That newly qualified wobble

I’ve worked on the frontline of the Ambulance service for almost 6 years. I’ve been to my fair share of horrific jobs and in the words of my veteran crew mate, I’ve “got chops” (I smiled and said thanks when he said it, but don’t really know what it means. I assume it means I’ve got bragging rights). 

For the last year prior to qualifying, I’ve been working all but autonomously with my Paramedic crew mates; assessing, making decisions about treatment, administering drugs and handing over to hospital staff. I’ve been confident in my decision making and felt happy to take the lead. Albeit with a safety net of my colleague sat next to me. 

Last month I completed my degree course, qualified and registered as a Paramedic. “Finally” I thought to myself!

So, I’m now in a position to do all of the above; assessing, making decisions about treatment, administering drugs and handing over to hospital staff, BUT it will be on my registration and me signing the paperwork off. I still feel confident and competent and am looking forward to the challenge. 

Imagine my horror then, at the following. 

999 call to a 12 month old little girl who is “hard to wake”. My crew mate and I make good progress through the busy city traffic in our big Mercedes Ambulance, sirens wailing as we speed to the address. 

Upon our arrival the front door is ajar, we grab all of our kit (4 bags, oxygen cylinder, tablet computer and defib) and head in calling “hello, ambulance” as we tentatively enter the house. 

We’re called into the living room by the patient’s dad, who’s holding little one in his arms. She looks round at me as I introduce us which reassures me she’s fully conscious and alert. We take a brief history from dad which includes details of breathlessness for 2 days and a fever. Reduced food intake and being tired and clingy. 

Between my crew mate and I, we take a full set of observations which give us her respiratory rate, heart rate, temperature, blood glucose level and a test to establish how well perfused she is by pinching her finger and seeing how quickly it returns to a normal colour (sometimes the simple tests are the most effective).

We establish that although she seems calm, she’s working hard at breathing with an increased respiratory rate. Her heart rate is also raised. 

6 weeks ago, I would’ve made my decision. Bosh. Sorted. Confident and competent, remember? But I sat there looking at the child, looking at her numbers and I could not for the life of me make a decision about what to do. 

I knew she needed to see a Doctor but couldn’t decide whether to refer her to the out of hours GP or take her directly to A&E.

Her dad was sensible and would’ve known what to look for should we decide to leave her. But what if she deteriorates. Equally I don’t want to fill an A&E bed with a child that could be treated easily in the community. A hundred thoughts whizz through my mind but I could not extract a decision.

After what felt like an age (but was less than 30 seconds) I decided to convey the child to A&E for urgent assessment by a Doctor. 

We took her in, she needed no treatment or drugs so it was an uneventful journey. I had a nice chat to her Dad about this’n’that, and handed her over to the hard working team at the local A&E.
Afterwards I spoke with my Paramedic colleague when we got back to station and confessed that I had struggled to make a decision. 

“It’s completely normal” she reassured me. “You looked at all the facts and made the right decision based on what you had, it was fine.”

Apparently a ‘newly qualified wobble’ is quite normal, and shows that we care about our patients and outcomes. 

My crew mate tonight has been a Paramedic for upwards of 30 years and said he still airs on the side of caution if he’s doubting a decision. That helps 🙂 

Spice is the spice of life…ish

‘Legal highs’ are becoming a bit of a concern in healthcare circles. They are becoming more and more prevalent, especially among younger children of school/collage age!

For those that don’t know what a legal high is, it is the broad term for a range of drugs that are available legally to purchase over the internet. They pose as a plant fertiliser or similar, and are usually in powder form. They are given unusual names such as ‘whizz’ or ‘spice’, the latter being more popular. Spice is a cannabis derivative mixed with a cocktail of unknown chemicals to bulk it out. It can be smoked with tobacco or sniffed like cocaine.

The trouble with spice is, it kills people. Kills them. It produces a fierce chemical reaction with the bodies own enzymes which increases heart rate, reduces oxygen to the brain which causes respiratory failure, coma and eventually death. But not before a period of psychosis, profuse vomiting, disorientation and symptoms of a heart attack.

Delightful, where can I get some?!

Well, it seems that if you want some spice, all you need to is end up in prison. It is rife!

Cue a flashback to a recent call in the middle of the day to a Category C prison (which is for those who cannot be trusted in an open space) for a 30 year old man who was found unconscious in his cell. He was witnessed to be fitting so the prison nurse was alerted who came and treated him while we were on the way.

Despite there being no packaging for Spice anywhere, the presentation of the man was very similar to someone who had taken it.

When we arrived, we had to pass through 4 double locked gates like a safari park before being signed in to the log in triplicate, then finally being taken to the cell block. After that, we had to grab all our equipment then be escorted into the cell block.

I don’t really get nervous easily with my surroundings. I’m always aware of any danger, but very rarely get scared. I’ve been to drug dens and large fights in small rooms and always managed quite well, but for some reason, I was cacking myself!

As we walked in, every inmate stopped what they were doing and looked at us. The high walls and railings and narrow corridors made it a rather intimidating place to be.

We were shown to the cell to find a male on the floor looking pretty sick. He had a reduced level of consciousness, a racing heart and his colour was pretty poor. We were on the first floor so I needed to get a carry chair, which meant I had to go back to the ambulance and get one! This meant walking along a gangway and down some stairs to the door. Seems simple enough, but I’ve never felt like more of an outsider. Guys stood in the doors of their cells just stared at me as a walked by, people in the gangway didn’t give me much space to pass them and I didn’t really fancy making eye contact.

Anyway, my concerns aside, in the time it had taken me to get the chair and return, my crew mate had got some oxygen on him and gained IV access incase we needed to give him any drugs to stop subsequent seizures. We carried him out to the ambulance, lifted him onto the stretcher and connected our monitoring devizes. By now, he was awake enough to talk to us so we asked if he’d taken any drugs. He denied taking anything so we got driving to hospital.

Back through the security gates to the main gate where they had to find two officers who would escort him to hospital. This meant signing them all out, as well as us and handcuffing them all together. This took quite a while considering he was so unwell, but we didn’t argue – we understood.

So, I got driving to the hospital, which was a good 23 miles away. Nice and steady to start with but then I hear some commotion in the back. There’s only a small hatch between the cab and the back of the ambulance so I couldn’t really see what was happening, but with that, my crew mate popped his head through the hatch and said “keep us moving mate”, which is code for “put the lights and sirens on and don’t stop”. So, I blued the 20 minute drive through the traffic of two small towns and a city until we arrived at the hospital.

It wasn’t until after we’d handed him over to the nurses and doctors I found out what had happened to cause such a stir: He blood pressure and heart rate began rapidly dropping to the point where my colleague believed his heart would stop. He was given various drugs to maintaining a level to keep him alive but he was rapidly deteriorating. He may survive, he may have to be sedated and put into intensive care, he may die, I don’t know. But people take these drugs for a quick ‘high’ and end up critically unwell.

Just to show how commonplace this is in prisons, as we were on the way to hospital, I heard a broadcast over the radio for an emergency in the same prison for another inmate who was fitting after taking Spice…

Ambulance Crew – A Basic Survival Guide

So, you’re thinking of joining the Ambulance Service. Have a seat, make a cuppa, and I’ll tell you what you need to know to survive being an Ambulance Person.

One of the most important things to realise about working for the Ambulance Service, is that it’s not all blood and guts. In fact, it’s been quite a while since I’ve seen any guts, or brains, or body parts that should be inside the body. A large amount of our work is medical complaints; chest pain; shortness of breath; abdominal pain; strokes; headaches etc. There’s also a very large portion of mental health and social concern cases. Because of that, you need my number one rule:

• Be able to talk to anyone.

I once heard a Paramedic of 30 years say he could talk to anyone with an asshole. I thought he was joking, but actually, this is a skill you need to have. As you become more experienced and knowledgable, you’ll be able to talk about more specialist medical things, but first, being able to talk and not being scared of you own shadow is a good start. This brings me to point number two.

• Trust in your training.

You’ll turn up to your first emergency call wearing the uniform of thousands before you and be expected to know what you are doing. Have faith, you won’t be on your own (hopefully) and your basic training will kick in, no matter what the call is. For a newbie, it’s all about A B C and not doing any harm. Increased skills and knowledge will come along in time. You won’t be expected to attend (by which I mean sit in the back of the ambulance and treat on the way to hospital) a very unwell patient, so you’ll be driving the truck more than your crew mate, and so:

• ALWAYS drive to the condition of your patient.

During your driver training, you’re taught to drive as fast as it is safe to go. In reality, when driving a 6 tonne ambulance through narrow city streets with a seriously unwell patient in the back, speed is the last thing you want. Smoothness is the key! I learnt that very early on after a bollocking from my crew mate who nearly fell to the floor while treating an unwell child in the back of the ambulance while I drove on blues to the hospital. These vehicles do not handle well, they wallow around every corner and feel every bump! You’ll be thankful of this advice when the time comes for your crew mate to drive you to A&E with a patient in the back.

• Support your crew mate

You’re with them for 12 hours (or likely more) a day in a very small space, during sometimes some very emotionally charged scenes. Unless the clinical decision is dangerous, always support your crew mate. It looks unprofessional to argue on scene and will create a difficult working environment for the two of you. You can always talk it out after you’ve dropped the patient off at A&E. I’ve done shifts with people I really haven’t liked, I’m talking about proper dicks, but when it came to the clinical stuff, you need to work together, especially when time is critical. Which brings me to point 5:

• Don’t panic!

It will be tempting. You’ll have to stop and take a few deep breaths, you’re ears will be ringing and your vision narrows, you’ll feel your own heart punching you in the chest, your legs will feel weak and your brain will be moving so fast you’ll forget your own name. This will happen the first time you come across something serious like a horrific car crash. And subsequent times after that. Don’t worry about it, but don’t let it affect your care. Even the most experienced medics have that surge of adrenaline during incidents like this. The key is to take your time with things: like a swan – calm and smooth above water, but underneath paddling like fuck!! Your colleagues will be excellent and you’ll fit into the team. You’ll either know what to do, or be told what to do – both are absolutely fine.

• You’ll have memories, good and bad

No need to elaborate too much here. You’ll see some of the funniest, strangest and most heartwarming things doing this job. You’ll also see things that will steal sleep from you, give you flashbacks and haunt you. You need to be ready for that. Take comfort in the fact that you won’t be alone, and there are support networks in place.

 

 

This list isn’t exhaustive, there are hundreds of survival tips I could throw at you, but that would make a very long post indeed.

Now probably the most important rule of all:

• Never, I mean NEVER pass up the opportunity to go to the toilet. You might not see another one for 8 hours! (That ‘drive to the patient’s condition’ rule will soon go out the window when driving to hospital with a bladder the size of a small continent fit to burst!!)

This really is the best job in the world. The government won’t ever appreciate what we do, senior managers will alter your terms to make 12 hours seem harder and harder in the name of ‘efficiency’. You’ll miss your family and friends, spend Christmas Day in the houses of strangers and your body clock won’t know what hour of the day it is. But really, this job is like no other – you’re trusted with people’s lives, you offer relief to those who are anxious and ease the pain of those in need.

It’s not for everyone, but if you can stomach it, do it!

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!

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 🙂

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.

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!

 

 

Broken Leg

Not having had any seriously interesting or ‘out of the ordinary’ shouts for a couple of weeks, I thought I’d write about a routine job that I recently attended.

We were on station when we received a radio transmission from our dispatching instructing us to respond to a Priority 2 backup request for a Rapid Response Vehicle (RRV) Paramedic on scene with an elderly lady who had fallen.

There’s 4 levels of backup that a RRV can request:

P1 – This is for a truly life threatening event. For example, a patient who has stopped breathing, having a stroke, heart attack or is so unwell that they will soon stop breathing. It’s also to be used for life threatening injuries, for example a traumatic amputation with catastrophic haemorrhage or a fall from a hight with massive head trauma. The reason this is only to be used for these types of events, is because no crew will be diverted from this priority backup to another call. We would, in theory, drive past an unconscious patient to arrive at a call this highly prioritised. Respond using blue lights and sirens, of course.

P2 – Not immediately life threatening, but could become so if the patient does not arrive in hospital soon. This could be used for chest pain with no ECG changes, pain that cannot easily be managed with morphine, broken limbs with deformity but no circulatory compromise or non-life threatening incidents where a patient is outside or in the public eye. Also respond using lights and sirens.

P3 – Non-life threatening cases where the patient needs admission to hospital urgently, but not immediately. This could also be used for stable limb fractures, falls where the patient is un-injured but is too heavy to lift with one person and they need assistance from the crew, or abdominal pain with no ‘red flags’. Respond at normal road speed with no lights or sirens.

P4 – Routine admission for a medical case. This is the only priority where an RRV would arrive, assess the patient, request backup and then leave the patient in their house to wait for the crew. The patient must be safe, able to walk or have someone to assist them to walk and not be likely to deteriorate. This is also normal road speed with no lights or sirens.

So, P2 backup to the city for a fall. That’s the only information we ever get. So, blue lights and sirens on and off we roll.

We arrive to find the RRV Paramedic at the top of the stairs with a fairly large lady who had fallen while walking out of the bathroom. She was sat on a small landing holding on to the hand rail, sat on one leg. As we arrived, he was giving her a drug to stop her being sick. He gave a quick history of the event, and told us he suspected a broken hip. So, we worked on a plan to get her up.

We would give her some Morphine for the inevitable pain when moving her then lift her onto a carry chair to carry her down the stairs. We dosed her up and got ready to move.

As I mentioned, she was quite large. And heavy. And old ladies have a lot of soft tissue and not a lot of muscle, meaning she had little strength and we had nothing to really get a hold of. She was sat on a small square landing, I was stood behind her in the bathroom, my crew mate was in front of her on the stairs, 2 or 3 steps down, and the RRV was to her side on the landing.

“On lift? Ready, set, LIFT….hmmmph, arrrrgh, heeeaaaa, oooommph. Lower, lower, LOWER!” Came the cries from all three of us in synch.

Plan a) had failed. If anything, we had moved her nearer to the edge of the stairs and we were all now in a rather precarious position.

I had the idea of using a special inflatable cushion called a Mangar Elk, to raise her to the hight of our carry chair that was with me in the Bathroom, then slide her backwards onto it.

Like this, but nobody is ever that smiley.

We had encountered a small problem though; after moving her to her new position, we noted the leg she was sat on was grossly swollen at the mid-shaft femur. We had a new diagnosis of a broken leg with a possible hip fracture as well. This meant that one of us would have to manually stabilise the leg before we moved her again.

So, we slid the cushion under her bum (no mean feat, let me tell you!) then began to inflate it. As we did so, she slid further towards the stairs!!!

Between the three of us (two of us really as my crew mate held her leg straight), we somehow slid her onto the carry chair. All three of us took the opportunity to stretch our aching backs before we carried her down the stairs. So narrow were the stairs that only two of us could use our chair.

Comfy, eh? No.

So, we heaved and struggled with our lady, all the while, not letting the strain show on our faces so as not to worry the patient or her family – though the red faces and beads of sweat probably gave it away.

In the end, we carried her down the stairs, down the other stairs out the front door and wheeled her to the ambulance. Then one final lift onto the stretcher and that was that.

Hot, sweaty and aching we had done the job. Thanks to the Morphine the patient had hardly felt a thing. We gave her a little more pain relief  before the bumpy drive to hospital and set off to A&E.

Handover to the A&E Nurse, slide patient to hospital bed, clean stretcher and replace linen, clean all reusable equipment, make a list of kit used to replace, wash hands, make cup of tea and make yourself available for another emergency – all in 15 minutes to keep the government happy.

That is a typical job. Heavy lifting, frequent patient reassessment, quick thinking and a well earned brew.

We actually received a thank you letter from the patient’s family for taking such good care of their mum and being so kind to her. It’s always nice to receive a thank you for the job we do, especially when it really is hard graft 🙂

A welcome arrival

My regular crew mate and I have had a rough time recently. We appear to be busier than ever as a trust and the two of us have been to some horrific jobs of late. So our second night shift revealed a welcome change.

We had just attended the second patient in a row that didn’t need to attend hospital, and had just arranged for an out of hours doctor to visit as soon as possible for a possible UTI (water infection). I radio’d control to confirm our availability. They confirmed with…

“Roger [callsign], I’ve got you clear on scene, I’ll add those notes to the log ‘out of hours doctor arranged’. Uuuummmm….”

Uuuumm. When they say uummmm over the radio, it means there’s a job outstanding. Not a problem, the night goes faster when we’re busy.

“Yeah [callsign], I’ve got an emergency in (18 miles away) for a 24 year old female ’38 weeks pregnant, waters broken, in labour’, is that received? Over.”

“Roger all received, are we the nearest unit? Over.”

“Negative, there’s an RRV (rapid response vehicle) that will be on scene in approximately 4 minutes. Over.”

“Roger, en-route. Over.”

“Thank you. 22:12 Red base, out.”

My crew mate was driving, so on went the blue lights and off we go.

It’s never nice to know that one of your colleges, whether you know them or not, it alone at a potentially difficult job, so we drove pretty quickly to get there.

When we arrived, ‘dad’ was outside smoking.

“Are we all good inside?” I ask.

“Yeah, she’s off her face on gas and air!”

So, in I stroll as my crew mate parks up, to find and screaming lady, bare below the waist and legs akimbo. Our colleague with gloves on and his maternity kit out and ready.

He looks at me with wide eyes and says with some urgency: “Ready to go then?”

“Right you are” I quickly reply as I walked back out the door I came in.

My crew mate, who has an odd sixth sense about this sort of thing, was already unloading the stretcher on the tail lift. Before I knew it, the lady was shuffling out wrapped in a towel, and plonked herself on the stretcher as another contraction gripped her.

“WHERE’S THE FUCKING GAS?!?!” She asked. We thrust it into her hand and loaded the stretcher into the ambulance.

As my crew mate gained IV access, the RRV took a blood pressure and some information for the paperwork.

While they did this, I set up a resus’ station (I saw an experience colleague of mine do this at a horrendous double-miscarriage we attended. In that case she was 24 weeks along so there was every chance they would’ve been viable so he set up resus’ equipment just in case). I do this every time now, because if you have to resus a baby, you don’t want to be fumbling around with packaging and alike.

It was decided that the RRV would travel in with us just in case anything went wrong – we’re an optimistic bunch!!

I took the helm and drove in – two para’s in the back would be better for the patient rather than a para’ and a student, I figured.

It was almost a 40 minute drive to the waiting maternity unit. The drive needed to be quick, but smooth. Not easy in an ambulance with 300,000 miles on the clock!

The whole time, I could hear her screaming and puffing on the gas and air and my colleagues telling her not to push! She joked with them that she would make a pact that she wouldn’t deliver in the ambulance. We all knew that she probably would!

Then, a nightmare happened! Around 11 miles from the hospital, I reached a ‘Road Closed’ sign. “Shit!” I slow almost to a stop and scan the map for an alternative route. I find one, but it adds 8-10 minutes to the journey time. No choice. I shout through to the back to let them know, and they look helplessly frustrated.

We carry on until I hear the dreaded instruction…….. “Pull over, PULL OVER!!”

I do so, quickly, grab some gloves and slip onto my clammy hands. I run round and open the door just in time to see my crew mate holding a baby being freshly delivered.

He places little one straight onto mum’s chest as I dry its back to stimulate breathing.

An eternity passes and then we hear it, the first little cry of a newborn miracle!

It was an incredible moment to be a part of. We had some quick health checks to perform on mum and baby. All was in order so I continued the (much smoother and calmer) blue light drive to hospital.

The midwives were expecting us and they welcomed us with smiles and coo’d over the baby.

A quick weigh revealed 5 lb 12 oz. A very happy family and very happy Paramedics that nothing went wrong!

We cleaned the resulting mess from the ambulance and had a well earned brew. Then headed back out for whatever the night threw at us. Whatever it was, we didn’t care. We were elated! My crew mate revealed that he had never delivered a baby before, so it was a first for both of us!

Sometimes this job is EXTRA amazing!

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!