Mirror mirror on the wall.

Over the last few months, I've had a steady stream of students on the ambulance with me. At first I thought to my self "What in blazes can I teach these people - I know squat and am far too new myself! Eeeek!" Having someone watching you, questioning your every move is quite daunting! And with the rapid pace that the Paramedic profession moves on, often they have had more recent and up to date training than me!

But, after the first few days I started to relax a bit. Even enjoy it. Having 3 people on a truck is certainly more fun and relaxing than just two! Those extra pair of hands, however inexperienced, always come in handy.

However, throughout the whole experience of different students, all at different levels, it has highlighted to me just how much I still need to learn, re-learn and keep learning! On a number of occasions something has come up, a question asked, an odd situation occurred, and where as before I'd have limited time to absorb what has gone on before being punted to the next job, I now have people asking me the most important question we as Paramedics can ask....

Why did that happen?

The enquiring mind. Vital for our job. Not only in the here and now of a job so we can predict what is likely to happen and prepare for it but, as I am continually being reminded, after the job. As I have been training I've had a bit more freedom to spend more time at hospital to debrief my students after jobs. It's allowed me not only to help them understand what went on but to give ME time to absorb it, to question what I did and to think how I may have done it better. Yes, I've been reflecting!

I know the R word can be scary for some people. Thankfully having gone through the university route into the Paramedic world I was exposed to this often alien concept from the off. Not that I enjoyed it, bloody essays! However, now that it is less formal, now I'm not being marked, I'm realising that I'm doing it more and more. I probably should write some of it down in a slightly more formal manner, keeps the HPC (Regulatory body for Paramedics in the UK) off my back! Particularly when a student asks me something which I'm sure I know, but do go and look up just to be sure. (Pleased to say that most of the time my poor grey cells have actually remembered the right things!)

So, what started out as a scary, daunting prospect has turned into a really positive experience. It's keeping me on my toes, keeping me reflecting and keeping me asking "Why?"

For those of you who are students, bombard your tutors / mentors / trainers or what ever you call them with as many questions as you can. Keep them thinking.

For everyone else, if you get the opportunity to take on a student, jump at the chance. It is not only good for them but it WILL help improve your practice as well!

Singing the same song in the same key

As a Paramedic, you are entrusted with a lot of responsibility. You are given lots of shiny toys, a fair number of drugs, even more if you become a PP (Paramedic Practitioner) or CCP (Critical Care Paramedic), and are let loose on the general public who, on the whole, will let you do almost anything to them when you turn up in your shiny ambulance.

This leaves us with a need to ensure we practice properly and are doing things because patients NEED them doing, not BECAUSE WE CAN do them. It means we have to be evidence based practitioners and ensure we are doing everything in the patients best interest.

Now, most Paramedics I know are ethical and sensible with their treatments, although I do know of some who cannulate "because they can". My question to them is "Why? How is you sticking a needle in them in a dirty out-of-hospital setting benefiting that patient?" Quite often they have no intention of giving them anything iv, and I think this is wrong. I do know of a service where some medics can take pre-hospital blooded when they cannulate to prevent a second invasive procedure, which is brill. However I have heard that some are using this as a justification TO cannulate. This I don't agree with. There are other practices done "because that's just the way we do things here" and other such phrases, and things done because it's easier.

I also know of some services where they have told medics to do / not to do certain things that fly in the face of all the published evidence for best practice. We as employees then have to follow these poor practices even when we know it isn't in the patients best interest.

So, where do we stand as Paramedics? As a fairly new medic (although recently I've looked around and started to feel more of an old hand on station than a newbie!) I still find it difficult to question practices of those who have been in the job for longer than me. I still see people doing things and want to stop or correct them but don't do it, and as such I feel I'm failing in my duty to give everyone my 100% best.

But as a whole, I feel we as Paramedics are not united as one. We have multiple unions who fight amongst themselves, the services we work for all seem to sing from different hymn sheets, and even within the same service there can be many people singing in VERY different keys. There are guidelines, protocols and evidence which all contradict each other. Yet as practitioners we are supposed to know what to do?

While I'm not specifically here to promote the College of Paramedics (Yes I know this is the second post in a row where I've gone on about them, I promise I won't on the next post!), I do firmly believe in them as a potential unifying force that all UK Paramedics should be getting behind. Only by uniting and getting one voice can we as a group of health care professionals begin to influence practice on a grander scale, to get one voice saying to all UK ambulance trusts "oi, let's get x y z standardised across all services", to have once voice TO all Paramedics guiding and advising us as a whole, and taking a lead in collating, disseminating and even producing research relevant to our profession and using it to guide practice. I know its more expense but I do feel that we need it and is ask any of you out there who are not members to seriously consider signing up.

On a personal note, I believe that we all as Paramedics also need to be prepared to do what we know is right and challenge that which we believe to be wrong, even if it is uncomfortable to do so. After all, its in out patients best interest and that's why we are here isn't it??

Who are we?

Paramedics.

We are a funny old bunch really. But recently I’ve been thinking, what exactly IS a Paramedic? And from things I’ve read from the College of Paramedics and other sources, this question is one that is coming up again and again.

It’s difficult to define really. When you stop to think what we actually do, then try to explain it, nothing seems to come close. Some will say “a Paramedic is like a Technician only they can cannulate, intubate and give more drugs”. Is that what we are? A Technician with extended skills? Personally, and I mean no disrespect to Technicians, I think that isn’t a very good description and sells us short. Besides, with the way the profession is moving I don’t think you can sum up what we are just by the mechanical skills we perform and drugs we are licensed to give!

Another description I hear a lot is “Jack of all trades, master of none”. While this hints at our need to have some knowledge about all and sundry in the medical world since we never know what we are going to come up against, again I think this sells us short. Master of none? I’d argue that there is one trade we are masters of – Pre-Hospital.

I’d say we are “Pre-Hospital Specialists”. While this may seem a bit vague, I think it is true. The pre-hospital world is a very strange, sometimes dangerous place. It is not just “here is a patient, please make them better”. While many doctors, nurses and other health professionals can deal with the medical side of our patients, dealing with the complex medical needs of the patient in ever changing environments with little or no backup, while being conscious of your own safety, and dealing with the often tricky extractions from said environments to your ambulance and then to wherever is appropriate for the patient... well that is a whole different ball game and one we are right in the middle of.

Much, if not a very large percentage of our job is not all about the medical knowledge, the things we do medically to patients, but about talking to people, dealing with their emotions, dealing with the people around them, problem solving, negotiating. It is hard, and often draining work but it is what we must do if we are going to truly help our patients.

Of course, there needs to be firm underpinning knowledge and skills to go along with the talking and dealing with people. A Paramedic who can’t walk in and recognise the “big sick” patient who needs rapid treatment & transport (drug of choice –DIESEL) is not very good at all. But increasingly we are not just dealing with the big sick patients. We have to be able to deal with the not-so-sick and all their complex needs as much as the big sick.

A blog post that really captures the essence of what we do is one from the Legendary Insomniac Medic and can be found here http://insomniacmedic.blogspot.com/2009/08/proof-of-creationism.html - And really, if God had that much trouble with us, will we ever be able to get a good definition of what we are?

In the ever changing dynamics of the NHS I feel it is important that we as Paramedics keep a sense of self. We need to make sure that what we do is recognised and appreciated by the wider health care community. We need to shout about what we are good at, make people realise we are no longer just stretcher taxies with first aiders on, but also to recognise what we are not good at and ask for help. In a little plug, I also feel that we need to get behind our professional body, the College of Paramedics, as without a strong professional body, how can we as Paramedics stand up and say “Hey, this is what we think and we do actually know what we are talking about”. Any medic who may happen to read this and is not a member, please do join. It’s not that expensive at all and they are gathering momentum. If we get over half the 17500 Paramedics in the UK as members, they can apply to be the Royal College of Paramedic – and that will provide even more clout!

So, next time someone asks you “what is a Paramedic”, pause for a second before you answer. If you really think about it, I’d say we are unique, special, highly adaptable members of the health care community who have to be able to deal with anything life can throw at us in a calm, professional manner with the highest levels of patient care and treatment available. We are Pre-Hospital Specialists.

NM.

Going to hell?

Pride.

Apparently its one of the 7 deadly sins (according to some). So, is it wrong that I am:

Proud to wear the uniform that I do. To put it on each day and know I’m doing something good with my life?

Proud to be trusted by complete strangers to come into their lives at their most vulnerable and try and help them as best I can?

Proud to help people in whatever little way I can, from a simple smile, a lift off the floor when they are stuck, to much more in depth medical interventions and life saving treatments?


Well, if it is wrong, then I’m going to hell because I know I am proud to be a Paramedic!

NewbieMedic

Who cares?

My heart sank as the familiar vibrating sensation got me and my crewmate out of our seats. Our radios had buzzed indicating we had a job.

"This one will be sick" I said to my fairly new crew mate.

"How can you tell?" they asked.

"Simple. We have less than 30 minutes of our shift left!"

We climb into the vehicle and my fears mount.

"Yep, gonna be a sick one. Just look at that address..."

Any job at a care home / nursing home tends to fill me with dread. And this one was no exception. Sure enough, more information buzzes down to our computer as we start to roll out the garage.

"Looks like you might be right" my crew mate says to me. I take one look, press the "999" button turning my big yellow custard box into a flashing yellow custard box and do my best to personally destroy the ozone layer as I make significant haste towards this job.

What had made me go like a rocket was a few notes in the description box "BP 66/33. Oxygen levels low". For anyone non-medical reading this, your Blood Pressure (BP) really should have the top number (the systolic) above 90. If it is not, then vital organs, such as kidneys and the brain, start having issues getting blood to them. This is bad.

As we pull up and get out, met by an aroma of rather hot breaks, I suggest we take the bed and all the trimmings in. Normally I take in my medic bag, O2 and a defibrillator anyway, but for this job I actually thought I was going to need them.

We start rolling the loaded bed towards the entrance when a lady appeared to show us in. I'll admit this did surprise me as I am more than used to having to wait for 5 or so minutes to get in / find someone who knows what is going on. Perhaps this was one of the better care homes in the area. How wrong was I.

We squeeze our trolley bed into the room that clearly had not been designed with getting patients in/out in mind, and are met by a nurse.

"Hello there. What's happened?"

"This is Edna" I look over and see this elderly bag of skin and bones sat up in bed looking not well. "Edna's had diarrhoea for the last 3 days. Now her blood pressure is low. So are her oxygen levels. And she's not really responding that well either"

"Ok, what are her obs?" I ask as I start trying to find a radial pulse, pop my sats probe (a device that measures the oxygen content of your blood) on her finger and indicate to my crew mate to do a temperature and check the ladies sugar levels.

"The last BP was 66/33 and her sats were 83%"

I look at the ladies badge. Yep, it does say nurse.

"So, why is she still sat up?" I ask. A blank look is my reply. "And do you have oxygen in this place?"

"Oh yes" the nurse replies.

"Any reason it is not on this patient then?" I ask.

"Er.... I don't know" they sheepishly reply,

"Well may I suggest that if a patient has a low blood pressure you lie them flat at least, and perhaps raise their legs if you can. And if they have low oxygen levels you actually give them oxygen?" There is a distinct bitterness in my voice at this point. Not entirely sure she realised how annoyed I was at her. "Do we have any notes for this patient? Any sort of medical history?"

"There should be some notes in her file".

"Then may I suggest you go and get us a copy of these notes as this would actually be useful". I may have over stressed the word actually, but I think she got the message as she left.

The radial pulse was all but non existent. A manual BP showed about 75/40. Better than what we had been told, but not by much. This still was a very sick patient. Temperature was slightly raised, so perhaps there was an infection on board. A quick listen to the lungs; nothing significant in there. Sugar levels fine. Pulse slightly quick. Oxygen levels initially a bit low had now come up since we had actually put oxygen on this poor lady.

I look at my crew mate. "Trolley, ambulance, scarper me thinks".

"I agree!" they reply. Considering they had been on the road less than 6 months, they certainly had more of a grasp of the severity of the situation than the "Nurse" did.

We move her over carefully. It wasn't hard, to be honest I could have blown her over. There literally was nothing over her. I turn around to put some bits back in my bag...

"I don't think she's breathing"

In the immortal words of James May, Cock.

I turn round. No obvious chest movement. Quick listen.... a beating heart but no sounds of breathing. I dive in the oxygen bag and pull out a bag valve mask (BVM) used to ventilate people, plug in the oxygen and pass it to my crewmate who was already at the head. As she starts to ventilate the patient, I grab the defibrillator and start sticking on the pads - once breathing stops, the heart often isn't far behind!

"She's breathing again". Sure enough, there was clear chest rise, not being caused by my crewmate.

"Let’s move before she goes again" I suggest, with which we grab all our bits (no staff around to help of course) and start rolling towards our ambulance. On route we bump into the nurse.

"One of our colleagues is coming with you. He has all the notes". Nice to be asked if this is ok! But at least we will get the notes.

On board the ambulance I pop a needle into the lady, which I must be honest I didn't expect to work as old people have veins that like going POP when they even see a needle. But, having not cannulated a patient for well over a month, first go and in it went. I connected up a bag of fluids, raised the patients legs, both in the hope of getting her blood pressure up a bit so that her brain and other vital organs would get a better blood supply. We shot to hospital, handed over to the staff in resus and left her there. I have no idea if she made it through the night, but I have my suspicions.

The thing that struck me about this job was the nursing home. Now, before I continue I should point out that, as a paramedic, tend to only see the less good nursing / care homes. The ones that are not looking after their patients. This is why we keep getting called. The better ones look after their patients and so we don't see them much. This may have warped my view slightly....

When we get older and frailer, we may end up in a state where we struggle to care for ourselves (there are some that think I can't do that now!). At this point we may well end up in a care home or, if we need extra looking after and have more medical needs, a nursing home. In these supposed sanctuaries we should be properly looked after until the day we pass away. However what I saw with Edna was a poor little old lady, suffering, skin and bones, not well cared for at all. And she is not alone. The number of homes I go into where patients all look so uncared for is scary. And it breaks my heart every time. Many of these patients are paying very good money for these places and they are being totally let down. Yet nothing seems to be done.

Not wishing to start a euthanasia debate, but we do appear to look after our beloved pets better than our elderly. They are either nursed back to health or, should they be suffering, put down. Yet our elderly are stuffed into these homes, with staff that are highly questionable and only care about their pay cheque and going home, and are left to suffer, usually prolonged by modern medicine trying to keep them alive, until they finally pass on.

I don't want to moan, I really don't. But this issue really gets to me every time I enter one of these "pre-mortuaries" (I did not make this phrase up but I do find it scarily accurate). We should be honouring our elderly. They should have prize place in our society. We should be ensuring their care is above reproach, top class, never faltering. So I ask anyone who has actually stopped to read this to do one thing:

Never be afraid to highlight a problem in one of these places. Be you a visitor to your relative or a visitor in green coming to take another poor person to hospital. If you have even the slightest doubt that the care may not be up to scratch, tell someone. If you are working, there should be reporting mechanisms. If you are a visitor either talk to the management, or if you are worried your relative's care may suffer because of it, go through your local social services and they should be able to help. Only by highlighting your concerns every single time can a body of evidence be put together to make changes happen. It may not be easy. It may make you late off work occasionally. But these people often can't stick up for themselves. We must be their advocates. We must be their voice.

Thanks for reading

NewbieMedic.

It's a love/hate thing.

I've been thinking about this for a long time, trying to put it into words. The only way I can say it is...

I love my job. I hate my work.

Confused? Well it kinda hinges on your definition of "Job" and "Work".

To me, my JOB is to get to the sick and injured, effect pre-hospital treatments etc, and if required, get them to a place of definitive care, be that A+E or another alternative. Rolled into this is caring, supporting, comforting and doing whatever I can to make a patient’s life that bit better. This may be from a bit of reassurance for the little old dear who has fallen over but has nothing seriously wrong with them, to full blown CPR for someone who is dead, and everything in between.

However for me WORK is my job PLUS all the politics PLUS all the time wasters PLUS the retarded computer system that believes a little old dear who has fallen over and probably done her hip in and has been on the floor for ages is less important that a 19yo who's just split up with their partner and is now having "Difficulty in Breathing" (aka Crying / Panic Attack) PLUS the ever pending threat of being run by management for the slightest thing PLUS all the pay cuts PLUS the distinct lack of moral getting me down day in, day out etc.

See the difference?

Now I am, or at least try to be, a positive person. I go to work with the best intentions. Unfortunately, over the last few months, this positivity has been worn down to almost nothing. I've been told off by management for various things, moaned at for doing my job properly rather than cutting corners, questioned by hospital people on my treatment even though what I did was best for the patient. I still love my job, but it seems day after day after day I am not doing my job. I'm a glorified clock stopper. I'm there to meet targets, not to help people. I am there to bend to the will of the management and not do what is right.

The worst of it all? I see myself turning into "the others". The old school lot who just sit around and moan. Who do as little work they can. Who will do everything not to carry a patient because they don't want to, even though they should. Who have extended skills but refuse to use them. Who don't assess because "What's the point - they ignore us at hospital. Lets just get them in and off to hospital and let them sort it out"

I don't want to be like this. I really don't. That is not why I became a Paramedic.

A few weeks ago I heard myself say "Well, all we can do is take you to hospital". I was shocked. Even though in this case that was true, and we did need to take the patient, it seemed awful to actually say that.

So, how do you cope? How do you stay positive when all around you is going to faeces? What can you do to keep that enthusiasm you had at the beginning intact? Is it so wrong to just want to help people? Perhaps I care too much and that's the problem. Because I do care, the fact I'm not being allowed to care is what is getting me down?

Soon things are going to be changing. In a couple of months I'm moving off the rapid response unit back onto ambulances (mostly). It's not as good a rota, it may even mean less time with my missus, but I feel that the car is partly to blame with in all this, so I'm having a change to see if it helps. If it doesn't, well I don't know what to do.

I am, however, going to make a promise to myself: I will do my upmost to continue to do whatever I believe to be in the patient’s best interests. Even if this means I am unpopular with the colleagues. Even if this takes me longer and I am off home late. If the patient warrants my care (which admittedly very few of my patients actually do!) then I will give 110% of my efforts to that individual. While I may feel shit at the moment with work, I am not going to let my patients suffer.

On a lighter note, my new years resolution to do at least one blog a month failed miserably. Mainly because of the above. I've been rather down recently and trying to muster enough energy (and find the time) to write all this down in a way I feel happy with. However, I'm hoping that this post, and the pending change of work conditions may help things. I've other things on my mind that I want to blog about, so hopefully there will be a march blog sooner rather than later.

As always, no idea if anyone is going to read this. No idea if anyone will actually care. I fear, having spoken to friends / colleagues / relatives in various services around the UK that I am certainly not alone in my feelings. But hopefully there will be someone who reads this and realises "it's not just me then" and feel slightly less alone. After all, misery loves company.

Keep calm and carry on!

NewbieMedic.

Volunteers

Voluntary Aid Societies (VAS). Some of you reading this may well be part of them, Red Cross, St. John Ambulance, St. Andrews Ambulance. I am. Which one is not important. Indeed it was getting involved with the VAS during my first degree that got me into EMS in the first place. However, being part of one of these organisations is often frowned upon by many in EMS. It’s almost a stigma and many think less of you because of it.

Now I do understand some of the reasons why. I see the good, the bad and the downright worrying within my organisation. While this can also be said of EMS (I’m sure we can all identify one or more individuals we would NOT want turning up to us or our families!) the appears to be a higher concentration in VAS possibly because the need to make up numbers and only having those who volunteer to do it with. So you sometimes take what you can get and have less room to be picky. Not a good excuse but a reason none the less. I have also been informed by some friends in London that during the ambulance strike back in 1989 St. John Ambulance volunteers worked and this was seen as them working against the strike so there is still some animosity from that.

However, I have found that, along with the bad and the ugly there is indeed some good in what these organisations do. Some support that ambulance services in times of need providing ambulances and crews to cover some of the lower grade 999 calls freeing up frontline NHS services to attend the higher priority calls. Some NHS trusts favour one VAS over the other, some don’t work with any. They also provide first aid provision at thousands of events every week. Volunteers. Not being paid. Surely that has to be commended? I personally don’t do much front line direct care (I do that at work) instead choosing to give my time in other ways within the organisation utilising some of my other non-clinical skills. But I also get something back from all this. I get courses which improve my skills from leadership to recognised planning, major incident and training qualifications which I can add to my CPD and aid my career progression.

But, what I wanted to know is this: Do VAS have a place within EMS? And if so what? Should we be actively working with them to raise their standards? Should they be confined to providing first aid at fetes? Should they be providing support to ambulance services? Do they have the skills to be answering 999 calls?

Well, I look forward to seeing what people think.

NewbieMedic.