Terrified Out of Hours Service

If you need the Police in an emergency, you call 999. If you need to contact the Police for any other business that isn’t life threatening or dangerous, you can call 101.

Similarly, if you need an Ambulance for a medical life or death emergency, you call 999. If you need non-urgent medical advice, you can call 111.

111 is a private contract that is split into dozens of sectors across the county. So the company that answers a 111 call in Devon will be a different company from the one that answers a call in Birmingham.

The tag line for 111 is that you can ring for medical advice……but we few in the Ambulance Service no this is rubbish!

We know this because we have attended people’s addresses, using blue lights and sirens to get there, when they have rang 111 to ask some advice about medication and they have triaged it as appropriate for an ambulance!

Let me explain. When you call the Ambulance Service on 999, you get through to a non-clinical call taker called an Emergency Medical Dispatcher. There medical knowledge is no better than that of a good first aider, but they use a robust triaging system to quickly and effectively decide if the call is immediately life threatening, or can be given a lower priority in order to allow precious ambulance resources to attend the most serious calls first (if you’ve read my blog, you’ll know that people do ring 999 for very un-serious things!).

When you ring 111, you get through to a non-clinical call taker who has in front of them, a screen with a series of questions to ask, your answers to these questions determine what the recommended care pathway is; self care, telephone call with a Nurse, visit and out of hours Doctor, or they can dispatch an ambulance. You don’t get advice when you ring 111, you get triaged!

I should note here, that sometimes, people ring 111 when 999 would have been entirely appropriate – I’ve attended 111 calls where the patient is barely breathing, where a child has a broken leg and a man was having a massive heart attack! My ‘beef’ is when 111 send us to calls that we don’t need to be at:

An elderly man had been suffering a nasty cough for 3 days, his wife thought he had a chest infection, so, one Sunday morning, she rang 111 to speak to a Doctor about getting some antibiotics. She was bombarded with dozens of questions about everything from whether his was bleeding from his anus or if he’d travelled to Africa and may have contracted Ebola. Eventually, 111 told her they would send an Ambulance. This terrified this poor old lady, she thought her husband only had a chest infection, but in fact, he must be seriously ill if they’re sending a blue light ambulance!

-We get the call “85 year old male, Chest Pain and Short of Breath” it’s coded as a Red 2, which is the code for the life threatening calls. So, we do our thing – blue lights, sirens and radio coms – arrive at the address to find our gentleman in bed most definitely not short of breath and not complaining of any chest pain at all .

We get told the story by his wife, and to my ears, it sounds like he has a chest infection and needs to speak to a Doctor about getting some antibiotics. We give him a thorough check over with all the tests to rule out a heart attack, severe infection/blood poisoning, shock or other concerning stuff and it was all fine. So we rang the out of hours Doctors (we have a special number that we can use to directly request a Doctor) to arrange for a home visit.

Time taken for us to drive to the address, assess the patient, complete the paperwork and wait for a callback from a Doctor: 55 minutes.

Time speaking with a Doctor (who agreed with my medical impression): 4 minutes.

That was an hour that an emergency ambulance was unavailable because somehow, that man’s chest infection triaged as an immediate life threat.

This isn’t an isolated incident, sadly. Here’s a list of calls that I’ve been sent on where people have rang 111 and unexpectedly ended up with a blue light ambulance. Ready?

  • Lady wanting to know if she can take Aspirin for a headache
  • Man who hurt his hand three weeks ago and wanted some pain relief
  • Lady with a painful elbow (we were told she was having a stroke)
  • Man who’s back was sore after bending to pick up some laundry (came to us as chest pain)
  • Baby who had a cough and parents wanted some advice
  • Earache

And the absolutely pinnacle in my extensive experience of inappropriate calls:

41 year old man who rang 111 in the middle of the night to see if there was a late night pharmacy anywhere where he could buy some cough syrup. For his cough. This coded as a Red 2 for Chest Pain.

Every single one of those was appropriate for 111. These people did exactly what they should have done, and yet, they each ended up with an ambulance being sent to their houses with blue lights flashing. I didn’t need to take any of these people to hospital,but if you look, that’s at least 7 hours of my time taken up with nonsense. 7 hours during which time someone may be having a stroke, someone may have fallen down the stairs and been found unconscious, there may have been a serious car crash where someone is trapped, someone’s baby may have stopped breathing.

All we can do is report it back, but bare in mind, if you ring the out of hours provider in your area, it may be more than advice that you get!

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The Christmas nightshift

…”should be easy”, I hear you say.

“Pop your feet up and watch some James Bond, maybe nip out to pick up granny who’s fallen after one to many sherries. Or maybe a drink driver crashed into a lamp post.”

Well, yes. It should have been something similar to that, but instead, it was a rather intense shift.

Our first call (admittedly almost an hour after signing onto the Ambulance) was to a lady who has possibly had a stroke. She was 84 years old. Now, we don’t play God. We don’t think “ah well, she’s had a good innings, lets leave her to slip away peacefully.” Especially when this particular 84 year old still cycled everywhere in the village she lived in, and WORKED 2 DAYS A WEEK!!

She was sat on the sofa at her daughters house where she went every year to celebrate Christmas, when suddenly, she listed over to one side. Her daughter asked if she was ok and the mumbled reply confirmed her suspicious; she was having a stroke.

We arrived quite quickly considering the narrow lanes surrounding the village, to be met by her daughter outside in a bit of a panic.

“Through here please!” We just caught what she said as she scurried into the house. We found the living room and saw our patient in quite good spirits, considering. She had a right sided facial droop, slurred speech and was unable to move her right arm – all the classic signs of a stroke.

If caught within a certain time frame, some strokes can be treated and in many cases, the patient will make a good-to-full recovery. But not all the time.

We were well within this window, so basically ‘scooped and ran’ (a term often used to mean just that: scoop the patient up and run to hospital on blues.

I put a needle into a vein in case we needed to give her any drugs and my crew mate blued us to A&E. It was an uneventful journey, but I pre-alerted the hospital staff anyway, as is protocol for stroke patients.  We arrived to be met by a doctor who sent us into ‘Resus” (where the illest patients go) as the CT Scanner was in use – another stroke patient brought in by Ambulance who’d arrived not 5 minutes before us!!

I later found out she was Thrombolised (treatment for a specific type of stroke) and was making a good recovery. Good times!

 

Next patient was a Priority 1 backup request from an RRV Paramedic on scene back in our home town. We darted through the empty city streets and out onto the country road leading to our station, which we sped past on the way to the address.

It was a 44 year old man who was a chronic (and still functioning) alcoholic. He had End Stage Liver Disease and many other health problems. He was completely unconscious, very jaundiced (yellow skin associated with liver failure), and barely breathing. Not a well man.

The RRV Para’ had given oxygen, gained IV access and was giving fluids as we arrived. We lifted him from his bed to the stretcher (thankfully he lived in a bungalow) and wheeled him to the Ambulance. We blued him in as well. On the way to hospital, he developed a dreadful habit of not breathing every now and then, meaning I had to ventilate him with a BVM. He remained unconscious the whole way to hospital.

I handed him over (to the same doctor as earlier) who very quickly set to treating him with the expert nursing team. Once his family arrived, the doctor had the discussion with them that he was unlikely to improve and if his heart stopped, they would not attempt to restart it. The family were in agreement and were in fact relieved that his agony would not be prolonged. He died a few hours later, peacefully and in no pain with his family by his side.

 

We then did a few ‘normal’ jobs – too much sherry etc etc.

Then we got sent to the next town for “18 year old male, stabbed”.

Now, that would fill most people with dread, but I’ve been sent to so many ‘stabbings’ that have in fact turned out to be paper cuts and not much else. One man had a graze on his arm, the sort you get from scratching an itch too hard!

Nonetheless, put down your dinner and pick up the Ambulance keys, blue lights on and off we go.

We arrived to see 2 RRV’s, 3 Police cars and Police dog team on standby. We walked into the house and followed the blood trail…..ah, first clue that this might be serious.

There were our two colleagues dressing wounds, taking vital signs and details while the Police tried to gleam information about his attackers.

We quickly grabbed the stretcher and wheeled him to the vehicle for a proper assessment (cut all his clothes off for a top-to-toe inspection to make sure we haven’t missed any stab wounds) in better light.

He’d taken a fair beating:

Black eye, presumed fractured cheek bone, fractured jaw, laceration to his neck, significant cuts to his hands (typical defensive wounds), cuts to his legs and a pretty nasty stab wound to the knee, of all places. He had lost a pretty decent amount of blood and was an unhealthy shade of white.

Despite his serious condition, he was reluctant, in fact he outright refused to give any details of his attackers to the Police.

We blued him in as well, with a Police escort which was rather exciting (I’ve never had one before). Pulling up at A&E, guess which doctor was waiting for us? “You guys are proper sh*t magnets tonight!”

“You’re telling us?!”

The last I heard, he was OK. It took over an hour to clean all the blood off of him. We hadn’t missed any wounds and he was preparing to go to theatres to have his hands operated on. We spoke with the Police later that night, who told us that when the searched his clothes that we’d cut off, they found a cocktail of drugs. They suspected it was a drug deal that went wrong, which would explain his tight lips!!

 

Even on Christmas Day, you can’t guarantee an easy ride. Still, mostly genuine jobs this time 🙂

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8 Minutes of reflection

If we get to a job in 8 minutes and 1 second, and the patient survives, it is deemed a failure.

If we get to a job in 7 minutes 59 seconds, and the patient dies, it is deemed a success.

Just reflect on that for a moment….but not too long!

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Bathrooms and lifelines

This isn’t a recent event, but I’ve only really just remembered it.

I was on my base-station but had no crew mate. This meant I had a few options (actually, I had none, but there was one of a few things that my control manager would tell me to do).

Option the 1st: Stay solo on the ambulance, first responding to Red calls (life threatening) being backed up as needed.

Option 2: Drive to another station to crew up with someone else who was also solo.

Option 3: Stay put and wait for someone else that had no crew mate to drive to me.

Option 4: Take a Paramedic off a rapid response vehicle (RRV) to crew up with me – They don’t like doing this as RRVs are very good at getting places in 8 minutes, which keeps the government happy, but they also know that double-crewed ambulances are the Trust’s most valuable resource.

Eventually, option 3 was decided on and I would wait for a Technician from another station (12 miles away) to drive to me. This suited me fine as I actually had time to check my vehicle, providing a Red call didn’t come in in my area!

So ‘Berk’ as I’ll call him, arrived. I immediately didn’t like him. He seemed arrogant and dismissive and bitched and moaned about having to drive to my station (in an ambulance, not his own car) to crew up with a ‘Student‘!

“This will be a long 12 hours” I thought to myself! Then I always remind myself that it is only 12 hours and for some of that, one of us is in the back with a patient anyway. ‘Keep calm and carry on’.

Actually, my short but stale encounter with Berk is not at all relevant to the story, but it’s good to vent. Berk!

 

First job around comes in: 78 year old lady, fallen in Bathroom.

“Priority 2 backup for an RRV please chaps”

“Roger, wilco’, all received”

We decide who’s ‘wheeling’ and who’s ‘healing’ and jump into our seats. Blue lights on, off we go.

It’s a short and uneventful drive to the address in a small, nearby village. We park up outside the bungalow and walk through the open front door.

“Hello, ambulance” standard entry call of the ‘medic.

“Through here guys” standard reply of the ‘medic.

We walk through to the bathroom where our Paramedic colleague tells us the story. Everything about a patient can be gained from a good history, so we listen intently.

“This is Joan (name changed, of course). Who 3 days ago….”

“Sorry mate, was that 3 hours ago?”

“‘fraid not guys, 3 days. 3 days ago, Joan walked in to the bathroom, lost her balance and fell into the [empty] bath. She was unable to get herself up. Thankfully, a neighbour became concerned that she hadn’t seen her so used the key safe to get in, finding Joan. We were called immediately.”

This poor poor lady had been stuck in the – thankfully – empty bath for 3 days!! Her feet were at the tap end, so she cleverly used her toes to turn the tap on and use a small just to fill it with water to drink from.

She was wet, soiled, cold, sore and afraid. And bloody relieved to see us lads in green!

She had a dreadful amount of pain in her back and bottom where she’d been led for so long, so we gave her some good pain relief before moving her. Once that kicked in, there was no other option than to man-handle her out of the bath and onto our wheelchair.

As we did so, we stripped off her wet clothes. She had an enormous pressure sore on her back and urine burns on her legs and buttocks. We cleaned her, dried her and put her into a hospital gown (always worth carrying a few on the ambulance) after dressing her wounds.

Systemically, she was well. Her blood pressure was excellent, her heart rate was normal and even her blood sugar was OK. She was, of course, mildly hypothermic, but otherwise stable.

We wheeled her to the ambulance and got going to hospital. I was in the back with her on the way, and she recounted the story to me through tears.

She genuinely thought she was going to die in the bath. She wept and I could do nothing but hold her hand and tell her she was safe. I recommended a ‘life-line’ pendant to wear around her neck so if she falls, she’d be able to summon help more quickly. She agreed that she would make enquiries when she got home.

I gave my clinical handover to the Matron in A&E who sent us to the High Care area of A&E with her. There she was given a comfortable bed while waiting for the doctors to come and see her. I told the nurses about the turmoil she’d bee through and they said they’d take good care of her. I knew they would.

 

Stuff like this terrifies the life out of me! We get called to people found dead by loved ones who have fallen and been unable to summon help. I cannot recommend life-lines enough, they are just that! It may take a while to get someone there, but someone will always get there. It makes me angry, as well, when people have them but don’t wear them, I feel like I’m forever telling off pensioners who have them hung over the bedside lamp! This is one of those ‘forever problems’. It’ll be a problem, forever.

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New skills

As I’ve mentioned before, I am a Student Paramedic studying part time through the Open University. This means that unlike full time students, I don’t do placement blocks as an extra person on an Ambulance, I work full time for the Service as a crew of (usually) two on a Double Crewed Ambulance (DCA).

Studying this way – I feel – gives me better exposure to lots of different types of emergencies and how to manage them with just the two of you (having a 3rd person there does make a massive difference in critical situations). It does mean that it takes longer (1 year probation plus 4 years study as a apposed to 3 years through University) and I have to study in and around my shifts – including hospital placements which have to be done in my own time, but I think that learning ‘on the job’ is a much better option. You can’t learn how to simply talk to people or reassure them at university, that’s evident from some of the young newly qualified Paramedics I’ve seen.

Studying this way also means that I am taught new skills as I progress and allowed to perform procedures on my patients. I’ve recently been given all of the Paramedic skill to add to my arsenal.

If you want to Google them, they are:

Cannulation

Intra-oseos (IO) access

Intubation

Needle Cricothyroidotomy

Needle Thoracocentesis and

Advanced Life Support (my assessment for this one is during my final year).

Cannulation is our most often practiced skill. It involves putting a small plastic tube into a vein using a needle (IV access). This allows us to give fluids, drugs and now in certain situations with help from our Air Ambulance Critical Care Paramedics, blood.

IO access is only used in truly life threatening situations, when the patient is so ‘shut down’ that you can’t get IV access, or if they’ve suffered amputations. It’s also the first line of access in paediatric cardiac arrest (no pulse and not breathing). It involves a much larger, longer needle which we attach to a special drill and drill into the bone marrow. Seriously, that’s what we do! I’ve seen it done three times and only once on a conscious casualty. It really is our last line of access because it’s so aggressive, apart from paediatric cardiac arrest – just think on that for a minute!

Intubation is only used in cardiac arrest. It involves using a curved metal blade to lift the tongue and jaw out of the way to visualise the vocal cords. We then pass a plastic tube through the cords into the main windpipe leading to the lungs, thereby blocking off the oesophagus to reduce the chance of vomit getting into the lungs. We then attach it to a ventilator of some sort to breathe for the patient.

Needle Cricothyroidotomy or Needle Cric’ (pronounced cryke) for short is when the shit really hits the fan. If you’re pulling this out of the bag, it really is do or die! We only use this when a patient has a complete upper airway obstruction that cannot be removed by the heimlich manoeuvre or by using the intubation blade to find and some special pliers to remove the blockage. This patient will die if you don’t perform this technique. It involves using the largest cannula we have (like a bloody scaffolding pole) and pushing it through the throat into the windpipe, attaching an oxygen tube to it and turning it on and off to emulate breathing. Once this is done, you have 20 minutes to get the patient to definitive care of they die. This will be a bad day at work.

Needle Thoracocentesis is used when a patient has a collapsed lung which is ‘tensioning’. This is when the lung collapses and then gets smaller and smaller until it compresses agains the heart impeding its ability to beat. Again, this is fatal if untreated. So all we do is get that massive cannula and push it between the ribs to allow the air that’s outside the lung to escape and the lung to re-inflate. Scary stuff.

Advanced life support is pretty much a combination of all of the above with a cocktail of different drugs used in the management of cardiac arrest. With all of this, we are able to offer the same treatment for cardiac arrest in someone’s living room that would be offered in an A&E resus’ room.

 

So far, I’ve cannulated plenty of actual human beings, but none of the other stuff. The time will come for me to use these skills *gulp* and it’ll be fine.

This is actual grown up stuff now…wish me luck! I’ll report back with tales of how I’ve used these skills to save hundreds and hundreds of lives!

 

 

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Critical Haemorrhage

I’ve mentioned before that our ‘Primary Survey’ (i.e your initial assessment of a patient to decide if there’s anything immediately life threatening that needs correcting) differs from that of a first aider, who’s primary survey will be:

D – Danger

R – Response

A- Airway

B – Breathing

and maybe C – Circulation

Our primary survey is:

D – Danger

C – Catastrophic Haemorrhage

R – Response

A – Airway

c (deliberately small) – Cervical Spine injury

B – Breathing

C – Circulation

D – Disability or Neurological signs

E – Everything else

F – Family/Friends for history taking

G – Glucose levels.

So, as you’d expect, it’s a bit different.

When it comes to managing Catastrophic/Critical Haemorrhage (by which I mean an arterial bleed which will bleed a patient dry in mere moments), we don’t piss around. As you can see, we control Catastrophic Bleeding before we even try to get a response from our patient, let alone try managing an airway etc etc.

Most if not all of our critical haemorrhage kits have been developed by the Military. Their ‘bread & butter’ work is dealing with traumatic amputations and massive trauma to the abdomen and chest.

They’ve developed very efficient tourniquets and dressings known as ‘blast dressings’, or to give them their proper name, ‘haemostatic dressings’. These have a chemical in them which promotes clotting to stop bleeding quickly. These dressings are idiot proof, very large and very expensive. They save lives.

I’ve never been unfortunate enough to have to apply a tourniquet, though my regular crew mate was – he was sent to a lady who was trapped under the wheel of a bus!

I have, however, applied a blast dressing to a lady with a catastrophic bleed from the chest. It works very well indeed.

We have a special bag which is a cool, special op’s style black bag with red writing which says ‘Critical Haemorrhage Kit, Trained Personnel Only”. In there we carry tourniquets, various sized blast dressings and haemostatatic gauze.

On my last day shift, we answered a 999 call for a man who’d cut himself shaving, so the bag was left on the Ambulance that day……*sigh*.

Needless to say, we recommended some basic first aid and left him to it. Another life saved 🙂

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Apologies

“Well, well, well”

I hear you say.

“It’s that bloody Ambulance bloke. I remember he used to write regular updates on his day-to-day life on a frontline Ambulance. I’d almost forgotten he existed.”

AHA! I have returned with an apology. It’s been a very long time since my last post but life has been very busy!

I went and got myself married, started my final section of studying for my degree in Paramedic Sciences and re-joined a band I was in many many years ago. I know it doesn’t sound that busy, but trust me, it is!

Anyway straight back into it, eh?!

On the subject of apologies, I did start a post I never finished which was along the lines of this:

On the ambulance, we carry a fairly limited range of pain relief, from Paracetamol tablets, to strong IV Morphine with basically only Entonox (gas & air) in between.

To enable us to give the strong pain relief, we need to get IV access with a cannula. This gives us access directly to a patient’s veins to give morphine or paracetamol in the form of a drip. But what if we can’t get access?

I was working in the city with a different crew mate. As soon as we booked onto the vehicles, the radio goes off:

“Morning chaps, sorry to be so prompt this morning. We have an outstanding call for a concern for welfare.”

“Roger, all received, on our way.”

On go the blue lights, no need for sirens at 0630, there’s no traffic about.

We quickly arrived to find a gathering of people, most in dressing gowns but all with bed hair!

It turns out the neighbour had got up for work and head shouting from the elderly lady next door. He went round but couldn’t get. He heard her shout that she was on the floor so called 999. They had also called the lady’s daughter who had a spare key.

We shouted through the letterbox to reassure her we were there and within a short time, her daughter arrived.

She unlocked the door and we walked in. It wasn’t pretty. The poor lady (who slept downstairs) had got up in the night and fallen forwards. She had scuffed her face down the wall as she fell. She’d landed face down and was unable to get up our to pain in her hip as well as general poor mobility and low strength. And there she stayed, for almost 4 hours until her neighbour heard her calling out for help.

We set to work. Quick ABC assessment revealed nothing immediately life threatening. Then we were concerned about a possible next injury as she’d hit her head. She had no central neck pain reducing the likelihood of a broken neck. We then assessed all the bones top-to-toe.

“Surely, just help the poor lady up” I hear you say. It’s certainly what we hear a lot, but if she’s broken a leg and can’t feel any pain due to nerve damage, then the bone pokes through the skin as we move her, that could prove fatal. So we methodically check top-to-toe.

Her injuries were some nasty facial skin tears, a laceration to her shoulder, a broken left wrist and a probable broken left hip. Unsurprisingly, she was in a lot of pain. We knew that before we moved her, we needed to try to get her pain under control. The best way to do so was with IV drugs.

This is where we got into trouble. My crew mate tried several times to get access, but her veins were so small that he couldn’t find one, when he did find one they just collapsed as soon as he touched them with the needle. While he attempted that, I made a plan to get us out of the house. It involved a second crew and moving most of the furniture into the garden. The plan would be to scoop her, carry her back into her bedroom, onto a vacuum mattress – which has hundreds of polystyrene balls in and we suck the air out of it to cocoon the person safely in – carry her through the house, up the front steps and to the stretcher on the pavement.

But, try and try as well did (the 4 of us) we couldn’t get any IV access. We decided to give her Oramorph (morphine drink) but it’s not as fast acting. We had to roll her onto her back before we could do anything.

We knew it would hurt, and so did she. When she was ready, and as quickly and smoothly as possible, we rolled her. She screamed and all we could to was apologise.

We were sorry that this had happened to her. We were sorry that nobody heard her shouting for 4 hours, we were sorry we couldn’t get into the house for a while and we were sorry we couldn’t get her pain under control before we moved her.

The rest of the plan worked like a dream. We dressed her wounds and drove her to A&E with the daughter.

My crew mate and I spoke about the job afterwards and both agreed that it is horrible when you can’t do what you think is best for a patient. It’s our job to ease pain, but when you can’t do that, you feel a little bit worthless. It may sound silly to you, but it’s true.

We returned to A&E an hour later with another patient and asked how she was doing. An x-ray confirmed a broken wrist and broken hip, but she was comfortable. We popped our head round the curtain and she was led there smiling. “Thank you both so much for helping me” she said.

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