulance to get closer. The patients wife, son and daughter were stood watching, grief pouring from them. Their pain was palpable for all involved. A neighbour suggested they didn't watch but nothing was going to stop them being by his side. When someone is begging you to save their loved one it is a pretty chilling feeling knowing that you probably can't.

We got him on board, put in the blue call and left. The other FRU took the relatives and we left en mass. 2 ambulances and 2 cars in convoy to the hospital. On route there was no change to the patients condition. As every minute passed, the outlook became bleaker. One hand on the hand rail and one on his chest, CPR continued over every bunch and round every corner. When we arrived at hospital he'd been 'down' for well over an hour. The only thing that could save him now was the definitive care provided by the hospital. If they could find the cause and it was something they could treat and reverse then maybe, just maybe he had a shot.

People watched on in shock as we emerged from the back off the ambulance on to the tail lift bouncing up and down on the patients chest. As the lift was being lowered my eyes met with his wife. I felt a lump in my throat as I pushed back the tears. The six of us, all doing or carrying someone, wheeled the patient into resus to the waiting crash team. There were fifteen members of the hospital staff who swarmed around him. He was transferred to the bed, the anaesthetist took over the airway, a nurse took over CPR, junior doctors begun getting further IV access and blood gasses, a scribe was writing everything down and the consultant insisted on silence for everyone to listen to my extensive handover. 

"62 year old male, witnessed collapse, 1 minute tonic clonic seizure followed by cardiac arrest. CPR started immediately. Initial rhythm was VF, he received 6 shocks and has been in slow, wide PEA ever since. We have a patent airway with good CO2 maintained with suction. He has patent cannula and IO access in the humeral head. He's had 18 x Adrenaline, 500ml of saline and 300mg of Amioderone. He's been down for 1 hours 18 minutes. We've been through the 4 H's and 4 T's."

I stood back and watched. The consultant was fantastic. Clear direction, paying personal attention to each member of his team, giving individual instruction and calming down the junior doctors who were getting a bit flustered. I've never seen a doctor so clear and articulate. He asked us to bring the family into resus which I haven't seen before. Normally they are left outside. They appeared in the cubicle, eyes red and clearly distressed. Blood gasses were sent of, focused heart echoes were done and to be honest I wasn't holding out much hope. He went over and quietly spoke to family explaining what was going on. 

A nurse returned with the blood gasses and handed them to the consultant.

"Right guys, this patient has been down now for nearly an hour and a half. He's had the best care possible. His blood gasses have returned suggesting he's at a point no longer compatible with life. On two focused echoes his heart is showing complete myocardial standstill. I've discussed this with the family and following that discussion, combined with what we are faced with I am of the opinion we should terminate the resus. Does everyone agree or does anyone have strong feelings that we should continue on?"

His statement was met with silence from the 21 of us in the cubicle. 

"OK, with regret, time of death 18:04. Thank you everyone for your efforts." 

The body of our patient was then covered, his face cleaned and airway removed so his family could spend some time with him and say their goodbyes. I was choked up. Everyone was. It is impossible to remain emotionally detached from your patients. Impossible.

The consultant called all the staff outside of the room. 

"Brilliant job guys. You guys in particular (talking to us) did a phenomenal job and thank you to everyone who helped out here. Lets all have a cup of tea, I'm here to answer any questions you may have or if you want to get anything off your chest, let me know"

He then did a full debrief, explaining his decisions, explaining possible causes etc. I've never had a consultant like him. Not only genuine care for his patient and the relatives but for all the staff under him. He didn't talk to anyone like a subordinate, but like an equal. It was refreshing and we all left somewhat lifted by his manor. Today the NHS can be extremely proud.

This job goes to show that death can't be avoided. Sometimes, even when all the cards are dealt in your favour, the house still wins. 

NB: I tried to find out who the boy was. No one recognised him and he left half way through the resus. Our patient only had a chance because of him. I wish I'd got his name. His efforts deserved recognition.

A Chance - Part 1

"82 year old male, collapse, ? seizure, O/S"

This wasn't just a collapse in the street, this was a cardiac arrest on a residential street on a weekday afternoon. It was witnessed by neighbours, family members and children. For many of them, it will be the single most distressing thing they will ever have the misfortune to see. Cardiac arrest survival is always improving but survival relies on a three things:

Early CPR. If CPR isn't started by a bystander within a couple of minutes the chances of survival decreases by 10% for every minute that passes. It takes an ambulance roughly 8 minutes to arrive. No CPR in progress means only a 20% chance of survival and they'd most likely be brain damaged. 4 minutes without CPR means the brain will almost certainly be damaged, regardless of whether we can start the heart again.

Early intervention. We need to arrive quickly to do advanced life support. On top of the CPR we need to secure an airway, oxygenate the patient, de-fibrillate and give various drugs to try and start the heart again then stabilise the patient and transport.

Good definitive care. A hospital with a crash team and any specialities that are required to treat the cause and assist recovery. Once stabilised, the long road of treatment lays ahead before the ultimate goal of discharge is reached. Only then do the government get what they want.....a return to tax paying status.

Miss one of those three and it is quite simply, Game Over.

"UPDATE: Patient now in cardiac arrest, CPR in progress"

I felt my foot push down on the accelerator, drop-gear kicks in and I accelerate. I'm only about half a mile away, I'm likely to be first there and on my own. Scrap that, as I crossed the next roundabout an ambulance appeared in my rear view mirror, driving with the same intent I was. We pulled into the street and headed to the crowd. About 8 adults of various ages waved frantically in the road. I screeched to a halt, grabbed my bag and rushed over. Lying on the pavement was an elderly man with CPR being done by a 13 year old boy. All the adults started talking / shouting at me trying to tell me what happened when the boy doing CPR shouted...

"QUIET.....I saw this man fall to the floor, he had a fit for about a minute so I called 999. He then stopped breathing and the lady on the phone told me to roll him over and start CPR. I've been doing it since. I've also done rescue breaths like I was shown in first aid."

Wow! Just wow! Despite the chaos the adults were causing, a 13 year old boy had taken the initiative and done an incredible job. I was so amazed. He didn't even know the guy, just saw him collapse while walking to a friends house. If the patient survives it will be down to him and him alone. I was a tad speechless. Clearly someone has had the sense to teach him first aid.

Whilst talking to him, one of the ambulance crew took over CPR and we began the 'Advanced Life Support' part of his treatment. As chaotic as these situations are it is important to recognise and encourage the efforts of others. Like I said, this is the most distressing thing they will ever see and they need to know they did well. As I have mentioned before, a resus is not as glamorous as 'Casualty' and 'Holby City' would have you believe. It isn't a case of a few gently chest compressions, a shock after rubbing metal pads together, shouting 'Clear' and one shock followed by High 5s and celebrations. It's messy and to be quite frank, brutal. 

The patient had been incontinent of urine and his stomach contents was filling his mouth which required constant suctioning through the airway. There was the unmistakable sound of ribs cracking, when the cannula went in there was a lot of blood. Throughout the resus this blood got spread about onto gloves and kit. To gain further IV access we drilled into his shoulder and his clothes were cut off. There is no dignity in a public cardiac arrest and no way to soften the blow to the watching friends, neighbours and family. With every shock, the electricity surges through the body causing it to jolt violently. All the while there is someone forcing air into his lungs, there is someone doing CPR with enough power to physically squash his heart through the rib cage to pump the blood around the body. I'm knelt by his side vocalising everything we are doing, giving drugs, trying to ignore the watchful eyes, many of whom are crying. This is the reality of a resus. Brutal.

After 5 or 6 shocks from the defibrillator his heart rhythm changed to one that couldn't be shocked. He had what is known as pulseless electrical activity (PEA). All we could do was continue CPR and push through adrenaline every few minutes. After half an hour or so we knew we had to go. There was nothing more we could do here, his only chance remained at the hospital.

To be continued.........

Cocktail

“18 year old female, chest pain, dizziness”

I’ve spoken before about young people and chest pain. Basically, I think common sense should prevail more often when it comes to sending an ambulance and a car to a teenager with chest pain. I once went to a 23 year old having a heart attack, it was the youngest the cardiologist had ever seen. On top of that, he had risk factors and presented like a heart attack; central crushing chest pain for more than 15 minutes, shortness of breath, cold, clammy ashen skin blah blah blah. If I had THAT information to go with this 18 year old I may, unlikely, but may suspect it was something more than a panic attack or anything equally as minor. My point is, based on what the caller had told the call taker this should not have wasted resources with two vehicles, especially as we were no more than 50 yards to the A & E entrance!

Regardless of what my opinion was, we pulled into the road at the same time as the FRU. En masse we headed down to the garden path to the front door. It was eventually opened but a guy styled on Kurt Cobain. You know the type, long hair, baggy trousers, skater shoes, a jailers chain hanging down to the ankles, black nail varnish, a beanie hat, scruffy bum fluff and a lip piercing to one side of the top lip. Oh....and can only grunt answers and is physically incapable of smiling! Anyway, as the door was opened and I’d looked up and down the smell of skunk, cigarettes and cheap cider hit me! Aaah THAT is what ‘teen spirit’ smells like! We followed ‘Kurt’ into the kitchen where our patient was sat on a stool. She was also having a teenage identity crisis! A cross between a goth and punk with a bit of hippy chucked in for good measure. One look at her and I knew she was stoned. Pupils like saucers and an inane look of amusement with a hint of confusion. 

“Hello there, what’s the problem today?”

She looked at me blankly for a moment, her head swayed slightly and after a few seconds to re-focus she mustered the energy and brain power to respond.

“Got chest pain”

“How long have you had that for?”

Again, the stoned routine of saying the question back in her head, concentrating hard, putting together a balanced, well conceived response and then saying it. The whole process takes about 10-12 seconds.

“All day”

“OK, now I can smell some pretty pungent drugs, how much have you had and have you taken anything else”

A look of sheer panic spread across her face and ‘Kurt’s’ for that matter. It was if they didn’t think we would be able to smell it because they had opened a window! 

“We are the ambulance service, not the police, you are adults, I don’t care what you’ve taken but I need to know because you have chest pain, you’re not in any trouble.”

“Well i’ve been on a 2 day bender, we went on a rave last night and didn’t get home till about 10am today.”

“So what have you taken?”

“I took some pills last night, and some cocaine, few spliffs here and there, and a bit of MDMA. Maybe some ketomine to.”

Brilliant! Well that would explain the chest pain! A drug cocktail, possibly with some horse tranquiliser in the mix!

“No probs, and have you been drinking to?”

“Yeah, on and off all day really, I only slept a bit.”

“And have you eaten?”

“Not really, I’ve only eaten a few bags of crisps in the last few days.”

Bingo! Well that will explain the dizziness! Sherlock Holmes would be proud as punch! Why she didn’t think that the best part of 48 not eating, not sleeping, drinking, smoking and taking all the drugs she could find wouldn’t cause her to feel ill is beyond me! Why the call taker wasn’t able to establish any of this I don’t know either! 

“Right, shall we pop you out to the ambulance so we can do an ECG etc then pop you up to hospital?”

“Do I have to?”

“No. You don’t. But, you called 999 for chest pain and diziness, you still have chest pain and dizziness so it’s a good idea to come with us.”

“Yeah but if you say it’s cause of the drugs i’ll be fine”

“But until we’ve done an ECG we won’t know what is going on with your heart.”

“I think i’ll leave it for now and if I feel worse i’ll call you back.”

“No, we are here now, we are next to the hospital, that would be a massive waste of an ambulance. Let’s get it sorted now.”

She shared a look with ‘Kurt’.

“Nah I think i’ll leave it.”

“So why did you call us?” 

“Cause I thought I was dying.”

“So let us check you over and take you to hopsital,”

“It’s OK, don’t worry about it, i’ll just get some sleep.”

AAAARRRRGGGGHHHHH!!!!! Seriously!!! Why call an ambulance?! There are very few things that wind me up more! It drives me absolutely bonkers! As kid, infact, even as an adult before I did this job, I would look at an ambulance and think that they were a) going to a life threatening emergency and b) be taking someone to hospital. I had no idea that people would actually call 999 and then did not go to hospital. There is a drive within our service at the moment to leave more people at home and apparently that is the future but personally, as much as I do that, surely the main problem is the amount of people calling 999 who clearly don’t need to be in hospital or don’t want to be?! That is why we NEED to leave people at home. That is why hospitals are at breaking point. JUST.....SAY.....NO!! I was barking up the wrong tree with this patient. No matter what I said, she was never going to go in. I got her to sign the back of my paperwork and ticked the box ‘declined aid against advice’ and stomped off.  

The Pursuit of Happiness

"32 year old male, fainted, DIB"

This was the first job of the day and amazingly we had been at work for a good two hours by the time we got it! We'd managed a relaxing Costa and a non-rushed breakfast so we were in high spirits. The address given was a gym so we were fully expecting a non-complicated faint in someone who had not eaten and been pushing themselves too hard. We pulled up outside and it was obvious from the name what kind of gym it was. There would be no treadmills, no cross-trainers and no pool. There would also be no middle-aged slightly tubby woman, or any women for that matter. It was a weights-only gym and appeared to be aimed at bodybuilders only. We walked in and were met by the manager; arms bulging, veins in neck pulsating and wearing a vest meant for a 10 year old. With his chest puffed out and his arms resembling a two-handled mug he led us up the stairs and to the patient.

Our guy was lying on the floor, unconscious, sweating and snoring. He was squashed up against some dumbbells so we pulled him into some open space. He was showing all the signs and symptoms of being hypoglycaemic (low blood sugar) but having no working kit to test it, we had to guess! We treated it as such and gave him an injection to raise his sugar levels. While waiting for him to regain consciousness I looked around; it was such a bizarre place. There were a good 25 or so blokes pumping iron, growling, grimacing and then starring at themselves in the mirror! The mirrors stretched around most of the walls allowing them to stare to their hearts content. Scattered around the place were hundreds of photos and posters, some signed, of male body builders all who looked like they'd been tango'd! In a setting where people are trying to act as manly as possible it all seemed very homoerotic! There was a long oak bar, about 25ft long like in old social clubs, the difference being no pint of lager and some pork scratchings; just protein shakes! I found the whole ethos of it bizarre!

Anyway, back the patient! He started coming round after about 3-4 minutes. He was very groggy and confused. Confused in his vocal response but also in his eyes! He clearly didn't have a clue where he was or what was going on! We gave him a Lucozade to up his sugars as when he came round he said 'yes' when I asked if he was a diabetic. It became apparent pretty quickly by the odour in the air that he had been incontinent, and not just a No. 1! We led him to the toilet and as every minute went by became more and more coercive. We got him a change of clothes while he cleaned himself up in the cubicle. I went back in and he was by the sink.

"Any chance you could give me some privacy while I wash at the sink."

"Of course, we'll be just outside."

We waited and chatted, and sniggered at some of the characters we could see in this testosterone filled cauldron of vanity. The FRU arrived with the kit needed to test his blood sugar and we explained what was going on. We asked the manager if there was any chance he'd been taking any under-the-counter steroids or anything like that.

"No, definitely not, he's not the type."

To be fair, he didn't look the type. He wasn't that well-built and didn't seem to have the obsession many of the others appeared to. After a few minutes of waiting I heard a bang. We burst into the toilet to find our patient naked and in a cubicle, upright and fitting. We got him on to the floor, got the oxygen on him and let him fit. We took his blood sugar and to our surprise it was relatively high. Clearly our initial diagnosis was wrong and he had been unconscious post a seizure. After a few minutes he stopped but then vomited; we rolled him into the recovery position whilst this was going on. Unfortunately, the use of all the muscles needed for the body to vomit had another undesirable effect. Like the eruption of Mount Vesuvius out came an explosion of poo. I've never been so close to vomiting. It went everywhere, and as he came round he rolled in it. It got on his hands which he then kindly transfered to us in the post-ictal melee. We eventually got him wrapped in a blanket, into a chair and down to the ambulance. I should have been concentrating more on what was causing his fits but all I would think of was:

"I have sh*t in my hair"

"I have sh*t in my fuc*ing"

"I have sh*t in my mother fuc*ing hair"

"I have fuc*ing shit in my mother fuc*ing hair"

It really is a panic stricken moment when you get bodily fluids on you. You want it off but often you don't get a chance. Often you know it's there but try and ignore it but once it starts seeping through your uniform you feel the damp on your skin. Sometimes it's spit in your face or blood all over you. It is just an unnerving experience and one I will never get used to. Surely I should get paid more than £9 an hour to get sh*t in my hair?!

Once on the ambulance our patient came round again. This time he said he wasn't diabetic! In fact, he said he had no medical problems at all. No history of seizures and on no medication.

"Have you taken any illegal, under-the-counter drugs to help you bulk up? You won't be in any trouble, we are not the police, but we need to know. It's really important."

After a brief pause he nodded. "Yes"

"Are they amphetamine based?"

"Yes"

"How long have you been using them for?"

"2 days. I bought them off the gym manager, he said I'd lose weight and bulk up quicker."

I couldn't be bothered to go back in to give the lying rat a dressing down. We needed to get our patient to hospital, ideally before another seizure. My crewmate got some IV access, I did an ECG and we left on blue lights. On route he had another seizure. He was still seizing when we arrived. He was still seizing when we left resus. It did eventually stop, we checked in on him a few hours later. He had been for brain scans and we were told by the doctor that the drugs he'd been given had raised his blood pressure significantly. This had caused the seizures and had probably triggered epilepsy. All for what?

This guy felt the need to take drugs to improve himself. He wasn't happy with the body he was in. Who really is though? Models often have eating disorders in their pursuit of a size 0. I don't think anyone is ever really content. The skinny amongst us often wish they could bulk out a bit or get even slimmer and the fat want to be skinny. People complain about needing to lose weight and I often look at them and think 'No you don't!' but it's personal. The people who are physically fit want to be fitter and the dedicated athletes want to get better. Will a body builder ever think they have reached perfection? Will a diet ever get anyone to where they want to be? I don't think so. If I set myself an ideal weight to get to, I am pretty sure that if I got there I wouldn't be happy. There would still be a bit that needs improvement. It's not just about weight, I know plenty of people who are happy with their size but there is always something. There would still be something to strive for, but for the vast majority of people the need for improvement is balanced with the enjoyment of the nicer things in life and we tend to find a middle ground. We want to improve and will occasionally do something about it, but deep down we want that Chinese takeaway and binge at the weekend. Basically, we don't care enough to do something about it. The other side of the coin is people who care too much; they will do anything to reach a goal that cannot be reached, and as I saw today that often comes at a cost. It is amazing the lengths people will go to in the pursuit of happiness that I don't think is ever truly obtainable. You tell me, is it?

You can't fool me........

"27 year old female, multiple seizures"

Another day, another dollar! We were on a late shift and were busy clock watching, timing our jobs nicely to hopefully be off on time. Unfortunately we got a late one! Couldn't be helped, it was a Red 2 and because of the nature of the 'life threatening' condition she got the ambulance + FRU response. Repeat seizures or status epilepticus is indeed life threatening and can cause permanent brain damage if left untreated. We shot round to the address and arrived at the same time as the FRU. We all piled into the house, met my a friend at the door. Apparently they had been watching TV and she just started seizing and had continued on and off for 15 minutes now. I was first into the living room. She was lying on the floor, surrounded by friends, shaking violently. Foam sputum protruded from the mouth and her eyes were staring blankly at ceiling. Her arms were in a decerebrate position and her toes were pointing downwards. This is normally a sign of severe brain damage. This meant only one thing........She had done her homework. 

She was faking. Admittedly she was doing a very convincing job but the first clue was in the eyes! She was staring and focused. Eyes would normally role to the back of the head. The second was that her movement looked forced and calculated. Then, there was a few little tests. Once I took hold of her wrist her 'decerbrate' flexion relaxed. That wouldn't happen. I then lifted her now limp arm, held it above her face and let go. Sure enough it fell to the side of her face. That wouldn't happen! It would hit her face because an unconscious person would have no way to stop it. A conscious person doesn't want to be hit in the face. Finally she made a miraculous recovery after we'd been there only 2-3 minutes! No post-ictal period or confusion at all. I wasn't impressed. I told her to stop faking it. She tried her best to carry on the lie and when asked what meds she took for her epilepsy she named Zarontin and Haloperidol. Unfortunately Zarontin is only used to treat 'absence' seizures, and not the tonic-clonic ones she claimed she suffered with and we saw her fake! As for Haloperidol, well that's an anti-psychotic used to treat schizophrenia! She didn't have any medication on her as she'd 'run out'! Hmmm......I smell a rat. We took her to hospital because that's what she wanted. She wouldn't admit the truth. She even asked us to do an ECG to check her heart. What a waste of time and money for both the hospital and the ambulance. I gave my handover and the nurse recognised her. She was a known faker, a frequent flier, a sufferer of Munchausen syndrome. Oh, and I was an hour late off!

'Munchausen's syndrome is a psychological and behavioural condition where someone pretends to be ill, or sometimes induces symptoms of illness in themselves. Munchausen's syndrome is also known as factitious disorder.'

The cause of it is largely unknown, mainly because the people with it refuse to accept they have it and therefore refuse any psychiatric treatment meaning very little is known about their motives, thought processes or social and family upbringing. I personally think it is no more than extreme attention seeking and a desperation to be noticed. The symptoms of Munchausen syndrome range from faking psychological symptoms such as hearing voices to pretending to have physical symptoms like chest pain. In extreme cases they will go as far as self harm in an attempt to make them ill enough for a hospital admission. Commonly though they'll complain of things like breathlessness, abdominal pain, chest pain, seizures and black outs because they are easy to fake and hard to disprove. Often they'll claim to have had a combination of many such as a fall, then a seizure, and now chest pain. It isn't uncommon for some minor self harming to occur to show an injury from said fall.

Munchausen syndrome differs from hypochondriacs in that sufferers are aware that they are lying and exaggerating and it is calculated. It is a psychological disorder which requires treatment but one I personally have very little time for. Sufferers can spend years jumping from hospital to hospital wasting resources everywhere they go. They tell similar stories and repeat similar symptoms but unfortunately due to the accuracy in the portrayal of symptoms staff have no choice but to repeat all the costly tests to disprove lies. Due to the nature of their condition they become very manipulative people and will stop at nothing to get the attention they crave. There are documented cases where people have died as a result of complications  arising from unnecessary treatment.

It isn't known how common Munchausen's syndrome is, it's hard to quantify and hard to prove. I suspect a large percentage of the patients I go to are faking it for attention but you never really know. There are two distinct groups of people who appear to be affected. Women who are 20-40 years of age with a background in health care like nursing, caring, even EMS and medical volunteers. This enables them to add detail and medical knowledge to their symptoms to gain credability. The other is unmarried white men between 30 and 50 years of age. It is unclear why this is the case. What I have noticed is that Munchausen syndrome isn't just limited to hospitals and my patients but it is commonplace on social media forums such as Facebook and Twitter. People can manipulate a 'following' to receive a constant stream of sympathy negating the need to actually fake an illness or self harm, behind anonymity. Maybe this is where it starts. In a society where ones life can exists solely on these platforms perhaps faking a seizure in front of friends is the next logical step. All I know, is that when these fantasies, delusions or attention seeking acts spill out into our work load it puts us into a dangerous situation of possibly giving drugs that are not needed putting our jobs in jeopardy. Not to mention the grave cost to the NHS in wasted time and resources. It's selfish behaviour and takes a resource away from where it is actually needed all so someone can get some sympathy and attention. Maybe i'm being harsh, but it really annoys me and is criminal. The medical version of perverting the court of justice.

I'm not sure what the best thing to do is. Personally, when someone is faking, lying or exaggerating I tell them. I'm certainly not going to indulge in their game, nor am I going to let them think it is acceptable. You can only treat people who need & want to be treated. These people need but don't want treatment. All you can do is make it as difficult and unappealing as possible for them to do it. Shout from the rafters and point! 

The Concrete Jungle

"19 year old male, ? Heroin overdose, history of violence *LOCATION MATCH"

First job of the day, it was early on a sunday morning, we were tired and a tad grouchy. As soon as the job came down our radio started ringing.

"Don't approach, police on route, the patient is violent. Hold for police"

Dur!! As if we were going to be cavalier.  Location match is a red flag. Previous crews have flagged the address as dangerous so either he has been violent or someone in the address has been violent. We would be waiting and then hiding behind lots of police officers! We arrived at the same time so grabbed our stuff and followed them up. It was in the middle of a council estate and one the countries largest. It contains almost 2000 homes and although still popular with the elderly residents, due to schemes like 'care in the community', problems came to fruition when large volumes of vulnerable and disadvantaged people became isolated from society. Concrete jungles like this are vast. This particular one has over 6000 residents and takes 20 minutes to walk from one side to another. The road network through the estate is scattered and complex making navigating for us and patrolling for police extremely difficult. In all seriousness the area is simply too large to police effectively and as such it became a breeding ground for crime, drugs and antisocial behaviour. On an estate where deprivation and violence are commonplace, hopeless life is the norm leaving children without ambition and little prospect of bucking the trend.

As a result, we end up with our patient. A 19 year old male, high on drugs, unemployed with a criminal record longer than the ancient scrolls of Jerusalem. He had no education, his mum was an alcoholic and his dad was in prison. His 3 brothers were all in the same boat as him. We entered the block via the large metal door, a small window hole showed the remnants of the glass that had once been there, bloodied tissues lied in pools of urine and tinfoil stained with crack drifted around the stairwell like autumn leaves. As we climbed the stairs, passing the masses of graffiti we could could hear the commotion. He was smashing up the flat. He was high on MDMA and Trips. He was hallucinating and being violent towards neighbours and his family. We didn't get near him. The police brought him to us already restrained. There wasn't much for us to do other than monitor him. He needed to be sedated at the hospital so for us it was a bit of a non job but it highlighted the problems we, the police, the government and the residents of council estates face.

This job was symptomatic of the problems that are common place all over the country. There are over 6 million people living on council estates in Britain and a large percentage of these people are living in properties that are rundown, isolated and abandoned. In the heart of every thriving city in Britain is a second city. A city hidden from visitors. A city hidden from public view. A city the government would like to forget. A city where more often than not, good people are kept prisoners by the fear of gang rule. And what chance do the police have? A few years ago on this estate, there were 6 officers and a sergeant dedicated to patrolling the area. Admittedly that isn't much for the size of it but dropping it to just 2 beat officers under the Tories has seen a lot of the good work undone. Despite the £12.5 billion flurry of initiative under recent governments promising the 'big society', promising community improvement, promising re-galvanisation, promising criminal justice and promising more policing the mish-mash of projects has produced very few results and have made little to no dent in the growing level of violence and drug abuse in deprived urban areas. Street violence, drug dealing, robbery and burglary have risen and the much vaunted Anti-Social-Behaviour-Orders have become a prize more than punishment.

These estates cause a huge financial burden on the tax payer in both policing costs, medical cost and benefit costs. Unemployment is high, benefit fraud is rife and crime is huge. With unemployment so high it is of little surprise that poor diets and abuse of drugs and alcohol cause a strain on ambulance trusts and local hospitals. This job alone required 12 police officers and an ambulance, let alone the hospital stay and the administration costs of sending him back to prison for breaching his bail. Then there are the costs of keeping him in prison. Multiply this un-isolated job by every estate the country over and it is painfully clear why a decade of broken promises and failed costly initiatives have put the country in a state of economic fragility. Fix housing, fix policing and fix the benefit system and you'll go some way to fix these communities. Or instead we could spend £10 billion on hosting the Olympic, allow bankers multi-million pound bonuses from tax payers profits and fund ailing countries in the Eurozone. The problems faces by communities all over the country can be summed up by one word: Poverty. Poverty of income, poverty of opportunity and poverty of expectation. Poverty is a term we use for 3rd world countries but it is a real problem that exists in our own country. A country billed as 7th richest in the world. Something isn't right is it?

Poverty in the UK

• Worst in the EU, longest working hours, lowest social spending
• By EU decency threshold the minimum wage should be £7.87. It's £4.98
• Three times more UK children fall beneath the poverty threshold than in 1970
• The base wage for the bottom tenth of the population is worse than 30 years ago (relative)

Crime in the UK

• 1% of the population suffers 59% of all violent crime
• 2% of the population suffers 41% of all property crime
• Most criminals commit crime within 1.8 miles of their home. 92% of these criminals live on council estates consumed by poverty and criminalised by war against drugs
• A lone 18 year-old woman with a child is five times more likely than average to suffer from crime

Homes in the UK

• Almost 6 million people - 10% of the population live in Britain's 2.9 million council homes
• A further 3 million live in homes that have left council control since 1988 through 'Right to buy schemes'
• Since the public sector reforms in the 70s many traditional jobs done by council tenants have been contracted to private companies making tenants less secure and worse paid. 62% earn less, 73% have fewer holidays, 53% have worse sick pay, 51% have worse pensions and 44% have less security

The longer these council estates are left to rot, the bigger the social disparity will become, the higher the crime rates will be and worse off this country as a whole will be. Lets get our own house in order before we try and fix others.

Diminished Responsibility or Bad Policing?

 "18 year old male, going out of his mind"

In my line of work I often get the opportunity to work at various events as a medic with private companies. I mainly work at festivals as it's a good chance to see some good music whilst getting paid. Win win! Last year I worked as a medic at Bestival on the Isle of White. It was a great weekend, I got to work with new people, got to work on an array of different vehicles and although the majority of jobs were drink and drug related it was pretty easy stuff. Pick 'em up and drop 'em off at the field hospital where they were monitored then discharged. It worked pretty well. At about 9pm on the Sunday evening, which was the last night, and while the headlining act was on I was sent to one of the campsite hubs to attend a girl with breathing problems. We jumped in our 4 x 4 buggy and headed over. It was a panic attack. Nothing special. Whilst talking to her however a steward came running over.

"Can you come and help us, there is a guy just up the hill going out of his mind, I think he's on something"

I radioed it in and headed over. I left my cremate who was a first aider to stay with the panic attack and went with the steward in the buggy to the space cadet. It was about 200m from wherer I was and about 20m into the campsite. I clambered over the guide robes and tents and eventually got to the guy. He was about 6ft fall, skinny and clearly wired. His friends were all stoned and laughing at him and said he'd taken a 'molly' of MDMA. MDMA or Methylenedioxymethamphetamine to be flash is basically ecstasy. A 'molly' means that instead of a tablet it's in crystalline or powder form. This was the drug of choice for this years festival. Last year it was Ketamine but MDMA was the order of the day this year and by all accounts it was a pretty potent batch. 

I gathered that the patients name was John. I tried talking to him but he was indeed out of his mind. He was hallucinating and begin to get quite panicked. I wanted to get him out of the campsite and onto the path but when I turned round to get assistance from the steward he had gone. I was on my own. As I turned back to John he punched me in the face which knocked me to the floor and then proceeded to jump on me and try and strangle me. His friends came to my aid and between us we sat on him. I was able to press the emergency button on my radio and after a few minutes stewards came running over and we got him to the buggy. He head butted me and spat in face numerous times until the police arrived and handcuffed him. I had a fat lip, a swollen face, cuts to my neck and general bumps and bruises. He was arrested and taken to the hospital. Once at the hospital the Dr gave him a hefty dose of Midazolam to subdue him. My boss made it clear the company would fully support me to press charges and were absolutely fantastic about the whole thing. I was told  by the police to come back in a few hours to give a statement. 

In the hours that passed, I returned to work and John came to. He was taken to the welfare tent to sleep it off and had been rather apologetic by all accounts. Too little too late! At about midnight, after my 12 hour shift I went to give my statement. It started off as all statements do, blah blah blah but then the following conversation occurred.

"So do you want to press charges?"

"Yes, definitely"

"Why? Don't you think that's a bit selfish?"

"Pardon"

"Well he's only a kid and it will stay on his record, that'll ruin his life, besides he had diminished responsibility because of the drugs"

"So, he assaulted me, drugs or no drugs, it's no excuse"

The other officer in the room then came wondering over and pulled up a chair as if I was being interrogated. I was only a desk light in my face away from a scene from Law and Order!

"I know it's no excuse but be realistic. If you press charges we have to provide officers to take him back to mainland, what a waste of resources, especially when he won't be charged with anything?"

"Why won't he be charged, he assaulted me?"

"Yeah but you've got no lasting injuries and at the end of the day it's your word against his"

"So what!! Look at me"

"Well if you do press charges we won't be recommending it goes any further, you'll just be wasting everyones time for no reason. At the end of the day, it's a festival. Things work differently"

"OK, this statement is ending here, it will be continued after consultation with my bosses and your inspector in control. I have both of your shoulder numbers. Goodbye"

With that, I stormed off to the office. A expletive filled rant ensued and my boss marched me off to see the inspector. A long conversation followed and at 2am the inspector decided to take be back for my statement and to press charges. I waited outside while the inspector had a very heated discussion with the officers. He then came out to me with an awkward look on his face.

"I'm afraid that since you left here earlier your attacker has been released without charge. We have his details but don't know if they are correct. I'm very sorry, we can take your statement and if we make contact with him charges will be pressed."

I just walked away. Since when did the police show such disregard for the law and for procedure. I wrote a 2000 word complaint letter but just received a pathetic standardised response. John wasn't caught, not that I believe any attempt was made to find him. Am I over reacting? Do drugs provide a reasonable defence for violence to emergency services? Was it really diminished responsibility? Or was it just a lack of willingness to do paperwork and put in the time? I hope the latter. If copious amounts of drugs is a reasonable defence then that gives all drug user carte blanche to assault who they like, when they like with no repercussions. Shameful policing.