Tag Archives: Danger

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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Heroin Overdose

Much to my Mum’s delight (not!!), we often attend patients who have overdosed on one kind of drug or another. Sometimes accidentally – as in the case of a diabetic lady who mis-read her insulin packaging meaning she’d taken too much., potentially life threatening if left untreated for ay length of time – but mostly intentional.

Many people take overdoses as a cry for help, others as they genuinely want to end their lives. People overdose on a range of drugs: antidepressants, pain killers, sleeping tablets, herbal remedies and once on eucalyptus oil (particularly dangerous believe it or not).

Heroin overdoses (generally) fall into the accidental category.

Heroin is an Opiate based drug and its affect, aside from the ‘high’, is respiratory depression. If one has too much of any opiate, one will eventually stop breathing. If they stop breathing but still have a pulse it’s called ‘respiratory arrest’, if not rapidly and aggressively treated, their heart will stop and they will be in ‘cardiac arrest’.

Today, while in a public toilet in the city, one young man had apparently taken a quantity of heroin. A member of the public was rather surprised to see a man flaked out in a cubicle, quite blue in colour through lack of oxygen, so called 999. Quite right, too!

We arrived within a minute or so (we were really close by) to find him half propped up against the wall unconscious. My regular crew mate and I have a young student paramedic out on placement at the moment and we let him take the lead for a moment.

Our ‘Primary Survey’ is as follows:

D – Danger

C – Catastrophic Haemorrhage

R – Response

A – Airway

c – C-spine protection

B – Breathing

C – Circulation

D – Disability

E – Expose and Examine / Environmental Factors

A little different from DR.ABC taught in First Aid.

There was danger present in the form of used hyperdermic needles, we all spotted them and were careful not to kneel on them (that’s the bit my Mum’s going to hate!). There was no Haemorrhage at all, let alone a Catastrophic one, so the he moved on in his primary survey.

The next bit is ‘Response’. A patient is either fully alert, responsive to voice, responsive to painful stimuli or unresponsive (AVPU). Now, our student is was a little delicate with this bit and his painful stimuli weren’t quite enough to cut through this man’s heroin haze.

Now, you’ll remember I said that we aggressively treat respiratory/cardiac arrest, to prevent death…so, as he was seemingly unresponsive, I grabbed his legs and slid him along the toilet floor to lay him flat with a view to commencing advanced life support. Well, he woke up! He work up and was most annoyed to have been dragged flat onto his back and was rather annoyed that we ruined his high!

He spoke to us clearly enough but was obviously under the influence of something as he was slurring and was wobbling all over the place. He denied the use of anything other than alcohol and asked us politely to leave, which, once we were happy he could walk, we did.

We stood down the Police and the Ambulance Officer that was on his way and cleared from the scene.

Thankfully, this is a fairly rare occurrence, but, does happen. If he wasn’t breathing, we carry a very clever drug which reverses the opiate affects on the respiratory system and brings them ‘back to life’.

Our student learnt not to be so delicate with his primary survey, and I learnt to have a quick check myself before flattening some poor unsuspecting soul to the floor.

Everyday’s a school day!

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Unwell kids….AARRGH!

Now, before I write this, let me just make something clear. I have a number of friends who work in the Police. They are as busy as we are (if not more) and equally, are under financial pressures with cuts to  Officer numbers and an ever increasing amount of paperwork. I will not have anything bad said about the Police as their job is, at times, unenviable!

Now, that probably gives some indication as to what I’m about to write about.

Many months ago, in the middle of the night, while working with a Paramedic from another station, we were called to a 2 year old girl having a seizure. As we’re a rural station, it was about a 14 minute drive. Our ambulances weigh almost 6 tonnes and are powered by 2.5 litre engines with upwards of 250,000 miles on the clock, so they’re not that fast, especially through the winding lanes around here.

We arrived to find a Rapid Response Paramedic who had been there around 5 minutes, administering Oxygen to a very grey, lifeless looking little girl lead on the floor twitching. I think we all simultaneously thought the same: “SHIT!”.

We set to work with our ABC’s. I first made sure we had an airway by inserting a Nasal Airway (google it, seriously) and taking care of the Oxygen, while my colleagues began trying to find the cause in order to correct it. We noted she had a high temperature and a new rash on her chest, her parents said she had been grizzly all day.

She was still fitting so we gave a drug which works to stop the seizure. It didn’t work. This is what we call Status Epilepticus – a condition that quickly leads to death if left untreated – possibly caused by ?Meningitis! Thankfully, a critical care doctor from our HEMS unit had arrived by road. She carried a greater range of drugs and was able to give something to sedate the girl in order to stop the fit as well as an anti-biotic to try to stop the infection doing any more damage. We lifted her onto the stretcher and prepared for the blue light drive to a Children’s A&E in the nearest city, some 10 miles away.

Off we went, me driving, 2 Paramedics and a Doctor in the back of the Ambulance with a critically unwell, unconscious 2 year old on the stretcher. At this point, the Doctor was breathing for the patient with a Bag Valve Mask (BVM).

It was an uneventful journey, taking it steady through the lanes making sure not to turn corners too hard as it makes working in the back very difficult. Into the city on the wide empty roads meaning I could make good progress. In the near distance just off a large roundabout, on the exit I needed, was a ‘Police, Road Closed’ sign, with a response car blocking the road and a single Officer stood there. I drove up, blue lights flashing, wound down the window and asked what was happening.

“A man is threatening to jump from the roof so I can’t let you through.”

“Oh” I replied “but I’ve got a patient I desperately need to get to hospital.”

“I can’t let any traffic through at all.”

“You don’t understand, I’ve got a critically unwell child onboard that I need to get to the Children’s Hospital immediately.”

“Sorry” came the reply.

I shouted through to the Doctor in the back that we would have to take a diversion.

“Didn’t you say that this child is critically unwell?”

“Yes, I did” as I fumbled with the MDT to find a new route in this unfamiliar city.

Diversion planned, we pulled away and continued ‘blueing’ to Hospital.

We arrived safely and took the patient into resus’ where the Doctors and Nurses worked hard to save her.

Thankfully – as I found out about a week later – she survived and was doing well on a ward.

My gripe here isn’t really about the Police Officer who was following orders, but to the selfish man who decided he wanted to try to jump from a roof!

All ambulances received a message stating that Police had requested a ‘silent approach’ to all jobs (lights but no sirens) in order to stop this man jumping. So, because of the actions of ONE man (who never did jump, following 4 HOURS of negotiations), multiple ambulances were hindered getting to emergencies, and the little girl who wasn’t breathing could have died due to the delay in getting to hospital!

I’ve been to suicides before. Those who actually want to do it, do so quietly without bothering anyone else. This idiot, it turns out, wanted attention from his ex-wife! Which I’m sure he got.

I’m glad nobody did die. and it is easy to get the ‘red mist’ when dealing with an unwell child, but this one really made me mad and still gets my back up a bit!

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ANOTHER public arrest.

Very much on the theme of my post last month, we were sent to another public cardiac arrest.

My crew mate, myself and a University Student on placement had just discharged a patient on scene; a baby who had diarrhoea the day before and her dad called 111. 111 had decided that this was immediately life threatening and actually passed the job to us a an ‘Unresponsive Baby’, which we were very glad to discover she was not.

I digress. We made ourselves available and immediately received details of an emergency in the city about 7 miles away. We were told that an elderly male had collapsed in the street and wasn’t breathing.  This is normally a 20 minute drive with traffic but I got there in 9.

We arrived to find a Rapid Response Vehicle (RRV) Paramedic doing chest compressions and one of our Officers who had also been dispatched, breathing for a patient with a Bag Valve Mask (BVM).

Between the three of us, we had already decided what our plan would be. My crew mate would jump out and help with advanced skills such as IV access or advanced airway management, the Student would take over chest compressions (because he is not allowed to perform any other skills yet, and it’s good experience to do so when the opportunity presents) and I would manage getting the patient off of the pavement and into the relative privacy of our ambulance.

I overheard that they had already delivered 2 defibrillator shocks prior to our arrival, and as I prepared our scoop stretcher, they delivered a third. Between myself and one other, we ‘scooped’ the man onto our stretcher and, while the student continued CPR, wheeled him into the ambulance.

There were Police on scene as well, who had been very proactive and closed the busy road. I was blocking it with my ambulance anyway. Sometimes that’s the only option.

A 4th shock was delivered in the back of the ambulance. For the 4th time, we had been unsuccessful in restarting his heart. But the battle continued.

We were informed that the Air Ambulance had landed in a nearby field and we were to drive round to meet them. I jumped in the front, and with the Police stopping traffic, made my way the half mile or so the the helicopter, where we were met by a Critical Care Doctor and a Critical Care Paramedic.

After a further 25 minutes of quick thinking and hard work, the man regained his pulse – something we call ROSC (Return Of Spontaneous Circulation), however, his heart rhythm was one which would not sustain life and another shock was given to ‘revert’ it back to a normal sinus rhythm. The Doctor, with agreement from all those involved, decided the ‘likely‘ cause – we never really know in these situations – was a Heart Attack which had caused the Cardiac Arrest. There is a specialist hospital that deals with this sort of emergency and it was decided that as the man was too unstable to fly, we would travel by road to this hospital in the next major city.

When everyone was ready, I began the 30 minute blue light drive. It’s a funny feeling up there in the cab on your own. You have a huge responsibility to deliver precious cargo there safely but quickly. The drive must be progressive but smooth. You need to look far into the distance to pick a route through traffic that will cause the least amount of movement in the back of the ambulance and have a 360 degree awareness. It is knackering!

30 minutes later, we arrived and I opened the back doors to lower the tail lift to unload the patient. I’m met by the Doctor who said “that was superb!” High praise indeed! I thanked him and continued to assist with unloading. The patient had maintained ROSC and was making respiratory effort but was unconscious and still very unwell.

We wheeled him in to the resus’ bay and the Doctor handed over to the lead hospital clinician where they set to work attaching leads, taking blood, checking the airway, listening to his chest, arranging scans and a host of other things.

We then were left with the mammoth job of clearing up.

He was alone shopping when he collapsed, but the Officer and I had found his wallet and ID so had his name and address, he also had his next of kin details which we passed to the Police.

I have no idea what happened to the man after we left, but I do hope he survived. If it was not to be, I hope his family were able to come and be by his side before he passed away. Either way, he had been given every chance of survival.

When reflecting on the job, I realised that was the first Cardiac Arrest I had attended where I had not done a single chest compression! Many hands and all that.

The following day, I attended an incident in Bath with my other Crew mate. I don’t like putting city names in my posts but this is important.

We were first on scene at a horrendous incident that made national news on the 9th February 2015 where 4 people were killed in a dreadful accident. I just want you to know that yes, I was there. Yes, it was horrific. And no, I will never be posting it on here.  My trust has been superb in supporting all ambulance staff involved and I have had lots of support from colleagues, friends and of course my beautiful fiancé.

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“Winter pressures”

This could well be the winter that breaks the NHS, or which has come the closest to it.

Every year, there are “winter pressures”, this refers to an expected uplift in work for NHS teams across the country, in particular front line services like Ambulance Services and A&E departments. However, this winter (and we’re not really even at the busiest bit yet), has been borderline ridiculous.

As an Ambulance Trust, we have REAP levels (think of them as Def-Con levels all the American films have). We usually bimble around at REAP 3, this is where everything is at its normal; many many calls, but just about enough resources to cover it, enough vehicles and enough staff.

REAP 4 is slightly more chaotic. The sheer volume of 999 calls puts serious pressure on everyone and there is a really struggle to find resources (by which I mean Ambulances) to answer the calls. Staff sickness/absence means that shifts are dropped as there are no medics to cover them.

We’ve spent a large majority at REAP 5. There are only 6 REAP levels, and at level 6, the trust is in melt down. At REAP 5, there are not enough ambulance, not enough medics, not enough call takes and not enough dispatchers to cope with the huge volume of calls we receive. Calls come in faster than we can triage them and the difficult decision is made not to respond to low priority green calls (such as non-emergency transport to a department, minor cuts to limbs or vomiting).

At this point, our trust was on the verge of declaring a Major Incident. I’m not wholly sure what happens at this point, but as a crew we can only do one emergency at a time, so there’ll probably be little change.

Let me give you some numbers. In our division, we normally receive around 1000 999 calls in a 24 hour period, lately, we’ve received over 1500 calls in the same period. There are no more Ambulance and probable less staff to answer those additional 500 cries for help. This is why we are REAP 5.

Hospitals have it just as bad. There are simply no beds for the patients that need to be admitted. At one point, I counted 17 patients on trolleys and in wheelchairs in the corridor of one A&E department, but let me say that. Every one of those patients was receiving excellent care. They were having medical obs’ done, Doctors were speaking with them, they were taken to a private room for examination. It was a joy to watch this level of organisation.

With all this in mind, I’m worried. January and February are typically our ‘busy’ months, and we’re almost at capacity now!!  Lord help us and all NHS Staff!

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Ebola…

…is a concern for the health service in England. There’s been lots of planning for the possible/eventual contraction of Ebola by a UK citizen.

It was a very surreal moment when I heard on the news, that if there was any concern about Ebola, and somebody had phoned their doctor or out of hours service, the case would be passed to the emergency services to deal with.

“Good”, I thought, “they’re the kiddies to deal with this”. Then I realised – I’M THE BLOODY EMERGENCY SERVICES!!

But it’s ok; our ambulance trust promptly released instruction on what we are to do when faced with a possible case.

We’ve been provided with Tyvek suits (yes, the ones worn by decorators to protect them from paint, not lethal bloodborne pathogens) and paper masks similar to those worn on a building site to protect one from brick dust.

As you can imagine, ambulance staff were rather worried that if the people in Africa with the pressurised suites and breathing apparatus were still contracting the disease, what protection would a paper suit afford us?!?!

The Trust then upgraded to filtered masks, which is kind. They have also ensured every operational member of staff is trained in the fitting of the mask and an assessment carried out. The rules of the assessment are as follows:

  • If you have a beard, it is in automatic fail.
  • If you fit the mask incorrectly twice in a row, it is a fail.
  • If you fit the mask and can still smell/taste the testing agent in the room, it is a fail.
  • If you fail the assessment, it does not exclude you from still being sent to a possible Ebola case.

Let me reiterate that last point – If you fail the mask assessment, for something as simple as having a beard (which many of our male employees do….and some female ones but that’s a different matter), you will still be sent to a potential case. Good.

So, although I’m sure the media are hyping up the disease more than is actually necessary at the moment, I’d like to wish all my fellow, bearded, ambulance colleagues – both male and female – all the very best of luck while holding their breath during the treatment of their patient. Lovely.

(My mum’s going to be furious at reading this!!)

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Major Incident.

A few weeks ago, there was a ‘standby’ for a major incident. It came in just after my nightshift finished so I was praying it wouldn’t escalate into a full ‘declared’ major incident – especially after I heard the details of what it was.

This was the recorded phone transmission (minus the exact location, and as best I can remember it):

“Major incident standby, major incident standby. [Location, which was a disused unit in an industrial estate in the city]. Incident type – Illegal Rave. Hazzards include alcohol, drugs, weapons and violence, persons reported in the water. Access via [Roadname]. Between 300 and 800 persons and potential casualties. Currently on scene – Ambulance, Air Ambulance x 2, BASICS Doctors, HART (Hazardous Area Response Team), Fire & Rescue, Police including Riot Police. Details to follow, standby.”

-For those that are interested, this is a METHANE report used to cascade the information of a major incident. If a full incident is declared, then people start to get called back into work.

Although this sounded like a juicy incident to attend, it was most likely just a load of people who’d arranged an illegal rave, it got a bit out of hand, someone phoned the police to complain and all hell broke lose.

It was never declared as a full major incident. Which I was glad about as it meant I could get some post-nightshift sleep before my next 12 hour shift. Nobody died or was injured as far as I know and the ‘persons in water’ was probably someone high on acid who thought taking a swim in the River Avon would give him super powers!!

I’m yet to deal with a ‘proper’ major incident, but I’m sure that they’d see my potential to deal with a serious incident and let me be in charge…..of parking. Yep, there’s a ‘Parking Officer’. You even get a high vis’ tabard and tell crews where to park.

My friends and family would be like “WOAH, we saw that huge incident on the TV, were you there?”

And I’d wryly reply “Oh that? Yeah I was there”, while casually sipping a cup of hot chocolate.

“Bloody hell, it looked bad. Bet you saw some stuff there, mate?!”

“Yes, yes I did; have you ever seen 12 ambulances try to parallel park? Nightmare….”

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