It was the middle of a night shift, around 3am. The time I usually struggle. I was sat on standby with my crew-mate; he was driving and I was in the attendants seat. I could feel my eyes beginning to close.

“DMA001, please respond to 1 Night Street, Nosleep village”

The radio sprang to life. I jumped and the sudden surge of adrenaline brought me to my senses. I leant forward and pressed the button to say that we had received the job and were mobile.

This job was a category 1 job – the highest category. Usually reserved for potential cardiac arrests, major haemorrhage or unconscious patients. The MDT showed that the patient was unconscious.

As we headed toward the job more information was coming through as the call taker was receiving it. We now knew that this was a 52 year old male who had been unconscious and now was conscious but very confused.

Night shift fatigue is a very real thing. Most ambulance staff work off of coffee and sweets, riding a sugary caffeinated high throughout the shift – not particularly healthy, but effective. However, regardless of my sleep pattern or diet; I always hit “the wall” at around 3am.

Luckily, it would seem that between the adrenaline from the initial jolt that the radio gave me plus the fact that this job sounded serious woke me up and would provide the boost I needed for the rest of the shift.

We arrived outside the house. Upstairs, one of the lights was on and we could hear shouting as we approached.

“Calm down!” a woman’s voice cried.

We approached the door, and knocked.

“We’re upstairs!” The voice cried “The doors open, I can’t hold him much longer!” A voice cried.

My crewmate and I looked at each other, eyebrows raised. We stepped forward and opened the door.

The house we stepped into was nice, the hallway lined with photos and the air perfumed with the smell of the air freshener that was on a table by the front door. We shut the door behind us and head upstairs, wandering towards the light that had been left on in one of the bedrooms.

We walked in to the strangest sight.

On the bed was a pair of legs, flailing around as the person face down underneath tried to get free of the thing pinning them down. That thing…..was the patients wife.

“Oh I’m so glad your here” the middle aged wrestler said to us.

“It’s my husband Don, he’s having a hypo” She quickly explained

“Geerrrrroooffff me!” The man under her screamed and bucked, in a scene that can only be described as the same way a bucking broncho would. The patients wife holding on for dear life.

I walked round the other side of the bed so I could get a look at the patient, watching out for the flailing arms and legs as I went.

Hypoglaecemia is a condition where the patients blood sugars can fall to low. It leads to agitation, confusion and ultimately a coma. If untreated it is fatal. Usually diabetics have these episodes, which are referred to as “hypos”.

The wife quickly explained that the patient has recently been having hypos as his insulin dose had been increased. She went on to tell us that each time he has one he becomes confused, agitated and wanting to fight everyone and anything.

The patient was naked, extremely sweaty and fighting hard. I quickly restrained a hand and took a blood sugar reading – finding it to be 1.2mmols (the normal range is 4.0-8.0). The patient was definately having a hypo.

As a paramedic, there are four treatment options available to me in order to manage a patient suffering from a hypoglaecemic episode:

1. If the patient is able to, encourage them to eat something sugary and follow it with some carbohydrates (the short term boost from the sugar is then reinforced by the carbohydrate)

2. Administer a tube of Glucogel. This is a sweet smelling paste that the patient absorbs into their gums when it is squeezed into their mouth. It gives enough of a boost of glucose to allow further treatments to be used.

3. Intramuscular Glucagon – this is a vial of powder that is mixed with fluid and injected into the arm. It is good as a last ditch attempt as it stops the liver from storing glucose – if it is given the patient must be taken to hospital

4. Intravenous glucose. IV glucose is given through a cannula in the vein. It allows the body a supply of glucose to then regulate the blood sugars. It is fast acting and effective.

The fact that this patient was so combative meant that getting a cannula in would be difficult. However, I quickly explained to the wife that this would be the fastest course of action in order to boost the patients sugars. She agreed and said that this was what had been done before.

We started planning what we were going to do in order to make this safe for everyone. Luckily for us, the patient was pinned down in a sort of star fish type shape. This meant that it was easy to get to an arm in order to put in a cannula.

Between us all we managed to get the patient into a position where movement was difficult and limited. As I placed the cannula in the patient started fighting more intently. I thought to myself about how well this wife was managing to restrain her husband considering the force he was fighting with.

Cannula in and secured, I started pushing through some IV glucose. The first 50ml went in with no change. However, by around 70mls the patient had started to relax and the wife managed to get up off the patient. This was the first time we had managed to get a good look at the both of them. The wife left the room for us to carry on our assessment.

The patients wife was around 5’10, and of a slight build. She looked flushed and was out of breath. Looking at the patient it was amazing that she had managed to hold on so long and stop him from either hurting himself or from her.

The patient was a little larger, he was around 6’2 and probably weight 20 stone. He was dripping in sweat and looking around extremely disorientated.

Luckily for us, the glucose was working and the patient was slowly returning to normal. I quickly covered him up with a blanket that was on the end of the bed for his dignity as we set about assessing him fully. As we were doing so he was becoming more co-operative, apologetic and starting to ache all over.

The patients wife returned carrying a plate full of jam and toast. She explained that she knew we would ask for it next as it is what normally happens. She obviously knew exactly what to do.

For the next twenty minutes we sat with the patient and his wife. The angry man that was fighting on the bed was gone, and the patient was now extremely apologetic.

After we referred the patient onto the diabetic team at the hospital and printed out our notes for the patient we left. Stepping out into the sunrise.

“I’m glad she was there” Said my crewmate, referring to the patients wife.

“I couldn’t think of anything worse than having to pin him down at 3 am” he continued.

The adrenaline from the job fuelled us, as it did her. We were lucky it was there. It helped us break down what felt like a very big wall.

“DMA 123, you are being dispatched to a 24 year old male with a leg injury at Nicehotel”

The radio came alive. It was 2am on a weekend night. My crew mate (an experienced ECA) and I were just tucking into some chips. We looked at each other, put the food down and drove towards the job.

The hotel we were headed to was one that neither of us had been too before – which usually was a good thing.

As we pulled up outside the lobby we noticed a lot of people hanging around outside in little groups. All were dressed up; jackets, heels and dress clothes. A bell boy waited for us. As we pulled up he stood outside – a human windmill waving us down.

“This looks posh” My crewmate muttered as we got out of the cab and grabbed all of the kit we would need – response bags, monitors, oxygen and the tablet computer that our paperwork was completed on.

The bell-boy asked us to follow him – we walked into the grand hotel lobby. As we walked people stopped and turned – looking to see what was going on. We headed towards the ball room – and on the way I asked what had happened.

“I’m not sure, there is a wedding on tonight and I think one of the guests has hurt his leg” answered the bell boy. We went into a grand looking ball room – lights on bright, disco tidying away and tables littered with alcohol and fancy looking centrepieces all around.

We headed to what was the dance floor – where I quickly noted the bride was sitting on the floor – with a man leaning on her lap. Her dress making a great place for him to rest his head. He looked to be in considerable pain. As we got closer, I could see why.

Where his foot should have been facing straight, it was off at an ankle with a deformity just below his knee – it looked a bit like a banana. No X-ray needed to diagnose this fracture. We placed our kit down next to the gentleman and asked what had happened.

“They told me to break a leg – so I did” answered the man. Voice trembling, his attempt at humour masked behind the obvious pain he was in. The bride answered:

“This is my new husband. He was showing off on the dancefloor when he got his leg caught in my dress – he fell over and we heard the crack over the music. The worst part is – I think he has ripped my dress!” She half shouted.

I quickly explained the plan to the patient – I would quickly assess his vitals – and check for any other injuries and then we would sort out his pain relief. My ECA was tasked with getting the Entonox (Gas and Air) a vacuum splint and the stretcher. I roped in the bar staff to assist with this too.

While they were gone I did my assessment – found that the patient had no other injuries and that his foot had good circulation to it. I explained that I needed to put a cannula in – a plastic tube into the vein in order to give him some good pain relief.

Where the patient was leaning on his new bride; the top half of his body was against her dress. Sometimes – putting a cannula in can be messy. There can be a little bit of bleeding. I was aware that this dress was already ripped. However, thought that the bride would not appreciate the blood that could potentially end up on her dress.

During my assessment I had already cut the grooms trousers after a bit of an argument as they had been hired – and there was quite a big deposit on the suits (In the end I cut up the seams and the new mother in law was going to try and sew it all back together).

I managed to get the cannula in with no mess – thankfully. By this point the ECA had come back with the equipment and the groom was taking deep inhalations of the gas and air. He found it worked very well, a bit too well as he told everyone who was listening how much he loved his new family and started serenading his bride.

We splinted his leg and got him on the trolley – as we walked towards the lobby the bell-boy from earlier told us that the wedding party had formed a guard of honour and that the photographer was waiting to take some photos of the bride and groom leaving to start their life together.

What a way to start it.

Working during a Pandemic is hard. There is a lot of anxiety as well as poorly people and difficult decisions. When this all started I was working extra hours in a busy emergency department. I worked in Majors, Resus and Rapid assessment and triage. The role for me was new. I had not worked in a busy emergency department before.

On this day I was working in Majors, cubicles 16-22. These cubicles were side rooms and were for patients who needed isolating. The work was full on. I was responsible for these 6 patients. At the beginning of the shift the consultant in charge of the department gathered us all together.

“As you are all aware – we are seeing cases of COVID-19 within this hospital. We do not have the swabs to test everyone, and our intensive care is nearing capacity. Any patient with respiratory symptoms will be isolated in side rooms – this is including those that would normally be seen in resus”

I already had one patient in a side room who I took handover for. She was a lady with cancer who had an infection. She did not have coronavirus and was being isolated to protect her as her immune system was so low. I went in, placed an IV line in her arm and took some blood. I then went to the drugs room where I got her antibiotics ready. While I was in there two of the health care assistants came in and were talking amongst themselves.

“We dont have enough PPE. We are low on masks and aprons.”

Hearing this made me anxious. I was working in isolation bays where I would need to change my PPE every time I went in and out of a room to see a patient. I went to the trolley where my PPE was laid out and made sure I had enough stock for the day.

My next patient was a lady in her forties. She had called an ambulance that morning as she was coughing and having difficulty in breathing. The ambulance crew had pre-alerted her to hospital and instead of going into the resuscitation room she was coming into one of my side rooms. I watched as she was wheeled in. She was on high flow oxygen and looked agitated. I asked the crew to take her into the isolation room while I put on my PPE.

Once all my PPE was on I entered the room. I introduced myself and the patient was only able to grunt in response. Her breathing was so bad. Her shoulders heaved, wide eyed she looked at me. She was obviously very scared. I set about taking an initial set of vital signs. I took her pulse, it was quick. Her breathing was also very fast. Her oxygen levels were low (despite having the oxygen on full) and her temperature was high. The only positive was her blood pressure was spot on.

I went to escalate this – I needed a doctor to come and see this patient. I stepped out, removed my PPE and went to find one. I felt she needed ventilating as well as some sedation. I was aware that she was panicked and that her oxygen levels would affect her level of conciousness. I found a doctor and told him. He came and looked through the slats in the door. This struck me. Was he also scared to enter the room?

He agreed. I was to take the blood from the patient and pop a cannula in to start some antibiotics and give the patient some medication to lower her fever in the hopes that she would start to feel better. The doctor would speak to his senior to see what the plan would be moving forward.

I obtained all the pieces I would need to set up an IV and prepared the drugs that would be needed. I placed on my PPE and entered the room. The patient was trying to pull her mask off. She was claustrophobic and struggling to breathe. This for her was fight or flight. I wasn’t sure which one it was yet.

I tried to reason with her, but she was so confused. I placed the mask back on and this helped a little. I then told her I would have to place a cannula in her arm. This was when she panicked. Unfortunately, she did not have capacity. Her oxygen levels were so low that she could not make a decision. I placed the cannula anyway. As I was holding the cannula to secure it – her other arm came around in a fist and punched me square in the face.

I was torn. On the one hand – she was not fully aware of her actions. She was fighting for her life. On the other hand, she had just punched me. Somehow I managed to bandage that cannula, and start her treatment. With the medication the doctor had prescribed she calmed down.

I went to report back what had happened. I was asked if I would continue and I did. About half an hour later the patient had a chest x-ray. They were planning on placing her on ventilation and needed to make sure one of her lungs had not collapsed. The bloods I had taken had come back unfavourably and showed that the patient was extremely unwell.

The chest X-Ray came back and the patient was classically showing signs of COVID-19. Unfortunately, we were unable to swab her. I managed her until she was ready to move up to a high care respiratory ward. At one point we used the ipad her family had given her to facetime them. She wanted to talk to them before she was potentially intubated. She managed a few words, they said a few back.

She was one of 20 patients I saw that day. All with varying levels of respiratory distress. When these patients are escalated and need ventilation we up our PPE to match the level of care. However, I did not feel protected. It is a vulnerable feeling working in a pandemic.

Unfortunately, more recently I am seeing more of this again. The cases have increased and the government has announced a month long lockdown. I want to see my family at Christmas. So I welcome this.

Stay Safe.

I’ve been quite lucky in my career so far. I have worked on traditional ambulances, I have worked on rapid response cars. I’ve struggled to treat patients in fields in the middle of the night and I’ve treated them in field hospitals behind the main stage of a festival.

I’ve commenced treatment on VVIP in secure areas. I’ve worked on high profile sports events and in busy emergency departments. I’ve triaged over the phone and via video link.

There were many things I have picked up on the way from patients, situations and the people I have met along the way. I thought I’d share these with you.

1. Always arrive a few minutes early. Check your equipment. You never know what the day will bring and knowing your equipped for anything will make you feel a little more prepared.

2. Never run to anything. Running increases your heart rate, your gloves are harder to get on and your out of breath. Walking buys you headspace to make a plan.

3. Never underestimate a mother’s intuition. Ask them what they think is wrong with their child if you are treating them 9/10 times – they already know.

4. Oxygen tubing cut into pieces makes a great straw if a patient needs a drink.

5. If a patient says they feel like they’re dying – take them seriously. They probably are.

6. Create time for silence – a well timed pause can create opportunity. Wether it be a patient asking a question in this gap or the family seeking reassurance.

7. Holding someone’s hand is one of the best treatments you can give.

8. If it’s wet and sticky – don’t touch it.

9. If you get stuck – take the patients pulse. It buys time to create a plan.

10. Offer to clean. If you have just been to something traumatic then cleaning up after can be therapeutic. It buys time to reflect.

Any healthcare professional will tell you the value of your gut feeling in the assessment of a patient. The British Medical Journal published an article citing it as:

“clinician’s intuitive feeling that something is wrong, even after examination that suggests otherwise, appears to have diagnostic value, even greater diagnostic value than most symptoms and signs”

In this case, stood looking at the patient in front of me. I knew something was wrong. We were in the living room of a family home – children’s toys were strewn across the floor and we were surrounded by pictures, ornaments and children’s pieces of art.

I was working with a student paramedic and an emergency care assistant. It was the early hours of the morning after a busy night shift. The patients wife had phoned 999 – she did not speak any English and gaining a history from her was proving to be difficult.

The patient – a tall man in his 40s was sat on the chair on the sofa. He was leaning slightly forward. He was pale, clutching his head and vomiting.

The student was doing the initial observations – the patients blood pressure was extremely high and his pulse low. He had slurred speech. I asked the ECA to get us a chair.

In the ambulance service this is a code phrase – it means we need to get moving quickly. Whilst the ECA was doing this the patients daughter came downstairs.

The daughter was around 10, she was young. However, she was the only person there at the time that was able to tell us what had happened. Her dad was struggling to speak, her mum spoke very little English.

She told us that her dad had been working that night on the late night bus. She then started translating for her mum – she told us that the patient had come in and complained of a sudden, severe headache.

This was all I needed, I knew what this looked like. The patient was presenting with a subarachnoid haemorrhage – a dangerous bleed in the brain. He was very unwell.

We managed to get him onto the chair, our sense of urgency reflected by the flashing blue lights on the windows around us. We carried the patient out of his front door and down the steps outside.

At this point we noticed a change. The patient slumped to the side. His eyes fixed and glazed to the right. His arms were trying to draw up to his body – a position called decorticate posturing. The brain was injured and was pulling the limbs in to protect the bodies core and central organs.

We managed to get the patient onto the trolley. As we did so the patients wife was getting more upset. There, stood next to her. The patients daughter. She was silent.

I had to get my student to help me hold a limb straight. I needed to get a cannula in. The patient needed medication to stop him vomiting and protect his airway. We managed it between us.

I was acutely aware that the patient was possibly still aware. His eyes were open and fixed to the side, I was trying to reassure him as tears rolled down his cheek.

At this point – the patient started fitting. I quickly got my ECA to close up the ambulance and instructed the student to get the oxygen on the patient. I drew up the diazepam and administered it. The seizure stopped.

There was a gentle tap on the door. I opened it and found the daughter stood at the bottom. She asked me what had happened. I was honest. I told her that her dad was unwell, it was critical that we got him to hospital quickly.

She translated this to the patients wife, her mother. This 10 year old was having to deal with something that she would be dealing with for years to come. The mother vomitted. We got her a bowl.

“She wants to come with you”. The girl said.

We only had the seat in the front spare and one seat in the back. The daughter was doing a great job of remaining calm and collected as well as translating for me.

I kept her in the back. Wether or not this was the right thing to do, I am still unsure. I needed a translator. I also needed calm. She was both. She was amazing.

The patient remained stable the whole way to hospital. The daughter held his hand tight the whole way. The mother sat in the front.

Sadly, I don’t know the outcome of this job. I watched in the resuscitation room as the patient was put to sleep and prepared for transfer to a neurological unit.

I like to think the patient survived. The resolve in the face of the ten year old girl as she gripped her fathers hand as we raced towards hospital will forever be with me. Our treatment did half the job – she did the rest.

Sometimes holding a hand is the most important treatment you can give. It encourages hope, gives purpose; and sometimes – can make someone fight.

Working on your own on the rapid response car can be very rewarding. It forces you to make your own decisions about how you manage your patient based on your own assessment. However, at times it can make you very vulnerable.

On the night shift that this incident happened. I was working on my own on a rapid response vehicle. It was mid winter, so it was cold. However, it was a clear evening.

I was travelling to a job I had been dispatched to. On the way the mobile data terminal (MDT) blared to life.

“STAND DOWN” The electronic voice blared at me.

I pressed the button acknowledging the stand down, and with that another job flashed up. The radio started ringing.

“TGM1 this is control, we are dispatching you to a 55 Year Old Female. Difficulty in breathing”.

The address was in a rural part of the patch, where there are lots of farm houses and the distance to hospital can be quite far. I knew I had to decide what I was going to do early, in order to get back up running as soon as possible if the patient needed to attend a hospital.

As I drove down the country lane I turned the full beams on and the headlights lit up the road, allowing me to see clearly what was coming up. The reflection of the blue lights flashing bouncing off of the puddles on the road and lighting up the eyes of the odd dear or owl.

I started to approach the address on the sat nav so I started to slow ready to look for the house. Lucky really. There in the middle of the road, was a figure. I slammed on the breaks.

I took a deep a few seconds to steady myself. I was unnerved. It was the middle of a night, in the middle of nowhere and this woman was just stood in the middle of the road. Facing me. I changed the blue lights on the car to only flash from the rear of the vehicle as I did not want to dazzle her and left the headlights on.

I quickly activated the run-lock feature on the car, a feature that allows the engine to run with no key in the ignition. However, would cut the engine if any pressure was applied to the accelerator. That way I knew the lights would stay on and the car would stay warm.

I took ahold of my torch and stepped onto the road. I pulled on my hi-viz jacket and approached the figure.

“Ambulance Service, are you OK?” I called out.

“Yes, I called you. I couldn’t breathe.” Came the reply.

I was suddenly very aware of how alone I was. I ran the torch up and down the patient. She was a lady in her 40’s wearing jeans and a hoody.

“Do you live nearby?” I asked, slowly stepping towards her. I could see from the way she was standing that she was not struggling to breathe. Her shoulders weren’t moving, and there was no difficulty in taking a breath that I could see.

“No, I don’t. I didn’t want to die at home. So I went for a walk” she calmly replied.

“Ok, tell me what’s been happening and Ill see how we can help” I said.

The patient then went on to tell me how she had been under the mental health team for a while but thought they weren’t helping any more so cut all ties and stopped her medication. I enquired what medication she was on and she replied with the name of a potent anti-psychotic. She then said that she believed that she had been poisoned by her family; became short of breath whilst walking and so called 999.

I invited the patient to come and sit on the edge of the boot at the rear of the car, that way she would be partially sheltered and I could give her a blanket to stay warm.

“No thank you, its time for you to follow me” She stated.

“Follow you where?” I enquired

“Back to my house, its warm there and I can tell you more about what is happening” She suggested.

At this point. I definitely was not comfortable. I explained that an ambulance would be on the way and it would be warm and comfortable in the back of that.

By now my assessment was complete. Medically she was well, she had a fast heart rate (tachycardic) but this was due to her mental state. I told her I was going to ring the mental health crisis team for the area and walked to the front of my car.

As I discussed the patient to the crisis team I found out a few facts that put me more on edge. This patient was known to become aggressive – and was normally accompanied to appointments by a security guard. The nurse on the phone said that there was room in the 136 suite (a secure room that mental health patients can be kept in whilst being assessed).

Luckily, at this moment the trees in the distance started pulsing the familiar blue of my colleagues approaching with their lights on. I felt a wave of relief wash over me.

10 minutes later. The patient was handed over and on her way. I had to sit in the nearest fuel station forecourt to calm my nerves.

I took a deep breath. Pressed the “clear” button and watched the screen light up with the next job – an 85 year old male had fallen. Perfect. I fired up the lights and headed towards the patient.

I was working on an ambulance with an Emergency Care Assistant on a hot weekend in the summer. We had both just finished an ice cream that we managed to sneak in between calls and were looking out over the city from our standby viewpoint.

I was just starting to lull into a false sense of security when the screen came to life.

79 Year Old Female Difficulty in Breathing

The address of the job was an upmarket restaurant in the tourist district of the city. The ECA was driving so started the engine and we headed towards the location, blue lights flashing and sirens blaring.

We pulled up outside the restaurant and could see a long table inside with lots of balloons and people sat around. One of the waiting staff was stood outside.

“Thank you for coming so quickly, shes inside. Follow me” he said as he led us inside.

Sat at the table, leant forward and looking panicked was our patient. She was covered head to toe in a rash and I could hear a wheeze. She was having an anaphylactic reaction to something.

I asked the family what had happened whilst I started my assessment of the patient in the form of a primary survey (a 60-90 second assessment that highlights any life threatening conditions that need immediate management)

“We were having dinner for Grannys birthday. We all had a set menu that we chose for her. She was having her starter when she started to cough and feel strange. That was when we called you” A lady sat at the table answered.

“Has Granny got any allergies?” I asked.

“Shellfish” the lady answered.

“Ok, and what did she have for her starter?” I asked, quickly followed with: ” And did anyone near her have shellfish”

At this moment I could see the realisation hit her. Her facial expression changed and she went pale. I followed her gaze to the table just in front of her granny. There. Sat on the table, was a half eaten prawn cocktail.

“She ate a prawn cocktail!?” I asked, shocked.

“Yeah, we organised for us all to have the set menu as it was cheaper” the lady replied.

We quickly set about getting the patient to the ambulance. Anaphylaxis is life threatening if not treated quickly so I was preparing an injection of adrenaline to give her as well as a nebuliser. When we got on the ambulance I would give her the rest of the medication she needed through a cannula.

“Nice to see I’m going to get my Birthday shots!” The patient wheezed as I gave her the injection. She hadn’t lost her sense of humour.

Once on the ambulance I asked her why she had eaten the prawn cocktail.

“My family organised me a lovely meal, I don’t get to see them all very often and my eye sight isn’t brilliant. I wasnt sure if it was prawn so I just gave it a go. We were having such a lovely time and I didn’t want to make a fuss. I’ve certainly done that now!”

With that there was a knock on the side of the ambulance. The lady from earlier was waiting.

“How are you doing Granny?” She asked.

“Would you like the good news or the bad news?” The patient replied, the nebuliser hiss making her sound a lot like Darth Vader.

“Let’s start with the bad news” the lady replied.

“Thanks to this young man your attempts at getting your inheritance early have been thwarted”
The patient replied, smiling.

“The good news” she continued, “the bill will be cheaper”.

As paramedics sometimes we have to assist patients in their final stages of life. These jobs can prove to be challenging but extremely rewarding. It is an honor to enter someone’s home and ensure their comfort and dignity is maintained in those last moments.

“45 YEAR OLD MALE – DIFFICULTY IN BREATHING” The mobile data terminal in the car flashed up. I put the TV series I was watching down, fired up the engine and headed toward the address.

It was a Friday evening, the sun was setting and their was a warming orange glow to everything – the perfect night to be sat in the garden after a barbecue watching the world go by.

As I pulled up outside the address I quickly noted a couple of things – firstly, there was a lot of cars on the drive. Secondly, there was a boy – around 10 years old. Waving me down.

“My dad isn’t very well, mum is in there with him. I wanted to see if you came with flashing lights – you did!”

After greeting the boy I walked through the hallway of this well kept house – it was very homely. There were pictures all over the walls showing holidays, weddings and birthdays. In the centre of most of the pictures stood a tall man, smiling and happy.

“Through here!” A woman’s voice shouted from further down.

I walked into what would have been the living room and took in what was in front of me. The room looked like your average front room. However, one side of the room was partitioned off and there was a hospital bed.

On the bed, sat forward was the patient. He was in trouble. I could see that he was in pain, his breathing was fast. Too fast. With every breath he was struggling. Next to him, the figure of calm. The woman, who I would later learn was his wife was calm and coaching. She turned to me and smiled.

“Its ok Brian, someone is here now” she said. Sometimes you wonder who is more reassured – the patient or the relative. However, she was like a rock in a storm. Totally calm.

She quickly told me what was going on. Her name was Alison – she was Brian’s wife. She explained softly that Brian has terminal lung cancer and recently had been struggling to breathe due to the amount of secretions he was having to clear from his airway.

Secretions is a medical term for build up of fluid that comes from systemic failure. It is normally a lot like saliva and can be very hard to clear. It is described by some as drowning from the inside out.

Brian had been a train driver for most of his life, until he had started coughing up a little bit of blood a mere 6 months before. I could see the toll this had taken on the family. I knew then that I had to rethink my strategy. My goal here was not to save Brian’s life, it was to help him have a good death.

This was something that at that moment – he was not having. His breathing was erratic, shoulders heaving and I could hear his chest bubbling from where I was stood.

Most patients who are end of life within the UK have a box known as a “Just in Case Box”. Within this box their are various medications that have been prescribed for exactly this scenario; when it is out of hours and medication is needed in order to control symptoms and the patients distress. This is exactly what Brian needed.

I asked for the box and Alison took it out. She had read into the medication in there and wanted Brians secretions reduced; however, did not want any of the medications for agitation.

“At the moment he is still here, we don’t want him sedated”.

I drew up the drug she needed to be given through an injection. As I was doing this Alison was telling me about Brian. I heard all about his life and his family. I knew he had two kids who were currently upstairs doing their homework and with the mother in law who was staying to help look after Brian. They knew what was going on and the whole family had been honest with them throughout. I thought back to the boy who had been waiting for me earlier. He was so calm. I admired their way of dealing with this.

“We have called it Terminus”. Alison said.

She was referring to the cancer. I had heard of cancers being given names before. This name; however, was a new one to me. She must have sensed my confusion.

“When a train driver finishes their day working. The train returns to the end of the line. Terminus.”

This was how Brian’s family were dealing with this. This was their journey. Brian was a train driver. My job was to get Brian back on track.

I gave Brian the medication that would help reduce the secretions and assisted him in taking the oral morphine that would help with his erratic breathing. As he started to calm down and fall into a peaceful sleep Alison called the children.

Two boys came downstairs. The young one from earlier and an older boy. Around 15. Both of them kissed Brian and said goodnight. Brian was able to mumble a good night back, following it with a tender “love you”.

Alison dimmed the lights and pulled Brian’s duvet up.

“Thank you”

Being a paramedic isn’t about all the life saving interventions and fast pace. Although, this is the job we train for and we all get excited attending those jobs. Patients like Brian are just as rewarding. Getting in my car after this job knowing that Brian was comfortable, that the boys said goodnight and that Alison was reassured makes this job the best job in the world.

I managed to get Brian back on track following a minor delay. He is heading comfortably to Terminus and whatever awaits him after that. I just hope the rest of the journey is comfortable.

For Brian.

Whilst working on a Double Manned Ambulance on a day shift we were dispatched to a bus terminal to reports of an adult male collapsed. I was working with Tom; an Emergency Care Assistant and Mel, a first year Student Paramedic.

On the way to the job I was driving, so I had Mel in the front – a lot of the time students sit in the back so it’s nice to swap this around to get the full experience. It also meant I could ask her questions or run through scenarios on the way to the job – something that challenged the student and kept me focused.

“Talk me through your Primary Survey” I would ask. Mel would reel it off word for word, these algorithms were drilled into the students.

We also designated positions in case the patient was in cardiac arrest –“Mel, I would like you to do the immediate assessment and then if worst comes to worst you start the compressions from the patients side”

“Tom” I called through the divider that allowed me to look into the back of the ambulance when driving . “If needed you can get straight onto bagging and sort the airway while I do drugs and get access.”

With everyone prepped, we carried on toward the job. As we pulled up the bus staff were waving us in. As we got closer I looked over and could see a man lying on his back, star-fishing. At his head knelt a lady knelt down, doing mouth to mouth.

I heard Mel take a deep breath. I new the feeling – she was trying to quell the adrenaline that was now surging. I quickly re-iterated the roles I had delegated.

“Mel, make sure you arent distracted by the CPR. You need to quickly pause it, do a pulse check and then start chest compressions if you cant feel one. If your not sure just let me know.”

As I got out the drivers side I could hear the door slide open on the side. Tom jumped out and started handing out all of the kit we would need; the primary bag, the secondary ALS (Advanced Life Support ) bag, the oxygen, suction and monitor.

We approached the patient. As we walked towards the patient I took in the scene around me. This was a busy bus terminal – there were many people stood around. Most were watching. Some were filming. The police had arrived just behind us and were helping the bus station staff to get screens out to give us, and most importantly the patient some dignity.

The patient was lying on his back, his eyes were open and his head was bobbing off of the floor in time with the very effective compressions. Mel kneeled down at the head end and performed a head tilt chin lift to open the airway. All the while I was gaining a history from bystanders.

It turned out the patient had got off of a bus with friends when he looked a bit disorientated and fell to the floor. His friends however, were nowhere to be seen.

Mel quickly stopped the compressions and felt for a pulse.

“I have a pulse” she proclaimed. “No effort of breathing”

“Plan?” I asked her. In my head, I had already made it.

“I think we should start bagging” Mel stated. Excellent.

Without hesitation Tom passed Mel the equipment she needed to do this. It was all prepped. Tom had done the one thing I love in a good ECA. He had pre-empted what would be needed and had it ready. I made sure that Mel was OK with ventilating the patient. She had inserted a basic airway and was getting good chest rise – she was doing great. I told her.

Over the 60 seconds I quickly did a primary survey. I found the cause of the collapse pretty quickly. As soon as I cut the sleeves up the patients arm I found tract marks. He was an intravenous drug user.

I pointed this out quickly and asked Mel what the treatment was.

“Naloxone” She replied. Great.

We drew up a dose and gave it quickly by intranasal administration.

It was effective.

We got the patient onto the ambulance in order to facilitate his transfer to hospital. The patient was coming to a bit more – ideally I wanted to keep him groggy. In my experience, when you reverse the effects of an illicit drug that the patient has taken by administering the life saving medication that prevents the respiratory depressant action of said drug; it can go one of two ways:

A) They are grateful. They apologise for what’s happened and usually come to terms with the fact that they need to be transferred to hospital.

B) They aren’t grateful. They become agitated that you have in effect wasted their money. Despite the fact that in doing so you have saved their life.

This patient was a B.

“GET OFF OF ME” The patient yelled.

We reasoned with him. We attempted to calm him down. For a couple of minutes it worked. The patient explained that he had been on the bus for ages and decided that he would “shoot up” in order to make the trip faster. He had taken some heroin from a new dealer and in his own words:

“It was much stronger”

After this discussion the patient went about refusing treatment. This is often the case with heroin overdoses. Once assessed to have the capacity to make this decision we offered him the alternative, an injection with a loading dose of Naloxone in order to help mitigate any second pass effects of the drug and boost the existing dose. The patient agreed and this was given.

Up until this point the patient had been refusing treatment but had not been particularly aggressive. However, as soon as he looked down. This changed.

“Who cut my F****ing jacket!?” He yelled, looking down at the rags on his arm where the arms of his jacket should have been.

I explained that we had to cut his jacket in order to get to his arms when we tried to look for a vein to cannulate. With this he jumped off of the trolley.

Screaming and shouting incoherently the patient started moving towards Mel. She was between the trolley, monitor and attendant seat. Completely trapped.

Luckily, Tom had already seen this happening and managed to slide the response bag in front of the patient. This gave a bit of distance. Tom then slid open the side door. The door rolled open and to my amazement; there, arms crossed, were a couple of police officers.

The patient was grabbed and dragged off of the ambulance. Kicking and screaming. The police restrained him and he calmed. I explained the situation and the patient was still refusing treatment.

The police reasoned with the patient, took my concerns and communicated these to the patient. The patient still refused. Fortunately, the police had a plan for this – the patient had assaulted one of them in the struggle.

They explained that they would arrest him – and he would be monitored in custody by a clinician there. Although not ideal for the police, the patient would be safe.

Mel was fine. A little shaken, but fine. I realised this as soon as she thrust her portfolio towards me beaming.

“Airway management signatures please”.

I signed the competency. After all. She had earnt it.

• 

We booked onto our double crewed ambulance. Today, my ECA and I would be with an observer from the local hospital. He was a nurse who wanted some insight into pre-hospital care. I was happy to have him. It makes the day go quicker, and he brings some more hands to the party if needed.

We logged onto the MDT and radioed control. “BG01 to Control, Log on and Radio Check”

“BG01 this is control, we have received your log on and hope you have a good shift.“

We then set off from our station and did a few jobs. A fall, a chest pain and an abdominal pain. All was going well, with all of our patients left at home. However, the observer wanted to see more. He was hoping for a cardiac arrest, or as he put it “Something interesting” .

I had explained to him that ambulance work was 90% routine and 10% “interesting” so the chances of him going to a cardiac arrest for example were slim.

We were just cleaning the vehicle at hospital when my ECA pressed the button to say we were clear and ready for the next job.

Beep, Beep, Beep

The MDT came to life. Looking at the screen we could see that this job was to a 35 Year Old Male for “Mental Health”. The nurses interest peaked. He had never dealt with anyone with mental health before. He explained he had had very little training in mental health but always found it interesting. I explained that I was the same. However, I had undertaken more training to be able to assist me with these types of patients as unfortunately, it is something we come into contact with quite regularly.

Usually, mental health was all about communication. We would go in and build a rapport with the patient and see what we could do to help. Wether that was to refer him to a mental health unit, transport him to the emergency department or to a mental health facility. There were numerous options. I explained to the nurse that usually they are calling as they want assistance and are receptive to help.

I didn’t realise quite how wrong I would be.

We arrived at a block of flats and found the property. It was on the third floor. We gathered our kit and made our way up there. When we made it to the third floor we walked through a corridor filled with furniture. It looked like someone was either moving in or out.

One of the doors in the corridor opened and a man stepped out.

“She has been doing that all day, we can not seem to get her to stop”

I thanked him and then made my way to the address. I knocked on the door, which I noted had some repair work done from what looked like someone forcing entry in the past. The door opened and there stood the patient.

This was a middle aged lady, her hair was wild and she was wide eyed – she looked like she had been awake for weeks and not washed for longer.

“I told them I did not want any help”

I reasoned with her that we could just check her over and then give her the options and that we were there because people were concerned about her. She relented and let us in.

The flat was bare. She had clearly moved all of her possessions into the hallway. In what would have been the living room there was an arm chair and pile of books. On the wall there was a TV and on the arm chair was a remote control. The back of it was off and the batteries were loose on the chair. The windows were covered in newspaper, allowing a little light in but making it dark. Strangely, the curtains were open.

We introduced ourselves. I then asked how we could help and what had been going on. The patient seemed lucid and happy to converse. Initially.

We had managed to do a set of observations. The patients heart rate was 130, her blood pressure slightly elevated. As the ECA was getting these from her I was asking the usual questions about what had happened – I then asked about medical history. With this, something changed.

Suddenly the patient amped up her speech tempo. We were finding it increasingly difficult to get a word in and she was becoming agitated. Sensing the situation escalating my ECA started moving some of our kit into the hallway.

It was difficult to communicate with this patient, she was just escalating in front of my eyes. The ECA came back in.

“The nurse went downstairs to take a call”.

We both knew this was not the case – the nurse had been told to withdraw from the scene by my ECA. The patient was getting more and more agitated. Now she was pacing and had stopped making eye contact.

Ambulance service staff are trained to recognise when someone is becoming hostile. The conflict resolution training and experience ensures that when a situation is heading south, you know.

In the kitchen on the side, there were knives. We had noticed them earlier. The patient was slowly pacing towards them. She had also changed the subject. Now she was referring to voices. Voices telling her to kill.

At this point, the patient gave us an opportunity.

“My TV doesn’t work” She calmly switched back to apparent normality.

The ECA cleverly jumped on this. The patient was still clearly agitated. However, had stopped pacing. She was asked how it was broken.

“The batteries don’t work!” She snapped back.

With this the ECA asked her to show us – at the same time looking at me, and motioning towards the door. We were going to run.

At this point, everything slowed down. It was one of those moments. You become super aware of everything. The ECA went to pass the remote control to the patient, and dropped it. The patient bent, and we took off.

Unfortunately, the bags in the hallway had become a bit of an obstacle. Between us we grabbed them and carried on. In the background, the patient was screaming. It was not a scream I had heard before.

Not fear.

Not loss.

Not pain or frustration.

It was rage.

We got halfway down the corridor when I heard the sound of metal being slid off of a sideboard. The patient had a knife. At this point, it should have been time to press the “man-down” button on top of our radios. This is a panic button that opens a channel to all of the ambulance vehicles in the area as well as our control room; crucially allowing them to hear what was going on and arrange for immediate assistance. However, we both forgot.

I don’t remember how I got from the top of the stairs to the bottom. Somehow I was there. I looked up to the landing above in time to see the patient tearing out of her flat after us. Knives in each hand.

The door was in sight, the ambulance through the glass looking like safety. We pressed the exit button. The door slowly, painstakingly opened automatically and we got through. The nurse looking panicked stood by the vehicle.

“In! Get in the vehicle!” I shouted. He jumped in.

We climbed in the front. With no time to get the kit into the back as the nurse had shut the door I had it all on my lap. We drove out of the property and down the street. Parking over the road so we could see the doors and react if necessary.

I phoned control and explained the situation. I didn’t even have time to hang up before the first of many police cars arrived. We explained the situation. The police were not surprised – the patient had markers on her address for violence towards her mental health staff when in a state of crisis. The police had a plan in place to not enter the property without a team of them – all kitted in riot gear.

The police asked if she was medically well – we agreed. With that we were stood down and returned back into service ready for the next call.

“Well, that was interesting.” The nurse calmly said from the back.