Nee Naw

My trainee and I had another BBA (that’s “Born Before Arrival”!) in the middle of a long, hard nightshift. I’m beginning to think she attracts them; I’d only had five in the two-and-a-half years I’d been at Control and now I have had two in three weeks!

Anyway, this BBA was a bit different from the usual variety. Normally someone rings up as the woman realises she is about to give birth and isn’t going to make it to the hospital by conventional means in time. In this case, the baby had made it all the way out before the husband had managed to scramble to the phone.

“She gave birth, she gave birth…” he kept telling us. At first I thought he was telling us that his wife had recently given birth and now had some kind of problem, but then I clocked that she had actually just given birth that very second.

“What’s the address?” asked my trainee.

“101 Clajakjstaiteiowhkdstnaskykajstykasyasoyjsahajalalallaala Street, E16!” said the man. I’m not exaggerating; his address really was that complicated. To make matters worse, he had a really strong accent of some variety, which made it hard to understand his spelling of the word, and spoke very quickly. He then got a bit annoyed that we hadn’t managed to find the address straight away, and started yelling at us to “hurry up” (really annoying when you are waiting for someone to convey some information to you) and then told us that the baby was “floppy and not moving”.

Uh oh!

Fortunately we got the address on the second attempt and set about examining the baby. There was no crying whatsoever - I couldn’t even tell the baby was there, but the father told me — rather uncertainly — that the baby was breathing and moving her arms and legs a little bit. I wasn’t 100% convinced that the baby was breathing, and neither were the dispatch desk, who’d been listening to the call. They had sent two crews, giving both the message that the baby was possibly suspended.

Trainee and I ran through all the instructions, including clearing the baby’s mouth and positioning her to open up her airway, but the baby remained silent. According to the father, she was making a slight gurgling sound (which worried me even more because I didn’t know if it was normal baby gurgling or agonal breathing gurgling) but there was absolutely no hint of crying. It’s not often that anyone wants to hear a crying baby, but believe me, I would have given my right arm to hear a resounding “Waaaaah!” at that point! All we could do was tell him to keep watching the baby and ask every five seconds if she was still breathing, which he said she was. Still no crying.

The first ambulance arrived soon afterwards and the father thanked us for our help and handed the baby over to the crew. We then had a very anxious wait where we checked the call log every 30 seconds to see what was happening. I was terrified that the crew would find that the baby had actually stopped breathing, and that we should have started CPR whilst still on the phone.

After half an hour, a message popped up on the log:

“Rang Royal London to arrange midwife to scene. Mother Jamila Khan, 1/1/80, baby and mother well.”

Phew! Apparently the baby had been fine after a little bit of suction to clear her throat and everything else was totally normal. Still, I will never forget the nasty feeling of not knowing if that baby was really breathing. I wish we had video phones so we could see what was really going on in caller’s houses. I’m so glad this one had a happy ending.

You might remember my recent post about a misleading article in Metro about the death of Kayleigh Christie. Kayleigh died as a result of a prolonged epileptic fit; she may have been saved if she had been taken to hospital quicker (she had to wait 30 mins for an ambulance, though an FRU was on scene within five minutes) or if she had been sent a paramedic crew rather than EMTs, as EMTs cannot give diazepam. There were a lot of comments on my post, and I thought you would be interested to know that a long statement is now available on the LAS intranet (though I can’t find it anywhere on a public site, which is rather odd). The report clears up some of the confusion arising from the various articles in the press. It states that the nearest FRU (response car), who was an EMT, was dispatched and, on arrival, reported that Kayleigh was in status epilepticus and that a paramedic crew was needed. One was dispatched straight away, but on the way to Kayleigh’s house, it came across a serious road traffic accident and had to stop and help. The next ambulance to become available was sent to Kayleigh, but this was an EMT crew. Kayleigh’s case was never “downgraded to a lesser emergency” as reported in Metro, nor was the ambulance cancelled for a higher priority call — it was “cancelled” because it had come across the road traffic accident. It is not clear whether the Control staff tried to find a paramedic crew, or simply sent the nearest. (I suspect that if things were busy enough to warrant a 30 minute wait, the EMT crew were the *only* crew available, but I don’t know this for a fact). Kayleigh stopped breathing after she reached hospital. There is no comment as to whether the delay and lack of paramedics caused her death.

Since the statement appeared, there have been changes in the control room. A memo has gone round stating that ALL calls to epileptic fits should be sent a paramedic crew. Every paramedic crew is now flagged on the computer with an “H” (don’t ask me why it isn’t a P!) so Control staff can easily identify which crews are paramedics and allocate calls more appropriately. The LAS also want the rules changed so that EMTs can administer diazepam.

I hope these changes will prevent another tragedy like this happening.

“I am very seeeeek! I have too much pain. Pain all over. Womiting, womiting, womiting. Too much womit. Coughing. I cannot breathe. It’s an emergency! I am Category A! I have severe respiratory distress! Where is my ambulance? Send it now, or I will sue you!”

In other words, I have woken up with a bit of a cold, sore throat and slight temperature. Poor me. After another three nightshifts and the freezing cold weather, I bet I will end up iller than half our patients.

I think I was a little optimistic with the last entry — I’ve been struggling with the training a bit. It went well when it was me showing her what to do but now she is doing things and I am supervising I am not really sure what to do. Still, the Call Taking Controller has been very understanding and if I can’t get the hang of it in another couple of days they will find her a new trainer. I feel rather guilty about this, like I am letting her down, but I have been trying my hardest and she is really good anyway, so I don’t think her progress is going to be affected.

I know I am good at my job but unfortunately I am not so sure I am good at teaching other people to do it :-/

It’s not all been bad, though — there have been some interesting calls. We had a BBA (baby delivered over the phone) the other day, which is always exciting. We also stayed on the line with the relatives of an unconscious diabetic and the relatives actually asked the ambulance crew to thank my trainee for being so helpful — this rarely happens, so they must have been really impressed with her. I bet they’d be surprised if they knew how long she’d been there!

I was dead nervous about starting training my newbie, probably more nervous than I was about being a newbie myself (way back when, when ambulances were horses and carts…) It’s silly really, because I don’t get nervous about teaching people to do CPR on their relatives over the phone, so why should I get nervous about teaching someone to do their job? Anyway, there wasn’t really anything to be nervous about as my trainee is doing very well and is a pleasure to teach. Phew! Training is not that hard, although I do catch myself sounding a bit like my driving instructor at times, and occasionally catch myself uttering a banned phrase like “ambulance” every now and again, at which point I have to slap myself in the face and tell her to pretend she didn’t hear me.

It is probably as good practice for me as it is for her. By the end of the 10 shifts I will have totally eliminated all my bad habits.

Computers went down for “planned maintenance” for a few hours this morning, which always creates a bit of controlled mayhem. All the tickets have to be handwritten and people are appointed to run backwards and forwards between call taking and dispatch with them. The ambulance service worked for years just fine without computers, but for someone like me who arrived long after the computers did, losing the ability to see exactly where the ambulance is, the prompts for the triage questions and other facilities is quite unnerving. I hope it didn’t put my trainee off. At least she got to see how Control works on paper whilst she was still training, and not be plunged in at the deep end when she is signed off.

I have to write a school report style thing on her tomorrow. I’m quite looking forward to this. I might dig out my own school reports to assist… “Newbie must not talk in class… Newbie should pay more attention in Geography…” okay, maybe not.

Peter Bradley, the chief of the ambulance service, says there is no such thing as an inappropriate 999 call — all our callers have rung us because they need help and have nowhere else to turn to. I’m afraid to say that after two and a half years of stubbed toes and runny noses, my attitude is a bit less sympathetic than his. Here are some statistics for you:

• 10% of Londoners would call 999 if suffering from flu symptoms. (Elsewhere in the country, the figure is 3%)
• 50% of Londoners would call 999 as a first course of action if a pregnant woman began to go into labour.
• 40% would call 999 if having difficulty getting through to their GP. 30% would call if they were told they could not get a doctor’s appointment for several days.
• Around 60% of 999 calls made in London have no medical need for an ambulance at all.

The ambulance service has tried campaigning to stop people calling 999 inappropriately, but campaigns such as “Only one of these is a taxi service…” weren’t terribly successful. Apparently they inspired even more people to call 999 with rubbish, their rationale being “well, if other people are doing it and getting away with it, why shouldn’t I?” Instead, they’ve tried a new tack. They will let the inappropriate callers continue to call, and tailored their services so the calls are no longer inappropriate.

The 60% who call, but don’t need an ambulance, is made up of various types of call: complete timewasters like the Toe Taxi man, people who need hospital but not an ambulance (eg. someone with a broken arm, women in normal labour), people who need medical treatment but not hospital (eg. someone with chronic backache), people who need non-medical help (police, social work, carer, alcoholics anonymous), etc, etc.

Instead of sending a bog standard ambulance to lower priority calls, they can be dealt with by one of the following. Most of these are sent out by the Urgent Operations Centre, a separate control room upstairs from ours:

• Introduction of “intermediate tier” vehicles, which have a grade 1 technician crew with basic training (not the same as the technicians on ‘normal’ ambulances, who have a wider range of skills and can give some drugs) . Their role is just to get people to hospital if they need to go, but not as a life threatening emergency.
• Emergency Care Practioners, a paramedic with extra training who arrives in a car and treats the patient at home without them needing to go to hospital. They are particularly useful for stitching and dressing wounds.
• Telephone Advice, who call back the lowest priority calls and either tell the patient how to deal with their situation themselves (either homecare advice or by contacting their GP/midwife/etc) or determine that they do need an ambulance, and if so, what kind of ambulance and how quickly.
• Sending a car to every call. This system has not been introduced yet, but my understanding of it is that they will get a responder on scene to all calls as quickly as possible, and that responder will evaluate what is needed next. An ambulance will still be dispatched at the same time if possible, so this will not cause delays, but it can be cancelled by the car responder, so time wasters will not get their free ride to hospital.

Things I’d like to see happen too:

• Fines for those who lie to get an ambulance, or call us out for something they know not to be a life threatening emergency.
• Small charges for all calls (perhaps refundable with a doctor’s signature?) to deter people using ambulances because they can’t afford a taxi.
• Help with transport costs to hospital in taxis for people on a low income.
• Better availability of emergency GP appointments and visits. My local surgery only offers emergency appointments if you ring up between 9 and 10am - not much use if you get ill at 1030am!
• More education for what you should and shouldn’t call an ambulance for, coupled with what you should do instead, and the consequences of calling an ambulance that you don’t need, both in terms of punishment and the other people who will be deprived by your actions.
• Ability for patients to request non-emergency ambulances for themselves in certain circumstances via a different phone number. At the moment this can only be done via a doctor or other healthcare professional
• Reforms to AMPDS for more accurate categorisation of calls

All the methods that I’ve mentioned here are in their early stages, and right now they’re very overstretched. There are not enough Intermediate Tier vehicles and people have a long wait for a call back from Telephone Advice (half an hour to an hour is usual). Any overspill goes back to Nee Naw Control and interferes with the emergency workload, causing delays reaching the most seriously ill patients. But the situation is getting better - even in the two and a half years I have worked in Control, I have noticed the difference. Let’s hope things continue to improve.

A new set of trainees begins at Nee Naw Control on Monday and I have been asked to train one in call taking! This is the first time I have done training (unless you count teaching illiterate nurses how to switch their computers on in my last job) so I am a bit nervous about it. I’m going to spend the whole weekend (well, apart from going to the football… and the pub afterwards…) pouring over my training folder and my old diary entries so I remember what it was like to be a Newbie. I am sure I have picked up some bad habits over the years — saying the forbidden phrase the ambulance is on its way is the one that springs to mind — so I had better make sure I don’t pass them on to her. Obviously, I won’t be reporting on my trainee’s progress as that wouldn’t be fair on her, but I expect I will learn something from it myself, which might make for interesting blogging. I was getting a bit sick of being on the radio all the time; it’s like watching the action rather than participating in it yourself.

I hope my trainee is nice!

Wish me luck!

I stumbled across a worrying article in Metro (a free newspaper, given out at train and tube stations). Not only was it worrying because of the events described — the tragic death of a teenage girl from epilepsy, which may have been prevented if a paramedic ambulance had been able to reach the scene earlier — but because of the portrayal of ambulance control staff and Emergency Medical Technicians.

Before I go on I should state that I was not in any way involved in this incident and have no insider knowledge of it. The following is based entirely on reading the article and my experience of similar situations at work.

The phrases that worried me were:

A controller then downgraded her case to a lesser emergency, further delaying the response.

This is impossible. There is no facility on our computers to downgrade a call once it has been taken. Even if it were possible, it would not be allowed (in cases where we get a second call about a patient, where the patient’s condition has improved, the second call will be discarded and an ambulance will be sent on the first, higher priority ticket). Finally, even if it were not impossible and were allowed, it would still be incorrect, because continuous epileptic fitting is a Cat A emergency.

An ambulance was then dispatched but it was forced to stop at an accident scene and so never reached Kayleigh.

How is this a “999 blunder”? Running calls are an unfortunate coincidence and a fact of life - not anyone’s fault.

Despite her mother Jean Murphy pleading for a qualified paramedic, the control room sent a series of ‘technicians’ instead…
When that vehicle finally arrived, not one of the three staff on board was qualified to provide anything other than oxygen.

First of all, an explanation of the difference between paramedics and technicians. Non-medical people tend to think of all ambulance crew members as paramedics, probably because it’s a more familiar and shorter term than “Emergency Medical Technician”. In actual fact, only one third of road staff are paramedics. A paramedic is simply an Emergency Medical Technician who has taken on some extra training, which allows him/her to administer drugs intravenously, intubate patients (put a breathing tube in their lungs), perform cricothyrotomies (putting a breathing tube into someone’s windpipe and other basic surgical procedures. A few paramedics qualify via a university course, but most will apply to go on to a paramedic course after years of experience on the road as an EMT. It’s not easy to get a place on a paramedic course; there is a long application form, exams and interviews before you are even accepted. For this reason, there will always be more technicians than paramedics, and while the service try to put one paramedic into every crew, it isn’t always possible.

The assertion that EMTs are not qualified and cannot provide anything other than oxygen is incorrect. They are not merely ambulance drivers as the article implies. As well as oxygen, they are trained in providing pain relief, CPR, airway management, defibrillation, taking vital signs including reading ECGs and immobilisation. They can administer aspirin and GTN to patients who have had heart attacks, glucose to diabetics, salbutamol to asthmatics, and epinephrine to people having allergic reactions. But no, they can’t give diazepam to someone who is fitting.

Most calls - I would estimate 95% - can be dealt with by EMTs without the need for a paramedic’s extra skills. When a call comes in that seems like it is going to require a paramedic crew (examples - suspendeds, BBAs (Born Before Arrival), continuous fitting, severe trauma) we try to send a paramedic crew. If a technician-only crew is closer, we send them too and ask them to “report on arrival” to confirm the paramedic crew is definitely required. Sometimes crews arrive on scene and radio us to let us know they will be needing a paramedic. Sometimes there will not be a paramedic crew available at all (which is what I imagine happened in this case) and the crew has to make the decision whether to wait for one or rush the patient into hospital. The article makes it sound like the patient’s mother was “pleading” for a paramedic and the control room/FRU technician were telling her that she didn’t need one. I’d be very surprised if this were the case - I think it’s most likely that there just wasn’t a paramedic crew available. (Don’t get me started wondering where all the paramedics were. Probably dealing with “unconscious” patients who really only had a broken toe.)

The patient’s family are campaigning for a paramedic to be on every ambulance, and I can see their point — it may well have prevented the death of this patient — but I also have misgivings. To train more paramedics would cost money, which would have to come from somewhere — perhaps cutting the number of vehicles or other staff. Relaxing entry to the paramedic course might mean some staff become paramedics before they have had sufficient experience as an EMT. If it is against the rules to send an ambulance without a paramedic, there are likely to be less vehicles over all, which means longer waits for patients, most of whom don’t need a paramedic anyway. Personally, I would prefer to see a change in the way we dispatch calls - perhaps a change to AMPDS so that certain calls are flagged as “must send paramedic”, and making sure paramedic crews are not dispatched to calls that obviously won’t need one if there is a technician crew available.

On the whole, I thought the article was very damaging towards people’s faith in the LAS and their perception of a technician’s competence. They seemed to lose sight of the fact that it wasn’t the ambulance service that killed this patient, it was epilepsy. Hopefully in future methods will be in place that help the service to save such patients, but we should not shoulder all the blame when someone dies.

My sympathies to the patient’s family and friends.

… you do a twelve hour call-taking shift, and the only person to be rude to you all day is the woman from NHS Direct in Sheffield.

As predicted, Nee Naw Control was ringing with the sound of suspendeds today. The girl sitting next to me must have taken about five billion, but for some reason all I got all day were blokes who had dislocated their knees or similar playing football. I must have had at least fifteen of these. I even had two who injured themselves on the same football field, five hours apart.

There was just the one suspended call, the first I have taken in about four months. I’d forgotten the way people skirt around saying words like “dead” or even “not breathing” and was initially rather confused by the call, which went rather like this:

Me: “What’s the problem? Tell me exactly what happened?”
Old lady: “I need an ambulance for my husband!”
Me: “What’s wrong with your husband?”
Old lady: “Everything’s wrong with him!”
Me: “What happened?”
Old lady: “It’s very urgent!”
Me: “What is wrong with your husband?”
Old lady: “It’s an emergency!”
Me: Is he conscious?
Old lady: “No!”
Me: “Is he breathing?”
Old lady: “NO!!!”

It’s rather frustrating when someone is telling you that something is very urgent and an emergency, and from their tone of voice you are inclined to agree, but they won’t explain why. Unfortunately just putting “It’s an emergency and very urgent” on the ticket is not going to inspire Dispatch to send anything in a hurry, so you just have to plod on with the questions and hope it all becomes clear, as it did in this case.

The doctor son was doing CPR all along and the patient was blued into hospital, but I don’t know anything beyond that.

I also can’t believe that I didn’t have one single firework related incident all day. I know the night turn will probably cop a few, but still, three hours of darkness with no fireworks up noses or thrown on to commuter trains is good going. Those telly adverts must have worked.