Back in January I wrote for the BMJ about the phrase “trust me” and this afternoon I found myself using it in an unfamiliar way.

With most patients I use “trust me” as, in honesty, a pacifier/dummy. Here, take this and suck on it for a bit while I get on with fixing you.

Your panic and stress are getting in the way, your endless questions and frantic messing about your keys, your jacket, how you’ll get home, whether we’ll drop you.

I’m pretty good at what I do. We’re all pretty good at what we do.

But I’m not allowed to say “wheesht, you, I’m busy saving your life”.

So instead we say “Trust me”.

And they do.

That’s not entirely true. They pretend to. That’s their part of the bargain. I say “trust me” and they play along by chilling out for a wee bit.

Because they’re adults and they’ve all read the “how adults interact and don’t cause a ghastly scene…” leaflet that the British public get issued with in high school.

But today the words did something different.

They meant….what they mean.

Young lad. Ten years old. Fifteen feet up, rapid descent, even more rapid deceleration on impact with the ground.

I was concerned that he’d broken a vertebrae or two and the way he winced whenever he took a deep breath made me suspect that the big graze and haemotoma over his ribs was suggesting some horrible pleural contusions underneath.

He held things together quite well. Far better than I would do in the same situation. He had a bit of a blub when his Mum arrived, but then, as would I.

And when we rolled him into the vehicle his face suddenly changed, he chewed his lip, his eyes flicked sideways.

“What’s going on, mate?”

“Nothing.”

“Your face tells me something is going on. Does something new hurt?”

“No.”

“Can you tell me what you’re thinking?”

“No.”

“Can I guess? Sore? Embarassed? Scared? Worried? Cross?”

“Worried….and scared.”

“Scared of anything in particular? Or just all the everything?”

“All the everything.”

“That’s fair enough. How’s this? You trust me and I’ll look after you, ok?”

And he nodded.

And his face relaxed.

And he got on with trusting me.

Not because he thought it was the socially acceptable thing to do, but because it was something he could actively get on with.

Give it a go with your patients next time - make trusting you their job. Not lip service, not an empty, placating mumble.

But a deal between the two of you.

“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.

I’m noodling around Parliament Square on the High Street, chatting to stewards and watching shows when my phone blares in my ear. I’ve got all SAS numbers set to a particularly obnoxious ringtone, a submarine’s dive alarm.

I blip the handsfree button at my jaw.

“This is Kal.”

“Kal…where are you?”

“On the High Street. Where’s the job?”

“We have a male colla….correction…we have a male in cardiac arrest just down the road, can you attend?”

Damn straight I can, even with the dense crowds between myself and the patient I’m on scene in just over a minute. A man lies on the floor and a couple are performing textbook CPR on him, bobbing up and down in perfectly timed synchronisation.

My wheels stutter on the granite setts in the road as I approach.

“Paramedic!”

The man doing compressions looks up as I approach.

“We need a defib!”

“No problem.”

There’s a crowd around the patient and I point at the largest member, a burly, tattooed man with mirrored shades on.

Dismounting from the bike, I thrust the handlebars into his hands.

“You. Hold this.”

Congratulations, dude, you’ve just become my bike stand.

The bike is a big heavy mother fucker to try and unpack in a hurry, with six weeks experience under my belt I’ve learned to do it without dumping everything all over the pavement, but the simple act of pulling the bags out can make the front wheel swing from side to side. Far easier to get a bystander to hold it tight.

The defibrillator lies right at the top of my panniers. Funnily enough, it’s remarkably similar to the model I first trained on with the British Red Cross almost eight years ago, a simple “shock-box” with one cable, one socket and one button to press. They’re hard to screw up, but I realise as I unpack it that I’ve never actually used one in anger.

Thankfully the defib proves to be simple plug and play, truly idiot proof. As soon as I plug the pads in it starts shouting at me in its Mid-Atlantic twang.

“Apply pads to patient’s bare chest.”

I shred the patient’s teeshirt, cutting right up the front and through the collar, the fabric flops backwards over his shoulders in a tattered yoke.

The couple are still pounding away at CPR and haven’t delivered their classic panicked bystander lines of “We’ll get out of your way?”.

That’s odd.

I nod at them both.

“You guys doing ok?”

They nod back.

“I’m a GP, my wife’s a midwife. He just dropped in front of us. We could see he’d gone off.”

“No pulse since collapse?”

“None.”

“You ok to carry on?”

He’s red faced and sweating, but nods steadfastly, putting his hands back on the patient’s sternum.

“Sure thing.”

The pads in place, the defib is now yelling at us “Do not touch patient, press flashing orange button to deliver shock”.

Its cheap LCD screen shows coarse ventricular fibrillation, the first thrashes of an arresting heart. It is arguably the healthiest “dead heart” rhythm to be in.

“Ok, I’m shocking. Stand back, please.”

The GP and midwife sit back on their knees, I swing my eyes from the patient’s head, down his arms and torso, legs and feet. No puddles, no metal grates, no-one still clinging to a hand.

“All clear! Shocking now.”

I push the orange button and the patient turns rigid for a second, before flopping limbs back down onto the pavement.
The screen still shows VF, the defib recharges and yells again for us to shock. The GP reaches for the button, before I stop him

“Hang on, please mate, let’s give him another round of CPR first.”

The heart can only take too much punishment and we’ve just electrocuted it, plus we’ve been “off chest” while we did it. A phase of CPR will do the myocardium the world of good, flooding it with oxygenated blood and giving our next shock the best chance of a good result.

“Back on the chest, please, somebody?”

Compressions start again. I kneel by the patient’s head, pull his chin up and back and snag the intubation board from my bag, push a mask over his mouth and nose and breathe for him.

A voice in the crowd shouts out.

“I’m a cardiologist…can I help?”

“Right here, please, doctor.”

He’s by my side.

“What can I do?”

“I’m going to tube him, everything’s on the board there, can you prep for me, please?”

This is clearly not the role to which he is accustomed, but he makes no complaint, busying himself with endotracheal tubes, lubrication and laryngoscope blades. He passes me every piece of equipment as I need it and I’m just pushing the ET tube through the patient’s vocal cords when I hear the chord of siren and engine behind me. Squaddie jumps from his response motorcycle, flips up his visor.

“Do you need any kit?”

I shake my head and he jogs over to us, all creaking leather and armoured boots.

“You got any access yet?”
“Nope.”

“I’m on it.”

Returning to the patient’s airway I find my ET tube has slithered back up the throat and is lying, useless, in his mouth. How the hell did that happen? Dead folk don’t spit back.

I feel like I’m in an emergency Punch and Judy show, whenever I turn my back someone steals the sausages - “Now children, if that naughty crocodile extubates himself while I’m away, you will shout for me, won’t you?”

I’m sliding the laryngoscope back down his throat when the defib starts up shouting again - “Push orange button to shock!”

The GP takes his hand from the patient’s chest and reaches for the defib.

“All clear please.”

At this point I’m still holding the laryngoscope, all steel and carbon fibre, inside the patient. A defibrillation at this point will probably fire me across the street.

“No shock, please, doc.”

He stifles a quiet laugh, my voice clearly had hints of panic in it.

“It’s ok, we’ll wait.”

Once again I push the ET tube through the cords and again the patient’s gag reflex fires it back up the trachea at me. I’ve never met a person who’d lost their pulse and breathing, but maintained the ability to protect his own airway.

My textbooks come back to me - “If the patient repeatedly rejects intubation, reconsider if the procedure is necessary.”

It’s not just the procedure, I need a moment to reconsider the whole job. This is the first arrest I’ve run as a paramedic. There’s plenty to be gained in a resus situation from backing off and taking a moment. I sit back on my heels.

“Go with the shock, please.”

The GP checks us up and down, Squaddie puts his hands in the air, as do I. The patient jolts from the shock and slumps down again.

The defib screen shows pulseless VT, a cardiac rhythm that is significantly more coordinated than VF, but just as bloody useless at sustaining life.

Of course, VT is “more coordinated” than VF in the same way that a cat is more likely to organise a successful jumble sale than a set of patio furniture.

A dark blue Beemer pulls up alongside us and TopCat, our resus doctor, hops out in shirt and tie. He appraises the situation while Squaddie shocks the patient a third time.

The violet patient’s face suddenly regains its pink hue. He drags one long breath into himself. I feel for a pulse at his neck and grin when I feel it hammering along under my fingers.

“What’s the story, Kal?”

“Witnessed collapse, immediate bystander CPR, shocked three times, VF, VF, VT, now regained an output, rejected a tube twice, no drugs yet. “

He surveys the scene and smiles, satisfied.

“Cool.” He looks me up and down in my shorts, bike shoes and teeshirt.” ..are you on the mountain bike?”

“Yup.”

“Sweet.”

An ambulance arrives and we hoist the patient onto the trolley, lifting his head and shoulders with his shredded teeshirt. He vomits copiously over everything and I regret not getting that tube into him, but within minutes he’s fully conscious and asking the ambulance crew what happened to him.

Squaddie and I are left to tidy up the wreckage on the pavement, both grinning like idiots. TopCat hops out of the back of the ambulance and snaps a shot of the two of us, arms round shoulders, grinning at his camera.

“The day the Parabike proved itself!” he declares, before returning to the patient.

Squaddie and I return to picking up, he rips into me.

“You’re not going to claim this is a save for the Parabike are you? You wish. It was MY finger that shocked him the third time.”

“Fuck you cunty baws!” I retort “It was my legs that got the defib to him in the first place!”

The head of security for the Fringe is standing on the sidelines. We used to work together at the Edinburgh Dungeon as actors before we both got ourselves proper jobs. He’s shaking his head at the two of us.

“That was the most amazing thing I’ve ever seen. You just saved that man’s life.”

“Pretty much.” we answer.

“What does it feel like?”

I’m beaming at him, jiggling up and down in my shoes.

“It tastes pretty damn good.”

I take my bike back from the man in the sunglasses who shakes our hands, a barman from a nearby pub offers to drive the patient’s family, total strangers to each other, to the ED.

I restock my panniers from Squaddie’s kit and we say our goodbyes. We clip helmets back onto our heads and he claps my shoulder.

“Good job, son.”

“Cheers mate.”

He starts his bike, revs the engine and is about to vanish into traffic when I wave him down.

“One last thing?”

“Yes mate?”

“I think you’ll find you owe me a fiver.”

He laughs, gives me the finger and roars off.

The taste lingers for hours, I spend the day smacking my lips, running my tongue over my gums. The potent visceral rush of life from death clings to my teeth; it shines when I grin.

The security guard and other bystanders tell each other the story at coffee breaks.

I duck my head, shy now and bashful of the attention, but still breathe out the flavour into my collar and, while no-ones looking, inhale it back inside me for one (just one more, I promise…) last illicit taste.

He wasn’t quite a regular, but I knew his face. A few months ago we found him sitting on the pavement outside a children’s play park, reaching out with wobbling hands to steady himself on the smashed kerbstones. He was guttered, the smell of cider rolling off him in fetid clouds. His cheek was broken, one eye swelling shut. The victim of a misunderstanding? A mugging? Maybe he’d been mouthy and taught a lesson?

Perhaps he’d just happened across one of Edinburgh’s more delightfully racist inhabitants who’d decided that physical violence was the best way to express his political views.

His English wasn’t up to much, though whether that was through linguistic inability or intoxication it was hard to tell.

I reached my hand out to him.

“ID?”

He dug a card from a wallet stuffed and bulging with notes and photos, I didn’t recognise the identification - maybe a driver’s licence? Maybe state ID? A stark, angular eagle shimmered at me from its holographic perch. I managed his first name, “Sergei”, but struggled with his family name, probably mangled it.

He gave me a wan smile for my troubles.

Another guy from Eastern Europe, his identity hidden by a state that struggles with his language. Polish? Chechen? Romanian? Czech? Serbo-Croat? Another face to join the legion of young men seeking their fortune here. I say, good luck to them, make your money where you can.

I know I am.

They all wear the same uniform, baggy street/sports wear, big trainers, cropped hair, high cheekbones. The women carry impossibly huge gold handbags, totter on precarious heels.

These people hardly ever call us, they’re self sufficient to a fault. I once attended a young Polish man who’d sutured his own abdominal stab wound before calling for an ambulance. Another family called me with a sick toddler. His parents had been carefully dosing him with over the counter medications, meticulously recording his temperature through the day. They knew his weight, his age to the week and they gently, gratefully and proudly cooried their baby into my jacket, total trust, total respect. They ‘d called for a paramedic when they had no more ideas, instead of most of my British clients, who phone because they can’t see a GP on order.

There is no escaping, however, that Scotland and Eastern Europe share one thing in common. We’ll take a drink.

A fair percentage of these young men (and it’s always the men) are hardened alcoholics. Vodka, beer and cider, mostly. As paramedics the drunks all blur together into an amorphous conglomerate of vomit and air freshener, shit on the mattress and another bag of intravenous fluid. Scots, English, Polish or Russian, a drunk is a drunk. Pick him up, roll him into A&E and go out for another one.

There’s always more.

But back to our patient.

The scar on his cheek is readily visible, but this time he’s lying in bed, a duvet pulled to his chin. His brother, sober and speaking English like a BBC broadcaster, explains that last night he’d been drinking, again. They’d had an argument, he’d stood up and jumped from the balcony into the garden below.

I lean over the balcony and have a look. The flat is on the first floor, but the garden begins at the basement, rising in a gentle slope away from the building. Two storeys. Thirty feet or so. Like a super-hero shattering the pavement in a gaudy blockbuster, two foot-sized craters in the bark around the rose bushes.

“It’s his legs…”

I pull back the duvet. His ankles are black, purple, yellow, swollen to the width of his thighs. His feet aren’t much better, the tissue around his heels fat with fluid, he growls when I palpate them. Impossible to tell without an xray, but I’d put money on his calcanei being fractured; stalwarts that have carried him around for thirty years now rough lumps of chalk, grating and rubbing against themselves. His metatarsals, once filligree roots for dancing, sprinting, twisting now a jagged mess, wet branches splitting down their own length.

“When did this happen?”

“Last night.”

“How did he get back up here?”

“I carried him.”

Any damage to his cord would be done by now, but I check his C-spine for signs of fracture. We find none, so pad and splint his mangled feet as best we can. My partner raises eyebrows at my old first-aid “pillow splint” concept, but it holds things steady for the trip down the stairs. Thankyou, voluntary service background.

In the vehicle I talk to the patient’s brother, while Sergei stares at the ceiling, muttering to himself in a haze of pain, hangover and the morphine I dribble into him.

I’m intrigued.

“What brought you guys over here?”

Sergei’s brother starts to explain, unravelling the political mess of his home country for me, laying it out at my feet like a blanket. Here is the corrupt emperor, here the politicians who lined their own pockets with taxes. Here is the collapse of industry, here the civil war over the border that killed his cousin. Here are the exorbitant business rates that closed his father’s shop. Here is the burned out shell of their holiday home in the mountains, here is the crowd of fascists that gathered in a town square when he was out shopping with his children.

“And what did you do back home?”

He points at Sergei.

“He drove an ambulance….I was a chef.”

“And now?”

“Now we work in a factory. We gut chickens and package them for restaurants.”

“Is the money worth it?”

“It’s better than at home. But him? He doesn’t like it here. He didn’t drink at home. It’s hard.”

Sergei is paying fierce attention to our conversation, I suspect he understands more English than he speaks.

He asks his brother a question in their mother tongue, listens to his response and viciously, vehemently spits out a minute of raging diatribe. He removes his wallet from his jeans, the same as he showed me months ago and pushes a sheaf of photos at me.

A pretty woman, blonde, Jackie-Ohs and sandals dances on a beach with two children. The sun is shining. The sea is blue.

A little girl, maybe six years old, turns from a piano’s keyboard and smiles at the camera.

A wee boy, pressed and coerced into a suit and tie, holds the hand of the blonde woman at the door of a church.

Sergei, his wife and kids and a host of faces, old and young, men and women cheer at the lens; a man (an uncle, perhaps?) is flush-faced and out of line, clearly having raced the camera’s auto-timer to get into the photo.

His brother translates for me.

“He has been here three years. Every month he sends what he can back home. His wife, Katja? She was here also, the children lived with their grandparents. But his father was very sick, so Katja went home to care for him.”

Sergei is still speaking. His brother placates him with gently waving hands, he smiles apologetically at me.

“He has not seen his children for three years. Last month his son started high school. He came here to make a better life for the four of them, now he can’t afford to go home and they can’t afford to come here. He says “Wouldn’t you drink?””

In fairness.

Yes.

Yes, I think I probably would.

I don’t hate you because you called me a cunt.

Or because you’re planning on staying at home with your kid, her eyes bloodshot and weeping pus and snot.

Probably conjunctivitis.

Probably.

But possibly early orbital cellulitis. Possibly an infection that could cost her her sight, or pour infection and toxins into the rest of her system.

I don’t hate you because you’re screaming at me.

I don’t hate you because you refuse to step up to the plate and take some responsibility.

It’s nothing to do with the fact that, when the state doesn’t roll over and pay for your demands, you respond with aggression and threats.

And I don’t even mind you telling me that if your kid dies it’ll be on my conscience, because it won’t.

It’ll be on yours.

I’m bemused by your refusal to phone your father to drive you home from the hospital, you respond by shouting that it’s my fault, that if I’m taking you to hospital I have to take you back.

When I ask about public transport, you light another cigarette, put your sparkling trainers on the coffee table and switch off the gargantuan TV on the wall, before telling me you can’t afford the bus.

You, apparently in all seriousness, propose “kicking off” in hospital to get arrested, surmising that “they’ll not put us in the cells with the bairn, they’ll drive us home.”

I hate you because you refuse to consider that maybe, just maybe, you could try taking some responsibility for yourself, stepping outside the bare minimum that has to be done to get along.

I hate you because you’d sooner see your kid stay at home, crying, scrubbing chubby fists at her swollen eyes than step up to the plate when she needs you.

I hate you because when I ask a final time if you’re coming with us, you smugly refuse, preferring to score sordid, childish points than have your kid see the doctor.

I hate you because when I describe you, I hear myself sounding like a Tory bigot, frothing behind his Daily Mail, scared of anyone darker or poore than himself.

I hate you because I can find no words to describe you other than “scum”.

I hate you because, faced with a situation in which the establishment won’t bail you out, you respond with aggression and violence.

I hate you because you denigrate everything I believe in about socialism, about people being inherently good, about giving everyone a chance and supporting your fellow man.

I hate you because you make me hate myself.

You’re not all that fat, but still a tricky airway to manage; I knew you’d give me problems when your head dropped back in that heavy, final way. Your wife didn’t know you’d arrested, but she knew you were very, very sick. I shut the back doors, shaking my head apologeticaly - no, no, you guys drive to the hospital, there’s not a lot of room in here, we’re going to be very busy.

She doesn’t want to watch this. She may think she does. She really doesn’t.

Your face is slick with sweat and makes my hands slip over your cheeks and chin, just a hint of middle aged jowl pulling your face away from the mask, reducing the efficacy of the seal, blowing oxygen around your face rather than into your lungs. When I do push air into you, your chest rises and falls while your stomach rises and remains. I’m breathing for you, but your stomach is filling up rapidly.

You say “Urp.”

A sludgy tide of orange vomit crawls up into your mouth while I’m doing chest compressions; passive regurgitation, we call it. Not vomitting, just opening all the tubes and letting fluids and pressures find their own levels. Your mouth brims with the stuff and as the vehicle bumps over potholes, you slop like an over fill soup bowl in a ferry’s cafeteria. Vomit cascades out of your mouth, up your nose, into your eyes and hair.

I whack the suction up as high as it can go, hoover the goop out of your mouth and nose; momentarily fret about the state of you - live fast, die young…

The bag and mask still won’t push air in. It’s blocked by something, but your mouth is empty, your nose is clear.

Fuck this.

I grab the response bag and pull out a laryngoscope with the longest blade I can find. The last time I did this was on a 64 year old man, with no teeth, having a laparoscopic cholecystectomy. I had two anaesthetists and an ODP watching me.

And the fucking bed and floor weren’t moving at the time.

Push the head into position, slide the blade down the right hand side and sweep the tongue, now lift…don’t lever on the teeth…lift, pull his neck towards the far corner of the room.

There. His larynx. Packed full of spew.

The suction catheter shimmies down along the laryngoscope blade and sooks the last of the gunk from his airway. His vocal cords wave at me, a fleshy “peace out” V shape, with darkness behind them.

You’d be such an easy intubation. I could shove a tube down there right now. It would secure your airway, you could vomit all you like and it wouldn’t matter a docken, I could concentrate on CPR, rather than clearing your throat of acrid lentil soup.

But you’re young. And you’re going to die. I’m realistic about this.

There will be a post-mortem. They’ll ask who intubated.

And the response will come back - “The unregistered paramedic in the ambulance.”

And I’ll be struck off before I’ve even practiced.

Sorry mate. There’ll be folk in my career who I’ll tube who AREN’T going to die. From the history your family gives me, your chances are terrible. I’m confident I know what stopped your heart today; I’ve never seen anyone survive this.

You’re a lost cause.

But I’m not.

We’re way overdue a meal break and heading up town to pick up some munchies when the screen starts wailing. Officially we’re not available for the job, but the message makes us think twice.

“Patient unconcious and not breathing.”

“Fuck it - you happy to go?”

You’d have to be a hard-hearted cunt to choose your sandwiches over a cardiac arrest; Bryson punches the “Go Mobile” button on the screen, a navy line tracking across the map, leading us to a darkened towerblock.

The carpark is spread with shattered concrete, dogshit and glass, purple yellow security lights shine across the entrance from behind black mesh cages.

“I thought these were being pulled down?”

Bryce is attending, so he takes the bag and oxygen, I lift the defibrillator from its cradle and slip my Maglite horizontally across two belt loops under my jacket.

“Tooled up?” Bryson grins at me.

“It might be dark…” I answer, grimly. We both know I’m a chicken, that I want the security blanket of a big metal stick on my belt. Not that we’d ever admit to it, the line is always that “it might be dark.” It’s said with good reason, we’ve been here before.

We ride the lift, shuddering and shaking, all steel and sweat and fading council notices, up to the first floor. Our patient is apparently in 1/4, or floor one, flat four.

Flat four is boarded shut with sheet metal, rivets the width of my thumbs pounded into the concrete on either side.

“Four stroke one?”

“Could be…”

We tramp up the stairs, October’s wind hissing between the crazed perspex that passes for windows. Names are scratched into its surface, lovers and enemies, couples and hits, Croick Kirk resurrected with Stanley blades and needles.

The fourth floor has four metal doors, humming gently in the breeze.

“Nobody in here.”

“Bad pun.”

He stares at me.

“No…body?..Forget it.”

We slope back down the stairs to the vehicle, the radio boops rhythmically before our controller’s Irish tones come through the speaker, thin and sharp.

“403?”

“Yeah, nothing found at this locus. Can you call back and confirm the address for us?”

“Police are on their way, we’ve already tried to noise up the caller, phone’s dead.”

A sandwich and van pull up, five cops raise ten eyebrows at the two of us standing in the cold.

“Where’s the job?”

We explain, the unclear address, the boarded up flats. As a group we stare up at the blunt obelisk. Two windows are lit.

“Someone’s still living up there?”

His shoulder badge has five figures. Most cops have four. I’m confident he’s been working for less time than I have.

“Looks like it.”

As a group, we start up the stairs. The defib is heavy, its plastic handle starts to sweat and rub against my palm as I plod up the concrete steps.

At each floor, one or two members of our gang leave the stairwell, confirming that every flat is welded shut, prodding the doors to the bin chutes open with our feet, stepping around rusty puddles of effluent and damp, shining torch beams into dark corners where … something scrabbles down a hole away from us.

On the sixth floor we find our first wooden door, warm golden light spilling from its transom. The spyhole has been pushed out, a hole as wide as a pencil through the wood of the boundary. I close my eye to it.

A classic smack den. No floorboards, no furniture. The man of the house staggers to the hall wearing only ragged boxer shorts and a stained teeshirt in response to my knocking.

“Who is it?”

“Ambulance! Come to the door, please.”

“I don’t need an ambulance.”

“You didn’t call?”

“No. Fuck off.”

Good enough for me, I join the climbing party.

By the time we’re at the seventh floor, I’ve found myself with two officers, one male, one female and as a threesome we swing into a leapfrogging pattern. He checks floor eight while she and I climb to nine, she checks nine while I leave her to clear ten, meanwhile he passes us both and sweeps eleven.

The building is confirmed empty in minute, so the police search their database for anyone matching the patient’s name we’ve been given. His address is just round the corner, so the entourage troops round to wake him from sleep. He’s drowsy and angry at being disturbed, but clearly not in cardiac arrest.

There is nothing else to do.

We can’t reach the original caller, we can’t find the patient.

We climb back into our vehicles and drift off into the night. If the call was genuine, somebody, somewhere, is dying on a floor with an intoxicated friend staring over him.

We’ll find him some day.

We always find them in the end.

Part II of “We open on a room…”
“25YOM, septicaemia, will need a stretcher”,

25 year old males rarely find themselves so acutely ill that they can’t walk.

It happens, granted, but it’s rare.

We’re growling, hackles sky ward, at the direction from whoever’s booked this call that he’ll “need a stretcher”.

I have five ways of moving prone people: two stretchers, a trolley, a canvas and a vacuum mattress, not to mention a bewildering series of bondage-esque lifting and moving harnesses, sheets, handles and cushions.

He’ll need a stretcher to get out of the house will he?

Jolly dee.

Which one would you recommend?

At the front door of a well kept Georgian town house, we’re met by a woman in her sixties, slate grey hair brushed time and again out of her eyes, no make up this morning,  one earring swings at a lopsided angle, shoved in any old way.

“He’s through there.”

Unshaved and apparently wearing the clothes he slept in, the young man sways across the floor towards us.  His gait so languid and deviant his hips seem to climb to his shoulders with each spastic, shuffling stride.  I wouldn’t startle to hear him mumble about my braaaains
Instead he has his own lines.

“Ohhhh….fffffuck…..fuckfuckfuckfuck.”

Whatever’s going on, he certainly looks uncomfortable, but the swearing seems to be for our benefit.  Like a kid with a new toy, insistently shaking it in the face of a visitor to the house.

His mother sighs as he hirples past us through the front door, glancing at my partner to see if we’re impressed by his spectacle.

He’s clearly not interested in talking, just as long as we all see how terribly ill he is.

His mum, my partner and I follow him down the house steps to the back of the vehicle, where he loiters like a fart in a lift.

My frustrations at his total absence of manners aside, I’m pleased to see that he’s alert and pink, breathing and walking with ease (“needs a stretcher” my ass).

In the grossly septic patient I’d be concerned about shock or at least dehydration, with a casual eye for rocketing temperatures that send people a wee bit loopy.

He has none of these.

In fact, other than being a little shabby and gasping like a steam kettle at climax whenever he walks, he doesn’t appear all that unwell.

I get him settled in a seat.

“So what’s the problem, Mark?”

He stands upright, pulls down his trousers and underwear.

“It’s this, mate.”

So it is, by the way.

His scrotum and thighs are howling red, an abcess the size of my fist snuggles at the top of one of his legs, the skin strained and tight.  Pus and plasma seep from the edges; it is, in short, everything you hope your tackle will never be.

“How long’s it been like that, then?”

He fills his lungs and launches into his story, clearly a tale he’s told before and, like the stories of fights told in the pub the next night. The highs and lows are escalated, the near misses, punishing defeats and shining victories are more dramatic and exuberant than Bollywood, without the choreography.

Regardless of the tides of his past, his opening line catches me and won’t let go, the rest of his chat fades into soft focus.

“I started shooting up 13 years ago…”

I recycle the maths in my head over and over, but the answer always comes out the same.

He first took smack when he was twelve.

Twelve.

And I may be speaking out of turn, I may be presumptuous, I may be coming to conclusions that have no foundation.

But it showed.

It wasn’t his glowingly visibly clavicle or sunken ribs or concave cheeks.

It wasn’t his matte eyes or sulking skin or open sores

It wasn’t the shadows in the cleft of his elbows or the screaming livid pink foliage that climbed up his wrist (“I got a hit that was mixed with rosin, it melted fine but solidified in my veins, I had to cut the lumps out with a Stanley knife”).

It showed in his personality, which had hung at twelve years old.

He was pubescent, brash and rude, evident in his inflated accounts of heroic injustices.

Between the two of us, his mother and I had to guide his conversation as with a teenager.

It was clear that his mother was stupid and understood nothing of his life, that I was an idiot meddling in issues of which I had no comprehension.

He idly made phone calls in the middle of my asking him questions, his mother twisting him back into an appropriate social response - “Mark, the gentleman was asking you something…can you listen to him, please?”

Where he differed from an adolescent was in his knowledge of the world.  He was armed with opinions, facts, figures and concepts; current affairs, politics and social challenges.  He just lacked the maturity to apply them; like giving a sugar-rushing eight year old a Kalashnikov in a party bag, lethal, excited and totally misguided.

The addiction therapy services in the UK were “completely fucking stupid” and would be better supplying their patients with street heroin “Because we know what’s good and what’s not”.

Methadone was a government conspiracy to keep “people like me” down.

He would “fucking kill” his mother if she went into his room while he was at hospital because he “had stuff that she had no business dealing with”.

By the end of the journey his Mum and I were sharing glances, agreeing with each other without words, conspiring against him to manage his conduct and treatment.

It was immediately clear that my skills with Mark paled in the shadow of her’s. She obviously had years of ambulance rides, discussions with doctors and patient management of his behaviour.

Her love as a parent stretched her tolerance far beyond the point at which mere mortals would have stepped aside and let her son fall.

Astonishing and far beyond my comprehension…but it certainly gave me some perspective as regards my own problems.

A straight fall backwards, no trip or stumble, no complaint of dizziness.  Just a sudden drop from perpendicular to parallel, arrested only when the back of her head smashed into the kerb.Sitting up on our arrival, Meridian the RRU Paramedic raising her eyebrows at us.

“Blood from her left nostril, Kal.  Really watery…left eye’s funny, too.”

Nosebleeds don’t phase me.

Watery nosebleeds scare me shitless.

The brittle little doll of a woman leaning back against the railings tips me a wink.  Her right eye blinking rapidly at tears, her left staring straight ahead.

Once she’s on the bed with her spine secured I can take a closer look.  Both pupils focus, both cower down under the beam of a torch; but only the right will close.  The left glares accusingly at me under a collection of grit and dust, the surface visibly drying as I look at it.

I stroke my fingertips over her eyelashes, a trick we normally exploit on ATIT unconscious patients.  Your nervous system can’t help but blink when your eyelashes are stimulated.

Unless it has suffered a serious insult.

Like having the bottom of your skull stoved in against the pavement.

And drowning your brain in blood.

I soak a dressing with saline and lay it over the eye.  Protecting her cornea is a long way down the list of priorities, but short of trepanning with a biro, it’s all I can do for her in the vehicle.

She babbles to me en route, grabs at blankets, seat belts, BP cuffs.  I sacrifice a third set of obs for holding her hand and softly shushing her frantic, meandering yammering.  Clinical responsibility has its place, stabilisation and rapid transport is right there alongside.  There’s a time for reflective jackets, flashing lights, vehicles slewed across lanes of traffic, torch beams in the dark.

And there’s another for recognising that your patient is scared and alone and dying.