“Once in green, always in green.”

That’s what a paramedic said to me recently – “Once in green, always in green.”. Its stayed with me, round and round my head. It’s true though, you never get away from the training, or the effects of the years of heavy lifting and other abuse you put your body through. Most of all, you never get away from the way it shapes your views on life.

I’m now a first aider in my current job, a position I “volunteered” to do, and had to undergo a day long training course for. There was an incident recently, and the duty first aiders were concerned so they asked for me. I was in the staff canteen and had just put my plate of food on the table. As I sat down a colleague ran into the room and explained what was going on. I left everything and went to see what I could do. Not until I walked away after the incident did I realise that I had taken over, passing requests to the person on the phone to the emergency call taker. By the time the ambulance crew arrived, I had done all the tests and checks I was able to and I gave a reasonable handover. Then I said “I’ll leave you to it, it’s not my job anymore”. That’s when they said it: “Once in green, always in green”. I knew the paramedic, they had been a help to me when I first started.

I later apologised to the duty first aiders for walking in and taking over. “You didn’t forcefully take over. You did your job. You looked like you’re missing it too” one of them said. Back in the staff room I reheated my food…just like the old days.

After much thought I’ve come to the conclusion that you choose to be part of an ambulance service but, once you are part of it, you don’t ever get to walk away. It affects you and your life in many different ways. I’ve already repeated it a few times in this post, but it’s still going round in my head – “once in green, always in green”.

Part of me likes that, part of me is not so sure..

Stiff little fingers

Hands are amazing, each one made up of 5 fingers. We use them for everything. Every child learns to count on them. Countless wars have been fraught with them (whether firing arrows or pulling triggers). A music genre was borne from them (Google Tommy Iommi and heavy metal). It’s difficult to imagine life without them…..

Saturday night, once again we had been pulled into the big city. The call came half way through clubbing time. A young person had fallen over in a night club and their hand had landed on a broken glass on the club’s floor. Rather quickly, they realised their hand was bleeding and the top half of their fourth finger was no longer present. It was a perfect cut, through the bone too. When we arrived, the club staff had removed the, mildly drunk, patient and her friends from the club. This was common practice, partly so the revellers weren’t distracted by an ambulance crew in the club. There also seemed to be some belief that the club was no longer liable for the injury too, but we had no interest in the legalities.

Unfortunately the club staff in this instance made things slightly worse. a. They removed the patient from the scene of the accident so we weren’t entirely sure what had severed the finger (the police also had something to say to the staff regarding this). And b. The staff put the rather grubby finger into a glass of ice which they quickly handed to us as they, unsuccessfully, tried to hurry us away. Unfortunately for the patient this rendered the finger useless und unable to be reattached. Thankfully, after much wailing from the patient on the way to A&E, it was a doctor who broke the bad news….once we’d gone.

A 3 year old, in a posh suburb, Sunday afternoon. The poor child had caught their finger in a door, removing the top third. The parents had, sensibly, put the finger in a freezer bag, then in a cup of ice. It was a busy afternoon for us in our own area, lots of genuinely unwell people. This job was out of our area and took us some time to get too. It was also not classed as a life threatening emergency so we arrived without lights and sirens. This seemed to bother the parents, how could their angel not merit an emergency response?! Then began the complaints about the 3 hours they had waited since their first call. I looked at the peaceful but slightly distressed child, and thought about the severe, life threatening, seizure I had just come from. I said nothing. We loaded the patient and one parent in the Ambulance. Then the other parent announced that they’d follow us in their executive 4×4, asking if we’d be rushing them in. After a deep breath, and some thought about how best to respond, I said we’d not be rushing and asked why they had not driven their child to hospital themselves. “But that’s why we pay for ambulances!” was the horrified reply.

A severed finger will rarely merit an emergency response. I say that because there are factors such as blood thinners, and what caused the finger to be severed. In most cases, if the severed part is kept clean and dry and the wound too, and it is within an acceptable time scale, the finger can be reattached. But situations aren’t always that perfect.

I believe the nightclub was investigated and did not come away unscathed. The 3 year old’s parents probably still blame everyone but themselves. I still count myself blessed to have kept all of my fingers…this far.

You can’t hide those lyin’ eyes.

Being an ambulance crew member involves bending the truth quite often. It’s a skill you develop early in your career, an essential part of your job. Not in a nasty way, but in a clinically reassuring way. Reassurance, one of the strongest tools in our arsenal – “It’s going to be ok….”.

When your patient is having a heart attack before your eyes, the last thing you should be doing is telling them! I sat my initial training exams many years ago. Most of the questions gave a story. A patient was presenting certain symptoms, what was my diagnosis and how would I treat them? In the treatment section, we were guaranteed at least one point if we wrote, simply, “Reassurance”. This applied to unconscious patients too.

Sometimes reassuring the patient involves a slight… embellishment of the truth. You learn to hide your feelings of concern for the patient and develop an ability to put on a friendly, caring face. Neither of the latter are fake, if we didn’t care we’d not be in that job. It was more an ability to decide what our faces displayed to the patient, what was in their best interests. A good crew mate will have come to the same conclusion as yourself, and a silent look would confirm “GLF on the journey to hospital!”.

Other times your face had to hide sadness. Our job was to care, and that’s what we did. But sometimes that brought sadness – the elderly who had no relatives, the young disabled patients who’s lives had been changed forever by unfortunate circumstances. Most didn’t want our sadness of sympathy, they just wanted our help and a brief moment of support. That’s what our faces showed them.

Often it was the relatives who needed our support. If the patient had CPR ongoing, we would try to remove the relatives from the room. They didn’t need to see some of the treatment involved in a cardiac arrest – the broken ribs as a result of the chest compressions, the tube placed down the patients airway. If more crew members arrived to help or, as sometimes happened, the police arrived, one of us would take the relatives into another room. This would always involve them asking how their loved one was. Rather than tell them that, at that point they were clinically dead, we would tell them that they were “quite unwell but we were doing our very best for them”. What that meant was that, until protocols dictated, or a doctor appeared and called things to a halt, we weren’t giving up. The feelings of futility were hidden, although we were very cautious not to deliberately instill false hope in the relatives.

“Embellishing the truth” was part of the job, but your fellow crew members could usually see in your eyes exactly how you were really feeling, what you were really thinking. Mostly that was because they were feeling the same thing. Not telepathy, just an understanding. It was never malicious, and none of us enjoyed doing it. It was an unfortunate but very important part of patient care.

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.