Brand New Babies!

If there’s one type of job most ambulance people, especially male ambulance people, are apprehensive about it’s maternity jobs.  For me they’re the scariest type of job.  Part of our job is to deal with obstetric emergencies (emergencies in pregnancy), delivering babies and life support/resuscitation, and general newborn baby care.  I’m always reassured by the thought that Homo sapiens have successfully been giving birth to their off springs for about 200,000 years.  It’s only in the last 100 years or so that birth has moved into the domain of the medical profession.  Still scares me though.

Most of our maternity cases are in early stages of labour.  Birth is not imminent.  These types of jobs get called ‘maternitaxi’.  This isn’t really an appropriate case for an emergency ambulance, if we politely question why the ambulance was called, normally we are told that the potential mum has rung the Maternity Unit (MU) and “they told me to ring 999”.  When we arrive and hand the patient over, normally the midwife scolds them and says that they said to get a taxi not and ambulance!

Maternity cases differ from other emergencies in many ways; one major difference is the destination.  When we deal with most non-maternity jobs the destination will usually be the emergency department (ED) of the local hospital.  Certain conditions are taken to specialist units but generally for a given emergency in a given region the destination is determined by location and condition.  Maternity cases however the potential parents choose in advance which hospital MU they want to go to.  Obviously this has to be within reason – if a mum-to-be is hundreds of miles from home and labour starts an ambulance can’t travel hundreds of miles we have to settle for one of the local units.  The other main difference is that we can’t just turn up at a MU unannounced.  If the mum or dad hasn’t rung the MU then we have to get our dispatcher to ring and we can’t set off until the MU agrees to accept.  It can and sometimes does happen that a particular MU is full, in which case we are told to go elsewhere.  This is stressful for the prospective parents because they will have had lots of visits to the MU they chose during the pregnancy and to be told at the big moment that they have to go to an unfamiliar unit must be scary.  It’s scary for us too because it normally means longer before we can hand over to the midwife!

When we arrive and birth is imminent we don’t transport, we deliver the baby at home.  One of the first tasks is to request a community midwife to come to the address.  If he or she arrives before the baby then that is fantastic, midwifes are the experts in assisting birth.  If not it’s down to us.  The area where I work is covered by several MU’s.  One is a specialist MU where it is recommended all high risk pregnancies in the area book into.  Ironically, that one MU does not send midwifes into the community so the higher risk home births are left to us.  Another benefit of a midwife attending is that if all has gone normally and mum and baby are well we don’t need to transport anywhere and the new family can stay at home.  If we deliver with no midwife present then mum and baby have to go to the MU.  We then have 2 patients: mum and baby (possibly 3 if dad has fainted during the birth!).

The biggest risk to a new born is the cold.  A baby comes into the world naked and very wet.  They have very little body fat at that stage so lose heat quickly.  A priority once we know the baby is alive and breathing is to dry baby off and get them in skin-to-skin contact with mum to warm up, then wrap both up and make sure the room is warm.  A hat is an excellent idea for baby.  My regular mate Tony is a big fan of baby hats and it has become a bit of a catch phrase for him once baby is dried off: “get a hat on that baby!”

I have assisted with many births over the years, some stick in my mind:

One dad tried to drive his wife to the MU but had just left it a bit too late (or baby was impatient) and mum started to deliver in the car.  Luckily we were driving past and he was able to flag us down.  I opened the passenger door of the car to find mum with one foot on the dash board and baby’s head just visible.  I assisted the birth in the car foot well then quickly got mum and baby into the ambulance.  I asked if mum and dad had a name for their new daughter and dad joked that he would call her Corsa after the car.  I asked if he was glad he didn’t drive a Skoda…It seemed funny at the time.

Another time we were on the way to an imminent birth and we were told that the baby was breech.  The normal position for a baby about to be born is head down in the uterus so the baby comes out head first.  Breech means the baby is bottom first.  This is a complication because the head may get stuck after the body has been born.  This is a very scary situation.  As we arrived the response car was already there.  To our great relief Stella, on the car was assisting the delivery and thankfully baby came out with no complications.  Stella said that when she got there baby’s foot was visible and that was all.  She had a very anxious wait for the next contraction when mum managed to push the rest of the baby to the world.  Since no midwifes had been available to attend we had to transport mum, dad and baby to the MU.

One final birth which sticks in my mind is a 17 year old girl who lives with her parents.  She was 36 weeks pregnant and hadn’t yet figured out how to break it to her parents – she had spent the last few months wearing baggy clothes.  One Sunday morning she thought she needed the loo and baby decided to make his appearance.  Mum and baby were fine the new grandparents were shell-shocked, they had no idea when they went to bed the night before that they would be grandparents in the morning.

Typical day at the office

This is a timeline of a typical dayshift I worked last week.  It developed into a longer blog than normal for me.

06:40  

I arrived at work.  My mate, Tony arrived pretty much at the same time.  The station we are based at is in a pretty rough area.  We are allowed to put our cars in the garage as there is a high risk of them being vandalised while we are out and about on emergencies if left out on the street.  We walked into the mess room and I made straight for the kitchen to put my food in the fridge and more importantly make coffee!  The night shift had already arrived back on station and were pleased to see us.  They handed over the radios and Pat, the paramedic I was taking over from gave me the key to the safe in which the controlled drugs are stored.  We chatted about their night shift and they started to get their belongings together to get home to bed and a well earned sleep.  Tony and I drank our coffee while we contemplated the 12 hours ahead of us.

07:00

Time to sign on.  We carried our personal equipment onto the ambulance.  We take it in turns to drive – Tony and I usually swap half way through the shift.  This morning Tony was driving first.  I got into my side of the ambulance and put our staff numbers in the data pad in the cab.  When I pressed ‘send’ this told our dispatcher who we were and that we had signed on for the shift.   Our dispatcher called us up on the radio to say good morning and check we had all our equipment and were ready to go.  While I had a brief chat Tony had started the engine, put all the lights on and was walking around the vehicle making sure that they were all working and that the tyres all looked ok.  In an ideal world we would be given time to check equipment in the back of the ambulance, restock any consumable equipment we were running low on and check and sign for the drugs and the controlled drugs.  However….

07:04

The first job of the day was passed.  An 86 year old lady had fallen in her bedroom; her elderly husband had made the call because she was unable to get herself up.  It was fairly local so we were there in minutes.  I got the First Response Bag from the side door of the ambulance.  This is a (heavy!) rucksack which has all the equipment we need to assess and start treating just about any emergency.  Mr J was waiting at the door for us and he pointed up the stairs.  “She’s up there lads, don’t think she’s hurt, but I can’t lift her.”  We found Mrs J lying on the floor next to her bed; Mr J had covered her with the quilt to keep her warm while she was on the floor.  After checking her, there was no sign of injury and from her baseline observations no sign of illness.  She said that she had not fainted or felt unwell, just lost her balance while getting up from bed. We helped her up and she was able to walk down the stairs as normal.  There was no need to take Mrs J to hospital or arrange a doctor’s appointment.  I rang her son to let him know what had happened and then, with Mrs J’s permission I passed her details onto the local falls team, a multi-disciplinary team who would visit Mr and Mrs J with a view to giving advice to prevent further falls.

09:30   I cleared the job, making us available again for the next emergency.

09:30

We were passed details of a 13 year old boy who was unwell with stomach pains.  We arrived and were shown into the front room where Toby was curled up on the sofa hugging a bowl.  He had vomited twice while waiting for us.  From the history and his presentation the most likely diagnosis was appendicitis.  We needed to take him the hospital for assessment and possible operation.  Appendicitis is difficult to diagnose with absolute certainty.  Toby would be seen by the Emergency Department (ED) doctor and referred on to a surgical specialist.  Even the surgeon would not know for certain, they operate if the “index of suspicion” is high that it is appendicitis.  We dropped Toby and his mum off at the ED and took the chance to make a cheeky coffee to take out to the ambulance while we checked and signed the drugs check sheet.

10:30   I cleared the job.

10:30

The next job was passed, a 93 year old gent who had fallen in the night and his carer called us because he “wasn’t himself”.  We arrived to find Albert sitting in his chair.  His morning carer had visited and was about to leave as we arrived.  He was annoyed that his carer had called us, he didn’t like fuss.  There was no sign of injury from his fall and he was able to walk with no problem since his fall, which he said was just down to being half asleep when he got up in the night to go to the bathroom.  His baseline observations were all normal.  There was no need to go to the ED.  Once we told him this he brightened up and started to talk.  He was feeling low because he didn’t want to leave the house he had lived in for 50 years and was scared that we would take him away and that would be it.  I reassured him that we were all there to help him and to keep him well so he could carry on living in his own house.  He agreed that I could phone his grandson who he was close to and Tony made him a cup of tea while I did this.  His grandson agreed to call round with fish and chips after he had finished at work.  I suggested that Albert made an appointment with his GP (GP = General Practitioner: the doctor who looks after us in the community and co-ordinates our health care) for a general check up and review of his medication, which they agreed to do.  I also passed his details to the falls team – we were keeping them busy this morning!

11:58   I cleared the job.

11:58   We were told to Return to Base (RTB) for meal.

We set off back to station but two minutes later…

12:00

We were passed another job (dinner would just have to wait!).  This was in the next town, a 27 year old female who was 30 weeks pregnant and was passing blood with abdominal pain.  We arrived and the family met us at the door.  They had phoned the local maternity unit (MU) and they had said to come in.  We helped Safira onto the ambulance and her mum then after quickly assessing her baseline observations set off to the MU.  They were obviously subdued on the journey in and didn’t want to chat so after getting the essential details I needed I let them have peace.  We cleared at the MU and this time we would have to be allowed back for a break because we had been out more than 6 hours.  Sometimes ‘Health and Safety’ works in our favor.

13:20   RTB for meal.

13:35   Arrived on station and demolished our packed lunches.  Sometimes I pick up a take away but generally prefer to bring a packed meal.  Meal break is 30 minutes long and when we have been out longer than 6 hours cannot be disturbed by control.

14:05

Right on cue, the next job was passed to us.  It was my turn to drive.  We were given a 55 year old man who was in severe abdominal pain. We walked into his flat to meet Joe.  Joe admitted he was alcohol dependant (we guessed by the empty cider bottles next to the sofa).  He suffered with chronic pancreatitis as a result, and the pain had flared up this morning.  This is a long term condition where the pancreas is damaged, in Joe’s case by many years of daily drinking cider.  Joe had taken his usual amount of cider this morning (it can be dangerous for an alcohol dependant to suddenly stop drinking) but the pain was not subsiding.  We helped him onto the ambulance, checked his observations and I cannulated him and gave some morphine.  This dulled his pain and we took him to the local ED.  We raided the ED staffroom for a cheeky coffee and a few biscuits.

15:20   Tony cleared the job.

1520

The next job was waiting for us, the jobs were stacking up in control now and this had waited 50 minutes before an ambulance was available to allocate.  It was a 25 year old male who had cerebral palsy, development problems and epilepsy.  He lived in an adapted house with 24 hour care support to enable him to live as independently as possible.   Jamey had had a seizure.  The care staff were concerned that the seizure had been triggered because Jamie had an underlying chest infection and had contacted Jamie’s GP to arrange a check up.  The GP had insisted an ambulance was needed.  We checked Jamie’s observations.  We worked slowly and got the carer to help keep Jamie calm as we explained each test as we did it.  Jamie had fully recovered from his seizure by now and was back to his normal self.  There was no need to take Jamie from his secure, familiar house to a noisy, busy ED, so Tony convinced the GP service that Jamie was safe to stay home and wait for a doctor to start treatment for a chest infection.  (This sounds straightforward but actually is frustratingly time consuming: we make a phone call to one of the GP services we use and give the basic details to a call taker.  We then wait for A GP to ring us back to discuss the case.  This can be up to an hour later.  Then, during the daytime office hours the GP will often ring the patient’s own GP (we’re not supposed to do this directly ourselves – don’t ask!)  Then our GP will ring us back with a decision).

17:10   We cleared the job.  We were over due our second rest break of the shift, 20 minutes this time, but control asked if we would take a look at a child involved in an RTC they had no ambulances available to cover.

17:10

We were passed the job, a 14 year old girl who had been struck by a car.  The girl’s friends had made the call and were hysterical so our call taker had no idea of any injuries.  We arrived at the scene and were relieved to see everyone was on their feet – no one was lying on the road – a good start to the job!  Chelsea had been checking Facebook on her phone and had stepped out into the road. A car had managed to almost stop in time but had connected at low speed with Chelsea’s right leg, knocking her to the ground.  She had managed to avoid banging her head and jumped up immediately.  She was more upset that she had dropped her phone and the screen was smashed.   We got her onto the ambulance and checked her over.  We were happy from the mechanism and from the examination that there was no spinal injury.  She had some bruising to her right thigh and bruising and a cut to her left elbow where it had hit the road.  As we were checking Chelsea we heard raised, worried voices approaching – mum was here. Chelsea’s friends had rung her mum as well as phoning for the ambulance.  With a loud hammering on the ambulance door mum arrived.  I opened the door to let her in and calm her down as Tony was getting some details from Chelsea.  When mum saw that Chelsea was basically ok she burst into tears of relief then started shouting at her and threatened to kill her for the worry she had caused.  I asked her to wait until after 7 o’clock before she killed her because that was when we went off duty.  That lightened the mood.  We took Chelsea and her mum to the ED to get her elbow x-rayed and the cut closed.

18:35   We cleared the job and were RTB’d for our belated rest break.  At least it meant we would finish on time.

18:45   We arrived back on station, for the second time since we left at 07:04 this morning.  We took our gear off and I grabbed a mop to give the floor a clean as Tony got a few things from stores that needed restocking.

The night crew arrived and we handed the vehicle, radios and controlled drugs keys over to them.

1900    Time to go home.  Quite rare to finish on time, normally we are still on a job when finish time comes around and we obviously have to finish the job before we can go home.

Time now to relax until 07:00 tomorrow when we get to do it all again.

When a summer swim turned to tragedy.

Today this is a guest author spot.  It is written by my long term, long suffering workmate Tony and describes an incident he dealt with one day while not working with me.  I leave him alone for one day and see the trouble he gets into… Over to you Tony…

Thanks.  It was a sunny day.  I was working with Rachel, an experienced paramedic on an overtime shift.  Overtime always seems like a good idea when you book it, never seems quite so good when you actually come to start the shift, especially on a sunny day.  The day started pretty uneventfully – A steady stream of routine jobs, nothing too taxing.  Everyone was enjoying the sunny Saturday afternoon, the parks and pub beer gardens were all full of happy people.

We were driving back to base after a job when we were passed the next job.  It was a possible drowning at one of the local reservoirs.  We live about 50 miles from the nearest coast and on hot, sunny days we often see groups of children and teenagers climbing over the gates and fences into the reservoirs and dive and swim around.  The water authorities issue warnings every year about the dangers of swimming in reservoirs yet every year people ignore them and carry on swimming.  The problem with any body of water in the UK is that it tends to be cold.  Even on a run of hot weather it rarely warms the water below the surface layer; experts say the water below the surface doesn’t rise above a breathtaking 10˚C.  Reservoirs have the additional problem that there can be unexpected strong currents due to underwater valves and suction pumps.

We arrived at the reservoir to a crowd of bystanders all frantically waving us forward.  We had to climb over a fence to get to the edge of the water.  Two teenage lads were treading water a distance out from the edge.  They were shouting for help saying that they had hold of their mate but couldn’t get him out of the water.  They had been jumping from the edge of a building into the water on the opposite side of the reservoir all afternoon with no problems but on the last occasion their mate just never surfaced again – maybe he had banged his head on the paved floor and become unconscious, maybe the cold had made his muscles cramp, maybe the diving reflex kicked in – a reflex which all mammals have where the body responds to sudden immersion of the face in cold water by slowing the heart rate and diverting blood flow from the outer parts of the body, possibly leading to a faint.  Whatever the reason was, he never surfaced again.  Two of them tried to find him and drag him out while the rest called for help.

I shouted to the lads and asked if they could drag him to us.  They replied that they were struggling and couldn’t keep hold of him much longer.  The lad on the left was starting to have problems keeping his head above the water.

With some trepidation I took off my heavy work boots, emptied my pockets and waded out into the water.  It was cold! The deeper I waded the colder it got. The stone floor of the reservoir sloped steeply and the water quickly became deeper and colder.  The lads were still some distance out so I had to swim a short distance.  The lads by now had to let go of their friend to stop themselves from going under, one of them swam himself to the shore and I helped the lad who was struggling.  By now an ambulance response car and the police had arrived.  Stuart on the response car was taking his boots and tunic top off and one of the police officers was taking off his boots and body armour.  Rachel dished out blankets to the two friends and was preparing the resuscitation equipment on the shore.  After a quick conference we decided that since we knew pretty much where the lad had last been seen we would swim back in and have a look.  The fire service had mobilised the specialist water rescue unit but that would be ages before it arrived.

Back into the cold water we went.  The second time was no better; it still took my breath away.  We swam to where the lads had had to let go of their friend and looked around.  The police officer spotted him under water and we dived and managed to get a hold. We made our way slowly to the shore, Stuart joined us and we managed to get him back to the shore where we quickly dried off as Rachel started to dry him off and assess him.  He was in cardiac arrest: no pulse and not breathing.  We started to resuscitate and as we did his heart started to beat again.  He still wasn’t breathing for himself and was completely unresponsive.  We headed off to the local hospital after pre-alerting them that we were on our way, me driving (still damp and shivering) and Rachel in the back still ventilating the patient (using a machine to mechanically push air into his lungs and then allow the lungs to breathe out relying on the ribs and chest wall muscles to relax and force the air out).

He was kept alive for a few days on Intensive care but sadly was only alive because of the drugs and machines, the decision was made to turn off the machines and allow him to die.  I like to think that at least his family had time to see him before the machine was turned off and hope they got some slight comfort from that to help them through the grief.

That’s it really, all I’ve got to say.

Thanks for that Tony.  Just one point I’d like to add:  Tony and Stuart got a bollocking from the service for the risk to their lives they took that day, apparently there are rules somewhere which forbid us from doing stuff like that. However, they and the police officer got a very well deserved commendation from the Royal Humane Society for their bravery that day!

Halloween (true) anecdote

This is a true anecdote and seems appropriate for Halloween time.  Here goes…

One morning Tony and I had signed on for our 0700-1900 shift and we were given a job straight away.  It was a reported elderly male who had collapsed and was unresponsive to his family.  A suspected cardiac arrest.  The family had declined to attempt CPR.  On the way to the job, we didn’t speak much – neither of us are morning people.  I was mentally preparing what equipment to take in – all the gear we would need to attempt resuscitation.  I would grab the first response bag and drugs bag and go straight in, Tony following shortly behind me after gathering the monitor/defibrillator, suction gear and advanced airway bag.

We arrived outside the address, a terraced house.  The front door was open so I went straight in.  I walked through the front room into the kitchen dining room where several family members were gathered: an elderly gent was sitting next to a low table looking at his cup of tea and toasted tea cake, an elderly female was standing, in tears with a middle aged man holding her.  As I walked in, the lady pointed to the stairs in the corner and sobbed “He’s up there…”  As I walked across the room to the stairs I asked what had happened.  The Lady said her husband had collapsed on the way to the bathroom and she had been unable to wake him.  She called her son who came straight round and then rang the ambulance.  By now the gentleman had been down about 30 minutes.  I always feel that on jobs like this I must seem very abrupt and almost rude, but at this point of the job we quickly need some basic information as we are assessing the patient to make the big decision whether to attempt resuscitation or not.  I walked quickly up the stairs, Tony behind me with the rest of the resuscitation gear and found the gentleman collapsed on the hallway.  After assessing him we decided that it would be pointless to attempt to resuscitate – we would have had no chance of success and would have only prolonged the pain of false hope for the family.  As Tony started to pack the equipment away, I went back down the stairs to break the news to the 3 family members in the kitchen.  I was quite struck by the resemblance the patient had to the elderly gent sat down by the table, I presumed they must be brothers, maybe even twins.

I walked into the dining room and now there were only 2 people there, the patient’s wife and middle aged man who was his son.  The elderly ‘twin’ was not there.  I broke the news as gently as I could that the patient had died and we would not be able to resuscitate.  I gave his wife and son chance to comfort each other as the terrible news sank in.  As I got the paperwork ready to get some details, I wondered where the patient’s twin had gone, I assumed he must live very near; I made a mental note that we would have to make sure he was also offered support along with the family before we left.  I started to get the gentleman’s details from his wife and son and generally chatted about his life as I was explaining to them what would be happening over the next few hours and advising of the various means of support available to them.  As part of our conversation I asked about the gentleman’s brother and if he had any other brothers or sisters.  His wife looked puzzled and said that he had no brothers, sisters or any other family than her and their son.  She saw me looking at the small table with a cup of tea and toasted tea cake on a small plate and started sobbing again – that was the table he always sat at for his breakfast, she had prepared it and put it there just before he collapsed – he never got chance to have it.

Later in the ambulance talking to Tony, I decided to risk his derision and told him what I had seen; normally very skeptical of anything supernatural he said that he had goose bumps because he had seen him too.

Heroin Overdose.

One autumn afternoon, Tony and I had just cleared at a local hospital and were hoping to be RTB’d (Returned to Base) for meal.  Instead, with its usual irritating bleep, the data terminal announced another job for us.  It was a few streets away and was a reported heroin overdose, possibly more than one patient; the caller was too agitated and panicking for our call taker to clearly get all the details, but possibly the patient was not breathing.  This is the thing with heroin, as with all opiates such as morphine, as well as being excellent pain relievers they act on the cardiac and respiratory systems to reduce the respiratory effort, ultimately causing respiratory arrest which if left untreated rapidly leads to cardiac arrest – death.

We were on the street within minutes. Unfortunately we weren’t 100% sure which house number we were going to.  The caller had been hysterical and shouting making it hard for our call taker to understand clearly what he was saying.  Our call taker said to try number 51, that’s what it sounded like.  The caller had ended the call and wasn’t answering when our call taker tried to ring back.  We knocked at number 51 – no reply. By now we were joined by Stuart, a paramedic on the response car.  We waited for control to listen to the tape recording of the call to have another attempt at interpreting the address (all calls to the service are recorded and it has often been proved useful to get vital information on a second or third listen).

As we waited, a man further down the street popped out of the door and started waving and shouting frantically.  It was number 31.  We quickly moved the vehicles and Tony and I grabbed the equipment we needed for resuscitation.  Stuart followed us in.

As always seems to be the case when you need to act quickly, the house was cramped and the room we needed was hidden by the open front door so we had to enter one at a time and close the front door behind us to get in the bedroom before the next one could open the front door get in.

I was in now. Instantly I had a flash back to training school where as part of the training for resuscitation we set up scenarios for each other and as we got the hang of the resuscitation procedure we would make the scenarios more ‘interesting’ with multiple casualties and confined spaces.

One patient, a lad in his mid twenties was asleep on a single bed near a window.  He was breathing but only occasionally and his lips were blue.  A male aged approximately 50 was on the floor next to the bed and was in cardiac arrest.  The man who had called us down the street was doing chest compressions on him.  A third patient was in the doorway, also in cardiac arrest.  There were needles and syringes scattered over the floor.

Stuart updated control and requested two more ambulances as I managed to shake the patient who was breathing occasionally and wake him up enough to breathe normally.  Then I took over the resuscitation of the 50 year old, with assistance from the man doing chest compressions.  Tony and Stuart started to work on the third patient.  I also had to keep an eye on the sleepy lad, make sure he didn’t fall back asleep unnoticed and stop breathing.  I could reach him with my outstretched leg as I was resuscitating my patient so every so often I had to kick him to wake him up. All the while we were working we had to be very careful not to injure ourselves on any of the discarded needles scattered around the room. Luckily the service wasn’t too busy that afternoon and the backup crews arrived quickly.

The first crew took over the resuscitation of the patient in the doorway and moved him out of the door.  The next crew took the sleepy patient so then Tony and I could concentrate on my 50 year old patient.

Despite the initial chaos, the job flowed smoothly.  We had all three patients out of the house and in hospital within about 20 minutes from first arriving on scene.  The sleepy patient survived and was discharged from hospital that afternoon.  Sadly the two cardiac arrest patients died.  What made the job more poignant was that the 50 year old patient was not a regular heroin user – today on a whim he’d decided to try it for the first time because his friend was a user – first and last time.  The man who had tried to help with the resuscitation had supplied the sample for the three of them.  Because our patient had never used before, his ‘friend’ the supplier had actually injected it for him.  The last I heard he was arrested and being tried for manslaughter.

After this we did eventually get RTB’d for meal break – a somber and reflective meal break.

Suicide on the canal tow path

SPOILER ALERT:  Some readers may find the content of this post distressing.

 

It was early one spring morning.  Tony and I had been working the night shift, starting at 7pm the previous night.  It was 5 o’clock in the morning and we were looking forward to the end of the shift.  It was starting to become daylight and there was a mist: the sort of morning that usually precedes a pleasant sunny day.  Not that I was planning to see much of the day, I was planning on a nice long sleep today.

We had just finished our break on station and were wondering what our last job of the shift would be.  The phone in the mess room rang right on cue (this was the old days where control rang the mess room and a dispatcher spoke to us.  Now it’s much more impersonal/’efficient’ with a bleeping of our airwaves handsets).  The dispatcher said that she had a report of someone who had hanged himself from a tree on a remote path by the side of a canal.  The call may be a hoax, the caller said he was a cyclist who had run into the hanging body and then ended the call.  When the call taker tried to ring back for more information the number was unavailable. “Could you go and check it out please?”

We set off, Tony driving and me studying the map book trying to work out the most likely bit of the path to check and the best access point for us.  I decided on a car park where a road crossed the canal and the path was accessible.  The roads were still fairly quiet and we were there in good time.  As we pulled up there was a man sitting on a wall smoking a cigarette, his bike propped next to him.  He jumped from the wall and started talking as soon as I opened the ambulance door.

“He’s about half a mile up there. Just hanging from a tree.  I didn’t see him, had my head down.  I bumped into him, nearly fell into canal. It’s horrible.”

He was obviously distressed and I tried my best to be reassuring as I was getting equipment from the back with Tony to deal with a possible resuscitation.  I asked why he had not answered when control rang him back; I said it might have helped him by talking to our call taker as we were on our way.  He said he didn’t have a phone and had to flag down a car with a phone (hard to remember the days when we didn’t all have our own mobile phone).  The car driver had then driven off once the call had been made.

Tony and I gathered the three bags, cardiac monitor and suction equipment we would need if we were going to start resuscitation.  If it came to that, we would then have to figure out how to get the patient back to the ambulance – the tow path we could see was bumpy and narrow – probably too narrow for the stretcher.  However, one thing at a time.  We set off along the tow path.  The mist was quite thick here in the valley by the canal and we couldn’t see very far ahead.  The gear was becoming quite difficult to carry now, along the bumpy path and both Tony and my patience were wearing thin, made worse because we didn’t know how far we had to walk.

It seemed very quiet walking in the early morning mist; it would have been a pleasant walk if it wasn’t for what was waiting for us.  Eventually, slowly out of the mist a figure hanging from a tree materialised as we approached.  It was the most haunting and sad sight I’ve ever seen, still can clearly see it in my mind after all this time.  We found a male, in his forties or fifties hanging by a rope from a branch of a tree.  It was obvious on examination that we could do nothing for him – he was beyond resuscitation.  Once we had made that decision our priority is to shield the patient from public view as much as practical to preserve his dignity and to preserve the scene as much as possible.  Until proven otherwise we assume that this is a crime scene and it is important that crime scene investigators can gather all the available evidence with as little contamination by us as possible. We updated control and confirmed the patient was dead and we needed the police to attend as soon as possible.  People were walking past occasionally, we did our best to reassure and move them along, we couldn’t do much to shield the patient from view he was right next to the path.  About five went past before the police managed to seal that section of footpath.  Eventually a police officer arrived and we updated him as he quietly took in the grim view.

A small patch of grass had been trampled flat near the foot of the tree and a collection of cigarette ends was scattered around along with a few empty beer cans.  I couldn’t help wondering if the man had sat there smoking and drinking as he contemplated his life.  In my vivid imagination I could picture him there.  My heart went out to how dejected and desperate he must have felt.  Did he come there with the rope intending to end his life or was he just trying to walk off his depression and the rope was already there?  An innocent children’s swing which he had decided to use to end his life on a desperate impulse?

When the officer had spoken on the radio with his sergeant we were released from scene after giving him our details.  In cases like this crime scene officers would need to see the scene before the patient was moved to ensure there were no signs of foul play; the ambulance service would not be needed to move the patient, the local undertakers would do the job when the police had finished investigating.

I never heard any more about our patient, never got to find out his circumstances.  As I write this it is Mental Health Day.  I wonder if our patient was getting any support or help with his mental health? How long had things been building up for him? Had he tried to reach out and talk? Had he asked for help? Was there anyone in his life he could talk to?

I sincerely hope that eventually the stigma attached to mental health will be lifted and patients like this one will get help and support to help prevent such a lonely, desperate end to a life.

Child RTC – unknown if breathing

(SPOILER ALERT: To avoid undue distress this anecdote ends happily)

 

One Saturday afternoon Tony and I were passed details of a job: it was a reported child RTC (Road Traffic Collision – in other words the child had been hit by a vehicle).  Due to the panic of the caller and language differences, our call taker was unable to establish if the child was breathing, responding or conscious.  All we had was the street name and possible age, 7.  The street was not far away and we were there in minutes.  On the way we were both apprehensive and anxious.  There’s something about an unwell or injured child that that I dread. I think that every emergency worker feels the same – it’s just so heartbreaking when a child is harmed or killed and even after 20 years I feel very scared when a child’s well being and even life is in my hands.

I turned the ambulance onto the street, blue lights still flashing, and the sense of dread increased.  A large crowd of people were standing in the street and on the pavement.  As soon as we arrived members of the crowd started waving and shouting at us.  At this point we couldn’t see the child through the crowd.  We got out of the cab and the shouting got more frenzied as people tried to rush us.  Tony got the response bag (a large rucksack which contains most of the equipment needed to start treating almost every conceivable emergency) out of the side door and we started to walk toward the area of the crowd that we were being jostled towards.  People sometimes think that ambulance staff are too casual and slow when approaching an emergency, they expect us to run.  During training it is emphasized that you should never run – that’s when mistakes are made and injuries happen.  We are trained to take a calm, measured approach and observe as much of the scene as we approach to evaluate and minimise any dangers to us, the patient and any bystanders.

We pushed through the crowd and finally got to the young boy, Bilal, who was lying on the street on his side with his mum cradling his head and sobbing and praying.  A multi-person-vehicle (MPV) was parked a short distance away with a large, obvious dent in the front where it had collided with Bilal.  We had to gently get Bilal’s mum to let go of him so we could roll him onto his back so we could protect his neck and assess his breathing and circulation.  Tony gently held Bilal’s head in neutral alignment so his spine was in its natural position and to our relief we saw that he was breathing and had a pulse, both were in the normal range for his age and there was no obvious difficulty with breathing.  His blood pressure was normal for his age. A man came forward and introduced himself as Bilal’s uncle, Ash, who offered to interpret for us as Bilal’s parents spoke very little English.  Tony knelt on the floor holding Bilal’s head in neutral alignment, also protecting his airway and explained to Bilal’s parents, via Ash, what we were doing and what we needed to do.  I tried to clear some space around us by shepherding some of the crowd away onto the opposite pavement.  I went to the ambulance to get the equipment we needed: a rigid collar to help immobilise Bilal’s neck, scoop stretcher plus padding to fully immobilise and various straps and a blanket.  As soon as I started back to Tony and Bilal the crowd had resumed their position in a tight circle around them.  I forced my way in with the equipment and Tony and I began the delicate task of immobilising Bilal so we could safely move him from the floor to the ambulance and then on to the Emergency Department.

Bilal had a large swelling above his right eye from his collision with the MPV and a swelling to the back of his head which had a small laceration on it: as with all scalp wounds this had bled profusely.  His level of consciousness was reduced from normal and was constantly changing.  He would be restless and agitated crying in pain then lapse into a quiet phase then return to the restless phase. We tried to apply the rigid collar but he became very agitated, fighting us off.  We made the decision to compromise and leave the collar off.  Although this was reducing the immobilisation of his spine this was one of those cases where it’s better to leave the collar off and keep the patient calm than try to keep the collar on and have the patient agitated and restless – probably doing more damage to a potentially damaged spinal cord.  We managed to get Bilal on the scoop and place the padded head blocks and body straps on without disturbing him too much, and moved to the ambulance.

In the ambulance we settled Bilal’s mum and uncle Ash and closed the doors so we could work in relative quiet.  We rechecked all Bilal’s vital signs and checked him thoroughly from head to toe.  His main injuries were the swelling above his eye and the laceration to the back of his head.  There were several other superficial cuts and abrasions on his elbows and his back.   His pupils were equal size and both reacted when a light was shone into them.  If one or both pupils became dilated and stopped responding to light that would be a sign that there was internal swelling in the brain.

Before we left the scene we had a quick word with the driver of the MPV and some of the witnesses, they all said that he had been driving along the street at about 25 mph when Bilal had run out in front of him giving him no chance to stop.  Bilal had been knocked to the floor and had been completely unresponsive for a few minutes before recovering to the agitated state he was in now.

We set off to the ED of the local hospital with no further delay (this was before we had specialist trauma centres).  As we set off we asked the control centre to pre alert the hospital so they were waiting for us as we arrived.

The rest of the shift carried on as normal but both Tony and I kept dwelling on the job, analysing everything we did and wondering if we should have done things differently, if there was a better way to have handled the job.  As always, I had a vague sense of guilt that I had not done enough for Bilal, although I couldn’t put my finger on anything specific.

A few days later we checked and were relieved to hear that Bilal had made a full recovery and was discharged home.  A happy ending this time, hopefully in future he’ll be more careful on the roads!

Putting his foot in it.

One day we were called to a job in a local factory.  The factory produced, among other things, corrugated steel sheeting for roofing and other uses.  One particular machine corrugated the steel sheets.  A plain sheet of steel was fed into a slot on top of and the machine spat it out corrugated.  Apparently the machine was prone to jamming and required frequent maintenance.  This afternoon the machine had jammed and due to the pressure to get the current order out of the door, the operator had tried to help by climbing onto the machine and giving the stuck sheet a kick.  It worked and the sheet flowed into the machine to be corrugated.  Unfortunately the rollers also grabbed the lad’s boot and dragged his foot in too.

When we arrived the fire service had already arrived, the factory supervisor had rung them first since the lad, Rob, was trapped in the machine.  I climbed up a set of step ladders and joined Rob and two fire fighters on the top of the machine.  The fire fighters had dismantled part of the machine and just freed Rob’s foot.  He was fully alert and while his foot was trapped had not really been in much pain, just his left leg felt numb. Now the leg was free the pain started. I started him off with some pain relieving gas, entonox.  There was no sign of active bleeding so we carefully passed him down from the top of the machine to my mate Tony and a group of firemen at the base of the machine and they placed him on the ambulance stretcher Tony had prepared.  Once on the ambulance we could have a closer look.

The skin on Rob’s foot had been stripped from above the ankle and was all bunched up around his toes.  A single, thin and very stretched strand of skin joined this skin to the skin above the injury.  The tendons and bones of Rob’s foot were exposed and it reminded me of one of the model feet you see in anatomy class (and also in art schools life art classes!) to show the students the underlying structure of the foot. The term for this injury is ‘degloved’ and applies to hand and feet injuries where the skin is fully or partially removed as in taking off a glove.  The term applies to feet as well as hands, there’s no such term as far as I know as ‘desocked’.

The degloved tissue was very cold to touch, numb and pale which told us there was virtually no remaining blood supply – a time critical emergency as without quickly restoring the circulation Rob would lose the foot.  Rob’s pain was increasing now and the entonox was not really helping.  Tony checked his baseline observations and I quickly checked there were no other injuries.   I gained IV access and gave some IV pain relief to back up the entonox.  This was in the days before we were trusted with the controlled drug morphine, a very effective pain reliever and the best we had was called nubain – a synthetic opiate which was supposed to work in the same way but in my experience didn’t help people much, nowhere near as effective as the morphine we carry now.

This was also before we had trauma centres we could take serious injuries such as this one to where all the specialist staff are in one place, we had to take Rob to the local Emergency Department (ED) where he would be assessed by the ED doctors and then referred on to a specialist unit.

On the short ride to the local ED two things were worrying him: the first was that he played football for a pub team and was supposed to be playing the next weekend.  I said he probably wouldn’t make the match, he jokingly asked if he’d be OK to play in goal.  The second worry was that he was getting married in a few weeks.  The thought of all the surgery he was faced with scared him less than the thought of his future wife’s reaction.  I hope it went well for him!

Shooting in a nightclub

Many years ago one Friday night shift, Tony and I were directed by our control room to a reported shooting at a night club in our local town.  There were possibly multiple casualties, but the local police were on scene so the scene was ‘safe’.  This was long before our service had response vehicles (ambulance cars with solo clinicians), HART teams (specialist paramedics with extra training in all sorts of hazardous conditions) or a structure of senior clinicians (senior or advanced paramedics with extra education and responsibility) to talk to on the phone or radio.  There was Tony and me.

We arrived to a scene of utter confusion.  The few police officers on scene were trying to organise the large crowd of party goers into some sort of order.  We joined the melee and tried to find the wounded patients.  At this point we did not know how many patients we had or the extent of their injuries.  A hysterical girl grabbed my arm and pointed at a lad who was sitting on the doorstep holding his chest.  He was very calm and didn’t seem drunk.

“I think I’ve been shot” he said, more unbelieving than anything.

A quick look revealed a wound to the back and a wound to the front of his chest.  There was very little external bleeding. He was obviously conscious and his airway was safe, a quick feel of the pulse at his wrist indicated no sign of immediate major bleeding so I left a police officer keeping a very close eye on him while I joined Tony who had found another casualty.  This lad had a single wound in his abdomen with no other obvious wounds; he was also conscious and couldn’t quite believe what had happened.  He was conscious but was quite sweaty and breathing fast.  His airway was safe so an off duty nurse from the crowd who seemed quite sober was left to watch him while we continued to search.

No other casualties were obvious. I couldn’t quite believe I heard myself shouting at one point: “Has anyone else here been shot?”

For now, we were happy that, miraculously, there were only two casualties.  I asked control to ‘make vehicles two’, the concise and unambiguous way we ask to make the total number of vehicles two.  Of course we were told that there would be a delay as there were no available vehicles anywhere in the area.

There began a hectic period of treating the two casualties on the pavement while we waited, oxygen and fluid lines for both and constant monitoring of vital signs.  All the while a large crowd of noisy, drunken partygoers were jostling around us as the police barely managed to impose order and give us space.  As the backup vehicle arrived I handed them the lad with the abdominal wound, his heart rate was increasingly rapid, along with his rate of breathing and his abdomen felt rigid to touch.  These are sure signs that there was significant internal bleeding, for now his body was managing to compensate but it wouldn’t take much longer for his blood pressure to crash.  This was long before we had haemostatic dressings or the drug tranexemic acid to help slow down blood loss.

I was then able to concentrate on my lad with the chest injury.  Once on the ambulance it was possible to listen to his chest to assess the degree of pneumothorax, that’s where air gets into the space between lung and chest wall causing a collapse of the lung, I couldn’t hear a thing outside in the crowd. Incredibly there was still good air entry despite the entry and exit wound in his chest, his vital signs were stable and didn’t indicate much internal blood loss.  There was no respiratory distress and he claimed he was in very little pain.  He said that the most pain came from my cannulation (IV line); obviously a little bravado was coming out to mask his fear.

After a final quick check that no further victims had been found we were able to set off to hospital.  Several people had come forward to say they were “in shock” from seeing the shooting and wanted to be “checked over”.  We gave self care advice to these and managed to not be delayed any further.  It was finally time to set off for the local hospital.  This was before we could go direct to specialist trauma centres, so the ED of the local district general hospital would have to cope.  Our control had already given them a warning that there was a shooting with possible multiple victims in their area as soon as the job came in but now we gave them specific details of our patient.

On the brief trip to hospital, the bravado (and the adrenaline) wore off and he changed from the laughing ‘gangsta’ with his ‘badge of honour’ gunshot wound and he became the scared little boy who was terrified of death. I reassured him as best I could and I was very touched when he said he was glad I was with him as I was a very kind man.  He shook my hand. The gangsta mask went back on at hospital as the nurses were hooking him up to the monitoring gear.

I still have no idea why the two lads were shot, were they just in the wrong place at the wrong time? Were they deliberately targeted?  Rumours were widespread in the following weeks, most seemed to be that they were selling drugs on someone else’s territory.  Sadly the lad shot in the abdomen died in the ED from blood loss, the lad shot through the chest survived.

I think people like to have a reason to justify or explain horrific incidents, if the lads brought it on themselves then it somehow reduces the risk of any of us being shot at random for no reason, although this ignores the fact that opening fire with a handgun in a crowd is as likely to injure/kill the innocent as it is the targets.

As a parent of two children who are now at the age they enjoy a night out at a club with friends, this is one of the reasons I feel such secret dread whenever they are out and feel such relief when I know they are safely home.

This was many years ago before it was routine to offer the crews time out after an intense job and the chance to debrief (talk the job through with a manager or senior colleague, a very therapeutic process).  The next job was waiting for us….

Motorway Tragedy

One Saturday evening several years ago, I signed on for my 1900-0700 night shift. I didn’t have a crewmate that night so I told the control room and left them with the task of finding another un-crewed person to put us up together.  A short while later, my partner for the night arrived.  Sue was a new technician who had not done many shifts since leaving training school; this was her first set of weekend nights, she was happy but nervous.  I did my best to put her at ease as we signed on and she put her personal gear on the vehicle.

The night started uneventfully, the normal hectic set of weekend night type jobs: mainly alcohol and drug related mishaps, with some normal medical problems mixed in too.  About 3 o’clock in the morning we did a transfer from our local hospital to a specialist urology department – an elderly gent whose urinary catheter had been causing problems needed a specialist review.  After we dropped the gentleman we cleared and were told there were no outstanding jobs so we could head back to station for now (this was in a time when we did have quiet patches during a night shift with no 999 calls, not like now where every minute of the day we seem to have calls waiting for us).

I was driving back on a short stretch of motorway and Sue and I were chatting about the job, I remember saying “This has been a typical shift; this is what weekend nights are like…”  Sometimes I should just keep my big mouth shut!

A few miles further on we noticed a crowd of people standing on the hard shoulder of the opposite carriage way.  This was a region of motorway with a sharp bend in it – lots of cars misjudge the bend here and lose control (not long after this incident a permanent reduction to 50mph was imposed on this stretch). As they saw us they started waving.  From a brief glance in the dark it was impossible to see what the problem was.  Sue contacted the control room to see if there was a call for the group of people we had seen – the answer was no.  I decided we should leave the motorway at the next exit and join the opposite carriage way and come back to investigate.  As we were rejoining the motorway, control called us up on the radio to tell us the job had just come to them from the call takers – it was an RTC – details were sparse but possible fatalities.

The motorway was fairly quiet, not too much traffic at this time in the morning.  As I approached I slowed down so we could take in the scene and pick the best place to park the ambulance.  From a distance we could see debris in lanes 2 and 3 with two cars at angles in lane 3.  A crowd of people and several parked cars were on the hard shoulder.  I left the ambulance a distance from scene straddling lanes 2 and 3, the blue lights left on to warn traffic and with our helmets and high visibility jackets on we approached on foot.  Sue said on the way that she had not had a job like this yet so I  said to stay close and follow my lead.

What had at first glance seemed like debris in lane 2 was actually a body, a young male in his twenties.  Two other bodies were in the carriageway between lanes 2 and 3.  One car had its nose in the central reservation barrier, a second car was parked in lane 3, its windscreen was broken in a ‘bulls eye’ pattern, a circular and radiating pattern of cracks from a central point of impact – typical of when a head hits the screen.  The screen was deflected inwards, implying that the car had hit someone who was outside the car rather than been hit by an un-restrained body inside the car as it crashed.

The first priority as I was assessing the scene was to start to triage the casualties in the road.  I was confident that we were as safe as we could be, the ambulance was protecting us, we just had to be mindful that cars were still using lane 1.  Sue updated control and requested police and back up vehicles as I quickly assessed each casualty in turn using the ‘triage sieve’ system we use for multiple casualties. This is a first triage system where a casualty can be assessed very quickly (mass triage has evolved since the incident to include a first step of addressing any massive bleed as a first step, this describes the triage sieve in use at the time).  The next step is to check is if a potential casualty is actually injured, if not they are directed to a clearing station area.  If they are injured but can walk, they are categorised as priority 3, the least urgent category of injured casualty. If the patient is not breathing despite an attempt to open the airway, he or she is classed as dead. For the breathing patient, rate of breathing, heart rate and capillary refill is quickly assessed and the patient is categorised as priority 1 or 2.

As I started to triage the police arrived and quickly closed the motorway, at least we were safe now and we knew the bystanders were safe from further injury.

Sadly, all three casualties all came out of the triage system as dead.

By now it was daylight and an hour past our scheduled finish time – quite a subdued end to what had started as such a routine shift.

The next night shift all the crews involved were called to a de-brief, a meeting where we have a chance to discuss the incident, run through the decisions made at each stage and also to get an overview of the whole incident.  When you are busy dealing with parts of a large incident you often do not know the whole story which is quite frustrating.  The de-brief is a very therapeutic thing and it helps to get things off your chest and have your peers and managers justify the decisions you made.

The three young adults who died were travelling in one of the cars and had lost control on the sharp bend in the motorway and had over steered and collided with the central reservation.  They were all fine at this stage.  They all got out of the car and were standing on the motorway looking at the damage when the second car came round the bend, didn’t see them in time and hit the three.  This explained the ‘bull’s-eye’ in his windscreen and why the three were widely scattered.  The driver of this car did not make himself known to us when we were on scene.

It still moves me how suddenly events like this can happen:  A moment of bad judgement by the three young victims and an instant of inattentive driving leads to such a sudden, tragic end to three young lives and three families devastated forever.