So I’m standing on a street corner with my bike, giving directions to lost tourists and trying to stop the local kids from switching the lights on. Suddenly, down the hill, two cops come careering past and “dynamically deploy” me to a job.

“Might need you, mate.”

Fair enough, I swing onto the bike and free-wheel down the hill while a police van hammers past me on the right hand side. A total of six cops hair down a wee alleyway between two shops at gather at the foot of a flight of stairs in a small courtyard.

“What’s the issue?”

“Disturbance call…but they say he’s smashed some glass, so there might be an injury too.”

I look up at the building, a traditional Edinburgh tenement. Well kept, clean courtyard, one window smashed out, a black eye in its face.

“You guys crack on. I’ll be here if you need me.”

They gather at the door, ringing the buzzer, shouting at the intercom.

“Police! Open the main door.”

The door buzzes open and they tramp inside, I can hear their footsteps zig-zagging upwards, back and forth on the staircase. Police calls with injured parties are usually a paperwork exercise, they can’t discharge an IP without having them medically assessed.

I casually remove my bike gloves, slide the bags out of the panniers and am gloving up when a lone set of footsteps zig-zags back down the stairs and a police officer arrives, white faced, at the front door.

“Kal!”

He beckons me in and I follow him at a run up the stairs, onto a landing and left into a corridor. The room is about fifteen feet long, five feet across. There isn’t a clean patch of lino to be seen, the entire floor is covered in blood. It spreads a good half foot up the skirting board, splashes on the walls, shards of glass from the broken window float in it.

In the centre of this gory tableau lies a young man who appears to be doing backstroke while his left wrist squirts blood. His right hand is pinned to the floor by a cop, squeezing a tea towel onto his forearm.

I throw my bags beyond the scene into an open doorway (which doesn’t have claret all over the floor) and unzip them, grabbing a couple of large bandages. The patient’s left arm has a wide, triangular hole in the centre of it, blood pours out until I pack the dressing into the wound, wrapping the bandage around it as hard as I can, then tying a second over the top of it. It holds for a moment before a dark red stain blooms through to the surface, spreads and stops, holding its shape as a circle on the dressing.

Fair enough, that’s almost controlled.

I realise, with a fair dose of alarm, that I’ve come running up the stairs without A. an oxygen mask and B. a tourniquet, both of them are in the saddle bag on the bike and not in the main bags. This is a major issue, since I have a tank of oxygen right here, but no way to give it to the man whose entire supply of blood is trying to escape. I’m also keen to get some IV access so that once the crew arrives we can start pushing fluids into him in an attempt to , you know, make him not dead and that.

I improvise.

Looking over at the cop on the patient’s right hand, I see that the pressure he’s pushing on the arm is making the patient’s veins bulge in his lower arm - better than any tourniquet I could put on, it should be a simple matter to slip an IV cannula into that.

“Open that bag and pass me a grey needle, please?”

The police officer by my kit unzips one of my bags and looks in bewilderment at the contents, I try to explain.

“On the IV board?”

He lifts the defib and hands it to me.

“Don’t worry, just pass it over here.”

I expect him to hand me the kit, but instead he slides the entire thing across the floor and into the blood puddle. That’ll take some cleaning up.

Snagging a grey cannula from the board, I move to stick it in the patient but realise I’m going to have to secure his arm somehow before I go waving sharp pointy things about. The traditional method is to shove the patient’s hand between your knees, but I’m crouching, loath to put my bare skin on the filthy floor.

There’s nothing for it.

I splosh my knees down into the bloodbath, wishing I was wearing long trousers and not cycling shorts. The cannula slides easily into his vein and we’re able to move to protecting him against shock, lifting his legs above his head and delivering high flow oxygen therapy via a bag/valve mask, rather than a normal non-rebreather.

The crew arrives, we bundle the patient down into the ambulance and run bags of fluid into him. They take off to hospital in the wake of a traffic car escort, leaving me with a conundrum.

On an ambulance, if you get tagged by body fluids, you’re normally going to the hospital anyway. You can slide your green shirt off, or scrub the worst of it off your trousers with wipes before heading back to station to change clothes. You’re in the vehicle, nobody sees you, it’s all terribly discreet.

Out on the bike, I’ve nowhere to hide. My bare arms and legs are literally dripping with blood and though the police pull a roll of paper towels from their car with which to mop up, I’m still a ghoulish figure that walks back to the Fringe office to clean up.

The next morning I see the cop who deployed me, she laughs when I tell her I’m ignoring her next time. I’m crap with names and I tend to fall back on “Alright, mate?” when I meet the cops who populate the Information Centre on the High St (free coffee, handy loos, my favourite stand-by point!). Regardless of learning names, however, it’s another step to a closer working relationship.

Off the back of my recent post about stress responses, I found myself the only HCP amongst a host of volunteer first aiders recently. As a team we’d managed and packaged the sort of patient that gave me the shivers, the type of patient who clearly thinks that they’re dying, asks if they’re dying and I am unable to answer honestly.

Volunteer first aiders train for this sort of thing to an extent and I have to say that the group I found myself inadvertently leading were slick and proficient. They did exactly what I said when I said it and stopped when instructed to do so. They performed tasks that were far beyond what they anticipated on their first aid duty.

One held a young man’s head in her lap and told him he’d be fine, to just keep breathing and try to relax.

Another was improvising dressings from a first aid kit that was never intended to treat injuries such as this and she kept her cool when I snapped at her to “just open fucking everything”.

One guy was standing over us, handling the burgeoning crowd and organising marshalls to bring an ambulance immediately to our side.

And the fourth was opposite me, kneeling in mud and piss up to our thighs. She had her hands under mine, my fingers moulding and turning hers just so and pressing them down. She was pushing onto parts of a human body she’d probably never seen before, let alone held, hot and wet and twitching in her grasp.

Aware that five sets of eyes were expecting me to know exactly what to do, I wasn’t about to let on that I’d only ever seen that body part before on an autopsy table.

The patient shipped out on an ambulance, we reconvened as a group. Reactions were interesting. One was talkative, jabbering excitedly that she’d never seen multi-trauma. Her excitement lasted half an hour before she dissolved into embarrassed tears . The coordinator was grim-faced, though the water in his drinking bottle trembled when he lifted it. My equipment specialist was cold and analytical, asking pertinent questions about her performance and the patient’s prognosis. And the fourth was silent, fascinated by her shoes.

My brain swung into “bad job” mode, automatically playing the cards that we do at work, that just a few weeks ago I’d been analysing amongst my colleagues and myself. My arms swung out, clapping shoulders, touching arms and shaking hands. I dropped my paw around the shoulder of number four and she stiffened at my touch. The team fractured into a one, two, one formation.

I gave them a minute and cracked a joke; humour didn’t go down well and I realised that the rest of the group were not only unaware of how we decompress, but that they mistook my attempts to do so as crass and degrading.

And I, recognising the offence I was causing, backed away from the process and joined them in their brooding.

For me there was no reset. I did my best to warn people about adrenaline come-down, to ensure that they would get home safe and be looked after by friends. I tried to explain about questioning your own performance and realising that finding out the patient’s outcome may be impossible. I strove to make people see that what they’d done was amazing, had probably saved the young man’s life and encouraged them to take comfort from that thought.

It was only on the following evening, when I gathered with like minded friends, that I was able to hammer through the stages, to get my quota of physical contact, to make flippant remarks about a horrendous situation and to clink beer bottles together and agree that things had gone well.

We all have our rituals, developed through years of experience, trial and error.

Until you know what works, you have no choice but to have a go at decompressing through any means you can conceive.

Find a your system and employ it when you need it.

Just realise that it’s a personal or collegiate decision.

And it may not translate beyond borders.

The fireys have folded away their cutting gear, the traffic cops have swept up the glass and I’m standing in A&E writing in my notebook, taking notes of names and ages. Dezzy and I were first on scene, before the call even came in, the car smashing head first into a victorian stone wall.

Three patients, two trapped, one critically injured.

The untrapped girl screamed at me to give her “a fucking painkiller” to address her broken foot. The rear seat passenger was blacked out and gurgling. The driver pinned to her seat by the steering wheel folded against her pelvis.

By the end of the incident I was swapping numbers and details with police and fire chiefs.

The driver four times the limit, I dropped into resus to confirm her address and was about to leave when she called me back.

“Can I ask you a question?”

“Sure.”

“Will the police charge me, do you think?”

“I can’t comment on that, sorry.”

She starts to cry, softly, silently.

I squeeze her shoulder and she whispers to me.

“I’m starting my police training next week…”

I leave her with her shortlived present tense.

I look up at Turismo and mouth the word “thrombolyse!!!!” at him (my facial expression adding the exclamation marks) and his eyes widen with mine.

We draw masks over our faces, calm and professional, friendly and reassuring as we load the patient onto the chair and begin to roll him down the stairs. Dezzy has the handle at the back, I’m lifting the front wheels, Turismo following behind with the oxygen bottle and tubing snaking over the patient’s shoulder and into his non-rebreather.

Turismo tells me later that he only hears what happens next, that he sees nothing, but hears me shout:

“Pete?”

Then, anxious.

“Aww, fuck!”

Followed by a thick, fleshy thud as I punch the patient hard in the chest.

Pete’s head swings uselessly at the end of his neck while his limbs stutter for a few seconds as their oxygen reserves run out, his heart having stopped on the way down the steps.

I’m not mathematically minded, in fact I’m practically innumerate, but I’m running lightning calculations in my head - how far are we from the vehicle? Is it more dangerous to delay CPR by rolling him to the ambulance or will the more controlled environment help us to run this arrest most effectively? I reach my conclusion.

“In the motor - go!”

We roll the chair, fast as hell, Pete’s arms and legs flapping in the wind as we go and shove the whole shooting match into the back of the ambulance, slinging the patient onto the bed.

I’m shamed to admit it, but a tiny part of me is relieved that now I won’t have to thrombolyse.

This is just a cardiac arrest - I can do those.

“On chest, Dez.”

He jumps to it while Turismo unpacks me a BVM before ripping open a set of shock pads and slapping them onto Pete’s chest.

“Coarse VF.”

“Shock it.”

“Charging! Clear!”

We all throw hands in the air as the defib shock bangs Pete up and down on the bed. Dezzy is back on the chest immediately and I’m thinking about what size of ET tube I’m going to stick down the guy when Dez interrupts.

“He’s responding!”

Pete is eyes open, mumbling. As his face grows increasingly pink, he becomes more vocal, ripping the BVM off his mouth and nose, crying, shouting. I shush him, try to calm him, but his brain has been starved of oxygen for too long.

Nothing but time will bring him back and, sure enough, a few minutes of gentle talking and oxygen therapy and he’s back to full consciousness, looking around himself at the three of us.

“Did I black out?”

“Yes, mate.” Turismo begins, before he’s interrupted by the mobile ringing again.

It’s CCU, requesting an update.

We fill them in, the patient is now post-arrest, he’s had a minute of CPR and one shock.

“Ok, go ahead with the Tenecteplase.”

Turismo and I rendezvous at the bulkhead of the vehicle and sotto voce for a minute.

“Have you done this before?”

“Nope. I was hoping you had.”

“I’ve seen it done.”

“Me too. Shit. Right, look. You have the chat, I’ll push it. OK?”

“Done.”

Because we’re not just preparing to inject this guy with a kill-or-cure drug. .

We need to ask his permission to do so.

Put yourself in Pete’s position - he’s suffered crippling chest pain, the worst pain he’s ever experienced. He can’t breathe, he wants to vomit, his brain is telling him that he is going to die. Then he wakes up on an ambulance trolley, two burned patches on his chest, his ribs aching like someone’s been punching him in the sternum a hundred times a minute. The effects of oxygen starvation have him feeling like he’s got the worst hangover of his life.

Then someone leans forward and says “Hey Pete? We can fix this with drugs that might reduce your brain to summer pudding. Fancy your chances?”

Before we go any further, we need to know that he’s fully competent, so I question him as to the date, our location, who he is, who we are and why we’re all in this fix today. He’s a little frustrated by the questioning, but answers correctly everytime.

Fully oriented, person, place, time and situation, or “AOX4” as I’ll later record him.

Turismo crouches by Pete’s bedside and runs him through the situation - how the benefits of this therapy greatly outweigh the risks, but that “it may cause bleeding and that could include bleeding into your brain, causing stroke or death.”

Pete nods along with us as Turismo completes his consent conversation.

“You’ve already had one episode of unconsciousness due to this chest pain.”

The patient looks him in the eye.

“What would you do?”

“I’d take the drugs.”

He mulls this over for a moment, nodding slowly.

“Are you happy for us to go ahead with this procedure?”

Pete delivers his killer line.

“I’m not happy, no. But if you tell me it needs to be done, then we’ll do it.”

Turismo gives me the nod and I rip open the cardboard box of Tenecteplase. The last time I did this was in my paramedic course at a sunshiney desk.

I mix the drugs with water in its handy wee plastic cup and sook the mixture back up into the syringe, lifting it to the light to check that the powder has dissolved properly, that there are no particulates that may lodge in the syringe, or worse, in the vein.

Then I double check the dosage with Turismo. And he double checks it back with me.

The walk from the bulkhead to the patient’s side is two steps, but it feels like it takes an age. I turn his arm and flip open the cap on his cannula, slide the tip of the syringe onto the drug port and give it a half twist, locking them together.

I’m reminded of the course director at my para course when he dressed down an arrogant technician student who asked “Really, what’s the difference between their job and our job?”

He coolly replied - “I teach technicians to use drugs that save lives. I teach paramedics to use drugs that kill people.”

In honestly, I’m also remembering Pally’s thrombolysis story. How he pushed the drugs and watched the woman arrest in front of him, how her husband screamed at him for the journey to hospital, how he didn’t sleep for days afterwards, how he was summoned to CCU to discussion the situation with the consultant.

And I’m also remembering the patients I’ve had arrest in the back and reminding myself, loud and clear, that without this therapy, this man is going to die.

I slip my thumb over the plunger, look Pete in the eye.

“Ready?”
He nods, closes his eyes and leans back in the bed.

I push the drugs, twist the syringe from the cannula and call through to the cab.

“CCU, please, Dez. Smooth over fast, but fast as you can, OK?”

He gives me a thumbs up through the bulkhead window.

“Don’t throw us around, mate. We’re working back here.”

“On it.”

The engine starts and the vehicle pulls away from the kerb. I strip my green shirt off and throw it in the corner, my chest and back dripping in sweat already.

Pete remains in position, lying back, eyes closed. I place a hand on his arm.

“How you going?”

He doesn’t open his eyes.

“I’m ok.”

“And your chest pain?”

“It’s bearable.”

“Still there, though?”

“Yes.”

We reassess his blood pressure and give him another dose of morphine. There’s no need for either of us to be standing, but neither Turismo or I can seem to sit down, preferring to hang from the bars in the roof, hovering around Pete.

At one point the colour drains from his face and he scrambles to sit up straighter - I’m rechecking the monitor for arrythmias, but he instead grabs a sick bowl and fills it to the brim with rancid, watery brown vomit. Turismo and I form a human chain and work an operating line, replacing clean for dirty, stuffing paper towels into the bowl to sop up the puke and shoving the soggy mess into orange rubbish bags. Again and again Pete vomits until he’s left with just dry heaves which eventually subside. He sits back in the bed and I mop the sweat from his face.

“Better?”

“A little.”

I try to start a conversation about his hobbies, his family, his friends, but he denies having any of the above. We ride the rest of the journey in relative silence, only asking Pete relevant clinical questions as we go.

At CCU we’re met by a chest pain nurse, the same lady who taught me most everything I know about acute 12-Lead ECGs. We roll Pete on the trolley into the hospital, the monitor clipped to the side of the bed, one of us always watching him, his rhythm, ready for him to arrest as we go.

Instead we roll into the ward without incident, transfer him to a hospital bed and hand over to the cardiology team - they apologise for not being able to take him into the operating theatre and thank us for thrombolysing - “Now I can go home early!” laughs one nurse.

We head back down to the vehicle to complete paperwork and while Turismo is typing, I go back up to CCU to collect a replacement box of Tenecteplase. A gentleman in shirt and tie buttonholes me as I enter.

“His 12-lead is almost completely normal, now. He’ll be home in a few days.”

“Really? That’s great news, thankyou.”

“Been working hard?”

He nods at the spreading damp stain across my chest and I laugh.

“Oh, no. That’s the first time I’ve thrombolysed in the field - raises the pulse a bit.”

“You should be proud of yourselves, early thrombolysis is better than poor angioplasty and poor angioplasty is delayed angioplasty. You said he arrested on scene?”

“Yup.”

“He’d never have made it without the Tenecteplase - you guys saved his life, without question.”

“Thankyou.”

He turns to go and I realise I have no idea who he is.

“Sir, forgive me? I’m afraid I don’t know your name.”

He extends a hand, introduces himself with a name I’ve only heard in conversations.

He runs the entire department.

Remembering Wilco doing the same for Sophia and I in Abu-Dhabi after a shitty job, I grab three ice cold lemonades from a machine in the corridor before meeting Dez and Turismo in the ambulance. We sit together on the trolley and grin at each other, though the can in everyone’s hand trembles just a little.

-

Dez takes our paperwork back upstairs for us and on his return recounts his conversation with Pete as he sat up in bed, rubbing his chest and frowning.

“When I blacked out, did I stop breathing?”
“Yes.”
“And did my heart stop?”
“Yes.”
“You guys did CPR on me?”
“Yes.”
“And shocked me, too? You shocked me with that machine, didn’t you?”
“That’s right.”
“I was dead?”
“Briefly.”

The patient stares at him, wordless. Dez wishes him the best and leaves him to it.

For every pisshead, smackhead and time waster, for every late job or NHS24 - scared-of-your-shadow “meningitis” and “chest pain”, for every snotty GP or adolescent hawking phlegm on the floor, for every “spiked drink”, maternataxi and pseudoseizure.

I will take a thousand of you for this feeling.

You will not dilute why I joined this profession, you will not browbeat me into submission.

Because occasionally?

Just occasionally.

All of your shite is eclipsed by knowing that, through the actions of my colleagues and myself, someone is alive who otherwise wouldn’t be.

That’s why we do what we do.

And that’s why we keep doing it.

Spring sunshine pulls families from their houses - on a scabby corner of grass at the end of a terrace an extended family flip fatty burgers on a barbecue, smoke spitting in the air, pasty white chests flexing in the sun for the first time in months.
Our patient is round the corner.
Turismo has arrived already, his motorcycle at the kerb on its sidestand. We grab our defib before heading up the stairs, the motorcycle (like my parabike) doesn’t carry a full cardiac monitor. The patient’s called for chest pain, so we’ll need the extra kit to take an ECG

The door carries scrawls of magic marker graffiti and the stairs are dirty, the paint flaking and tired, shreds of carpet clinging to old nails. Dezzy is a few paces ahead of me as we walk into a living room, the curtains drawn against the bright sunshine outside. I can’t see the patient, he’s obscured by Turismo and Dezzys’ backs, coupled with the shadowy conditions.
Turismo machine-guns off a handover - “Pete is forty six, he has no cardiac history and complains of one hour’s crushing retrosternal pain, onset at rest, radiating into left arm, jaw, temple. Described as 10/10. Short of breath, nauseous and dizzy. You can see how sweaty he is…”
Sweat scares me, sweaty chest pains especially so. The gallons of perspiration that pour from people when their circulatory system is shutting down is a huge red flag for us.

Sweaty people are frequently dying.

“Can you go and get me some metoclopramide, mate?” Turismo asks, a syringe of morphine in his hand. No point in giving opiates to an already nauseous patient, we’ll just set him off onto a vomitting cycle, best to give an anti-emetic first.
The patient does not approve, twisting and squirming in his seat he shouts at the three of us

“Please, give me the morphine. Just fucking put it in, I don’t care….please.”
I run down the stairs for the metoclopramide, pulling a vial from my drug pack and slipping the neck of the glass vial between my lips. Before I leave the vehicle I also grab the carry-chair and blanket - I have no doubts that this patient is coming to hospital with us today.
Back up in the living room Dezzy has the ECG connected to the man’s limbs.

We operate two types of ECG, a “four lead” and a “twelve lead”, the first being useful for general cardiac monitoring, the second being a diagnostic tool to examine the heart’s function in detail. A 12-lead ECG is how we check whether or not your chest pain is originating from your heart.

Think of it as the difference between you hearing a funny noise under the bonnet and a mechanic stripping down the gear box to really see.
The thing is, we don’t need a 12 lead here - the four-lead is enough to tell us that the front of his heart has a massive clot forming in it, blocking the blood supply to the surrounding muscle

We transmit a 12 lead ECG to the Coronary Care Unit above the ED for their perusal - a bit like having a cardiologist in your pocket and being pleased to see them.

We have no sooner sent the ECG over the airwaves than the phone is buzzing in my pocket. I listen to the nurse at the other end and she breaks some bad news to me…..

The best treatment for an MI is to breakdown or remove the clot that is forming within the heart as fast as possible. The longer you leave things untreated, the longer the tissue beyond the clot is starved of oxygen and dying.

We have a number of options available to us. We can rush the patient straight to the ED and have a chest pain nurse assess them, though this slows down the patient’s treatment and is far from ideal.

The gold standard treatment is fast angioplasty, where we bypass the ED and transport the patient direct to the operating table in Coronary Care where the surgical team can be bore or drag the clot out.

Assuming the patient can be in hospital within an hour of the diagnosis being made, this is the route we take. The procedure is low risk with minimal anaesthetic and the results are exceptional.

In Edinburgh we’re spoiled. We are never more than an hour’s blue light drive from the hospital and as such whenever we transport to CCU we have little clinical responsiblity other than to give drugs to lessen the risk of the clot growing any larger.

Then we drive the patients super fast to hospital and pass the buck, our hands in the air - “Here he is! He didn’t die in my motor! You fix him!”

We do have an alternative, though.

In all front line vehicles we carry a drug called Tenecteplase. This is a thrombolytic - it dissolves clots to liquid blood. Once the drugs reach the clot in the heart it is immediately broken down and blood flow is restored to the damaged heart muscle beyond.

Tenecteplase is only administered prehospital when it’ll take more than an hour to get the patient to CCU.

For this reason, Tenecteplase is used far more regularly in remote and rural areas than it is in the larger towns and cities and for urban crews it carries a near-mystical quality. Because thrombolysis is not a safe procedure.

Tenecteplase whizzes around your body breaking up any clots it encounters, but it can’t differentiate between a clot in your heart and a clot anywhere else.

So if, for example, you had a nosebleed this morning and we give you thrombolytics? It’ll start up again. If you’re coming to the end of your period, you’ll find it kicks off again with a vengeance.

Or more alarmingly, if you have a small, weakened part of the blood vessels in your head- you’ll develop a brain haemhorrage.

And here’s the humdinger. Because we’ve also given you drugs that stop clots forming in the first place?

You won’t stop bleeding for a very long time.

Bleeding aside, we should also mention the euphemistically titled “reperfusion rhythms”.

Your heart tissues do not like being starved of blood and, just like the agonising burn you feel when you fall asleep on your arm and roll over, the myocardium can get seriously pissed off when blood suddenly rushes back into it.

But it doesn’t burn, or tingle. It frequently goes nuts, shivering and trembling in ventricular fibrillation; the rhythm that we shock with a defibrillator.

The rhythm that kills people.

So in essence, thrombolytic therapy will fix your heart attack. But it might also give you a CVA.

Or make you bleed to death from any orifice you choose.

Or maybe just stop your heart stone dead.

Back to my phone call with the nurse from CCU.

“You’re aware he’s having a massive anterior MI?”

“Yes.”

“How soon can you be with us?”

We’re on the wrong side of town, still in the house, with heavy traffic outside.

“ETA with you, thirty minutes.”

I hear her suck air through her teeth.

“Are you a paramedic crew?”

“Yeee-eees….”

“We already have a patient on the table…he’s proving more complex a procedure than we anticipated…doctor’s not convinced he’ll be free to see your guy. Go ahead and thrombolyse him….

The cinema is deserted when we walk in, just a girl lying on the steps in the centre aisle, Cubics the RRU Paramedic crouching by her, a huddle of concerned friends and a young man looming over the lot of them.

I head up the stairs and, before Cubics can start his handover, the standing man is in my face.

“I’m one of the doctors at A&E.”

Look him up and down. Don’t recognise him.

Odd.

“It’s a simple enough case for you, this is a female who’s suffered a vaso-vagal episode.”

He pauses while I stared dumbfounded at him, Cubics grinning from ear to ear at his back, not bothering to approach with a handover but instead sitting back and letting the fun develop.

“That’s a faint,” he continues, misinterpreting my stunned silence as incomprehension.

“Yes. Thankyou.”

I brush past him and join Cubics at the patient’s side, he tells me she has a history of fainting, that her blood pressure bottoms out a few times a week and she was under investigation for the same.

“Can she sit up?”

“Nup. We’ve tried, she decks out when she raises her head.”

“Fair enough, let’s say we pull the trolley to the bottom of the stairs and scoop her onto it?”

Simple enough manoevure, keep the patient flat and lift her without having her sit up.

Keep ‘em conscious, that’s my motto.

The young doctor interrupts.

“I don’t think she’s a resus case.”

“Ummm. No, I would agree with you there.”

“But you’re absolutely right, scoop and run, scoop and run.”

Cubics is beginning to turn purple, turns his head and stuffs fingers into his mouth to suppress the magma flow of laughter that’s rising, this boy’s been watching too many episodes of “Real Rescues”. ‘Scoop and Run’ indeed. We’re not in a Paris underpass, nobody’s dying.

I let him off the hook.

“Actually, Doc, we were discussing her extrication.”

He doesn’t even have the grace to look embarassed.

We stand in silence, the doctor loitering at the edges of our ensemble while we wait for my colleague to bring the trolley up. Cubics sets him free.

“You know, Doc, you can go ahead and clear. We can handle this.”

He looks at the two of us.

“Are you sure?”

The magma grumbles higher in my throat.

Am I sure? Am I sure I can handle a faint?

A career ending comment is forthcoming, but Cubics cuts in fast.

“We’ll be fine, thankyou.”

He stands, brushes his knees down.

I’m fucked if I’m letting him away with this.

“Before you go, Doctor, may I have your name?”

He hesitates.

“For the paperwork…you understand, since you were on scene?”

“Oh…yes…of course…it’s Anderson.”

There’s a beat, I raise my eyebrows.

“Does anything come before Anderson?”

He frowns at me.

“Doctor Anderson.”

Cubics lets out a snort, turns it into a cough. I stare at Doctor Anderson as though he’s a puppy that’s pissed in my cornflakes.

“And does anything come between those two words?”

“Well…ummm…Sam.”

I stick my hand out, aggressively friendly.

“Sam, lovely to meet you, Sam, I’m Kal.”

He shuffles off into the backgroud, we transport the patient.

In A&E I find a registrar and quiz her.

“Do you have a Doctor Sam Anderson working here?”

She sighs, lays her head on the desk.

“We have a student Sam Anderson here, yes. What’s he done now?”

I tell her the story, she agrees to discuss “Respecting your colleagues in their specific field.”

We leave on better terms than Sam and I.

Sixteen years old, just round the corner from these clowns a month ago. I shivered when the name of the district came up on my screen - working alone in a Rapid Response Unit I’m supposed to think a little harder before storming into less desirable areas. No mate behind you to watch your back or second set of six senses letting you know that things have turned south.

I park up at a six-in-a-block, this corner of the estate small and clear enough for my back-up crew to see the vehicle from the passing road, no need to leave the roof lights and red strobes to guide them in. From the boot I swing the response bag over my shoulders, hopping in place as I tighten the straps to suck the weight into the small of my back. The defib comes next, lifted from its housing on the left hand side.

Working alone on the RRU you get the luxury of carrying lightweight O2 cylinders. Carbon-fibre over old steel, half the weight, same capacity and tiny. Small enough to snuggle into the bag itself, leaving a crucial one hand free for your approach to the scene.

You can tell a lot by the state of peoples’ front doors and these are clean, new (but not the-polis-raided-last-week new) and in good order. The stair’s shitty, but on a weekend, so’s mine.

A woman in her 40s answers the door and leads me into a sitting room.

“He’s in the toilet just now…”

Perfect. Unless things have gone horribly wrong in the past 30 seconds while he’s in there, I can at least log the patient as “Alert and ambulatory”.

He’s at my back before I’m in the living room, grey cotton trackie bottoms, the hems slack on the floor behind his feet, a football shirt, not this season’s (I assume, like I’d know) if its soft, frayed edges are anything to go by. No shoes and an asymmetric curtain of hair under a woolen beanie. He is, in short, the ultimate image of kid-from-a-bad-estate.

Except for his body language. There is no stuck out chin, no sneering eyes and mouth, his left hand lacks a bottle of cheap cider, his right shows no signs of being lodged permanently down the front of his pants.

Instead his shoulders are up, his head down, his hands curled in front of his chest in a like a foetal boxer, covering up. Shivering manically, when he looks up in answer to my greeting his eyes are red rimmed and exhausted. Pale and gaunt, cracked lips, his shoulders banging up and down as he pants like a well-run mutt.

“Appears unwell” is often recorded on medical records, but I’ve got a better phrase for him.

He looks like cold shit.

He tells me he’s felt unwell since the morning, but tonight he started throwing up and now he can’t keep anything down, not even sips of water. When I ask him if he’s sore he drops his hands, crushed , to either side of him.

“I hurt everywhere. My head, my chest, my belly, my arms, my legs. Everywhere. My head’s the worst. I go to pee and I can’t, but I have to. I’ve had nothing to eat all day…but my sugar’s high, it’s weird.”

Bing!

“You’re diabetic?”

He nods.

“Let me check on my machine? Not that I don’t trust yours, but…”

I jag him, drop blood onto a plastic strip and we wait dutifully while the monitor counts down from 20.

2…1….

It reads 27.8 and underneath warns me “Ketones?”

I sniff his breath, a dusty carpet of stale vomit and dehydration, cut through with just a shard of nail varnish remover.

Ketones.

-
Here comes the science bit…

I want you to imagine that insulin is a stern school teacher, keeping everything on an even keel in your body. It ensures that your liver, pancreas and blood all toe the line, playing together nicely.

Diabetics have either insufficient, or no insulin in their systems. With insufficient insulin managing his body, a number of things have started to happen.

The hormone glucagon has a vital role in your body, it bullies your liver into converting a chemical called glycogen (which it jealously hordes) into glucose and pours it out into the blood stream.

Think of glucagon as a meanie who torments the fat kid into sharing his sweeties.

Given the chance, glucagon would bully the liver all day long, producing an unending stream of humbugs, but it’s kept in check by insulin, the stern teacher, who moderates the number of sweets the liver has to give up, making sure that glucagon doesn’t spoil dinner by stuffing itself.

In a diabetic with insufficient insulin, however, glucagon can go hog-wild, beating shit out of that chocolate hording little hepatic pansy. And so it does, the liver having no choice but to empty its pockets of every precious ju-jube and eclair into the blood stream.

You know how rough you feel when you have too many sweeties?

Your metabolism feels the same way.

Across the other side of the playground, your fatty tissues are freaking out. They’re the obedient, but dumb kids in class, never doing anything too interesting but sitting still and trying to win gold stars by not falling over their own feet too many times in a single day.

But now there’s no-one to impress, no-one to put your hand up to, insulin is gone and nothing else will keep them under control.

The fatty tissues can’t handle this; sycophantic, but ultimately stupid, they’re likely to eat the glue sticks and piss themselves. And so they do, peeing out acids that the liver quickly turns into ketones.

See, your body’s not useless. It knows something’s horribly, horribly wrong and that you can’t maintain this insulin-less condition for too long. So it makes ketones. Your brain can run on them for a good wee while, they’re sort of like cerebral iron-rations. When times are tough, your brain can survive on acid.

Didn’t know that, did you?

Ok, ok. Now that we’re all congratulating ourselves on being X-Men who can run on acid…back to the point.

While ketones are terribly clever and amazing emergency brain fuel and all that business, they’re acidic and make your blood acidic too.

Your body runs brilliantly at pH 7.3/7.4, slightly alkaline. At that point the electricity that runs your nervous system works just great. You shuttle chemicals in and out of your cells at top efficiency. Everything inside you stays, pretty much as it’s meant to.

Step beyond normal blood pH, though and you’re fucked. Your nervous system gets thrown out of whack, your ability to absorb oxygen decreases, ultimately your organs fail in a big soupy mess. It’s really not very nice.

Your body’s good at dealing with acidosis, though. One of the ways it can fix it is by increasing your respiratory rate and gulping down extra oxygen.

But this adds to your problems further. Breathing excretes moisture from your body; not a huge amount but enough to worsen the situation if, say, you were massively dehydrated.

Did I mention the dehydration?

See, when your blood gets jam-packed with glucose, it reaches a point of exceeding saturation and the glucose molecules start to spill over into your urine. This would be fine, since it’s the excess glucose we’re trying to get rid of in this situation, but like a drowning man, glucose pulls extra bits and pieces into the urine with it. Bits and pieces like water, sodium and potassium. All the important things that make your metabolism, you know, work. Ketones do the same thing, being excreted in the urine but dragging water molecules down with them as they go.

I suffered a sodium/potassium drop in Abu-Dhabi last Autumn, I wrote about it here. I felt *hideous* and only had the slightest of slight cases.

I dread to think how grim our patient feels.

Anyway, science lesson over. Back to the story.

“So, Luke…here’s the plan…”

He barely raises his eyes and head at me.

“…we’re going to take you into the hospital and get this dealt with, in the meantime we’re going to give you some fluid to sort out your dehydration. Deal?”

“Sure.”

You can tell a lot by how someone reacts to getting an IV, some people complain and squirm, jerking their hand away when they feel the point of the needle against their skin. The average teenager is a fucking nightmare to cannulate.

This guy, though, is cool. He stretches his arm out straight when I ask and, though he grimaces and complains when I stick him, keeps it where I need it until the wide-bore cannula is in place.

The crew arrive to back him up, two technicians, so one of them takes my car while I stay with the patient on the way to hospital. We pass a standby to hospital and run lights and sirens to resus while I stand by the trolley squeezing litres of fluid into his veins.

We’re on the bypass when his Mum asks me a baffling question.

“What do you think’s wrong?”

“What do you mean?”

“What’s wrong with him? Why’s he ill?”

“Well…he’s in DKA.”

“Deekie what?”

“His blood sugar…?”

“Is he having a hypo?”

“No, he’s…how long has he been diabetic for?”

“About a month.”

Ah.

That explains a lot. I take some time to bring her up to speed on what’s going on and, after our short chat, I look back at the patient.

He’s curled in a loose ball on his side, the blanket pulled around his chin. The shakes have gone, his face is pink and relaxed.

“Luke?”

He opens his eyes.

“How you doing?”

A nod.

“Feeling a bit better?”

Another nod, this one more emphatic.

“Still sore?”

Shake, no.

“Cool.”

It’s nothing major, nothing special or Hollywood, no babies born or hearts shocked.

But there’s a massive thrill to be had from just making someone better.

“Fallen from window” should tingle my spidey-sense, but a second look at the location calms the hairs on my neck. A favoured night-spot in the centre of town, the Mecca for stag nights and hen parties, I imagine a sozzled backwards lean into a ground-floor window seat. Maybe even a drop from the first floor, God’s benevolent palm cradling idiots, drunks and bairns safely to the ground.

The falls from height I’ve attended before have snapped ankles, broken wrists, maybe even clattered their heads against the wall on the way down. A collar and board for show, really, until a radiologist can confirm their linguine like spines are intact and here’s-some-Ibuprofen-and-don’t-do-that-again.

The message ends with “conscious and breathing”, which stamps it firmly as originating from the police, so I’m bemused when we pull up at the pub and find ourselves the only emergency vehicle present. There is nobody on the pavement and, crucially, no body on the pavement. A door steward waves us over.

“He’s down there, boys, but the gate’s locked.”

Beside the bar is a narrow alleyway, a full length metal gate and entry system guarding against intruders from the pavement. I peer down the vennel with my torch, but see nobody.

“At the back…you can maybe get through the pub’s back door?” suggests the bouncer.

My partner, DezzyBell trots into the pub with him to assess the route, while I rudely press every flat’s button on the door panel.

Nobody answers, accustomed, I’m sure, to drunken wankers playing tap-door-run late at night. I walk back to the vehicle to get the tool roll. Bolt cutters, crowbar, hacksaw. Loaded for bear, I’m back at the gate, now joined by two cops and a sergeant, all squinting into the gloom.

With a “snick” the gate unlocks remotely, from somewhere. Dezzy returns to our happy band, the back door of the pub having come up devoid of solutions.

The alleyway cuts through the bottom floor of an ancient tenement, we’re deep under the shadow of the castle here, right in the guts of the city’s medieval centre. These are not buildings that were built with emergency access or egress in mind. To the right climbs an impossibly tight spiral stair, up into the middle of the flats above and at the far end sits another lockfast metal gate.

Great.

This one is less secure, held to its post by a dodgy bike-lock, plastic coated wire and one of those keyholes that can be forced with any cheap screwdriver.

A man in a coat and hat, the patient’s brother, it transpires, runs down the stairs with a set of keys.

None of which fits the chain.

He runs up the stairs again, shouting that he’ll be back in a minute, just wait.

Beyond the gate sits a wide courtyard, paving stones and wooden pallets are stacked against the walls and, to our right, I can just make out a large man in his sixties. He’s sitting up, sort of, resting back against a stack of smashed building materials, facing away from me.

“Sir? Can you hear me?”

He raises a hand in greeting, tries to turn.

“No, no! Sir, stay still, try not to move, we’ll be in with you in a minute. Are you hurt?”

“I don’t think so.”

“OK, where did you fall from?”

“Up there.”

He points towards the roof.

“Which floor?”

“The top one.”

Four storeys. Four high, lofty Edinburgh tenement storeys.

Sixty feet. Give or take.

Jesus.

“How did you fall, sir?”

He drops his voice, ashamed, embarrassed, euphemistic to the last.

“I was trying to…do away with myself.”

“Alright boss.”

One of the cops, impatient with waiting, gestures at the lock.

“Fuck it, just force that. It’s nothing, eh?”

Fair enough.

The bolt cutters chew through the flimsy cable in a satisfying chomp and I slip them into a belt loop and swing the response bag over my shoulder as I step into the courtyard. With just the dim light from the back windows of the bar I’m glad of the mini Maglite my brother bought me for Christmas. I screw its metal head tight against the housing and focus the beam into a tight, bright point.

His face is cut, a large laceration over his forehead that bleeds down into his eyes, dust and mud stuck in a thick layer over his features. His shirt is ripped open to the navel, but I see his chest rising and falling comfortably. He rests both his hands on the floor either side of him, steadying himself, so I assume they’re largely uninjured. Left leg is dressed, smart suit trousers, missing a shoe.

Right leg…

My stomach flips over, I lose my cool and inhale hard before babbling a litany

“Right…right…ok…”

It’s just words, but they stop me swearing out loud.

His right leg is interrupted halfway down his thigh by the smashed end of his femur. Fat as my wrist it pokes obscenely through the tattered remains of his thigh muscles, a wicked scarlet grin slashed across his skin, yellow fat bubbling at the corners.

The tissues across the front of his leg are ripped and torn, sliced by the sharp edges of his bone when it snapped across its width and forced its way out of his skin like some triumphant parasite. It glares at me, mannerless, pointing and laughing from the mush that used to be the space above his right knee.

The lower portion of his leg lolls uselessly on the floor, twisted and filthy, connected to his body only by his hamstrings and a fat, twitching bundle of blood vessels, drawn up hard and tight under himself.

Somewhere in there is the lower half of his thigh bone.

Muscles only work when they’re tethered at both ends, with his quadriceps severed they’re now useless fleshy ribbons, pulled up tightly at his hip. They contract and relax, shiver and shake, frantically trying to get up and run like a road-struck rabbit. Hot and wet, they suck and slobber at my fingers as I cut his trousers away from the wound.

When I pull the shoe and sock from his foot the squeamish kid inside me shudders. The bottom half of his leg is pale and cool, the foot is white, grey, blue, frozen and shocked, dead before its time, its circulation strangled somewhere in the mess that was once his thigh.

A number of things strike me as my brain spools desperately.

That leg injury alone could kill him.

If he’s hit the ground hard enough to snap his femur, he’s almost certainly damaged other things.

Like his neck. Jesus…I haven’t even LOOKED at his neck.

Or his abdomen, I’ll bet the inside of his belly is just soup by now, organs pulled from housing, tissues shearing. Everything’s going to be bleeding in there.

I want a collar on him.

And two IVs.

And fluids up.

I want to put this leg in traction.

Am I meant to put open femurs into traction?

I can’t remember.

Fuck.

I haven’t put a traction splint on anyone in years.

There’s too much for me to do.

Dezzie, God bless ‘im, is dutiful and will follow instructions to the letter, but he’s a probie and pretty green with it.

I need more hands and I need them now.

“Can you call for a second motor, please?” I ask one of the cops. He nods and dips his chin to his radio. Dezzie runs back and forth from the ambulance, bringing kit and equipment, while I lay the traction splint out alongside the patient’s leg.

For those of you who’ve never seen such a piece of gear, I want you to imagine two long, telescoping parallel metal rods connected between by six canvas and velcro straps. The idea being that you fix one end to the patient’s hip and the other to their ankle and then, using a ratchet winder, drag the leg into a full extension, just as an intact femur should do.

My description doesn’t do it justice - some of you reading this might be thinking that it sounds sort of like a torture instrument and I wish to set you right.

It is exactly like a torture instrument. It allows me to grab the two broken ends of your leg and haul them back into position. I’ve only seen it used twice before and both of those patients screamed from their boots when we started twisting the ratchet.

This guy has hardly said a word since we got here, not a moan or a murmur.

Dezzie returns with the last of the kit. Both he and one of the cops ask the same question.

“What can I do for you?”

“Dez, start him on a Hudson, please. Fifteen litres. Then hold his head. Officer….”

I cast around the scene for something for the cop to do. He can’t dress a wound, fix a collar or start an IV.

“Can you get us some more light? Do you have a Dragon in your car?”

He looks to his colleagues who both sadly shake their heads; with no flood lights available he instead commandeers every torch they’ve got, holding them in a bundle.

It’s still dark.

I start turning the little silver wheel at the bottom of the traction splint and watch as the slack is taken out of the straps, squeezing tighter and harder against the skin of his leg. The cog-wheel snick-snick-snicks against itself and protruding six inches of bone in the top half of his leg snick-snick-snicks along with it, inching back into his flesh.

There’s a massive infection risk, I’m almost certainly pulling gravel, soil, debris, oil and shit deep into the wound. The sepsis that will result will take hours of surgery to clean out, endless rounds of brutal antibiotics to reverse.

And chances are that at the end of everything, the whole thing will rot and have to be amputated anyway

But if I don’t straighten this? If I don’t pull it back into position now and restore the circulation to the injured part?

I might as well hack it off here and now with the lock knife in my pocket. Split bone from ligament, muscle from tendon; slice it away like a joint of beef and bury the whole bloody mess in the mud in this medieval courtyard.

We’ve one chance to save his leg and a slim one at that, but as the splint’s tension pulls muscles and bones into something that at least resembles normal alignment, I’m warmed inside by the pink and purple rush that hurtles down his shin as blood pours into his hypoxic foot.

That’ll do in the meantime.

The patient, his head firm between Dezzie’s hands, breaks his silence and mumbles at me.

“Sorry, Sandy?”

“I said….”Can they fix it?””

I suddenly realise that I’ve missed the picture from the patient’s view. Here we have a man who planned to die tonight, who stepped from the window of his living room into blissful oblivion, no worries, no fears, no stress…. and now is a failure. A failure and a cripple. A failure and a cripple and the-brother-who-tried-to-kill-himself.

My head still whirling with the injuries that he could have, my answer is relatively honest.

“We need to look after both you and your leg. Right now I’m more interested in keeping you safe than the leg and you’re doing just fine, ok? We’ll get you to the hospital and get the surgeons to see you straight away.”

From the end of the passageway come voices and The Sisters Of Mercy come in like green-suit wearing angels, Sister Kay has years of experience on me, while Sister Ess registered as a para just a few months after I did. They are both Officially Lovely. One of them makes muffins and cupcakes and leaves them lying in the mess-room.

When a great crew backs you up, they slip seamlessly amongst you and your partner, diluting the problem. Unfettered by considering what-ifs, they can get on with getting on, taking the next necessary step without getting bogged down in details.

Their arrival marks the corner of the job, in minutes Sandy is collared, boarded, immobilised and lifted onto the trolley. We roll him into the ambulance and lock the trolley in the centre of the floor so that Sister Ess and I can both attack an arm each with IVs, doubling our chances of getting access.

Needles in, fluids up and wheels rolling, Ess and I ride to resus with Sandy, a cop in the passenger seat, Dezzie driving. Having dropped him off with a mob of specialists, I book the patient in at reception and thank the Sisters, dropping a kiss on their heads as they stand beside me.

“Thankyou.”

“Anytime. Night.”

-

It’s hours later when I cross my legs in the cab and wrinkle my nose.

“I can still smell blood…”

There, lodged in the tread of my boot, is a dark red glob of…blood? Muscle?

Sandy.

I stamp him out in the snow at the roadside, leaving smeary red bootprints like a hunter.

It doesn’t look like much, a single police van parked neatly in the roadway, its roof beacons laconically spinning in the dark and rain. The streets are quiet, black and wet, but we’ve still managed to acquire a small crowd of rent-a-starers. How they get here before us every time, I’ll never know - perhaps we should hire them as consultants to solve our response problems.

The technician is out of the vehicle first, she’s attending after all, and I follow half a dozen steps behind, lifting the bag and oxygen from the side door.

“Kal?”

Her voice tells me it’s bad and I flash my torch over the body in the gutter. I see blood, skin. Limbs that were born perfectly formed are now twisted and smashed beyond any Vetruvian blueprint. I swing my torch over the crowd. One young woman is supported on her forearms by another, screaming.

I tune her out.

Standing at the end of the line is a young Asian man, staring intently but apparently undistressed. I point at him, then at the floor beside me.

“You! Come here,” then remembering my manners, “please.”

He steps forward and I give him the torch.

“You shine this wherever my hands are, right?”

It’s an LED and its light is the white and blue as frost and sea glass. The lenses that surround the bulbs produce three concentric circles of light, two bright and one dull. These halos slide up and down the body, echoing the round mouths of the crowd, echoing that one woman who Won’t. Stop. Screaming.

The driver of the police van is already kneeling by the patient, barking into his radio, I catch the end of his conversation.

“…definitely appears LTP at this point.”

There comes a point where medical training becomes redundant and you just know that people shouldn’t be bleeding this much.

“D’you want me to call Medic One?”

“No point. We’ll be in hospital before they have their boots on.”

“You’re the boss. If you need anything, just tell me, whatever you say.”

“Go to the cab of my motor and get yourself a pair of gloves. I’m going to need you.”

I send my colleague off for spinal board, collar, straps, blanket and trolley and survey the damage. The cop hurries back with gloves, though they look a size too small. He fumbles with cramming his fingers into them, making embarrassed little jokes as we wait.

I’ll give him as long as it takes, I need him. I run a todo list in my head, the patient’s airway definitely needs attention, his snoring and grunting breaths tell me that.

Similarly I want to sound his chest for collapsing lungs, or to discover if he’s drowning in blood. Finally I want to prod his belly, his pelvis and the long bones in his legs. Anyone of them could quietly secrete enough blood to send him off into an EMD cardiac arrest. If that’s on the cards, I’d like to know sooner rather than later, thanks.

I’m pretty sure he’s dying anyway.

I take the cops hands and mould his fingers into two guns, thumbs up, index and middle out and clamp these hands around the patient’s head, pushing them into the corners of his mandible.
“You feel those sharp points? Lift them up.”
He does so, the patient stops snoring.
“He shouldn’t make that noise, ok? If he starts again, tell me. In fact, if he looks or sounds different in anyway, shout at me.”
I’m the senior clinician on scene, I should be on the airway.

And I am.

Sort of.
I’ve just got an assistant, that’s all.

I have too many other things to be worrying about right now. With his airway secured, I shred the patient’s clothes. Blades down his chest and along the seams of his sleeves. The car ripped his trousers off on impact, and I briefly consider dropping something over him to preserve his decency. Then think about it again. Car accidents are neither decent nor dignified.

I settle for pulling his slashed jumper down a little while strapping an oxygen mask to his face.
Airway protected. Breathing failing. Pulse present, but crashing blood pressure. His blood leaking out of him, probably into that pelvis, definitely into his lungs.
Back up at the head I wriggle my fingers down underneath, feeling torn flesh, sticky hair. His shattered face reminds me of nothing more than overcooked cherry pie, the crust brittle and cracking, dark red fluid seeping to the surface.
My fingers are muted by the gloves and cold, I cant tell what I’m touching.

Is that flesh or fabric? His clothes and collar are soaked with rain and both give, soft and pliable, under my probing fingers. I’m trying to feel if it’s knitwear or brain matter when my hands, befuddled in the cold, tell me that there’s fast moving fluid running through them. Lots of it.
My torch bearer crouches down at my call and shines the light under the patient’s ear where I anticipate a torrent of blood.
Just water. We’re on a hill, in the gutter, in the pissing rain. A vigorous stream runs under us both. My knees and lower legs are soaked and freezing from kneeling in it.

I never noticed.
An RRU pulls up and it’s driver, Ferrero, joins me at a run.

“How’s his breathing, Kal?”

“Shite. Can you take the head?”

“Sure.”

The extrication equipment arrives and we throw a collar around his neck, shoving him onto the board as fast as we can. There’s a time and place for text book C-spine immobilisation and this is not it. I’d take a wheelchair over death any day.

Sadly, this chap isn’t in a state to let me know his preference. I elect to operate under the assumption that most people would choose “not death” over other options.

Many hands lift the board onto the trolley and we’re in the back of the motor in seconds, the technician standing at the back doors jingling the ignition keys.

“What’s the standby?”

When people are dead or dying, pre-alert messages become terribly simple. Relatively stable people need lots of information passed, but this guy’s easy.

“60 YOM, massive head trauma, peri-arrest.”

“Done.”

The journey to hospital takes minutes, we’re so close and moving so fast that we don’t even have time to take a blood pressure, the cuff puffing and wheezing, straining to hear his pulse over the howl and rattle of the engine.

I take a tourniquet out of my pocket to give him IV fluids, but Ferrero, with years of service on me, shakes his head.

“No point, son, we’ll be there in a second. Just watch him.”

Nothing to do en route but hold fingers against his throat and wait for his heart to stop.

He arrests on the bed in resus, I pump his chest while the team drive chest drains into his lungs, blood cascading out into the bottles at the bedside. Bags of fluid and blood run into his veins while they drain his own from where it pools inside him.

I lift the spinal board from the floor and carry it back to the vehicle. Thick, liquorice clots and bright ruby puddles drop from its surface as I walk along the corridor and I run back a moment later with a cloth to wipe it up. A nurse catches me at it.

“Sorry about the mess.”

“Don’t worry about it. How is he?”

“Doesn’t look good.”

She nods at the blood on the floor.

“That off your board?”

“Yeah.”

“The waiting room’s packed. They’re all arseholes tonight. You should take it in and show it to them. “This is why there’s a four hour wait.” “This is what we’re doing.”

I nod and leave her to it, returning to station and pressure washing the board on the floor, spraying soap and water into its crevices and watching the run-off turn an ever lighter pink until nothing remains but clean bubbles and clouds of fine jet spray in the cold air.

The job itself sounds straight forward, 69 year old man fallen, with a head injury. It’s in a house, rather than the street so is potentially less likely to have alcohol at its root, despite it being past midnight on a Friday.

The front door is closed, but opens when I try the handle. Nobody meets us in the corridor but a woman’s voice answers me when I shout my arrival.

“Up here…please.”

In the bedroom a well dressed woman in her sixties stands in front of her husband, his face is caked in dark red blood, it congeals and hardens in his wrinkles, drips from his chin. His entire shirt front is rigid where it’s clotted and it seeps, bright red, from the split across his forehead.

A simple enough job, confirm no C-spine injury, clean and dress the wound, assess for skull fracture and/or neurological deficit and transport.

But the patient is on his feet, his face twisted with rage and as I step across the threshold he lifts his left hand to point a finger in my face.

“You can get out! Get out of my house!”

I rock back on my heels. The patient’s right hand is wrapped tightly around his wife’s wrist, her skin puckered and convoluted as it bulges between his fingers.

“Please, Ronnie…” she begins and he stops pointing at me to lift his hand up and back. I catch his wrist as I step inside the room.

“Just calm down, sir.”

“Let go of me.”

“No sir. Calm down and take a seat. Let go of the lady.”

“You can’t do this! Get out of my house! Shirley! Get them out! I’m your husband!”

Shirley pulls back from him, trying to tug her arm from his grip.

“Ronnie, you’re hurting me…”

“Ronnie, let go of her now or we’ll call the police…”

“Call them then, call the bloody police!”

He twists her wrist a little harder, she glances between her husband and I

I don’t have a problem with aggression, it’s a relatively common feature of the job, to some degree or another. Fear, pain, embarassment, drink, drugs and metabolic discrepancies can all cause a normally placid person to respond to our presence with anger and threats of violence.

I have no desire to get involved in a ruck and will, given the opportunity, get back in my motor and drive away. Verbal threats roll off my back, angry people shout and bluster, but when it comes to attempted or actual violence towards me or a third party on scene, I have no qualms about engaging someone physically.

On the other side, this is no swaggering drunk with a bottle in his hand and a belly full of bravado, no shrieking, cat-fighting woman pulling hair and scratching at her friends. He’s a pensioner, one half of a pleasant couple in a nice house in a nice part of town. He’s shorter and slighter than me with a potentially serious head injury.

I’d happily leave this guy to it, call for police back up and let him blunder around the room, bleeding from his punctured head until they arrive and we can take him up to A&E in cuffs.

But he’s threatening his wife and her eyes plead with me to deal with the situation she finds herself in. She’s begging and placating her husband, promising him that the police won’t come, that everything will be fine as long as he lets her go.

I hear her words and it strikes me that she’s not just calming her husband down, there’s a part of her that’s genuinely frightened this hulking, uninformed brute in the door will go fighting with the man she loves.

Stuck between protecting herself and her husband she again begs with him to let her go and this time he does, releasing her from his right hand and turning towards me, pulling his fist back. I put my hands on his shoulders and push him backwards, he sits heavily on the bed behind him and I, momentarily, lose my rag, raising my voice and hollering.

“You try that again, pal? I’ll put you on the floor, you understand me?”

He sulks back.

“I’ll put you on the floor.”

Aye, and so’s yer maw.

But now things have changed. He’s sat down, we all back off and he resorts to sniping and blustering at us all. We are all bastards, all three of us, his wife is a bitch and should obey him, he’s her husband. He wants us to leave, to get out of his house. It’s his house and he wants us out.

“I can’t leave, sir.”

“Yes you can.”

“No, sir…you’ve had a drink and you’ve…”

“Shut up! Shut up and get out.”

“There’s no need for that, Ronnie. You’re a gentleman, let’s have a conversation like gentlemen, shall we?”

He glares at me.

“You’ve had a drink and you’ve hit your head. I can’t leave you behind, I’d be in dereliction of duty if I did.”

His shoulders slump.

“Right. Fine. Do what you have to do.”

My partner fetches a basin of warm water and a flannel and I put one knee on the ground beside him, keeping my other foot flat. Body sideways, my leg protecting my groin, tucking my chin in over my throat, watching his hands. He relents to my care, lets me clean the blood from his face, mopping and wiping, bathing and scrubbing while he stare straight ahead like a kid who’s been caught playing in the coal bunker.

An awkward silence.

“So….Ronnie…you were at the bowling club tonight?”

“Hmmph.”

“Do you play?”

“I do.”

I recognise a chance for him to regain his dignity and play it.

“I can’t understand that game. I watch it on TV, the way they curl the bowls? I couldn’t do that, never had a head for that sort of thing.”

He is, immediately, engaged and starts telling me at length about the weights of different bowls, how you’ve got to pitch them just so to reach the jack. How golf players make good bowlers because they understand the contours of a green.

Five minutes later we’re laughing together, he tells me he watches “all they programmes” on daytime TV and how “it’s disgusting the way folk get drunk and waste your time.”

“Oh, it’s terrible, Ronnie. It really is. Just tonight I was dealing with this drunken old goat who was wanting to go fighting with me…”

His eyes widen and he begins to commiserate before recognition kicks in.

“Old goat! You cheeky wee bugger!”

We shake hands, make friends, he apologises for his behaviour and I for mine. By the time we get to hospital he’s making sweeping statements that, once he’s out, he’ll take me and “your wife, girlfriend, whatever” out for dinner. He sits forward every few minutes to clasp my hands in his.

I leave him in Immediate Care, Shirley in the waiting room with a cup of tea, her wrist bruised, her hands gently trembling the tan liquid in the plastic cup.