A PARAMEDIC'S DIARY_Life and Death on the Streets

by Stuart Gray

I received an early morning call to a Road Traffic Collision (RTC) in the West End. It was evening rush hour, it was dark and raining and the traffic was hell. I was a mile or so away. The call details stated ‘vehicle vs. ped. - ?inj’.

  Nothing could have been further from the truth than ‘? inj’.

  After battling through the traffic, sirens and blue lights going, I arrived at the scene and found it cordoned off by the police. I’d been expecting someone, possibly drunk, to have been superficially injured after bumping lightly into a parked vehicle. We get that end of the RTC market, too. The cordon put paid to those thoughts. This meant that it was a serious incident. I continued down the road until I got to the scene. There was an ambulance in attendance but I couldn’t see the crew or the casualty. Two buses were blocking my access to the area and the bus drivers, who were parked side by side across the entire road, were having a conversation and not paying any attention to my flashing blue lights. I sounded my siren and they looked. A police officer waved at them and one of the guys climbed aboard his bus and moved it out of my way. I drove around the wrong side of the road to the accident scene.

  I parked up and glanced over my shoulder at the road behind me. One of my colleagues was attending to a casualty on the ground. Then I realised what I was seeing. A young woman, in her early twenties, lay in the middle of the wet road with a large pool of blood around her. Her red-soaked clothing had been cut open, so she was lying on it and exposed to the air and the rain. We always do this with serious injuries because we need to inspect the body; we also need access to skin for defib pads.

  His crewmate rushed back from the ambulance with some equipment as I got out and ran over to them.

  This young woman was in serious trouble. She had a massive and very obvious head injury: the whole left side of her face had been obliterated. She lay there and her legs and arms moved in a grotesque slow-motion mime for help. I have no idea whether she understood what was happening to her or not; all I do know is that she squeezed my hand once when I spoke to her but that she didn’t respond like that again afterwards.

  Someone had hit her hard and had left the scene. A coward with a car as a weapon had wiped this young girl’s future out in a split second and hadn’t had the guts to stay and help her. Nobody witnessed this apparently and she had been lying in the middle of that road for God knows how long, with her life bleeding onto the street, until somebody saw her and called for help.

  All her personal belongings were strewn around her and we worked frantically to keep her alive. To be honest, I expected her to die on us in the road, but miraculously she was staying, just hanging on by the thinnest of threads.

  Another FRU arrived and the four of us gathered her up in the scoop and got her into the ambulance. The oxygen mask didn’t sit properly on her face because of the extensive damage and intubating her (if it became necessary) would be almost impossible. I had called for an emergency doctor to attend but it was going to take too long for him to get here; she had us and we weren’t waiting. I gave her a large dose of morphine before we set off.

  In the ambulance fluids were given and, as well as her more obvious injuries, a left side pneumothorax was identified.

  PNEUMOTHORAX: The lungs are lined with a double membranes separating them from the chest wall. A pneumothorax involves air getting between these two membranes, which causes the lung to collapse and makes breathing difficult.

  An attempt was made to de-compress - we use a large bore needle, inserted into the chest to get the air out of the chest cavity, which allows the lung to re-inflate and is a potentially life-saving technique - but it was too difficult to deal with immediately, so we had to leave it. She was fighting for her life and continued to breathe, albeit agonally - agonal breathing is weak, near-death breathing - until she got to hospital. There she was put to sleep and intubated (RSI) so that her breathing could be managed properly - we’d simply not had the time to do this on scene or en route. When I left, she was still being worked on and I had no idea whether she would come through.

  Amazingly, this woman beat the odds after a long stay in hospital. Her life will never be the same, but she survived one of the most horrific head injuries I have seen on a living person.

  I don’t know whether the evil scumbag who hit her and left her was ever caught, but I hope it’s on his or her conscience. I felt terribly angry after that job, and that anger is still with me. Alongside it, though, there is a feeling of some satisfaction. What my colleagues and I did to keep her alive worked. She would have been dead within minutes without our aggressive intervention.

  Not all hit and run incidents result in such horrific injuries. They range from immediately fatal to very minor cuts and bruises (and sometimes nothing at all), but the mechanisms for injury are similar in every call of this nature and so we tend to treat all those patients with the same precautions for their spine. They get a collar around their neck and blocks by their ears before being unceremoniously strapped to a rigid board or orthopaedic stretcher (scoop).

  A taxi hit a young man who stepped into its path on a rainy afternoon. He wasn’t looking where he was going and, by his own admission, was completely to blame. I guess he was so relieved not to have been killed that he couldn’t absolve the driver of guilt quick enough. The driver, meanwhile, was sitting on the kerb in a daze, worried sick about how badly he may have hurt the man.

  In the end, even though we strapped him down and took the necessary precautions as usual, he didn’t have a scratch on him. His leg may have been damaged but there was no sign of it when I examined him. The taxi had hit him at around 30mph - in a 30mph zone, that’s the speed they all say they were doing.

  ‘How fast were you travelling when you hit the pedestrian, sir?’

  ‘Oh, I dunno. What’s the posted limit for this street, officer?’

  ‘It’s 30mph.’

  ‘Yes, now I think about it, that’s the speed I was moving at.’

  There’s no point in trying to glean a confession for speeding because it just won’t happen. Unless, of course, the whole thing was witnessed by credible people or is on camera.

  Like the case of the small car and the large man. He was hit whilst crossing a busy road by one of those little ‘easy to park and put in your pocket later’ cars. When I arrived, he was sitting among a small crowd who had gathered to tend to him on the pavement. A Good Samaritan had dragged him out of the road before something else small and vicious had a go at him.

  The driver of the car had screamed on around the corner, parked up (they are very easy to park) and legged it. The whole thing was witnessed, from beginning to end, by at least ten taxi drivers who just happen to congregate at that spot for a bit of a chat and a brew.

  The patient was taken to hospital with a minor head injury and a possible fractured hand but was otherwise unhurt. The taxi-driving witnesses reckoned the car was doing at least twice the legal limit.

  Some people simply bounce off the bumper of the car that has left them lying in the road. Usually, alcohol has influenced the outcome and their rubbery response to a 30mph impact by a ton of vehicle has left no impression on them whatsoever. This flies in the face of all we are taught on mechanisms of injury and sticks two fingers up at my school physics teacher, much as we used to during class.

  A Polish drunk who got hit by a car which sped off afterwards had to be tracked down when he, too, left the scene. We had been called to the incident by police, but the victim was nowhere to be seen - witnesses said that he had been hit hard enough to send him flying but that he had then just got up and wandered off, shouting a few Polish phrases after the disappearing vehicle.

  We found him staggering down an alley way behind an estate. He was still drinking and verbally abusive when we asked him to stop so that we could check him out. In broken English he told us that he didn’t need our help and that he had no intention of going to hospital. A cursory check (that’s all he would allow and only then because the police were present) of his obs
and physical condition seemed to verify that he was unscathed by his journey through the air.

  On his insistence, which was often less than gracious, we left him alone and no further action was taken as far as I am aware. Neither did we hear from our Polish friend again.

  A 31-year-old Frenchman who was allegedly hit by a black cab, which subsequently left the scene, sat on a bus stop bench with British Transport Police (BTP) taking care of him until I arrived. It was 3 o’clock in the morning and the streets were all but deserted; somehow this guy had managed to get his head bashed in by one of the few fast-moving vehicles around. I mean, he must have tried, almost. The rest of his body was fine but he had a significant head wound.

  I carefully removed the loose dressing that had been applied by the BTP and looked at his injury. A long, meandering laceration worked its way along his scalp, from his eyebrow to the middle of his head. The flesh had been completely torn away, exposing the skull underneath, yet he sat there joking about having a ‘bad headache’. He wasn’t drunk and he hadn’t taken drugs. He had just finished a long shift and had been drinking Red Bull all night. Maybe it has an analgesic property they don’t tell us about in the ads; if he’d had the wings, I think he would have been more than happy to have flown off and gone to bed.

  The more I looked at him, the more I couldn’t figure out how he’d got this one nasty injury and nothing else. Maybe only the wing mirror had hit him, but then the wing mirror of a black cab isn’t high enough to have done this, unless he had bowed his head as he crossed the road and the vehicle had clipped it. Perhaps he had actually been hit by something with a much higher wing mirror - a bus, for example. I didn’t think he was high enough on Red Bull to mistake a bus for a cab, so I dismissed that theory. He could, I suppose, have sustained that injury when he hit the ground after being thumped by the taxi, but there was no tell-tale pool of blood on the road or pavement. As I examined the wound it bled profusely and I had to re-dress it quickly to get the bleeding under control, so there would certainly have been a little puddle somewhere if he had lain on his head for any period of time... but there wasn’t. The blood-puddle fairies had been.

  He was wearing his iPod, and that gave us a useful clue. He was probably listening to music and not watching for traffic as he crossed the road. He could have been ‘side-swiped’ by a vehicle if the angle was just right, so his body wouldn’t be involved, thus the isolated head injury.

  He remained stable and in good spirits as he was taken off to hospital. His scalp flap would need to be closed properly, and he would probably need specialist treatment for some time afterwards to ensure it healed fully. He was a strange, happy, injured Frenchman, and he made treating someone who had ‘gotten away with it’ a pleasant experience for a change.

  I know I will deal with many more hit and run incidents, and not all of them will be survivors. I know I’ll face the task of keeping someone together until a crew arrives to help me out, and I know that it will happen some day soon, but I’ll remind myself of the incredible difference we make to the patient’s chances of survival once they are in our care. That way, it’s easier to accept the aftermath of such incidents.

  STREET PEOPLE

  THIS JOB CAN PLAY with your sense of humanity sometimes.

  We meet so many people over the course of a career that we set distances according to who we think we like and those we automatically dislike, sometimes just because of their circumstances. I grew up on a council estate and had a very working-class childhood; now I dislike anything that reminds me of that. I think it’s human nature to feel that way, and working with the homeless as a pre-hospital professional presents the same barrier. It becomes too easy to forget that these people have had lives before all of this, and that not all of them have abused those lives by drinking or using drugs to excess. Many homeless people are ex-soldiers, for instance, guys who’ve fought for their country but find it impossible to readjust to life in Civvie Street after their service has ended. But even rough sleepers who seem deserved of their fate require a pause for thought.

  The charity CRISIS estimates, based on Government figures, that there are as many as 400,000 homeless adults in the UK. A large proportion of these are single homeless people, who are not entitled to any accommodation in England and Wales unless deemed to be ‘vulnerable’. This gives them less incentive to apply for accommodation and they end up sleeping rough on the streets. In Scotland, the same individuals would be entitled to temporary accommodation, and from 2012 will get permanent accommodation. I can see a big shift in the homeless population to northern climes in the near future, unless the inclement weather is a problem for them.

  The vulnerability of those with ongoing health problems is plain to see out there on the streets. There are individuals suffering some of the worst illnesses there are but, although the country’s healthcare system applies to them as much as to anyone else, access and treatment monitoring can be impossible.

  I was sent to a 41-year-old homeless alcoholic who had been found semi-conscious and coughing up blood. He was lying on the steps of a church that gives refuge to the local alcoholics and drug addicts. The parish takes responsibility for feeding them, clothing them to some extent and giving them a place to lie down, and thank God they do.

  I knew this man. He had been a patient of mine the previous year and he had been drunk and abusive. Now he was too ill to raise a snarl, too out of it to care. He was still drunk, and he was lying in his own filth. There was an eye-stinging smell of urine about him - I had to hold my breath several times to deal with it - and he clearly wasn’t well. His body needed to go to hospital, even if his soul was meant for somewhere else.

  His buddies were sitting around him and all of them showed genuine concern. There was a sense of community among them, as if they all looked out for each other. Of course, a few of them were drunk and could barely keep themselves upright when demonstrating the extent of their anxiety, but I sensed they were used to being ignored and vilified; one of them, a woman who looked 50 but was probably in her 30s, said: ‘We are good people, but we’re alcoholics.’

  It stopped me in my tracks. I could hear her, in my head, saying, ‘We get treated like crap all day… please don’t do it to him now.’

  I had no intention of treating them any differently to anyone else, but I could understand her concern.

  The ambulance arrived and the man was taken away to hospital, with the thanks of the other homeless people following in the air. I packed up my gear and walked to the car, and as I got in the woman shouted out to me.

  ‘I didn’t know what else to do,’ she said. ‘I’m sorry I called you, but I didn’t want him to wake up dead.’

  London Street Rescue, a comparatively new charity, sends its people out and about to ‘rescue’ those rough sleepers who wish to have some kind of roof over their heads (they don’t all want this). They target the most vulnerable and have asked the ambulance service to work with them to help eliminate the problem. We are asked to identify people that we come across in our working day (or night) who may be vulnerable and therefore deserve rescuing. We call the charity, give some details, including the whereabouts of the individual concerned, and leave it to them. They send an outreach worker to find them and arrange emergency accommodation, give advice and information about available support services, provide blankets and food or put them back in contact with their families where possible. All in all, a good thing.

  The statistics for the number of rough sleepers in the Capital are difficult to get and more often than not are woefully out of date. Ever since Ken Livingstone’s initiative in the early 2000s, officially accurate figures for the reduction of street people, which he planned to reduce dramatically, have been strangely elusive. The only useful source I could find was The Simon Community, one of the oldest homelessness charities.

  In April 2006, The Simon Community sent its own people out onto the streets to record the actual number of rough sleepers. This is not an easy thing to d
o, considering the introverted nature of some of these individuals and the inaccessible places in which they choose to bed down for the night. Nevertheless, they concluded that there were 332 people sleeping rough in London. They also phoned round the 66 hostels in Central London and discovered that there were 42 free bed spaces available but not being utilised.

  One of the ways that street people make a living is by selling The Big Issue. In turn, the magazine uses its profits to raise funds for homelessness projects and is a registered charity.

  There is, as you’d expect, fierce competition for your money and Big Issue sellers seem to have appeared on every street corner. To get an edge on sales, some of them have adapted ‘skills’ to attract your attention and hopefully your loose change. I know of a man who stands on one leg, holding out a copy of The Big Issue with an outstretched arm. He will stand like this for a very long time until someone takes the bait. Even more impressive is the man who stands on his head and can stay that way forever (seemingly) in an attempt to persuade you to part with your free cash.

  I think there needs to be another way for these people to earn a crust. If they can’t get rid of their papers maybe that’s because the interest of the general public has waned and a new approach is needed. They don’t want charity - for that they would simply beg (and get arrested) - but they do want the means to earn their day’s food and lodgings.

  * * * * *

  Not all of the people who live on the street are pleasant. Not all of them care about what we are trying to do. Some of them deliberately abuse us.

  I was called to attend a known patient who wears a surgical mask over his face for tuberculosis (TB), though he doesn’t really need it because he doesn’t have TB. He uses this as an excuse to get to hospital, where he can get free food and abuse the staff when they ask him to leave. When I got on scene, the ambulance crew were just getting to him ahead of me and so I stuck around to see what was what. He didn’t have any problems and considered his imaginary TB to be enough of an excuse to go to hospital. The crew were wise to him and he was told to get a bus. I didn’t disagree, I have to say; he would make his own way and we could free up an ambulance. He toddled off with his mask on, scaring the general public as he made his way to the crowded bus stop. Once he thought he was out of sight, I saw him take his mask off. He obviously decided to end the charade.