“So if she can tell the call-handler that her spare key is at number thirty-four, how come she can’t just phone number thirty four and get her neighbour to let us in?”

“Maybe the call’s from Careline?”

Careline are a faceless entity, a telephone service accessible by pulling a cord, or pressing a panic button. Their voices come, mechanical and shouty, preceded by a squawking tone, through speakers in the corner of bedrooms, halls, kitchens.

We shout at the plaques on the wall when our patients contact them, a remote and sterile system for caring for the elderly.

I leave Milhouse standing in the street while I nip over to the front door of 34. Her neighbour across the road at 31 is, apparently, in some distress, having phoned three nines. Before we can treat her, we need to get into the house.

I ring the bell.

Brring.

Nothing.

Granted, it’s late. Folk’ll be in their beds.

Brrrrrrrring.

Nada.

Please don’t be deaf…or if you are, please sleep with a hearing aid in.

Brrrrrrrriiiiiiiiiiiiiiiiiiiinnnnnnnnggggggg.

And just for good measure, some letterbox action.

Kerflackaflackaflacka.

Beat.

Beat.

Soft! What light from yonder window breaks? It is the East and….

Oh.

Curlers. Squinty eyes at net curtains.

The window opens.

“Who is it?”

“It’s the ambulance service, ma’am.”

“Who?”

“The AMBULANCE SERVICE. We need to get into number thirty one.”

“Who?”

“WE NEED TO GET….CAN YOU COME TO THE DOOR?”

“Who?”

“CAN YOU COME TO THE DOOR, LOVE?”

“I can’t hear you! I’ll come down.”

I give Milhouse a thumbs up. He nods, shuffling his boots on the icy road, clapping his gloved hands.

Keys, locks.

The door opens.

Ajar.

A chain.

“Who is it?”

I lift my ID up, shine a torch on my face, the badge.

“Ambulance service, ma’am. We need to get into num….”

“Ambulance?”

“Yes, ma’am.”

“At this time of night?”

“Yes ma’am, I’m sorry to wake you so late, it’s just tha…”

“What do you want?”

“We need to get into number thirty-one, ma’am. Do you have a spare key?”

“This is number thirty-four.”

“Yes, ma’am, I know. The lady in thirty-one said yo…”

“Thirty-one is Jessie, across the road.”

“Yes ma’am. We need to get into Jessie’s house.”

“Is she going to hospital?”

“I don’t know yet, I need to examine her.”

“She lives at thirty-one, over the road.”

“Yes ma…she said on the phone that you had a key. Do you have a key?”

“To her house?”

“Yes.”

“Yes, I do.”

“May we have it? Please?”

“I don’t know…let me call her first and check.”

“I think she might be on the pho….”

But she’s gone from the doorway. I turn to Milhouse and close my eyes, breathe slowly through my nose. He stifles a laugh.

“Eight….nine…..ten.”

Much better.

I try to remind myself that I am a great big bloke, waking up a small, alone lady in the middle of the night and demanding keys to her neighbour’s house. She’s right to be cautious.

Of course, if I WAS a burglar, I’d be a fucking gallous one. Having stolen an ambulance, ambulance uniform and an ambulance technician all to support my ruse of getting a key to access a small two-up-two-down in an Edinburgh suburb.

It’s hardly busting the Louvre, is it?

I think if I was planning to burgle Jessie’s house I’d go for the traditional jemmy-through-the-back-door system.

She hangs up the phone, gives us the key to the house and insists on coming with us, just in case we’re planning on stealing all Jessie’s biscuits.

Inside number 31, we creep through the house in darkness, following her shouting and find her wrapped in a duvet on the bedroom floor. Uninjured, a bit confused and muddled up and pretty rubbish on her feet, she has occasional weepy jags.

“What’s wrong with me?”

We help her into a nightie, give her a hand to walk through to the bathroom and Milhouse and I have a wee conference on the stairs.

“Diabetic?”

“Nope. Blood sugar’s ok.”

“Septic?”

“Doesn’t smell septic, not hot enough.”

“Dementia?”

“Could be. House is pretty slick though and you’d think she’d have people staying with her?”

Jessie totters out of the bathroom, nearly loses her balance and Milhouse catches her. She lifts a hand to his face, clumsily strokes his stubble.

“You’ve lovely…”

We help her down stairs and into the ambulance, her neighbour watches me keenly as I lock the front door behind us. I’m about to let Milhouse know that we’re ready to roll when he leans in close.

“Can you smell vodka on her?”

“Not that I’d noticed.”

He shrugs.

Her conversation en route swings wildly from maudlin to shockingly flirtatious. At A&E I hand her over to a nurse with “This is Jessie, collapse query cause, but I think she could be PFO.”

The nurse pops a breathalyser into Jessie’s mouth.

“Blow.”

She doesn’t try very hard, just exhales gently. Even with a weak breath sample, she blows four times the legal driving limit before we leave her on a trolley to sober up.

Last week’s BMJ Doc2Doc post questions when legitimate clinical investigation overlaps with invasion of personal privacy.

Take a look.

A cutting from my Mum that she found in the Guardian some time ago. I knew some of these, but a number of them were new and made me laugh. Most medical readers will recognise some or all, but for the rest of you:

Doctors’ Notes Translated:

UBI: Unexplained Beer Injury
CTD: Circling The Drain
NFN: Normal For Norfolk
LOBNH: Lights On But Nobody Home
GPO: Good for Parts Only
GLM: Good-Looking Mum
TFTB: Too Fat To Breathe
GOK: God Only Knows
TEETH: Tried Everything Else, Try Homeopathy
TLR: Two Legged Rat (a patient undergoing extreme or experimental treatment)
DBI: DirtBag Index (number of tattoos x number of missing teeth = estimated period in days since patient’s last shower)
FLK: Funny Looking Kid
NQR: Not Quite Right
TUBE: Totally Unnecessary Breast Exam

Freud Squad: Psychiatric Department
Rear Admiral: Proctologist
Code Brown: Faecal Incontinence Emergency
Gasser: Anaesthetist
Cheerioma: Terminal Cancer
Dump: To arrange for a patient who should probably attend your service to be seen by another service
Knuckledragger: Orthopaedist
Rule of Five: If more than five of the patient’s orifices are obscured by tubing, he has no chance.
Donor-cycle: Motorbike
Cock Doc: Urologist
Baby Catcher: Obstetrician
Foreverectomy: A surgical procedure that takes a long time
Plumbum oscillans: Malingerer.

Any more?

There’s a new article from me up on Doc2Doc, this week we’re discussing to what extent you communicate with your patients.

The call had originally listed “17 YOM, allegedly unconscious after drinking alcohol.”

En route it updated to “CPR in progress.”

We chuckled, picturing the scene vividly. 17 year old laddie gets pissed, falls over. His friends call an ambulance and when the call handler asks if he’s breathing they lean over his face for a whole half second before, panicking, inform them that no, he is not.

CPR instructions follow, we arrive and find a very alive patient with sore ribs.

Same old story.

The job is a long way away, the roads are icy, it’s risky to push the vehicle much faster than 40, however much I’d want to, the back wheels step out on the tighter bends anyway.

Kahuna in the attendant’s seat is leaning back against his headrest.

“I was just thinking…”

“Hmmm?” I reply, not taking my eyes from the road.

“This might not be shite. This could just as well be a kid who’s come home pissed, gone to bed and aspirated. What if his Dad’s found him?”

“True.”

We ride along in silence, pulling into a high-rise scheme. A crowd of teenagers at the front door are arguing with the police about how long it’s taken us to arrive.

Kahuna grabs the bag and oxygen and runs to the stairwell. I shout across to one of the cops.

“Is he talking to you?”

He nods.

“Sitting up?”

“Yup.”

“Not in cardiac arrest, then?”

He laughs.

“No, I don’t think so.”

I dump the defibrillator back into its housing. Very little point hauling its heavy carcass up the stairs just to hump it all the way down again.

The peanut gallery - five of them in tracksuits and woolen caps, standing at the front door, swearing as I approach.

“About fucking time…”

“Fucking hurry up!”

A cop wanders over, warns one about his language, another shoves my shoulder as I walk past; I turn on a heel.

“D’you want me to help your pal, or what?”

“Get on with it, then!”

I lean in close, stick a pointy finger in his sternum and turn into a sixty year old man.

“Don’t you dare order me around, sonny.”

Sonny? Where did THAT come from?

I’m moving up the stairs, shouting up at Kahuna.

“Mate? What’ve we got?”

“Not an arrest.”

Good, that’s what the police outside said.

But as I turn the corner onto the landing, I don’t find a sitting-up drunk laddie. I find Kahuna leaning over a supine patient, wiggling his fingers behind the patient’s jaw, tugging on his sideburns.

“Pretty flat. Constricted pupils. Narcan?”

The patient doesn’t look like a heroin OD, but, frankly, he’s in the right neighbourhood to be abusing opiates. Constricted pupils and unconsciousness are good enough indicators for me. Kahuna draws up the opiate reversing drugs and I sling a cannula into the kid’s elbow.

I’m taping it down when I realise I’ve just started an IV without spending a minute planning it, questioning my ability to get the tube in the vein.

It’s only taken a year of being a registered Para for this procedure, one that I perform at least twice a day, to feel natural.

We push the Narcan into him and wait, it normally takes a minute or so to kick in. Standing over us is a woman in her 40s.

“Are you his Mum?”

“Aye.”

“D’you know what he’s had?”

“He doesn’t drink.”

It’s New Year’s Day. He’s 18 years old, out with his mates and he doesn’t drink.

Right.

The patient suddenly vomits copiously over the floor. The room is filled with a keenly acidic, fruity smell, though his puke is clear.

Kahuna sniffs.

“Vodka. Or schnapps, maybe.”

His Mum jumps in.

“He’s only had two pints. He only ever has two pints.”

“I thought he didn’t drink?”

“He doesn’t, he’s only had two pints.”

“So he’s been drinking with you?”

“No.”

“So how can you know….ok, look. This is a nasty question to ask, but has he ever taken anything else? Any dope, or ecstasy?”

“No, he wouldn’t. He’s a good lad.”

I try a different tack.

“I’m sure he’s a great laddie, but, in fairness, you wouldn’t be the first Mum to get a nasty surprise. Is there anyway he could have had any drugs tonight?”

She explodes.

“How DARE you? He’s a GOOD BOY. I go CLUBBING with my bairns, we’re CLOSE. He’s not DRUNK. He’s not HIGH. He’s SICK.”

I give up, fuming at her naievity.

Other than more vomit, the Narcan hasn’t done much to rouse the boy. He’s still snoring, needing to lie on his side to keep his tubes open, drunk enough to smother the instincts that make most of us cough or gag when something blocks our airway.

“I’ll get a chair.”

Walking down the steps, the friends at the door restart their baying.

“What’s wrong with him? Is he ok?”

“He’s pished, he’ll be fine.”

“No fucking thanks to you…”

I bite my tongue. At the foot of the path a police traffic car sits on coiled haunches, engine idling. The driver leans out to me, a grin on his face.

“You’ll not be needing an escort, then?”

Professional to professional, I let my guard down, “Load of shite…” and stomp to the ambulance before remembering my manners.

I return to the traffic car.

“Guys? In the spirit of the seaon, thankyou for turning out to a query arrest. It’s appreciated.”

They smile, shake hands, we wish each other a happy new year. They didn’t have to turn up for us, but if the kid upstairs had been dead? I’d sooner be speeding along the bypass with an escort clearing the traffic for me.

We’re back upstairs, humphing the patient’s dead weight onto the chair when a woman comes running up the stairs, screeching.

“What the fuck is going on?”

“Who the fuck are you?” Kahuna mutters under his breath, while a police officer asks the question in a slightly more polite manner.

“I’m the woman who owns the flat where this has all happened!” she howls, before shoving past us all, swinging her front door open and treating us to a background medley of screaming, banging and crashing noises.

One of the cops sighs heavily before calling for colleagues to come upstairs “And assist with a domestic.”

At the bottom of the stairs we’re met by a man in his forties who’s dragging a younger man about by the collar of his shirt. He pushes his puppet towards us.

“Have you told them everything?”

“Yes!”

“EVERYTHING?”

“Yes!”

We’re rolling the patient at the time, so I’m busy paying him little heed when a wee voice enters my head.

“Maybe he knows if the patient’s taken anything.”

Aha. Good idea, wee voice.

I point at the dangling youth.

“You! You don’t go anywhere, k? I want a word with you.”

And with that we load the patient into the vehicle and reassess. He’s really, really flat. Just drunk or otherwise, he’s still GCS 5. Anything under GCS 8 is classed as “coma”.

Kahuna and I agree that, whatever we may think about being pissed as a fart, he is still flat enough to warrant a run to resus. Kahuna hooks him up to the monitor and I jump out of the ambulance to track down that dangly informant.

I find him crying on the pavement, his father (as it turns out) is shaking him by the lapel.

“Fucking tell them! If you know something, you fucking tell them!”

I seperate them, step the young man to one side. His father follows us. I pointedly make eye contact, take a few more steps away and raise my eyebrows.

He gets the message.

“That your mate in there?”

“Aye.”

“What happened?”

Through a throat full of snot and gulping down sobs he tells me how he watched his friend deck out on the landing, how he phoned for an ambulance, how he thought he’d stopped breathing, how he pumped his chest and blew in his mouth, how he’s sorry and please say he’ll be ok.

“Look. I’m not the polis, right? Honestly, I don’t give a fuck either way, but I need to look after your mate and I can only do that with the truth. Has he taken anything?”

Terrified and shell-shocked, his face is the first one on scene that I genuinely believe.

“Nothing. I swear it. Spit swear.”

He hacks onto the floor between his toes before continuing, his arms stretched out, face to the sky, snowflakes hitting drying tears.

“Strike me down, dead, here, now, if I’m lying. He doesn’t do drugs. Never would. I swear….he’ll be alright, yeah?”

I give his arm a squeeze.

“Yeah. We’ll look after him, eh?”

“Thanks…”

Back at the ambulance I’m about to shut the doors when I remember the patient’s Mum, she’s chatting to the police, she should know we’re leaving.

“You coming, Mum?”

“Nut.”

“But he’s…”

“It’s New Year, I’ve got better things to do than sit in the hospital. I’ll see him later.”

A closer mother/son relationship, I’m sure, you’ve never seen.

How come “Being a cock” isn’t a criminal offence?

I’ve mentioned before about stock phrases, little bits of script that we roll out in recurrent circumstances.  The framework of the job (person nae weil, we come along, male them a
wee bit better, take them to hospital) means the same issues come up repeatedly. 

The experienced ambulance crew will see te same patterns emerging at jobs and second guess them, allaying a patient’s fears before they’re voiced.
“We’ll lock up.”
“Your neighbour will look in on the dog later.”
“You’re not wasting our time at all.”

This week I saw a colleague trying to persuade a reluctant gentleman to travel to hospital with us.   BP on the floor, he we struggling to stay awake, let alone stand up.  He was adamant, however, that hospital was an unnecessary fuss.

“Its no bother…” began my colleague “Theyll bring you back afterwards.”

The room erupted into laughter, uproarious and unprofessional.  Unlike most patients, this one was guaranteed travel home after attending A&E, being in for a long stretch and chained as he was to one of the prison guards on his block.

Sometimes autopilot just catches up with you.

Sorry, Kev, I know I promised I’d tell nobody…but really!     

One of those nights between Christmas and Hogmanay, nothing much to celebrate but no framework of work and routine to hang oneself from, she swallows pills and vodka.

We puzzle over foreign medications, pharmacological mysteries tangled up in Ks and Zs, Ws and Js, a family friend is called to translate, the phone shuttled back and forth between us.

I crouch before her and break out my one line of Polish - “What’s your name?”

She responds, with a faint smile. Her husband laughs, clapping my shoulder.

“You speak Polish!”

No, no. Just a few phrases, “What’s your name? Please. Thankyou. Hospital. Pain. Police. Stand up, please. Get up!”

They laugh, the police arrive and I become Polish consultant. Spelling names is difficult when your letters are pronounced differently, the cops take the names of everyone in the room, even the baby staring at us all from behind her drooly fingers.

“Catteeyah?” the policewoman struggles with it. “See-Ay-Tee-Tee-Ee?”

“No. Gee.”

“Gee?”

I wander over.

“Kat-Yah, right?”

He nods, my nerdy love of words and etymology drops into play.

“A Jay, mate. Kay-Ay-Tee-Jay-Ay.”

She writes it, shows it to him, he smiles broadly.

It works.

-

I’m downloading an Audiobook and Course in “Polish for Beginners” as I write. I want to be able to hold a conversation, or at least be able to speak to people who don’t require frog-marching off the street.

With language comes understanding.

With understanding comes decency.

These people live here, they are our neighbours.

Time to make an effort.

We’re already rolling fast when the CBT boops at us, a text message from Control - “Police called back requesting hurry-up.”

The original call was for a male fitting, with blood coming from his ear. We’d rolled our eyes at each other; most of these calls come about when someone hits their head and lies on the floor. Wounds bleed downwards and blood frequently settles in the ear canal. There’s a difference between “Bleeding from your ear” and “Bleeding into your ear”.

Of course, on the other hand, if you ARE bleeding from your ear canal, that’s a Very Bad Thing Indeed.

In what passes for a shopping centre in this concrete corner of the city a crowd have gathered around three police officers and a man on the ground. Standing in the door of a nearby kebab shop a man in a stained apron shouts at us.

“Where the hell have you been? Can’t you see he’s ill? What are you playing at?”

I’m days after No. 6 and, frankly, not in the mood for this guy’s shite. I stick my chin and nose into his face and sneer at him.

“I’m terribly sorry, am I meant to drive fast to emergencies?”

The phrase “you stupid fucker” dances in the wings of my brain before being pulled to the side by professionalism wielding a shepherd’s crook.

The patient sits up on the deck, his left ear firmly plugged with blood. It’s not coming from his head…at least, not the OUTSIDE of his head.

He’s the exception that proves the rule, once in a while the police are right - he really IS bleeding from the ear.

I crouch down behind him and try to hold his head steady, assuming he’s got a skull fracture there’s a good chance he’s got a spinal injury too. The crowd are howling at me and I raise a hand for quiet. The cacophony reduces to a dull roar.

“Did anyone see what happened?”

“He took a fit!”
“He fell over!”
“He hit his head!”

“Whoa, whoa. He fell over, hit his head and took a fit?”

“Naw, he hit his head, took a fit and fell over”

“What did he hit his head against?”

“When he fell over.”

*sigh*

Right then.

His neck is draped in gold, St Christophers and chunky chains tangled about themselves. They’re at just the right level to cut his skin when we collar him, so we wrestle with finicky catches, slick with blood. He claws at our hands, swings his arms left and right. His family stand around him, pleading with him to sit still, calm down. He’s safe, they promise.

We manage to get a collar around his neck and Steamie rolls the trolley and spinal-board from the vehicle while I struggle to hold him in something approaching in-line stabilisation. All the while he’s screaming at us.

“Fifnugga…talloging hedorRASA! Shallermak!”

With an element of heaving and pushing, we slide his bum onto the spinal board and try to encourage him to lie flat. He’s having none of it, bucking and twisting, throwing his limbs out to the side, terrified and baffled, his brain insulted, crushed and panicking.

I make a decision I don’t take lightly.

“Can you cuff him, please?” I ask one of the police officers.

Handcuffs hurt, ostensibly they look like they pin your hands together, but in fact a major part of their restraint comes from the fact that pressure over your radial bone hurts like a mother fucker. They can be set to tighten if the prisoner struggles, biting harder and deeper, or locked off to remain loose and “comfortable”.

Sadly, the pain aspect of their restraint doesn’t carry much weight when you’re so ill you don’t know where, why or who you are.

Cuff injuries are horrible, I wouldn’t wish them on anyone.

He glances at me, licks his lips nervously.

“We’re not really meant to…”

“For his own safety?”

“Well….”

“Look, I’ll write you a statement taking responsibility for any injuries he suffers as a result of restraint, ok? We can’t transport him like this.”

“Ok. D’you want his legs wrapped too?”

“Please.”

They snick the metal hoops around his wrists and the crowd bays its disapproval.

“He’s not well! Cunts! Pig cunts! He’s not well, can’t you see that?”

The patient’s son is crouched by my side, he’s quiet, I lean into him.

“I know it looks bad, mate. He’s not under arrest, ok? But I can’t get him to hospital like this, he’s going to really hurt himself.”

“Can’t you knock him out with something?”

“Not with a head injury, pal. You understand, right?”

He nods to me, turns his voice to the peanut gallery.

“It’s for his safety! Leave them be, they’re looking after him.”

Cuffed and legs in velcro strapping, we lay him on the bed as best we can, hustle him into the back of the motor, the two police officers leaning on his hips and knees, my wrists on his shoulders, his head cradled between my forearms. We get a frighteningly high blood pressure and a pulse count, but that’s about it. He’s fighting too hard to take an ECG, even the weight of an oxygen mask on his face sends him into a howling rictus.

We’re a long way from hospital, even with the lights and sirens running. We lash straps across the patient and tie them to the board, then that to the stretcher; seat belts follow and the cops are about to flip up the bed-sides before I stop them.

“You’ll need to sit there, boys. Don’t have a rail up your arse all the way to hospital.”

The journey gives me time, as he wriggles his bloody temples against my hands. gnashing his teeth, to think him up and down. Red faced, sweating profusely, ranting nonsense and fighting with anyone who lay hands on him.

The thing is, as I run my hands over his head, I can’t FEEL a skull fracture. There are no boggy depressions, no sudden steps like an errant heel off an icy kerb. When I spread my fingers across his cranium it holds, steady, firm.

His writhing hands start to bleed, gently, from the chewing of the cuffs, the blood on his fingers.

Fingers.

Fuck.

The red face, the aggression, the speaking in tongues. What if he’s hypoglycaemic? That would cause all of these symptoms, save the blood from his ear. Low blood sugar is easily reversible in the field, we carry three different drugs for it.

It’s not a condition that I can justify having a patient restrained for. If his family complains about the cuts on his wrists, the first question that will be asked will be “Why didn’t you treat his low blood sugar?”

I shove a tester strip into the BM monitor and contemplate stabbing his finger to get a blood sample before choosing instead to dunk it in the steady red dribble that runs from his ear.

The timer counts down from 20….and comes back with a result.

1.2

Shit. Shit shit shit.

Mother fucker. We consider a symptomatic measurement under 3.0 to be an acute medical emergency. I’m yet to meet anyone with a reading below 1.0 that wasn’t comatose.

I draw a needle of Glucagon from the bag, it’s a drug that pushes sugar reserves from the liver and into the blood stream; doesn’t need an IV, just shove the needle into the nearest muscle mass and push the plunger. Sit back and wait for them to wake up.

I push the syringe through and give the cops a nod.

“If that works? It’ll make my life a lot easier…might make yours a bit harder.”

“How?”

“It might wake him up, give him a bit more spring in his step.”

“Oh that’s fuckin’ great, pal. Thanks a bunch.”

They hunker down, hold him tighter. In a few minutes I dip his blood again.

7.2

Still thrashing. Still shouting.

That’ll be a brain injury then.

I spend the rest of the trip watching his breathing, taking his pulse when he lets me, the metal rings chewing the flesh on his arms further and further down.

Those cuts are the least of his worries.