Thai cave rescue – World Cup class teamwork.

Respectfully dedicated to former Thai Navy SEAL Saman Gunan.

As I write this we are currently in the latter stages of the football (ok, soccer to my American friends) world cup competition.  It’s hard to escape from it.  Even people who don’t follow football are quite taken up with the excitement.  The England football team are a few hours away from the semi final against Croatia.  This will be the first time England have made it this far in the World Cup since 1990 – 28 years ago.  Understandably most of England is excited and proud.  The English team consists of a group of professional athletes all at peak fitness and progressing this far in the competition is a testament to teamwork, dedication, hard work and perseverance.   The team are all household names and hailed as heroes.

I think the term ‘hero’ is overused.  Yes, I have a lot of respect for professional athletes at the top of their game and yes I have a lot of respect for the way most of our celebrity athletes use their fame and influence for good – inspiring young people into sport and being a positive member of society and away from crime.  It’s particularly pleasing to hear famous sports people recently helping to push the message about talking about mental health issues and helping to remove the stigma.  However, I will still be sparing with the ‘hero’ label.

Thailand hasn’t been involved in the World Cup, not sure if they have a national team.  I don’t know much about club football over there, I only know of one team (go you Nakhonratchasima Swat Cats!!).  However, over the last 18 days a Thai football team has been involved in their own competition: against rising flood water.  A group of 12 young boys from the ‘Wild Boars’ football team and their coach entered a cave system as a team building exercise and became trapped in the cave by rising water levels, not helped by the heavy rain.

An international team has worked around the clock to affect the rescue of the trapped group.  Rescuers from Australia, England, Japan, Laos, Myanmar, Sweden and the USA have worked with Thai rescuers.  In a display of teamwork, perseverance, determination, hard work and bravery second to none the rescuers have shown the very best qualities of the human species.

Over the last three days the group was successfully retrieved from the caves.  Every one of the group was shown how to use cave diving equipment and then led by rescuers through approximately 3.2km (2 miles) of cave to the outside world and safety.  Part of the route was submerged and the boys had to swim tethered to a rescuer and part of the route was through dry caves where the boys were dragged on rescue stretchers.

I think everyone involved in this rescue, although not famous household names, deserve the title ‘hero’.

Tragically one of the rescuers paid the ultimate price.  Former Thai navy SEAL Saman Gunan was involved in the preparation for the rescue effort.  Initial thoughts when the trapped party were found was that they could be supported in the cave until the end of the monsoon and the water level would drop naturally making the rescue safer and easier.  The presence of hundreds of rescuers in the cave was using up the oxygen in the air increasing the risk of suffocation to the trapped boys so part of the support was to bring air containers into the cave.  Saman Gunan was returning from delivering one such air canister when he became unconscious.  His diving buddy tried to resuscitate him but was unsuccessful.

As we all turn our attention back to the football I think it’s nice to think of the joy felt by the families of the Wild Boar football team at their reunions with their children.  I can’t imagine the heartbreak felt by the family of Saman Gunan, I hope that they take some comfort from the fact that due to his sheer bravery the 12 boys and their coach survived.  A true hero.

 

 

Instruction Manual For Dating Ambulance Staff

This is a jokey look at the trials, tribulations and rewards of dating or being in a relationship with a member of an Ambulance service.  It is written in the style of an instruction manual.  Boom – think I’ve just lost most of my male readers!

It applies equally to male or female and in the absence of any universally recognised gender-neutral pronouns I will use he, she, him and her at random (I’m not going to use the clumsy “he or she” every time), just assume that each applies equally in all cases.

I’m going to use the term ‘ambo’ in the interest of fluidity and shorthand to mean all ambulance staff whatever grade or job title.

 

Introduction

Congratulations on choosing to date or relate with an ambo.  You are guaranteed an interesting, possibly turbulent but hopefully never boring time.  By following a few simple guidelines and considering a few simple insights which follow you should get years of enjoyment out of your ambo.

 

First Meeting

You may meet on-line, in a bar or just out and about.  The fact that he’s an ambo will probably crop up early on in proceedings. It’s something that’s a fundamental part of her life, as the saying goes, it’s not just a job; it’s a way of life.  It’s a career choice that most ambos identify strongly with and define themselves by.  If they don’t mention it here are a few clues that may suggest your new friend may be an ambo:

  • Permanently tired. This comes from the long shifts and rapid changes from day to night shift and vice versa.
  • Slightly confused. Particularly noticeable after the ambo has worked a series of night shifts.  Your ambo may ring you mid morning for example, after having woken in a panic after night shifts convinced he has overslept and missed your date scheduled for that later that evening, or even the next day – it can be that confusing.
  • Strange meal choices: admitting to a whisky or beer for breakfast may not necessarily mean a serious addiction problem it may simply signal the end of a run of nights.
  • Eating or drinking very quickly. This is a very bad habit picked up at work trying to eat or drink between emergencies.

 

Uniform

Particularly for customers involved with a male ambo there can be a certain mystique or glamour about a ‘man in uniform’.  Sadly not the ambulance uniform.  It tends to be a shapeless green outfit (UK model).  Even if you find your ambo quite appealing in green polyester, you may be disappointed that he changes out of it at work before meeting you, or if he has no changing facilities at his particular place of work, the minute he gets home, probably before allowing you a hug.  The reason is that most ambos due to the nature of work develop a healthy level of germ-o-phobia.  In his mind’s eye it will be a stinking rag crawling with thriving communities of bacteria and viruses. Not to mention the occasional fungus or crawling things.  Ewwww.

 

In the relationship.

You’ve had a few dates and somehow that mystical change happens and you’re in a relationship with your ambo.

You may find the constant tiredness and occasional exhaustion-fuelled confusion initially quite cute.  As the relationship progresses it may become a bit tiresome.  It’s worth bearing in mind at this point that your ambo usually has no choice about the range of shifts she has to work.  Ambulance work is 24 hours a day, 7 days a week, 365 days a year.  Different areas will operate different systems but all involve taking your ambo away to work nights weekends and public holidays at some point.  Given enough notice, your ambo will usually be able to get a specific day or night off but short notice changes are usually quite hard to achieve.  Partners of ambos become used to attending family events alone and having to explain to family and friends that “..he’s working! Again!”

Some newer models of ambo may have very irregular shifts patterns, there is often an initial period of ‘reserve’ or ‘relief’ working where the ambo has to fill in for sick leave or holidays.  Usually only a few weeks’ notice of shifts is possible. This can last months or years depending on the employer.  Eventually this period ends and a position on a regular shift pattern becomes available.  This still means shift working but at least the ambo (and you) knows what he will be working at on a particular day in the future allowing for better planning.

 

Pregnancy

Either planned or unplanned, you may find you are pregnant.  This is a huge subject and is beyond the scope of this manual, but here are a few guidelines.

Your ambo is trained in obstetrics and has probably delivered many babies while at work.  While this may be reassuring, it’s probably for the best to rely on the professional services available in your area.  On the big day when baby is about to make an appearance, keep him at your head end, not the baby end – leave that to the midwife.  This will probably be what he wants also.  Besides, you need him to hold your hand as you squeeze and break his fingers during the contractions and swear at him for putting you through this.

 

Parenthood

Your ambo will generally make a good parent.  As the child grows, during the early years at least, being an ambo will be ‘cool’ and she will be proud of him.  Shift working will often mean that the ambo parent will be able to do school runs and get to events during the school day.  On open days at the school (fairs and fetes for example) you will probably be able to persuade your ambo to bring an ambulance for a couple of hours for the children to look at and sit in.  Obviously it won’t be an active operational one but he will probably be able to get hold of a ‘spare’ one for a couple of hours.  Most ambulance services love their staff to engage with the community.  Don’t listen to any complaints that she doesn’t want to, ambos love doing school visits, and they love the attention!

 

Breakdown

You may sometimes experience episodes of your ambo seeming withdrawn and quiet.  Records show this This may be more than just tiredness.  It may be due to a particularly unpleasant job he has done.  He may find it hard to talk to you about it.  This is not because she doesn’t trust or respect you it’s more likely that he wants to spare you the horrible details.  Evidence shows that male ambos are more prone to bottling things up and not talking about feelings than female ones.  Work is ongoing to try and overcome this design defect but it may take time.

Hopefully the occasional episode of low mood will pass as the ambo processes and comes to terms with the event and will return to his usual bright and responsive normal self.

Sometimes however the problem will not easily resolve and specialist assessment and repair may be required.  Watch out for the following signs that your ambo needs help:

  • A low mood which does not pass quickly.
  • A low mood that seems more serious than usual everyday low moods.
  • Your ambo becoming withdrawn and not talking to you.
  • Your ambo no longer wanting to be physically intimate with you.
  • Your ambo become irritable and unusually bad tempered.
  • Your ambo using unhealthy coping mechanisms: drinking alcohol more often or heavily than usual, using drugs.
  • Your ambo losing interest in the things she used to enjoy doing.
  • Your ambo no longer making the effort to keep in contact with friends and family.

The best thing to do is to keep encouraging her to talk but meanwhile encourage her to engage with professional services to help.  He may find he can open up to total strangers who are professionally detached.  For UK models the charity ‘mind blue light’ is an excellent start point, or their own doctor.

 

Final words

So there you have it.  A brief guide to the workings of an ambo and suggestions which hopefully help you understand and get the best out of your ambo.

GOOD LUCK!!

Child cardiac arrest

Warning:  this is a grim post with a tragic ending – some of you may find it distressing (I do).

Tony and I were on a day shift.  We were in good spirits; it was our last day shift before our shift break so we were both looking forward to a few days rest.  We cleared from a job at one of the local hospitals, time was passing and it was nearly the end of our shift.  We still hadn’t had our rest break and were ‘out of the system’ meaning control had to return us to our base for twenty minutes.  The radio bleeped which tells us control are about to speak to us.  I expected it to be them telling us to return for our rest. I was wrong.

“Guys, I know you’ve not had a rest break and I hate to ask, but, I’ve got a 3 year old child in cardiac arrest.  I’ve got another ambulance running but we need to use you too…”

One of the improvements to the ambulance service recently is our management of cardiac arrests.  When I first started, a single crew would be sent to a cardiac arrest and would be expected to perform CPR, Advanced life support then transport to a local ED – too much for a single crew to achieve properly. Now the service sends at least two ambulances to each cardiac arrest.  When it’s a child they send at least two ambulances and normally senior staff in cars to help too.  A child cardiac arrest as well as being more emotionally taxing is more complex.  Drug doses and fluid volumes have to be reduced according to the weight of the child.

We arrived onto the street a few minutes later. As I pulled onto the street another ambulance was already parked outside the address.  A senior paramedic, Joe, arrived in a car just behind me.

I saw the paramedic, Andy, from the ambulance carrying a child onto his ambulance.  I went straight onto his ambulance and saw that Andy had already connected the defibrillator and was doing chest compressions.  He quickly told us what had happened when he went in the house; the child was lying on the floor in cardiac arrest (no breathing and no pulse) in a pool of vomit.  Mum and auntie were obviously distraught and screaming – Andy made the decision to move straight to the ambulance so we could treat the child, Naz, more quickly.

I went to Naz’s head to clear his airway and start to ventilate his lungs.  His mouth was full of vomit so we quickly turned Naz to his side to empty his mouth.  Then I inserted a small tube to keep his tongue free of his airway, but his mouth immediately filled with vomit again.  I used the suction machine to clear his mouth and decided to intubate.  This involves inserting a plastic endotracheal tube (ET) tube into the patient’s mouth and through the vocal chords into the top part of the trachea.  Once in place vomit can no longer block the airway or sink into the lungs.  I connected a bag ventilator to the protruding end of the tube and was able to breath for Naz.  While I was doing this Andy was continuing with chest compressions.  Part of the procedure for resuscitation involves regular doses of adrenaline (epinephrine) into the blood stream.  With a child it is quicker and easier to get intra-osseous (IO) access than intra-venous (IV) access.  This sounds brutal but is quick and effective – a drill is used to drill into a long bone in the leg or arm and a cannula is left giving access to the marrow space within the bone.  This leads directly into the blood stream for drugs and fluids. While I was intubating, Joe was getting IO access and started the drug therapy.  Tony was assisting each of us as we needed and trying to reassure Naz’s mum while at the same time getting some details and general medical history.

We were ready to go to hospital.  We all decided to travel in the ambulance to assist with on-going resuscitation on the drive to the ED.  This meant leaving our ambulance and Joe’s response car on the street to be collected later.  We just had to hope they would still be there and not vandalised when we got back later.

The journey to the ED seemed to pass very quickly with me ventilating Naz, Andy compressing his chest and Joe periodically giving a dose of adrenaline (epinephrine).  Tony was in the back with us too trying to comfort Naz’s mum and get some basic details for us for when we arrived at the ED.  Andy’s mate, Jack was driving.

When we arrived at the ED Andy scooped Naz up in his arms to carry him into the resuscitation room (much quicker than using the tail lift and wheeling the stretcher in). I followed a step behind with the bag-and-mask ventilator still attached to the end of the ET tube protruding from Naz’s mouth.  The resuscitation room was crowded with the receiving medical team – anaesthetist, consultant ED doctors and several junior doctors plus a range of ED nurses – they were pulling out all the stops for little Naz.  The team listened to our handover as they took over the resuscitation.  We stayed a while to watch. It may seem a bit strange that we hung around just watching but that type of job is hard to just walk away from – we wanted to see if the medical staff could pull off the miracle that we hadn’t been able to and restore life to Naz.

Sadly after nearly an hour of effort they had to tell Naz’s mum (and dad who had arrived at the hospital now) that they weren’t able to resuscitate Naz.

A few days have passed and I’ve managed to process things.  Typically with me for a couple of days I tend to ruminate on jobs, playing them over and over again in my mind wondering if I could have done anything differently.  I can’t imagine the pain and suffering that the family are going through now and feel for them.  I don’t suppose mum and dad will ever forget or get over that day.

My paramedic learning journey

As a ‘vintage’ paramedic in the UK my learning journey is quite extensive.  As the saying goes ‘every day is a school day’ this is very true for all of us who work in emergency care.  I have been asked a few times about how the education for a paramedic has changed over the years so here goes.

In the distant past when I joined the ambulance service, all the training was in-house.  I had a six week residential course at the training centre.  On that course we covered the basics of anatomy and physiology, an introduction to most types of medical emergency and the basics of trauma (trauma in our context = physical injury).  The training was a mixture of classroom work and practical sessions.  Once we had learned the basics we then went on to learn the basic treatments options which we as an ambulance service could provide.  These all entailed transport to an Emergency Department (ED) of a local hospital with some intervention en route.  At the end of the six week course we had a two week driving course to learn to drive the ambulance safely.  Surprisingly, we weren’t taught ‘blue light drives’ on this course.  At the time, UK law wouldn’t allow a blue light drive unless on a medical emergency, we picked up the blue light driving skills ‘on the job’ when we were unleashed onto the public roads.  After these eight weeks, we were unleashed on the public as a trainee ambulance technician.  The trainee status lasted a year and during that year we worked with a wide range of paramedics as part of the crew.  At four points in that year we were scheduled to work with a work based trainer paramedic who assessed our progress and pointed out areas to improve.  At the end of the year, assuming we passed all the assessments, we were qualified ambulance technicians.

A year after qualifying as a technician we were eligible to take the paramedic entrance exam.  Paramedic training was only offered according to the demand for paramedics in the service. If it was deemed that we had enough paramedics it could be several years between courses.   After having passed the exam I was invited back to training school for a further four weeks of slightly more advanced Anatomy and Physiology, and the ‘paramedic skills’ of cannulation (inserting a needle into a patient’s vein which has a plastic tube around it.  The needle is then withdrawn leaving the plastic tube in the vein allowing us to introduce a range of lifesaving drugs and fluids directly into the bloodstream) and Intubation (inserting a plastic tube into an unconscious patients mouth and through the vocal chords into the trachea (airway tube leading to the lungs), once in place a balloon on the outside of the tube is inflated and so the airway is protected from blood and other nasty secretions entering the lungs while still allowing air in and out).  In training school we have plastic dummies to practice on, similar to the ones you can practice CPR on but more lifelike to allow intubation and cannulation.   After successfully completing the four week course we had a four week placement in a hospital, spending time in the ED, critical care units and operating theatres.  This was where we got to try out cannulation and intubation on real people, supervised by doctors.  Once the departmental consultants (senior doctors) deemed us competent we were signed off to practice independently.  After the four weeks we were released in public as qualified paramedics.  We were recalled to the training centre every 3 years to re-qualify – a scary two days of exams and practical assessments.

That education was enough to enable us to fulfil the job as a paramedic back then.  We were essentially a transport system to hospital with the ability to stabilise en-route.  Our area of specialisation was resuscitation; that was where we did basically everything that the hospital can do, and then transport to hospital.

What about the modern day UK paramedic?

The requirements on the ambulance service in general and paramedics in particular have changed a lot.

The modern idea of care is to provide ‘the right care in the right place at the right time’.  It acknowledges that the ED of the local hospital is not always the ‘right place’ to provide the ‘right care’.  To carry this out requires paramedics who respond to the call for help to be able to quickly assess where the right place is.  We needed to improve our diagnostic skills, we need to quickly assess and diagnose what the basic problem is and then establish a safe and appropriate care plan for the patient.  Sometimes this is still a trip to the ED, sometimes making them an appointment to see a doctor, sometimes passing details on to social services for review of social needs, sometimes nothing needs to be done other than offer reassurance.  To be able to do all this safely and without risk to the patient needed more education.

The current system for paramedics is university based:  a two year diploma course, much more in-depth and intensive than the old in-house training.  During the two years at university a series of placements are planned at various hospital departments and out on the road with paramedic crews.  Existing paramedics like me were offered the education on a part time basis while continuing to work full time.  I completed my diploma with a series of five modules over five years.  It was hard work but I enjoyed the learning and found it awoke a new interest and level of enthusiasm for my job.

The role of the paramedic is evolving all the time and I wouldn’t like to guess what direction the education will take in the future. It’s exciting to be part of an evolving profession.

Surviving night shifts.

I’ve just finished working a run of night shifts and survived more or less intact so I thought I would share some tips which help me to function (almost) normally while on nights.  I do prefer night shifts to days and have written about why I do here.

Sleep.

The biggest difference between working nights and normal day shifts is obviously sleep.  You’re awake and working when your body wants to shut down and sleep.  You have to convince your body to sleep during the day when it would be awake and functioning.  The main environmental factor which triggers sleep or arousal is light.   To sleep during the day you need to shut the light from your room.  I have dark blinds and lined curtains.  Even in the middle of summer (my room faces south so catches the lovely sunlight all day) it can be nice and dark.

The first night shift of a run of shifts can be challenging because you’re still in day mode.  I find a couple of hours sleep in the afternoon help to prepare but you’re still shattered by the middle of the first shift.

Noise.

Noise can interrupt a nice sleep so it is important to cut out noise where possible.  I’m lucky that it is fairly quiet where I live.  Occasionally I have to use earplugs for example when the local council decide that the only possible day they can dig holes in the pavement outside is when I’m on a set of nights.

Mood.

On a long run of shifts the lack of natural daylight can lower your mood, especially in winter when it’s dark when you go to work and dark on the way home.  Some days I wake up early and go for a short walk while it’s still light.  The exercise and exposure to the daylight always do the trick for me, especially if I throw in some affirmations and run through my list of things I’m grateful for.

Food.

Obviously your eating routine is totally thrown out of the window when on nights.  I haven’t got to the bottom of adjusting nutrition to suit night shift working yet, it does interest me however and is an area I intend to study.  I have a big meal before I start work and make a fruit smoothie to drink while I’m getting ready to go.  I take a few sandwiches and snacks to eat during the shift.  Time to eat on shift is a big problem at work.  I take a series of (healthy) snacks out on the road to eat between jobs.  It seems to work for me – I don’t fade away or pile on the pounds. I manage to resist the urge to buy junk food (most of the time, anyway).

Hydration.

It is important to keep your water levels topped up on nights as it is during the day.  There’s a certain type of headache I only ever get when I’m on nights.  It’s when I wake up mid-afternoon: a vague, sickly sort of headache which lasts for about five hours.  It seems to come when I’ve forgotten to keep sipping from my water bottle and never seems to happen when I’ve had a well hydrated night so I assume it’s a dehydration thing (not very scientific, I know, but the results corresponds very well to the data!).

After the nights are over.

That wonderful morning finally arrives when the night shifts are over.  The trick now is to return to day mode as quickly as possible.  It’s tempting to have a nice long sleep.  The trouble is that if you do have a nice long sleep you will carry on the night shift mode and won’t be able to sleep that night.  I find I have to cut short my nice long sleep and get up early.  I feel like a zombie and have a head full of fog so in the afternoon I don’t try anything too taxing, just catch up with a few jobs around the house.  Then that night I generally sleep well and wake up the next morning back to normal – well as normal as I ever am.

Professor Stephen Hawking – Paying my respects

On 14th March 2018 Professor Stephen Hawking passed away.  This date is Albert Einstein’s birthday.  The Professor was born on January 8, 1942 – the 300th anniversary of the death of Galileo – two bizarre coincidences linking him with two other giants in the scientific world.   These are some of my thoughts on the impact this man made on me.

I consider the professor to be inspirational on many levels; here are three levels which occur to me:

As a physicist.

As a young man I went to university to study physics.  Professor Hawking was one of the great minds in physics, particularly in the areas of physics which interested me most – cosmology.  He pushed back the frontier of knowledge of the extreme conditions in and very close to black holes.  Although now I am obviously in a totally different career, I still enjoy following the developments of science.  I don’t claim to have the intelligence to be able to follow the details of modern physics but Professor Hawking was one of the scientists who had a knack of being able to explain complex physical phenomena so that us ‘normal’ people can understand (well, almost understand).

 

As a man determined to live life to the full.

As a young man Professor Hawking was diagnosed with motor neuron disease, a crippling, degenerative disease and was only given a few years to live.  I can’t imagine the degree of torment and despair this must have caused him but he still managed to live a family life, to forge a brilliant career and travel the world giving lectures to educate and inspire scientists.  Even when the disease took away his ability to talk he still gave lectures using his electronic voice simulator. His travels included a ride in the zero gravity experience plane. He obviously managed to maintain a sense of humour, he appeared in an episode of ‘The Simpsons’, an episode of ‘Futurama’, an episode of ‘Star Trek – The Next Generation’ and was credited as a guest vocalist on two Pink Floyd songs.

 

As a supporter of the NHS.

Professor Hawking was a great supporter of the NHS, our healthcare system here in the UK.  He spoke out publicly in support of the system and spoke against the underfunding and lack of support from the current political regime, much to the irritation of our ruling politicians.  An absolute hero to all of us who care about or work in the NHS.

 

To end this blog I would like to send my thoughts and condolences to his family and friends and include my favourite Stephen Hawking quote:

“However difficult life may seem, there is always something you can do and succeed at. It matters that you don’t just give up.”  Professor Hawking 2016.

Professor Stephen Hawking.   1942 – 2018.

The less serious side of emergency care work

There’re a lot of serious issues in the world today, especially in the world of the emergency services so I’ve decided to take a light hearted look at some funny episodes I’ve encountered over the years.  No one was seriously harmed in any of these jobs and everyone involved saw the funny side of the event at the time so I’m not laughing at peoples misfortunes, I’m laughing with people at their own misfortunes, so that’s ok!

  1. At a Halloween party one guest had a nose bleed and another guest fainted at the sight of the blood. You guessed it, the fainter was dressed up as count Dracula.
  2. All the ambulances have fire extinguishers on them, one in the cab and one in the back where the patients are. They are fixed to the wall in a wire frame from which we can quickly remove them if needed.  This particular day, the extinguisher was stored at floor level on the side wall near one of the fold down chairs.  For some reason the safety pin had been knocked clear and a particularly heavy footed colleague accidentally kicked the trigger and discharged all the foam.  The back of the ambulance looked like an Ibiza foam party after a few minutes and he was covered from the waist down in foam.
  3. A young lady had spent ages working on her hair for a party and had used a large amount of hairspray. She was admiring the finished result and stopped to have a cigarette.  As the lighter sparked, her hair on one side of her head ignited due to the hairspray fumes. All that work, not to mention a significant amount of hair disappeared in a flash.  Luckily her skin was not burned.
  4. I was dealing with a hiker who had fallen down a steep, rocky slope. Due to the possibility of spinal injury from the fall we had immobilised him on the scoop stretcher before moving him onto the ambulance.  He was complaining of a lot of pain from his arm.  It was not possible to take his jacket off in the normal way because he was strapped to the scoop stretcher and also his arm was causing too much pain to move and bend.  The only way was to cut it off.  Sometimes people are more worried about us cutting and ruining their clothes than they are about their injuries.  This hiker had a lovely warm duvet jacket, as soon as the scissors cut into it the feathers seemed to explode out of it.  There seemed to be an impossible amount of feathers crammed into that sleeve, we were finding them in the ambulance for days after.
  5. It was ladies night in a club and a troop of male strippers were entertaining the local ladies. As part of his act one stripper picked up a lady to swing her round. Unfortunately the baby oil she had just rubbed into his arms and chest had got onto his hands to and she slipped from his grip onto the floor straining her ankle.
  6. One young man had enjoyed a night at a club with his friends. When he got home he was hungry.  Looking round his kitchen, he fancied a can of beans.  He couldn’t find the tin opener so to save time his drunken brain thought he would stab the tin open with a screw driver.  One slip later and we were called to tend to the self inflicted stab wound in his hand.
  7. A young lady had spent a boring evening with her boyfriend and his best friend. The friend had called round for a quick drink and was still there hours later while she wanted some quality alone time with her boyfriend. Finally the friend left and as the door shut she leapt into her boyfriend’s arms expecting a passionate kiss at last but unfortunately he dropped her and she sprained her ankle.  She spent the next few hours of quality time with her boyfriend in the waiting room of the local Emergency Dept.
  8. A young couple were trying things to spice up their love life. This particular night they were playing with a pair of toy handcuffs.  Unfortunately when they were finished one of the handcuff bracelets jammed on the man’s wrist and wouldn’t unlock.  The more he tried the tighter it got until the circulation was being restricted and his fingers were tingling.  I managed to break them without hurting him by using a pair of pliers and a screwdriver so he didn’t have to face the embarrassment of sitting in a waiting room at the hospital wearing a pair of toy handcuffs.
  9. A woman was in her loft organising the stuff she kept up there. The loft didn’t have floorboards so she was balancing on the rafters.  She misplaced her foot and stood on the plasterboard between the rafters.  It didn’t take her weight and she fell through to the bedroom below.  Luckily she landed well and didn’t hurt herself.  Unluckily she was disorientated and couldn’t see because of lots of plaster dust which had got everywhere and she staggered to the top of the stairs and fell down them too.  Thankfully the xrays showed that there were no broken bones, just bruising and a big job of redecorating her bedroom to look forward to.
  10. One day we were dealing with a fall and had immobilised the patient on the scoop stretcher.  My mate and I went to pick the scoop up and place it on our trolley.  As I bent and squatted to get in position for the lift, with a loud rip my trousers tore from front to back.  Despite it being a warm summer day I had to wear my jacket to cover my embarrassment until I could get back to base to change.

 

Surviving Storm Emma

That’s a very dramatic title.  Sorry.  Here in the UK we now seem to love dramatic titles and headlines.  According to the press we are currently in the grip of ‘the beast from the East’ (a weather system blowing from the East) and ‘Storm Emma’.   A few years ago we would have called it ‘a spell of winter weather’ but I suppose that wouldn’t sell as many newspapers or get as much internet traffic as ‘the beast from the East’ ravaging us.  To put it in perspective, where I live, we’ve had approx 2 inches of snow with drifts of approx 4 feet in places, blown around by a 40mph breeze.   It’s lasted 3 days so far and caused widespread travel disruption closing roads and forcing train and bus operators to cancel services.  We don’t cope well with the winter weather; I get a bit embarrassed when I think about how some countries cope with months of ‘proper’ snow and drifts without a single sensational headline.

Sadly however there have been a few deaths caused by the winter weather so here is my guide to coping and maybe even thriving.

  1. Keep warm. Very obvious one to start with.  If you have to go out, spend a few minutes preparing what to wear.  To stay warm in this weather you need to keep dry, nothing cools you down like being wet (just think how lovely it is to jump into the pool on a scorching holiday in the sun and how effectively it cools you).  A suitable layer next to skin can help to move any sweat caused by exertion away from your skin so it stays dry.  Nothing feels more uncomfortable than a cold, damp tee-shirt against your skin.  A few layers then to keep hold of layers of warm air near your body and stop your heat from convecting away into the winter’s day. On the outside, a good waterproof layer.  If possible, a modern, breathable waterproof is best, lets the aforementioned sweat get out while still keeping the rain or snow out. Top the outfit off with a hat.   It used to be thought that 40-45% of body heat is lost from the head.  Modern sport science experiments have disproved this but you still lose approx 7% so a hat will make a difference.
  2. Check the news reports for advice on what the roads you’re planning to use are like. If the police are saying not to risk them then it’s probably best not to.  They’re not being spoilsports but are trying to prevent you from being yet another car they have to get towed from a ditch or snowdrift.
  3. If you do have to drive anywhere, prepare. Assume you will be delayed, possibly for a few hours.  Take spare warm clothes, even in your car it can get very cold out there if you’re not moving.  Make sure your mobile (cell) phone is charged or that you have a charger for it in the car.  Take a snack or a drink.
  4. If you’re on regular medication, consider taking it with you then in the worst case if you are delayed by several hours you won’t miss a scheduled dose.
  5. You don’t need to panic buy. In the UK bad weather only normally disrupts things for a couple of days at most.  If snow storms are predicted (and we do normally get a couple of days notice) then just make sure you’ve enough of the basics to last (don’t forget the wine and chocolate!).
  6. Make sure your neighbours are ok, especially the elderly. It may not be as easy for them to get to the shops in foul weather.

 

The local police have found the snow helpful.  One burglar was caught when the officers followed his footprints from the crime scene to where he was hiding.  A cannabis ‘grow house’ was found when it was noticed that it was the only house with no snow on its roof at the height of the storm.  The heat required to grow the plants in the loft had melted it as it landed.

So there you have it.  As always, though, at times of adversity, human goodness tends to shine through.  There are lots of stories of people volunteering to help stranded people providing food warmth and shelter.  Farmers and 4 wheel drive owners have been helping to tow stuck cars.

Keep warm and safe.

Death – the elephant in the room

Warning: this blog may be distressing to some.  It’s not particularly graphic but I talk about death and describe a patient dying peacefully.

Death here in the UK still seems to be a bit of a taboo subject.  We don’t like to talk about it and mostly try to ignore that death will happen to all of us – as they say, it’s an ‘elephant in the room’.

It’s getting better than it was.  Twenty some years ago when the rusty siren was still shiny and well polished (when I started my training), death was regarded as the enemy.  It was to be defeated at all costs.  A patient who died was to be resuscitated and wherever possible brought back.  Things were starting to change though.  It was acknowledged that sometimes when we arrived on scene it was impossible to resuscitate.  Some patients would have needed resurrection not resuscitation.  A protocol was introduced in our area called the ‘Diagnosing the fact Of Adult Death’ (DOAD).  This set out various situations, such as prolonged down time with no bystander Cardio-pulmonary Resuscitation (CPR), or obvious, unsurvivable injuries, in which case we did not attempt to resuscitate.  Over the years, in line with evidence-based best practice this guideline has evolved and extended to include children and is now the Diagnosis of Death (DOD) guideline.

It’s now quite common in the UK for a person, especially one who is approaching the natural end of their life to decide with their doctor to establish a ‘Do not attempt CPR’ (DNACPR) document.  If the person, in consultation with their doctor and if possible family, agree that a resuscitation would not be successful due to various serious medical problems (co-morbidities) or if successful would not result in a good quality of life then a DNACPR is raised.  This tells us that if a patient with us goes into cardiac arrest we are not to attempt any resuscitation.  The DNACPR is a distinctive A4 sized single sheet of paper, printed on distinctive lilac paper to be kept in a prominent place in the patient’s home or care plan file so it is known about and easily located if needed.

In addition to the DNACPR document in the UK there are now ‘advance decision’ documents – legal documents where a person can dictate the level and limits to care they wish to receive in the event that something happens and leaves them unable to make or communicate a decision at that time.

Don’t get me wrong: we still resuscitate.  I often think that we paramedics are ‘jack of all trades, master of none’.  Most of the time we arrive at someone who is ill or injured, assess them to have an idea of what is wrong, come up with a differential diagnosis (list of possible medical problems which would cause the displayed signs and symptoms), treat the symptoms and refer to specialists for definitive assessment and treatment (often the Emergency department (ED) of the local hospital but sometimes other specialist centres).  When it comes to resuscitation though I think we are the specialists.  We keep up to date with best practice; and now when we get a confirmed, viable cardiac arrest even in these resource-scarce times control send several resources, including senior staff to carry out a full resuscitation at scene.  If someone collapses in cardiac arrest now I think they have the best chance ever of survival – provided someone witnesses the collapse, calls for immediate help and starts CPR immediately.

Because we carry out Advanced Life Support (ALS) on scene; when dealing with a medical cardiac arrest, if after 20 minutes of ALS there are no signs of response it is clear that further efforts would not be successful, we terminate the resuscitation and diagnose death.

Over the years I have attended many collapses; some we have successfully resuscitated, some we have not, some we have terminated after starting and some we have not started because of a valid DNACPR or the DOD guideline has been applied.  Last week for the first time I witnessed a patient die and was not able to attempt resuscitation.  It was very strange and unnerving.

We were called to a care home in our area to a 69 year old female.  I’ll call her Josephine in this (obviously not her real name).  She was short of breath.  My usual mate Tony was on leave, I was on with a fairly new EMT called Mark.

We arrived to find Josephine on the bed in her room.  Her daughter and care staff were present.  Josephine was obviously struggling to breath.  She was on supplemental oxygen but it was not helping.  A few quick questions to the care staff and I established that Josephine had breathing problems due to asthma and also heart failure which can manifest as difficulty in breathing.  While trying to reassure Josephine and her daughter I listened to her chest with a stethoscope and decided that a nebuliser would provide some relief.  Mark quickly set this up for me and I started to explain that we needed to take Josephine to the ED for further help.  Josephine shook her head.  Her daughter (Sam) explained that Josephine had made it clear to everyone that she had had enough of hospitals and treatments and now just wanted to spend her remaining days in her room in her care home.  Sam showed me Josephine’s DNACPR.  I explained that the DNACPR was limited to resuscitation and that while Josephine was alive I had a duty of care to her and the hospital may be able to ease her breathing and make her comfortable.  Josephine was adamant that she did not want to go.  I could tell that Josephine had mental capacity (was able to understand what was going on, understood and accepted the risks of staying home and was able to communicate this to me even though she was breathless).  I reassured Josephine and Sam that because Josephine has mental capacity I would respect her wishes and was not allowed by law to take her anywhere against her will.  Josephine seemed to relax a little and her breathing improved a little, helped a little by the nebuliser we administered.

I still had to do something though.  Josephine agreed to allow me to speak to her doctor by phone to see if her doctor had any further help to offer.  I rang the receptionist and gave an outline of the situation then had to wait for the doctor to ring back.  While we were waiting I tried to make Josephine as comfortable as possible.  I gave another nebuliser and gave a hydrocortisone injection (to lessen the squeezing of her airways caused by the asthma) and a nitrate tablet to dissolve under her tongue (to take the strain off her heart due to her heart failure –  her blood pressure was high enough to tolerate this).  Her breathing seemed to ease and Josephine relaxed and smiled at her daughter who was holding her hand.

The doctor rang me back and agreed that Josephine would be better off going to hospital.  She also agreed with me from knowing Josephine that I would never be able to persuade her to go.  She agreed with my treatment so far and agreed to call in and visit after surgery.  The doctor rang off and I explained what the doctor had said.  I once again offered Josephine a trip to hospital; she grinned and said “not a chance.”  She seemed relaxed and comfortable now.

I sat down in a corner of the room to document what had happened and been decided while Sam and Sam’s daughter who had just arrived held Josephine’s hands.  The room was very pleasant and fresh and the sun started to shine through the window.  Without any words or drama Josephine stopped breathing.  It was remarkably unremarkable, Josephine was breathing and then she wasn’t.

I gave the family a few minutes to process this then confirmed that Josephine had died.

It brought home to me how my early training has hammered home the message that death is the enemy to be fought and defeated at all times.  Yes, death is often very wrong, stealing life away – but – sometimes it is a natural end to life.   Sam thanked me for making her mum’s last hour of life comfortable and for making her death ‘beautiful’.

I’m still trying to process all this myself and wonder about my own attitude to death.

My top ten favourite moments at work

I think it’s time for another top ten list.   This is my list of my favourite work related moments.  Not in any particular order.

 

  1. When we’re trying to resuscitate someone who is in cardiac arrest (not breathing and no pulse), it’s a great feeling when we get a pulse back (Return of Spontaneous Circulation (ROSC)). Even better if the person starts to breath for themselves too although this normally happens a bit later when the person is in the resuscitation room and we’ve handed over to the hospital staff.  It’s nice to track the patient’s progress through the hospital to the point where they are discharged home and back to their families.
  2. When a job flows smoothly. There is a certain flow from the point when we are given a job to the point where we hand the patient over in the Emergency Department (ED).  Sometimes the job flows more smoothly than other times.  Things can go wrong, equipment can let us down or the patient may not agree to the recommended care path way.  Sometimes it’s not easy or possible to cannulate the patient if required (insert a small tube (cannula) in the patient’s vein by inserting a needle which is encased in a plastic tube on the outside and then removing the needle leaving the tube in place).  A range of our drugs are given through the cannula (intravenous (IV) so if I can’t cannulate then I can’t give the patient any of the IV drugs or fluids.  It’s great when everything works and flows smoothly.
  3. When pain relief starts to work. Many of our jobs are people who are in pain.  This can range from sudden pain due to an injury or illness or ongoing pain caused by a long term condition which has gradually got worse to the point the patient can’t cope and calls us for help.  We have a range of techniques and drugs (analgesics) we use to relieve pain.  For an injury, eg broken limb, using a splint to immobilise the injury helps to ease the pain.  Reassurance also helps because fear plays a part in making the perception of pain worse, particularly in children.  No one likes to see another human in pain so it’s a great feeling when the patient starts to relax as the pain eases.
  4. When an unwell, scared child relaxes and starts to smile and laugh. When children are unwell or injured they are usually scared too which makes the feelings much worse. As long as the illness or injury is not time critical, we take a while to let the child get used to us.  We involve mum, dad or any other care-giver and encourage the child to show us their favourite toy or book.  It’s a good feeling as the child starts to relax and even laugh.
  5. When we can hear back up crews approaching. When we’re on a big job and have requested back up, it’s a huge relief to hear them approaching in the distance.
  6. When someone says thank you. I know it’s our job to help and it’s what we get paid to do, but we’re human too and it’s fantastic when someone appreciates the help we’ve given them and thanks us.
  7. When we get a free coffee. Very cheeky one this but some places give us free coffees while we’re on duty. Fantastic!
  8. Seeing a student progress. I’m a mentor so I quite often have a student for a year.  In the UK paramedics study at university and have frequent placements with us on the road during their course.  I love to see the student progress over the year from being nervous and confused to become a confident, competent paramedic.
  9. Hearing the relief crew arriving at the end of the shift. If we happen to be on station towards the end of the shift (very rare but it can happen) it’s an unbelievable relief when you hear the relief staff arriving.
  10. End of the shift. Home time!!