Confessions of an ER Doctor: Death, Dangerous Patients, and Lives Saved
There are many questions for domestic medicine, as well as claims that every second person expresses at any convenient or inconvenient occasion. Often, dissatisfaction with the work of an ambulance slips among them, but few people think about how it looks on the other side - through the eyes of doctors. We talked with one of them about why people do not want to go into medicine, how many false calls are received per day and what to do with dying patients.
About career
I've been in the emergency room for over 20 years. We have a local division of teams: linear, pediatric, cardiological, resuscitation and neuropsychiatric. I started as an orderly on the line, then switched to cardiology, became a nurse, returned to the line, became a doctor - and again switched to cardiology.
We are still working as an intensive care team - in principle, it replaces everyone except neurologists. We travel both to ordinary patients and to various accidents and mass road accidents. Usually there are two or three people in the crew plus the driver.
I can say that a huge percentage of doctors who are now employed in various fields started with an ambulance. If we take the third city or regional hospital, then many local specialists have gone through this school.
Most often, students come here as a temporary job - it has its own exoticism, you can learn something, for example, make decisions quickly. And the schedule is more or less free, not tied to a place. It used to be that way.
I stayed in this service a little longer than others. They call me to the hospital, but I don’t want to leave - I like this job.
About problems
Recently, the number of calls has been growing, the intensity has been increasing, but the number of brigades has been declining. Previously, there were 10 teams per 100,000 people, and now there are about seven teams for the same number of patients.
At one time, it was believed that the norm for a cardiological team was eight calls per day. Now 10 calls are already considered an "easy" day, 12 is an average number. Basically there are 14-16 trips per shift. Additional load is not paid.
Because of this, not everyone wants to work on an ambulance, and there are fewer and fewer of us. Now there are doctors whose average age exceeds 40 years. There are very few young doctors. The problem with the medical staff in the ambulance is in the first place.
About calls
There is an unspoken order that all calls are recorded and an ambulance leaves for them. That is, we do not have the right to refuse, even if help is not actually required. Theoretically, this should be determined by a dispatcher who has a secondary specialized medical education - he is a paramedic with the highest category. Of course, I don’t like it - riding in vain, some kind of stupidity, but what can you do.
Calls can be conditionally divided into those that require assistance, communication with the patient, those that are refused and cases where the patient was not found. Well, for example, compassionate people call and say that somewhere a drunk man has fallen and is lying. We arrive and he is gone. Well, or he is, but sends us far, far away. You can’t even leave him, because another grandmother, passing by, will call us again.
The police in such situations arrive later, and sometimes they call us to determine the severity of intoxication. Here sometimes it comes to scandal. Recently there was a situation when a major called us, we arrived, made a conclusion and left. After a while, he calls again and says that he will not pick up a person, because he cannot reach the car. Passers-by have already helped there, who brought the peasant to the police "bobik". In general, we do not conflict with other services, because we work in conjunction with the Ministry of Emergency Situations, the police, and the traffic police.
Now there are many patients who cannot go to the hospital. Due to queues and initial appointments, it is sometimes possible to get to a therapist only after a few days. I believe that this is the scourge of domestic medicine, when people do not have the opportunity to immediately go to the clinic and they have to wait. But the fact is that there are fewer doctors, and more paperwork. And we are called by such patients who think that the arrival of an ambulance can replace the initial appointment with a therapist. This is wrong.
There are many false calls - several dozen per day. A large percentage is an overdose of drugs, but while the brigade is driving, many call and cancel the call. Also, these are people on the street who fell somewhere. Recently there were three calls in a row, we accompanied a woman who was walking home and falling at every corner. And people called us every time. As a result, we reached her entrance, and she refused to help.
Very often grandmothers suffering from loneliness call. They also need help, but psychological. As a rule, they are abandoned by relatives and children who come once a week at best. And they also need communication. Worse when they call us at night. They say: "I'm afraid to stay with my sore at night." She endured all day though. It's like being scared to die at night. In such cases, we also come, of course. You will say two or three kind words, you will measure the pressure - and it seems that the tonometer cured her, it became better.
About violent and strange patients
As a rule, the most violent patients are people in a state of intoxication. Even drug addicts treat doctors more calmly. In drunks, the stage of excitation is more pronounced. They sometimes have to swear and conflict. But if you build a conversation correctly, they quickly calm down. There were also fights with such comrades, but, frankly, I don’t want to talk about it.
But I can't remember any strange calls. Situations when, say, a person puts a light bulb in his mouth on a dare, are quite common. Or when someone gets a burn of the whole body in the bath - too, although it seems wild. Just breaks the taps and the person is scalded. There are three or four such cases a year.
There are, of course, hypochondriacs who call an ambulance for any reason. As a rule, all brigades already know them. Some addresses I remember by heart.
Of course, there are those who really have some kind of serious illness, but they also call an ambulance for every trifle. That's what's bad: you come to a person six or seven times in a month, and on the eighth, knowing in advance that he has nothing, you can really miss the real problem if it suddenly appears or worsens. This also happens. Of course, both doctors and patients are to blame here. The first - because they reacted carelessly, the second - because they do not want to be treated normally and panic about every occasion.
About the traffic situation
Recently, drivers have become more loyal to ambulances. By the way, imported cars pass more often than our UAZs. The logic of people is clear: if a UAZ is driving, then this is most likely a linear brigade, the patient can wait. Although this is not true, because a general-profile team can also carry a seriously ill patient.
Rudeness happens, but rarely. There were cases, of course, when you had to get out of the car and say that they gave way. Most often, such situations occur with taxi drivers who drive into the yards, and then they need to turn around, they don’t want to take a couple of entrances back to let help through. Literally in the autumn it was like this - we could not part with the taxi driver and went to the right house on foot.
About death
Death is a common thing to deal with. Several times a week, sometimes per shift. Deaths are also different - both before the arrival of the brigade, and with it. In the first case, these are either clinical patients or patients with sudden acute illnesses who came to the ambulance late. It also happens that doctors do not have time to get there. But more often than not, people turn up late. While others call doctors for every trifle.
There is also such a thing as "predictable death", when you know that the patient will die soon - it's easier. But there is also a sudden one, when even the cause cannot be established, then it is hard.
I don't remember the first time I faced death. But I distinctly remember an incident that made an indelible impression on me. It was about 20 years ago, I guess. A family was driving along the highway - the husband and child were sitting fastened in front, and the wife was in the back seat. During the accident, she flew out through the windshield of her car, and after that the same car ran into her. We managed to take her only to the Crystal Hotel when she died. She had multiple injuries: fractures of the chest, pelvis, base of the skull. Of course, it's better not to remember.
In general, there is such a law that patients must die in the hospital. But older people, as a rule, want to die in their bed. I believe that this is a normal desire - if without suffering, then why not. Perhaps this is correct. My grandparents at one time also refused to go to the hospital and stayed at home.
But here is a double-edged sword: we cannot forcibly hospitalize a patient against his will, but from a legal point of view, a person at such moments is not always able to adequately assess his condition. On the spot it is difficult to determine how sane the patient is. As a rule, in hospitals such decisions are made at consultations. And in an ambulance every time you make a decision at your own peril and risk.
About the specifics of work
Emergencies, when there are more than three victims, or cases with a fatal outcome, do not happen so often, but emotionally, of course, they are more difficult than everyday work. But at such moments you understand why you are needed.
Of course, each doctor decides for himself whether to provide assistance on the spot or quickly take him to the hospital. In the first case, you need to understand that a person will be able to be hospitalized later, quickly assess the risks, weigh all the pros and cons. It is only in films that they show that doctors can do something on the way, but the reality is that, moving along our roads, the patient cannot be helped. If he is already intubated or has catheters, then you can change bottles or put solutions on the go - but that's it.
There is also a kind of burnout - as a rule, such moments occur before a vacation, when you know that you will soon have a rest, and it is already hard to look at patients. It may not be pretty, but that's the way it is. You understand that this is wrong, but you can’t do anything with yourself. You start working like a machine, and abstract from people.
About medical humor
Doctors joke about everything in the world - even about death and about cancer. It doesn't work otherwise. Sometimes, when we return to the station, we need to yell loudly and immediately laugh. It happens in our staff room - it helps to relieve stress.
Doctors have a lot of rude and obscene jokes, but this is the specificity of our work, we can’t do without them. It helps us keep going.
We often see them on city streets. Disaster medicine vehicles or simply ambulances. Few people saw them from the inside, as a rule, these are the doctors themselves and patients. But a reanimobile patient is usually not up to interiors and equipment, if I were alive, and doctors are also reluctant to expose pictures from the inside. But it's interesting.
So let's go inside as a reader. It's better to look now than on occasion.
Here is a car for resuscitation teams. Next is the equipment. 
Lots of light, lots of space. If desired, two victims can be served in the car on the way at once.
Patients get into the car from the rear doors, so let's go from the side. 
The left side of the reanimobile is completely occupied by medical equipment, accessories and medicines. 
All free space is used, for example, there are clamps on the neck on the handrail, an electric blanket hangs on the right. 
The resuscitation monitor connects to the patient and displays information, pulse, heartbeat, temperature and a few more parameters. Seen in the cinema? The cap is put on the finger and the patient is under control. 
An artificial lung ventilation apparatus, it is like an on-board one, but it can also be used autonomously, there are cases when it is necessary to carry out mechanical ventilation to a person blocked in a car.
And at the bottom right is a syringe dispenser. Not all drugs can be administered in a stream and quickly or drip.
A syringe is inserted here and the medicine enters the body at a certain speed. Doctors are busy with the patient at this time. 
Defibrillator monitor. Well, everyone saw him in the movies. With the help of a defibrillator, you can also take a cardiogram. 
Anesthesia-respiratory apparatus. It's also portable. 
Doctors call this device a "one-room apartment" - it costs the same.
Apparatus for artificial ventilation LTV-1200. It can work completely autonomously, does not depend on a compressed oxygen cylinder, like the ventilator above.
The LTV-1200 produces breathing air mixture on the spot. 
There is another interesting thing, a pain stress detector that is still rare in Russia.
The device can determine whether a person is in pain, even if he is under anesthesia, or unconscious. You can connect and see if the anesthesia is strengthened.
Exhaled air analyzer. Almost like a chemistry lab. You can determine what a person has poisoned and what kind of help to provide him.
Intraosseous access system. It is not always possible to inject into a vein. The veins can hide with little pressure, the patient can also be pinched somewhere.
To do this, you can quickly and reliably inject drugs directly into the bone. 
Red resuscitation case, there's a lot of things. 
Everything for injections, everything is at hand. 
There is also an obstetric set, the guys can freely take birth. There are toxicological kits, in case of poisoning, rinse the stomach and so on.
Surgical instruments. Quickly sew, cut, darn. Sets for tracheostomy and puncture of the pleural cavity 
Well, besides that, tires, blankets, cylinders with oxygen, nitrogen and other things, a couple of shelves with medicines, several suitcases of what was not shown. In general, there is a lot of things, but I just do not advise you to use it all! Take care of yourself!
On December 19, Novosibirsk and the NSO regions officially received the keys to new ambulances - doctors showed how the cars are arranged from the inside.
18 new emergency medical vehicles - 9 GAZelles and 9 UAZs - arrived in Novosibirsk at the end of the week, and at the beginning of this week the cars dispersed to their regions. Novosibirsk ambulance station will receive 7 GAZelles. The rest of the cars will go to Bagansky, Barabinsky, Kolyvansky, Kochkovsky, Krasnozersky, Kyshtovsky, Chanovsky, Chulymsky, Tatarsky, Toguchinsky districts, as well as to Koltsovo.
“This is a special federal program to upgrade ambulances… I think that this is just in time - today we see how the load on the efficiency of the ambulance is growing every day. More calls for influenza, SARS, such an epidemic is still suitable. I congratulate the doctors and I hope that they will respond with care and efficiency in relation to people who hopefully dial 03 - they will come and provide assistance, ”NSO Governor Vladimir Gorodetsky explained to reporters after the solemn presentation of car keys to doctors of the region.
Earlier, the ministry said that in 2016, about 21.5 million rubles were allocated from the regional budget for the purchase of new cars. - they want to spend the same amount on new ambulances next year. In total, there are now about 330 ambulances in Novosibirsk and the NSO.
The Minister of Health of the NSO, Oleg Ivaninsky, was asked by journalists how the combination of Novosibirsk roads with their features correlates with the domestic auto industry.
“Very well correlated. It is clear that any car requires maintenance, a domestic car is repaired today much better and cheaper. Mercedes and Volkswagen, of course, break down less, but life is life. We live in an extreme enough climate - yesterday it was warm, today it is already -20, it is always extreme for a car.
But what was in the UAZ 20 years ago and today is generally heaven and earth. Try to stand up to your full height in the UAZ in the old one and work on resuscitation activities here as well,” Oleg Ivaninsky said.
At the request of NGS.NOVOSTI, ambulance doctors spoke in detail about the arrangement of new cars.
Alexander Balabushevich, Deputy Chief Physician of the Novosibirsk Ambulance Station, stressed that all the cars brought belong to class B. “This means that it can be used not only for transporting patients, but also for performing medical evacuation, providing medical care during the journey,” - he explained.
Alexander Balabushevich
Showing the UAZ, the deputy chief physician noted that thanks to the all-wheel drive, the car can be used in rural areas. “On non-asphalt roads, especially during spring thaw and so on – where other cars won’t pass,” he explained.
A mandatory device in the car is a defibrillator-monitor. “It allows you to monitor the [patient's] heart rate while the car is moving, while the patient is being transported,” said Alexander Balabushevich.
The ventilator makes it possible to transport patients who cannot breathe on their own - the device breathes for them. An electric aspirator helps to suck out various fluids accumulated in the body, and a nebulizer compressor is needed for patients, for example, with bronchial asthma.
Also, the machines have an electrocardiograph and the necessary set of tires. “The whole complex of equipment allows us to provide full-fledged modern assistance to any patient in any condition,” Balabushevich assured.
Naturally, each car has a wheelchair, with which the patient is loaded into the car. According to the deputy chief physician of the station, one or two ambulance workers do not need to have great physical strength to cope with this.
A feature of the cars is the so-called evacuation shield (orange, to the left of the gurney). “It serves to transport patients with severe spinal injuries. Moreover, it can be used not only for transportation, but also for evacuation from the scene,” he explains.
Special medical ambulances are used for urgent transportation of patients or providing them with emergency care at home. Vehicles of this category, when leaving for a call, have an advantage on the road, they can pass a prohibitory traffic signal or move in the oncoming lane, without fail turning on special sound and signal beacons.
Linear category
This is the most common variation of ambulances. In our country, for line crews, modifications of ambulance carriages based on the Gazelle, Sobol with a low roof, UAZ and VAZ-2131 SP (oriented to the countryside) are most often provided.
In accordance with international standards, these vehicles, due to the insufficient dimensions of the cabin, can only be used to transport people who do not require urgent medical care. According to European requirements, transport for basic treatment, monitoring and transportation of patients requiring emergency intervention should have an increased working part.
reanimobiles
According to GOST, ambulances for resuscitation, cardiological, toxicological teams and intensive care doctors must comply with a certain category. As a rule, these are vehicles with a high roof, equipped with devices for conducting intensive events, monitoring the condition and transporting the patient. In addition to the standard set of drugs and special devices for linear analogues, they must have a pulse oximeter, perfusors and some other equipment, which we will discuss in more detail below.
In fact, the purpose of the brigade is determined not so much by the equipment of the resuscitation vehicle, but by the qualifications of the personnel and the profile of the disease for which it is used. There are special analogues of resuscitation machines for children, which is a rarity in our country. As far as we know, even in Moscow there is only one such brigade - in the Filatov Children's Clinical Hospital.
Neonatal model for newborns
The main difference between this type of ambulance is the presence of a special compartment for a newborn patient (an incubator-type incubator). It is a rather complex device in the form of a box with opening walls made of transparent plastic. It maintains an optimal stable temperature and humidity level. The doctor can monitor the condition of the baby, the work of vital organs. If necessary, he connects the artificial respiration apparatus, oxygen and other devices that ensure the survival of a small patient. This is especially important for premature babies.
Neonatological ambulances are assigned to special centers for nursing newborns. For example, in Moscow this is City Clinical Hospital No. 13, 7, 8, in St. Petersburg - a specialized advisory center.
Other modifications
Among other medical transport, the following options can be noted:
Classes of ambulances
Depending on the dimensions, equipment and technical parameters, there are three categories of ambulances:
Below is a table that shows the drugs and equipment available on board the ambulances, depending on their category.
| Ambulance crew kit | Class "A" | Class "B" | Class "C" |
| Infusion set NISP-05 | |||
| Trauma kit NIT-01 | |||
| Obstetric set NISP-06 and resuscitation NISP | |||
| Paramedic help kit NISP-08 | |||
| Raincoat stretcher NP | |||
| Wheelchair and longitudinal folding stretcher | |||
| Defibrillator | |||
| Ventilator TM-T | |||
| Device for inhalation anesthesia | |||
| pulse oximeter | |||
| Nebulizer, glucometer, peak flow meter | |||
| Sets of splints for fixing the hip, neck | |||
| Reduced Type Medical Gas Cylinder | |||
| Injection stand |
In history and the modern era, there are cases when non-traditional vehicles, sometimes very original ones, were used as rapid medical response carriages. For example, during the Second World War in large cities, trams often acted as an ambulance. This was due to the fact that almost all road transport, not to mention specialized medical vehicles, was mobilized to front-line sectors.
Along the line of demarcation, also during the Second World War, sanitary trains ran, which can be classified as emergency aid very conditionally. They were entrusted with the obligation to urgently transport the wounded and sick from the frontline zone to hospitals.
In the remote territories of modern Russia (in the taiga regions of Siberia and the Far East), snowmobiles or all-terrain vehicles serve as emergency vehicles. The peoples of Chukotka and other regions of the Far North often use reindeer harnesses to deliver patients. In some regions, both now and in the past, the fastest way to get to the hospital is by water. “Floating” hospitals are used there (boats with motors, boats, motor ships).
In conclusion
In most domestic cities, it is the most popular ambulance GAZ-32214 or 221172. It is these cars that most often go to standard calls, have minimal equipment, and save many lives.
We would like to hope that this industry will develop, especially since its financing has been carried out for several years at the expense of the proceeds from compulsory medical insurance.
The color scheme of ambulances - white with red - was first fixed by GOST of the USSR in 1962.
Since 1968, according to GOST, an orange flashing beacon has been installed on ambulances. Unlike the blue lighthouse (modern "flashing lights"), it did not give advantages over other road users.
The fastest ambulance in Soviet history and among production vehicles was the Volga GAZ 24-03, whose maximum speed was 142 km / h, which is 2 km / h more than the ZIL-118M Yunost special bus with a V8 engine.
In the 1970s, RAF-22031 minibuses were the first to receive a blue flashing beacon on the roof. Similar UAZs (“tablets”), due to confusion with GOSTs, were produced for more than 10 years with an orange beacon.
The fashion to put inscriptions on the front of emergency vehicles in mirror image came from the West. The driver of the car in front could read the inscription in the mirrors already in normal form and give way.
According to the reviews of drivers - ambulance veterans, the most reliable medical vehicles were modifications of the Volga GAZ-22. A run of a million kilometers in 8-10 years was a common thing for them.
The ambulance siren differs in tone from both the police and the fire brigade. Cars such as ZIM, Pobeda and Volga GAZ-22 were not equipped with sirens.
The unified telephone number for calling an ambulance "03" was introduced throughout the USSR in 1965, simultaneously with the emergency numbers of the police and fire department.
