A Day in the Life of a Paramedic

The news is full of reports about ambulance delays outside hospitals, and the job I left in January was very different to the job I started 8 years before. I have spent literally hundreds of hours caring for patients, some of whom were critically ill, inside the ambulance parked outside A&E. Over the last 3 years since lockdown, finishing on time was a rarity, and you counted yourself lucky if you got a break.

But every so often, a shift would surprise you. You’d need all your skills, move from proper job to proper job, and feel like you had made a difference. Those shifts reminded you why you’d signed up to be a Paramedic in the first place. This was one of those shifts…

Patient 1 - Alcohol dependent. Mid 40s, European male. 


My superpower as a Paramedic was the ability to smell ketones!  


Ketones are a chemical released when the liver breaks down fats and they smell sickly sweet, a bit like pear drops. They’re common when someone has high blood sugar, but only 60% of people can smell them. The presence of ketones is a sign of a condition called Diabetic KetoAcidosis - you can look that one up! But my super sensitive nose didn’t let me down and as soon as we walked into the house I knew what we were dealing with.


The patient had had his pancreas removed due to alcohol abuse and knew that his blood sugars were getting high 4 days before. It wasn’t the first time it had happened. Symptoms classically match the body’s efforts to get rid of the sugar any way it can… vomiting, sweating, drinking fluid, peeing excessively, diarrhoea - you get the picture!  He lived no more than a 10 minute walk from the hospital but hadn’t thought to make his way there over the 4 days he’d been ill.


Our kit allowed us to measure ketones and it confirmed what my nose had told me - his were dangerously high. We cannulated, got on the vehicle and alerted the patient to Resus on blue lights. 


We don’t judge, but there’s always a little surprise that someone with a chronic condition, who recognised a flare up, didn’t seek help sooner and ended up more seriously ill than they needed to be.

Patient 2 - Alcohol dependent. Early 50s, British female.


I had been to this patient before and our first clues as to what was happening came from a disgruntled neighbour (who had made the 999 call) who expressed frustration about regular police visits to the property, plus a front door that had signs of recent forced entry by the police.


Inside our patient was lying on a sofa, intoxicated. The duvet and sofa were soiled and the patient was unkempt. Straight away, the patient was abusive towards us. She hadn’t called for help, didn’t want us there and made it extremely clear that she didn’t want to go to hospital. But we have a duty of care. 


She refused all observations, though just from talking to her we knew she had a patent airway, was breathing, had a pulse and so nothing needed to be done immediately.


That said, the state of the property and patient indicated a fairly advanced stage of self neglect. The patient stated that she couldn’t walk - this is a red flag for the ambulance service as someone must be able to look after themselves if they remain at home. They must be able to get food and drinks, go to the toilet and be able to get out of the house in case of a fire. There’s also the issue of capacity because patients must have mental capacity and be able to make an informed decision about their care. 


A discussion ensued! We stated our intention to take the patient to hospital. We stated that as she was intoxicated and could’t walk, she had to go to hospital. The patient refused, but also refused to prove that she could walk. Despite our best efforts she still refused and the situation persisted for a significant time.


Though intoxicated, a lack of capacity isn’t a given, but it can complicate the issue. So we carried out what’s called a ‘functional test’. Our diagnostic test confirmed that the patient did have an impairment of the function of her mind or brain (due to being intoxicated). But the functional test goes into more detail.


Firstly, we gave the patient details of the reasons that we believed she needed to go to hospital - including self neglect and being unable to walk. Sometimes it’s necessary to be quite brutal in advising the patient and telling them that if they stay at home it could be a fatal decision. She stated that she understood the information.


The next part of the test involves the patient retaining the information and fully understanding it, in order to make an informed decision. Finally, the patient must prove to us that they have weighed up the information, come to that informed decision and communicate that back to us in their own words.


In this case, the patient did pass the test. Once she realised that her being able to walk was the deciding factor, she jumped up and walked to the kitchen and back with no difficulty at all. So, we made the decision to leave her at home. 


But our responsibility didn’t end there and we advised the patient that we would be completing a safeguarding report due to her self neglect. This report flags up a patient to Social Services and other agencies with the aim of providing support short or long term,  when hospital isn’t the right answer and isn’t the only answer.

Patient 3 - Alcohol dependent. Mid 40s, European male. 


Again, I had been to this patient before. As we walked in, the patient shouted to us from upstairs and his wife led the way. The patient was intoxicated and rolling around in bed. He suffered from pancreatitis and had been on an alcohol binge for a few days. Not surprisingly, his pancreas didn’t like it too much and flared up!


From the get go, the patient was abusive. We were repeatedly sworn at and despite his pain, he hadn’t thought to take any pain relief. We gave him some paracetamol - we use a stepwise approach to pain management and that’s the first step in most cases. 


Again this patient lived no more than 10 minutes walk from the hospital and in reality, could have made his own way there. But we told him we would happily take him and went downstairs to get the vehicle ready. At this point the patient turned around and said ‘you’d better not be taking me to that A&E place’. Which is fine, except it’s not like there’s anywhere else that we could take him. We explained the situation but he didn’t like it. 


The level of abuse increased. Fists were shaken in our direction and the patient told us to ‘xxxx’ off several times. His wife (who I felt sorry for) apologised for his behaviour. The patient refused to calm down and shouted that he wasn’t coming with us if he had to wait in A&E. When his brother joined in the abuse, we decided enough was enough, gave the patient one last chance to come with us, received more abuse for our trouble and left the property.


Sadly this kind of abuse (and worse) of Ambulance crews is pretty common and we were annoyed but not that worried by his behaviour. We reported the incident back to control and went to the next job.

Patient 4 - Alcohol dependent. Early 20s, British male.


There were two main issues with this job. 


1) The police should have been there but weren't. 

2) The caller gave a cover address - the incident was actually down a narrow, unlit alley opposite to the address and at the back of a property known to be a drug den.


The job came through as a stabbing with a neck injury and knowing the area, we suspected the worst. But on our arrival, the house was in darkness, with no one around. My colleague got out of the vehicle and was approached from the alley by someone claiming to be a cousin of the patient. She advised us that he was down the alley and was seriously hurt. But he was armed and we shouldn’t go near him as “he's very dangerous”. She also advised us that the attacker was still on scene. 


Our spidey sense immediately went into overdrive. We instructed the cousin to bring the patient to us and told her we would park around the corner. Police were requested. We moved our vehicle, locked ourselves in the back and got out all of the trauma kit and drugs we thought we’d need.


A few minutes later, we heard voices outside and opened the side door. A bloodsoaked patient was shoved inside, and our manager who’d just arrived, followed on. We locked ourselves in again. There was a lot of blood and the patient was holding a soaked tea towel to his neck. We got the patient onto the stretcher and the 3 of us got to work. The patient had a number of superficial wounds around his neck and had lost the top of an ear. But he had a deep laceration to his jugular vein. We couldn’t really pack the wound and it had mostly stopped bleeding, so we scrunched up some haemostatic dressing and the patient held it pressed into his neck.


But there was blood coming from somewhere else. The tuff cuts came out and an arterial bleed on his leg was located and swiftly dealt with. Blood pressure was low. The patient was cannulated, TXA started and fluids set up.  The patient wouldn’t give us any information other than a first name and that he was alcohol dependent. We left the scene, leaving the manager's car there. The police still hadn’t arrived. 


From the time the manager and our patient arrived at the vehicle, to the time we left was just SIX minutes! It felt like 6 hours.


With the patient safely in hospital and the ambulance cleaned up, we took the manager back to the car. The police were now in attendance and had made an arrest for attempted murder. Over the next few days statements were required and we had time to reflect on the job. Thankfully we had all stayed safe, but arriving on scene with no police, a patient so dangerous his own family advised us not to go near him, weapons and an attacker still on scene… we knew we’d been lucky and that it could all have ended very differently for us and the patient. 

Patient 5 - 100 years old, British female.


After all that excitement, we had a long drive to the next job, a 100 year old lady in a care home. Staff had called us as she had complained of some neck pain. But we quickly established that she’d had a neck problem since childhood and sometimes it was painful if she slept on it the wrong way. She wasn’t in any pain by the time we got there and to be honest, she didn’t really need an ambulance.


But we did all our checks to rule out any injury or illness, while the staff made us cups of tea and we enjoyed watching the sunrise, chatting to the lady about her fascinating life. A total contrast to the chaos and stress of the previous jobs that night, and a job that really renewed our faith in human nature. It was an honour to meet this lady and learn about her 100 years on the planet.


And I guess that’s it in a nutshell! The variety in the work of a Paramedic was one of the things I valued and enjoyed the most. There are few jobs where your shift can literally take you from birth to death, one patient to the next. Did we save any lives that night? Probably… Did we make a difference to anyone’s life? Maybe…


All in all, that shift highlighted some of the issues of alcohol and drug abuse in the UK. Four out of five patients were alcohol dependent and the attempted murder was drug related. We were verbally abused and physically threatened. It sounds dramatic, but we risked our lives to save someone else's. Being part of a team to get through a shift like that is a bonding experience. But at the end of the day (or night in this case!), we had the privilege of spending precious time with an incredible, 100 year old lady who I’ll remember forever!

Go on....give it a share.....

The Recovery Position - an STCW refresh

by Rachel Smith • 18 December 2024
Welcome to our December blog, which is all about the recovery position and how to manage an unconscious casualty who is breathing normally. Unconsciousness is a medical emergency as the person is very vulnerable and may not be able to manage their own airway effectively. We also need to think about the cause of unconsciousness. Is it a simple fainting episode due to illness? Is it a massive hemorrhage causing hypovolemic shock? Or is it due to some kind of external factor or injury? This blog looks at how to manage an unconscious casualty. So, if we have a casualty who is unconscious, but who is breathing normally for themselves, and we’re not suspecting a serious injury, the recovery position is the best position to use while monitoring them. The recovery position keeps their airway open and makes sure that vomit or liquid won’t cause them to choke.

Revisiting our guest blogs

by Rachel Smith • 11 December 2024
All the guest blogs! When we started adding blogs to our website back in early 2021, we did a little feature on each of our instructors of the time. They’re quite a fascinating bunch and the series proved quite popular amongst our followers. In addition to our amazing instructors, we work with some utterly incredible human beings all over the world, and the idea of sharing their stories grew and developed into what eventually became a monthly guest blog. It’s been interesting to find out more about how medical care at sea or in remote locations features in their work, and to discover a few fun facts along the way. This month, we thought that it might be a fun idea to give you a chance to go back into the archives and review all the guest blogs over the last few years! Maybe even let us know which your favourite one is?

Cayman Maritime Report 2023

by Rachel Smith • 27 November 2024
We’ve taken a look at the 2023 Casualty Summary Report from the Maritime Authority of the Cayman Islands (MACI) to see what kind of incidents and trends their data shows us, even with relatively small data sets, and how this may be able to transfer to our own risk assessments and actual practice. You can find the report here: Cayman Maritime Report 2023 The first thing we noted was the authors note that the data is split out into incidents. This means that one incident may include a number of events. So a collision and any resulting injury is one incident, but is reported as two events, or more, if more than one person is injured. It made us wonder whether this method of reporting by an authority represents how incidents are reported onboard and whether it should be a consideration? Of course, for any set of statistics presented at the moment, we also have to consider the COVID-19 pandemic and the impact this has on trends including that period. While essential shipping continued, the cruise and superyacht sectors reduced activity and staffing, often to a skeleton crew while anchored somewhere. So this will be reflected in the historic data sets that we analyse from 2019 to 2021 and may not accurately reflect increases and decreases during and since then. In some situations, we may need to look further back for accurate data. We also need to consider whether increases in incidents and events is also down to increased reporting - suggesting an improvement in the awareness of reporting requirements and greater engagement from the industry and individual sectors - this can only be a good development. Since 2020, the type of injury has been recorded in 8 different categories, with hand and foot injuries topping the leaderboard, closely followed by head, body, and back injuries. So if you were looking to run drills, or practise medical skills, these would be the key areas to cover. Only one death was an occupational accident, and is being investigated here: MAIB Investigations (search for case #9229607). It relates to a fall down a ventilation shaft on a bulk carrier in a Greek shipyard. The full report was still pending at the time of writing. Merchant ships are heavily regulated by a number of authorities, and the requirements for personal protective equipment and safe systems of work are enforced and applied to reduce accidents and incidents onboard. This has led to a lower reporting of incidents than in the commercial yacht sector. Could there be room for improvement here in this area? We certainly think so. Many of the hand and foot injuries reported can be career ending or life changing, but are preventable. Follow up has shown that there is a link here with injuries being sustained when inappropriate or no PPE was used. The supply and use of appropriate PPE is mandatory on vessels subject to the MLC and it’s worth remembering that some PPE can be produced in styles and designs compatible with the aesthetics of a yacht if required! On a much wider scale, a lack of transparency and standardisation globally can affect the collection of data and the issue of under reporting. While the MACI figures may be accurate, we need other accurate figures to compare them to, in order to build a bigger picture across the world as we have in aviation. From December 2024, the Maritime Labour Convention (MLC) will be enforcing an amendment so that seafarer deaths will be recorded and reported annually. The MACI and Cayman Islands Shipping Registry produces a number of safety flyers that are publicly available HERE that may be useful. In summary, analysing data can sometimes result in more questions than answers. But even this can lead to interesting and important developments that result in improved safety and reduced incidents and accidents onboard. Key points to take from this report are: Use the correct PPE for the task. Employ approved systems of work and risk assessments for the task. Reporting is key for safety in the future of our industry. Enjoy a night ashore, but don’t over do the cocktails! As always, if you’d like any input on medical training onboard or ashore, or drills that you can run yourselves, please just get in touch. References: https://www.lloydslist.com/LL1145359/Increase-in-incidents-of-deaths-at-sea

James Griffiths - Guest Blog

by Rachel Smith • 6 November 2024
Welcome to our latest guest blog where we’ve been chatting to James Griffiths, General Manager of Ocean Operations for Scenic Group and finding out more about what happens behind the scenes in order to keep a fleet of luxury expedition ships running. Here’s what James told us… As General Manager of Ocean Operations, I’m responsible for the operations of our fleet which includes four ships in service with around 850 colleagues. I currently live in Mumbles, near Swansea in the UK, but due to the nature of my work I spend a significant amount of time living in Croatia. Prior to this role, I spent many years working at sea and worked up through the ranks to Captain and over the last 15 years, my main focus has been on polar expedition travel. I hold a master mariner certificate of competency in addition to a degree in engineering and a post graduate diploma in law. Part of my job is to work with our medical service provider (Red Square Medical) to ensure that our ships are offering medical services that are appropriate for their deployment, and this can often be to some of the most extreme and remote locations around the world. It’s extremely varied, though during the COVID-19 pandemic, I came ashore when our operations paused for a significant period of time. I was fortunate enough to be given the opportunity to lead the restart of our Ocean Operations, which included setting up everything from a company to manage the ships, to selecting our crewing, medical, helicopter and submarine partners and providers, amongst many other things. Our areas of operation, and the nature of our cruises (expedition), plus having aircraft and submersibles onboard some, do mean additional elements involved in the management of these ships. You could say that this current position is more of a happy coincidence than one that I actually planned for! In some ways this is a great positive - I do think it’s possible to plan a little too much and then be disappointed if things don’t go quite the way you had imagined. But there’s no danger of that here!

Paramedic on tour - Simon Lawton heads to Mexico

by Rachel Smith • 3 October 2024
Back in February 2022, we brought you one of our very first guest blogs from Simon Lawton, a Paramedic who has swapped out his ambulance for a Superyacht! You can read the original blog here: https://www.redsquaremedical.com/superyacht-paramedic-a-guest-blog-from-simon-lawton Over the last 2+ years, we’ve followed Simon’s career, and some of you may even recognise him as he does put a Red Square Medical instructor hat on from time to time. But, as for all healthcare professionals, Simon has to keep his skills up to date. So, we asked him to tell us a bit more about how he juggles this along with a rota onboard. Here’s what he told us… I’m originally from Stoke-on-Trent in the UK and trained as a HCPC registered Paramedic. I’ve spent almost 5 years working at sea now, with almost continuous employment on three different vessels, after leaving the ambulance service in 2019. My first role was as a Paramedic/Deck hand on Superyachts, and I now work as a Medical Officer on a maritime vessel. Even before I applied to become a Paramedic, I intended to complete my studies to help find employment in a remote or offshore environment. I had always been attracted to the idea of being able to travel the world while earning a salary. Working at sea has meant that I have travelled extensively, earnt a higher salary, and have a better work/rest balance than would be possible in a role on land. Note: At the time of writing, a qualified Paramedic’s starting pay in the UK was £28,407 and Simon’s old rota was 2 days, 2 nights (all 12 hours) and 4 days off with very inflexible annual leave. This year I decided to carry out some continual professional development (CPD) at a hospital in Mexico, to keep my skills up to date. I was interested in travelling to find out more about how healthcare services are provided outside the UK and Europe. The CPD activity in Mexico allowed me to do exactly that, while caring for and treating a wide variety of patients who had either self-presented in the emergency department, or been conveyed to hospital by ambulance.

Inequalities in CPR on Women

by Rachel Smith • 25 September 2024
Welcome to our September blog, and as we all start (in the UK at least!) to think about adding a few layers for warmth, we’d like to talk about getting naked! Well, to be more specific, getting bra’s off. Fact: Women are dying because bystanders are less likely to carry out CPR on women than men. Research shows that women are 27% less likely to receive CPR than men and if a defibrillator is used, their chance of survival is affected by bra’s being left on. Most of us have never had the chance to train using a female manikin. The #BraOffDefibOn campaign aims to address the inequality in CPR for women and we’re supporting it.

Dr. Will Duffin - Joint Medical Director WEM

by Rachel Smith • 4 September 2024
In August, we brought you a Guest Blog from Mark Hannaford, the founder of World Extreme Medicine. This month, it’s the turn of another of the key WEM faculty members… introducing Dr Will Duffin. Hello everyone, I’m Dr Will Duffin and I’m a GP in Devon in the UK. I’m the Joint Medical Director of World Extreme Medicine (WEM) and the Lead Medic for the US CBS TV show ‘Survivor’ - for Seasons 43, 44, 46 and 48, which is also through WEM. Extreme Medicine is healthcare that is delivered across the full spectrum of remote, austere and challenging environments. This includes high mountains, deep oceans, jungles, deserts, polar, low earth orbit and refugee camps… the list is endless. Being a part of the wider Extreme Medicine community through WEM has been a portal into new worlds of possibility and opportunity in my medical career as an NHS GP. It’s a huge privilege to treat patients in a remote setting. You get to do proper ‘hands on’ medicine that truly tests your clinical skills, risk management and decision making. Even basic techniques and principles done well can transform patient outcomes. That’s the big reward. I graduated from Bristol Medical School in 2008 and completed my GP Training in Cornwall, UK in 2016. In between, I spent 18 months in Australia to gain as much emergency department experience as I could, whilst doing Wilderness Medicine Courses. I landed my first expedition gig 12 years ago when I was post-FY2 (Foundation Years follow on after qualifying as a doctor). I covered a Kilimanjaro Trek after another doctor dropped out at the last minute. Once I had this under my belt, I was able to leverage this experience to get the next trip. So, I soon found myself providing regular medical cover for various commercial and charity sector expeditions. These expeditions have taken me all over the world: Kilimanjaro, the Peruvian Andes, the Himalayas, Northern China, Eastern Europe, Myanmar and Madagascar. One highlight was working as the private doctor for a Luxury Trans-Siberian Train! Though I became frustrated having to constantly wrangle annual leave to go away, so I made the switch to being a freelance (locum) GP, which has given me the flexibility I need. I joined WEM in 2018 after responding to a Facebook Ad for the ‘Survivor’ job. I was invited to a selection weekend in the Peak District, which is when I first met Mark Hannaford WEM founder and CEO and Dr Joe Rowles, WEM’s other Medical Director, and it all went on from there. Early on, I was given the opportunity to lead on the content for the annual World Extreme Medicine Conference and our various podcasts and webinars. Through doing this, I have met a colourful cast of characters; other extreme medics who are as audacious as they are inspirational! We have a lot of fun at the conference every year, learning from one another. https://worldextrememedicine.com/registration/wem-conference-2024 (Note from the RSM team – the conference is highly recommended and well worth a visit!)

Mark Hannaford - Founder and CEO of World Extreme Medicine

by Rachel Smith • 5 August 2024
Last year, the Red Square Medical team descended on the World Extreme Medicine (WEM) conference for the very first time. We’d been aware of this unique organisation for many years, but just not had the chance to get involved. Liz was involved in a panel discussion and spoke at the conference, and we came away literally buzzing with enthusiasm - our first impressions were that WEM is a place with no ego’s, where everyone wants to learn, and is willing to share. We met some of the most fascinating people ever and can’t wait to go back this year. But what about the person who started it all… We spoke to Mark Hannaford, founder of World Extreme Medicine and its far reaching impact. Here’s what he had to say. I’ve been involved in expeditions, working in low resource environments and extreme medicine for the past three decades! My family was made up of generations of seafarers from Cornwall although I was brought up variously in Devon, Antigua in the Caribbean and the Middle East; reflecting my father’s job as a Master Mariner. My father was at one time the youngest captain aboard the UK’s largest registered vessel, and my grandfather was Harbour Master for Malta and the first in that role in Plymouth at the start of Queen Elizabeth’s reign. I wear a number of hats but primarily I am the founder and CEO of World Extreme Medicine, and the annual WEM Conference. I also founded the MSc in Extreme Medicine at the University of Exeter and Graduate Certificate program at Bouvré College of Health Sciences, Northeastern University, Boston.

Women's Health

by Rachel Smith • 3 July 2024
Women’s health is a huge topic, while it’s true that in the maritime sector women make up just 2% of seafarers at sea, up to 34% of the shore based staff are female. Looking at the bigger picture, women’s health directly affects just under half of our population globally, and indirectly (whether you like it or not!) the other half, we thought it was worth a blog about some of the issues, and the taboo’s, that could be affecting our maritime workforce and the women in our lives. It's common knowledge that women experience huge hormonal changes at puberty and menopause, both of which can have significant physical and mental health impacts. In the UK, there is a growing discussion and openness about peri-menopause (the years before periods stop altogether) and how for some women, this has devastating effects across all aspects of their lives, including work. Of course men experience changes at puberty, but their later life changes are less significant and generally don’t affect their ability to work. In December 2023 the World Health Organisation (WHO) issued a statement to advise that every year, at least 40 million women are likely to experience a long term health problem caused by childbirth. So there’s a good chance that we all know one or more women affected, or if you are female… this could be you. As part of a special series on maternal health, the study showed a high burden of postnatal conditions that persist in the months and years after giving birth. These issues include more than a third of women experiencing pain during intercourse, urinary incontinence (8-31%), anal incontinence (19%), anxiety (9-24%), depression (11-17%), perineal pain (11%), a fear of childbirth (6-15%) and secondary infertility (11%). All in all it doesn’t paint a great picture of life after childbirth for some women. If any of your workers experience these issues, either on or off shore, it could have a significant impact on areas of their working life and it’s something they may be reluctant to open up about. Even before childbirth, we may take it for granted that contraception is available, certainly in the developed world. But in developing countries where sexual violence is not uncommon, contraception is considered lifesaving due to the high level of unsafe abortions carried out. Around 13 million women (and girls) under 20 give birth annually and complications in the pregnancy and birth is a leading cause of death. Consequently abortion is an option, but this carries its own huge risks.

Guest Blog - Wendy Sullivan

by Rachel Smith • 25 June 2024
We just love speaking to and finding out more about the people who inspire us and we guarantee that this month’s blog will not disappoint! We first got in touch with Wendy Sullivan via LinkedIn and thought she seemed like a pretty awesome human. Wendy and her company, Maritime Medical Solutions in Australia, certainly share the same outlook as Red Square Medical. Fast forward a couple of years and we’re now collaborating on a project in Australia and the Pacific Islands. What we’ve learnt along the way is simply fascinating and Wendy has kindly agreed to share her story with us… Here is Wendy’s Guest Blog: I was born in Canada, grew up in Africa and now call Australia my home. I feel lucky to live in paradise where the weather allows us to be on the water year-round. I had to work hard to gain my Australian citizenship and I credit my work in the marine industry with giving me a pathway to stay in Australia permanently. It took years of hard work and uncertainty to gain my residency and is still one of the achievements I am most proud of. I started sailing in Canada and since emigrating to Australia gained my professional and commercial qualifications as a vessel master, marine engine driver, trainer and assessor. I also have a Diploma of Paramedical Science, ship masters medical qualifications, business administration and development and there is still so much more to come.
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