Some People!

"78 year old female, fall, ? Injuries"

Friday night. A & E was an absolute war zone! Nurses were near to running between patients, the resus door were repeatedly swinging open and shut as doctors ran in and out. Porters were going back and forth moving patients from minors to majors, majors to the ward, resus to ITU, and even one, I saw, off to the morgue. Down the corridor from the department was a queue of ambulance trolley beds, at its worst, 8 in total. That's 8 patients, 16+ ambulance staff and 8 ambulances that can't answer calls because there was simply no room at the inn!

Slowly, we crept towards the front of the handover queue. It was simple, if your patient could go to the waiting room, they would, if they could sit in a chair and be observed then they would. If they needed a bed, they'd have to wait. And wait a long time. 

Our patient had been a prat. He was a 17 year old guy who had felt he was more than capable of jumping the gap across a large outdoor staircase. Even I could see that it was a gap that Greg Rutherford would struggle to breach! Unsurprisingly outpatient had fallen woefully short. Even his landing had been found to be wanting! He managed to break his ankle and possibly his wrist in the process. When we arrived on scene, his opening line was...

"Sorry guys, I've been a total idiot, again!"

By again, he was referring to the previous time we went to him after he fell down the stairs and dislocated his shoulder whilst trying to do something fancy with a hand rail! He was indeed an idiot! But a likeable one all the same!

Anyway, despite his injuries, he was more than suitable for a chair. We put him in a wheel chair and my crew mate wheeled him round to the waiting room. No doubt he had a 6 hour wait ahead of him! I then went to hand over to the nurse.

I was half way through explaining what happened when she had to rush off! It's one of the perils of being the Charge Nurse on a Friday night! Lying in the bed in front of me was frail old lady. Her arm was in a soft sling, her head was bandaged and she was looking sorry for herself. We shared a little smile! Then out of no where my arm was grabbed in a manor to turn me around.

"I want a word with you!"

I immediately took huge offence at my arm being grabbed, even more so when relished it was a total stranger doing so! Stood in front of me was a woman, 55ish, hair up in a 60s perm and covered in lavish jewellery. She also had the most bizarre looking drawn on eyebrows and lipstick that appeared to have been applied by a drunken toddler! Before I got a chance to even reply, she launched into one!

"How dare you?! You lot have no consideration for your patients. There was absolutely no need to bring my mum here. You could have picked her up, put her back to bed but Noooo, that wouldn't suit you now, would it? You don't think of the consequences for the family. It's MY sons wedding tomorrow, don't you think I've got better things to be doing than being sat up here because some bloody ambulance driver couldn't be bothered to do their job properly. It's a disgrace. A total abuse of your power. Disgusting."

I starred at her blankly for a few moments to see if her tirade had finished and said:

"Who's your mum?!"

"Who's my mum?! Who's my mum?!" she said, looking around for spectators to be shocked! "The woman you just dragged to hospital!" she said, pointing to the woman with head and arm injuries who only moments before I'd been smiling at!

"I didn't bring her to hospital. I've never met her before. I brought in a 17 year old with a foot injury. Is he your son?"

She starred at me realising what she'd just done, planning her next move.

"I don't care who you brought in. You're all the bloody same. You're just selfish, only thinking about yourselves. People have families you know"

The nurse returned to the desk so I turned around to continue my hand over.

"DON'T turn your back on me." she said grabbing my arm.

"Touch me again and I'll call for the police. I didn't bring your mum here, I don't know you or your mum and I'm handing over MY patient to the nurse."

She stood starring at me for a few moments until the nurse told her to go back into the cubicle. I heard her continue to slag me off as if she were addressing a crowd like Martin Luther King! Sadly for her, her mum was the audience and wasn't big on conversation or applause! 

Some people!

Managing the Unmanageable

"Is it always a case of bad managers or are we bad at being managed?!"

Seriously, I'm so bored of people saying "Bloody management" time and time again. No doubt I'll get stick from people about my views on this but I'm fed up with hearing the same grumblings over and over again. Hearing about people who have apparently been 'run' for this and that. I'm yet to hear of anyone in my trust who was suspended or fired for something I wouldn't have suspended or fired them for. I'm also yet to hear about someone who got a totally unwarranted bollocking or warning about something. Obviously the management in my service isn't perfect, but is it anywhere?! It can only ever be as good as the individual in that position. You get some really bad managers and equally you get some really good ones. You get some really bad paramedics and equally you get some really good ones! That's life. It isn't a management thing. It's an individual thing. No one likes being told what to do, and no one likes getting in trouble. To me however, I think ambulance services have the impossible task of managing the unmanageable. And I'll explain why....

Let me break this down into the five main areas that managers are involved in. Lateness, sickness, dress code, compliance and times. Luckily for some people, once qualified, your clinical knowledge isn't really monitored but these five areas are. As a manager, I'm guessing it is their job to ensure all five are at the required level for the staff they are in charge of. If any fall below what is expected, then that must be dealt with. Why do people resist it?!

Lateness - People are late. It's a fact of life. In some jobs being late has little impact on things. In our job it prevents an ambulance starting. Managers really don't care if you are late once in a blue moon. It happens. We don't have ultimate control over power failures, cars starting and traffic. In 5 years I have been late once. The manager at the time told me 'good people have bad days'. I made up my time and it hasn't happened again. A hard stance happens when people are persistently late. I've heard people moan about being put on formal disciplinaries for lateness. 'I was only one minute late'. SO WHAT?! YOU WERE LATE! There is no excuse. If you are frequently arriving late that should tell you that you should frequently be leaving earlier. Yet who is the baddie?! The manager. Why? Because they are doing their job, following their protocol and ensuring their staff have a reasonable deterrent for being late.

Sickness - Sickness is THE biggest gripe when it comes to the way it's managed. I have written before about how it often seems the people who are off sick a small amount get in trouble and the ones off the most get away with it. Unfortunately, there is a system that can be played and boy, do people play it. The sick leave policy was brought in to combat the institutionalised sickness within the ambulance service. To put it bluntly, for far too many years, people were taking the piss. I found out quickly when I started that people planned their sick leave. If you took a long period of sickness each year you didn't hit the triggers for proceedings and were getting away with a months holiday basically. It really is frightening how many people are at it. Sure, it's a stressful job and like I've said before the mental health of staff isn't managed well, but how do you tell the difference between someone who is faking stress to get the summer holidays off and someone who is genuinely stressed?! You can't! So what you are left with is a strict sickness policy that prevents most piss taking, but in that large net, is left a few people who have had a bad year and are now in trouble! And who is to blame? The bloody managers who are doing their job! I went over the sickness limit, I had a rational discussion with my manager, that was the end of it! Basically, piss takers don't like having their freebies taken away and the managers get the blame!

Dress code - This is my biggest bug bear! I will say this once and once only. WE ARE A UNIFORMED SERVICE. It is quite simple. All our uniform is provided in generous quantities. We are provided with shirts, t-shirts, fleeces, trousers, socks, a belt, a utility belt, a stab vest, a hi-vis jacket, a hi-vis tabard, hi-vis trousers, a beanie hat, epaulettes and boots. WEAR THEM. The policy is quite clear from day 1. You wear the uniform you are given and nothing extra. One set of studs in your ears are permitted. No more. We are not in a fashion parade, we don't need flowers in our hair or funny t-shirts. Just wear the uniform like you are supposed to and do your job. Simple. We have epaulettes. Why don't people wear them?! We have belts. Why don't people wear them?! Tuck your shirts in, polish your boots, make your hair presentable and keep it off your shoulders. Don't come to work with 40 piercings in your face! It is not the place to show how individual or alternative you are. As far as I'm concerned any manager has the right to pull you up if you don't follow the uniform policy. It may be nit picking but if I was a manager I would be all over the uniform policy like a rash. We are representing the service in public and personal image carries credibility. If you look like a mess expect that to be mentioned in complaints.

Compliance - Unlike most jobs you can go months / years without have dealings with your management. You say hello in the garage but during your shifts they are not breathing down your neck. You are left to do your job. It is therefore hard to monitor your performance. It can't be measure with a 'Lives save 2 - 4 Lives not saved' quarterly figure. For this, and other reasons, our paperwork is monitored and audited. You are expected to get a certain % of compliance in various areas. If you don't you are given a print out of where to improve. If you persistently don't improve it will escalate. Sure, paperwork is a bore, but it has to be done. Deal with it. Build a bridge and get over it. It isn't rocket science. Yes, it is only a box you didn't tick. So just bloody tick it rather than blaming 'bloody management' for tell you to tick it! Simple!

Times - The other way we are monitored is our times. By times I mean how quickly we mobilise on calls, how quickly we get on scene and how long we spend at hospital after we have offloaded our patient. It is these times which is a bone of contention with many staff. Surely, as an emergency ambulance service it SHOULD be all about how quickly we get there. I see staff get jobs on a daily basis and dawdle over to their truck, then spend ages looking at the map (when the sat nav is already telling them where to go) and eventually bumble off to the call. This isn't good enough. There is no reason not to try and get there as quickly and safely as possible. Delays cause the service fines and in the long term, fines will cost staff. Sometimes traffic causes delays or a million other things out of our control but mobilisation is down to us. If you are too slow, a manager is well within their right to pull you up on it. 

Then there is time at hospital and this is a culture thing. People need to get over the good old days where they did two jobs in a shift, had water fights in the garage and sat at hospitals for hours with other crews. Those days are gone. The service is busier than ever and cannot afford to have 8 ambulances unavailable because someone is telling a good story in the hospital car park. Like it or lump it, we do a job, hand the patient over and then have 15 minutes to get our coffee, go to the toilet and do whatever else is needed. Over a 12 hour shift that's over an hour we are getting. Sure, there are days and there are jobs where it goes over that for any number of reasons but an average takes that into account. It was amazing how many people managed it when there was money on it! Just sayin'. A managers job is to implement policy and manage staff who are not performing properly. Dragging heels at every stage makes that impossible!

There is so much resistance to any change within the service that sometimes it feels like there is no progress being made at all. I've heard horror stories about managers but in all honesty I've had about 12 since I started and none of them have caused me any problems. They have been accommodating and understanding. Maybe I'm just lucky or maybe the 'bloody managers' aren't as bad as the mess rooms would have you believe. What mustn't be forgotten is that where we answer to them, they answer to above and so on. They do what they are told. It's a shame that road staff don't do the same. People seem to feel the need to push boundaries, see what they can get away with, and make the job of managing them an impossible one.

Perhaps the fact that much of the service is still far too unionised and the Us vs Them attitude from the 1980s contributes. Maybe if we started working with managers and making positive changes everyone would be less stressed and angry. It is easy to get along with managers. Turn up on time, dress smartly, be polite to patients and don't drag your heels or take the piss with sick and they'll never have a reason to bother you! Or as I like to call it, 'Doing your job'! For now though, it seems that managers are going to be left managing the unmanageable.

Stuck

"53 year old female, passed out in car, drunk"

A big part of this job is thinking on your feet. Annoyingly, people don't tend to get ill or injured in ways and places that the textbooks say they will. You really would be amazed at some of the bizarre places we find people! Be it in the eves of a loft or upside down in a manhole, people manage to defy physics just when they need an ambulance. It's then our job to work out how to get them out! At our disposal we have the fire brigade, the HART team or just sheer numbers. Unfortunately, when you need 6 people, inevitably there is only room for 1! C'est la vie!

We were called by another crew, or part of crew even! They had been on a job and whilst dealing with their patient one of the crew had gone to get the chair. Whilst at the ambulance, he was called over by a member of the public who's wife was stuck in the car. He took one look at her and called for a second crew! When we arrived he greeted us with a wry smile....

"Hi guys, 53 year old female, been drinking heavily, has passed out slipped into the footwell of the back seats and is now stuck and asleep. Oh, and she's covered in vomit. I'd love to stay and help but I've got my own patient!"

With that, he patted me on the back in the most sarcastic of fashions and left faster than Road Runner.

I peered into the car and scratched my head. Let's just say she was a lady with a full figure. Very full indeed. She also wasn't just stuck, she was shoe horned. Oh, and did I mention the car was Nissan Micra...... 3 DOOR! She was properly out of it, massively intoxicated and totally unrouseable. As amusing as the whole situation was, we were aware that airway compromise was something to be aware of. She was stuck on her back and if she vomited we could be in a whole world of trouble! 

Right, the plan......erm......we had nothing! I used my tried and tested methods of waking up drunk people but she was having none of it! For those in the know, I had her at GCS 6 (1-15). It was quickly apparent we needed more hands, and ideally hands with better ideas than ours!

Twenty minutes later our second crew arrived, by which time I had a rough idea of what to do! 

The Plan: With both seats forward, one of us on the back seat and one wherever they could fit, using brute force,  would lift her to sitting, where a spinal board would be slid diagonally under her bum. A bed sheet would be wrapped under her arms and a lifting belt round her waist. Then, with two on the lifting belt and two on the sheet, she would be carefully be slid along the spinal board inch by inch until she was half out the car. At that point the two inside would exit from the other side, and come and assist to lift the board on to the bed. Simple.

'No battle plan survives contact with the enemy' Colin Powell

The Reality: We sat her up, she projectile vomited into my lap, we all grabbed a bit, and dragged her out of the car. I don't think there are enough words to describe just quite how unpleasant the felling of having someone's vomit on your crotch really is.

By the time we got to hospital her eyes were open and she was complaining of not feeling well. I won't be sending her a 'get well soon' card anytime soon! Her decision to drink too much cost £1000 in ambulance resources alone. It took two ambulances away from the public. She caused our ambulance to need a deep clean and me to shower and change my uniform. All in all, the job took 3 hours when all was said and done. Next time you read about ambulance services being criticised for response delays, bear this in mind!

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!

Access OK

"68 year old male, ? Stroke, slurred speech, access OK"

You will see shortly why the words 'access OK' was the least of our worries! Generally, access is always OK. If it isn't, it's made OK via a well placed boot or the police's universal red key! Normally it's the exit which is troublesome! Never more so than today! 

I...pulled...up to the house around 7 or 8 and I yelled to the patient 'Yo homes what's the problem?!'.... only kidding! We pulled up, grabbed our stuff and knocked on the door. The patients wife came to the door looking extremely worried. 

"He's been up there for ages and isn't making any sense, something's not right."

"OK my love, where is he?!" 

"Upstairs, in the loft"

THE LOFT! Obviously! Where else would he be?! The MOST inaccessible part of any house! Sure enough, at the top of the stairs was a rickety old ladder, leading up to a hatch in the ceiling. Being an old Edwardian terraced house they were high ceilings too. I poked my head up into the darkness and shone my torch around. The loft had no lighting, no proper boarding and insulation everywhere that made my skin itch just by looking at it! Oh how I was cursing the 'bare below the elbows' uniform policy now. Sitting about 20 feet away from me, against the water tank was our patient. I pulled myself up and using the rafters as support carefully traversed the floor beams to him.

Within about 3 seconds I was aware of two things:

1. He was having a massive stroke.
2. Getting him out was going to me HELL.

There isn't much we can do for strokes other than get them to hospital quickly. There is a 4 hour window in which the hospital will be able to give a stroke patient treatment. We were possibly two and a half hours into that window. I clambered back to the hatch where my crew mate (who was conveniently terrified of heights) was waiting at the bottom.

"FAST positive CVA (stroke), no way we can get him down safely as he is."

"HART (Hazardous Area Response Team)?"

"Yeah, it'll have to be. Can you grab me the Lifepack too please."

Crewmate vanished and returned a minute later with all the monitoring equipment! She tentatively climbed a few rungs of the ladder until I could reach her.

"HART not available! Fire Brigade on way!"

The ONE time they are needed! No wonder road staff see them as a joke! Aarrrgghh! I won't waste my breath on ranting about them again. The sensitive souls will only moan about me being mean! Anyway, the fire brigade are better equipped and much more experienced at this kind of thing, probably for the best! 

Within minutes they were on scene. One of them appeared through the hatch and promptly provided the whole loft with light! He asked me what I wanted, and I just said I wanted the patient down to the ambulance quickly! Kit and more fireman gradually started appearing the loft. I stepped back and let them get on with it! They quickly got him into their deep scoop and strapped him in. The scoop was attached to some ropes and eventually, with a combination of make shift pulleys and man power he was lowered down the ladder and promptly carried down the stairs to the waiting bed! 

My eyes took a moment to adjust to the light and by the time I'd passed my stuff down and clambered out my crewmate, the patient and wife were on board! Groups of neighbours were out on the street watching the drama unfold. We didn't stick around, the clock was still ticking and we had a 30 minute blue light run to the nearest stroke centre. I thanked Trumpton and off we went. We arrived at the hospital with 25 minutes of 'X time' remaining. A job well done!

'Access OK'! Pah!