The show must go on.

Someone recently asked me how I coped with the death and dying when I was in the Ambulance Service. I spoke in a previous post about how the crew depersonalise jobs. It’s something you learn the importance of very quickly. Often a crew will be required to give a police statement regarding a death, if a patient’s death is unexplained (usually the case, until a doctor writes a death certificate or a post mortem is carried out). One of the questions always asked is “Would you recognise the patient again?” to which I always answered “No”. The patient could be lying in the next room, but I had blanked their face from my mind, I had to. Occasionally the patient would be someone we had dealt with a number of times, one with an ongoing illness, someone you had built a rapport with. On those occasions there was sadness, and the family usually appreciated your precence.

On one occasion, I took my old school master in to hospital for a planned stay. I didn’t recognise them initially but, when I did, the respect came back as I remembered this kind person who had helped shape me and my school mates. Little did I know this would be their last journey, but I’m glad I was able to pay some kind of respect before they passed away.

The terminally ill patients were frequently inspiring. They knew the life they has left was short but they spent their time preparing, and preparing the people around them. “Live every day as if it’s your last” one of them said to me. Something I still need to remind myself of constantly. Those were the ones who lived life to the full, who often saw so many positives, even when facing their own end.

“There’s always someone worse off than you”. Words from another terminally ill patient. Words that kept me going often during my time in the service.

Some didn’t know death was coming – cardiac arrests, RTCs… The patients who had passed away before we arrived were the ones that were easy to blank out. The ones who we worked hard to save, only to have the A&E staff make the difficult decision that it was hopeless to continue, those were difficult to blank. While still being able to depersonalise the job, it was still hard to forget the effort we put in. Sometimes there was anger – anger at the patient for dying, anger at the hospital staff for giving up…anger at ourselves for failing to save a life.

I remember my first cardiac arrest. It was also my first real CPR. The horror of breaking ribs lasted seconds as we worked hard to save the patient. We rushed them to hospital but it was all hopeless. I thought I had come to terms with it until we returned to A&E the same day. One of the nurses pointed out the patient’s family being shown to the relatives room. They looked up at us as they walked past, and my heart sank as they tried to smile, grateful smiles for our efforts. Our part in it all would be forgotten quickly, but at that point in time we had done our jobs as best we could.

Sometimes relatives would ask to see us so they could thank us for our efforts. The first time I initially declined because I felt that I was “only doing the job I was being paid to do”, but a nurse politely explained how it was part of the families’ grieving process. Those moments were hard. This was someone elses’ grief, but I was being involved in it.

I saw death in many forms. While the memories of the lost ones will live on in those close to them, most will be forgotten by me over time. But there are those that will stay with me – some for good reasons, inspirational patients, some for bad reasons, the circumstances around their death. But all will have one thing in common – I don’t remember their faces.

Ice, Ice Baby

Since the weather is warm, I thought a story from winter might help cool things down a bit.

Alcohol – many enjoy it, many abstain, many consume too much. Alcohol related incidents are regular events for ambulance crews, the majority of jobs involve its cusumption somewhere in their creation.

I often wondered why, after dealing with drunk people during a shift, I wasn’t completely put off the thought of drinking alcohol myself, but that may be to do with the ability we develop whereby we are able to compartmentalise and, as a result, disassociate with certain things.

It was winter. Icy pavements, festive revelers. Myself and someone else had travelled to a different city to meet with a friend I had trained with. We had a few drinks and were walking to a different establishment for more. Ahead of us we saw a but of a fuss going on. As we got closer, we noticed someone on the ground. Instantly my training friend and I switched into serious mode. The person on the ground had slipped on the icy pavement and fallen backwards. They had hit their head on the ground an were slightly dazed when we arrived. My friend was from the area, it was their turf, so I let them take the lead. They went straight to the “patient” and began to examine them. Without any medical equipment, this didn’t take long. As I asked the “patient’s” friends what had happened my, now partner, was helping the patient to their feet. As they straightened up we both had the same thought – they were tall, therefore the distance their head had travelled before impact with the pavement was significant. As they were still dazed, we became concerned. We both agreed this person had to go to hospital but, being the festive period, we saw no need to call an ambulance. We suggested to their friends that one of them drove the patient there, but this was met with blank faces. No one was sober enough, the patient was their designated driver that night. Eventually we convinced them to flag down one of thd many taxis and they all bundled in, off to the nearest A&E department.

While this was all happening, unbeknown to us, our other friend had been talking with some surprisingly impressed onlookers. There were comments around our obvious medical knowledge. One person asked if we were doctors, or medical students. On hearing we were ambulance crew they exclaimed “Wow, they got here fast!!”.

The job never ends. Even when you leave the service, people want your medical opinions and advice. I still find myself diagnosing ailments. Thankfully, I manage to be correct in most situations.

It’s humbling to have people ask for help, although I recently had to undergo a first aid course to officially be able to assist in my current workplace. That was an….interesting experience.

I joined the Ambulance Service partly because I was a rubbish onlooker. Now I sometimes wish I could just blend into the crowd!

Go Greased Lightning..

There are many acronyms in the Ambulance Service as a whole, each division and each service will have its own. Some are common across the UK, some are local.

Examples such as GLF – “go like the wind!”, TFBUNDY – “this patient is unlikely to survive”, and ATIT – “I’d like to question the patient’s apparent unwellness” are probably still all used regularly.

The first, GLF, was a common one. A simple way to indicate to the driver the urgency of the situation, usually without distressing the patient or their relatives. While we were all trained to drive at speed and negotiate traffic, we were also taught to drive safely, constantly mindful of your partner and the patient (and their condition) in the back of the vehicle. Emergency driving is a skill that is taught at the start of your career, and is constantly assessed throughout.

One thing none of us, and no crew member in the UK will dispute, is “kiddy gear”! Every ambulance in the UK has a special gear for when the crew know a child is involved. It is, of course, a mythical gear, but it’s also an instinct that kicks in as soon as the job appears on screen. No matter what the job, the driver’s senses are heightened and kiddy gear is engaged. Often the attendant, the crew member dealing with the patients at that point, becomes more aware of the road and assists the driver. When you work closely with someone you learn to second guess them after a while.

I’ve already written about Red Mist, and how there is no place for it in an ambulance. But with heightened senses comes extra adrenaline and, when another driver makes a poor judgement (as happens frequently) the ambulance driver is likely to respond. They are only human. Each crew member usually has their favourite curse they use (most not printable here), often entirely out of habit then, once vocalised, it’s over. During the whole incident the driver will never lose control or concentration.

I was often asked what happens when you trigger a speed camera? It generates lots of paperwork and someone in an office somewhere has to show that the job in question merited excess speed at that point, otherwise the driver may be prosecuted. If the job was not an emergency we could not just use our lights and sirens. However, if the patient deteriorated or if we felt it was in the interests of the patient to hurry, we had to call in to Control and explain, then the controller would note that we were “proceeding on systems”. The stories of using blue lights to get back to the station for tea are extremely untrue!

There was, however, a road with a number of speed cameras on both sides, that may or may not have been subject to a local challenge…..strictly only ever on emergencies though, and always within the tight boundaries if safety.

Emergency Ambulance driving is not all breaking speed limits and driving fast. It’s about safely progressing through traffic and staying “shiny side up”. It’s not easy, it’s stressful, but it’s essential.

Free falling

Falling any distance is never good. During my career I saw falls from many different heights.

Often we were called to elderly or disabled people who fell out of bed. Sometimes we simply helped them back to bed and made them a cup of tea, other times they’d break bones or their social circumstances were unsatisfactory and we would take them to hospital.

I also spent a number of hours at a popular local site for jumpers – people who had decided they’d had enough of life and chose to jump from a height, in these cases, from a high bridge in the city centre. We would sit out of sight with other emergency services, “silent standby”, waiting in case they chose to jump. Thankfully, my experiences were good outcomes and the patient changed their mind or was talked out of it, usually by a trained negotiator. For some of my colleagues, their experiences were not so good. There were other occasions, at other locations where the person jumping got their wish. It’s really not a good way to die.

Then there were the accidental falls from heights, the unfortunate ones who lost their grip or hadn’t realised it was so far down. One of these was a young climber who slipped while climbing a natural rock face. They hadn’t fallen far, or at least if didn’t look that far, but it was enough to do some damage. By the time we arrived they had scraped their way back up on a pathway next to the rock face using their hands. We began to examine the patient and discovered they’d landed on their feet. The narrow bone in one of their lower legs had fractured in the impact and was protruding from the side of the of their foot in a very strange and grotesque looking way. The patient had panicked and was so pumped up with adrenaline that they hadn’t noticed!

Another memorable “fall” was self inflicted. The patient lived on the second/top floor of an apartment complex. It was a reasonably nice apartment complex so their apartment had a roof garden. Having had a rather large argument with their partner in that roof garden, the patient fount themselves locked out of the apartment and worked out that they were stranded on the roof. At this point I should probably mention the high quantity of recreational drugs both parties had taken. In their, somewhat scrambled state, the patient decided that, since they couldn’t get into the apartment via the roof garden entrance, they would go in via the front door on the ground floor, and the quickest way down was…. You can guess the rest!

Luckily there was slightly springy grass at the bottom. That didn’t prevent multiple fractures. We arrived to a still very high, fairly cheery and bemused, somewhat broken patient, lying next to a sizable dent in the grass where they had landed. After fully immobilising the patient and splinting both fractured legs, we put them in the Ambulance and began the journey to hospital. That was when the recreational drugs began to wear off and the pain kicked in. Unfortunately, due to the nature of said recreational drugs, there were strong contraindications regarding all the analgesia at our disposal. The latter part of the journey was noisy as the pain got worse. I never found out how long it was before the A&E staff was able to give the patient some pain relief, but they were still making a lot of noise when we dropped our next patient off (bad pun intended).

Gravity – use it as it’s intended to be used. Misuse is usually painful, sometimes fatal.

Rest in peace.

I’m feeling controversial….again.

Working 12 hour shifts requires energy. Some dispatchers seem to think ambulance crews have unlimited supplies of energy.

When I first began we had the option to choose “uninterruptable” meal breaks. That meant that the dispatcher could only assign us a job once the meal break was over. Almost every time, within seconds of the break finishing we would be given a job. Crews set stopwatches at the start of breaks and proved this.

Many of the old school crews initially chose to remain interruptable, any other way showed a complete lack of dedication in their eyes. Most changed to be uninterruptable after being pushed hard and realising they were changing nothing but their own health.

A prime example of this was an older crew member I worked with when I first moved to the rural station. They worked late, took extra shifts (“not because of the money, but because the community needed us!”) and basically ran their body into the ground. They became a hazard on shift because their body was no longer coping. Finally they retired and, after a handshake from some senior officer who’d never worked with them or particularly knew much about them, they never heard from the service again. They have their NHS pension, but two knee replacements later, no one has shown them any form of gratitude whatsoever for their decades of service, dedication and long term severe body wear and tear.

We enjoyed our breaks, we enjoyed the peace, a short period of time to switch off from the day’s jobs, sometimes to talk about the bad ones.

Then one day it happened – somewhere in a remote village, a trainee crew member was accused of letting a patient die while they were on a meal break. There was public outcry! The newspapers reported “Patient dies while ambulance paramedic drinks tea!” and other dramatisations. Details still appear to be sketchy regarding the whole incident, and the crew member was later found completely innocent, but the outcome was the removal of uninterruptable meal breaks nationally. Rumour has it that the patient actually died of hypothermia, not something that becomes fatal in the relatively short time it takes to drink a cup of tea, but no ambulance service officer ever stepped up to verify this, or defend the crew member in any other way.

For months, ambulance crews were being run for hours without breaks. Stories began circulating of crews testing their own blood sugar levels, finding them lower than acceptable levels then signing off unwell. The most I was was run was over 8 hours without a break. Finally the unions stepped in…

The union in my area was pointless. The reps knew the rules and they knew how to argue, but they were too close to management. “Yes” men, so nothing changed quickly. Eventually, nationally as far as I’m aware, rules were put in place whereby time windows were created within which crews must be given breaks, now known adamantly as “rest periods” by dispatchers. The only problem was that they could be given said rest period anywhere, and there were strict rules about being able to carry food, and consume it, in ambulances. Also, in winter especially, crews wanted access to microwave ovens to heat their soup etc.

Finally, after a number of incidents across the country, it was decided that crews would be returned to their home stations “wherever possible” for their rest periods. These rest periods could still be interrupted for a high priority job, but they had to return you as soon as possible for the remainder of the break.

For months, the distain was audible in the dispatchers’ voices over the radio as they returned you to your home station. For months they gleefully called, just as the microwave pinged, to send us to Cat A (the highest category) jobs. They also became experts in emotional blackmail, knowing that we would never turn down certain jobs. We got used to cold food, just as we had with cold coffee.

Things eventually settled, and dispatchers realised crews were actually happier after food…or rest. The public never knew any of this. Heaven forbid a patient found out the crew that was sent to them was tired and very hungry, possibly with reduced functionality, possibly with baseline observations unhealthier than their own.

There are many things the public don’t know about the Ambulance Services in the UK…….

Afternoons and coffee spoons.

If an army marches on its stomach, many ambulances run on caffeine. I once heard someone in a coffee shop, in the queue behind me, state “if you want to know where the good coffee is, look for the Ambulance outside.”. Its the only time I got away with parking on yellow lines. Traffic wardens (or whatever their title is at the moment) used to wave at us, often from behind us in the queue!

12 hour shifts, especially night shifts, often required multiple cups of coffee to keep me going. The only problem was trying to sleep when I got home. Worryingly, I found, over time, that stopped being a problem.

A family member got involved in the coffee culture in the city they live in a long time ago. Their coffee snobbery turned me slightly snobby. I had already lost my taste for most instant coffee, then the “microground” varieties became popular. A small tin would last a week or so, but I blame that on the fact they were so small. I knew all the good places to buy coffee in my city, and the ones who made it quickly for ambulance crews. The staff in one store, part of a huge chain, even started making mine as soon as we pulled up outside, and it was ready at the end of the bar by the time I got inside, free of charge.

I knew it was bad when one of the dispatchers deliberately sent us to the areas of certain coffee shops when they put us on standby in the city. We were always happy to do them favours. One of the local petrol stations, with a good coffee shop attached, even started to offer ambulance crews free coffee through the night. The intention was obviously to get us to fill our vehicles there, but we didn’t mind because we didn’t pay for the diesel. Unfortunately that ended because some crews abused the kindness.

Probably 75% of the time we would end up drinking our coffee, whatever the origin, lukewarm or cold. Inevitably we’d get a job, or a few in succession, shortly after the kettle went on or we left the coffee shop. Friends still comment on how long I leave my coffee before drinking it, even though I’m no longer waiting for an emergency call.

Now I get to sit and enjoy my coffees more. I drink less, I think, but I’m still a bit of a coffee snob.

I don’t think it’s an addiction, more of an appreciation…

Turn to the dark side

In-jokes are a part of every job. If you’re easily offended, I suggest you close this post now. I make no apologies for what’s coming.

My first days in an ambulance mess room were memorable for many reasons, some more than others, but it was the first time I had truly encountered that dark humour of the ambulance crew. It’s a humour I struggle with now I’m back in “normal life”, because no one else gets it. To many people it’s offensive, to ambulance crews it’s essential.

I was based in the big city at the beginning, the mess room was a busy place. A crew had just come in from a suicide attempt, a hanging. When asked about the job the jokes began about “hanging out with the patient”, the patient was “hanging around” when they arrived. The puns went on. I was horrified. How could they be so disrespectful, so blasé about the loss of a life? Another job, also a suicide. This one reported in the papers, stating “unfortunately the patient died before the ambulance arrived”, brought ridicule on the crew for taking so long to get there. The fact the patient was very dead before anyone had called for an ambulance was irrelevant.

I learned very quickly why this humour exists. It’s a coping mechanism. A way of dehumanising jobs. A way to make the things we saw acceptable, bearable. Nobody saw what we did. Nobody else understands. When we got home our partners didn’t ask how our day had gone, not because the weren’t good partners but because they hadn’t seen the things we had that day, they hadn’t experienced the emotions we had, they could listen but they would never understand. Most did the right thing and didn’t try.

During my time a crew was reported for being seen laughing in the front of the ambulance on the way to an emergency. I still don’t know what was going on in the head of the person who made that complaint. Not sympathy, not care, not gratitude. Nothing good. I know what the crew were going to, and what they saw. I know why they were acting the way they were and I know it fully justified.

Frontline emergency care can be a dark place. Your crew mates are your only support because they are the only ones that actually know what you are going through because they are going through it too. There is no room for uneducated “do gooders” or interfering members of the public who think they know best.

Being a front line member of any ambulance service is a unique way of life, and the lows are mostly bearable because of the highs, but until you have experienced the life first hand, please don’t condemn the seemingly twisted humour. Don’t frown when a crew member says something that sounds uncaring. If they didn’t care, they’d not sign on again and again, knowing there was yet another heartache out there….waiting, ready to take on their defenses. And if they make a joke that you find unfunny, or possibly even offensive, show your support and laugh anyway. And please don’t look down your nose next time you see the crew of an ambulance laughing on the way to a job. Their professionalism, dedication and commitment is being demonstrated right there – they are potentially on their way to something most people will never have to see or deal with, what you are seeing in that cabin is nothing more than their way of coping.

“Alpha 62. Purple call…..”