A PARAMEDIC'S DIARY_Life and Death on the Streets

by Stuart Gray

  The first time I met this guy he was lying on the grass outside a busy train station, extorting sympathy and worried looks from the general public. He had collapsed and caused a scene, which included the use of his face mask, in order to get some kind soul to call an ambulance. Of course, there were many who obliged, partly out of fear of whatever it was that might be so dangerous as to warrant the barrier on his face.

  I was sucked in by this because I didn’t know him at the time, so I assumed he was a rough sleeper with a genuine medical problem (I was naïve in those days). He was filthy and unkempt. He had a long, shabby beard which trapped his saliva during spitting sessions, so it was sticky and wet, and he mumbled when he spoke, so I had no choice but to get close to him to hear. His breath wasn’t great. It was quite unpleasant, but thankfully the hospital was only a few minutes away.

  We took him in to A&E and I did my paperwork before leaving. As I climbed into my vehicle, a highly amusing scene unfolded in front of me. He was so smelly that the staff had decided it was best to have him sit in a wheelchair outside until someone could clean him up. He wasn’t happy with that and promptly wheeled himself back inside. Then he was wheeled back out, this time applying resistance to the wheels in an effort to thwart the expulsion. I watched a nurse wagging her finger at him, clearly telling him to stay put, or else. As I left, he was sitting in the chair, beady eyes above the mask daring anyone who passed by to get close. On the upside, he may even have acted as an effective deterrent to anyone else hoping to turn up and waste the hospital staff’s time.

  Another regular caller had me out on a CAT A emergency because he was ‘coughing up blood’. When I got on scene I could see no evidence of this. He wasn’t weak and he wasn’t ill. He was just cold and homeless. I took him to hospital myself and when I booked him in the staff told me he had walked past the hospital to make the 999 call for an ambulance (to take him where he had already been). Remember, we are all paying for this, and apart from the cost it uses up medical resources which might actually be needed.

  I have noticed that street people have extremely well-behaved dogs. It must be the bond created when you have to rely solely on one person to feed you and keep you warm. There is one particular young man that I know from regular sightings who uses this to his advantage. His dog is trained to lie on its back with a baby’s dummy in its mouth. Sometimes he will adorn its head with one of those frilly baby caps for additional emotional impact. The result is that lots of people, especially women - more especially, drunken women - will stop and pay attention to the animal as he lies there waiting to be stroked and cuddled. Then they part with a few quid to ensure that the dog and his master remain well-fed and healthy. I have never seen this man drunk and I have never had a call to him. He lives on the street and begs for money for food and basic comforts. I’m positive the dog is well-fed because street people take good care of their dogs.

  Another regular street person became an acquaintance of mine over a two-year period, though I haven’t seen him for a while. He used to sleep in the entrance to one of the large cinemas on Leicester Square, but he can no longer do that since they have completely refurbished it and turned it into a casino. I’m not sure the door staff would appreciate him turning up with his sleeping bag and settling down for the night as punters weave past to get to the debt machines downstairs.

  He has a long white beard and looks older than he is (the street will do that to you), but he is a very intelligent and reserved man. He only started speaking to me when he felt he could trust me, and that only came about because I used to check that he was OK if I was passing the Square. I’d seen him having trouble with the local drunken yobs a few times before.

  During one of our conversations, he told me that someone had broken his leg while he was sleeping. He didn’t elaborate on how it was done, but I’m assuming they simply jumped or stamped on it. He has a permanent limp and is in constant pain as a result, but he still prefers to live on the streets. He’s been doing it for over 20 years - it must be a difficult thing to get out of. It wouldn’t work for me, but for some the concept of a roof overhead, and all the associated ties and bindings, must seem less and less appealing as time goes on.

  Many people on the streets are vulnerable to attack - my younger brother still bears the scar from a knife slash to his face, carried out while he was sleeping in an arcade in Soho. (He slept rough when he first moved down south.)

  Many of our calls to rough sleepers involve incidents in which an assault has taken place, either because of a dispute over a ‘patch’ or sleeping area or simply because there are some very bad people out there. Rough sleepers get killed, too.

  I knew of two young girls, Kerry and Jane. Both were aged about eighteen, and they were nice girls who had ended up on the street and got involved in prostitution. I had treated Kerry, but Jane I knew only by sight. They were part of the regular cast of characters you get used to seeing if you work a patch over a period of time, though to most of the tourists and office workers passing by they were probably invisible. After a while, they just disappeared and I didn’t see them around. Then I saw one of them, Kerry, the girl I’d treated in the past, sitting on the steps of a train station. The radio was quiet, so I went up to her. ‘How are you?’ I said. ‘And how’s your friend?’

  ‘She’s dead,’ she said, with a deadpan face and a flat voice. ‘They found her in the river.’

  She then related a terrible story, one which I had read about in the papers but hadn’t associated with either of these young women. Her body had been fished out of the Thames a few months back and she was found to have been brutally murdered, probably by someone she had gone with when she was ‘working’. Her body had been dumped in the river soon after. It was a while before anyone noticed she was missing, and her corpse was only found by accident.

  ‘Oh,’ I said. ‘Right.’ I was shocked, and found myself unable to say anything remotely useful considering the horror of it. Still, here was the other girl, sitting on these steps waiting for her new friend so that they could go to work again. During the time of Jack the Ripper, prostitutes in the East End continued to ply their trade because, for many of them, the risk of death was outweighed by the necessity to find money for food and shelter. It’s ironic that such a young person should be exposed to an event like this and still view her life with the same cold logic that her predecessors did over a century before.

  FAKERS

  I’VE DISCUSSED HOAX callers and timewasters at length but there is one group of individuals who just can’t help calling us out for their ‘emergencies’. These people usually have nothing wrong with them - nothing physical anyway - and suffer instead from the desperate need for attention, particularly the attention of medical professionals. This impulse becomes an obsessive clinical condition known as Munchausen’s Syndrome.

  People with this condition act as if they have a physical or mental problem, when they have actually caused the symptoms themselves. They like to be seen as ill or injured, and will even undergo tests and operations, many of them painful or risk-laden, in order to get the sympathy and attention given to people who really are ill. Named after Baron von Munchausen, an 18th century German who liked to tell tall tales about his life and experiences, we also know it as ‘hospital addiction syndrome’.

  I have come across a number of cases over the years. In central London there are a few ‘regular’ culprits, well-known to the hospitals they frequently visit. Unfortunately, there isn’t a list available for us to refer to so that we can identify these people when we first encounter them. Nobody tells us who is faking and who isn’t, so we treat these patients in the same way as all the others, even to the point of administering drugs and pain relief for problems that don’t exist. You don’t need a medical degree or 15 years’ experience as a paramedic to see how dangerous this can be.

  My crewmate and I were called to a man who had ‘severe chest pain’ in Piccadilly Circus. He had been taken to the little police office locat
ed at the end of Shaftesbury Avenue where he was being helped by the police. When we arrived, we found him rolling around on the floor, apparently in utter agony and deathly pale. Between yelps and gasps, he told us he had a history of heart problems. The police officers were convinced he was going to have a heart attack and die where he was.

  We took him into the ambulance and I went through my usual procedures with him. Once I’d established the scale of his pain (we use a number system, where ‘0’ is no pain and ‘10’ is the worst pain), I cannulated him and gave him some morphine. He had also been given an aspirin and some Glyceryl Trinitrate (GTN) spray but nothing seemed to be helping him.

  Glyceryl Trinitrate works by making the veins and arteries relax and dilate. This reduces the resistance within the blood vessels and makes it easier for the heart to pump blood around the body.

  His ECG looked normal, if a little erratic, and his other vital signs were within normal limits. I was starting to wonder what was going on with the man. His pain was real enough (or so I believed) and he had a cardiac history (or so he said) - although that didn’t make sense, given the normal ECG. I was confused. We took him to hospital, on blue lights and sirens, and we were inside the Resus room within a few minutes. The doctors and nurses were dealing with him using their own protocols for acute chest pain and it all seemed to be going smoothly. He was about to be given another dose of morphine when one of the nurses did a double take and pulled the doctor to one side and said something quietly. She then turned to the patient and it quickly became apparent that she recognised him and that he was not having chest pain - he was faking it. I’ve never learned to this day how he managed to look so pale.

  During the course of my experiences with these people, I began to understand how much skill was involved in creating a truly believable illness - so credible, in fact, that experienced ambulance crews were more than likely going to treat them as real without hesitation. However, there are hints - things they say or do that will alert you to the possibility of a Munchausen patient.

  I was on stand-by at Leicester Square when I was approached by a member of staff from one of the big cinemas there. ‘We’ve got a bit of an emergency going on in here,’ he said, jerking his thumb behind him. ‘We just wondered if you could nip in for us?’

  They’d called an ambulance and then seen me, so I called it in and made my way on foot to the cinema. Inside, I was directed to a man who was slumped in the aisle between seats up in the ‘Dress Circle’. The film had been stopped and there was a small and uneven audience around me, a few dozen people shuffling nervously about, looking in my direction and waiting for a major drama to unfold. Off in the other rows, I could hear sweets and popcorn being munched and a buzz of low, unconcerned chatter.

  The man in the aisle looked completely out of it and would not respond in any way to my questions. He was breathing, albeit slowly, and it was hard to find a pulse in his wrist. I checked his carotid (neck) pulse and it was strong. He looked to me as if he had suffered a stroke. His limbs were limp and one of his pupils was bigger than the other (although this can mean nothing at all). He was fairly big and had wedged himself in between the seats at an awkward angle, half-twisted with his lower body sticking out onto the steep stairs of the balcony area.

  I busied myself with my usual checks, including blood glucose, which is always a good start with sudden collapse, and blood pressure, but nothing was amiss. All the time, I was aware of the eyes boring into me from all directions in this quiet cinema. All chatter had stopped now and everyone was looking over.

  I was there for fifteen minutes before the crew arrived because the job had been categorised as a low priority for some reason. When they turned up, I had exhausted all of my checks and tests. He was still breathing and he still had a pulse but he wasn’t responding to a thing I said or did. He remained floppy and heavy.

  We moved him, clumsily at first, from the cinema to the ambulance and I continued my care with the help of the crew. As I tried to put a cannula in (which was tricky) he became more alert (the oxygen, I figured) and he began to speak a little.

  He didn’t give his name or details but he did name his ‘usual’ hospital, which was further south of the river than we were taking him. This was Clue 1.

  I also noticed that his arms were badly scarred and that some of the scars were perfectly straight. This was Clue 2.

  The scarring was the main reason I found it so difficult to find a decent vein, the tissue was so tough and it was clear that his veins had been ‘got at’ many times in the past so they were uncooperative. This was Clue 3.

  ‘Are you a self-harmer?’ I asked.

  Not a word. He was back to his previous slumped and unresponsive self.

  Just as we were about to set off on a routine journey to hospital, with me following in the car, the crew reported that his breathing had become noisy and his level of consciousness had dropped. I re-checked him as the crew tended to his airway but I couldn’t find anything different in his vital signs; no blood pressure changes, no ECG variation, nothing. We decided to ‘blue’ him into hospital just in case.

  When we arrived he was taken immediately to Resus. Again, all the usual tests were carried out and the doctors worked around him frantically. An anaesthetist was requested, to intubate him and stabilise his airway, and I went off to help with the paperwork.

  When I got back into Resus 20 minutes later to check on him, I heard the nurse shouting his name (apparently) and trying to get him to respond. I listened more closely.

  ‘Come on, Steven,’ she was shouting. ‘Wake up. It’s time to go home now!’

  Unorthodox, I thought.

  Then I twigged. She knew who he was, and she was thoroughly unconcerned. She’d cancelled the anaesthetist and continued her attempts to wake him up, but he was having none of it.

  ‘Who is he?’ I asked.

  ‘He’s well known,’ she said. ‘He’s just pretending. If you have a look at his records you’ll see he does it a lot.’

  You’re torn between feeling sorry for these people - they clearly have something wrong with them, it’s just not anything that an ambulance and A&E can sort out - and getting angry. What if a kid had been knocked down a few feet from where I’d been on stand-by? It might have taken several minutes for another crew to get there.

  Some Munchausen patients make it easy for you to make your mind up: they can be unpleasant and demanding, using the ambulance service and the hospital staff like crutches for their emotional needs and becoming petulant and rude when they don’t get what they want.

  I was working an early shift on an ambulance with a colleague when we received a call to a ‘known’ patient complaining of chest pain. When we got there, we found her in her front room remonstrating with the FRU paramedic who had arrived earlier.

  ‘I want to go to the Royal Free!’ we heard her shout as we walked in.

  ‘The crew will take you to the nearest A&E, that’s how it works,’ replied the FRU medic.

  My crewmate and I accepted the hand-over for this patient and immediately got embroiled in the argument she was currently running with the FRU guy.

  ‘I have chest pain,’ she said, almost stamping her feet. ‘I have a heart problem and I want to go to the Free!’

  The Royal Free Hospital was a long way off compared to the nearest, which was University College Hospital (UCH). Unless there is a clinical reason for us to divert to a particular care centre, we must - for very obvious reasons - take the patient to the nearest one if it is an emergency call.

  ‘If you have chest pain, we have to go to the nearest hospital,’ my colleague said. ‘I’m afraid you can’t just demand to be taken to one of your choice.’

  I got the impression that the woman was an old hand at this, and that the arguments she was perpetuating had been rehearsed and used many time before on different crews - crews who had perhaps relented and taken her where she wanted to go. My colleague was becoming exhausted with the fight.

&n
bsp; ‘Look,’ he said. ‘Why don’t we get you into the ambulance, check you out properly and then we can decide on where to go. Is that fair?’

  I thought it was very fair and the loud woman calmed down and agreed.

  We took her out to the ambulance, checked her ECG, gave her pain relief and prepared to go to hospital. We never mentioned which one she would be taken to and I drove to the only hospital that was an option - UCH.

  All the while, she flopped and rolled around in the back, determined to make us realise she was in pain, despite the analgesic gas she had been taking. She could have won an Oscar, honestly; unfortunately for her, she was so caught up in the role that she didn’t notice where she had been taken as we wheeled her into Resus.

  She moved from the trolley to a cubicle bed, looked around, blinked a few times, and then recognised a few people (nurses she didn’t like).

  Furious, she started screaming at the top of her voice. ‘This isn’t the f**king Free,’ she yelled. ‘This is the f**king UC-f**king-H!’

  On and on she went, suddenly and miraculously cured of all that chest pain. Finally, realising she was getting nowhere, she tore off her blanket, threw away her oxygen mask and stormed out of the hospital. She turned right, realised that was the wrong way and did an about-turn. We watched as she walked back past the glass doors with a finger raised in our direction and out into the cold morning air. She still had her nightgown on.