The Laws in Practice

"56 year old male, Cardiac arrest, CPR in progress"

It was the end of a very long, arduous run of nights. I was tired and only had half an hour to go until home time and, to be perfectly honest, I couldn't wait! My bed was calling me.  Due to poor time / job management by the student who was with us we were 'on the hook'; basically, at very high risk of getting a late job and thus being off incredibly late! I wasn't annoyed as I made similar mistakes when I first started, but that didn't prevent us winding her up and piling on the guilt trip! I was getting hungry so as we were at the station I decided to take advantage of having a table and chair at my disposal. I poured myself a bowl of cereal and made a cup of coffee. I sat down to enjoy this rare treat and yep... you guessed it... we got a job!

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

The timing of the job was not lost on any of us. Had it been any other job we would have politely pointed out that we would be finishing our shift in 17 minutes, as it was it was a Red 1; A cardiac arrest. We might not like finishing late but no one really minds if it's for a genuine job. This was, so off we went.

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.

We began our journey through the early morning traffic. I don't know if everyone was tired and in a 6am daze but drivers seemed intent on ignoring us! (please see 'Drivers: Take Note'). If by chance they did see us they simply stopped where they were. It was a highly stressful journey and that's without contemplating the job we were on our way to.

The EMS rule of Warning Devises: Any Ambulance, whether it is responding to a call or travelling 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.

We arrived at an extremely lush block of apartments in a particularly lush part of town. We were the second ambulance and there was already a car on scene so we grabbed a spare oxygen and headed in. We were met at the door by the concierge (I know!) who directed us to the 5th floor apartment. Of course it was the 5th floor of 5! Why would it be anything but?

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.

Luckily the lift was working, but as the door slid open I saw a future problem. It was tiny! Just about big enough for 2 or 3 people to stand in like sardines in a tin. It was barely big enough for a chair and certainly not big enough for a patient in cardiac arrest. Gulp! As we exited the lift we were greeted by a long, long, long corridor of least 100 meters. Guess where the apartment we wanted was?! Yep! Last one on the right! We entered and followed the noise. The patient was in the bathroom. 

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.

A resus can appear to be chaos, organised chaos, but chaos nonetheless. There is kit everywhere; defib, lifepack, oxygen bag, suction, paramedic bag open, cannulation roll out, intubation roll everywhere. Plus, on top of that 6 of us present; 2 doing CPR alternately, 1 bagging, 1 cannulating, 1 coming and going fetching things and one writing stuff down, attaching leads and monitoring etc. There simply wasn't enough room for all of us in such a tiny bathroom!

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.

As far as cardiac arrests go, the resus part was simple; 3 shocks and his heart was beating again. IV access and airway had also been easy, it was now just a case of getting him to a hospital and quickly. It's probably worth mentioning that the patient was large. Very, very large! At a guess I'd say 22-23 stone. 

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.

It wasn't that the lift was broken thankfully; it was that he wouldn't fit inside. We got a carry sheet and began preparing to get him out. A few of us 'ran' back down to the lobby with as much kit as we could carry and got the bed set up and ready at the bottom of the 10 flights of stairs. Back up we then went for the extraction. Whilst 1 bagged the remaining 4 of us carried him along the corridor, watching the monitors as we went. We slowly worked our way down to the stairs, followed closely by the family. We were all sweating. Even the simplest of resus's take their toll, but a confined space and a nightmare extraction with a heavy patient meant we were all feeling it. Eventually we were at the bottom and loading him on to the truck. A short journey to hospital and he was handed over and getting the treatment he needed. We had a clear up operation and a mountain of paperwork to complete!

I didn't write about this job because it was a cardiac arrest. I didn't write about it because we saved him, nor did I write about it because we were 2 hours late off. I wrote about because it made me laugh! Every stereotype we see, joke, and moan about was all present in that one job. We can never eat properly, we are always off late, the sick patients are all upstairs, in a tiny room and if they need carrying they are heavy! That's a fact. That is of course how they became Law! (The Laws of EMS) 

Personally, I think Murphy was an optimist when he said if it can go wrong, it will go wrong!

Pain

"56 year old male, abdo pain"

Pain is a funny old thing. I am told it is subjective and it is different for everyone. Different people have different pain thresholds. Women are better at dealing with pain than men. The same things are said repeatedly. Personally, I think that some people are just wimps and need to man up but that's just me! The ambulance service isn't very well equipped to deal with pain either. We have entonox and morphine which are two extremes. Basically, fancy oxygen or heroin! The latter relies on there being a paramedic available to give it and the former seems to be way over and above the comprehension of the lay man. The concept of sucking air threw a mouthpiece is lost on so many, not to mention the vast number of people who would rather be in pain than suffer temporary light headedness. In fact, most patients seem less than willing to do anything to relieve their pain! The mind boggles!

We arrived on scene and were let in by the patient's son. We were shown into the living room where our patient was sat on the sofa with a pained look on his face. To be fair he looked in discomfort, so whilst checking his vital signs I asked about his pain. All EMS staff will recognise the following conversation:

"Are you in pain at the moment?"

"Yes, it's really bad."

"How long have you had the pain for?"

"About 8 hours"

"Have you taken any pain killers?"

"No"

"Why not?"

"I didn't think they would help"

Really?!?! The clue is in the frickin' name! PAIN......KILLERS. They will kill your pain. They are cheap, can be bought anywhere and you have tonnes to choose from; Paracetomol, Aspirin, Ibuprofen, Codeine, Co-codomol, Tramodol, Gabapentin, Pethidine, Naproxen, Diclofenac & Morphine to name but a few. OK, so a lot of them require a prescription, but there is a clue in that. Go and see your GP! The conversation continued:

"Do you have any pain killers in the house?"

"Yes"

"What do you have?"

"Nurofen, Paracetomol or Aspirin"

"OK, lets take some Paracetomol"

The son went off to go and get them while I continued to find out about the pain and look through his medications. 

"If you were to give the pain a score out of 10, 0 being no pain and 10 being the worst pain you can imagine, what would it be?"

"It's just really bad"

"OK, but how bad, out of 10"

"It's just there, it's hard to describe"

"OK, but I need a number out of 10 to judge how bad it is"

"It kind of comes and goes"

"So when it's at its worst how bad is it, out of 10, I need a number"

"I don't really know"

JUST GIVE ME A GOD DAMN NUMBER! Seriously, why is that concept so difficult?! Obviously I didn't say that. That is what is happening inside my head; in reality, I gave up and gave him the Paracetomol! The job ran its course. We ended up taking him for a GP appointment that he already had arranged; complete with his bag of medications including prescription Tramadol no less!

This job is not an isolated case, far from it. It's the norm. People appear to not take pain killers for pain, although they do like to have them in stock anyway. WHY?!! Some people believe that by taking analgesia their symptoms would be masked by the time we arrive and therefore we wouldn't treat them! Perhaps... Perhaps if you took them and your pain went away you might not actually need us! Just sayin'! Pain killers are there for a reason; there are few things more frustrating than being told by a patient that they are in pain but haven't tried to do anything about it. Far too often 999 is the first point of call when someone is in pain but it shouldn't be. It is perfectly treatable without us and there are other ways to get to hospital. There is NHS direct, pharmacies, GP surgeries, walk-in-centers, urgent care centers, minor injury units, a lift from family or friends to A & E, a taxi. But why bother?! We are free phone, we guarantee to come, and guarantee to take you to hospital, we will give you pain relief and it's all totally free! FTW!


NB: I must add, if you ARE in severe pain, and you ARE genuinely worried do not hesitate to call 999. We will come and you will get the same treatment and options as everyone else.

7.9 miles

First job of the shift was nothing to write home about. It was just another job that made me despair. I questioned why we were even dispatched, why no one made the decision that the patient didn't need an ambulance for a 'blocked nose'. Yes, a 20 year DID call an ambulance for THAT and they DID get an ambulance. I know! Move on; I am... ish! In what was a rarity, after leaving hospital we actually made it back to our ambulance station. We even managed to park the vehicle! Those who work in ambulance services will know only too well, it is one thing to get back to station but managing to get out of the vehicle without getting another job is an achievement! Today we made it to the mess room. Another crew was sat there on their break. I sat in the armchair. No sooner as I had relaxed back into the pit of the chair the radio started screaming and vibrating. When we get a job, a message is sent to the handset with the details. We started walking towards the ambulance as I had a look at the radio: 

"Red 1, Cardiac Arrest, 10 year old male"

I read it out loud and our slow walk significantly increased into an 'ambulance run'. It's kind of a fast walk, but not a walk... but it's not a run either. We never run (except away!), but the fastest we ever go is for sick kids. As I 'ran' I hit the garage door button and jumped into the driving seat. We accepted the job and sat for what seemed like an age for the garage door to slowly bimble open. We edged out to the road, blue lights already flashing and the traffic stopped in both directions. This was a little awkward as the sat nav hadn't kicked in and I didn't know whether to turn left or right! Luckily it was only a few seconds delay and off we headed. My crew mate called control to see if there were any other vehicles en route due to our distance; there were. We were also told that CPR was in progress. There it was... the adrenaline rush!

7.9 miles 

It was dark outside, the roads were wet and the traffic was still quite heavy. You are driving to the vehicle's limit and your own. There is silence in the cab. Your crew mate runs through the paediatric guidelines for resus and the drug dosages while you are trying to get there as quickly and safely as possible. That is a fine balance! On the way to a resus you form a plan in your head of what you will do on arrival. You have worked together for a long time and don't need to discuss it. You know what your crew mate will pick up; you will grab the rest and follow in shortly after. You know the role each of you will play when you walk through those doors. Every emotion runs through you on the way to a job like this. Sick kids are everyone's worst nightmare. 

6.5 miles

You think of all the outcomes; you think how you will feel in each of them. The thought of it is quite distressing and emotionally draining. You think of similarities to your own family. You think of how the family will be when you arrive. You think of how you will hold your emotions together in the face of the horrors that may lie ahead. You think of what you will do, where you will go. You hope it's not as reported. You hope you are second on scene. You are basically hoping that a child's life doesn't rest in your hands. You are hoping you will not have to do CPR on a dead child. 

5.2 miles

While all these thought are running through your mind, ahead of you is the road. Your eyes are wide open; your senses are all heightened. Your heart is pounding as you weave through the traffic at high speed. The volume of the siren changes as you pass under bridges; you rotate through the different tones with every change in road condition. The blue lights are reflecting off everything, lighting up the roads like a Christmas tree. You are aware of everything. The revs are screaming, you are planning your path hundreds of yards ahead, planning for the unpredictable movements of people, pets, car, vans, lorries, buses, bikes, cyclists and the police. I say police because when you have sirens on, you can't here other sirens and the police go faster than us. Slamming the anchors on as you round a corner because the police are overtaking a learner isn't a new thing! 

3.8 miles

You find yourself glaring at every junction waiting for confirmation everyone has seen you and everything has stopped. You take a racing line, accelerating out of every corner. The rush of the drive with the rush of the job means you are very emotionally charged.  You are getting closer and closer. Every minute that passes makes the job all the more real. This is what you have trained for. This is the extreme of what you have trained for. It doesn't get more real or more serious than this. 

1.8 miles

A feeling of apprehension and nervous energy begins to filter in. The truck swings left and then right around corners; the engine is screaming and you can smell the breaks burning. You are aware that you are both jolting up and down with every deviation in the road surface, your bodies lurch from side to side, eyes permanently fixated on the road in front of you. Your mind is working overtime; processing the road ahead, processing everything that could be, processing everything that will be. You are as alert as you will ever be.

0.4 miles

'Cancelled, no longer required'

A Calling

"26 year old female, made a change, found her calling"

On the 22nd of May EMS Week 2012 begins and EMS1.com is running another competition. It is all about informing people of why we do the job we do. They ask the simple question: 'When did you know EMS was your calling?' It's a very good question and one that I'm sat here thinking about at 4am on a rather horrendous night shift. Here I am, exhausted, standing in the back of a cold ambulance, listening to rain crash onto the windscreen whilst I clean vomit off the floor. Is this what I had chosen to be? Is this what I had chosen to do? Yes it was! And I would do it over and over again. Some will raise an eyebrow and say...'really?!' Let me explain why...

About 5 years ago I came home from another day at work. It was 'just a job'. It paid the bills but it wasn't fulfilling at all; I had ended up doing it through a number of poor choices and various inactions. Today was no different to the end of any other day. I  sat down on the sofa, puffed my cheeks out and exhaled deliberately. There was nothing to say really. It was just... just the way it was. Was this really what I would do forever? I hoped not but I couldn't see any way out of it; my training and qualifications only really allowed me to do work in a very particular area, and it wasn't one I savoured. That night, things changed. I flicked through the newspaper's job pages with the usual air of resignation and chanced upon an advert; 'Student Paramedic'. Hmmmm! I read on. It described a great opportunity where I could become a paramedic in just 3 years. All the training would be provided, I would be paid whilst training and it was a career that offered progression and a pension which was something my current job lacked. I applied on a whim not expecting to get an interview. To my surprise 4 months later I received a letter inviting me to an assessment day. To cut a long story short I was assessed, I went for an interview, I had a driving assessment and a medical, and got offered the job. I was made up! Could this be the job, the career, the life I had been looking for?!

Training began. It was a tough six months, a lot of home study, multiple exams and assessments and a large proportion of it was done without any knowledge of what it was like to work on an ambulance. It was a little scary to be honest; I was putting in all of this work with no real idea if I would truly like the job. Then I had my first placement. It was the first time I indeed entered the world of EMS. Dressed in my brand new uniform, polished boots, company branded rucksack and a hi-vis jacket you could eat your dinner off, I arrived for my first ever shift. Due to the fact I was at training school I was 'third manning'; there were three of us on the vehicle: a paramedic, a technician and me. It being my first day I was observing and helping out with obs etc. It was the first time I had done a 12 hour shift and 6am is not a good look on me. At 6:01am we got our first job. Sat in the back, looking through the bulkhead door as we drove through the dark streets, blue lights flickering off every window and road sign, sirens blaring, I was so excited! What a rush! I soon got to see what a Materni-taxi was but I didn't care! When you're new every job is a good job. I suppose I was just so happy to be there. The shift passed by very quickly. We saw a variety of patients; chest pains, drunks, an overdose, an elderly faller, a pyrexic baby. I remember every job from that day, none more so than our off job:

"64 year old male. DIB. COPD patient. On home o2"

It was about 4pm and already dark, it was raining and we were flying through the city streets with all the drama I had imagined; I was loving it! My neck was hurting from peering through to the front for the last 10 hours but I wasn't going to miss a second! We arrived at the address and all piled in. 


The first thing that hit me was the smell of stale smoke. Our patient was sat in his armchair, clearly in trouble. To this day I still haven't seen anyone so blue; not alive anyway. He was surrounded by empty bottles of vodka and it was a sad case of a life of excess laid out in front of me. He was given oxygen and my mentor's sense of urgency was evident. We got him onto the chair and out to the truck. We didn't hang around and before I knew it we were driving; and then I saw why we had been rushing. My mentor said, 'Shit, he's gone on us, start CPR', and so I did. I was very task focused and did what I was told. Whilst the ambulance was swinging from left to right I was doing a concoction of CPR and bagging. It was a surreal out of body experience. I remember it as if I am some fourth person, looking on at me working; I don't see it from my eyes. We arrived at hospital and wheeled the bed out onto the tail lift. There I was bouncing up and down on this guy's chest, being lowered on to the tarmac. We entered the hospital through its double doors. About 100ft away, at the end of the corridor, was resus. The doors to resus were open and inside were the awaiting crash team. We sped down the corridor towards them, continuing CPR as we went. My heart was pounding, shivers ran the length of my spine and I could feel the hairs on the back of my neck stand up. This moment was when I knew that EMS was my calling. This was what I had chosen to be. This was what I had chosen to do. This, I will remember for the rest of my life.

I soon found out that it isn't all like that, far from it. I quickly learnt that there are time-wasters, hoaxes, violence, vomit and abuse. Many of the people we go to don't need a hospital. We work long, arduous, unsociable hours, and get little or no thanks, and little or no breaks, but we take the bad with the good. There will always be that one job which makes everything worth it. 

I am left now cleaning vomit off a floor. Vomit from someone who drank too much. Vomit from someone who was rude to me. This is my calling and I love it!

Once You've Popped, You Can't Stop

"33 year old female, burn to stomach"

This job never fails to amuse. Very rarely do you go through an entire shift where you don't see some form of sheer stupidity, or a bizarre injury, or a faker, or something that makes you question people's right to reproduce. I mean seriously, some people just don't get it! It's an emergency ambulance service predominantly meant for emergencies. OK, a lot of what we do isn't an emergency or even urgent but it is often necessary and that is fine. The term emergency is subjective and a trivial complaint to one person is an emergency to someone else; I get that, I really do. But, sometimes I really do wonder the thought process behind what some people do. Were they really brought up with such a little amount of common sense? Do they have no perspective on what constitutes an emergency? In the past month alone I have been to people with: a cold, a stubbed toe, a cut finger, a headache, a 'vomited once', a stiff back and a bad dream. Surely these things have happened to everyone?! Unfortunately, time and time again, valuable resources are being wasted because we are too scared of litigation to say no! 

Today, I didn't say no either. I treated what I discovered, I was polite but firm, and although I didn't and wouldn't ever refuse hospital, I did strongly advise against it and instead offered three other alternatives. It was a weekday morning and we were in the queue in Costa grabbing our daily fix; on this occasion our fix would have to wait! Our radios started blaring so off we went in haste! If only you could hear our moans and groans on seeing what we were going to. To be fair there was a fair bit of laughter too, but it was a frustrated 'is she serious?' laugh. Above is the abridged version of what the call was given as, this is what we were sent to:

"33 year old female, burn to stomach, let off party popper on stomach"

I can safely say this was my first Party Popper related injury. We headed round to the address and gave 3 slow knocks on the door. We were greeted by a young woman who seemed perfectly calm and not at all flustered or injured. 

"Hello there, who are we here to see?"

"Me" she replied as she walked off into the living room.

I asked what had happened and she explained she had been fiddling with a party popper and it had gone off and hit her stomach. She lifted her top up to reveal a small pink area the size of a 2p coin. It wasn't burnt; she was fully dressed at the time... I KNOW!! Why call an ambulance? Don't get me wrong, I know there are dangers around party poppers. The pulled string ignites 16mg of explosive charge which when combined with air pressure causes the popper to launch a small rocket of joy. Avoid the face; don't aim it at  aperson, especially from close range, blah blah blah. Let's be honest though, if you are hit by one on your torso it isn't life and death!

"Are you in any pain at the moment?"

"No"

"What would you like us to do?!"

"Take me to hospital for a check-up." 

The hot head inside me wanted to scream and rant at her! The girl in green said:

"What are you worried about? I don't think you need to go to hospital to be honest."

"Because people don't always have pain when they have internal bleeding do they, so it's better to be safe than sorry isn't it?"

I spend 25 minutes trying my best to alleviate her fears. I did all her obs and explained if she had internal bleeding there would be signs and symptoms. I also did a full abdominal examination to put her mind at rest. Alas, my offers of: staying in the comfort of her own home, referring her to her GP or taking her to the walk-in centre, were all declined. Sadly, we cannot refuse hospital so as futile as it appeared off we went. My handover at hospital consisted of:

"The lady sat over there has been hit in the stomach by a party popper. There is no injury. All her obs are fine. There is no bruising or swelling. See has no pain. She declined to stay at home, see a GP or go to the WIC. We are here because she fears she has internal bleeding"

"Waiting room"