The radio bleeps and I kill the sirens, we’re already on our way to a job - “Patient’s partner is threatening her with a gun, armed police en-route.”

Norrie and I are like terriers on leashes, it sounds a bit different, a moment of excitement in a night of driving little old ladies with very slightly swollen wrists to A&E. The controller’s voice comes from the speaker on the dash.

“410? You can stand down from this job, police advise you’re no longer required.”

Norrie’s shoulder’s slump.

“Can I get you making for a job in WeeVillage? It’s a police call…male assaulted.”

There’s a minor explosion in Norrie’s seat.

“Fuck’s SAKE….stood down from something with a bit of excitement to deal with a polis call.”

The police have a difficult time of it, when they deal with people who are complaining of pain or have been injured in any way, they have to get us to come out and check their charges over. As such we spend a lot of time going to “Police call - male assaulted,” confirming that nothing’s broken and leaving everyone to it.

We’ll never get to the job, it’s a long way away and we’ll have to drive past the hospital. I’m confident that someone will clear from A&E before we get near and the job will be transferred to them as the closest available unit.

A&E flashes past on our left as we drive south…looks like we’re it.

The house is buried in a estate, the NarkyRobotWoman in our GPS spits out her mid-Atlantic litany as we follow her directions, the ambulance making turns before she’s finished her instructions.

“Turn left in fifty metres…turn right in ten met….in forty metres take…”

I half expect her to sigh any minute and snap “Just look at the sodding map, right?”

Like breadcrumbs in the forest, we’re lead into the appropriate cul-de-sac by a caravan of parked police vehicles. Two vans, two cars. This looks heavy, I’ve seen fewer jam sarnies turn out to raging bar battles. A sergeant waves us down to the kerb, the house behind him has a solitary light on in the hall.

There’s no shouting, no screaming, no indication of any kind of altercation. The whole street is eerily quiet.

I wind my window down and in his haste to tell us the story and get us into the house the cop raises his chin to the widening gap, leaning forwards, talking before I’ve stopped the engine.

“…etty bad. Serious head injury.”

“He’s been assaulted?”

“We’re not sure, it doesn’t look like it.”

“But it’s his head?”

“Aye…it’s bad like, really bad.”

I tend to take statements about head injuries with a finger of sodium, your scalp is enormously vascular, it bleeds like buggery from even the smallest nick. Scalp lacs always look dramatic, but the body’s well able to control the bleeding and the blood vessels in the head clamp down fast. It’s extremely rare for people to exsanguinate from scalp injuries, the system is just too slick to let it happen.

As such, I’m somewhat blasé about the whole situation, Norrie heads up the path and through the front door and I follow, sanguinely swinging the O2 from a finger.

A gelatinous blob of arterial blood lies just inside the front door, a good size with no splash, smear or spatter. Looks like our patient spent some time lying here without moving. Maybe he’s been knocked out? Either way, it’s only about 50mls of blood, nowhere near enough to cause him any bother.

He’s sitting on the bottom half of the steps, Norrie to his left, a cop behind him and a Sultan’s turban of bathtowels wrapped around his head. As I look to his face to judge his skin colour my heart scrabbles against my ribs.

His left eyebrow, eyelid and cheek are slumped, the skin over his cheekbone lollops languidly as he speaks.

He looks like he’s had a stroke, but considering he’s had a head injury, it’s much more likely that he’s had some kind of brain injury, something that affects the facial nerves and muscles.

This is really, really bad. I’ve only ever seen one head injury with associated major nerve deficit and you can bet your arse that she’s dead.

This guy isn’t, so let’s start talking to him, shall we Kal?

“Alright mate?”

He nods, taciturn and pragmatic.

“Not bad. Been better. My head’s nipping me.”

“Ok, we’ll have a look and get you sorted out.”

I grab the hem of one of the towels and start untwizzling the fabric from his head, the towel’s wet with blood and as I ease it away I immediately realise why his face is drooping.

A chasm of skull grins up at me.The laceration starts at his left eyebrow, travels straight back across his crown and finishes two inches away from the top of his left ear. At its widest point the gap in his scalp is four inches across, a pink creamy expanse of bone hits Norrie and I at some primal point, you don’t need medical training to know that you’re not supposed to see that much of anyone’s skull.

It’s suddenly clear that his face isn’t drooping because of neurological damage.

It’s falling off his head.

I catch my breath and swallow my reaction, Norrie isn’t quite so lucky and blurts out a “Holy fuck.” Teeth gritted and eyes hard I throw a glare in his direction, a mental “Shut UP”, but it misses its target, Norrie’s eyes are fixed on the vista of bone, gently pitted, slightly rough, but clearly meant to be smooth, like a ketchup smeared formica table in a truck-stop.

Pushing the towel back on, I get Norrie to clamp his hands on tight to stop the bleeding and hold the patient’s head still and I run back to the vehicle for the spinal immobilisation gear. The patient is denying neck or back pain, but he’s clearly had a massive force exchange to his head and I’m not taking any chances.Dumping the equipment on the hall floor I sneak another look at the collapsed brow, it looks uncomfortable and, when all’s said and done, it’s just another skin-flap. I’d replace the same tissue if it was on his leg.

Laying careful fingers onto the skin above his eyebrow, I shove his face back where it belongs, literally putting his head back together.

This is emergency medicine, this is what I wanted to do, this is what I was talking about when I told the interview panel that I wanted a green suit rather than being an A&E nurse because I wanted to be “By the roadside, in the house, right in the thick of it.”

What a smart-arse.

We juggle the patient onto the stretcher, someone always has his head, someone else is always pressing on the dressings we’ve wrapped round his scalp and as I blurt instructions, helpful hands grab corners of the board and we carry him to the back of the vehicle.

Once loaded I hop back into the cab and grab the radio mic to pass the standby…and dry up.

What am I meant to say? If I describe this as “serious head injury” they’ll assume he has skull fractures and I don’t believe he does, what he’s got is “a major scalp avulsion”, but that doesn’t sound like the type of job we interrupt A&E for, dragging doctors and nurses into the resus room.

What I really want to do is yell “I can see his fucking skull!”

But that’s not appropriate either.

In the end I plump for “major scalp avulsion with significant skull exposure.” and concentrate on driving us all up the road. One eye stays on the bulkhead window behind me as I watch Norrie sitting with the patient and ten minutes later we’re outside A&E.

As we roll the trolley down the ramp, the patient stops us with a shout.

“Hey lads?”

“Uh-huh?”

“Is my head coming off?”

Norrie cracks up as he catches my eye, the patient’s half-joking, but Norrie leans over his face and with a smile says “Well…yes, mate, frankly.”

The patient sagely nods as far as the head restraints will let him.

“I thought so.”

Into resus, off the board, scrub the blood from the equipment and call clear to Control.

Off we go.

PS. There’ll be a prize for the first person to explain the title of this post.

In addition to Sarge lining up a run of days off for me, he also asked me if I was interested in having a few shifts where I wasn’t supervising anybody - “Just being the new guy again” - as he put it.

Quoted below:

“Similarly, I believe everyone asks for truth with regard to my health issues - no sugar coating - but when I write something raw and painfully honest to hold up for public consumption, there is a silence that is at once eerie, disturbing, and disquieting. The post becomes something like a curious lump in the blogosphere, and it lies there like someone who has fallen on the sidewalk, and all the busy people who come across this person step carefully over and around him, mindful not to disturb him.”

From The Sloth

I get exactly the same situation, but with unpublished posts.

There is a post that I’m working on and will continue to work on for several months, it won’t be my best by a long shot, because my best stuff happens when I come home from work, rant and rave to Giles drink a rapid succession of shots and sit down with loud music.

The long term posts? They are my curious lumps, they fester and grow and you all love them, because they’re huge, detailed posts of emergencies, blue lights, death, injury, bravery, human emotion, pathos and bathos.

I love them because when they’re posted they generate a huge response, but they’re long and tiresome to produce.

And they do my tits in.

Because after No.3, I said to Sarge who organises the shifts, “I’ll work the weekend, nights if necessary, but I want a long run of days off.”

But not resting on my laurels, no siree-bob, in fact right now I’m finishing my breakfast, then I’m going climbing with Jaffa and then (then!) I’m first-aiding at the Foo Fighters concert just up the road.

The Red Cross taught me many things, they gave me patient exposure and clinical skills and I have my time with them largely to thank for my current job.

And by ‘thank’, I really mean ‘use to get into gigs for free’.

All together now…”Don’t wanna be your monkey wreeeeeeeench….”

Seeya!

“Hi folks…what’s going on?”

It’s my opening line, my brain hard-wired to spout it unbidden as I sweep my eyes across a job on approach. On occasion, it’s extremely obvious what’s going on, there’s occasionally things sticking out of people, or heavy things on top of them, or the patient is lying on the floor looking sort of…dead.

But often it’s not clear and the stories that we get back don’t help.

They range from the bloody obvious - “I’m bleeding.”

To the outlandishly detailed and irrelevant “Well…I had an operation on my knee four weeks ago and it’s not given me any bother at all, but this morning I woke up and I’ve got this terrible ache in my shoulder and my Dad died of lung cancer so I’m a bit worried.”

Kids often give you an entire story before getting anywhere near the bit where they hurt themselves “I was running down the left wing and I was about to shoot when Darren came sliding in…”

And young men who REALLY don’t want the police involved will just shrug and answer “Dunno.”
“You don’t know how your nose got broken?”
“Nut.”

But mostly its all delivered to me in layman’s terms, medical professionals either identify themselves as such or try and hide their positions. Others who watch too much Casualty posture, pose and reveal themselves. I’ve had people tell me that patients are “GCS Two”.

Two nights ago I responded single-crewed to “Female collapsed/unconcious ?D&I”, the rain was pissing from the clouds in it’s all encompassing dark, wet manner that only central Edinburgh can summon. I’m flagged into the kerb by a pedestrian and fight my way through a half dozen young women standing around a wet, shivering bedraggled speciment on the pavement. I am then subjected to six people trying to give me six very different and very bad handovers.

“She’s taken alcohol and drugs and her airway is fine.”
“Both her pupils are reactive, but I can’t find a pulse.”
“She’s not making much sense.”
“I think she’s unconcious.”
“She’s GCS 12 and breathing normally.”
“Her radial pulse is thready and I can’t find any medicalert tags.”

I wave my hands in front of my face, warding away the ward-wasps. Laughing, I take stock.
“Whoa…whoa, ladies. Jesus, this is all a bit medical, isn’t it? You’re med students, I take it?”
“YEAH!” they chorus, though one pipes in with “I’M not, I’VE graduated, I’m a DOCTOR.”

I nod.

“FY1?”
“Yes.”
“Sorry mate, didn’t recognise you without a white coat on.” I grin, but I’m showing my teeth, junior doctors HATE the white coats that staff make them wear in hospital, it’s a badge of dishonour. A friend almost slapped me at work once when I told her she looked like she was playing dress-up.

Do they teach junior doctors to hand over?

I digress.

Many, many months ago I’m called to an elderly gentleman with chest pain. We pull up to a well kept house, large doors and windows and I march up the stairs, green bag over one shoulder. As I turn the corner of the stair case my bag swept a picture off the wall, the cheap moulding of it’s frame cracking as it hit the steps at my feet. Spouting apologies to the patient’s wife I continue up into the bedroom where a man in his 80s is sitting up in bed.

“Evening sir, what’s going on?”
He takes a deep breath.
“I’ve got chest pain, it’s like my angina pain, but my spray hasn’t helped it. I’ve taken the spray three times in the past half hour and it’s not improving. My pulse is also very irregular.”

Now there’s a strange thing for a patient to tell you…irregular pulse? Not “palpitations” or “my heart feels funny”, but “My pulse is irregular.”

I continue with my work, oxygen, aspirin, 4 lead ECG. I spot his glasses case on the bedside table, it’s monogrammed “Dr. A.B MisterMan”.

“Dr Misterman, is it?”
He nods.
“May I ask what you’re a Doctor of, sir?”
“I was a consultant anaesthetist, before I retired.”

Great. Just great.

He continues, hastily.
“But I don’t want that to change how you treat me.”
“Oh no, sir, absolutely not. It may change how I TALK to you.”
“No, I refuse, I want to be treated just the same as everyone else.”
“Well…alright. I’m going to put this cuff on your arm, sir, it’s going to blow up quite tight, but if you keep your arm still, it will quickly ease off.”

He’s glaring at me.
“With respect, sir, you did ask.”
His glare turns to laughter, we pop a pill under his tongue to dilate his blood vessels, his ECG doesn’t look good, it’s fast, irregular as hell and has some other worrying symptoms.

My partner bring the carry chair to the bedside.
“I’m quite sure I could walk downstairs, it’s really not that bad.”
I fix him with two raised eyebrows.
“Would you allow a patient to walk downstairs with chest pain and tachycardia?”
“Well…no.”
“Well then.”
“I just feel like a bloody fool.”
“Not at all, sir. In you get.”

Outside in the ambulance I shave patches of his chest, slapping electrodes in an arc across the left side of his pectoral and take a 12-lead ECG, giving me a three dimensional view of the electrical activity of his heart. I don’t like the look of it at all, he’s got marked ST elevation across various leads. In layman’s terms…he’s having a heart attack.

I’ve got a cracking ECG poker face, I read them every day and calmly lay them to one side, my patients (hopefully) never get a clue about what’s on there if it’s a problem.

This patient’s different.

“How does it look?”
“I’m afraid you’re elevating, sir.”
“May I see?”

Fuck it, why not?

He takes the strip from my hands, casts an eye over the peaks and dips on the pink graph paper as calmly as a man reading the cricket scores and hands it back to me.

“I am rather, aren’t I?”

The ride in is largely calm, the occasional howlet whoop from the sirens as we move errant early-morning taxis from our path. At one point he reaches for my hand, draws me near, out of earshot of his wife.

“I don’t mean to alarm you…”
“Mmm-hmm?”
“But I haven’t felt this scared since I sat my finals.”
“You know that we’ll look after you, sir?”
He fixes my eye.
“This isn’t a rational fear, young man.”

Shit.

“Sense of impending doom” is a symptom associated with worsening myocardial infarctions, I’ve only seen it a few times, but it’s strongly linked to the brain’s ability to tell the body when it’s going to die. Pally and I have crashed otherwise asymptomatic patients into Resus on the strength of these feelings.

We step up the gas and are into the Resus room within minutes, where our patient is recognised by the Registrar at the head of the bed. I stand in the corner while my patient hands himself over to the receiving team, grinning to myself as he talks the reg through the intricacies of his own ECG. He’s barely in the door before he’s hustled up to the cath-labs for surgery and thrombolysis where he begins his road to recovery.

If he’d just kept his mouth shut…he could have avoided all that fuss, just as he wanted.

My knackered winky case study was returned to my pigeon hole from the Training Department, a Post-It on the front that read “Do you really want this to be on your records forever?”

Because I loved Half Life, because it ate my life for many many months when I was but a young’un, I want to play Half Life 2.  All of it.  A lot.

What it says on the tin.

You are seventeen months old.

You are still fitting when we walk into the living room, the family GP looks relieved to see us. She shows me the empty packet by her.

“He’s had 5mg of Stesolid.”
Not bothering to try and get IV access on someone so wee, she’s scooshed liquid sedatives up your bottom. It should stop your seizure and make you sleep.

You’re still seizing, her fingers clamped against the back of your jaw, holding your airway open.

You don’t react when I clip an oxygen mask over your face, when I lift you, saggy limbed from the sofa, clipping orders from my mouth.

“Someone get my bag, doctor, grab the O2.”

Your Granny at my back.

“I’ll pack a bag?”

“He’ll be fine in what he’s wearing.”

“But they’re soaking.”

“Ok. Be quick.”

You’re still twitching when I lie you onto my stretcher, slapping cardiac monitors on you, digging a sticky oxygen monitor out and wrapping it round your finger.

Norrie passes me the radio handset, as asked, I blurt a stand-by message to the Paeds unit, hear a squawk and crackle from the speaker in the cab. I didn’t catch that.

“Was that “Received, thankyou?”" I ask.

He nods, starts the engine, lights up the roof.

“Smooth over fast, mate, ok?”

Nod.

I stop for a moment and yank your vest up to your neck so I can see your belly moving up and down, breathing fast, the ECG a staccato series of spikes, 180bpm. Too fast, but nothing to be done for it at the moment.

I pull your lips back and see two rows of very tiny, very white teeth smiling back at me, chittering against themselves as you shudder, I’m not getting an airway into there, am I?

You won’t let me open your mouth any further, so I’ve got nothing to do but push your mandible forward, I watch your lower teeth shimmy past their upstairs neighbours, hear your snarky, snoring inhalations quieten. I liked it better when I could hear you breathing.

Your Granny sits in one seat, Grandad in another, I’m in the jump-seat, you pulled so far up the stretcher that my knees gently

nudge the sides of your crown, I want you close, where I can watch you.

“Have you got an item of his clothes? A vest, or a jersey?”

Granny digs in the bag she threw together, passes me a vest. I roll it into a flat sausage and slip it under your neck. It extends your head, pointing your chin to the roof, it’s not as good as a permanent jaw-thrust, but I need my hands and it’ll hold you in position

for the occasions when I need to let go of you.

You are utterly oblivious to me as I roll each of your eyelids open, shining my torch into first one pupil, then the other. Your gaze is blank and flat as slate, your pupils twitch, but don’t tighten.

You’re really, really flat.

You make no movement or complaint as the alarms on the monitor start screaming, a yellow box flashing over your blood oxygen levels, 74…70…65. Spiralling away from the big fat 100 that I want you at, where I’d be thrilled and not scared to death that your heart, beating ever faster, is about to stop. I stare at your belly button as it thumps up and down as your lungs work overtime.

Are you breathing less than you were?

Not as deeply?

Violet hypoxia has begun to creep up your arms. Your fingers were dusky when I first got here, now they’re blue. Your wrists are purple, your elbows darkening.

You’re hypoxic.

So, so hypoxic.

Hypoxia kills people.

I hook my toe through the straps of the response bag and rip open an infant bag/valve mask. They deliver the highest concentration of O2 possible, a true 100%, with a good seal over the mouth no atmospheric air can enter. It’s also comforting to have if you DO decide to arrest.

Granny lets out a moan, puts her face in her hands.

“I know this looks dramatic, but it’s the best way, ok?”

She nods behind her shield of wrinkled digits, the gems on her wedding ring quivering with each hacking sob.

Grandad reaches out a finger and strokes your leg, he’s quiet.

“Is he ok?”

“I’m doing everything I can, he’s not waking up very fast, but I’ll look after him.”

Two thumbs against the sides of the mask, two fingers behind your jaw, oxygen pouring into you hard and fast.

You suddenly grimace, twist your face left. My right hand is my dominant, it’s obviously the stronger grip, that jaw thrust is hurting you. I’m sorry to hurt you, but at least you’re responding now, a positive pain response will often be enough to have someone’s cough and gag reflexes return, maybe I can move from A to B, more accurately consider your breathing.

You have no idea how happy you have made me, my squirting adrenal glands ease off, my facade slips as relief overtakes me, I stroke your cheek with a spare pinkie, take a deep breath, briefly dip my chin, sinking my forehead to yours. It’s an instinct and I catch myself, sit up straight.

“Good lad, well done…well done.”

I lift my gaze to see Granny. She suddenly sees through me, sees how scared I was, how shaken and rattled. “You don’t need to panic unless you see us panicking.” we quip to patients.

By Christ, you should have been panicking, lady. I see in your eyes that you’ve worked that one out. I lied to you, told you I’d look after him, and I have done.

But Jesus…….I was scared.

You scramble up from the depths of unconciousness, you’re more agitated, more upset by my hands on your head, heart rate eases off, breathing steadies, oxygen levels start climbing.

Thankyou.

We pull up outside the hospital, I spit orders at Granny and Grandad, usually we’d get them out first, it gives us more space to work in the back. Not today.

“Ok guys, I need you to sit right where you are, don’t move, don’t stand up, ok?”

They both nod.

I snap monitor leads off your hips and shoulders with one hand, pop your seatbelt with the other, switch the oxygen from the vehicle’s system to a portable tank.

“Norrie, I need you here, now.”

Gather you up and as I lift you from the bed your pupils suddenly slam wide, you take the first, concious breath I’ve seen from you.

Your eyes focus on my face.

Hiya. Thanks for joining us.

Into resus, lay you on the bed and run through my story, the team take over.

A doctor looks you over, stands and surveys us both.

“Who was on the radio?”

“That would be me.”

“A word.”

He walks from the resus room, into a cubicle, pulls the curtain closed.

I suddenly feel like I’m in the Rector’s office at school.

“Your radio message was far too fast, far too clinical. You blurted it out and hung up, we didn’t hear any of it. My team have been

waiting for this coming in with no idea as to what was arriving. Do you know how stressful that is?”

“I’m sorry…I thought the message had been received.”

“Well it wasn’t, you need to slow down when you talk, be less clinical, more colloquial, you were far too abrupt.”

“In my defense….”

“Just slow down, right?”

“I was told that the message had got through, I’m sorry if I’ve caused you upset.”

“Just slow down.”

He walks from the cubicle. I’m shaking, one part adrenaline burn off, one part anger. My forearms cramp and curl inside themselves, my breathing hard and jagged.

I return to the vehicle, trembling. A host of retorts come to mind, but all my comments about “Supervising a new start” “On my own in the back of a moving vehicle” and “Not having ten people standing by me to help” sound pathetic, infantile and whiny.

Discretion being the better part, I slope back to the resus room and apologise to the nurses for leaving them hanging, a communication problem, I explain, sorry if I stressed them out. They wave their hands dismissively, it’s no problem, Kal, shit happens.

Back in the cab and the adrenaline burn off physically hurts. Norrie is sheepish.

“Sorry…I really thought they said they’d got it.”

“S’cool mate.”

“No, I fucked up.”

“Mate, you drove brilliantly, it was smooth and easy and I didn’t have to worry about holding on to him. It was great, chill.”

I’m the one with the weight coming home with me, because what I really, really wanted was “This must have been hard to deal with in the back of a moving vehicle, while worrying about your new partner’s driving, trying to comfort two terrified family members and fending off sternum chewing terror that a baby was about to die in front of you and notch your belt. Good job, well done.”

By now, I’m sure, you’ll be home in the arms of your family, they’ll have a stiff drink once you’re in bed tonight, perhaps they’ll sleep on the floor of your room for a few days, before this afternoon just becomes another chapter in your upbringing.

But you’re still with me.

And you’re not going away for a very long time.

(This may have spelling mistakes, or be awkwardly worded, or have punctuation problems. I don’t care. This whole story happened 3 hours ago, excuse me if I’m not the Poet Laureate for an evening.)

Six months ago to the day I was writing about this incident and pondering on my reactions to the aggression and violence that we often face in the course of carrying out our duties.