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!!

It was on the news, it must be right, right?

I’m writing this week’s blog about a recent news article in our area.  It featured some community first responders (CFRs) speaking out to a news team.  They were expressing various concerns among which were that CFRs were spending a long time on scene waiting for the ambulance staff to arrive and another concern that CFRs were being asked by the ambulance service to ‘discharge’ patients without the need for an ambulance to attend.

The tone of the article was quite negative.  It implied that the ambulance service were being quite negligent and trying to do things ‘on the cheap’.  The general public may have their confidence knocked in the ambulance service.  Some of our excellent (and very competent) volunteer CFRs and ECFRs feel de-motivated by the article.

As always, these are my own opinions and do not necessarily represent my employing ambulance service, my union or any of my colleagues.  It is all just my own humble opinion.  I also only speak about my own area, other areas may and probably do have different procedures and guidelines.

Community First Responders are volunteers who undertake training in their own time and at their own expense.  They are then provided with a uniform, pager and some equipment.  In their spare time they log on duty with the emergency operational control centre (EOC).  Then when certain categories of jobs come in details are passed to the CFR by pager and they set off (in their own car, no emergency lights or sirens) to the address to assess and provide initial first aid until the ambulance or response car arrive and then lend a hand to the paramedic or technician.  Some CFRs have undertaken extra training to become Enhanced CFRs (eCFRs).  ECFRs are trained to the same level as Emergency Medical Technician level 1 (EMT1).  ECFRs respond in the same way as CFRs and use their extended skills to assess the patient and provide certain treatment while waiting for the ambulance or response car.  I’ve already blogged about them here.

Getting back to the article:

CFRs (and eCFRs) waiting on scene for long periods with no ambulance response.

It’s true that people are waiting long times for an ambulance response.  At the time of writing it is winter and the well known ‘winter pressures’ are putting a seasonal strain on all aspects of healthcare.  Phenomenal demand for services means that a high volume of 999 calls are coming in.  Added to this, hospitals are pretty full with very few spare beds.  This means that patients in the Emergency Departments (EDs) are waiting for beds on wards with no beds available so they have to wait on trolleys (gurneys) in the ED.  This in turn means that the EDs become full so ambulances have to wait longer to hand over our patients meaning that ambulances are tied up at EDs and not out responding to emergencies.

I know it’s difficult for the CFR/eCFRs on scene for ages but I know that the members of the public are relieved and grateful to have you there, every one generally understands the current political climate and know that you (and us) on the ‘front line’ of emergency care are not to blame.

Discharging patients.

This is an emotive point.  The word ‘discharge’ in this context means to provide a safe, appropriate plan for a patient without the need to attend the ED.  This can mean a visit to or from a doctor (General Practitioner (GP)), either the patient’s own GP or the Out of Hours GP service (OOHGP).  It may also mean a visit from a nurse, or it may mean that after assessing a patient reassuring them that they don’t need to do anything now, just wait for natural healing to occur and see their own GP in a few days if needed. The minimum level of education needed to discharge a patient is nurse, paramedic or EMT2 (the cover-all term for medical staff is clinician).   Some cases the clinician can discharge with no further referral, some cases the clinician has to consult a doctor (usually one of the OOHGPs) by phone to affect the discharge.  The emphasis with any discharge is always safety.  Advice is always given about what to look out for which may show that the patient is deteriorating and what to do in that case after the clinician has left the patient.  This is called ‘escalation advice’.

The point of the article seems to be that CFRs are being expected to discharge without the patient seeing a trained clinician.

Discharges have already for many years been safely made by phone without a clinician actually visiting the patient.

If a patient rings the OOHGP or their own GP for a consultation the patient will speak to a call taker or receptionist who will take basic details.  The patient will then speak to a clinician who will ask detailed questions about the symptoms experienced by the patient and their detailed medical history.  From this, sometimes the patient is then safely discharged with a safe, appropriate care plan without seeing the clinician.

When someone rings 999 for an ambulance the call taker asks lots of computer generated questions.  Based on the answer to these the job is categorised in terms of seriousness.  Certain of the lower category jobs are then passed on to a group of clinicians in the EOC who ring the caller back.  In the same way as the clinician at the GP service they will assess over the phone and may be able to safely discharge the patient without an ambulance or any clinician visiting the patient.

The CFR or eCFR would never be expected (or allowed) to make a discharge decision alone.  The CFRs have access by phone to clinicians in EOC who with the benefit of the clinical observations measured by the CFR (pulse rate, respiration rate, blood pressure, blood sugar level) in addition to the signs and symptoms experienced can safely make a discharge decision if appropriate before the ambulance or response car arrives.

I guess my messages from all this are:

  • Although far from ideal response times are currently being experienced, if a discharge decision is made it is by a fully educated and trained clinician to national guidelines. Safety of the patient is always foremost in a discharge decision and escalation advice is always given.
  • CFRs and eCFRs should be proud to serve their communities and I know from talking with many of my patients that they are admired for their unselfish contribution to the local community.

Collapse in the street

I’ve just noticed that most of my anecdotal blogs seem to end in tragedy.  Just so people don’t get the wrong idea about me and my paramedic skills I thought I’d include this one which has a HAPPY ENDING!

It was a Saturday afternoon, Tony and I were just over half way through our day shift.  Through the morning we had drifted further away from our normal area and were in a neighbouring town.  We were on our way to the next emergency when a category 1 emergency jumped the queue and was passed to us – a 45 year old female had collapsed on a street and was in cardiac arrest.  Luckily a bystander who saw her collapse was first aid trained and recognised cardiac arrest and started CPR immediately while other bystanders called 999.

It didn’t take long to get to the general area, a pedestrianised street of shops on the edge of the town centre.  We were lucky; the lady had collapsed conveniently near an access road so we could get the ambulance near.  As we arrived a response car arrived too, a local paramedic, Steve got out joining us.  We took a mixture of our and Steve’s equipment to the pavement where the lady, Amy, was lying on the pavement with a first aider, Carol, doing CPR.  A local shop keeper had thoughtfully brought some screens out and arranged them round Amy to give some privacy.  I asked Carol to continue with chest compressions while we prepared our equipment.  Tony connected the Bag-Valve-Mask (BVM) device to an oxygen cylinder. A BVM is a rugby ball shaped rubber reservoir connected to a face mask.  The mask can be placed over the patient’s mouth and nose, then the reservoir is squeezed and this forces a lungful of oxygen-enriched air into the patient’s lungs.  He inserted a basic airway into Amy’s mouth, a small plastic tube which prevents the tongue from blocking the airway and took over the job of breathing for Amy as carol continued chest compressions to keep the blood circulating.  Steve and I were preparing the defibrillator – we placed 2 large, sticky gel covered electrodes to Amy’s chest.  We could monitor Amy’s heart through these and, if needed, deliver electric shocks.  In the old days we had 2 manual paddles which we had to coat with gel and hold against the chest while we analysed the rhythm and delivered the shocks. The stick-on pads are much more efficient and safer to use.  Amy’s heart rhythm was not one which would benefit from an electric shock (she was in Pulseless Electrical Activity (PEA)).

At this point we decided to move Amy to the ambulance.  We used a ‘scoop’ stretcher (a long board which splits long-wise in half so can be fed under the patient from each side and clipped together with minimal movement of the patient) to pick Amy up from the floor onto our stretcher (gurney) and then onto the ambulance, all the while continuing with chest compressions and breathing for Amy.

On the ambulance Tony took over the chest compressions (Carol the first aider was exhausted by now).  I moved to the head end of the stretcher to monitor Amy’s airway.  She had a basic airway protector in but I intubated her to fully protect her airway.  This involves putting a tube (Endotracheal tube (ET)) into the top of the wind pipe (trachea). The ET has a small balloon around the outside which once in situ in the trachea this is inflated to seal the airway and prevent vomit or other secretions getting into the airway and lungs.  Once this was in place we attached a mechanical ventilator to the projecting end of the ET.  The machine now takes over the breathing for Amy. While I was intubating, Steve was finding a vein in Amy’s arm and had cannulated.  We could now give drugs directly into Amy’s blood stream.  During resuscitation we give the drug adrenaline (also known as epinephrine) every 3 to 5 minutes.  This circulates round the body and causes surface blood vessels to constrict so all the blood is concentrated to the major organs.  We also give fluid, water with salt dissolved in to the same concentration as in the body.

During this activity I thought I noticed a slight flicker of movement on Amy’s face.  This can be a normal part of CPR, we compress the chest quite vigorously and this tends to move the whole body but as I did a pulse check I was excited to feel a pulse on the side of Amy’s neck.  We stopped the chest compressions immediately and checked Amy’s baseline observations.  Now the heart had resumed its duties in driving the blood around Amy’s circulation her baseline observations were surprisingly normal.  Her heart was beating at a normal rate, her ECG (trace of her newly started heart) looked surprisingly normal too. Amy’s blood pressure was good, she was still unresponsive and not breathing for herself but things were looking good.

This was the time to get to the local hospital.  Tony gave the hospital a pre-alert call via our control room so the staff would be ready for us and have time to prepare for us.  During the short drive to hospital I sat with one hand on Amy’s neck feeling the pulse.  She still wasn’t breathing for herself but the ventilator was breathing for her.  We transferred Amy to the care of the Emergency Department staff and then began to tidy up and make a list of the equipment we needed to restock (over a well earned cup of coffee).

Over the next few weeks we were happy to hear that Amy progressed from Intensive care to a general medical ward and was finally discharged to home having made a complete neurological recovery.   The key to Amy’s survival was the immediate good quality CPR provided by Carol, the first aider.  No amount of work by us will resuscitate a person who has been down with no CPR for the 5 minutes or more that it takes us to get to the collapse.  I can’t stress enough the respect I have for first aiders and feel that everyone should learn basic CPR – it really can make the difference between life and death.

Male on the road – no sign of life.

Warning:  contains material some might find distressing.  No happy ending.

It was a cold and rainy early morning in winter.  Tony and I were looking forward to the end of our night shift.  The shift had been busy with the usual routine type of emergencies – nothing too taxing for us.  We were on our way to the last job of the shift, a category 2 emergency – an 83 year old male who had fallen while making an early morning visit to the bathroom.  With a bleep on the data pad our plans were changed.  We were passed a category 1 emergency – immediately life threatening.

It was a report of a male lying in the road outside a bar; the caller didn’t want to get too close but was unsure if the male was alive.  It was about 6am, most bars in this area had closed hours ago so it was unlikely to be a drunk sleeping it off.  We were only a few minutes away so we would know soon.  We arrived at the bar and stopped.  We looked around but could find no trace of any male lying in the road.  Two police cars arrived shortly after us and started to look around the immediate area as Tony contacted our control room (EOC) to ask for any further details about the location.  We were both thinking that this was after all a case of a drunk male who had miraculously come back to life and wandered off before we arrived.  The message came back from EOC that the man was a few hundred yards further along the road, hidden from our view by a hill.  We jumped back in the ambulance and set off.  As we got to the crest of the hill we saw our patient.  He was lying on his back in the road with just his feet on the pavement.

We didn’t know his name, I still don’t know what his name is as I write this but I’m going to call him Jack.  This is to make the account personal and to honour the human being.  In the medical reports and police statements I referred to him as ‘the patient’ or ‘the male’.  This feels horribly impersonal and makes us forget that this is a person with a life history who has family and friends who love him.  This is for Jack.

We parked near Jack, using the headlights to provide as much light as possible on this dark rainy morning.  The police had already blocked the road in front of and behind us so at least we didn’t have to look out for cars speeding past inches from us.

I grabbed the first response bag and walked to Jack.  We rarely run, that’s when you miss things and risk having an accident yourself or further hurting the patient.  As I approached I was taking in the scene, trying to get an idea of what had happened. It was hard to see in the dark but I could see a quite large amount of blood on the downhill side of Jack’s head – obviously a head injury which was bleeding profusely.  He was fully clothed against the winter weather so it was hard to assess any other injuries.  He looked about 45 years old.  I knelt by his head to quickly assess.  Jack’s mouth was open and was full of blood so his airway was totally blocked, he was obviously not breathing and I couldn’t feel a pulse in his neck.  He was in cardiac arrest (No heartbeat and not breathing).  As I was assessing him I noticed that Jack was still quite warm.  Since he was lying on the road in the rain I knew he hadn’t been down very long.

This was decision time.

We don’t automatically try to resuscitate every cardiac arrest we attend.  Some are beyond all hope of help.  Medical cardiac arrests (caused by medical emergencies such as heart attack, stroke etc) have a slightly better chance of survival.  Studies indicate that recovery rates range from approximately 36% to 3% depending on the presenting heart rhythm, assuming immediate resuscitation attempts are made at the time of collapse.  This was a Trauma cardiac arrest (caused by trauma = physical injury).  Studies show that survival rates from traumatic cardiac arrests are 6% at best.  Certain injuries are deemed to be unsurvivable and if a patient has an unsurvivable injury we don’t attempt to resuscitate. If we decide resuscitation is viable and we start, trauma resuscitation guidelines advise that the resuscitation attempts should continue as the patient is transported to a specialist trauma centre.

The decision we had to make was: did Jack have a survivable or unsurvivable injury?  We couldn’t take long over this decision – if, after a prolonged examination we decided his injuries were survivable we would have killed him by delaying resuscitation attempts.

I decided we couldn’t say his injuries were unsurvivable here in the dark and rain on the floor so I decided to start working on Jack while we moved him into the ambulance for a closer look.  A police officer was ‘volunteered’ to do chest compressions then my next priority was to clear his airway.  Tony had brought the suction unit so I could use a tube to suck the blood from his mouth.  As soon as I cleared his airway it refilled with blood.  I decided to intubate as soon as possible.  I do this by kneeling above his head and use a laryngoscope.  This has a blunt blade at right angles to a handle with a bulb on it.  By using it to lift the tongue and lower jaw gently up I can then see the vocal chords – the structure at the top of the trachea – the windpipe.  After a last attempt to suction the blood out of the way I inserted an endotracheal tube (ET) through the vocal chords and into the top part of the trachea.  The ET is about 10 inches long and the end of the ET which sits in the trachea has a balloon on the outside, I inflate this and this seals the trachea, blood in the mouth can no longer block the airway.  The other end of the ET is projecting out of Jack’s mouth and by connecting to a ventilator we can breathe for Jack.

By this time a second ambulance, an off-duty paramedic on his way to work and a senior paramedic in a response car had arrived.  Tony was organising them to get the equipment we needed to immobilise Jack and move him to the ambulance.  Under Tony’s supervision as I concentrated on protecting the airway and neck, a police officer continued chest compressions we immobilised and moved Jack into the ambulance.

In the ambulance where it was brightly lit (and warm and dry) we could fully assess Jack.  While still carrying on the resuscitation attempt, we cut all Jacks clothes off.  It was obvious that Jack’s injuries were severe; this wasn’t just a case of falling over and banging his head on the kerb.  Multiple fractures were now obvious throughout Jack’s body and his head injury was substantial.  As a team we sadly decided that continued resuscitation would be unsuccessful so we stopped.

This was a breach of our guideline.  If we decide not to attempt or to terminate resuscitation we’re not supposed to put the patient on the ambulance. Legally speaking, the site of a traumatic death is a crime scene until the police have ruled out foul play.  By moving the patient to the ambulance the ambulance becomes the crime scene.  Our managers frown on this.  In the debrief, the senior staff agreed that this was an exceptional case and I couldn’t have done anything else.  I couldn’t have said that Jack’s injuries were unsurvivable without a proper examination and I couldn’t do that in the dark on the road.  They all reluctantly agreed that they would have done the same.

I still don’t know what happened to Jack that morning.  His injuries suggested high energy impact, not just falling over.  One possibility was a hit and run RTC – the injuries weren’t typical of impact with a vehicle though.  The road where Jack died passes through a cutting in the hill with steep embankments about 60 feet high on both sides.  The most likely explanation was that he fell or jumped from the top of one of the embankment walls.

It was a sad, late and wet finish to our night shift.

Blogger recognition award


I’m thrilled and very grateful for being nominated for the Blogger Recognition Award.  I would like to thank Noel Hartem who blogs at, with views on life expressed in powerful poetry and prose.  I’m relatively new to the blogging community and it’s fantastic that a fellow blogger thinks enough of my writing to nominate me.

The suggestions for nominees are:

  1. Thank the blogger who nominated you, include a link to their blog.
  2. Give a brief description of your blog site.
  3. Share 2 or more pieces of information for new bloggers
  4. Nominate 10 other bloggers
  5. Comment on each blog telling them you have nominated them with a link back to your award post.

My blog, rustysiren, is a mixture of my experiences from 21 years working as a paramedic in a big UK city and random views on life.  My passion is mental health; that of the patients I meet and try to help and also the work-related mental health of my colleagues.

Advice for new bloggers

  1. Work on your writing to make your content readable, interesting and compelling.
  2. Blog about the things you are passionate about. Your passion and excitement will show through your writing.
  3. Enjoy your writing.
  4. Read and comment constructively on other blogs, enjoy the comments you get in return, it’s great fun!


  1. Dr Perry at Make It Ultra.
  2. Rough Bandit.
  3. Elsie LMC.
  4. Damn Girl Get Your Shit Together.
  5. Merbears World
  6. Combat Medic
  7. On the couch
  8. Love,Nourish.Enjoy
  9. Brobeck at Homeless: Life on the Streets
  10. Emmanuel Rockan.


Gravity always wins!

It’s no secret and no big surprise but all aspects of the NHS in the UK are overstretched now.  The pressure is felt as much in the Ambulance service as anywhere.  The impression given by the media is that drunk and drug related incidents are the main cause.  We do get these jobs, of course, but in my experience these are not the most time consuming of our jobs.

My experience is that most of our jobs are elderly people unwell or falling.  NHS (in the UK) stats tell us that 1 in 3 people over the age of 65 will have at least 1 fall per year, about half of these fallers will have more than 1 fall.  At the end of the 20th century and start of the 21st we are living longer than our ancestors.  This means that the age range of the population is increasing and the proportion of elderly in the population is increasing.

With age can come weakness, balance problems and reduced co-ordination – these all contribute to the increased risk of falling.  The highest risk times for falling seem to be late at night and early morning.  Many of our elderly population seem to be prescribed medication to help them sleep at night this obviously leads to drowsiness and increased risk of falling when getting out of bed to visit the bathroom.

The consequences of falls in the elderly can be severe.  A common injury is a fractured ‘neck of femur’ (#nof (the hash symbol in this case is not a hashtag, it’s medical shorthand for fracture)).  The femur is the thighbone, the longest bone in the body.  At the top of the femur there is a ball shape which projects at an angle and fits in a socket in the pelvis forming the hip joint.  The portion of bone between the main shaft of the femur and the ball joint is called the ‘neck of the femur’ and is the weakest part of the whole bone.  With increasing age the bones can become less dense and more brittle.  If a person then falls and lands on his or her hip then this easily causes a #nof.  This requires surgery to repair with all the associated risks of surgery in the elderly and then a period of immobilisation in hospital (typically 6 weeks) followed by a period of physiotherapy.  Another common problem is a head injury – many elderly people are on ‘blood thinning’ medication (anticoagulotherapy).  In this case a trip to the Emergency Department is needed for a CT scan to rule out a bleed on the brain.

What do we do when we get to a fall?

First thing, as always, is to quickly assess airway, breathing, circulation and responsiveness.  Once we’re happy that the patient is alive and breathing we make them as comfortable and warm as possible on the floor while we assess their baseline observations and examine for injuries.  If there are no injuries and the patient is medically stable the next step is to get up from the floor.  If the patient is unable to get up themselves with instruction and assistance from us we use an inflatable cushion to lift.  When deflated, the cushion is flat and can be slid under the patient’s bottom (with some shuffling, leaning, sliding and under-the breath-swearing!).  Once in position we connect a series of pipes to a compressor and inflate the cushion.  The patient can then simply stand from sitting and we can assess his/her mobility.  If all is well, we can safely leave the patient at home (after we have completed the mountain of associated paperwork).  One further service we perform is to refer the patient on to a falls prevention team.  This is a multi-disciplinary team of people who visit the patient and get involved to try and prevent further falls.  This may involve physiotherapy to improve strength and balance, it may involve a review of possible walking aids with training in how to use them and it usually involves advice on lifestyle and adapting the home to remove or minimise trip hazards.

I’m not for one second suggesting that falls are not a genuine part of our job but falls do take up a lot of ambulance time.  What’s the answer?  I don’t know if there is an answer.  We are always going to be needed when elderly and vulnerable people fall.  I believe falls prevention plays a huge part in preventing repeated falling.  It’s a pity that you have to have a fall before the falls prevention team get involved; it would be good to see the falls prevention team’s roles increased so they could get involved with everyone as a certain age is reached to prevent even the first fall.