Blood and Guts

"32 year old female, in labour, 4th child"

When people think of an ambulance they think of blue lights, blood and guts! It's all drama, all Holby City, very Casualty, we climb scaffolding, there are regular explosions and everyone who goes into cardiac arrest is shocked with pads and we get them back. Oh and the helicopter is always there. In reality however there is none of that. There are a lot of drunks, a fair amount of vomit, minimal blood and guts and we rarely get people back to discharge. Oh and the helicopter is never there! Don't get me wrong, there are stabbings, shootings, major trauma and all the things you see on TV but they are few and far between. Today however was one of those 'good days' I often speak about  with 'good jobs'. When we talk about 'good jobs' someone somewhere is either dead or in a lot of pain, life & death is on the line or it is something we have never seen before and probably won't again. To get one in a shift is a rarity. To get two is frickin' awesome!

It was a short shift for a change, we had hadn't done much to be honest, a couple of non-descript bread and butter jobs when this 'in labour' job came down. Normally it is simply a case of get them on the ambulance and pop them off to their maternity unit, hence the tag 'maternitaxi'! The "4th child" rang alarm bells as more often than not, delivery can occur much quicker after a number of children. Then we got the following update:

'4th child. Last 3 have been delivered within 20 minutes of waters breaking. Waters have broken'

OK, so there was a good chance that today I would be playing the role of midwife. We pulled up on scene and grabbed everything and I mean everything; response bag, oxygen bag, entonox bag, paramedic bag, lifepack 12, maternity pack & loads of inco pads. Loaded up like pack horses we trundled in. Sitting on the floor, legs akimbo was our patient....screaming! I waited the 20 seconds until the contraction had passed and introduced myself. No soon as I had done that and off she went again. This baby was being delivered, by me, anytime now. During the following contraction out came the head, followed closely by the rest during the next one! Jobs a good'un! We cut the cord, cleaned up baby and sat back while they shared their first few moments together. The squeamish dad who had been hiding in the hallway came bounding in when the crying started. It's one of the few moments in this job where you can sit back and smile.

Sadly, that moment didn't last long. It became clear that the blood bath on the floor was increasing, she was having a post-partum haemorrhage; so we gave baby to dad and started trying to stop it! She was looking a little pale and in just two minutes her blood pressure had markedly dropped. My crew mate got IV access while I gave a Fundal massage to assist the uterus clamping down and stop the bleeding. Unfortunately it didn't help. We requested a second ambulance and started putting up fluids and administering Syntometrine to contract the uterus. The second crew arrived and fetched our bed from the truck. In cases like this, although a second ambulance seems overkill, we don't want to have to worry about a newborn baby if something goes wrong with mum en route. Similarly we don't want to ignore mum if something is wrong with baby. Two patients, two trucks! Simple! We loaded mum onto the truck, still bleeding heavily, and shot off on blue lights. We arrived at the hospital and left our patient with the doctors and we went to clean up! And oh my, there was a mess!

Having taken the short journey back to the station, to change our uniform and mop out the truck, we made ourselves available for one last job. Annoyingly, we sat there for 20 minutes without a peep coming from our radios so being late off was now a certainty! At last the telling ringing came blaring down our radios!

"30 year old female, had C-section stitches removed today, now bleeding"

Hmmm... like I've said before, jobs tend to follow a pattern in a shift. Clearly maternity and blood was the order of the day. We were only about two minutes away so were there before the call had even finished. As impressive as this was in terms of image for the service, it meant we walked in without the full picture. We went in with the bags we normally take in, nothing extra; what we were confronted with I can safely say I will never forget...

Our patient was sat calmly on the sofa, smiling sweetly and topless. Oh... I should probably point out that her intestines were sitting on her lap. Yep... intestines... on her lap. Her intestines were on her frickin' lap. I starred for a moment and looked at my crew mate for inspiration! 

"Well that's not normal is it?!"

This is not in the book. We have not had specific training on 'intestines on lap' per say but we are trained to improvise, adapt and overcome. My crew mate RAN off to the truck for fluids and extensive wound dressings. After some crashing and banging he appeared with a bed too! How he got it up the three steps on his own I don't know but it was a stellar effort. We soaked a dressing with saline and placed it gently over her 'eviscerated bowel'. I believe that is the technical term for 'guts on lap'! She wasn't in pain; apparently it felt like butterflies in her tummy. She had the stitches removed a few hours ago and the wound started oozing, she then stood up and felt a sharp pain, sat back down, had a peek and phoned 999. Very sensible! In all honesty we really didn't have a clue what we were doing but we blagged it pretty well; after all we wanted a 'good job'! It really is true that life begins outside of your comfort zone!

We rushed off on blue lights having got fluids flowing. We assumed fluids were a good call! 'Intestines on lap' wasn't an indication but was good enough for us. On arrival at the hospital every HCA, nurse, student, junior doctor, registrar, anaesthetist and consultant was waiting. The blue call of '30 year old female with eviscerated bowel, intestines on lap' must have got people talking. No real handover was needed. I lifted up the dressing and said 'she's got tummy ache'! It got a laugh so I left the department sporting a cocky grin! It appears that this job really is all about blood and guts! Home time!

Time for change

"26 year old female, wanting to change things up"

I've been writing my blog now for a little over 6 months. The reaction has been amazing! I've been nominated for a number of awards and the support I have received has been fantastic. When I started the blog and named it Diagnosis: LOB I had simply aimed to share the funny, farcical jobs that were indeed a Load Of Bollocks. To a point I still do and that will always be a part of my blog, but I found myself doing a lot more posts about personal feelings, healthcare, politics and the NHS and I don't think Diagnosis: LOB is a suitable title for what the blog has become. To that end, I'm going to re-name and re-brand. Change is a good thing and I don't want it to become stale. At the same time I want the people who read it to have a say in what it becomes. I have always liked to engage as many people as possible in my posts, hence the increasing number of joint and guest bloggers I have. I have come up with 3 names that I feel are a) more appropriate and b) don't set a negative tone to what I am writing about. They are:

• Wearin' Green, Livin' the Dream

• Trying my Patients

• Blue Lights & Bandages

I've set up a poll on the right hand side of the website for you to vote for your favourite. I will take the most popular and continue under that name. If you have any other suggestions I'm all ears. Thanks again for all the great feedback you have given me! 

Ella x

The Law of Stairs

"24 year old male, fallen down 24 stairs, neck pain, head injury"

To be brutally honest, up until this point it had been a crap shift. We hadn't been abused, we hadn't picked up any drunks, but everything we had done had been nondescript and boring. No one really needed us or needed to go to hospital. It had just been 7 hours of blah blah blah! This popping up on the MDT woke us up at tad; it had potential to liven things up! We headed round to the address, only a few minutes away and pulled up outside some shops. I knocked on the door to the flat whilst looking through the window. I could indeed see 24 stairs, sadly for us there was no patient at the bottom of them. The good old Law of Stairs eh! We were met by our patient's friend. They were Russian and had been drinking. Vladimir, or Vlad as he wanted to be called, had fallen from top to bottom. By his friends admission he had been unconscious for a couple of minutes, then got up and gone to his room. His room wasn't 24 stairs up. His room was 24 stairs + 5 + 13 + 4 up and round various corners. Vlad was sitting on his bed, in obvious discomfort and bleeding from a large laceration on his forehead. He spoke very little English so trying to explain what I was doing was tough. I introduced myself in Russian which calmed him down, but after that I was lacking in any vocabulary other 'Da' and 'Niet'!

The position he was in made it rather difficult to assess him, my crew mate held his head still whilst I half clambered on to the bed to reach him. I began stepping my way down the spine asking about pain. Half way down the neck he yelped. If that wasn't enough to indicate a problem the lateral ridging that I could feel was. With the aid of sign language and demonstrations I explained what was going to happen then got to it. We fitted a collar and my crew mate went off for the scoop, the straps and head blocks. When he returned he told me there was no way we were getting him out on the scoop as there was no room to turn around the corners. Vlad was also becoming more and more combative and was becoming at risk of causing permanent damage to himself. Although only a spinal injury, which is something that ordinarily we can deal with without assistance, I decided to request HEMS. Firstly, we needed more hands, secondly, I suspected our patient may freak out when strapped to a board and due to the nature of his head injury and becoming combative, may need sedation. For those not in the know HEMS is the Helicopter Emergency Medical Services, though at night they work on cars!

HEMS agreed to come, so whilst they were travelling we decided to attempt some immobilisation. We carefully stood him up and placed the board behind him, all the while keeping his head manually immobilised. We performed a rapid takedown which is a manoeuvre where we lower the patient to a flat position using the longboard or scoop. Now on his back Vlad, as I had hoped he wouldn't, became agitated. We decided not to strap him to the board as it was causing more danger to him so I just held his head until HEMS arrived.

The EMS Law of Stairs: The severity of a patient's 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 

Eventually HEMS arrived and I gave them a full handover. The HEMS doctor re-assessed the spine and agreed it was most likely a fracture. The only way to safely get him out to the ambulance was indeed strapped to the scoop but no amount of translation calmed him down enough to be able to strap him tight. He was more concerned about getting to work in the morning. I admired his work ethic but his decision making was clearly lacking. Due to the nature of his head injury HEMS decided to sedate him to make extraction easier and safer for everyone; it also stopped the considerable pain he was in. We got him strapped to the board and began the painstaking task to getting him down the 46 stairs. At times he was upright on the board, at times he was horizontal, at times he was on his side and at times he was at a 45 degree angle. Gradually we got him around every corner and down every flight, on to the ambulance. 

Due to his injuries we put in a blue call to the nearest trauma center and headed off with HEMS in the back. I'm always much more relaxed when the grownups are there. I know if the shit hits the fan they will clear it up and when it comes to the handover they will make sure nothing is missed. It was a 'good job' as far as jobs go, though many of the difficulties could have been avoided. I don't know why but ill people are always on the top floor of whatever building they call from. The Law of Stairs is so so true. I hope this job will serve as a lesson to anyone who reads it. If you fall down the stairs, stay downstairs! Please!

GPs: Take Note

"GP's with varying amounts of experience acting like muppets"

Everyone has a GP. We call when we are ill and are normally greeted by a receptionist with far too much power who tells us there are no appointments. If we eventually get an appointment and are still ill enough to need it, we have our 5 minute conversation with the Doc! Invariably they listen to our ailments for a few minutes then write a prescription for some antibiotics, send us for a blood test and/or advise us to come back if the problem persists. For the vast majority of us this works; if it doesn't, the GP will try something else. It's a big guessing game of 'the most likely'. Working for the ambulance service however I get to see a different side to the GP surgery. I get to see them when they need an ambulance. Rest assured it is not every surgery, there seem to be certain ones that attract more ambulances than others. From an EMS perspective a number of GPs abuse the service, the same GPs who are being put in charge of running the NHS. In the 6th instalment in the 'Take Note' series i've compiled a list of don'ts for GPs who like to call an ambulance. By no means am I suggesting I know best, I don't, my 6 months of 'death by power point' is no match for their 7 years at medical school; I do however know the difference between someone who needs an EMERGENCY ambulance and someone who doesn't. Just sayin'! Bearing that in mind, I hope that some GPs read and take note of the following:

• Don't leave seriously ill people in the waiting room.
• Don't call just because it's Monday morning and you are busy. We are too!
• Don't call just because it's Friday afternoon and you want to go home.
• Don't call because it's 18:30 and you want to go home.
• Don't call for chest pain and leave alone in a side room.
• Don't call for 'chest pain' just to get a quick response for your panic attack.
• Don't leave seriously ill people in the waiting room.
• Don't call for meningitis and not treat it. 
• Don't wait for the ambulance to start CPR. It's not beneath you.
• Don't call an ambulance for a patient you have not yet seen or spoken to.
• Don't say "It's above your pay grade". Ever. 
• Don't leave us to guess what is wrong with your patient.
• Don't leave seriously ill people in the waiting room.
• Don't refer to 'medics' and then not refer to medics.
• Don't call because you are running late with your appointments. 
• Don't book an ambulance for a patient well enough to get a lift or taxi.
• Don't call an ambulance and say 'within 4 hours'. That isn't an emergency.
• Don't leave your receptionist to give the hand over.
• Don't leave seriously ill people in the waiting room.
• Don't refuse to come out. If hospital was appropriate we would be there.
• Don't call for a CVA without checking blood sugar! The slurred speech is a hypo!
• Don't call for 'diabetic problems' without checking blood sugar.
• Don't leave a patient on their own when they are peri-arrest.
• Don't call for a panic attack. It isn't an emergency.
• Don't leave seriously ill people in the waiting room.
• Don't talk down to me.
• Don't give me sarcastic answers to my questions.
• Don't leave someone having a heart attack alone. 
• Don't call for someone having a heart attack and not give aspirin or GTN.
• Don't roll your eyes when I ask you a question.
• Don't leave seriously ill people in the waiting room.
• Don't tell me I HAVE to take a patient somewhere they are refusing to go.
• Don't call if your patient has a cold. It's a cold. They'll get over it.
• Don't call the DIB and low oxygen levels then not give oxygen.
• Don't call us for an asthma attack and not treat it.
• Don't leave your asthma attack unattended.
• Don't leave seriously ill people in the waiting room.
• Don't lie to me.
• Don't leave us to guess what room you have hidden the patient in.
• Don't tell us a stretcher is required when you have stairs.
• Don't tell us a chair is required when your patient has a cut hand.
• Don't call us to a head injury and not put a dressing on. 
• Don't leave seriously ill people in the waiting room.
• Don't leave a letter that is completely unreadable.
• Don't call an ambulance for a patient who has refused hospital.
• Don't call an ambulance and not tell the patient we are coming.
• Don't call an ambulance and not tell your patient why.
• Don't send a patient home in their car and then call 999 for them.
• Don't leave seriously ill people in the waiting room.
• Don't call for anaphylaxis and not give adrenaline.
• Don't call for a hypo and not give glucose or glucagon.
• Don't leave a 95 year old with a pulse of 28 alone. CPR is inevitable.
• Don't say it's immediately life threatening when it clearly isn't.
• Don't call an ambulance when one has already been and referred on to you. The patient will still refuse hospital. You need to visit.
• Don't leave seriously ill people in the waiting room.
• Don't ask your receptionist to call an ambulance and not say why.
• Don't say 'MI' on the phone unless you have ECG proof. It's just chest pain.
• Don't send a patient with chest pain home and then call an ambulance there because you are closing for lunch. Seriously. Bad form.
• Oh, and for god's sake, get a bloody defibrillator! If Tesco can have one, a GP surgery can have one.

GPs have a very difficult job to do, they really do. They have to see and treat everyone for every possible medical condition and they are hugely oversubscribed. I do think though, that this is the case because most refuse to work outside of Monday-Friday 08:30-18:30. This causes the Monday backlog and the Friday rush. Outside of those times we are left referring to a skeleton staff of OOH GPs who don't have the time to see everyone. And I did say most! There are some brilliant GPs who do regular home visits, give great handovers and are everything you want from a GP. Maybe if GPs worked unsociable hours as part of their £100,000 salary some of the pressure would be relieved. In the meantime, being sensible about who requires an ambulance would go some way to easing pressure on the already bulging A & E departments. If the GPs are to be in charge of the NHS they'll have to stop looking after themselves and see the bigger picture. Then again, what do I know, I'm just a stretcher monkey and this is way above my pay-grade!

As always, if there is any I have forgotten, leave it in the comments and i'll add!

Click the Take Note photo at the top to see the other posts in the series!

Chasing Geese

"Unknown age, unknown sex, ? fainted"

It was about 2am on the first night shift. The first is always the worst. I'd been up since about 7am and was seriously lagging. No amount of cold air or coffee was helping and despite being busy and having an in-depth conversation with my crew mate my eyes were shutting at an alarming rate. We got sent to the most bizarre sounding church with no other information than ? Fainted. It sounded like a hoax to be honest, the area that it was in wasn't a nice one but regardless of our scepticism, we began the 6 mile journey. I requested more information about what we were supposedly walking into but they had none. The caller was vague and had called from a phone box and there was now no answer apparently. The roads were nice and empty so before long we were approaching the address; as we pulled into the road the location updated.

The new address was 4 miles in the other direction. We queried how someone who had fainted 'outside the church' was now so far away and now 'lying in the road'. No reason was given, we were basically told to get over it and get driving! So we did! After 5 minutes or so we pulled into the new road. Like all sat navs ours has a flag when you arrive at the location, not always exact but normally pretty close; so we sat at the flag, no lifeless body in sight, and called up for instructions.

"Right, the location has changed, just sending you the new one"

Again! Now the location was a fixed address. It was 5 miles away but now we had no sat nav as we had already pressed 'at scene'. One of the many bugs in the system! Out came the map book. Slowly we navigated ourselves to the new address; it was in the middle of an estate, so it took a while to find the actual house. We pulled up outside and looked the place up and down, it was in darkness, in fact, the whole road was in darkness. I wasn't remotely convinced that a)this job was genuine and b)the people possibly asleep in this house had called an ambulance. I decided to share my concerns with control.

"Red base, we are now sat outside the third location, the house is in darkness, it seems like a hoax and I'm not too happy about waking someone up at 2:30am because their address has been given as part of a joke"

"Sorry but that is the address that was given, you'll have to go and investigate"

Call me a wimp but it's quite a nervy business knocking on the door of pitch black houses in the middle of a rough estate. I gave a tentative knock and took a few paces back. I felt reassured when the FRU arrived; he too had been taking part in the wild goose chase across the city. There was no answer and no movement of the blinds. I knocked again, this time with much more conviction. Nothing! I looked through the letterbox and shouted whilst knocking. Nothing. There was no one here, THAT I was sure of.

"Red base, the house is in darkness, there is no answer, can we treat this as a no trace?"

"Negative, we will have to treat it as a collapsed behind closed door, standby for police, over"

"Roger" (said in the most sarcastic tone I could muster)

We waited and waited and waited. 45 minutes later the police arrived. I told them the situation thus far, and that control wanted us to gain entry as this was now a collapsed behind closed door. They were not happy or convinced this was the case and neither were we, but at the end of the day, these decisions are above our pay grades. The officer tried to kick the door in. Based on how this job had gone so far it was no surprise he was unsuccessful. Another 20 minutes went by waiting for the enforcer to arrive with the 'universal key'. A few well-placed acts of violence towards the door and we were in. I say in, I mean hiding behind the police who were in! We searched the place. Nothing! Not a soul! 

(Back to the sarcastic tone) "Red base, we have gained entry, there is no one at this  location, would you like us to treat this as a no trace or is there something else to try"

(prolonged pause)........"Treat as a no trace"

It was a victory for me because I love nothing more than an 'I told you so' moment but in all seriousness almost 2 hours had been wasted on this job. That's an ambulance and a car not available for another job because someone had decided this hoax call was genuine, not to mention the police time wasted too. It was a hoax from the moment it was called. It was never anything but. A constantly changing location, called from a phone box nowhere near any of the locations, the call back not answered, no age or sex given, no real presenting complaint... is it just me who smells a hoax?! This was a wild goose chase from start to finish; it was a waste of everyone's time and as far as I was concerned, not in the public's interest to pursue it to the length that we did. The door will now have to be replaced at a cost to the tax payer and for what purpose? To satisfy the curiosity of a non-clinical manager and amuse a time wasting fake caller who was probably watching from the block opposite laughing away. What a cock-up!