Thai cave rescue – World Cup class teamwork.

Respectfully dedicated to former Thai Navy SEAL Saman Gunan.

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

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

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

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

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

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

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

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



Instruction Manual For Dating Ambulance Staff

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

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

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



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


First Meeting

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

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



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


In the relationship.

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

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

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



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

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



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



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

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

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

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

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


Final words

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


My paramedic learning journey

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

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

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

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

What about the modern day UK paramedic?

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

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

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

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

Surviving night shifts.

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


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

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


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


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


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


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

After the nights are over.

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

Professor Stephen Hawking – Paying my respects

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

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

As a physicist.

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


As a man determined to live life to the full.

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


As a supporter of the NHS.

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


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

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

Professor Stephen Hawking.   1942 – 2018.

Surviving Storm Emma

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

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

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


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

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

Keep warm and safe.

My top ten favourite moments at work

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


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

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

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

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

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

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

Getting back to the article:

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

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

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

Discharging patients.

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

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

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

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

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

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

I guess my messages from all this are:

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

Blogger recognition award


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

The suggestions for nominees are:

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

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

Advice for new bloggers

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


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


Gravity always wins!

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

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

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

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

What do we do when we get to a fall?

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

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