Out of Place

"93 year old female, fall"

It's that time of the shift again, 'Nan down'! I've said previously that these are generally my favourite types of job. The patients are normally polite and extremely grateful for us being there. Sometimes we get tea and biscuits and more often than not, they don't go to hospital. It is also nice to go to someone who genuinely needs us.

We pulled up outside and were beckoned towards the house by the concerned neighbour who had found her on the floor.

"She's been there for 12 hours, bless her. She's in the downstairs toilet."

Poor thing. I headed round the hallway to where she was and what I saw shocked even me. I just starred for a few seconds and made the following observations.

1. That shouldn't be facing that way!
2. That shouldn't be up there!
3. That shouldn't be that colour!
4. How in God's name are we going to get her out?!?

So, with or without medical knowledge we all have a grasp of human anatomy. We all know, therefore, that the foot has no place anywhere near the shoulder. We also know that it shouldn't be blue. THAT is what was facing us! Not only was her leg so badly twisted / fractured / dislocated, but her other leg was wrapped round the toilet and her arm was stuck behind some pipes. It was like a contortionist meets a Rubiks cube + injuries. 

We immediately asked for more hands. No way would 2 of us be able to get her out of there. She apologised for wasting our time! If only she could have met our last patient who was drunk in the street and full of venom. (In fact the way he was spitting resembled a venomous snake!) I started her on Entonox while we tried to assemble some kind of plan. Unfortunately, like most other bizarre jobs, this ISN'T in the books! A couple of FRUs arrived and joined in the "ooohh's" and "eeeek's" and "ouch's". We decided it was going to be best to free the limbs that would be 'easily' freed, get some IV access, load her up with morphine, get her out with the bad leg still in that ghastly position, and then finally straighten her leg. Simple!

Bear in mind it was a tiny downstairs toilet, and there was a step down into it, we managed to get two of us inside and one in the doorway. We set about freeing her arm first which just involved forcing the pipes away from the wall long enough for the arm to be retrieved. I had visions of the pipe bursting and us all being in a whole world of difficulty! Luckily the arm came out without drama. With some light force and assistance her good leg shortly followed. Luckily for a 90+ year old she had relatively good veins so cannulating her turned out to be rather simple! Within a few minutes, the morphine was in and she was complaining of less pain. Now the 'fun' bit!

The doorway wasn't wide enough for us to be able to lift her in the position she was in and carry her out. The room wasn't wide enough to realistically straighten her leg inside and then get her out so some more head scratching occurred! It was decided that a rescue board would be slid down to us. We'd lift her off the floor a few inches whilst the board was slid underneath. Then, we'd carefully slide her along the length of the board, through the doorway and into the hallway. It worked a charm! Now for the leg. After another dose of morphine and plenty of Entonox we went for it, slowly. I felt a vile click as her knee cap moved about but now her leg was straight (ish). By 'straight' I'm not taking into account that her foot was still facing the wrong way. The fracture dislocation of the ankle was going to be left for the hospital to deal with. We secured it into a vacuum splint, continued with pain relief and got her out and off to hospital as quickly as possible. 

The position she had been in was so bizarre, it was hard to explain to the waiting trauma team just exactly how we found her and what state her leg was in when we got there. Even the Orthopod, who enjoys breaking bones on a daily basis, pulled a grimacing face. He said it was the worst case of 'shoulder foot' he'd heard of!

Very rarely do I see injuries that make my stomach turn and it isn't often that I look at someone and literally don't know where to start! People manage to fall and get stuck in some of the most incredible positions! I really don't know how. I just hope I'm never unfortunate enough to do anything similar. I can't even comprehend the pain. It doesn't bear thinking about!

Closed Doors

"83 year old female, collapsed behind closed doors" 

It was a long winter. The dark seemed to last forever, the cold seemed to bite eternally the feeling of being cooped up seemed never ending. But hey, this is England. If we can't bitch about the weather, what can we do. The reason I mention it, is because I feel it may have contributed to the events that followed. 

'Collapsed behind closed doors' is an unnerving situation. A lot of the time you have no idea what lies beyond the door, thus serving its purpose! Still though, day or night, doors must be kicked in to get to someone who may be dead or alive on the other side. Today was the same uncertainty and the same vague details. All we knew was that there was a lady, behind a door, that her daughter couldn't get to. 

We were met at the day by the worried looking daughter. She had been out all afternoon and when she'd got back her was in her room, door locked and not responding to the knocking. She also 'never locked her room'. We went thought the motions of knocking and shouting but to no avail. My crew mate called control and requested the police. Meanwhile I was trying to peer through the key hole but couldn't make anything out. It was an old house and the doors weren't perfectly straight so the was a small gap at the bottom. I laid down and put my cheek to the floor. In that single moment my heart rate doubled and I could feel the adrenaline pouring through my body. About 3 feet from the door, lying facedown on the floor was our patient. 

"We need to get in now!" 

My crewmate took a sizeable shoulder barge at the door but just bounced off it. He the kicked, and kicked, and kicked some more. After about 5 hits the door swung open. I rolled her onto her bad, her eyes were closed, she wasn't breathing, but she was still warm. She was linked up to our machines and there was signs that her heart still had some activity going on. Due to that, and the fact the distraught daughter was screaming for us to do something we started the resus. We called control back and said that this was now a working resus and we needed more resources. 

After 1 shock her started beating again, unfortunately, this was short lived and within a minute or so we were doing CPR again. As the resuscitation moved on it became apparent we weren't going to be successful. The a bin was put next to me by my crew mate. Inside the 100s of tablets she had presumably taken. A glance around the room left reveals a suicide note to her daughter. It was unanimously agreed after we'd exhausted our protocols to cease our efforts and confirm her passing. 

Her daughter was beside herself with grief and guilt. I sat in the kitchen with her whilst she read the letter over and over. I also read it and it really was heart breaking stuff. She had lived a full life, a life of adventure, a life of many tales, but that was a life she had shared with her beloved husband. She explained she simply couldn't live without him anymore. She had her enthusiasm for life had died with him and she could no longer go on being a burden on her daughter. When you read words like 'seeing you grow into the woman you have become fills me with immense pride and joy' was touching to read but little comfort to her daughter. 

I don't know why, but I suppose I associate suicide with younger generations but depression is all to common in the elderly. It's often dismissed as part of being old and the anti depressants are handed out like smarties by GPs. Behind the tablets though the real people. Real people who are not coping with the loss of independence. Not coping with the loss of life long soul mates and not coping with having to impose on their children's lives. As she said, her enthusiasm had gone, and if you take that away from

any of, all that is left behind is apathy. In her mind she wasn't living the life that she had always stood for. The joy and adventure had gone. I suppose she realised that she didn't want to live her final years with apathy and sadness. It did make me think. When the time comes, do I want to go on my own terms when it's right for me. Probably. 

I have no doubt it was a decision that she agonised over for a long time. I'm sure she was well aware of the pain and hurt she'd cause her daughter but it was what she needed to do, for her. At 83, who is to argue when she says 'that's my lot'. 

"Nobody grows old merely by living a number of years. We grow old by deserting our ideals. Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul" 

           - Samuel Ullman

Not Again

"84 year old female, fall"

It was the start of the shift and this particular patient had been lying on the floor for about two hours. Not a priority right?! Patient care is the ambulance services number one focus right? Hmmm. Anyway, grumbles about the right and wrongs of making an 84 year old wait on the floor for two hours, off we went! We were let into the house by our patients husband who clearly suffered with dementia. He shuffled up and down the hallway for most of the time we were there. Very sad to see. Our patient was lying on the floor in piano / bedroom. Her bed was now downstairs and placed a few feet away from a wonderful grand piano. She used to be a professional pianist and this way she could still lose herself in her music without the need to struggle with the stairs. 

We assessed her whilst she was on the floor and quickly determined that there were no injuries. The only problem was that she had been incontinent. We got her up and onto the chair. The evening carer hadn't shown up which is what had caused her to venture to the toilet in the first place so we were left doing the carers work. We undressed her, gave her a flannel wash and re-dressed her in her night clothes. She hadn't been wearing an incontinence pad when we found her so I assumed it was because she'd been on the floor so long. She was so thankful and grateful and apologetic, it must be so horrible to lose your dignity in such a way. Hospital wasn't on the agenda because she cared for her husband who was still shuffling up and down the corridor.

Once it was established that she would normally help her husband to bed, we said we'd put him to bed, then come and put her to bed, to save her walking around with her frame too much. So, for the second time we did the work that the carer  that they pay for should have done. We took her husband to his bedroom, undressed him, washed him, re-dressed him, gave him his pills and put him to bed. Job done! Now, back to our patient.

My crew mate had prepared her medication and a glass of water. We gave her all the pills which she took so now it was just a case of bed and goodbyes. We stood her up and immediately noticed the wet patch on the chair. A cursory glanced down made it clear she'd wet herself. Not again! Remember that assumption I made?! They really are the mother of all f**k ups! It was then that I noticed I pile of incontinence pads stacked behind the door! So, we undressed her, washed her, re-dressed her and got her into bed. Again, she couldn't stop thanking us and apologising despite my threat of charging her £5 for of every time she said 'sorry'! We packed up our stuff and said our goodbyes when she said:

"I'm really sorry, but I think I need the toilet."

Bags down, duvet off, swing legs around, help up with frame and usher quickly towards the toilet. Unfortunately, at 84 'quickly' wasn't something that was going to happen. She slowly shuffled, one step at a time towards the toilet. 4 meters, 3 meters, 2 meters, fart, 1.5 meters, fart, 1 meter.....

"Sorry, I didn't make it."

The smell confirmed our fears. Not again! We got her onto the toilet, we undressed her, we extensively cleaned her, we got yet more clothes and redressed her, we got her back into bed and we put a load of washing on. I finished off my paperwork including a vulnerable adult form (she clearly needs more help and commode) and then said our goodbyes. On cue, the front door opened and in walked the carer......

Getting Schooled

"71 year old female, fall"

Elderly fallers are our bread and butter jobs. We do them day in and day out and unlike drunks, I don't get bored of them. They are always appreciative and more often than not it's a case of getting them up, making a tea, having a chin wag and leaving! Who wouldn't like that?! Sometimes of course they do injure themselves, head injuries, neck of femurs (NOF), hips and wrists. One slight saving grace, is as we get older, we feel pain less and less!

We pulled up outside the house, navigated the overgrown path and got the torch out to open the key safe on the wall. Key safes are wonderful things but I don't like them! I like that you get into the house when someone is in need, but I don't like letting myself into a dark house! It creeps me out! I always open the door with a very tentative 'Hello, ambulance' desperate to hear a response. Luckily, today, I got a response so followed the noise!

Lying on the floor was the loveliest of ladies. We were greeted with a huge smile and despite her clearly broken ankle she was full of the joys of spring. That was a good thing for me because at 1am on a Friday night my joys of spring were somewhat waining! We chatted away whilst we did what we do! Check for neck pain, pulse, respiratory rate, blood pressure, temperature, blood sugar, look at pupils, head to toe survey, check for pain down the back, assess the injury, check for a pulse in the foot, find it and mark it with a cross and place foot in a box-splint. While this was all going on, chat about life through the haze of the Entonox, laugh when she laughs, stick a cannula in her vein, give some morphine and when she starts feeling sick give an anti-imetic. Once ready to move, lift her up onto our chair, grab an overnight bag of stuff, carry her down the stairs, lock up the house, load her onto the ambulance, quick ECG due to medical history and off we go to hospital! Simple! 

Despite her blood pressure being very good on arrival, the morphine and dropped it a fair bit so we raised her legs on the bed. We wheeled her into the A & E department and 'offloaded' her (it's a phrase that makes her sound like a Tesco delivery but it's the term that is used!) onto the hospital bed whilst being watched by the handover nurse. I then went to give my handover, complete with a smile on my face. 

Before I continue, bear in mind the patient is in her nightie, her legs are raised and her left leg is in a huge, bright yellow box splint. It was pretty  obvious what was wrong, roughly speaking! 

Anyway, the handover, I put on my best smile and my cheeriest voice! 

"Good evening"

"Hardly"

"That good eh?! 

"Right, what's the problem?"

"Ketamine overdose......." I said with a rye smile.

*cue the awkward silence and a death stare from the Matron*

Wow! If looks could kill! She glared at me like I had just drowned a kitten. Clearly I'd picked the wrong crowd to waste my best gags on! I'm sorry, THAT IS FUNNY! Maybe it isn't! Maybe I just think I'm funny! Surely though, a bit of light humour at an appropriate time isn't a bad thing. Obviously I wouldn't do it on a blue call or when I've got a patient who wouldn't find it funny but this one had a wicked sense on humour and shrieked with laughter! It's part of the job! If you can't have a laugh to cheer up your patients or a grumpy looking nurse, what can you do?! 

I completed a very mundane, highly factual handover, the nurse vaguely listened and then left. We bid farewell to are patient who was still smiling and very thankful and off we went. As we walked away my crew mate turned to me and said:

"You got schooled!"

That I did. And there was me thinking that laughter was the best medicine!

A Generation Gap

Working for the ambulance service I get the opportunity to see all parts of society at its best and its worst. I see some truly amazing people but also some truly despicable people. Being an ageing population we are seeing more and more of the elderly and that's not going to change. What amazes me most of the time, is how vehemently independent they are, in comparison to how totally unable to cope our younger generation is. Last night I did two jobs that summed this up. Two patients who were both perfectly pleasant but showed exactly what has happened to society in just 60 years and the stark differences in character and ideals that have emerged.

"26 year old male, ? broken ankle"

We were called to a sports hall. When we arrived, the caretaker (who acted like our presence was really putting him out) showed us to the hall. Everyone in there was still playing football, but one paused to point us into the changing room. Inside, lying a the bench, moaning in agony like he had been shot was our patient. He pointed at his ankle and told us it was broken. That information was given to a backdrop of 'bruvs' 'truss' 'ya get me' and 'innit'. That is how people talk now, I didn't hold it against him for a change, the manners were not omitted. What was amusing is that it clearly wasn't broken.

It was slightly swollen but no bruising or abrasions and certainly not at a funny angle! He had full sensation and full movement (despite the tears) and the way he described the injury, it was most likely a sprain. Still, an x-ray would confirm! The charade of being shot continued and for this I blame the footballers: the play-acting wimps that throw themselves on the floor and cry at the hint of being touched. These are the role models that kids are growing up learning from. You only have to have seen 'BallBoygate' to know what I mean! There is no pain threshold, there is huge overreaction and absolutely no sense of shame in doing so. His first thought was to call an ambulance, not a relative or taxi. This is because that's what you do these days, innit!

We got him onto the bed, because when I tried to get him of hobble with my assistance he wailed! Once on the ambulance I cannulated him because the Entonox didn't agree with him. I gave him morphine, mainly to give me some peace and quiet, but also because he gave a pain score of 10/10. He stuck to this despite me asking if it was the worst pain imaginable. He said it was and even said it was worse than my suggestion of having his arm ripped off by a bear. I refuse to believe any pain score of 10/10 because we all know there is no worse pain than stubbing your toe! Anyway, once the morphine was given we got on our way. 

En route to hospital I was doing paperwork and our patient was regaling his tales of heroism to what appeared to be everyone he has ever met. And he was really hamming it up. 'Bruvs' this and 'bruvs' that. He was telling everyone he'd broken his ankle and may need an operation. He made it clear he wouldn't be allowed to work for at least 6 weeks and was basically going to be crippled. It was also the end of his footballing career! Apparently his body couldn't take it anymore. Just for the record, he was an estate agent and this 'football career' was an indoor 5-a-side kick about on Friday evenings! Soooo melodramatic! 

We got to hospital and the play acting continued. His entire family, extended family and friends were waiting for him. He thanked us for helping him with a well placed 'Safe yeah', which I understand is a gesture of appreciation and we left him to it! 

Three hours later, and back at the same hospital and there he was limping around having got zero sympathy from the nurses!

"Is it broken?"

"Nah, just a sprain, a lucky lucky escape innit."

"96 year old female, fall, head injury"

In stark contrast to our footballing hero, this patient met us at the door....ish! Well, she was lying on floor but had crawled from the stairs and been able to lift herself up enough to let us in. There she was, beaming smile, lying on the floor. The was blood in her hair and she was holding her arm. It turns out it wasn't just a fall, it was a fall down the stairs. Top to bottom with a somersault and half twist on the way down. The first thing she said to us was 'so sorry to have to bothered you'.

Under normal circumstances she would have been collared and boarded and fully immobilised. Unfortunately, we couldn't because a) should had severe spinal curvature and b) she wouldn't let us. In fact, she was quite insistent that we got her up off the floor immediately. I checked her neck before letting her get up and there wasn't any pain or obvious injury. Once up, we dressed the injury on her head and put her broken arm in a sling. My crew mate got the chair. 

"What's that for?"

"You need to go to hospital my dear!"

"Do I have to?"

"I'm afraid so, you've had a big fall and you've broken your arm."

"Ok, but I need to go to the loo and pack a bag."

With that, she shot off up the stairs despite all my attempts to stop her! She packed a bag without any difficulty despite only having one arm at her disposal. All the while, she was apologising for being an inconvenience. She spoke very eloquently, no use of 'bruvs' or 'innit'. It was the way I was raised to speak too. I simply don't understand this new language that people speak. It really does leave me in despair when I hear the ridiculous voices that the younger generation are using. And what worries me more is that they are breeding now! Where will this lead?! Will the Prime Minister in 2065 address the nation by saying 'Yes yes me rude boyz, safe'?! 

After much fussing and packing she had everything she could possibly have need. Notes were left for her cleaner, her gardener and the milkman. The lights were switched off, as was the heating and we got her to the ambulance. 

"I'm so sorry to be wasting your time."

As we arrived at hospital, the 'footballer' was getting into a car. I thought of the dying swan act he put on and then wondered how he'd have behaved if he'd fallen down the stairs and broken a bone! I dread to think. We wheeled our patient inside, smile still spread across her face, and handed her over to the nurse. We left to a chorus of thanks and appreciation. 

There really is a huge void between generations. I know the elderly generally don't feel pain as much but they are made of stronger stuff. They respect society and society respects them. They hail from the days where respect meant something and where getting help was truly appreciated. The younger generation have been spoon fed throughout childhood, spoilt rotten and taught that services in this country are their right. The first patient wasn't a bad person and in his own way, was polite to us, but the gulf in generations was painfully obvious.

A Beautiful Death

"97 year old female, DIB, terminally ill"

There is always a sense of appreciation when you are sent to someone so elderly. So many years of experience and knowledge. It's hard to comprehend being alive in 1915. George V was king, Herbert Asquith was Prime Minister and the world was at war. It's an era most of us are lucky not to have been a part of but similarly it's an era and generation where respect is embedded. We arrived relatively quickly, despite the weather and the traffic and were met at the door by the patient's son-in-law. A welcoming smile greeted us and we were thanked for coming. It may sound silly but we a rarely thanked for coming, it's not that I look for thanks or notice when it's not given, but I do notice when it is given and appreciate the gesture. We followed him through the house and up to the bedroom of the annex. 

Our patient was laying in a cot-bed with her daughter at her side. She looked very frail, very pale and exhausted. Her respiratory rate was about 50 and you could hear the bubbling on her lungs as you entered the room. Her oxygen levels were extremely low so we started her on full flow oxygen. She was suffering an acute episode of heart failure. Basically, the heart wasn't pumping properly and fluid was backing up on her lungs. She needed hospital and she needed it quickly. I started to set up the chair in preparation for moving her while my crew mate did her blood pressure.

"We don't want her to go to hospital. She has said she doesn't want to go."

Unfortunately, she was now in such a bad way she was unable to talk, her eyes fixated on the ceiling, breathing was taking every bit of her being. There was no DNR (Do Not Resuscitate) order in place or any palliative care program despite her late stage kidney disease and heart failure. She had been seen by her GP a few weeks previous, who had stopped all of her medication and recommended palliative care but as yet nothing official was in place. This put us in a the very grey area of capacity and our duty of care to act in the patients best interest. We knew that if we left her at home she would die and if we took our oxygen away she would die, but we also knew that with no DNR in place, if she was to die in front of us now, we would have a very difficult job to justify not starting a resus. As horrible and futile that would be on a 97 year old we have to start unless a DNR is in place.

We explained all this and the family were very understanding of our predicament but also quite rightly adamant that they wanted what was best for her and her wishes.

"She wants to die at home, with us and not in a hospital, we are scared that if you take her she won't come home."

She was right, she probably wouldn't. Our thoughts were, that this episode of illness was terminal and it was going to be a matter of hours not days. We needed a plan B and we needed it pretty quickly! We called our local out of hours GP service and explained the situation. After much much debate and various phone calls later, the GP said he'd be with us within the hour and would be able to provide a DNR for us and some medication for the patient. That was a great relief to the family. It was now not about taking her to hospital but about what we could do to make her comfortable. We spent the hour monitoring her and talking to her daughter and son-in-law. Despite the obvious emotion of the situation they showed great interest in us. We talked about the job, what we did before the job, our families and health care. All the while our patient was lying in between us all, fighting hard. Nothing we had done had improved her breathing, it was as bad as it was when we arrived and that was hard to watch. 

Before long the GP arrived. His professionalism and bedside manor was excellent. He engaged with us in everything he was doing and we assisted him drawing up various drugs. He explained everything he was doing to the family and explained he was making her as comfortable as possible. The DNR was openly discussed, written and signed. Everything was in place now for her to die on her own terms. 

We had been on scene for just over two hours before her breathing started to settle down. Her blood pressure was gradually dropping, 102/68, 93/52, 77/44, 63/38. My crew mate was outside the room with the GP and the son-in-law whilst I stood with the daughter, who was holding her mums hand tightly. 

"Is she going to die tonight?"

I knew the answer but didn't know how to respond. Partly because I was choked up and holding back the tears but also because telling someone that their mum is about to die isn't something that is said easily.

"Stay holding her hand, she knows you're there."

She knew what I was saying and asked us to remove all of the monitoring equipment. I left her by the bedside. She told her mum how much she loved her, how much she has inspired her and how much her grandchildren loved her. I ushered the son-in-law back into the room and we stood in the doorway as they said their final goodbyes. The time was now. She wasn't afraid of death and neither was her daughter. Her respiration rate slowly dropped and dropped until she drew her final breath. Very slowly her eyes closed and she let go. There was a peaceful smile on her face It was in that moment her daughter turned to me with a look of fear and desperation and said:

"No, Has she gone?" with tears pouring down her face.

It was as if as much as she knew it, and had made peace with it, but in the moment of death a fear of death had gripped her. I just nodded my head. I walked over and removed the oxygen mask, unable to hold back the tears trickling down my face. We shared a look, one I'll never forget. A look full of appreciation that our inaction had been the greatest gift we could have given their family. It was one of the most heart breaking and distressing things I've ever witnessed yet beautiful at the same time. To be there with someone who isn't afraid of dying and is ready to die, and share that with the family is a humbling experience and one I will never forget. I was so thankful that we avoided a resus because it would have seemed such a tragic way to end what had been a wonderful lifetime.

We went downstairs and in a very British way made them a cup of tea. That is, after all, the done thing in such circumstances. After saying their final goodbyes they came downstairs, teary eyed yet almost relieved. Relieved that they had been able to fulfil her final wish. Death in any circumstances is difficult, but ultimately it's the sacrifice we must all pay for living.

'To die proudly when it is no longer possible to live proudly. Death of ones own free choice, death at the proper time, with a clear head and with joyfulness, consummated in the midst of children and witnesses: so that an actual leave-taking is possible while he who is leaving is still there.'

                Friedrich Nietzsche

92 minutes earlier

My cup of Costa went flying as our brakes ground to a halt at the same time as the second ambulance. The patient was lying there motionless. A woman was doing CPR. Blood was trickling out of his ear.  We all rushed over (no ambulance walk today) and each started doing our thing. As the crowd began to gather, I began to suction his airway. It refilled with blood almost instantly. Where was it coming from? He was still alive.....just. We stopped the CPR, he had a pulse albeit very faint. It was a case of two of us managing the airway, a combination of ventilating, suction and draining. We just had to make do. He still had a gag reflex so without ‘grown ups’ we were powerless. There was now 6 of us swarming around him. IV access was gained in both arms, 2 bags of fluid were hung up. He was attached to the heart monitor, his pulse was fast but regular. His blood pressure was still in his boots. 

“Can someone raise his legs please?”

“On it”

“Right, lets get these clothes off him”

“HEMS are on way”

“More suction please”

“How’s the BP looking”

“Try some more ventilation”

“What’s the SPo2?”

“About 77 over 40”

“80%, did we have an ETA?”

“I’ve got decreased air entry on both sides, possible bi-lateral pneumothorax”

“More suction please”

“18 minutes” 

“Want some cannulas?”

“Yeah, you alright to do the right side?”

“His left pupil is blown”

“Yeah, no probs”

“Can you grab us bed, blocks, straps and a scoop?”

“Who’s conveying?”

“Think the pelvis is gone, can we get a strap on here?”

“What was the resp rate when you arrived?”

“Did anyone see what happened?”

“I’ve got a sheet, we can use that until HEMS arrive”

“About 4”

“No idea”

“That’ll do, we’ll get it underneath on the log roll”

“I’ve got no respiratory effort, how’s the pulse?”

That’s the conversations that were going on between the 2 crews, the FRU and the duty officer. It’s probably worth mentioning I only knew 2 of the 5 people who were there. That was the same for all of us. At one point I thought to myself that it was amazing how we were all task focused on different parts of him without ever discussing who was doing what. There were two of us solely on the air way, two were getting IV access and decompressing the chest and two were removing clothing, getting kit and monitoring obs. 

The crowd was getting bigger by the minute. My crew mate lent over to me:

“His entire family are over there watching”

That always adds an extra emotion to an already chaotic scenario but for now we just had to ignore that. 

“Are we ready to move him?”

“I think so, lets get the scoop in here?”

The scoop was split into two, I was on the head so couldn’t move, leaving 3 of them to do a log roll, 1 to slide the scoop in and the other to carry on suctioning. 

“OK everyone in position?”

“Yep, on your count”

“OK, one, two, three, roll.....hold it there....one, two, three down”

(Everyone swaps sides)

“OK, one, two, three, roll.....hold it there....are all the clothes clear?”

“Yep”

“OK, one, two, three down”

“Right, lets get some straps on”

“More suction please”

“Police are here”

“How long for HEMS”

“About 2 minutes”

“OK, how’s BP, pulse and sats?”

“BP is up slightly, lets get the bed over.”

The beautiful sound of HEMS sirens could be heard in the distance. Being early evening the helicopter was offline so they come by car. The three orange jump suits came bounding towards us. A handover was given by my crew mate and then they took over. 

“Right guy, lets get him on the bed and move him over here. We need all round access”

We followed the instruction, all the while bagging and filling up our 4th suction unit. They were going to perform a Rapid Sequence Induction (RSI) which would basically put him into a coma. Once under, he would be able to be intubated and his airway would be protected. Whilst one of HEMS were setting that up, the other two were playing with scalpels! Two incisions were made in each side of his chest, fingers were inserted into the holes to see if his lungs were inflating properly. I could still sense the family watching from afar as well as the eyes and expectations of the crowd baring down on us. It was quite a scene, 9 of us standing around him, some performing procedures, some drawing up blood transfusions, some ventilating and others just doing.....stuff!

The drugs were administered and they managed to intubate. Now we could think about leaving. Or not......

“We’ve lost him, CPR please”

I started compressions and after a minute or so, couldn’t help but look over to the shocked faces 20ft away. Hands were over mouths, some people were crying. I could feel the hairs on the back of my neck stand up. 

“OK, he’s back with us, well done guys, let’s get moving”

In all honesty, I had zoned out, I don’t know what was done in those 4 minutes, I just know I was doing CPR and now I didn’t have to. The guy was loaded on. In the ambulance was the patient, 2 of HEMS, me and my crew mate and a copper. In the second ambulance was the other crews and all the kit that was lying where we had been. The police followed with the family and the HEMS car and another police car drove up front. Off went the convoy. 

24 minutes later we arrived at hospital. The bed was rolled out and onto the ramp. The door swung open revealing the long corridor ahead of us. The huge trauma team was waiting in resus and the now 8 of us did a rapid walk towards them. Some pushing the trolley, some holding fluids, 1 ventilating, others carrying monitoring equipment. He was transferred to the hospital bed while a handover was given. We then left to clean up the bomb site that was the back of our ambulance. About 25 minutes later HEMS came out to us.

“How’s he doing?”

“Not great, he’s got a sub-dural and extra-dural haemotoma, bleeding on the brain stem, a depressed skull fracture, a shatter jaw, fracture spine, bi-lateral haemo / pneumothorax, bleeding into the abdomen, a shattered pelvis and a broken mid shaft of femur.”

92 minutes earlier......

A man was celebrating his 75th birthday in a pub with his family. They had had a sunday roast. He had treated himself to a few whiskeys and why not?! He’s 75, he can do what he liked! He was with his wife of 55 years, his two sons, their wives and his 5 grandchildren. I can only imagine the joy he was feeling seeing all that was important to him sat with him smiling and laughing. It was time to go home, but before he got in his sons car he wanted to nip into the shop to grab a paper. He left them all getting into cars in the car park, he went to cross the road.

“RTC, car vs pedestrian, 75 year old male, cardiac arrest, CPR in progress”

In that moment, the joy was gone. In that moment 75 years was over. Maybe it was the alcohol that made him cross without looking on a bend.  Who knows? He’ll never be able to answer that. 

I remember looking down as his 3 piece suit was being cut off and his pocket-watch fell to the floor. I remember thinking to myself:

“I bet he was a lovely guy”

I never found out his name.

R.I.P

You cannot be serious!

“66 year old female, diarrhoea“

It was a weird morning; weird because it was very quiet. Obviously we never say the "Q word" whilst at work, we just ignore the elephant in the room. We chat away, drinking coffee, eating crap; all the while thinking ‘blimey it’s quiet'. We managed a nice breakfast in peace, a hot coffee and a newspaper. After 2 hours of relaxing we were finally sent a job! The cheek of it! There was only an address to go on so started trundling in the right direction: 

“Diarrhea, really?! I’ve just eaten! Surely we will be cancelled?!”

Sure enough we were. Result! We pulled over and got back to the arduous task of doing nothing; sadly, this was short lived:

“66 year old female, diarrhoea & chest pain”

This stank to high heaven; not of diarrhoea, but of ‘been told you’re not having an ambulance quickly so ring back with chest pain-itis’. It’s a very common condition, and is a bi-product of a campaign telling people to call an ambulance if they get chest pain. It didn’t take long for people to realise that by saying those two magic words they would get an ambulance every time; quickly & regardless of age, sex, medical history. I believed the chest pain we were en-route to would be just that; a load of tosh (but I’ll stay open minded, ish!)

We pulled up outside of the block of flats; there was a huge grassed area, so we parked in the bus stop on the road and walked over. Because we were told chest pain and she was semi-elderly we took the chair with us, just in case. We made our way across the grass and up the stairs to the first floor. The door was ajar so we made our way in giving the obligatory ‘Hello, ambulance’.

To our surprise, there was a first responder on scene. His car wasn’t parked out the front so I assumed it was just us. He had a fed up, angry, dejected look on his face. He was kneeling on the floor in front of our patient who was sitting up in the chair.

“Hello guys, it’s not as given. This is Cheryl; she doesn’t have any chest pain or any diarrhoea for that matter. She has an appointment at the hospital for her eyes in 45 minutes and doesn’t fancy getting the bus. I was just explaining how this is an inappropriate use of the ambulance”

I think I still have a bruise on my chin from where my open mouth hit the floor. In the words of John McEnroe ‘YOU CANNOT BE SERIOUS?!’ Obviously I didn’t say that, but my jaw hitting the floor with a thud said it all!

“So can you take me to the hospital for my appointment then?”

“I’m afraid that isn’t what we do. We take patients with a medical need to accident and emergency and you have said you are not ill.”

There was a brief pause……

“I have some chest pain”

“You have chest pain?”

“Yes”

“OK, we’ll have to do an ECG etc here and then take you to accident and emergency where you will be booked in as a patient with chest pain”

“I don’t want an ECG but I do want to go to A & E”

We were powerless to do anything about it. She was playing the system and intending to self-discharge and get to her appointment.  We are not allowed to refuse hospital to someone, let alone someone saying they have chest pain. She declined the offer of a chair and walked off to the ambulance. Oh, incidentally, the bus stop we had parked in was the stop for a direct route to the hospital main entrance. Oh, and she has a freedom pass. 

“Couldn’t you have got the bus?”

“I didn’t fancy it”

“...Or a taxi?”

“That costs £16”

We drove to hospital in silence while I wrote the most sarcastically professional paperwork I could muster. As we arrived, I said:

“How’s the chest pain now?”

“It’s gone”

Hmmm, funny that! We took her into A & E, her appointment now 15 minutes away. I could sense she was waiting for an opportune moment to leave, luckily for us A & E is nowhere near the eye clinic and she needed directions. I gave a full handover to the nurse in charge. The whole time I was talking she was glaring at the patient.

“Where is your appointment?”

“At the eye clinic”

The nurse walked over the phone, looked at the list of phone extensions, picked up the handset and dialled. 

“Hi there, we have Cheryl Smith (not her real name) in A & E with chest pain, can you cancel her appointment please………thank you”

She came back over to us:

“Right, your appointment has been cancelled, you can wait in the waiting room until your name is called, just be aware, it’s a 4-6 hour wait.”

With that, she signed my paperwork and walked off.

VICTORY!! Now why can’t we get away with stuff like that?! Her face was a picture, she whined and moaned, swore and shouted but it all fell on many sets of deaf ears. 

Age is no excuse for bad behaviour and this is all this job was; bad behaviour. She simply called 999 to use us as a taxi. Seriously though, what can you do when someone plays the system like that? As a service, or as individual clinicians, we are in a very grey area when it comes to refusal of an ambulance or refusal of conveyance. We end up playing another game of ass -covering and passing the buck simply because that is what we are told to do, or realistically, not doing so is more than our job is worth. Until decisions are made at a high level, and I don’t mean ambulance management, I mean government level, nothing will change. This is a national policy problem and not something we can fix with well-placed lectures. Needless to say, I had an epic rant afterwards and spent the rest of the shift well and truly riled by the whole thing!

Dial 999... & wait?

"A country in apparent shock at having to wait for an ambulance"

On Monday 3rd September the BBC aired a programme called 'Dial 999...& wait?' detailing the failings of the emergency services in this country. It's shocking isn't it; having to wait for something? Just terrible. Like with most documentaries, articles and reports about the emergency services, we all come under attack. I say all, as per usual the PR department for the Fire service has been working overtime so they came away unscathed. There was no such escape for the Police and Ambulance services. The culture of targets and response times was what the programme was about and, rather than talk about the real causes, it just highlighted the failings of the services using some well-placed stories about people suffering due to waiting times. 

First in the firing line was the police; the shocking statistic that out of 1 in 5 calls made, the police take more than 15 minutes to arrive. Outrageous. We surely expect more from our police?! I wonder what the government had to say about it... oh yeah, they declined an interview. Obviously the cuts are to blame, there is no denying that; a 20% budget cut is huge, but instead of doing a programme blaming the government they blame the police for basically being greedy. The short interview with Andrew Haldenby from the "think-tank" Reform showed only the attitudes of those not directly involved in working with or in the police. The police have 'never had more money than they have now' and 'for far to long, forces have rested on their laurels'. If cuts are being made, services will be affected. The reason the police have more money now than ever before is because year-on-year the call volume goes up. Don't for one minute believe isolated statistics of a decrease in crime; it is simply that the type of crime is changing. The police still require resources to deal with the 100's of 1000's of daily calls. This call volume will not change, yet somehow, on skeleton staff, they are expected to arrive anywhere within minutes of a call.

The example they used of peoples' suffering was a shop owner who had been burgled. She was 'shocked' at the police not arriving for 20 minutes. How many shop alarms are triggered each night? How many violent assaults are there? How many domestics? How many hoaxes? How many RTCs? How many requests from the ambulance service? How many raids are being done? How many criminals are being hunted? That is just a fraction of the work our police force is doing. In the London borough where I live there are about 330,000 residents. The borough covers 87 square kilometers and is the second largest in London. While chatting to an officer a few weeks ago on a Sunday morning, he told me there were only 13 front line officers responding to calls. He also told me he remembers when there were 30+. It's no surprise that with such huge cuts low priority calls like a shop alarm are getting a delayed response. To be perfectly honest I'm 'shocked' that the police got there so quickly.

Avoiding the fire, ironically, was the Fire Service; no shock there. No talk of missed targets, only that they arrived at a fire within 6 minutes. To be fair, it is easy to arrive anywhere in 6 minutes if you are sitting and waiting for that call to come in and get to spend all day perfecting the art of getting into your vehicle quickly. Last year the London Fire Brigade had a budget of around £437 million compared to £288 million the Ambulance Service got. They received 230,000 calls compared to the 1.6 million the London Ambulance Service received. They attended only 138,385 calls compared to 1.2 million that LAS did. They did so with their 5800 operational staff (almost double that of the ambulance service) from their 112 fire stations (compared to the ambulance service's 70), and of their calls attended, only 29,215 were fires. That is about 80 a day across London. Considerably less than 1 per fire station. Is it any wonder that they are able to respond quickly?! What was highlighted by the programme though was the crippling cuts that they are now facing. A whopping 3% in their budget! Wow! How will they cope?! Maybe they will have to send less than 25 fire-fighters to rescue a seagull from a 3ft pond. Oh wait... they refused to go in; they just sat around and watched a member of the public go in. Yes, THIS happened. Click here. It's weird how all of these facts and figures were omitted from the programme, hmm?

Saving the best until last, the Ambulance Service came under attack for people having to wait. They opened with a tale of an elderly lady waiting on the floor for hours, with the addition of an interview from her daughter about how terrible this was. I agree. In an ideal world no one would have to wait for an ambulance, least of all our elderly population. Unfortunately, the medical world uses a triage system based on what the caller tells the call-taker. As horrible and uncomfortable as it is, an elderly lady with a knee injury is not a high priority and when there are only a handful of ambulances covering a large area priorities have to be made. In this instance it wasn't life or death. Who knows what other calls were in progress. Long have I banged on about the fact that time wasters and nonsense calls just need to be told 'NO'. Sadly, Panorama decided to interview Tony Hughes for the GMB union who decided to highlight the few calls that slip through the net and are wrongly triaged. SO WHAT?! Out of the millions of calls the services receive that is bound to happen every now and again. There are not enough ambulances and staff to send one to every single 999 call that comes in.  Fact.

What annoyed me most about the programme was the failure to highlight the cause of these delays and lack of ambulances. Yes, we have faced cuts like everyone else but as of yet it hasn't had a huge impact in the amount of ambulances working on the front-line. The problem is that the call volume is going up year on year. This wasn't mentioned once. Nor was the massively high proportion of calls that we go to that are a complete waste of time and resources. No mention of the alcohol related calls we go to, the hoaxes, the split nails, the stubbed toes, the headaches, the colds, the can't sleeps, the noise in ear, the finger injuries, the needing a lifts to hospitals; basically 80% of the work we do. No mention at all that the delays people are facing are caused by the public's misuse of its ambulance service. Despite all of that though, for the first time all of the services met the category A target of reaching 75% of life threatening calls within 8 minutes. Instead of leaving it there and heaping praise on the service they interview people to highlight the apparent cheating that is going on. Calls being downgraded to meet the target? Calls being upgraded to meet the target? Is there any proof that this goes on? All ambulance staff, myself included, moan about the conspiracies, the stitch ups and mis-categorising of calls, but personally I don't think this is done to meet targets. The categories of calls change as new information comes in and I think it's highly irresponsible of Panorama to throw out accusations without a scrap of evidence. Then again, who ever said investigative journalists were supposed to research...?!

In the presenter's introduction he said 'What happens when the ambulance service decides you're not sick enough to get an ambulance?' Well as far as I'm concerned the answer is pretty simple; you don't get an ambulance because you are not sick enough. If the public and the media want an ambulance immediately then give us a budget proportional to the calls we attend. Based on the London Fire Brigade's budget per calls they receive, the London Ambulance Service's budget should be around £3 billion a year. Now mirror that across the across the country and you'll see the shortfall we face. Just imagine how quickly we would arrive with that budget at our disposal! We could probably all sit around waiting for calls, practicing getting into our ambulance really quickly, sending 5 ambulances to an elderly faller and do countless public demonstrations of our equipment... ring any bells? People expect miracles and in this economic climate miracles are not going to happen. 

So, you dial 999....& wait?! Yes. That's life. Build a bridge and get over it.