You could be EMS if.......

• You find humour in other people's stupidity
• You believe than 90% of people are a poor excuse for protoplasm
• Discussing dismemberment over a gourmet meal seems perfectly normal to you
• Your idea of fine dining is anywhere you sit down to eat
• You get an almost irresistible urge to stand and wolf your food even in the nice restaurants.
• Your diet consists of food that has gone through more processing than most computers
• You believe chocolate is a food group
• You refer to vegetables and are not talking about a food group
• You believe a micropore tape job will fix anything
• You have the bladder capacity of five people
• Your idea of a good time is a traumatic cardiac arrest
• You believe in aerial spraying of Prozac
• You have your weekends off planned in advance
• You believe that 'shallow gene pool' should be a recognised diagnosis
• You believe that the government should require a permit to reproduce
• You believe that "Ask-a-Nurse" is an evil plot thought up by Satan
• You believe that having an ambulance at a "Health Fair" was his next idea
• You believe that unspeakable evils will befall you if the say "Wow, it's really quiet" is uttered
• You threaten to strangle anyone who even starts to say the "q" word when it is even remotely calm
• You take it as a compliment when someone calls you dirty name
• You think to yourself "great veins" when looking at complete strangers 
• You refer to someone in severe respiratory distress as a "smurf"
• You have ever wanted to hold a lecture entitled "Suicide...Doing It Right"
• You feel that most suicide attempts should be given a free subscription to "Guns and Ammo" magazine
• You believe that "too stupid to live" should be a diagnosis
• You have ever had to leave a patients room before you begin to laugh uncontrollably
• Your favourite hallucinogen is exhaustion
• You think that caffeine should be available in I.V. form
• You believe the waiting room should be equipped with a Valium fountain...
• You believe that waiting room time should be proportional to length of time from symptom onset 
• Your most common assessment question is "what changed tonight to make it an emergency?” 
• Your feet are slightly flatter and tougher than Fred Flintstone's...
• Your immune system is so well developed that it has been known to attack squirrels in the garden
• You've been chipping away at your Bachelors Degree for longer than most people take for a Doctorate...
• You might be an EMS professional if you find any of this funny!

This is not my own work but I related to it so thought i'd share it. I gathered them from various lists on the t'interweb. 

Heads up

"33 year old female, abdo pain"

Bore! OK, not the enthusiasm that should be expected for a potentially life threatening emergency call but in my experience, 95% of 30 year old females with abdo pain are either on their period, about to start their period or have a non-acute common stomach problem.  We headed off with no other information than that, working our way through the busy London rush hour traffic. The rush hour brings out the worst in drivers, not a moment passes without hearing a horn pressed in anger or an angry swerve to stop someone pulling into the line of traffic. Despite the blues and twos progress was slow so the 2 mile journey took us almost 10 minutes. We pulled up outside the house. We'd spent the journey driving through some of the worst parts of east London I've seen but had ended in up in a rather quaint cul-de-sac with a collection of grand Victorian properties. We grabbed our bags and headed up the garden path. As we rang the bell our radio vibrated violently. This is the message that appeared:

"Called states he thinks the head is showing"

What head and why in god's name is it showing? This isn't what we signed up to! Talk about being unprepared. As the door swung open my crew mate run off back down the garden path to grab the Entonox, PALS kit, paramedic bag and maternity packs. He also called up EOC to hurl abuse about the apparent breakdown in communication and request a second crew. BBA's generally have a second crew dispatched as standard in case both mother and baby need taking to hospital. Whilst all that was going on I went in to meet our patient and 'the head'. I'd been let in by the mother-in-law who told be Kate had been in labour for only 45 minutes. I entered the living room to find her propped up by the sofa, naked and legs akimbo. Her husband who was crouched down by her feet gave me a look of sheer joy and relief! Relief that delivering the baby was no longer his responsibility. Nope! It was mine! Obviously I felt prepared, I mean it was only 2 years ago that I did my 2 day course on maternity.......! Eek! Her husband stepped aside, frantically telling the LAS call taker that the crew had arrived, and I knelt down and introduced myself. 

"Hi Kate, I'm Ella, fill me in on what's been happening"

"Here comes another one..."

I looked down and out came a head. I had no gloves on, no maternity pack, nothing of any use. I reached for my gloves but it was too late, she pushed with the contraction and out she came. It was a good catch if I say so myself! On cue my crew mate burst through the door clutching the entire contents of the ambulance but dropped everything in disappointment when he saw me holding a baby. He'd never delivered one, nor seen one being delivered but nature waits for no one. He clamped the chord and I passed the baby to mum. She was crying, the baby was crying and when I asked dad to cut the chord he started crying. It was a very touching moment. With all the death, destruction, drunks and disease we see it's so refreshing to bring an innocent life into the world. It's a feeling I can't really describe. This lovely couple had just become a family and we were privileged enough to be there for that moment.

After a few minutes I took the baby from mum, put a nappy and clothes on and wrapped her up in a blanket while my crew mate phoned for a midwife. Baby was fine, mum was fine, dad was a wreck and we were beaming. 

"Have you decided on a name yet? Because if you haven't Ella is a lovely name!"

Luckily my suggestion was met with laughter rather than disdain!

"Yes we have, we are going to call her Olivia"

Not as good as Ella I thought to myself! BBA's are not only a lovely job because you are delivering a baby but they take ages! Ages spent in the warm, nowhere near violent drunks. Free of pressure from control and free to just sit there drinking tea and eating the biscuits provided by the moth-in-law! Result! We sat there for 40 minutes, chatting about their lives and ours.

"How many babies have you delivered?" she said to me.

"One!"

"Really?! This was your first?! What about you?" she said to my crew mate.

"None!"

"So neither of you had ever delivered a baby?!"

"Nope!"

Luckily this awkward conversation was interrupted by the delivering of the placenta, and that, I assure you, was gross! Within a few minutes the midwife arrived, delivered by an FRU. We left them to it, not before we were forced to smile in photos and get hugs from all! Had having my photo taken at work! 

It was a great job, one I'll never forget but that aside, the fact neither of us had delivered a baby before scared me. So many 'What ifs?' passed through my mind. What if it was breach? What is it didn't start crying? When if there was a hemorrhage? What if the cord was round the neck? I don't think a two day theory only lecture on maternity is enough and if the public were aware I'm sure they'd agree.  That fact we walk in to someones house dressed in green carrying all the kit in the world fills people with confidence. There is an assumption we know what we are doing and can deal with anything and if we act and sound like we do that illusion can continue. I can assure you, inside I'm a wreck when I'm out of my comfort zone! Unfortunately there are no funds for placements in maternity units so for now we'll continue to improvise, adapt and overcome. At least now I know what I'm doing.........

The Laws of EMS

The first law of EMS: All emergency calls will wait until you begin to eat, regardless of the time.

• Corollary 1: Fewer accidents would occur if EMS personnel would never eat.
• Corollary 2: Always order food "to go"

The EMS law of Time:

• There is absolutely no relationship between the time at which you are supposed to get off shift and the time at which you will get off shift.
• Given the following equation: T + 1 Minute = Relief Time, "T" will always be the time of the last call of your shift. E.g., If you are supposed to get off shift at 1900, your last run will come in at 1859.

The EMS law of Gravity: Any instrument, when dropped, will always come to rest in the least accessible place possible.

The EMS law of Time and Distance: The distance of the call from the Hospital increases as the time to shift change decreases.

• Corolloary 1: The shortest distance between the station and the scene is under construction.

The EMS Law of stairs:   The severity of a patients illness or injury is directly proportional to the number of stairs said patient has climbed to get away from the front door. The worse  the patient is the more stairs they will have climbed.

• Corollary 1: If a patient can't walk, has chest pain or is fitting they will have gone upstairs to call 999
• Corollary 2: If a patient is heavy they will have gone upstairs to call 999

The EMS law of Random Simultaneity:  Emergency calls will randomly come in all at once.

The EMS law of Respiratory Arrest: All patients, for whom Mouth-to-Mouth Resuscitation must be provided, will have just completed a large meal of Barbecue and Onions, Garlic Pizza, and Pickled Herring, which was washed down with at least three cans of Beer.

The EMS law of Options: Any patient, when given the option of either going to Jail or going to the Hospital by a Police Officer, will always be inside the Ambulance before you are.

The first law of Equipment: Any piece of Life-saving Equipment will never malfunction or fail until you need it to save a life.

The second law of Equipment: Interchangeable parts don't, leak proof seals will, and self-starters won't.

The first law of Ambulance Driving: No matter how fast you drive the Ambulance when responding to a call, it will never be fast enough.

The EMS law of Bathrooms:

• If a call is received between 0500 and 0700, the location of the call will always be in a Bathroom.
• If you have just gone to the Bathroom, no call will be received.
• If you have not just gone to the Bathroom, you will soon regret it.
• The probability of receiving a job increases proportionally to the time elapsed since last going to the Bathroom.

The EMS law of Light: As the seriousness of any given injury increases, the availability of light to examine that injury decreases.

The EMS law of Space: The amount of space which is needed to work on a patient varies inversely with the amount of space which is available to work on that patient.

The EMS Theory of Relativity: The number of distraught and uncooperative relatives surrounding any given patient varies exponentially with the seriousness of the patient's illness or injury.

The EMS Theory of Weight: The weight of the patient that you are about to transport increases by the square of the sum of the number of floors which must be ascended to reach the patient plus the number of floors which must be descended while carrying the patient.

• Corollary 1: Very heavy patients tend to gravitate toward locations which are furthest from mean sea level.
• Corollary 2: If the patient is heavy, the elevator is broken, and the lights in the stairwell are out.

The Axiom of Late Night Jobs: If you respond to any Road Traffic Collision after Midnight and do not find a drunk on scene, keep looking: somebody is still missing.

The first principle of Triage: In any accident, the degree of injury suffered by a patient is inversely proportional to the amount and volume of agonized screaming produced by that patient.

The Gross Injury law: Any injury, the sight of which makes you sick, should immediately be covered by a number 3 dressing and peerhaft.

The Basic Principle for Dispatchers: Assume that all front line staff are idiots until their actions prove your assumption.

The Basic Principle for Front Line Staff: Assume that all dispatchers are idiots until their actions prove your assumption.

Basic assumption about Dispatchers: Given the opportunity, any Dispatcher will be only too happy to tell you where to go, regardless of whether or not (s)he actually knows where that may be.

• Corollary 1: The existence or non-existence of any given location is of only minor importance to a Dispatcher.
• Corollary 2: Any street designated as a "Cross-road" by a Dispatcher probably isn't.
• Corollary 3: If a street name CAN be mispronounced, a Dispatcher WILL mispronounce it.
• Corollary 4: If a street name CANNOT be mispronounced, a Dispatcher WILL mispronounce it.
• Corollary 5: A Dispatcher will always refer to a given location in the most obscure manner as possible.

The first law of Duty Station Officers: Take the equation: X - Y = Quality of Care, where "X" is the care that you render and "Y" is the assistance supplied by any DSO. If you can eliminate "Y" from the equation, the Quality of Care will improve by "X".

• Corollary 1: Generally, DSOs have no business on the road.
• Corollary 2: The level of technical competence is inversely proportional to the number of pips on their shoulder
• Corollary 3: Technology is dominated by those who manage what they do not understand.

The law of Training Officers: Those who can't do, teach.

The law of Evaluators: Those who can't do or teach, evaluate.

The law of Protocols and Guidelines: The simplest Protocol or Guideline will be worded in the most obscure and complicated manner possible. Speeds, for example, will be expressed as ‘Furlongs per Fortnight’ and flow rates as ‘Hogsheads per Hour.

• Corollary 1: If you don't understand it, it must be intuitively obvious.
• Corollary 2: If you can understand it, you probably don't.

The first rule of Bystanders: Any bystander who offers you help will give you none.

The second rule of Bystanders: Always assume that any Doctor found at the scene of an emergency is a Gynaecologist, until proven otherwise.

The EMS rule of Warning Devises: Any Ambulance, whether it is responding to a call or traveling to a Hospital, with Lights and Siren, will be totally ignored by all motorists, pedestrians, and dogs which may be found in or near the roads along its route.

• Corollary 1: Ambulance Sirens can cause acute and total, but transient, deafness.
• Corollary 2: Ambulance Lights can cause acute and total, but transient, blindness.

Note: This Rule does not apply in Hackney, where all pedestrians and motorists are apparently oblivious to any and all traffic laws.

The rule of Rookies: Treat any rookie EMT or Driver assigned to you as you would a Bystander. (See The First Rule of Bystanders, above.)

The Rule of Rules: As soon as an EMS Rule is accepted as absolute, an exception to that Rule will immediately occur.

The above is a compilation of various lists scattered over t'interweb with a few of my own additions and tweaks chucked in for good measure!

Another Life Saved

"Old dude, collapsed outside"

Weekends off in the ambulance service are a rarity. For the first two years of service my rota required me working 7 out of 10 weekends. It's now improved to 5 out of 10.  At the time, I was living outside of London with my partner enjoying a rare sunday off. We were dressed and ready to meet friends for lunch. He was wearing smart jeans, shoes and shirt and I was donning skinny jeans, boots and a rather risque top. Why the hell not?! We were running late as usual and just as we were about to leave there was a knock on the door.

"Who the hell is that?!"

And the inventor of the door rests happily in his grave. We would have to open it to find out! With an air of frustration I swung the door open. A young lad stood there, about 15 years old.

"Are you guys the paramedics?"

"Mmm, yes. Why?" I said hesitantly.

"Some old dude has collapsed in the street"

Balls! Off I went up the garden path, and sure enough, about 6ft from the front gate on the grass verge besides the pavement was indeed an old dude lying on the floor. I recognised the look on his face. It was the dead face all EMS have come to know only too well. 

"What happened?"

"He was just walking along and fell to the floor, he didn't move so I got you"

"OK, call 999"

I checked for a pulse, nothing. Breathing......nothing. Airway clear. I started CPR. As this was going on my partner came to the door to see what the fuss was about. Seeing me bounce up and down was enough! He came running out, opened the car that happened to be next to the 'old dude' and got out our response and paramedic bags. Despite no oxygen cylinder I did CPR and ventilations while my partner started getting stuff ready to intubate and cannulate. The kid was on the phone requesting an ambulance and was understandably panicking. He had given the address but was trying desperately to describe what was going on with little success or accuracy.

"Hold the phone to my ear, you've done great"

"Hello there, this a confirmed cardiac arrest, witnessed collapse, CPR in progress by LAS Paramedic, cause unknown. I'll put the kid back on for anything else you need"

"Thank you, there are 2 vehicles on route, they should be there in 3-4 minutes"

We carried on doing what ambulance services do best. He was intubated and cannulated, chest exposed and chest shaved by the time the ambulance arrived. They clearly hadn't got the message about who was on scene as when they came over they said:

"Well done, you've done a great job, are you first aiders"

I think as she said it she realised that first aiders don't normally intubate and cannulate but it was amusing all the same. They attatched oxygen to the BVM and the defib to the chest. The 'old dude' was in Ventricular Fibrillation which is a rhythm we can shock. By now a large crowd had arrived and if you've read my previous blog 'The bystander and me....' you'll know how I thrive on it! 

"Stand clear, oxygen away, shocking now"

The body jolted as the shock was delivered, just as you see on TV. It was wonderfully dramatic! I continued CPR for 2 minutes as is customary after a shock whilst the crew got the bed ready. When the two minutes was up I checked the carotid pulse at the neck and the crew checked the radial pulse at the wrist.

"I've got a pulse!"

"So have I!"

We helped them load him up, still bagging him and then he started breathing on his own. We gave out details to the crew and left them too it. When packed up our gear and headed off to lunch. Arriving late with sweat on our brows and mud on our knees let to some suspect looks and awkward questions but we had a good tale to back it up. 

We heard on the grape vine that 'Peter' had survived but it was only rumour. 6 weeks later there was a knock at the door. There he was. Completely different to how I remember but he had come to thank us for saving his life. This was the first time i'd ever met someone we had 'got back' and it was a felling I will never forget. That feeling of ecstasy and joy was enough to forgive the lack of flowers and chocolates. It remains my only off duty cardiac arrest and the one I look back on with most fondness. It just goes to show the importance of early CPR. That more so than any of the drugs and skills we bring to the table. It really does save lives. 

Take the time to look at the British Heart Foundation's new advert campagne if you haven't already. Compression only CPR. That's what can be the difference between life and death. If you're lucky you'll be able to use the phrase we did as we drove off. 

"Another life saved!"

If you would like to attend a FREE 2 hour course in London on Basic Life Support contact the London Ambulance Service at resustraining@londonambulance.nhs.uk for more information.

The Fear

"5 year old female, shaking, ? Febrile convulsion"

Hot children are very common, as are convulsions and in all honesty there is no easier job than turning up to hot kiddy. Remove a few layers, give some Calpol and take them to hospital. No carrying involved, no real clinical decisions to be made and very little to go wrong. After all, they normally go hospital not because they need to but because the mother needs to for peace of mind! Unfortunately, this job was anything but 'as given' and anything but simple. We pulled into the cul-de-sac to be see a man frantically waving us down. He was panicked but it didn't really change much, parents who havn't seen a convulsion often panic. He ran ahead of us into the house and up the stairs. We were a tad slower as we were carrying all the kit we might need. Even though we suspected a convulsion we took stuff for a seizure just in case. Thank god we did! The second we entered the room it was clear this was no convulsion. She was foaming at the mouth, eyes back into the head, violent full blown tonic clonic seizure. 

"How long has she been like this?" 

"20 minutes or so, I thought she would stop but she didn't"

"20 minutes?!"

"Maybe 25, i'm not sure"

This was serious, for us, as serious as it gets. A child with no epileptic history in 'status epilepticus' was of major concern. Due to her age our first line of treatment was rectal Diazepam. We administered it and took her straight to the ambulance, still seizing. We did this as there was little room to work, the bedroom wasn't very clean and we wanted more monitoring equipment. We could also leave immediately if we had to. After 4-5 minutes there was no change in her condition. The nearest hospital was 20 minutes away and we wanted to explore other avenues before we left. I called our clinical support desk (CSD) to request if a second dose of Diazepam could be given IV. They authorised a further dose so we began trying to gain IV access. The ferocity of the seizure made it near impossible to find a vein. My crew mate had one attempt but failed. Neither of us had seen an EZ-IO on a child let alone do one. The idea of drilling into a child's bone to fit a needle is not a pleasant one. This is where 'The Fear' comes into play. The fear of doing something new, the fear of getting it wrong, the fear of the consequences of getting it wrong, the fear of being powerless to stop a child die in your arms, the fear of knowing you have to do it regardless of 'The Fear'. We quickly went through with each other of the point of entry then he went for it. And got it! We set up the 3 way tap, attached the IO needle and administered the drugs.

We had a couple of minutes before it would take effect so started attaching her to more monitoring and taking more OBs. Her temperature was extremely high. The highest I have ever seen. 41.6. We stripped her remaining clothes and around her upper thighs was a non blanching rash. It was highly likely the seizure was caused by meningitis. We gave the maximum dose of Benzylpenecillin, put in a blue call to the hospital and left. Amazingly only 14 minutes had elapsed since we arrived on scene but she was still seizing. Nothing was working and there was nothing else we could do. This is the second stage of 'The Fear'. We now had a 18-20 minute ride to hospital with a little girl who we couldn't make better. A little girl who could quite easily die in our care. A little girl who's parents were watching and questioning your every move. To be fair they were great and just went with it. Everything was ready in case the worst did happen but that was of little reassurance to us. She seized but survived all the way to hospital. When we got her into resus she had been seizing for an hour. The doctors and nurses jumped straight on it. Within 2 minutes she had stopped seizing. Still gravely ill but at least the first hurdle was cleared. 

When we left the department, mentally and physically drained, she was still fighting for her life. She was on IV anti-biotics and steroids with her parents by her side. I hate to think the thoughts going through their head. Why did they wait? Could they have spotted it sooner? It's every parents worst nightmare but in reality apart from calling sooner it isn't likely they could have spotted the severity of her condition. They had treated her symptoms but like with all paediatrics, they compensate extremely well and mask symptoms, then crash when it's too late. She was a time-bomb waiting to happen. One of the most frustrating parts of the job is not knowing the outcome of our patients. Not knowing if the 'The Fear' was justified. Not knowing if you made a difference or not. When we left, her prognosis was not good. That length of seizure alone would more than likely cause brain damage if she did survive. The hospital were waiting for transport to Great Ormond Street Hospital for specialist treatment. All we could do was hope. 

Three weeks later, we were back at the hospital and a nurse came running over.

"Do you remember the little girl you with status EP you brought in?"

"Yes!"

"She has been discharged and is home, no lasting damage, she made a full recovering, well done!"

That's why I do the job I do. Because those shivers up the spine cannot be replaced by anything. Fact.