Trapped in Darkness

As far as shifts go, it hadn't been a bad one. I hadn't been spat at, sworn at, I hadn't had to carry anyone and no one had wound me up enough to change my mood! That's not to say that anyone actually needed an ambulance. The mere fact everyone had walked on and walked off meant that in reality, no one actually needed an ambulance but that's by the by! It was late in the evening, we reckoned that we had about two jobs left to do to see us off, so made ourselves available. We were a fair way away from station so we started heading in the right direction as fast as possible (within the legal speed limit of course!). We didn't get very far at all! Within about 5 seconds.....

"Male, U/K age, One Under"

Action stations. We were only 2 miles away so there was a good chance we'd be first there. While my crew mate drove like a bat out of hell I dived into the back to get the hi-vis on and safety helmets out the top locker. Back in the front and...

"UPDATE: Patient is screaming, injuries, unknown"

....we started to get a plan. Once we had confirmation power was of and track protectors were in place, I would get under the train and assess, crew mate pass staff and liaise with fire brigade and train staff. I began stuffing my pockets with stuff I might need; gloves, tape, torch, cannulas, bandages and a tourniquet.

"UPDATE: HEMS on way. Eta 8 minutes"

Right, that should give us just enough time foe me to get under before HEMS take over and we are sidelines! (Trust me, totally happens!). We pulled up at the station to see we'd been beaten by the Fire service and Police.

"UPDATE: HART team on way"

They can bugger right off! HART or Hazardous Area Response Team is by far the biggest waste of money the service has ever had. Always late to any incident in their fancy suits and equipment and they just sit and watch the fire service. They have lots of fancy kit that they never use and it's a classic old boys network full of wannabe firefighters. I predicted they will be stood on the platform on mass.....watching at some point during this job! 

We were indeed the first medical staff to arrive so we needed to carry everything! Luckily some 'water fairies' were on hand to help. We took paramedic bag, response bag, oxygen bag, Life pack, dressings pack. suction, scoop, head blocks, entonox, straps and blankets! The problem with underground stations is some are very very very deep and going back for kit isn't really an option if you need something quickly. We made our way down, and down, and down to the platform. The fire service were on the tracks and doing a good job of talking to the patient. I jumped down to have a look and there he was. In one piece, very much alive and trapped. What was bizarre was that he wasn't trapped or tangled by a limb, which is common. He was trapped by his pelvis between the train and one of the tracks, on his side!

Now, there are no text books telling you what to do, no algorithm, no guidelines, nothing. It was going to be a case of improvise, adapt and overcome. Under I went. Blimey! I forgot how hot it is under trains! And dirty! By the time I got to him my hands were black. He was very much conscious and there was no obvious blood! Always a good sign! He was however in a lot pain from his pelvis and was obviously very panicked. He hadn't jumped. He was drunk and had tripped and was hit trying to clamber out and by all accounts the train had nearly stopped at impact. Via a gap between the platform and train, a hand appeared holding an oxygen mask. I popped it on the patient and then a blood pressure cuff followed. With a bit of a stretch I got it on his arm. All the numbers were relayed back to me. His blood pressure was a little low but if he had a fractured pelvis he could easily bleed out into that and it would only get lower. 

OK, a plan......erm......

"How are we getting him out?" I said hopefully.

"We are going to jack the train up off of him and slide him out." 

No idea who I was talking to!

"How long?"

"Half an hour. 45 minutes maybe."

"Is that the only timescale we have? If he has to come out quick to we have other options?"

"Afraid not"

That's was a long time as far as I was concerned but it wasn't as if he could just be dragged out! He was well and truly wedged! I stuck an orange cannula in the back of his hand as that was the only part of him I could get purchase on. Thank god for big veins! I wanted to give morphine but in the circumstances I felt a grown up should be consulted first. Luckily, as I fixed the cannula down a head torch appeared. It was the HEMS Doctor! 

"You look like a chimney sweep."

Oh goody.....a mascara joke! 

TO BE CONTINUED........

Does The End Justify The Means?

"36 year old make threatening to jump of balcony. HE IS VIOLENT"

Oh goody goody gum drops! Some mental health to end the shift! It'd been at least two hours since we had dealt with some! This time however, there was a little more gravity to the situation (excuse the pun). These 'jumping' jobs could literally be anything. I could be a Holby City'esque dramatic scene where we spend ages waiting while the patient is 'talked down'. It could be a cry for help where the patient has no intention for jumping and moves away from the balcony when asked. Or, it could be a major trauma waiting to happen and we don't know whether to leave our bags downstairs or go upstairs. The latter would be the least appealing and by far the most stressful but as always, it's a mystery until we arrive. These are things we think about on route to jobs like this. You need a plan for each outcome so you're not caught off guard!

We pulled up behind the police cars that were already there and looked up! Sure enough, about 4 stories up was a man leaning up against the railings of a balcony. About 20ft away were the police. Do we go up, do we stay down?! We went up and joined the police. The patient was shouting that he was going to jump and said he was fed with everything. The conversations between him and police went back and forth for a little while. Apparently this wasn't the block of flats he lived in so if he could be coaxed away from the railing s136 could be used to get him to a place of safety. Suddenly, without warning he ran! He ran down a stairwell, across a covered walkway and into the adjacent  block of flats! We all followed. By the time we caught up with the police, they were inside a flat. 

Inside was our patient sitting on his bed. His mood had changed from utter despair to one of anger and he would not be reasoned with. The police were explaining that he had to come to hospital to he indignantly replied:

"No I bloody don't!"

The 'yes you do', 'no I don't' playground argument went on for some time but at no point did he budge from his stance that he was going nowhere.

"You have no right to take me anywhere without a warrant. I'm in my own home, you need a court order to get me out of here."

He knew his stuff, the only power to remove him here and now was ours if we could prove that he lacked capacity under the Mental Capacity Act. His life wasn't in imminent danger now he was in his flat despite what had occurred previously. That was at least by the letter of the law. I went through the motions knowing full well that he would pass! And he did! He was able to rationalise his decision, he was able to retain information and he was able to explain in clear language that he didn't want to go to hospital and why! It is a frustrating part of mental health law. The only power available to the police was a s135 magistrates order that would need to be applied for by an AMHP to force someone to have a mental health assessment. We were stuck! Or were we......

We had a discussion with the police outside regarding what to do. No amount of pleading would make him come to hospital but the copper who seemed to be running the show said:

"We'll have to 136 him."

Alarm bells started ringing in my head! I'm no expert like @MentalHealthCop is but I know this can't be right!

"But he's in his own home so s136 is useless here."

"No, he was in a public place when we arrived so we can still remove him."

He said it with authority but I wasn't remotely convinced. Time to bring in reinforcements! Ah, the joys of social media and the professional connects Twitter gives us! Time to ask the expert! So, I texted @MentalHealthCop for some tactical advice!

Just what I thought! Needless to say I got bantered on Twitter for interrupting the rugby but I'll take that! It was what I thought but needed to be sure before I let me thought be heard. Before the times of Twitter there would be no immediate contact with people from other professions and I think it's great that it can be used in such a positive way. 

So, back into the flat I went. 

"Section 136 can't be used, he's exercised his liberty to remove that option. We'll need another plan. I know he's vulnerable and we've all heard him threatening suicide but I don't see there is much we can do now he's here."

"We are sectioning him, we are just waiting for the van to arrive."

Clearly I wasn't going to be listened to so we stood outside with our tails between our legs and watched the illegal kidnapping unfold. It wasn't a pleasant thing to watch, distressing to say the least. Seeing someone restrained in their own home, removed against their will and screaming for all and sundry to see was not in the patients best interest by any stretch of the imagination. He was already in a very fragile state, how will this impact on his future treatment? I don't know how the police involved documented and justified their actions but they certainly won't have said they sectioned him from inside his own dwelling. We watched as he was loaded into the van and my crew mate travelled with them while I followed. 

I know that the patient needed hospital, and as it was he was taken (albeit under an illegal section) to the mental health unit but it is NOT a case of the end justifies the means. Or is it? The mental healths laws and police powers that are there, are there for a reason. Breaking these rules only goes to put further barriers between patients the services available to them. This patient will never have trust in the police. I trust the police and I know this was one decision made my one policeman but a patient wouldn't see it like that. He knew his rights and he knows his rights have been illegally removed. Unfortunately, it will be his word against the police and who would believe a depressed, schizophrenic with a long history of crime and drug use. Rules are rules and laws are laws. He has been punished previously for breaking the law. What example does it set when the people who uphold the law are technically breaking it? The flip side is that in this instance the police were doing what they felt was right and were trying to act in the patients best interest. 

This job will also damage the image of the ambulance service in this patients eyes. We were party to it, guilty by association if you will. Sure, it's only one patient but that's not the point. Mental health is a challenging thing for all services to deal with. Like I have said many times before, working together and having an open dialogue with all services is essential but each service has its own responsibility to adhere to the rules, apply them within the framework that already exists and always act in the patient's best interest. The latter is where the grey area engulfs us all. Who really knows what is in a patients best interest? It will always be personal opinion and that will never change. You tell me, does the end justify the means?

Not Again

"84 year old female, fall"

It was the start of the shift and this particular patient had been lying on the floor for about two hours. Not a priority right?! Patient care is the ambulance services number one focus right? Hmmm. Anyway, grumbles about the right and wrongs of making an 84 year old wait on the floor for two hours, off we went! We were let into the house by our patients husband who clearly suffered with dementia. He shuffled up and down the hallway for most of the time we were there. Very sad to see. Our patient was lying on the floor in piano / bedroom. Her bed was now downstairs and placed a few feet away from a wonderful grand piano. She used to be a professional pianist and this way she could still lose herself in her music without the need to struggle with the stairs. 

We assessed her whilst she was on the floor and quickly determined that there were no injuries. The only problem was that she had been incontinent. We got her up and onto the chair. The evening carer hadn't shown up which is what had caused her to venture to the toilet in the first place so we were left doing the carers work. We undressed her, gave her a flannel wash and re-dressed her in her night clothes. She hadn't been wearing an incontinence pad when we found her so I assumed it was because she'd been on the floor so long. She was so thankful and grateful and apologetic, it must be so horrible to lose your dignity in such a way. Hospital wasn't on the agenda because she cared for her husband who was still shuffling up and down the corridor.

Once it was established that she would normally help her husband to bed, we said we'd put him to bed, then come and put her to bed, to save her walking around with her frame too much. So, for the second time we did the work that the carer  that they pay for should have done. We took her husband to his bedroom, undressed him, washed him, re-dressed him, gave him his pills and put him to bed. Job done! Now, back to our patient.

My crew mate had prepared her medication and a glass of water. We gave her all the pills which she took so now it was just a case of bed and goodbyes. We stood her up and immediately noticed the wet patch on the chair. A cursory glanced down made it clear she'd wet herself. Not again! Remember that assumption I made?! They really are the mother of all f**k ups! It was then that I noticed I pile of incontinence pads stacked behind the door! So, we undressed her, washed her, re-dressed her and got her into bed. Again, she couldn't stop thanking us and apologising despite my threat of charging her £5 for of every time she said 'sorry'! We packed up our stuff and said our goodbyes when she said:

"I'm really sorry, but I think I need the toilet."

Bags down, duvet off, swing legs around, help up with frame and usher quickly towards the toilet. Unfortunately, at 84 'quickly' wasn't something that was going to happen. She slowly shuffled, one step at a time towards the toilet. 4 meters, 3 meters, 2 meters, fart, 1.5 meters, fart, 1 meter.....

"Sorry, I didn't make it."

The smell confirmed our fears. Not again! We got her onto the toilet, we undressed her, we extensively cleaned her, we got yet more clothes and redressed her, we got her back into bed and we put a load of washing on. I finished off my paperwork including a vulnerable adult form (she clearly needs more help and commode) and then said our goodbyes. On cue, the front door opened and in walked the carer......

An Ode To Will

"Happy Birthday to my little friend that likes boys"

This is a short blog and has no medical relevance and nothing whatsoever to do with my job! It is simply to say happy birthday to my friend and loyal reader @halloikbenwill! He's been a reader since day 1 from the age of 17 as aspires to become a Paramedic! Today he turns 19 (which I hate him for) but I promised to post him a Happy Birthday blog for all his help with getting my out there! 

So.......

Happy Birthday Will!!!

Have a fab day and don't forget to post my blog on your Facebook page. If you don't I will hunt you down! If you don't follow him already, I suggest you do! This is why I love him!

"Who the FUCK decided to call it a sphygmomanometer? WHO?"

"Your mothers fathers fathers uncles great grandmothers aunt was Irish... You're American. Not Irish."

"I want a giraffe"

"If you get cat pee in your eye you will get pregnant and die"

"I don't like bowling. Or Beyonce #Superbowl2013 #SuperbowlXLVII#SuperBowl"

"I want to show Tom Daley my tweets and by tweets I mean my penis"

Need I say anymore?! Happy Birthday young William! And don't forget, a bear is for life, not just for birthdays.

Getting Schooled

"71 year old female, fall"

Elderly fallers are our bread and butter jobs. We do them day in and day out and unlike drunks, I don't get bored of them. They are always appreciative and more often than not it's a case of getting them up, making a tea, having a chin wag and leaving! Who wouldn't like that?! Sometimes of course they do injure themselves, head injuries, neck of femurs (NOF), hips and wrists. One slight saving grace, is as we get older, we feel pain less and less!

We pulled up outside the house, navigated the overgrown path and got the torch out to open the key safe on the wall. Key safes are wonderful things but I don't like them! I like that you get into the house when someone is in need, but I don't like letting myself into a dark house! It creeps me out! I always open the door with a very tentative 'Hello, ambulance' desperate to hear a response. Luckily, today, I got a response so followed the noise!

Lying on the floor was the loveliest of ladies. We were greeted with a huge smile and despite her clearly broken ankle she was full of the joys of spring. That was a good thing for me because at 1am on a Friday night my joys of spring were somewhat waining! We chatted away whilst we did what we do! Check for neck pain, pulse, respiratory rate, blood pressure, temperature, blood sugar, look at pupils, head to toe survey, check for pain down the back, assess the injury, check for a pulse in the foot, find it and mark it with a cross and place foot in a box-splint. While this was all going on, chat about life through the haze of the Entonox, laugh when she laughs, stick a cannula in her vein, give some morphine and when she starts feeling sick give an anti-imetic. Once ready to move, lift her up onto our chair, grab an overnight bag of stuff, carry her down the stairs, lock up the house, load her onto the ambulance, quick ECG due to medical history and off we go to hospital! Simple! 

Despite her blood pressure being very good on arrival, the morphine and dropped it a fair bit so we raised her legs on the bed. We wheeled her into the A & E department and 'offloaded' her (it's a phrase that makes her sound like a Tesco delivery but it's the term that is used!) onto the hospital bed whilst being watched by the handover nurse. I then went to give my handover, complete with a smile on my face. 

Before I continue, bear in mind the patient is in her nightie, her legs are raised and her left leg is in a huge, bright yellow box splint. It was pretty  obvious what was wrong, roughly speaking! 

Anyway, the handover, I put on my best smile and my cheeriest voice! 

"Good evening"

"Hardly"

"That good eh?! 

"Right, what's the problem?"

"Ketamine overdose......." I said with a rye smile.

*cue the awkward silence and a death stare from the Matron*

Wow! If looks could kill! She glared at me like I had just drowned a kitten. Clearly I'd picked the wrong crowd to waste my best gags on! I'm sorry, THAT IS FUNNY! Maybe it isn't! Maybe I just think I'm funny! Surely though, a bit of light humour at an appropriate time isn't a bad thing. Obviously I wouldn't do it on a blue call or when I've got a patient who wouldn't find it funny but this one had a wicked sense on humour and shrieked with laughter! It's part of the job! If you can't have a laugh to cheer up your patients or a grumpy looking nurse, what can you do?! 

I completed a very mundane, highly factual handover, the nurse vaguely listened and then left. We bid farewell to are patient who was still smiling and very thankful and off we went. As we walked away my crew mate turned to me and said:

"You got schooled!"

That I did. And there was me thinking that laughter was the best medicine!