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

"27 year old female, multiple seizures"

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

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

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

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

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

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

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

A Tragedy Laid Bare........

"7 year old female, drowned, CPR in progress"

I've been meaning to write about this job for a long while. I touched on it briefly last month in 'Success or Failure?' but wanted to share the story in full and wanted to share the effect this job had on me personally and professionally. 

We were driving through the far reaches of the city on a miserable Wednesday evening during mid-winter. It was cold, it was wet and it was rush hour. As much as ambulance staff want the 'good job' to come, no one wants this job. A sense of fear and urgency engulfed the cab. Normally the paediatric cardiac arrest jobs are not as given but this was confirmed. Control had rung to warn us that CPR was in progress and the call taker was talking the caller through life support. As I heard this, a shiver ran down the length of my spine. My crew mate was driving like a bat out of hell, we were only a mile or so away so whilst I was being slung from side to side I just stared blankly out the window thinking 'shit'. That was all I could do. For the first time I was scared. Scared about what I was going into. Scared about what to do. Scared about the atmosphere. Scared for the little girl.

We pulled up on scene and flew out of the cab. We grabbed everything and ran to the open door. This remains the only job I've run into, but I felt it warranted it. As we entered the house we could hear the gut wrenching crying coming from upstairs. I bounded up the stairs and as my head breached the top step I saw at the end of the small corridor ahead of me a sight I will never forget. A sight that will haunt me. A crying mother doing CPR on her child. I rushed in and took over whilst my crew mate got to work.

"Please save her, please save her, please" she screamed.

She went on to tell us that whilst her daughter was having a bath the four year old twins were playing up in their bedroom. The mum left her for two minutes and when she came back she was submerged. Was it a seizure? Did she stand up and slip? I don't know. Her naked, lifeless body lay there, full of innocence,  asleep almost, in this tiny bathroom while we went through what was the slowest five minutes I've ever experienced. The pads were attached and with every compression that went by I was just begging that it was a shockable rhythm. It wasn't. Asystole. I began the second cycle while my crew mate intubated and got IV access. Paramedics often worry and stress about missing a cannula but I'm yet to see a patient not get one when they desperately need one and this was no different. Just before the we got to the end of the cycle the second crew arrived. They shoe horned themselves into the bathroom and took over CPR. Asystole again.

"Right guys, any objections to running?"

We had all thought it but my crew mate said it. We don't have the experience, the drugs and the confidence to stay on scene. We'd done what we could, the rest could be done on route. We put a collar  on her to protect the tube, scooped her up and ran to the truck. In the back was me and the paramedic from the second crew, my crew mate drove as he knew the area and the other member from the second crew drove the mum. Obviously distraught she was desperate to come with her daughter but we asked her to give us room to work. A neighbour was inside the house with the other kids trying to get hold of the father. We left, putting in the blue call on route. We were two minutes away from hospital so the blue call was brief.

"7 year old female, cardiac arrest post drowning, IV access and intubated, drugs as protocol, ETA 2 minutes"

The paramedic was giving drugs, I was doing CPR and ventilating her. The sirens of both ambulances were screaming and although technically the ambulance following wasn't supposed to be on blues and twos under the circumstances I don't think anyone would have dared to argue. I remember looking down at her face, so peaceful, and feeling completely helpless. I was desperate for something to improve, desperate to shock her, desperate to see a pulse or some respiratory effort but there wasn't. There was nothing. We pulled up to the A & E. The back do swung open and a resus team was outside waiting for us. We rushed her inside and the hospital took over. There was a hive of activity, about 15 people of all different skills levels and specialities doing everything they could. We just stood and watched for 5 minutes, still in shock about what had happened. I went out to see the mum. Due to the emotional charge and the work that was going on in resus it wasn't appropriate for her to be inside. It was a pressure the staff didn't need. I sat with her for a few minutes in the relatives room and she just cried. I didn't know what to say so I just put my arms around her. I remember just staring at a non-descript painting of a plant over her shoulder. I don't remember what I was thinking, I just remember staring. Her husband, the girl's father arrived. He knew the story. I left them together just hoping the hospital could do what we couldn't. They looked broken.

The five of us stood outside, all smoking, shell shocked. Just utter disbelief at what had happened and was happening. I was choked. I had the lump in the back of my throat and was holding back the tears. As were everyone else. Shivers were running up and down my spine and I had a horrible knotted sensation in my stomach. We all sat in the back of the ambulance and started on the paperwork. As bureaucratic and seemingly unimportant as it was it had to be done. It would form a permanent record of want happened and as it was almost certainly going to be going to the coroner it needed to be detailed and accurate. It took a while. A DSO arrived and offered us all support and down time. It was a sombre affair. No one had dared to go back inside and see how things were going. I suppose we were just hoping no news is good news. We all piled out for another fag. Four of us stood in a line with the DSO in front of us. It was at that moment we fell to pieces. The doors in front of us slid open. The mother came running out, screaming tears of despair followed by her husband. Their daughter had died. I've never seen pain like it. Their world was shattered, their daughter had lost her life. I felt the cold tears trickle down my face. I looked across and there wasn't a dry eye amongst us. Gutted. I walked away. I sat on my own for a few minutes questioning whether I could put myself through this again. No amount of training can prepare you for it. Nothing can prepare you for it. Sometimes in this job your best is not enough, and when not enough means a kid dies, I didn't know if that was something I could live with or deal with again.

In the days, weeks and months that past I thought about it a lot and often they are very intrusive thoughts. I'm not ashamed to admit that I took up the offer of counselling to help deal with it. I still think about it. It hasn't gone away. It probably won't go away and part of me doesn't want it to. It may still choke me but it stands as a stark reminder though about how cruel life can be and how precious it is. Life can be pulled away in a moment without notice and nothing can be done about it. The mother will blame herself but you can't watch three children at once. Obviously you don't leave infants unattended in a bath but a seven year old? I don't blame her. It was just one of those tragic events which can't be explained or justified. The coroner agreed. Clearly I didn't quit. I carried on and I'm glad I did. I decided I'd feel worse if I wasn't that last hope for someone, be it a futile one. I'm content with that. I still look for the 'good job' whatever it may be. Ce la vie.

Patients: Take Note

"Patients of various ages acting like muppets"

Patients, patients, patients. Without them our jobs wouldn't exist. They are our bread and butter. They are what our job is all about. We get to see the best and the worst humanity has to offer. We see it day and night. They amuse, bemuse, abuse and confuse us on a daily basis but often make our jobs harder than they need to be. Indeed, our job would be so much easier without patients. Our wages are indeed funded by the tax payer and this is often pointed out but that doesn't give them carte blanche to abuse the service. This post, the fourth in the 'Take Note' series is aimed as a guide to patients the world over to make their EMS experience more enjoyable. We don't do or suggest things to piss people off (most of the time), we do it for your benefit and safety. Do as we ask and follow these simple suggestions (Rules) and I promise you a smooth journey and a happy, polite, sympathetic, caring, giving, chatty crew. Well, as long as we didn't finish an hour ago!

• Don't call if you have no intention of going to hospital.
• Don't look surprised when I suggest hospital.
• Don't start a sentence with "Can't you just....." No, I can't.
• Don't call me an ambulance driver.
• Don't call me an ambulance man.
• Don't lie to me.
• Don't call me a nurse.
• Don't tell me you need to be carried. I'll be the judge.
• Don't bleed all over my ambulance.
• Don't say "I pay your wages" Ever. 
• Don't forget to tell me you have something contagious.
• Don't lie to me.
• Don't pretend you're asleep when we arrive. It doesn't have the desired effect.
• Don't mumble. I'll keep repeating the question until I get an audible answer.
• Don't hide under a duvet. You have a cold. Man up!
• Don't go upstairs if you become ill.
• Don't sulk.
• Don't lie to me.
• Don't go upstairs if you have chest pain.
• Don't go back upstairs if you have fallen down them.
• Don't cough in my face. Cover your mouth or I'll place a mask on you.
• Don't give me sarcastic answers to my questions.
• Don't pretend you have neck pain at an RTC. I WILL cut the roof off.
• Don't lie to me.
• Don't swear at me.
• Don't be violent towards me.
• Don't call if you have a cold. It's a cold. Get over it.
• Don't walk without your frame. It was given to you to STOP you falling.
• Don't allow your relatives to answer questions for you.
• Don't have over priced thick rugs and carpets if a chair is likely required.
• Don't lie to me.
• Don't fake illness. A) We always know B) Painful stimulus is not enjoyable.
• Don't tell us not to drop you. Dur!
• Don't use anything other than tarmac for your driveway.
• Don't expect any sympathy if you're a time waster.
• Don't block the entrance to your house with your 4 cars. 
• Don't lie to me.
• Don't come out and meet us as we arrive. We know you're faking it. 
• Don't spit at me.
• Don't live on the 9th floor if you need an ambulance regularly.
• Don't start a sentence with "I need...." You might not.
• Don't start a sentence with "Shouldn't you......" If I should, I will.
• Don't start a sentence with "Don't you......" No I don't.
• Don't lie to me.
• Don't ask for drugs. 
• Don't quote stuff you've looked up on Wikipedia.
• Don't tell me your nephew is a Doctor. I don't care.
• Don't make a miraculous recovering as soon as you get into resus. I'll cry.
• Don't vomit on me. 
• Don't repeat "Oh my god" under any circumstances.
• Don't lie to me.
• Don't moan, groan or wimper. If it was that bad you'd be screaming.
• Don't die. Please!
• Don't sneeze in my face.
• Don't fall over in places I can't get to. 
• Don't say "Its bark is worse than its bite" about your dog. I don't care. Put it away.
• Don't lie to me.
• Don't pretend you can't understand English when you don't like what I'm saying.
• Don't swear at me in another language. You'll be amazed what I understand.
• Don't touch. Seriously. 
• Don't show me any faeces, blood, clots or urine you saved earlier. 
• Don't pretend you're more drunk than you are.
• Don't lie to me.
• Don't fake a seizure. We will 'out' you no matter where you are.
• Don't call because you want a lift home. You won't get one. 
• Don't argue. But...No! What if...No! Maybe if...No! Well if...No! What about..No!
• Don't fake tears.
• Don't lie to me.

Seriously, don't lie to me. Don't lie about your current condition, don't lie about your past medical history, don't lie about you medication, don't lie about your allergies, don't lie about your name and date of birth, don't lie about anything. We will know, we will call you on it and we will get wound up. We'll also tell the hospital and that will seriously effect how long you're left to wait. Well, I'm glad we cleared up the confusion as to what does and doesn't constitute ambulance etiquette. I look forward to meeting you.


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

Insomnia: At What Cost?.........

"25 year old female, tired, grouchy, can't sleep & fed up"

Seeing the word insomnia will give all EMS who read it a wry smile. A smile of knowing. A smile of understanding. A smile of tiredness. In fact it isn't just EMS. All emergency services. All shift workers alike. Insomnia is something large numbers of us live with and cope with.

'Insomnia is repeated difficulty in getting to sleep, staying asleep or getting enough good quality sleep, despite adequate opportunity, which leads to some form of impairment of performance of well being during the daytime. If it occurs regularly or over a long period of time, it's called chronic insomnia.'

I for one suffer with chronic insomnia. Self diagnosed yes, but with no more than 4 hours total sleep a night at least 6 out of 7 days that is what i'm going with. I've known for a number of years that I've had trouble sleeping but having had a few weeks off work and not feeling refreshed and not getting good rest made me realise the semi-permanent impact shift work has had on me. Shift work isn't the sole cause of insomnia but it is a common denominator amongst the emergency service workers. You'd think that having been awake for 24 hours and done a gruelling 12 hour night shift sleep would come easy. Well it doesn't, and I'm not alone. Getting to sleep is hard enough, but staying asleep is the bigger problem. Stress and worry are big contributors and combined with a pre-disposition to not sleeping well, you're left awake unable to sleep because you're worried about not getting enough sleep and stressed as to how this will effect you. Then, your shift pattern changes. After 4 shifts of nights, your body clock just about adjusted, you now need to fall into a normal sleeping pattern in preparation for an early shift in a day and half's time. This routine continues throughout any shift workers career. Grim!

For me, the major worry with insomnia is how I am at work and how my colleagues are at work. After a prolonged period of poor sleep you just feel drained. Physically and mentally. You exist rather than actively do. You float through you shift not really knowing how you got to the end. Driving on blue lights when physically exhausted is scary but at least you have the lights and sirens to keep your eyes open. When not on lights it's dangerous. I'm sure fatigue plays a huge part in EMS RTC's and I don't like to admit it but I have fallen asleep behind the wheel at traffic lights in the past. Thank god it was at traffic lights. Driving home after a 12 hour night shift is a hairy experience too. Fighting the body every step of the way to stay awake. Driving aside, you're expected to treat every patient you come into contact with, with the same professionalism and courtesy. You're expected to make on the spot decisions that in reality can mean life or death. If your husband, wife, child, parents or friends were gravely ill, how happy would you be knowing the crew attending had been awake for 22 hours, were exhausted, hadn't eaten and hadn't had a break for 10 hours? Would it fill you with confidence? It wouldn't me. Personally I don't think enough support is available, 'being tired' isn't a reason to call in sick and with the strictness and disciplinary procedures around absence being a very contentious issue it is of no surprise we just put up and shut up! We make do. We drink coffee (by the bucket load), take pro-plus, play loud music, keep the window open or in extreme cases take matters into our own hands.

Staff in London will be aware of the name Lorna Lambden. Lorna was a paramedic who worked Camden. I knew her and had worked with her on both ambulances and when she worked as an FRU. She was a lovely girl. Always smiling. Always happy to see you. Always tired. Like many, she suffered with sleep problems due to the effects of a 12 hour rota with a constant change in shift. In an effort to get some sleep on her rest days she bought some sleeping pills off the internet. Tragically, she suffered a heart attack brought on by the medication and she died. Her body was discovered two days later by her boyfriend.  For the full article click the link. This tragic loss of life is symptomatic of the problems insomnia can cause. The desperation to get some sleep can drive people to extreme and desperate measures. In Lorna's case it was non-prescription medication. Obviously the dangers of buying medication not prescribed by a GP are painfully evident but that is what she thought she had to do to get some sleep. Possibly because GP's commonly prescribe an anti-depressant which in small doses works as a sleeping tablet and like me, she wouldn't want a prescription for anti-depressants on her medical records. I don't know what the solutions are. I've tried all sorts to get a good nights sleep but little works.  What I do know is that whilst working a varying 12 hour shift rota with no breaks is deemed acceptable, little will change and until insomnia is regarded as being as debilitating and genuine as stress and depression we will continue to plod on regardless.  Insomnia at work is talked about with an air of humour about it, being tired is almost vaunted as right of passage in the emergency services and is something that is seen as 'just the way it is'. I think that speaks volumes about the length of time it's been ignored.

And just so you know: People who regularly get less than six hours sleep increase their chance of dying over a 25 year period by 12%. Bummer!

Passers-by: Take Note

"Passers by of various ages acting like muppets" 

Welcome to the third instalment in the Take Note series. Today we will be examining the good old passer by! I often speak about passers by in my blogs. They have their purpose. Sometimes they are the only hope for some people. They do CPR, they try and comfort, they stem bleeding and they call 999. They also flap and run around like headless chickens but to be fair, i'm sure I would if I didn't do this job! We actively encourage 'hands only' CPR from passers-by and if someone is ill or collapses in front of you then we actively encourage them to call 999. I don't in anyway want to discourage anyone from calling an ambulance. If in doubt, call! However, awfully large amounts of resources are wasted, especially at weekends because of the 'unconscious in street, called by passer-by'. Again, if someone is genuinely unconscious then phone us but just for the record, being asleep is not unconscious. I a vain hope that this blog is read by....well...passers-by, i've compiled a list of things that should aid you in making the decision to call 999 and aiding us in the treatment of the sick, injured, weak, drunk and needy. 

• Don't call 999 and give the wrong location. Unhelpful.
• Don't call 999 because you saw someone in the distance fall over.
• Don't call 999 because you think you drove past someone unconscious.
• Don't call 999 for someone at a bus stop. They are drunk. (OK, check first!)
• Don't call 999 if the patient is telling you not to.
• Don't call 999 and leave before we arrive.
• Don't assume that all tramps are dead. They are not. They just smell.
• Don't assume all drunk people are dead. They are not. They are drunk.
• Don't assume someone lying on the floor has collapsed.
• Don't do CPR on someone who is shouting at you.
• Don't say someone isn't breathing and then say you can't stay on scene.
• Don't call 999 and leave before we arrive.
• Don't take photos of us.
• Don't film us.
• Don't tell us you're a Dr unless you are Trauma consultant or A & E Doctor.
• Don't tell us you're a GP. I hear Generally Pants.
• Don't tell us you're a nurse who can cannulate. We won't let you.
• Don't call 999 and leave before we arrive.
• Don't run into the road to flag us down. We probably won't see you in time.
• Don't repeat 'Oh my god' over and over again while we do CPR.
• Don't stop CPR as soon as you see the ambulance.
• Don't follow us into the ambulance if you are not a relative.
• Don't stop and watch if you are just wondering by.
• Don't call 999 and leave before we arrive.
• Don't say 'It's like Street Crime UK'. It isn't. We are not the police.
• Don't tell us a drunk can't walk. They can. Just not un-aided.
• Don't open a closed ambulance door. Ever. 
• Don't tell me my ambulance is blocking the road.
• Don't ask me to move my ambulance because it is blocking the road.
• Don't call 999 and leave before we arrive.
• Don't ask me 'Are they going to die'.
• Don't ask me what is wrong with them? Mainly because I don't know.
• Don't phone your friends and give them a commentary of what's happening.
• Don't exaggerate to make it sound better. 
• Don't start a sentence with 'Don't you need to.....'
• Don't call 999 and leave before we arrive.
• Don't tell me they need something for the pain. I'll be the judge. 
• Don't try and help us lift unless we ask YOU specifically.
• Don't heckle.
• Don't stand too close. In fact, don't stand. Keep walking. 
• Don't judge me when I stop CPR. I've done so on sound medical grounds.
• Don't call 999 and leave before we arrive.
• Don't get in my way. 
• Don't go out of your way to peer in to the back of the ambulance.
• Don't tell the call taker the patient isn't breathing unless you have checked.
• Don't tell the call taker anything that you don't know.
• Don't laugh at us.
• Don't call 999 and leave before we arrive.
• Don't call us names.

• Do call 999 us if someone ISN'T breathing.
• Do call 999 if someone is fitting.
• Do call 999 if someone is struggling to breath.
• Do call 999 is someone is hit by a car.
• Do call 999 if someone has chest pain.
• Do call 999 if someone is hit by a train.
• Do call 999 if someone is bleeding heavily.
• Do call 999 if someone is a risk to you, the public or themselves.
• Do call 999 if someone is unconscious but please check first.
• Do call 999 if you are in doubt. Jokes aside.
• Do tell the call taker if the patient is being aggressive. Then run away.
• Do tell the call taker if the patient has a weapon. Then run away
• Do tell the call taker if there is more than one patient. 
• Do tell the call taker all the FACTS you have. No conjecture please.
• Do RUN when we RUN. Trust me.

Finally, make sure you ask the patient if they need an ambulance. They may well say no and just because their eyes are shut, doesn't mean they are asleep, unconscious or dead. On behalf of all EMS i'd like to thank you for all the help you do give us and all the lives you save. We do appreciate it and are merely trying to educate the muppets who make things difficult!


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