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.

Fifty Shades of Green

There is a common idea out there that uniforms are attractive.  Men are supposed to love certain uniforms and women apparently love a man in uniform too.  A quick survey of the people I know reveals that most women love a man in a fireman’s uniform and men favour a nurse’s uniform.  Not many people of either gender particularly find the ambulance uniform attractive.  It is a shapeless, dull green thing.  It normally comes in 2 sizes:  too-small and too-big.  As long as you avoid the too-small option it is actually quite comfortable to work in, except for the two or three days a year we have a heat wave in the UK, then it is heavy and suffocating.

Years ago, before the dull green uniform we had a more formal uniform:  a blue shirt with clip-on blue tie and blue trousers. Totally impractical for the job we do.  Before my time the outfit was finished off with a tunic style blue jacket complete with shiny buttons and a peaked cap.  Thankfully the hat and jacket had been removed from issue when I started the job.

One night years ago, dressed in the blue shirt-and-tie uniform I was given a job in a night club.  A member of the public had suffered an ankle injury. My mate for that night, Cliff, was excited on the way to the job because he knew that the club regularly hosted strip nights and lap dancing.

We arrived at the club.  Cliff was excited and I was nervous, I was relatively new to the job and still got nervous dealing with jobs in pubs and nightclubs.  We were shown in by the security guy on the door and the look on Cliff’s face was priceless.  It was ladies night.  The place was packed with hundreds of ladies in various states of intoxication, enjoying a night of male strippers.  One unfortunate lady had been lifted by the dancer and slipped due to an excess of baby oil on the dancer’s arms and landed awkwardly, twisting her ankle.

We worked our way through the crowd to the injured patient and some of the more drunk ladies thought we were the next act.  A chant started and was taken up by more and more of the crowd, suggesting we should start dancing and stripping.  It was the single most scary and yet hilarious night of my career, even the confident Cliff was trembling and perspiring.  We couldn’t get the injured lady out of there quickly enough!  Once in the safety of the ambulance Cliff and I laughed hysterically until we were both almost crying.  The lady with the twisted ankle thought it was hilarious too and joined us laughing in between gulps of the pain relieving gas, entonox.

For the rest of the shift Cliff seemed to be seriously considering erotic dancing and stripping as an alternative activity.  I am sure that the ladies of the North West would be very grateful to me for talking him out of it as a career path!

Girl on a bridge

One ordinary spring afternoon I was on with my regular mate, Tony.  The next job arrived with the beeping of the data terminal on the ambulance dashboard.

We were passed details of a girl threatening to jump from a pedestrian bridge crossing the motorway.  The girl had been spotted climbing over the railing on the bridge by an off duty ambulance man, Tom, as he was driving along the motorway.  He left the motorway and rang the details in.  He then drove to the car park near to the bridge to see if he could talk to the girl.

We arrived shortly after Tom; luckily we were available and fairly local when Tom rang control.  We were advised to use a ‘silent approach’ which as the name hints means turn off blue lights and sirens when near the incident so as not to startle a volatile person.  The police had arrived shortly before us, also using the silent approach.

The girl was on the bridge, on the wrong side of the railings, above the third lane of the carriageway.  Tom was half way to her and the police were on the car park.  As the police arrived the girl had become angry and threatened to jump if they didn’t go away so they withdrew out of her sight.  I stepped on the bridge and asked if I could come and talk to her.  At first she said she would jump if Tom, I or Tony came any closer.  I said that it was hard to hear what she was saying from a distance and I couldn’t keep shouting, she reluctantly agreed to allow just Tom and I to come nearer –  she repeated her threat to jump if any police officers or anyone else stepped onto the bridge.  The police officers stayed hidden in the car park, meanwhile requesting a trained negotiator to join us to help.  Tony stayed at the end of the bridge so he could relay information to our control centre as the incident evolved and equally importantly help Tom and I should we need help suddenly.

When I got near enough to talk I introduced myself and she said her name was Sonia (changed).  She was in her early 20s and from her early teens had suffered with depression.  She admitted that occasionally she harmed herself by cutting and I could see the faint lines of healed scar tissue confirming this on her left forearm.  The last few days had been particularly bad she said and today had got to the point where she felt she just could no longer cope.  I asked how she came to be here on this bridge and she said that she had gone to her GP surgery by the car park at the end of the bridge for help but had been turned away without seeing her doctor or any other of the doctors in her centre as there were no appointments that day or indeed that week.  This is a growing problem in the UK: GPs are so overstretched that it is really hard to get an appointment to see them, one of the reasons ambulances and hospital EDs are stretched is that people try to get an appointment and when this is not possible have to resort to going to hospital or dialling 999.

All the while Sonia was talking, she was crying and kept saying:  “I’m just not worth it, go and help somebody who deserves help, I’m going to jump now.”

She was standing on the ledge holding the railings and kept leaning back.  She was wearing a pair of flip flops so she was at risk of slipping and falling even if she didn’t intend to jump.  By now there was no traffic on the motorway; the police had stopped traffic entering this stretch in both directions to remove the risk to traffic passing beneath us.  I asked if I could check her pulse, any excuse to make contact so I could grab hold but she was smarter than that and refused, saying she was going now.  A quick glance at Tom and a quick nod, we both knew we were going to have to grab her, she was looking down between her feet and seemed to be steeling herself for the drop – we each grabbed an arm.  Her feet slipped from the ledge and Tom and I were pulled tight against the barrier as we held her up.  She was screaming, wriggling and swearing at us to let her go.  Things were happening quickly but I seemed to have lots of time to notice things.  I could feel the pressure of the barrier in my armpit and had time to hope that it would hold the combined weight of the three of us.  A pen in my sleeve pocket slipped out and I had time to notice it tumbling end over end until it hit the empty road beneath us.  We couldn’t lift Sonia; we just had to wait for the police to join us.  Suddenly I felt arms around my waist and more sets of arms reaching over to grab Sonia.  Somehow between the police officers and ourselves we manhandled her to safety.

Later at the hospital I handed her over to the triage nurse for a review by the mental health team.  I never got chance to check later that shift but have often wondered how she got on and how she is now.

We never did get the services of the trained negotiator that day but thankfully the only casualty was the pen which had fallen to its destruction from my sleeve pocket.

PTSD in the ex-serviceman.

Late one evening on a night shift I was called to a report of a male who was ‘feeling suicidal and unable to cope’.  We were also told that the man was known to the police for violent outbursts.  The police were not attending unless we asked them to after assessing the patient as they felt that their presence provoked him.

These jobs still make me apprehensive, who’s to say that the gent would not be equally provoked by my mate and me?  To some people a uniform is a uniform whether police, ambulance, fire, prison service, all symbols of a despised authority.  Let’s hope he wasn’t like that.

I approach all threats carefully, that is drummed into us from day 1 at training school: be aware of the surroundings, possible escape routes and hope that my calm friendly nature will diffuse any tense situation.  When all else fails, drop the gear and run! As I say to my mate, you don’t need to outrun the aggressor, just your crew mate!  Unfortunately he is younger and quicker than me.

We arrived and I knocked on the door, heavy response bag on my shoulder.  There was no answer.  My mate quickly asked for an address check to confirm we were at the right place as I knocked some more.  Once we knew we were at the right place I tried the handle, it was unlocked.  In these situations where there is a reasonable suspicion that a person is in danger or come to harm we are allowed to enter without a specific invitation.

I walked along the short hall, shouting ‘hello, ambulance’ over and over as I went and generally making noise so I didn’t accidentally sneak up on and make a volatile person jump.  As we went past the kitchen and a bedroom we put the lights on and checked each room.  All the horror films I have ever watched seemed to flood my mind with images of killers jumping out on the heroes from a darkened room.  This is definitely not the time to have a vivid imagination.

I went into the last room off the hall and saw the man, Alan (name changed for confidentiality), sitting on the sofa with his head down on his chest.  From the door I could see he was breathing, the rate was normal and his complexion had a normal, healthy appearance.  From a physical point of view I could relax a little, he didn’t appear immediately at risk.  I shouted ‘hello’ again and his head snapped up.  He looked startled but didn’t make any immediate moves so I introduced myself and my mate.

“What the **** are you doing in my flat?”  He shouted.  I explained we had been asked to come see him as the police were concerned for his welfare.  He admitted he had spoken to the police on the phone about a long running problem with his neighbours, he couldn’t remember but thought he probably had said if they (the police) didn’t ‘get off his back’ he would kill himself.  He seemed to calm down a little so I asked if we could talk and see if there was anything we could do to help.  As I glanced round his room I saw empty lager cans on the floor but no obvious weapons within easy reach.  On the shelf were a photo of him in an army uniform and several items of military memorabilia.

He started to tell me that he was alcohol dependant (must have seen me look at the empties) and that it was the only thing helped him damp the horror of some of his memories from the army.  We discussed counselling and Alan said he had some and it was good but after 5 sessions he had been told that was all the funding would allow and could have no more.  His GP’s answer was to give him medication to damp his emotions, presumably for the rest of his life as there didn’t seem to be a plan to get at the root cause and help him deal with it.

I would like to be able to say that we had a calm talk and I came up with a care plan which would lead to a happy ending.  I would really like to be able to say that.  However…back to the real world…at several points during the chat Alan became very aggressive and threatening to me.  Alternating between tearful remorse and shouting threats “Who the **** are you to judge me? What do you ******* know?”  I find this hard to deal with.  For one thing I never judge anyone, I’ve lived long enough to realize you can never tell what another person has been through and just accept that they are as they are.  It was quite scary too, thought I might have to run for it a few times, luckily for me at the height of the aggression the tearful recrimination phase took over.  I have a great deal of respect for anyone who serves in the armed forces, I’m aware that I’m able to sit here typing my opinions because people in the armed forces have suffered and sacrificed to protect this lifestyle.  I’ve never been in the armed forces so in that respect Alan is right: what the **** do I know?  This is a kind of dilemma for us: if a drunk assaults an emergency worker who is trying to help him then he is quite rightly reviled and we feel justified, obliged even, to press charges.  If, however, an ex military person assaulted me I would feel guilty about pressing charges, after all he acquired the PTSD serving his country.  Thankfully it has never come to that yet.

The best we could do for Alan that night was refer him to the out-of-hours GP service and ask them to refer to his own GP and ask for a review of his needs.  Far from ideal but the best plan we could come up with due to the late hour and his refusal to come to hospital for an emergency review.  Hope things work out for him but the chances aren’t good.

There was no time to dwell; the next job was waiting for us as we cleared….

The one job that still gives me flashbacks.

That one job…

Everyone who works in the emergency business has at least ‘one’ job.  You know the one.  The one which keeps coming back in your mind, even years after.  The one that can keep you awake at night and make you question every step of the job and every decision you made.

Mine was several years ago.

It was an ordinary Saturday afternoon.  Myself and my crewmate, Tony, had just cleared from a job.  We were at a hospital not on our usual patch.  To make the eventual comparisons more extreme we had just finished a job which had gone very well.  An elderly male had collapsed.  When we arrived we found he had collapsed due to a low heart rate.  We were able to quickly resolve this with a drug (Atropine) to the point where he looked 100% better, no longer pale and drenched with sweat, and was happily talking to us and his relieved family.  It was a happy family in the ambulance as we took him to the Emergency Department for follow up treatment.

We cleared the job and were passed ‘that’ job.

It was a report of a teenage boy who had crashed a quad bike on farmland.  This was before sat-nav or Google maps and was an area Tony and I were totally lost in.  I contacted the control room and explained we were unfamiliar with the area and asked for backup from any available local crews.  We were told there was no one else.  By now Tony had plotted the best possible route on the A to Z map book and I set off, blue lights and sirens on.  The farm was about 12 miles from where we were.

Soon after setting off we received an update from the control room:  The boy was in cardiac arrest (no heartbeat, no breathing).  His friend, who had called 999, was too distraught to attempt CPR by instruction from the call taker.  We were still about 10 miles away, relying totally on Tony’s map reading ability.  Any light-hearted banter immediately stopped and I started to feel that sinking feeling.

Miles passed and we were heading even further into the wilds toward the farm.  The roads were becoming narrower and bendier so against my desire to get us there I had to slow down – we needed to get there in one piece to be any possible use.  I made a turn as directed by Tony, concentrating on driving yet still mentally preparing for the job ahead, what equipment in what order to get from the ambulance.  The road became narrower; trees were closing in on us on both sides.  I started to doubt Tony’s choice of route, but then a police car closed in behind us, also with blue lights on, obviously heading to the same job, this reassured us both.  Not for long though.  The tarmac finally gave way to compressed mud, a steel bollard in the middle stopping any thoughts of pushing through.

A quick conference with the police officers and they managed to turn in the road and hurtle off to find another route.  I wasn’t so lucky, had to reverse until I found a spot I could turn round in then set off again with Tony sweating once more over the A to Z.  By this time control had found a local crew but asked us to carry on and back them up.

When we arrived the local crew were there and we could tell from their body language and lack of resuscitation activity it was not good news.

The boy had un-survivable injuries from his collision with a stone wall and was dead.  It would have been futile attempting to resuscitate.  By now his parents were there along with the parents of his friend.  Our job now was to try and support the families.  How exactly do you help someone who has just heard out of the blue that their child had been killed in an accident?  That area of our training was and is a bit sketchy.

Later on that day and following days my mind was flooded with the ‘what ifs?’  What if we had known the area and got straight there? What if we had picked a better route and got there earlier?  It goes on…

There was an internal enquiry, Tony and I were found to be totally blameless, anyone who didn’t know the area would have picked the same route we did and met the same steel bollard.  That reassured me a bit but still couldn’t stop thinking that would in no way help the family of the boy.  How does any parent get over the death of their child?

I was offered counselling by the service but foolishly declined – thought the best way to deal was to try and forget by just carrying on.  We even carried on working that day without taking any time out.

A depression settled on me which affected my whole family but still I refused counselling and any professional help.  Instead, once I actually realised there was a problem, I began a long process of self study and read many self-help books.

Many years have passed since that Saturday afternoon and I would say I have learned to deal with it.  It is still etched in my memory in a way that very few jobs are  (I normally can’t even remember details of jobs I did last week) but there is no sinking feeling or feeling of despair and guilt associated with the memory any more, just some residual guilt about the effect on my family.  Maybe the healing process would have been quicker with professional help; probably would have been less damaging to my family.  Maybe it was more thorough thanks to my long process of self helping, maybe all healing has to be done by yourself. Who knows?  I certainly don’t.  I feel strong now and able to cope with whatever the job throws at me, also able to help my colleagues by encouraging them to talk, talk and talk some more.  Talking bad jobs over with your work mates really helps you to put things in perspective and reassures you that your decisions and treatments were sound and that you did the best you could.  I would also strongly recommend anyone accepts the professional help offered.

I still wonder how the family are coping after all this time.