Carnival

More than a million people attended Notting Hill Carnival… I'm pretty sure this doesn't account for the hundreds of first aiders, healthcare professionals, logistics and communications staff and support staff from statutory and voluntary services – of which I was honoured to be one.

Our morning briefing highlighted the unusual nature of this event. Normal practices had been modified or delegated to optimise flow. Other measures indicative of a high capacity day: restricting access; strict triage; somewhat fluid procedures for escalation.

Apart from all that, one of the healthcare professionals assigned to the same treatment centre was a doctor I knew. Some students – medical or otherwise – sometimes have the reputation of sticking to doctors to chase the “interesting” cases. You'll know the type. The kind who displays open disdain for the boring, thinks they know the basics so well they don't do it, openly gleeful when they “find” something “juicy”, as if patients were prize specimens instead of distressed people trying to have a good day. I can't help having my interest piqued by stuff that I've learned on placement, but I consciously try to avoid that – pitch in with the heavy lifting, clean up after myself (not always…), fetch things for other people. Doesn't stop me giving that impression though, because I still ended up in “majors”, the section of the treatment centre which caters for one-to-one monitoring and more in-depth investigations such as ECGs, for most of the night. This was the area for more seriously ill people – yes, for things crassly referred to as “interesting”.

Out from the books (and hospital)

Almost by necessity, I have been learning medical conditions slightly in isolation. We learn about risk factors and start to make links between aspects of a medical history and a differential diagnosis. Rotating between departments, however, means that my differentials are easily restricted to the department I am at. Besides, in hospital, most patients have already been given a diagnosis or, if not, a list of issues.

Seeing truly undifferentiated patients challenges my diagnostic brain, and I'm not very good at that yet. When I saw a patient with pains all over, breathing fast, needing to go to the toilet, I hardly knew what to make of it. In the queue for the toilet, there was another EMT colleague waiting for her patient. She glanced at my patient – waved me over – “Does he have a UTI?” And I hadn't seen it until she suggested it!

Some of this diagnostic overshadowing and my resultant confusion was because I had been expecting intoxication with alcohol and/or drugs, and glass-related injuries. I hadn't been expecting “medical” problems – even though I had learned these for exams. Even if I had seen these conditions in hospital, my differentials would have been influenced by every other doctor's impression and in-hospital investigations. Working outside of these systems means one must have a good grasp of general medicine.

Getting a story

Now I start seeing patients by asking (them or bystanders) “Would you like to tell me the story?” That's essentially what a clerking is: the history of why they've come in, their health and social context.

One lady was carried in (over someone's shoulder, no less) in lots of pain. Another first aider tapped my shoulder, asked if we could do this together, so she did the paperwork while I did the preliminary examination and history. This lady's story turned out to be fairly complicated, so we got her into the area of the treatment centre where we could monitor her more closely, I had a look at what the FA had documented on the paperwork. It was... thorough. Down to who had done what. She also had documented that the patient had gone unresponsive without giving any further detail. In short, the paperwork was a minute-by-minute account of what she had been told.

Documentation is far more useful when it brings the reader through one's thought process. This has not been taught that much on my course, but I've come to appreciate it after reading other people's notes. For me, this reinforces my practice of taking a step back after getting a history to craft a coherent narrative.

“Fun” stuff

Having completed a year of clinical placement, I've been signed off on a number of basic procedures. In hospital, I can cannulate and take blood independently. Because it got so busy, the doctor asked me to do a number of cannulations. I think this was the first time I had cannulated pre-hospitally, too (and thankfully, nailed all of them)!

I realised that while I am proficient at these skills, I still need a bit of finesse. I've been spoiled by the way I was taught, with someone handy to hand me stuff. What I'll try and take from this is to spend more time preparing the kit, and despite the chaos of anything pre-hospital, to spend time to do it right.

While setting up IV fluids, I realised I had to hang up the fluids at height to use gravity. My height… had me at a disadvantage. As much as I enjoyed using my skills, I realised that having another pair of hands is sometimes essential. I can't do everything alone. Sometimes doing things together means it's a lot faster and more comfortable for the patient. It was still weird to be doing these outside of hospital, though.

At the time I was focused on each patient at a time, but realised later that our doctor had been so busy taking referrals (basically), giving ambulance handovers and handling ambulance requests that all this possibly sped things up for patients. An unfamiliar sentiment for a medical student who feels she's being a burden half the time!

On a complete side note

The best moment of the night? Making my patient who had been in terrible pain laugh.

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