by Stuart Gray
THE POLICE: Our best friends, bar none (though closely followed by the men and women of the London Fire Brigade). The Met police and BTP are pretty much always on our side, because they see what we are up against every single day (and night). They’re usually on scene, and they watch our backs and keep us safe. Like the LFB, they also make excellent drip stands. God bless you all.
I suddenly became more cautious and shouted into the front room.
‘Hello? Ambulance.’
There was a sobbing reply from inside the room - it was the young woman we had come to help.
‘I’m in here,’ she said.
We went into the room and she was sitting on a chair, dressed in her night clothes and shakily smoking a cigarette. Her face was smeared with old and current tears and she had minor cuts to her neck and arms. As I examined her, she told us what had happened.
‘I had an argument with my boyfriend and he started punching and kicking me,’ she explained. ‘Then he went into the kitchen while I was on the floor and he brought one of the knives out.’ She looked terrified. ‘I thought he was going to kill me, I really did.’
She started to cry again and we settled her down. We were all a little on edge. I walked into the kitchen and there, on the table, was a large carving knife. The sight of it sent a shiver down my spine.
When I returned to the front room, my crewmate was chatting to the young woman, who was busily dialling a number on her mobile phone. She looked up at us both and said that she didn’t want her boyfriend to get into trouble.
‘I’m going to ask him to come back so we can sort this out between us,’ she said.
My jaw probably dropped but I don’t remember for sure. ‘No,’ I said (I may have shouted). ‘You can’t bring him back here.’
‘Why not?’
‘He’s dangerous and he’ll put us at risk.’
‘No, he won’t. He’s harmless really. He’ll be sorry for what he did now.’
I couldn’t believe my ears, but I have seen this so many times that I should have anticipated it. She’ll have gone through it all again and again in the past; it’s become part of her life; but I sure as hell didn’t want to be introduced to her violently passive boyfriend.
The police arrived before she could get through. They began to interview her. She told them what she had told us, insisting that she didn’t want to press charges or go to hospital. She had received her care and attention, and now all she wanted was to be left alone so that she could reunite herself with her aggressive other half. True love.
Some families have their own way of settling scores and they wait for opportune moments, when alcohol is flowing freely, to do just that. A call to a ‘fight at party’ turned out to be a serious assault at a wedding reception being held by a travelling family. We pulled up outside the venue and found police on scene and a lot of menacing faces hanging about. We weren’t a welcome sight. In fact, I got the distinct impression that nothing with blue lights was welcome.
The injured man had been attacked in what the papers would probably call ‘a drink-fuelled frenzy’. He had nasty facial injuries, the worst of which was to his ear; it had been bitten off, leaving only a ragged pulp of bloody flesh on the side of his head. There was considerable bleeding and that had to be controlled first.
As he was treated, the man stared straight ahead with his wife and family looking on. I think his mind was busy with thoughts of revenge, rather than the serious nature of the wound, and he was also very pale and sweaty, so we moved him onto the trolley bed to keep his blood pressure up. Ideally, we needed to find the missing ear, so I asked around and eventually was pointed in the direction of where the ‘party’ had been taking place. I found myself standing in a large hall which looked, literally, like a bomb had gone off in it; they had trashed the place, either as a consequence of having a good time or during the fight (there had been a number of people involved).
A venue manager was standing there, looking slightly dazed.
‘I don’t suppose you’ve seen an ear lying about, mate?’ I said.
He just pointed to a large bin. I looked into the bin and started rummaging around among the half-eaten sausage rolls and pizza crusts. In the end, I had to admit defeat: the guy needed to go to hospital, the ear was proving elusive and even if I did find it the chances of it being in pristine nick had diminished to almost zero considering where it had been stored. So I went back empty-handed and we took the man to hospital for some urgently needed repair. I don’t know if he was a qualifying case for plastic surgery, but I doubt it; the ear was most likely stitched up and left to heal over into a ragged stump. He’d have a nice battle scar to show off to his friends and family. Personally, I’d rather have an ear.
Knives are never far from a modern-day fight, and they have produced some of the worst wounds I’ve treated. Many of the patients were innocent bystanders; they were just in the wrong place at the wrong time when ‘it all kicked off’. One or two of them, with relatively minor nicks, didn’t even know they had been stabbed until the blood was pointed out; others never stood a chance.
On a horrible, rainy night, my crewmate and I were called to a stabbing at an address in north London. We arrived on scene to see another crew bringing a patient out of the small terraced house on a trolley bed. They were resuscitating, and there was a lot of blood around. A lot. We joined them in their vehicle and I saw the extent of the injuries immediately. Lying on the bed was a young woman, probably in her early twenties. She had been stabbed a number of times and I could see at least two wounds, both in her chest. Her blood, red and sticky and metallic-smelling, was washing around the ambulance floor now.
I started working on her airway and breathing whilst CPR continued. The HEMS team arrived within a few minutes and I intubated her as they set about organising themselves with the crew. I saw a flash in my peripheral vision and thought nothing of it, but when I asked for a stethoscope so that I could check that my tube had entered the correct pipe and the lungs were filling with air, the doctor said, ‘Why don’t you just have a look?’
The patient’s chest was gaping open. The flash had come from the doctor’s cutting instruments - he had performed a thoracotomy (like the one nearly performed on the Scottish one-under discussed earlier) so that he could get to the heart directly and massage it. There was no need for me to check her lungs with a stethoscope, I could see them rising and falling.
With the amount of blood she had lost, she needed fluids. But her veins had collapsed, making IV access impossible, so I carried out an intraosseous access (the first time I’d performed this procedure, actually). This involves using a thick and pretty nasty-looking needle to cut through the bone and into the marrow cavity so that fluids can be given where there is no venous access. I tried several times, once in each shin bone (one of which was successful) and once in the pelvis, which also worked. Unfortunately for the woman, no amount of fluid was going to help her and she was pronounced dead in the ambulance.
This was one of the nastiest, bloodiest assaults I have dealt with to date, and if I never see a worse one I’ll be happy. The woman’s husband had stabbed her several times in the chest and back, and then ran off as the police were arriving, or so the story went. I don’t think he got far.
That same night, at another location, I was attending a young man who had gone home bleeding from a wound in his chest. He had told his family that he had been ‘punched’, but his condition had deteriorated so much that they had called an ambulance. His breathing wasn’t right and he was as pale as a ghost. Externally, the wound looked small and insignificant, but I had no idea how deep it was. As I examined him, he started going into shock, so I had to assume he had lost more blood than we could see. We wasted no time getting him to hospital.
The sad truth is, my colleagues and I could fill a book with the random assaults we come across.
A call to a petrol station in the City one Saturday night for a ‘collapsed male’ turned out to be a little more co
mplicated. I found him lying on the floor of the little shop. He had come in, staggered to the counter and collapsed. He was conscious but very frightened looking.
‘What’s happened?’ I asked
‘I’ve been beaten up by four men for no reason,’ he said.
I looked at his arms, which were bruised and bleeding, and then I realised his wounds were not the result of a simple beating. He had long, deep cuts to his arms and a few oval punctures to his neck and face.
‘Did you see a weapon when they beat you up?’
‘No, I don’t think so. Why?’
‘I think you’ve been stabbed,’ I said.
I went on to tell him that his wounds were not dangerous, but there was no doubt in my mind that the intentions of his assailants were deadly. They had tried to stab his neck and throat, narrowly missing his carotid artery and jugular vein. His arm wounds were probably defensive and, I thought, had quite likely saved his life.
‘S**t,’ he said. ‘Serious?’
I called the police and requested an ambulance for him.
Another hapless victim of this kind of violence was walking down the street minding his own business when he was accosted for his mobile phone. He refused to give it up and was rewarded with a blade to his eye. The knife penetrated just underneath the eyeball and pierced it from beneath. Whether he will recover his sight or not will be down to the skill of the doctors and a lot of luck.
A similar call had me attending a young man who had been stabbed. He’d been approached and stabbed in the leg before the muggers demanded his phone. He had handed it over, and wasn’t resisting, but the assailants had then tried to stab him again - this time in the chest. He’d stopped the knife with his hand, which was now sliced open. I was shocked at the ferocity of his attackers. They had what they wanted but they still tried to kill him. I didn’t see the point, unless the point isn’t just to gain the prize but a reputation too.
The other weapon of choice for our evil youth is guns. The Home Office report on gun crime in the UK shows a steady rise in shootings to almost 4,000 in 2006. The number of fatalities associated with these crimes has remained steady, however, with the number of serious or slightly-injured victims increasing. Whether this reflects the amateur nature of the shooter, who generally belongs to a gang and has no real weapons training, or a deliberate culture of shooting for punishment and as a means of terror, I don’t know, but the threat is clearly real and the incidence is on the rise.
On every shooting I have attended, the police were required to place armed officers at the entrance and exit to the Resus room in case of reprisal. Shooters don’t want their victims to survive and become witnesses.
In London, most of these crimes involve young black men. Sometimes they are gang members, sometimes they are drug dealers, sometimes they are just innocent people who found themselves in the way of a bullet. For all of us in the ambulance service, they are just kids and, sometimes, they are dead kids.
I remember working in a quieter part of London, where gun crime is not so much of a problem, when an ambulance crew brought in a 17-year-old lad who had just been gunned down in the street. He was being resuscitated aggressively as they brought him out of the vehicle and blood was pumping out of three wounds in his chest. There wasn’t a chance in hell as far as I could see, and the Resus team agreed soon afterwards.
His family arrived shortly after he was pronounced dead, and the noise of their understandable grief drowned out all of the usual hospital sounds around me. It erupted suddenly, and continued for a long time afterwards. I got the distinct impression that they were good people, and that their son had been another innocent statistic, ripped from them suddenly, terribly. I wondered what could ever console them, and I realised that nothing could or would. Except perhaps time.
BRINGING THEM BACK
RESUSCITATION CARRIES WITH it the high risk of failure. A few years ago, your chances of survival - even with a bunch of us working on you - were minimal at best. Only around 5% of people would survive a full-blown resuscitation with defibrillation. Now, though, the probability of survival is much better, thanks chiefly to the new CPR guidelines, introduced in 2006. We concentrate more on the compressions (that’s when you push down on the person’s chest), the drugs and the shock side of things than we do with airway and breathing (so mouth-to-mouth is often left until later). The changes came after research suggested concentrating on these areas would bear more fruit, and I have to say that it does. I’ve witnessed the near-miraculous results of this new approach a few times now.
I have contributed to the successful resuscitation of at least five patients in recent years. In all, they equate to a third of my ‘suspended’ calls during that time. I am tremendously proud of this, as I’m sure my colleagues are with their own successes: that means five mums, dads, brothers or sisters are back home, instead of in the ground. But although we’re getting better, death will always have the upper hand. We still have to cope with the probability, if not the near-inevitability, of fatality when we go to these calls. Yes, I’ve saved five, but that still means two thirds of my patients didn’t make it.
Before the new guidelines were introduced, a colleague and I were on a fairly routine night shift and received a call to a collapsed female. As we approached the scene, the call was upgraded to a ‘suspended’. We looked at each other; this was my colleague’s first suspended call as a paramedic, and it would be a test of her skills and knowledge.
There was an EMT already on scene - he was on the FRU that day - and we walked into the house and found him resuscitating the patient. She was a large woman who was lying half in and half out of the world’s smallest toilet. Her husband stood in the front room watching as his wife’s life hung in the balance. We started to unpack our equipment, but the hallway was so small that it quickly became a chaotic mess, with drugs, intubation and infusion packs strewn all around. My colleague took charge of the situation and attempted to intubate the woman whilst I got on with preparing the drugs and gaining IV access. Her airway was so messy (she had vomited) that getting into the trachea was proving very difficult. The little hallway was very dimly lit and there was no room for manoeuvre. Everything had to be done in a crouching position. Even the EMT had to straddle the woman to get on with the chest compressions properly. Everyone was having difficulty with this one.
The intubation attempts failed again and again, so the patient was ventilated using basic techniques whilst the trolley bed was brought into the house. There was no change in her condition; she had been in asystole (that means she showed no electrical activity or heartbeat) for some time now, and it was looking hopeless.
We lifted her onto the trolley bed and got her into the ambulance. CPR continued all the way to hospital and, for a short time, in Resus. At one point we thought they had some cardiac activity again but as we left I heard the doctor ‘call it’ and pronounce her dead. My colleague was devastated. She had wanted a positive outcome, but that rarely happened in those days. I tried to reassure her. Going from ‘green’ to ‘experienced’ with cardiac arrest management is not easy and it doesn’t happen overnight. We don’t have the same kind of support that is often provided in hospital. In the ambulance service, a paramedic must learn to carry the responsibility for every mistake made until there are so few (or none at all) that he or she becomes confident. I’m not suggesting that patient outcome suffers as a consequence, because there is usually someone on scene with enough experience to ensure the job is going to plan, but the outcome for this kind of call is always uncertain, even now and even with years of good quality CPR under a belt.
The next call we received for cardiac arrest was during an early shift. We were sent less than two hundred metres to a ‘woman, collapsed in street - now suspended’. This time, I thought, we’ll do better.
We were first on scene. It was a quiet street of Victorian terraces. A small group of people was standing around a woman lying on the pavement. We cleared a way through to her and con
firmed that she was in cardiac arrest. I was attending this time round, so I took charge of the resus while my crewmate fetched the equipment from the ambulance. CPR was quickly taken over by a FRU colleague who arrived within a few minutes. I intubated the patient and my crewmate gained IV access and gave the first drugs. A shock had been delivered because the woman was in ventricular fibrillation (VF). My feeling was that there was an outside chance of saving her.
VENTRICULAR FIBRILLATION, OR ‘VF’: A chaotic electrical state in which the heart muscle is contracting in a random, inefficient way. The pumping ability of the heart ceases when VF occurs and unless the condition is reversed within a few minutes, using an electrical charge – defibrillation, with the paddles applied to the chest – the heart will eventually stop working altogether and the patient will die.
A couple had stopped with their two small children to watch this spectacle and I had to shoo them away. I still don’t understand why parents think this is good entertainment for their kids.
They walked away.
As soon as we were able to, we moved the woman from the pavement to the ambulance and I continued CPR en-route to hospital. After a shock was delivered, I got a pulse and I asked my crewmate to slow down. I checked for breathing, but there was nothing, then the pulse went again. This happened three times on the way; a pulse appeared for a few seconds and then went again. It was very frustrating. It’s a crude metaphor, but to me it’s like lighting a fire, when the kindling keeps catching momentarily and then going out again. All you want is for the damned thing to take hold. ‘Stay with me,’ I said. ‘Come on.’
When we had transferred her, we’d taken with us a bag that she had been carrying and which she’d dropped on the ground. We checked the contents and found a Blockbuster DVD and a shopping list. She’d never made it to the shops, and now she never would: she was pronounced dead soon after arriving at hospital. I felt bitterly disappointed, but both my colleague and I knew that we had managed this one much better.
