Nee Naw

Our third call was to the local council estate for a middle aged man who was, apparently, feeling depressed and suicidal. Now I like psychiatric patients. Maybe it’s because I’m a bit nuts too, but I seem to have a certain affinity with them and often find myself having long, drawn out chats with them on quiet night shifts.

We rang the intercom and Raymond, our patient, unhurriedly let us in. Silently, he beckoned us into his bedroom, flopped on to the bed and sighed. I wasn’t surprised he was depressed; his bedroom was one of the most depressing places I have ever been in. Walls stained nicotine brown, carpet sticky, furniture ancient, it was severely in need of a make over.

“So, Raymond, what seems to be the problem today?” said Steve cheerily.

“I’m feeling very depressed,” said Raymond in a flat drone. “Worn out and worthless. I shouldn’t be here. I need to be in a home. With people looking after me.”

“Well, I’m afraid we can’t take you to a home,” said Steve. “Do you want to go to A+E? Or have you been an inpatient at a psychiatric hospital before? We can contact them and see if they will take you back?”

“I don’t want to go to A+E,” whined Raymond. “They can’t do anything for me. And you have to sit there for hours. And I’ve been in the psychiatric hospital too. I don’t want to go back there. I tell you, I need to be in a home.”

I couldn’t see any reason why Raymond should need to be in a care home, but it is not the ambulance crew’s job to question this, so Steve suggested to Raymond that he should see someone who could arrange a care home - his GP. Steve’s crewmate rang the GP for an urgent appointment, and Steve told Raymond that we’d run him up to the GP surgery in the ambulance.

“Can you take me back home too?” muttered Raymond.

“Sorry, no - we’ll be sent on another job as soon as we drop you off,” said Steve.

“I don’t think I’ll go, then,” huffed Raymond. “It’s too far to walk. And I can’t afford a taxi.” The GP surgery was actually five minutes’ walk away, and Raymond had no noticeable mobility difficulties.

“Well, what would you like us to do then?” said Steve. “Is there someone we can call for you or something else we can do?”

“I’ve told you,” said Raymond. “I need to be in a home. I don’t know why I bothered calling you. You can’t help me. No one wants to help me. The whole NHS is useless.”

“Raymond,” said Steve, with an admirable show of patience. “I can’t help you get into a care home, because we’re an emergency ambulance crew and we take people to A+E. But I’ve told you how you might be able to get into one, and you don’t seem interested. We can’t help you unless you want to help yourself.”

“No,” said Raymond. “Thank you, but I don’t think I’ll bother. It’s just not going to work out.” And he opened the door and motioned for us to leave.

Since we’d made the appointment with Raymond’s GP, we decided to go anyway, even if our patient was not with us. We piled into the surgery and a very harassed looking GP sat us down, pulled Raymond’s details up on his computer and turned the screen round to face us. I could see that Raymond rang the surgery several times a day, usually demanding to be put in a care home but occasionally wanting other things done for him too. He had a history of not taking his medications and of accusing the doctors of mistreating him in various ways. He would be deliberately misleading about what the other doctors had said to him on previous visits, and because of this he was now only allowed to see one doctor (who I assume drew the short straw).

“Raymond’s been assessed and we don’t believe he needs to be in a home,” said the doctor. “He needs to comply with his care plan and start taking responsibility for his own health. I’ll give him a call when you leave, but it’s nothing he hasn’t heard a thousand times before.”

I found Raymond to be a most perplexing character. On one hand, I know it is the nature of depression that patients feel everything is hopeless and won’t work and that would partly account for why he was so unco-operative. On the other hand, and I know this is a total cliche and supposedly the worst thing you can ever say to a depressed person, but I really did want to say “Pull yourself together! Take some responsibility for yourself! You don’t need looking after, you need to look after yourself. No one else is responsible for the way you feel but you!” I know how the whole argument goes, Raymond can’t help being depressed, it’s an illness, you wouldn’t say that to someone who had cancer, would you? The thing is that while I agree that it is and illness and he can’t help having it in the first place, he can change the way he deals with it. You wouldn’t say “pull yourself together” to someone with cancer because you don’t need to. Anyone I’ve ever known who has had cancer has been determined to fight it. They grasp any opportunity to make themselves better and take any treatment, however painful or expensive. Whereas Raymond just wanted to lie back whilst someone else sorted out his life. Perhaps I should be more sympathetic. Perhaps I couldn’t possibly understand unless I was in his position. But then I thought back to Elaine, the old lady with the broken hip, and how brave she was and how thankful she was for our help, and I didn’t worry about Raymond any more.

The second call was to the canteen of the local police station, for a member of staff choking on a fishbone. Great, I thought, a rare opportunity to watch a police officer get punched in the back without anyone getting in trouble! (I jest, of course I love the police. I couldn’t do their job, dealing with breaking bad news and horrible criminals all day long. It would drive me mad.)

Anyway, I was disappointed when we arrived because the patient, Alan, a) wasn’t a police officer, he was a handyman doing some work at the police station b) was standing up chatting to some other members of staff and it wasn’t entirely clear which one we were supposed to be attending to. It turned out that Alan wasn’t so much choking on the fish bone but had swallowed it and could now feel it in his throat. The “waste of time and taxpayers’ money” buzzer in my head started to sound.

Still, Steve and his crewmate were very professional and took Alan back to the ambulance for a full set of obs. Steve stuck something resembling a spatula and a torch down Alan’s throat and tried, without any success, to locate the offending fishbone. He explained that he couldn’t see anything, but if Alan wanted, we could pop him up to the hospital for an x-ray.

“Do you think this needs a blue call?” joked Steve’s crewmate. And I laughed my head off.

Then Steve took Alan’s temperature, and his blood pressure, and his oxygen saturation levels. And his pulse. And raised one eyebrow.

“I think there’s something wrong with this machine,” he muttered, using his fingers to take the pulse at Alan’s wrist instead.

In highly technical terms, a normal pulse is between 60-80 beats a minute and goes like this: be-dump, be-dump, be-dump. Alan’s pulse was 44 beats a minute and went like this: bump, bump, be-dump-bump, bump, bump, be-dump, be-dump, bump, bump. As Steve put it, it was almost regularly irregular. It was not at all the sort of pulse you’d expect from a otherwise healthy 40 year old with a fishbone stuck in his throat.

“Alan,” said Steve. “Have you ever had your heart tested?”

“No?” said Alan, a bit confused. What had this got to do with fishbones?

“Well, you’re about to,” said Steve, firing up the 12-lead ECG (a machine which records heart rhythms).

Minutes later, we had a print out. A normal ECG looks something like this. Alan’s printout looked something like this (or at least it did to the untrained eye). I understood the writing on the printout, though - the ECG machine’s option was that there was ST elevation and therefore Alan was having a heart attack.

Steve, his crewmate and I all looked goggle-eyed at the print out, then set about asking Alan if he had any other symptoms at all, in particular chest pain. Alan told us that he’d had chest pain on and off for the last two years, but at this moment felt absolutely fine. Except for the fishbone in his throat. He was looking at us like we were a bit mad.

“Do you think this needs a blue call?” said Steve’s crewmate again, and of course, this time he was serious.

“It could be a silent MI,” (MI = heart attack. Silent MI = heart attack without the normal symptoms of chest pain etc.) muttered Steve. “But he’s got no symptoms at all… and he’s only 40… and he’s had chest pain for two years… my guess would be that he’s got an ongoing cardiac condition which has been undiagnosed. Let’s take him to the nearest and get a doctor to have a look at the ECG, and if they suspect an MI, we can always take him on to the hospital with the cardiac unit.”

So with that decided, we explained to Alan what was going on and wasted no time in getting him to the nearest A+E and summoning a doctor to look at the ECG. She agreed that Alan almost certainly wasn’t having a heart attack and this was an ongoing problem, but nonetheless he was wheeled into Majors to be seen immediately.

“What about the fishbone?” whimpered Alan as we bade him farewell. “I can still feel it, you know.”

And the moral of this story is that you should always take a full set of obs, however rubbish you think the call is.

A few weeks ago, I went on an observation shift with Steve and his crewmate. We had a touch of Observer’s Curse - only four jobs over the whole shift, about half what I’d expect for a busy station like theirs - but all the calls were interesting in their own way and I’d rather see four “real” calls than eight cases of flu!

There was also a rather amusing incident when we took our rest break at another ambulance station, and all the crews at that station, not knowing who I was or even that I wasn’t just another paramedic/EMT, decided to launch into a diatribe about how much they hate control staff, how evil we all are and how all we care about is screwing them over and giving them rest breaks. I covered my “Emergency Medical Dispatcher” epaulettes and sank into my seat. I now know how it feels to be a mouse in a room full of cats. All I can say is that if the offending crews were on my sector, I’d have them attending every projectile vomiting call I could get my hands on for the next week!!

Anyway, on with the four calls. I don’t have time to write about them all at once so each will get a separate entry. Just to keep you on tenterhooks, the last one is the most exciting!

The first call of the day was to an elderly female on the floor. In Control terms, this is about as simple as you can get - it is non life threatening, so you do not have to bust a gut getting someone there, but it is also a valid call, so as soon as someone is available, off they go. But I was about to discover that something simple for us is not so simple for an ambulance crew.

Elaine, aged 80, has lived alone her house since the death of her husband. Her younger friend, Sandra, comes to visit every day and helps out with the shopping. She also has meals on wheels and a home help. Despite having arthritis, bilateral knee replacements, heart trouble, mild confusion and depression, she gets by. On this bitterly cold morning, she was getting out her electric fire and, carrying it to her bedside, slipped over. She felt awkwardly against the bed and an agonising pain shot through her right leg.

Luckily, Elaine had fallen by the phone so she was quick to summon help. Not wanting to bother the emergency services so early in the morning, she rang Sandra. Sandra had come straight round but after a quick examination she had realised Elaine had hurt herself badly in the fall and that an ambulance was needed. Enter us.

Elaine was in good spirits and not a lot of pain when we arrived. Her sense of humour was intact, laughing at herself for falling, and she was very apologetic about calling us out. The genuine callers always are. I wondered if it was going to be an “assist only” job, where the crew lift the patient, put her back to bed and make her a cup of tea. However, as Steve straightened Elaine’s legs, I could see clearly that one was shorter than the other and drooping to one side - a clear indicator of a broken hip.

Seeing the concern on our faces, Elaine became worried.

“What is it? What have I done?”

“I’m afraid,” said Steve, “you’ve broken your hip”.

“Oh!” said Elaine, relief coursing across her face. “Is that all?”

I wondered what she thought we were going to say.

Now came the difficult and unpleasant part. With the aid of some Entenox (pain relieving gas), we tried to assist Elaine into the carry chair so we could get her downstairs and into the ambulance. But the slightest movement had her in complete agony. The gas seemed to be making her confused, too, and she forgot what had happened to her and kept yelling out: “What’s happened to me? What could be causing all this pain? I have never felt this uncomfortable in MY ENTIRE LIFE!” She was shaking and turning terribly white. It wasn’t pleasant to watch. As control staff, you are generally distanced to people’s pain. You get all the emotional upset and lurid descriptions of gory events, but the physical pain is something you don’t think about. You tend to think - broken hip - non life threatening - simple without really getting your head around what it is like to have one. Elaine’s agony is something I will remember every time I have a “broken hip” call waiting on my screen.

Once we stopped trying to move Elaine, her pain subsided somewhat and she returned to the cheery old lady we’d first encountered and apologised profusely for “being a big baby”. Meanwhile, Steve’s crewmate, who is a paramedic, decided Entenox alone was not enough to get Elaine out of here. It was time to bring in the big guns. He fired up a vial of morphine and injected it into Elaine. Then we sat around a bit and waited for it to work. Sandra conducted some breathing exercises whilst I helped pack up Elaine’s belongings. Eventually, Elaine started going a bit woozy and getting a big grin on her face and we were able to lift her into the carry chair. There was a lot of hollering as we moved her, but this was immediately followed by relief from everyone as we all announced “Well, that’s the worst bit done! Off to the hospital!” It’d taken over an hour to get her into the ambulance.

By now, Elaine was away with the fairies. Steve tried to get her to give a score to her pain. Earlier, she’d given it nine out of ten.

“Oh,” she said, flapping her arms dismissively. “Hardly anything!”

“I need a number,” said Steve.

“Erm, I really don’t know,” said Elaine. “I can’t remember any numbers!”

“Elaine,” smiled Steve. “I’m not taking you anywhere until you give me a number!”

“Um….. sixteen!!!” announced Elaine, and broke into fits of giggles. Steve gave up at this point and we went off to the hospital.

I am sure Elaine will be fine although it is clear her bones aren’t what they used to be and perhaps she will have to give up living in a two-storey house by herself. It is sad that such a lovely person who is so cheerful and friendly and has clearly lived such a full and rich life has ended up being let down by her own body and even sadder to think that whatever I achieve with my life more or less the same will happen to me. I shall never look at “old woman on the floor” as just a simple, boring call again.

Right folks, this blog is back in business! And what better way to get things started but with my favourite topic, a rant about care homes?

The call went something like this:

Me: “Nee Naw Service, what is the address of the emergency?”

Care home worker gives an address which is not the address the phone is registered to. This is not unusual for care homes as they sometimes go via a switchboard. But I can’t get a match for the address she gives me. Computer says no. Computer says address does not exist. I try to get her to spell it, but she just keeps repeating the address. Then she gasps, and says “No, actually, it’s…” and gives me the address the phone is registered to which has been sitting in front of me all along. Great. Several minutes wasted.

Me: “What’s the problem?”

Care home worker: “She’s dying!”

I type “dying” into the computer and a similar uphill struggle ensues whilst I try to get this woman to explain what she means by “dying”. Unfortunately, it seems like suddenly “dying” is the only word she knows and that if she repeats it to me over and over again, all will become clear. It doesn’t. After all, someone with terminal cancer is dying. Someone who has just had their jugular slit is dying. A lot of the patients who ring with stomach ache *think* they are dying. If you want to be philosophical about it, we are all dying! The ambulance is halfway there by the time I manage to establish that the patient has actually stopped breathing. Not so much dying as dead then. But not necessarily irreversibly dead, if this has just happened. I press on with getting CPR started.

Me: Does anyone there know how to do CPR?

Her: Yes

Me: Have they started?

Her: No

Me: Are you right next to her now?

Her: Yes

Me: Right, get her flat on her back on the floor, remove any pillows and kneel next to her and look in her mouth for food or vomit.

Her: (instantly) Okay.

Me: Do that now.

Her: (instantly) Okay.

I can still hear her breathing at the other end of the phone so I know she hasn’t done it. We have to be very careful about calling the callers liars so I just press on with the next line - “Is there anything in the mouth?” thinking that she won’t be able to answer the question until she does it.

Me: Is there anything in the mouth?

Her: I don’t know.

Me: Have you looked?

Her: No. I am in the next room, I can’t see her.

Me: (Thinks: But you said you were with her! And you just said you were doing the instructions, you great big liar! Do you think I am telling you to do these things for fun?) Okay, go and do it now. Come straight back to the phone and tell me what you find.

Line goes silent. Caller goes away. Caller doesn’t come back. Five minutes pass. Two ambulances and a FRU approach scene, lights blaring. Caller still does not return to phone.

The FRU is a minute away by the time she gets back.

Her: “Cancel the ambulance! She’s fine! I put her on the floor and she complained and told me to get off her. I must have been mistaken! She was just asleep.”

Strictly speaking, ambulance service procedure is that if the caller says “cancel the ambulance”, we cancel the ambulance. However, there are exceptions to this rule and I decided that this was definitely occasion to make one. I had absolutely no trust in this care home worker who didn’t know her own address, could not answer a simple question and who appeared to have great difficulty in telling whether her patients were alive or dead. I noted what had been said on the ticket (since really it is the dispatch desks who should be making decisions such as sending an ambulance even when the caller says one isn’t needed) but finished the ticket as a complete call, rather than one which had been cancelled midway. Dispatch evidently agreed with me, and none of the ambulances were cancelled.

I kept an eye on the ticket, and nearly an hour later, one of the ambulances was off to hospital with the patient on board. Next, what should appear on the ticket, but blue call details! That means that the patient is in a very serious life threatening condition. The crew had established that she had actually had a seizure of unknown cause and now had a very rapid pulse, very low blood pressure and a GCS of 11 (ie. semi conscious). (Medical types - any idea what was wrong? All the other obs were normal and there was no mention of an ECG).

So, in summary, due to this “care” home’s incompetence, there was a delay of minutes reaching this critically ill lady, CPR was almost performed on her whilst she was still alive (which would have given her broken ribs to add to her problems) and she was almost denied medical aid at all because the care home went from thinking she was dead to thinking nothing was wrong in the space of five minutes!

And this is why no member of my family will end up in a care home, even if I have to move in and look after them myself. I appreciate there are a lot of care homes that aren’t like this, and plenty of care home workers who are caring and skilled, but incidents like this are far too common for me to ever take the risk.