Image by soapylove, on Flickr

This website was launched on Thursday December 4th, 2008, with my initial post, Snapshots.

As a Birthday celebration I asked Jon (my website guy) to pull some facts and figures out of the analytics for the website. Here’s what he came up with.

Aside from the homepage, the most popular page on the site is the gallery. I will definitely try to add more photos to this in 2012!

The three most popular stories (in terms of pageviews) on the site are:

1. June 2010 – where I wrote about how London Ambulance Service decided they would no longer use ECPs as part of their workforce. ECPs were officially redeployed to other roles as of April 2011.
2. August 2009 – where I wrote about the subject of Paramedic Prescribing – which continues to be a hot topic.
3. January 2010 – where Charlotte kindly wrote the first in a short series of articles on Life as a Student Paramedic.

Image by aeu04117 on Flickr

It must be something in the air at this time of year. One of my recent shifts was like a groundhog day. It consisted almost entirely of patients who had either vomiting or diarrhoea or vomiting and diarrhoea. These were all otherwise healthy young people; all had a pair of legs in good working order – perfect for walking to the ambulance with. None had had their symptoms for more than about 6 hours and none had considered contacting their GP before calling an ambulance.

Excuses for not contacting the GP were various and included; “I don’t like my GP” (well change your GP then!). “He’d have just sent me to A&E” (most unlikely). “I can’t get to the GP because I have to work from 12.00- 18.00hrs” (Well perhaps you could have gone in the morning). “I couldn’t go to the GP because I can’t walk” (see comment above about patients all being in possession of a pair of fully functioning legs) and my personal favourite “Well I had this once before 5 years ago and now it’s happened again, so I think I should have it checked out properly.”

Similarly, I did a shift in a hospital recently where I saw three patients with minor head injuries. None had been knocked out or had any visible laceration, bump or bruise (well apart from one who had a rapidly fading slightly pinkish patch where where his head knocked on the frame of some gym equipment that he had carelessly walked in to). None had vomited or even felt a bit sick; there were no visual problems, convulsions, loss of memory or co-ordination, headache – no anything in fact between the lot of them. (This list comprises of some of the things that we may worry about in head injuries – see NICE guidance on Head Injury if you want to find out more).

One guy even told me that he had actually bumped his head a whole week before and although he had no symptoms whatsoever, then or now, he decided to come to hospital simply because a bloke down the pub told him he should definitely get a check up and probably needed an X-ray – that ‘bloke down the pub’ has a lot to answer for in my mind – I have seen an awful lot of patients who pitched up following his expert medical advice now I think about it! Forget ‘Street Doctor’ let’s have a TV series called ‘The Bloke Down the Pub who is not a Doctor’ – because that guy really knows what he is talking about – NOT!

Image by fazen on Flickr

It can be a bit hit and miss when you take an observer out for a shift on the ambulance. No self respecting observer arranges an observation shift with the London Ambulance Service hoping for a quite night on station drinking tea and watching Strictly Come X Factor on Ice; and of course we want get a chance to drive fast, show off our skills a bit and generally give them a night to remember.

Clearly there is something of the Munchausen by Proxy personality in the vast majority of us ambulance personnel. On one hand, while not wishing for anyone to befall a dreadful accident, on the other hand we kind of hope that if they do, that it will be our ambulance that gets sent to them – particularly if we have an observer to show off in front of.

Our definition of a ‘good job’ of course, is probably your idea of a ‘nightmare’, one that will undoubtedly become the blood curdling subject of your dinner party conversations for years to come – long after we have forgotten how much we enjoyed bravely wading knee-deep in your body parts while heroically rescuing you from whatever horror you had succumbed (you can be certain that’s how we will retell the story anyway).

Most shifts we are damn busy and we barely pause for breath for the whole 12 hours. We tend to just lurch from one call to the next. Often we are then rewarded for our considerable efforts with a ‘late job’ to ensure we get home absolutely knackered and even later than anticipated.

In fact the chances of getting off on-time are inversely proportionate to how important it is to be heading away from work as the second hand moves into overtime. For example if, as has happened to  me in the past, your child has their first lead role in the school play you know with absolute certainty that you can kiss goodbye to any hopes of seeing their debut; some selfish bugger with an acute case of ‘No Discernible Symptom Syndrome’ (NDSS) will chose precisely those closing moments of your shift to call 999 for a check-up and you can bet your life that your ambulance will be the only available one within a 20 miles radius. You will arrive at the performance, exhausted just as the fat lady sings and your child starts sobbing because you missed her bit.

The moment one puts an observer into the equation things turn on its head. Rather than being run ragged, we instead run the risk of developing pressure sores from complete immobility, only offset by getting up occasionally to source the next round of tea. The deflated observer hears our pitiful plea that ‘it’s not normally like this – honestly – we’re usually really, really busy’ but it sounds hollow and you know they don’t believe you.

I worked a shift on an ambulance recently with an observer Alfonso who had travelled all the way from Italy for the shift – no pressure there then! Thankfully, fate was kind to us, if not to our poor patients. We had a full-on night. As well as the predictable run of unwell folk, including a couple of kids and a couple of ‘blue calls’, we went to a nursing home for the elderly victim of a cardiac arrest. This happened in a room that was not much bigger in dimensions than the bed it contained and it must have appeared like a surreal, uniformed version of Twister (TM) as we clambered and climbed over each other to undertake various aspects of the resuscitation – and why are those places always so uncomfortably hot?

Of course no observational shift would be complete without the obligatory comedy moment. We got a call to a lady who had had rather too much alcohol to drink and had vomited – prompting a a party goer to reach for the phone and call 999.

As soon as we arrived at the private house party where our patient had taken unwell, it was clear that things were going to get interesting. Firstly, our patient had got drunk on mead – who drinks mead these days? I noticed the flower garland in one lady’s hair ….and then her black cape. One man in the group was dressed like a glamorous undertaker, complete with heavy black eyeliner, top hat and tails. It transpired that this was a party for witches and our patient was a real live witch no less! During our assessment of her, she regaled us with a fascinating story; apparently her husband’s nickname for her was ‘Old Trunkard’

‘Do you mean drunkard?’ I asked in a non judgemental sort of way.

‘No, no it’s Trunkard’ She then went on to explain in detail how she earned the moniker after she fell on to an ornamental elephant and the trunk of the ornament ‘accidentally’ entered her body, necessitating a hospital admission to have the offending item removed from the orifice. She had us in hysterics and thanks to the considerate inclusion of many commonly recognised international hand gestures, no detail was lost in translation for Alfonso.

You know what it’s like when you have a new born baby to look after. You would do anything in your power to keep them safe from harm. One new mum took things a little bit far recently when she found a wasp’s nest in the family home.

A scaremongering friend panicked our new mum by saying that if the wasp went near her baby boy it could kill him. The same friend also helpfully offered a strategy for dealing with the creatures – unfortunately this strategy didn’t involve anything as sensible as contacting the local pest control company. No, this plan involved a lighter and can of hairspray!!! This was never going to go well, but thankfully it wasn’t as bad as it could have been – all things considered.

Fearing for her little one’s life when a lazy wasp took flight in the bedroom, our new mum rushed for the hairspray and lighter. Then with her home-made flame thrower directed at the wasp, things quickly took a turn for the worse. The curtains caught alight and smoke rapidly filled the room.

Luckily the baby was in the next room and mum was able to get them both out to safety. When I arrived the pair were seated safely in the fire-engine – mum was sobbing her heart out. Now, with the benefit of hind-sight, she couldn’t believe that she’d followed her friend’s stupid advice.

We took the pair of them to hospital for a check-up and thankfully the only harm done was to the fixtures and fittings so both were discharged home later that day. As for the wasp, well I have no idea how he did in all this!

X-ray of a foot showing Lisfranc fracture

Tom was brought in by a friend who wore a distinctly sheepish expression as he manoeuvred the wheel chair along the corridor. The patient had a particularly swollen and painful right foot; even I didn’t need an x-ray to tell me that something was amiss.

“This chap ran over my foot” he said by way of an explanation when I asked him what had happened. In fact, what he said differed slightly from that but as I am a lady I find I am unable to repeat the colloquial and somewhat colourful words that he actually used.

Tom had managed to bag a lift home after a hard day on the building site. He jumped out of the 4×4 while his mate was stopped at a red light but leant back in the car to retrieve his rucksack just as matey was beginning to pull away. The back wheel drove right over his steel toe capped boot that housed the afore mentioned right foot. Having witnessed Tom’s potty-mouth first-hand I can only imagine what delights must have been emitted as the vehicle lolloped over it – the thought made me blush!

His x-ray was quite spectacular (see below). You can see below that many of the bones in the mid-foot had been pushed outwards to the right (dislocated) and a couple of them were also fractured, the bone leading up to his big toe was also dislocated to the left, this type of fracture called a Lisfranc after Jacques Lisfranc, Napolean’s military surgeon in the early 1800′s. Surgery would be required to return the bones to their natural position and fix them there. I have put two radiographs here to show you how his foot looked and how it should look.

X-ray of a foot showing Lisfranc fracture

X-ray of a foot with no acute injury

Image courtesy megadem on Flickr

I was telling my friends and family about a call I went to recently. It involved a toddler hit by a car with possible life changing or life threatening injuries. My colleagues and I were busy – we had a child screaming with a head injury and the pain of numerous broken bones needing our urgent medical attention, not to mention a traumatised mother and older brother to consider. In the middle of all of this organised chaos I went to retrieve some equipment from my car and as I looked up I noticed that a number of bystanders were holding their phones out in front of them, focussed on the child, filming the incident.

I have to say that I feel considerable disgust at this new social propensity for members of the public to reach for their mobile phone to capture every detail of the suffering of another human being.

When it comes to the media, this is their bread and butter; even the police have no absolute right to stop them from filming. In their guidance it states they have ‘no legal power or moral responsibility to prevent or restrict what they record’. Some matters, arguably, are in the public interest; after all the media are responsible for capturing everyday situations and dramas to inform and record both for contemporaneous and future consumption and that is, perhaps, how it should be. For example, the amateur footage of the tsunami gave an almighty boost to the relief effort; court cases of police brutality have been won and lost on the basis of recorded material – often provided by the public.

However, it surprised me to discover that even if the mother of the child had asked the police to stop people filming him that guidance states ‘If someone distressed or bereaved asks the police to stop the media recording them, the request can be passed on to the media, but not enforced’ – Really? Should that be so?

Am I being a hypocrite? Undeniably.  I too have been ‘guilty’ of watching this stuff on numerous occasions, as has anyone who watches the News at Ten. Perhaps though, there are degrees of hypocrisy. This however, is about the lack of ability in each of us to regulate the setting of our own moral barometer. Have we really become so desensitized to the suffering of others because of the graphic images we are regularly bombarded with in the media that we actually delight in the pain and suffering of a small child to the point where we welcome its presence because it gives us something to share and talk with the family when there’s nothing good on the telly?

What will these non-media people do with their booty?

A) Share it with their children over dinner

B) Commit it to DVD format

C) Send it in to Harry Hill’s TV Burp because one of the paramedics rather hysterically tripped up on some equipment?

A big red helicopter landing on an urban lawn the size of a postage stamp is interesting material, and you can film me doing my job should you wish – I’m doing nothing wrong. Film the blue lights on the brightly coloured ambulance if that’s what you like; but please draw the line at filming a little child lying in the road clearly terrified and suffering during what could be his last moments of life – because next time it could be your child.

I saw a 25 year old man recently in an Urgent Care Centre where I work; he was in an awful state with an infected wound to his hand.

Just over two weeks earlier he had a nasty accident which involved white spirit and a lit cigarette. He sustained terrible, full thickness burns to his dominant right hand – the areas affected worst were his 2nd, 3rd, and 4th fingers and the palm of his hand. Following an initial assessment at a local emergency department he had been transferred to a burns unit some 25+ miles away for definitive care. There his wounds were treated and dressed. He was discharged and expected to return every other day to have his wounds redressed.

And therein lay the problem; this particular young man is homeless and penniless. He had no means to get himself the 25+ miles to the burns unit. But, each time he presented himself to a local emergency department he was turned away and instead advised to go back to the burns unit. Days passed, the dressing remained unchanged and the young man slept rough – perhaps predictably his wounds became infected and painful.

He came to our unit and we didn’t turn him away. Once I called him in he was given some strong painkillers. The filthy blood- and pus-contaminated dressings were by now, firmly adhered to his flesh. I soaked his hand in water to soften them up and eventually I was able to begin to gently remove them from his hand and fingers – the smell was absolutely dreadful and I feared the worst.

Unfortunately, I found that the top of one of his fingers was necrotic (blackened, dead tissue) and another two were practically falling apart as the dressings were lifted off. I put on some temporary dressings and referred him back to the burns unit, where he was taken by hospital transport for surgery. I hope they can save the rest of his fingers – life is already difficult enough for him – but of course I’ll probably never know…

Image Courtesy D. Sharon Pruitt on Flickr

One of the toughest tasks that I’ve ever had to do at work didn’t involve any blood or trauma, but it left me choking back the tears just the same.

We had been called to a young mother found by her husband when he arrived home after work, as he entered the living room he was confronted by the sad scene of his little daughter sitting beside her “Mummy’s asleep” she whispered to him.

It appears that she had unexpectedly collapsed while at home looking after her little girl. He called 999 immediately and we were there within minutes, but unfortunately it was already too late.

Initially the details were unclear due to the confusion that can naturally occur in these situations. However, once we realised that it had been more than an hour since her heart had ceased beating and she no longer breathed for herself we stopped our attempts at resuscitating her.

I broke the dreadful news to her husband that his wife had died. Breaking the news to him it was hard enough, but then he asked me to help tell their four year old daughter.

There was no hurry now; she had been taken upstairs by relatives by the time we had arrived, which gave us a bit of time to organise ourselves. I realised at this point that I had never had to break bad news, in particular the news of the death of a loved one, to a young child before. I felt ill prepared and emotional just thinking about it. I remembered some stuff from way back during my nurse training which I called in to play. It suggested not telling children bad news in their own bedroom, as that should be a sanctuary that they can retreat to in the future. It was also about the importance of using age appropriate language rather than medical jargon and using the term ‘has died’ or ‘is dead’ rather than ‘gone away or ‘gone to sleep’ so there is no room for confusion.

Dad and I talked and we decided that it was best if the news came from him with me there for support. We agreed that if he should feel unable to say it, he would give me a look and I would step in and say what needed to be said on his behalf; and when it came to it, that’s exactly what happened. He was too upset and unable to articulate the words when faced with his daughter’s open expression.

As I said the words ‘Sweetie, I have some very, very sad news for you…I am so sorry but Mummy has died…’ I thought my heart was going to bang out of my chest, and my throat squeezed and burned with raw emotion as she turned her head in to her father’s neck and began sobbing pitifully.

I’m not just a paramedic; I am first and foremost a mother. The pain of their loss touched me deeply, but children are amazingly resilient. She has a loving father and wonderful extended family to care for her so I’m sure that she’ll be fine, but of course the nature of my job means that I will never know for sure.

If you are experiencing a similar tragedy and are looking for support, please visit the Child Bereavement Charity.

Levitation, by theyoungthousands, on Flickr

Things aren’t always what they seem at first. When people are describing what has happened to them when they call 999 for help, it can be open to interpretation and even a small breakdown in communication can mean we find something completely different to what we were expecting when we arrive. Language barriers, third party callers and bad connections among other things may all contribute to the problem.

Let me give you an example ‘Male cut leg on food blender’ doesn’t sound too ominous does it? In fact maybe this patient should just take a painkiller, pop on a plaster and man up!

Well, when we arrived and found that actually this was rather more ‘Male cut leg on a great big, heavy, spinning, circular saw’ type of injury we realised quickly that a plaster and a couple of painkillers may not suffice. As we peeled off the two blood soaked sweat shirts to see what we were dealing with we discovered a deep wound that had reached the bone, it would certainly need some skilled surgical intervention. So, after we applied a pressure dressing and administered some serious painkillers through a cannula in to his arm we popped him to hospital ‘quick-as-you-like’.

Another patient was described with injuries thus ‘Female hurt foot when she dropped her drawers’ Oh come on, be honest, it instantly conjures up various possible scenarios in your mind, well it did for me! I was eager to see this woman, she sounded interesting…. Sadly, it would appear that this was nothing more than a common or garden injury sustained while putting together some IKEA furniture. This furniture was accidentally dropped on the aforementioned foot and caused some nasty bruising and swelling. I was quick to point out to her that although she had given me ample fodder for jokes at her expense with her unintentional double entendre, I had admirably refrained from doing so -  I am nothing if not professional and I think that she appreciated that.
Moving on in my assessment of her injury, I asked her if a she had taking any action to help herself deal with the pain and she replied;
“Well I’ve ‘levitated”
“‘Levitated’ you say?”I smiled encouragingly.
“Yes, since it happened, I’ve been levitating, you know?”
“Really? ‘Levitating’ excellent! Now I’d pay good money to see that, can you show me how you’ve been doing this ‘levitating’ please?” Promptly, she stuck her foot out in front of her.
“Ah – ‘elevating’ Well I’m sorry, but I’m not giving you any money for that!” I said, very disappointed.

When it comes to dislocation of the shoulder, rapid treatment is best to eliminate the stretch and compression of nerves and muscles in the area; it also reduces the muscle spasm which can make getting the shoulder back in to the correct position more of a challenge if left for greater lengths of time. Not least, early treatment resolves the not insignificant problem of unnecessary pain that the patient suffers.

In the hospital setting the patient is usually lightly anaesthetised and/or given a muscle relaxant. These medications are very powerful and therefore the patient will need constant monitoring in the resuscitation or high dependency area during treatment. As a student nurse and again while I worked in the Emergency Department as a staff nurse, I was occasional witness to what looked like tortuous efforts on the part of doctors to reduce (put back) dislocated shoulders. These eye watering procedures usually involved a lot of pulling while some doctor’s be-socked foot would be pushed in to the armpit region as a sort of counter-traction as they pulled the arm. Numerous methods to achieve the desired end exist, often deservedly named after the clever doctor who had spent long hours devising it.

Beautifully depicted here showing what appears to be a random child providing counter-traction is the Hippocrates Technique!

Despite the numerous methods, all with their relative merits, sadly, little has been written about or developed for application in the pre-hospital arena. This means that as paramedics we simply give the patient analgesia, stabilise the affected arm and convey to hospital navigating bumpy highways and byways en route which only add to the discomfort.

Luckily for me, during my placement in the ED for my Emergency Care Practitioner training, a kind and helpful registrar taught me a wonderfully easy technique to reduce a simple dislocation of the shoulder (by that I mean those dislocations where there is no suspicion of a fracture) and now I am pleased to say that so far 6 patients have benefited from the technique – all of whom have been very grateful!  The Stimson’s Technique doesn’t involve any torture and is relatively stress free. Personally, I’ve found that it has never taken more than 5 minutes for the shoulder to ‘pop’ back to where it should be. If I can get them to really relax or even better, have a laugh about something, it seems to help speed up the process. I’ve performed it on a pub table, the back of a sofa (x2) and a canteen table amongst other places! (Telling them just that often makes them laugh funnily enough!).

However, with one of my patients, the process seemed to be taking longer than expected; I rubbed and manipulated the joint for an age and still no ‘pop’. Finally, admitting failure, I said to him that I would have to refer him to a medical colleague for further treatment and he said.

‘Oh no, it’s ok,  it went back in ages ago’
‘Really? Why didn’t you tell me?’ I asked
‘The massage felt nice’ was his cheeky reply!

Another success story at least – even if he was a bit naughty!

These patients will still require good analgesia and a trip to hospital for a follow up x-ray but the ‘time to treatment’ is vastly reduced – which has to be a good thing for the patient. I would love to see it brought in routinely for pre-hospital use so more patients can benefit.