Emergency Care Assist.

How bad is bad? 

From the start of February, I can recall the only topic of discussion between my friends and I was the COVID pandemic in China and its gradual spread to the UK. As student health care professionals, we had taken an interest in the UK’s daily infection and death rates and I recall us talking about in in a rather dismissive attitude, joking that it was going to reach the UK and that it would be all that we would see on our upcoming two months of placement. We were finishing our first trimester of 2020 and would frequent a coffee house in the city centre where we would sit for hours at a time, talk all things medical and write our essays. We had been doing this for three weeks and were coming close to the deadline for our essay submission. I recall the first week of us being dismissive and joking that only 30 people in the whole country had it, but everyone was flocking to Tesco and clearing the shelves of paracetamol (as if that would help). The second week cases rose, and we all sensed that this was slightly more serious than we had expected, but still daily infection rates were in the low hundreds. On the third week this had increased, and we were all aware that we were at the starting stages of a potentially devastating national disease outbreak. However, we still joked calling it a “spicy cough” and referred to it like the beginnings of the iPhone game “Plague Inc” truly not knowing how bad this would be. Not knowing the implications on the country and the world. Not knowing how it devastates the body and picks people off indiscriminately.

Towards late February / early March my friends and I travelled up North for personal reasons. It was the day we were set to receive confirmation on whether or not the university was going to permit our upcoming placement. We found out that unfortunately it would not be possible due to the risks to students being too great. We were angry and disheartened by this news. We wanted to get out on the road, develop ourselves and I think deep down we all wanted to experience what all the fuss was surrounding COVID. We could not comprehend why we wouldn’t be allowed to go on placement and essentially be an extra set of hands to help those who needed it. Regardless it wasn’t going to happen, so we didn’t dwell on it. A few days later the news broke that the UK would be going into a nation-wide lockdown with schools and all non-essential places to be closed, including uni. Our next exam was some months away so my mates from Ireland returned home with only myself and a few others remaining in the city. I had recently bought a car and owed money to my family who had leant me some to buy it. Not one to miss out on the opportunity I put myself down for 30+ shifts for the private ambulance service that I work for. I figured I may as well do my bit, earn some money, and keep myself clinically active as my next placement would now not be until September 2020.

My role was that of an ambulance / emergency care assistant (ACA / ECA) with my primary jobs being mundane transportation of patients to and from hospitals for appointments. However, before starting these shifts they were all upgraded to frontline, non-blue light shifts. These shifts were like gold dust to get on (and me loving the frontline work, was not too bothered and if anything, happy that I was to be doing a different role). The main jobs we would go to were category (Cat) 2,3 and 4 jobs (usually GP referrals requiring transport to hospital for further treatment or backing up solo responding NHS clinicians). Every now and then you would get the occasional Cat1 jobs for patients who needed an ambulance immediately due to the severity of their current condition. We would be sent on these jobs when we were geographically closer than other vehicles in rural areas.

My first five shifts were to be as expected, low level medical jobs and transport jobs to hospital. The second five shifts came, this time something was different. (I had a weeks break in between these two blocks to study). I came back to find a mountain of boxes in station, I asked my crew mate that day what these were.

He replied, “It’s all PPE mate”.

I laughed and said “Come on! PPE for what, there must be 20 boxes easily, who needs that much PPE!”

“It’s all for COVID, there’s powered respirators in there too. They cost £800 a pop and we’ve bought 6.”

I proceeded to open the boxes and saw that it was indeed all PPE, hundreds of FFP2 and FFP3 masks, hundreds of aprons, hundreds of packs of antibacterial wipes, and litres upon litres of hand sanitiser (as well as almost £5000 worth of respirator hoods). I remember thinking to myself, sure, we are carrying PPE just in case we go to a patient with COVID symptoms, but we are never going to use all this. I was well and truly mistaken.

It was the next day and another shift had sailed by, two jobs deep and only two hours left. My crewmate and I were sat on station chatting with the other crews. She was supposed to be leaving at 19:00 but had messed up her shift booking so was rostered on until 21:00 alike myself. My radio buzzes and I get a call from the dispatch desk asking me to contact a certain channel as I had been “recognised as a usable asset with a qualifying clinical grade for the purposes of secondment to North East London for mutual aid.”

Mutual Aid – “In emergency services, mutual aid is an agreement among emergency responders to lend assistance across jurisdictional boundaries. This may occur due to an emergency response that exceeds local resources, such as a disaster or a multiple-alarm fire. Mutual aid may be requested only when such an emergency occurs. It may also be a formal standing agreement for cooperative emergency management on a continuing basis, such as ensuring that resources are dispatched from the nearest fire station, regardless of which side of the jurisdictional boundary the incident is on. Agreements that send closest resources are regularly referred to as “automatic aid agreements[1]”.

Having picked my jaw up off the floor after such a scary sounding channel change request, I changed my radio frequency to the requested channel. I was greeted by non-stop chatter over the radio, one message followed by a dispatch response, followed by another ambulance crew request to speak (RTS). I quickly realised that I had been seconded into London from the East of England region as there was a major incident in progress and that I was now on an open channel hearing the 80 seconded resources from the East of England Ambulance Service Trust (EEAST).

All of this was when the Nightingale in the excel centre had been nothing more than a rumour between passing ambulance crews at A&E, so all COVID patients in North East London were being funnelled into North Middlesex Hospital. I began putting the pieces together and had established this:

I’m now on a major incident channel.

There must be a major incident occurring in North East London.

Major Incident – “A major incident is any occurrence that presents serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented.[2]”

They want me to help.

I have two hours until finish.

My crewmate is supposed to be finished now and is getting ready to leave.

I want to help out and see what’s occurring in London.

As my crewmate was leaving, I grabbed a technician who was also about to leave and asked if he wanted some overtime pay by going to go help in a major incident in London, to which he agreed. After explaining this to the manager he allowed for us to help.

My crewmate alike I was very ignorant and oblivious as to what we were walking into (something I now wholeheartedly regret and will change my future practice), so we were looking forward to seeing what all the commotion was about. Not a single concern was raised between us, we were not scared as to what the major incident was, we were task focused on getting into London and getting mentally prepared for what it was that we would be walking into.

On route we got updated. The major incident was that the London Ambulance Service (LAS) was so inundated with calls (primarily consisting of COVID calls) that they were no longer able to adequately and safely able to provide care and ambulance provisions for the North East London, and this was why we had been seconded. I have never seen more than 6,000 jobs in a day, and yet at 19:00 / 20:00 with four / five hours left there had already been 7,500. We were also assigned a job:

Cat2 – 80 year old male, difficulty in breathing, presenting with COVID symptoms.

We progressed to London with the radio still going non-stop and arrived at our first patients house. As my colleague drove, it was to be me who entered the patients house while he stayed in the ambulance’s cab to remain sterile. I donned my PPE: white coverall suit, apron, FFP3 mask, face shield. I entered the house and found my patient presenting with shortness of breath and difficulty in breathing. He looked like any other patient I had been to over my time in the ambulance service that had respiratory infection. After an overall assessment the only problem that was identified was his blood oxygen saturations were low and unmanageable in the pre-hospital setting. Therefore, he needed transporting to North Middlesex Hospital. At this point I still had no concerns for this “COVID mass hysteria” that was going around, I had assumed that the reason for the increase in frequency of calls to LAS was just people overreacting to having cold and flu like symptoms and branding it coronavirus.

Upon arrival to the hospital I was presented with what I can only describe as something from a pandemic film like in “Contagion”. The paediatric department had been merged with normal A&E patients with the normal adult A&E rapid assessment room having been taken over completely by potential COVID patients. There must have been twenty COVID patients all struggling for breath and clinging to life laying on beds. Another ten were sat waiting in chairs, with ANOTHER ten waiting on ambulance beds in the corridors. The penny had finally dropped.

This was a major incident. People were desperately ill. This wasn’t a “spicy cough”. It was an unprecedented, never before seen disease that was like MERS and SARS times a thousand. I was now scared. I now understood the severity of this disease and I was speechless. I had taken off my visor, which had now been put back on and I wished I was anywhere else but in that hospital.

Something that resonated with me after my work was the viral video of the builder inside the Excel centre, showing the sheer scale of the hospital. My realisation was comparable only to his. Once I had seen it first-hand, I believed it and it scared me. I had only been that scared once before in my life. I remember my heart going so fast and feeling that I was going to puke, I had cold flushes followed by hot ones and felt myself sweating at the sudden realisation that I had not only put myself in harms, way but my younger brother, my Mum, and my Dad who has COPD (Chronic Obstructive Pulmonary Disease).

I handed over to the nurse in charge. I could see that she was equally as scared but had accepted what was going on. I pried for information as I now felt exceptionally underprepared for what I was dealing with. I was looking to her for reassurance, but she had none to give. She said two things to me that further re-enforced the severity of this situation. She said, “I have tested positive for COVID and am running a temperature of 39.1 degrees, but, due to all the staff sickness and me being the charge nurse, I have to work, because who else will.” She also had said that “private agency nursing staff were turning down £30-40p/h contracts as it wasn’t worth the risk”. People were turning down almost £500 a day because it was too dangerous. I handed over my patient and went to the reception to book him in, so he was on the hospital’s systems. The horrors continued.

Not only was the ambulance entry to A&E breaching, but also the public access entrance. Receptionists were wearing full PPE, behind glass windows. The waiting room was filled with the soundtrack of everyone coughing. Not like a tickly or a chesty cough, but a cough that was constant and was there to stay. A woman came in shouting for help as her daughter had just collapsed outside the doors. I was like a rabbit in headlights. I threw my paperwork at the receptionist and proceeded to the entrance with a junior doctor who had been tasked with taking the temperatures of the patients who were entering the hospital to help triage them. A young girl no older than 16 / 17 was folded on the floor, her clothes dripping wet from sweat, she was doubly incontinent and was vigorously shaking on the floor whilst vomiting with her eyes rolled back in her head. She was having at the very least a febrile convulsion. The other symptoms I had no idea. All my bandwidth was gone. It had been since I had entered the hospital. We rolled the girl onto her side and ensured that her airway was clear, that she had a pulse and that to some extent she was breathing. She was still convulsing when resus personnel arrived, loaded her onto a bed and wheeled her away. The receptionist had finished booking in the patient, I grabbed the paperwork and bolted for the exit. I met my crewmate who was as pale as I was, he doffed my PPE, and we began profusely disinfecting everything including ourselves. We said very little but were obviously thinking the same thing. We walked around the corner where he lit a cigarette, then another, then another. We jumped back in the ambulance and “greened up”. Instantly another job. Not having recovered from the last one I simply listened to the job, I didn’t even attempt to write it down, only the address:

Cat1 – 40 year old male, difficulty in breathing, presenting with COVID symptoms, has been outstanding for four hours but has now been upgraded due to patient deterioration as they were now unresponsive.

Again, we made our way, this time, not arrogant, not looking forward to seeing what was going on. It was now 23:00 and we had been working for fourteen hours and I had been up for seventeen. We discussed our plan as we made our way. We noticed, for London, a bustling city, the roads were empty, no cars, no taxis, empty busses. Along the residential streets, all the lights were off, but curtains not drawn our blue lights illuminated the faces of whole families glued to their windows which had become the insight into the very beginnings of this pandemic. The universal expression of fear was not only on the faces of the health care workers but the residents and people of London as well. Every house we passed was the same, faces lit up by our beacons, blank fearful faces in every window of every house on every street.

We arrived at the address, curtains twitched, phones were pressed to windows recording our arrival, dressed up like something from CSI. We were unable to gain entry to the flat by pressing the correct flat numbers buzzer. Windows were open on every level with residents staring down at us. We shouted up “can someone buzz us in please” but it fell on deaf ears. They were fixated on us but were not thinking. “Hello, can someone let us in please” we reiterated the need for access in a sterner tone. Still faces staring down at us cameras with their lights illuminating the flat block. “Oi! Someone open the f*cking door, we need to get in now, it’s an Emergency!” my crewmate shouted at the sea blank faces. Finally, a ground floor light turned on and a man opened the window to see what the commotion was – we had evidently awoken him. Without saying anything he ran to his door and seconds later we were in.

We made our way to the flat where we were met with the patient’s wife pacing and crying in the hallway space waiting for us, one of her children asleep in her arms, the older one half asleep holding Mum’s hand. She showed us in and briefed us on what had happened, at the same time we rounded the corner to find a male slumped face first, half on and half off the sofa. He was not unresponsive; he was breathing, and he had a pulse. However, he was breathing at such a rapid rate and was using every ounce of his being to keep breathing that he was unable to verbally respond to us. I won’t get bogged down in the differentials, the complications and the different things that were running through my mind at the time, but what was blatantly evident was that this man was barely alive and that he was undoubtedly “big sick”. My crew mate looked at me from across the room knelt next to the patient. His face said it all. He tried to get the man onto the chair and said “we need to take you to hospital, you’re really not very well”. Between breaths a laboured “no, no hospital” came out of his mouth.

His wife had stated that everyone in the household except for him had had COVID but nowhere near as bad as he has it. He was a type one insulin dependent diabetic. His observations were:

Heart rate – 124 (normal range 60-100).

Respiratory rate – 48 (normal range 12-20).

Oxygen saturations – 89% (target range 94-98%).

Blood pressure – 103/63 (optimal blood pressure 120/80).

Capnography – 6.6kPa (normal range 4.6-6kPa).

Temperature – 40.1 (normal range 36.8-37.6).

12 lead ECG – Sinus tachycardia.

GCS – 15 (4,5,6) all responses were undertaken with a great deal of fatigue.

Pupils – 4mm (normal range 2-4mm).

Blood glucose – 8.9mmol (normal range 4.0-6.0mmol).

Alone from the observations this man was incredibly ill, his heart rate was too fast, his respiratory rate was too high causing his respiration and oxygen / carbon dioxide exchange to be inadequate leading to low oxygen levels and high levels of carbon dioxide building up. He was running a high temperature with a low blood pressure meaning that this infection may have now become sepsis. And worse of all, his inability to eat and administer his own insulin meant he was unable to manage his diabetes.

Again, we reiterated with urgency, plain and simply “sir, unless you come with us to hospital now there is a great possibility that your condition, as well as your unmanaged diabetes, with progressively worsen and there is the potential that you will die.” The gentleman fought over a minute of so in between breaths and came out with “I won’t go to hospital, they will put me to sleep, and I won’t wake up.” We offered oxygen whilst we called LAS supervisors and advisors on what to do but he refused the oxygen. He also would not administer his insulin (a medication we are not allowed to administer on behalf of the patient). We called LAS control and spoke at great length with medical advisors who also urged an emergency transfer to hospital. However, the patient continued to refuse and had the mental capacity to refuse treatment and transportation, to the disbelief of his wife.

We ended up leaving the patient with worsening condition advice and documented everything that we had done. We advised that he get to hospital and if he changed his mind to not hesitate to call 999 with additional advice of taking anti-pyretic medications such as ibuprofen and paracetamol and that he must keep eating and drinking along with taking his insulin. As we were leaving the wife pleaded for us to take him to which we had to explain we could not against his wishes, which he is rightly entitled to in his current cognitive state.

We both left the premises and doffed our PPE. We got back in the ambulance at 02:00 and drove to a nearby off license where we got an energy drink each. We had been working for seventeen hours and awake for twenty, with still an hour’s drive back to our ambulance station and a further hour’s drive back home. We remained silent all the way back. Thinking and repeating over and over in our head what we had just experienced. All feelings and perceptions prior to arrival in London had been destroyed.

I was scared. Truly scared. Scared for my family. Scared for my friends. Scared for London. Scared for the UK. Scared for the patient we had just left to get progressively worse without intervention. Scared that he might not make it past the night. Scared that he would just not make it.

I continued to work for the following two weeks providing mutual aid in London with the same crew mate on a rapid response car. I finished with five shifts outstanding which I had to take off ill due to the amount of scrubbing my arms had been subject to over three weeks, which had caused me excruciating pain and chemical burns to both my arms.

I finished working in London with a totally different perspective to what I went into it with. I grew up and matured just over this three week period alone. I understand the implications of world-wide pandemics, something that I have never experienced since swine flu, where I was too young to comprehend the severity.

I understand the implications it has on people’s lives, whether they are a patient or health care professional.

I still think about my patient, and I wonder about his outcome. I pray he sought medical help and that he is still here today.

[1] https://en.wikipedia.org/wiki/Mutual_aid_(emergency_services) 

[2] https://www.emas.nhs.uk/news/media-enquiries/whats-a-major-incident/