It's cold out tonight. The first real jab of winter. The crowds are back on the streets, though, filling bars and restaurants after the first few sluggish weeks of 2016. A group of girls clatter down Old Compton Street, pulling their collars tight. Watching from the window of the car, it's business as usual in the city.
I'm out on an observer shift in one of London's Air Ambulance rapid response cars. Formed in 1989 as a charity that relies heavily on voluntary donations, its Helicopter Emergency Medical Service (HEMS) work closely with the London Ambulance Service and are dispatched daily – by an on-duty paramedic in its Emergency Operating Centre – in response to incidents of major trauma. When an emergency is too grave for paramedics to stabilise on scene, HEMS are who they call.
As we search for a place to pick up some food, I ask Dr Gareth Davies –medical director for the charity – how attending to major trauma every single day might affect one's perception of the world.
"It's one of the real burdens of this job," he replies in a low half-laugh. "You see danger where others don't. Particularly if you have children; you wouldn't allow them to do anything if you based things on what you saw. In a weekend, you may have two instances where a bookcase fell over and killed a child. Naturally you'll run home and make sure your bookshelves are secured to the wall."
"Or just buy them a Kindle," chips in the driver, London's Air Ambulance paramedic Richard Webb-Stevens.
"It can give you a fairly surreal view on life," continues Gareth. "But the things you see that appear common are actually fairly rare. And in a population of 10 million people, perhaps only five or six patients will actually meet the criteria for a London Air Ambulance dispatch."
Based at Whitechapel's Royal London Hospital, London's Air Ambulance is widely recognised for its daily aerial missions. Their red helicopter and advanced trauma teams played a critical role during the 7/7 bombings, when Davies and colleagues were deployed at all bomb sites, the helicopter ferrying teams and supplies, and helped to treat over 700 patients.
They were also instrumental in treating trauma after the Soho nail-bombing attack in 1999. But at night, they retire the helicopter and medics switch to ground-response cars, on call for immediate dispatch anywhere inside the M25.
We stop at a small, buzzy Indian restaurant. As we queue, I ask more about the nature of their dispatches.
"Most are road traffic collisions," explains Gareth. "The most common being pedestrians hit by other road users – usually cars – but in many cases lorries or motorcycles. The second is patients who've fallen from heights. And the third is penetrating injuries – shootings, stabbings and the like. Occasionally, drownings, hangings... In the end, major trauma tends to be random with very few predictable patterns."
A paramedic seconded to the team sits in the London Ambulance Service's emergency operations centre and filters 16 of the 36 brackets of 999 calls that come through their computers. It's their job to dispatch the team, sometimes further interrogating each call prior to a potential dispatch.
"So what are you listening for to qualify as major trauma? Like, with a stabbing?" I ask from the backseat of the car.
"We're looking for key words: neck stabbings, chest, junctional stabbings to the groin," replies Richard. "There's a slang they use with the gangs down here called 'bagging'. The idea is they'll stab you in the buttocks near the anal hole or the junction, resulting in you having to wear a colostomy bag for the rest of your life. Calling it that can be quite emotive. You think, 'It's a stabbing – dispatch, immediately!' But a lot of them can be dealt with by standard paramedics on scene."
"Or you can listen to an RTC [road traffic collision]," he continues. "With the public you may get around 15 emergency calls for the same event, ranging from 'It's the worst thing I've ever seen, the guy's leg is hanging off,' to finally ascertaining the person is conscious, with no significant injuries and a dislocated patella. It's quite a sticky area, so the questions are extremely rigid.
"One question the ambulance service will ask is, 'Is there serious bleeding?' Now, for me and Gareth, serious bleeding would be literally hosing out blood. A simple head injury can bleed profusely... you don't die – it's rare you'll even go unconscious – but it looks really dramatic to the average person."
As we chat, Gareth's radio splinters into life. It's a call.
After a few seconds planning the route on an iPad, we're pushing 65mph through central London. The car punches through traffic, Zone 1 opening out into motorways and flyovers, a slow swooshing sound as the cars around us shrink into the rear view mirror. A short time later, the car pulls over into silence.
The scene is windblown, sparse and desolate. Out here in the suburbs of Essex there's been a serious traffic collision. Police tape ripples on closed-off roads. There's a scatter of debris, police cars parked at hurried angles and two ambulances sitting in a nearby forecourt.
I'm told to leave my camera and dictaphone in the car as I step into the cold. A young police officer shows me around, highlighting the point of impact and the arc of the collision with broad movements of his arms. Patient details remain highly confidential, but the scene is extremely serious and Gareth and Richard disappear into the back of a nearby ambulance.
Less than half an hour later, after treating and stabilising the patient on scene, we drive back under convoy to The Royal London, Gareth riding in the ambulance.
"I like the humanity we bring with HEMS," says Richard. "You can offer adequate sedation like ketamine to relieve pain, something standard paramedics aren't qualified to do. Ultimately, there's the next step with really serious patients that require surgical interventions. As a paramedic on the road, you can't do those things. But with us, even when we're in the helicopter, it's all about bringing the hospital to the patient, as opposed to the other way around."
As well as their increased roadside capabilities, one thing that makes them different is the technology they pack. They are the first service to carry blood on board in the UK and have developed field-leading technology such as the Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). This small, balloon-like device is inflated inside the body to stop patients bleeding to death from a pelvic haemorrhage, an injury common among cyclists.
London's Air Ambulance carried out the world's first roadside REBOA in June of 2014 and has treated over 34,000 patients since 1989.
"In terms of serious trauma, the average paramedic will see one major trauma per year, whereas London's Air Ambulance will see around five a day. So by the time you've finished your nine-month secondment, you've technically seen about 100 years worth of trauma compared to the average paramedic," says Richard as we pull away from the hospital and back out onto the road.
As we sit for a coffee in a late-night spot opposite Liverpool Street Station a small group of city workers stumble past, balancing a tray of tequilas. The contrast is slightly disorientating, given the last few hours.
I ask what it feels like: hammering through the city under blue lights towards a road or a tube station, aware someone may be moments from death. Or in instances of gang violence, may still be dangerous.
"It's surreal, because I won't get told what the job is," says Richard, the paramedic who drives as the on-board doctor navigates. "You can kinda guess if it's a tube station and I have to put on a stab vest, for example, but the idea behind it is that you don't become emotive in different scenarios and drive differently – that every job is identical."
"And what about the potential for violence on-scene?" I ask Gareth as he sips his coffee.
"There's undoubtedly degrees of tensions. This can be in simple road traffic collisions or certainly in assaults and the use of knives, guns, baseball bats," he says. "For some people the only currency they have to barter for a friend who's dying is to threaten those that are tending to them – 'If he dies, you die' – that sort of thing. You have to have a bit of a sixth sense for when things are likely to flare up, even after they've appeared to calm down."
Halfway through our chat, the radio cuts in. It's a shooting south of the river. We exit the cafe, slip on some Kevlar and Gareth pushes the siren. But a few minutes later, midway over London Bridge, the job is cancelled: the patient may be stable.
This scenario is an extremely common one. Over the previous 12 hours, 3,000-plus calls came through the operating centre. London's Air Ambulance was dispatched to four, with ultimately cancelled as patients were likely stabilised, not as critically injured as initially thought, evacuated onwards to a hospital or died prior to their arrival.
As we head back to the Royal London for the shift change, I recall Gareth's story at the beginning of the evening. Growing up on the Isle of Man and seeing crashed motorcycle riders during its famous TT race lying in the road in need of help is what set the scene and brought him here. And I'm curious of his take on perception versus reality with London's emergency services.
"The public probably feel every vehicle with blue lights flying around is saving lives," he says. "In reality, there are only a small number of jobs where you can try and change someone's life.
"What's sadder, though, is when you get home you may have done many different jobs – from shootings to road traffic collisions – and not one bit of it makes the news. You suddenly realise that much of what happens is normalised in society; that those things are considered fair game. We see the trauma like a disease – like meningitis or leukaemia – we're here to prevent it. And when big events don't get acknowledged, you realise something like that's just not important to everyone."
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