Friday, January 19, 2007

animal welfare

Freighter's Lane may once have served the river that gently meanders a hundred yards at the end of it, when barges toted their agro-industrial cargoes to and from the English Channel, but now its metalled surface is pitted with deep holes; the few, expensive self-build houses off to the right all have four-wheel drive cars, and the dog walkers from the nearby village pick their way carefully.
S. drives the ambulance at a dead slow pace. The chassis rocks from side to side, and the equipment in the back shifts precariously. We are looking for a caravan where an elderly woman has fallen to the floor, query cause. So far all we have seen is an abandoned car chassis lying in a ditch, but S. has a feeling that there is a caravan site at the end of the lane.
Halfway along a driveway opens off to the right, leading to a substantial bungalow in a landscaped garden. Next to the driveway, set back amongst the trees, is a pristine antique caravan, picked out in Lincoln green, with large wooden wheels, a curved roof and a stable door carved with rustic patterns.
'Wow', I say, pulling on my gloves and jumping out of the cab, 'Now that's a caravan.' I climb up the three steep wooden steps and knock on the door. No reply. I try the door, but it's locked. I peer through the little porthole window. Empty. But it strikes me as odd anyway that an elderly woman would be able to live in this. Surely it would be difficult for her to get in and out.
'I didn't think this would be it,' says S. 'I'm almost sure there's a caravan site at the bottom of the lane. I'll head that way, if you get on to Control and ask for more information.'
By the time Control answer, we've made the end of Freighter's Lane, which terminates at a post and rail fence and a stile to the flood plain. We can see a caravan site off to our right, but access to that must be via another roadway. The sky is a vivid blue wash above us, and the air has a salty tang. It's great to be out in the country.
Control tells us that we are definitely in the right lane. They say that they will try to get back to the person that called us, a person out walking, but in the meantime, could we take one more close look back along the lane.
As S. reverses, the ambulance swaying precipitously each time we hit another crater, we notice in the mirrors a man waving to us. It looks to be someone from the bungalow we had passed earlier on, the one with the caravan in the grounds. As we draw alongside him we wind the windows down.
'Hello chaps. I bet you're looking for Mrs Meadows.'
I tell him about our search for an anonymous woman on the floor of a caravan that we can't locate. I tell him that I had a look in the caravan by his driveway as I thought that might be it. The man laughs, and the laugh seems to resonate caustically beneath the rest of what he has to say.
'I can absolutely guarantee that you won't believe me when I tell you where Mrs Meadows lives,' he says. 'We've all been trying for years to get her to move, to get something done. But she's very stubborn - well, crazy, actually. But you see the problem is, no-one seems ready to say that she is actually crazy, and of course that wreck is her registered address, so the whole sorry business drags on. I went as far as buying her a mobile home to live in. I cleared a site here, set it all up. But she wouldn't move and she wouldn't move, so eventually I had to have it taken away. Everyone's worried about her. The neighbours have been very good. We all take her food now and again. But at the end of the day - what can you really do?'
'So - where is she?'
He tells us that Mrs Meadows lives in the abandoned car that we passed at the top end of the lane, the one in the ditch. She has lived there for twenty five years, firstly with a husband, who had mental health problems and who disappeared a little while ago, and latterly with a number of cats. She used to be able to walk to the local shops until a few months ago, but now she is dependent on bags of food dropped off by passers by.
We use the man's driveway to turn around, and drive up the lane to Mrs Meadow's residence.

It is a desperate place. In the nineteen fifties it may have been identifiable as a caravanette, but now it is a blackened hulk. There are jagged, head-sized holes in the sides where rust has flaked away the metal, but the interior is dark and unreadable. What would have been the cab is lodged under a thick bush of blackberry thorns and filled with a sludge of detritus; the upper curve of the steering wheel is just visible, rising like the helm of a ship from the slime at the bottom of the sea. The whole thing is tilted into the waterlogged ditch at an angle. Around the back of the wreck where the door would have been there is now a filthy orange bathtowel strung across. I knock on the metal to the side and call out 'Ambulance. Mrs Meadows?'
I hear a voice inside.
'Can I come in?', and I pull the rag aside.
It takes a moment for my eyes to adjust not only to the gloom, but to the sodden chaos, a full minute before I can disentangle the animate from the inanimate, the human from the animal, the humanity from the neglect. Mrs Meadows is lying on her right side, her shape moulded around on all sides by a foetid morass of damp and unthinkable matter - a black tide of waste that fills this tiny space on a falling diagonal, from the back to where I now crouch, wondering what to say. Mrs Meadows seems able only to lift her head to see who I am, and to wave a small red plastic torch with her left hand. I count five cats at various points on the slope, one filthy white cat fastidiously licking a paw to the left of her head. There is a mulch of sodden cat biscuit boxes around Mrs Meadows' feet, and a shopping bag with some items for her, some buns, and a bottle of squash.
'Are you okay, Mrs Meadows? What's happened?'
She replies in a gently modulated whisper. If I shut my eyes I could imagine I was being invited to take tea with her in a cottage garden.
'Thank you so much for coming. I'm actually fine. It's not me at all, it's my cats. I'm desperately worried about them. You see I can't get about as much as I used to and it's really not fair on them.'
'Okay. Would you mind if I came a bit closer and gave you a check up?'
S. came to the opening just behind me. I heard him whince.
'No. No thank you. I'd rather you didn't touch me or come near me, thank you. I'm perfectly well. I simply want you to do something about my cats. Now - I have the number of a rather good animal shelter here somewhere.' She feels blindly with her left hand in the pocket of her coat, which is shinily filthy. She pulls out a scrap of paper and waves it out to me. The nails on her hand are curved and yellowed claws. I take the paper. It has the number of a cat rescue project written on it.
'Could you ring that for me and have them take my cats away? It would be such a weight off my mind.'
'Mrs Meadows,' I begin, 'There are lots of people very worried about you. We're very worried about you. These - conditions. They don't seem - all that good for you. And winter's just around the corner. What will you do? How will you cope?'
'Yes, yes. I know all that. But look. What I really want to know is - are you going to do something about my cats?'
'Let me just consult with my partner,' I say, withdrawing outside.
S. shakes his head. 'We can't just leave her here like this,' he says. 'No way. I've never seen anything like it.'
Back in the cab I call Control on my mobile phone. I tell them how shocked we both are. I tell them that I think Mrs Meadows should be taken into care - by force, if necessary. I cannot believe that this situation has been allowed to continue for a week, let alone a number of years. As I talk I have a dreadful image in my mind of her hand on the little red torch in the darkness.
But it seems that this is a formally registered address, so any forcible removal would have to be conducted via GP, mental health and social services. Control finds out that a recent assessment of Mrs Meadows' mental health had been made and she was found to be competent. Although I try to argue that the extremity of her living conditions must surely be interpreted as evidence of mental incapacity, Control are bound to say that these are questions for the mental health team in that area.
There is nothing more we can do.
I complete the paperwork. Mrs Meadows has refused treatment. All we can do is write a report highlighting our concerns.
And to notify the cat warden.
I have no doubt the cats will be re-homed immediately. This is no place for a cat.

Thursday, January 18, 2007

birthing partners

The first
The early hours, thin and grey. We lie sprawled on leather recliners beneath the sick and flickering light from the TV.
And then the alerter goes off and I find myself standing up, walking out of the door, incredibly. A fox looks up from amongst the bins.
In the vehicle the message on the terrafix gives us an incident number, address and then description: Abdo pain. Just as I turn the engine over, Control calls us on the radio. It's likely we'll be stood down before we make this one, he says, but in the meantime can we run routine until they've found out if we're definitely needed or not? I turn out of the drive. The fox lopes off.
A couple of minutes into the journey, it's Control again: proceed as planned, but nothing serious.
Another couple of minutes and I'm turning into the road we need, a decrepit square of two storey Georgian houses. It is dark and the numbers are difficult to make out, but after I cruise slowly round a light comes on in a porch the other side and I see a young woman step forward from the shadows to start waving over to us.

I drive round and pull up outside. The woman patiently waits for us as we get our bags and lock the vehicle. She stands hugging her arms to her chest for warmth, stepping from one foot to the other, a ghostly teenage girl with a scooped face and a mouth of decaying teeth. 'Follow me' she says, and leads us back up the steps with her arms still folded tightly to her chest. Sick as she looks, it turns out that it's actually her sister, Julie, who is the patient. D. asks her what the problem is.
'She's six days late.'
'Six days late for what?'
'For the baby.'
We exchange a look. 'Abdo pains?' Well, giving birth would fit.
'So - er - she's pregnant then?', he says.
The girl stops briefly on the stairs to drop a look back on us. 'Yes,' she says, without expression, then turns back round to carry on with the climb, but somehow slower than before.
This looks like some kind of temporary hostel. There is a fire alarm console in the hallway, and a noticeboard has been put up to display regulations and useful numbers. The lights on the stairs don't work, and it seems that every door we pass has been kicked in at least once in its life. The darkness smells sweetly spotted with damp. Eventually, at the top of the last flight of stairs, the girl shows us into one room and then disappears into another.
It is a fuggy, intensely lit space, with clothes, plastic bags, cigarette packets, hair brushes and newspapers strewn across every surface. And lying the wrong way round on the bed, looking as discarded as everything else, a pregnant girl, her swollen belly emphasised by a tight white top and the vivid tracings of blue veins standing out beneath the skin around the sides. Her cheeks are flushed, and strands of her hair stick to her forehead.
The bed sinks down to where another, more substantial teenage girl sits on the bed; standing over by the window is an angular, skinny guy in a baseball cap who gives us a nod and a raise of the hand as if we're waiters and he's ordering a beer. The girl on the bed dabs a face-cloth across Julie's forehead, the chunky silver links of her bracelet sway gently as she moves her hand back and forth. 'All right?' she says.
D. kneels down and tries to rouse her.
'Julie? Julie?' She gives a groan but does not open her eyes.
The sister comes back into the room and stands over by the window with the tall guy, who tells us he is Julie's boyfriend. He says he isn't the father of the baby, but wants to do what's right. He lights two cigarettes, one for him and one for the sister.
D. feels for a pulse and asks how long she has been like this. The sister tells us that they had all gone for a long walk along the front earlier in the day - Julie's idea - and she'd seemed fine then, fitter than any of them. When they got back they'd all had a bit of wine - Julie didn't have much - after that, Julie had complained she felt funny.
As D. asks the questions I take Julie's blood pressure and other essential observations, all of which seem fine.
The girl on the bed says that Julie's contractions are very spaced out, and that despite passing a 'show' yesterday, nothing much else has happened. 'I know all about it', she says, 'I went through it last year. I've got one of my own. A girl. A right pain.'
She tells us that no, Julie didn't faint or have a fit, she hadn't been complaining of any unusual pains or swellings anywhere. No, she doesn't have any health problems. She says that Julie is due for an appointment at the hospital in four days, when they say they will probably induce her. 'They'd better.'
It doesn't appear that Julie is either giving birth at the moment or in danger of pre-eclampsia, so we decide to sit her up, to see if we can lift her responsiveness, and get some information directly from her. We help her slowly into a comfortable sitting position - and the change is immediate. 'Where's my coke?' she says, and then smiles at us.
'Feeling a bit better, then?'
She nods as she sips. Her boyfriend comes across to us, holding out a clear plastic envelope with her notes in. I start filling in our worksheet. He says: 'Can we all come in the ambulance or ....?' but the silence that greets this makes it obvious that he's the only one in the room still thinking along those lines. The sister goes back into the next room, and he retreats back to the window.
D. says that the best thing to do is for us to call the maternity unit where Julie is registered so he can have a chat to one of the midwives there, relay all the observations we've made, and let them decide whether they want us to bring Julie in.
'We can do lots of things but one thing we can't do is check the cervix to see how dilated it is. That's the best way to tell established labour, I'm afraid. And it doesn't sound as if it really is that far along, to be honest. The contractions would be coming along much closer together, and the pain - well, I'm only a bloke, so what do I know - but I'm sure you'll notice a change in the quality of the pain.'
The friend has been turning the face cloth over and over in her hands as D. says all this, but she suddenly throws it across the room. 'I could tell you about that', she says. She brushes her lap. 'I had to have a caesarian. Twelve hours pushing, and then the baby got stuck.'
The boyfriend yawns and looks down into the street below.

The delivery suite confirms what D. already suspects. They're happy for Julie to stay where she is until the labour has progressed. We get a signature on our worksheet to release us, and leave. Julie waves to us from the bed, and we find our own way back down the stairs.

The second
The blue lights are leaping around us on the dark buildings as I drive quickly along to the incident given as: birth imminent. Control has told us on the radio that it's a busy night for maternity and the midwife is having to come from quite a way away. It means we will be on our own for at least half an hour. No problem.
The early morning streets are quiet, and we pull up outside the address in no time. I jump in the back to get the maternity pack and the resus bag, then lock the vehicle and join D. at the front door. He rings again. No reply.
A cosy Victorian semi in a quiet street. The hazard lights on the ambulance seem a terrible intrusion. He rings again, and knocks loudly.
Then, just as he bends down to have a look through the letterbox, we see a muted light through the door's delicately patterned glass panels. Someone's coming out. Slowly.
The door opens.
A large woman stands with one hand on the door and one on the frame, blocking the hallway. She has vividly spiked blond hair, thick framed black glasses and an expression that seems to me - at this hour, and in this situation - to be a curiously controlled hybrid of discretion and hostility.
An introduction seems redundant - here we are, paramedic and technician, for the pregnant woman, with all the gear - but after a pause, when it becomes apparent that one is necessary - D. says: 'Ambulance?' And then: 'So - where's the patient?'
The woman steps closer up to us.
She speaks quietly, and what I think she says is: 'I'm Adula' - which I take to be a variation on Adela. So I nod and smile and say 'Hello Adula - I'm Spence and this is D.' I can feel D.'s patience dissipating like drops of water on a griddle.
She looks at me, demonstrating even tighter control. 'Well. I'm Diane,' she smiles, 'Could you follow me into the front room, please?' Which turns out to be dark, and noticeably without patient. I am confused about the introduction, until it strikes me that she probably said she was a doula - a term which I hadn't come across before, but which must be some kind of birthing partner. Meanwhile D. insists on being shown to the patient right away.
'There is no patient,' Diane says. 'There is nothing wrong here. All that's happening is that a woman is having a baby.'
'Excuse me,' D. says, 'But - who exactly are you?'
'I'm Jane's Doula. I'm here to make sure her wishes are respected, that everything she planned for the birth goes ahead exactly as she wants it, wherever possible.'
'Do you have medical training? Are you a midwife?'
'No,' she says, 'I don't catch babies.'
D. straightens at this. 'Look. Someone called for an ambulance because a woman is in labour. That's why we're here. And we have been trained. We're wasting time talking to you whilst this patient is unattended, possibly in danger. How am I to know if I can't examine her?'
Diane is prepared for this. I wonder if she's faced this situation before.
'I'm not being obstructive. I'm not getting in the way, or stopping you from doing your job. Jane is in the birthing pool, with her partner, just in the next room. Everything's fine, and they don't want you in there. But if you feel that you need to go in, then of course I won't stop you.'
'Well there's absolutely no point in us standing here in the dark like this. I need to be sure that the patient is happy for us not to attend, and if that's the case, we'll wait outside for the midwife to turn up. If we're not wanted, it's all the same to us.'
'I'll go and talk to her now and see if that's what she wants.'
Diane leaves the room, and I switch the light on.
D. shakes his head. We put our bags down and stand looking around us. There is a large, painted canvas on one wall, a baby angel descending between two melting figures. Simply framed black and white family portraits. A book shelf crammed with books on travel, novels, books on film and jazz. Wall charts for identifying creatures of the shoreline, birds, woodland animals. Diane comes back in.
'Jane has asked me to thank you for coming. She says that she doesn't need anything at the moment, and asks that you wait - either here or outside in your vehicle - until the midwife arrives. Is that okay?'
D. shrugs, and she leaves again.
We wait for about twenty minutes in the front room. The woman's contractions are obviously coming intensely, now; with hardly any gaps, her cries resound throughout the house. Every so often she seems to sing as she shrieks. I look at D. He raises his eyebrows and shakes his head.
'If something goes wrong...'
And then we hear a car pull up. We go outside to brief the midwife. D. tells her about the Doula, and the midwife tuts. 'That's all we need.' She asks us if we'd mind hanging around until the baby is delivered, and then hurries inside. We wait in the hallway.
The labour progresses, with the midwife giving Jane encouragement and instructions.
At one point we hear her say: 'The head is out.'
And then: 'You must get out of the water if this next push does not deliver the rest.'
Soon after it is apparent that the baby has been delivered, but there are no crying sounds. The midwife speaks very sternly to the mother: 'Jane. You must give the baby to me so I can put him on the towel and get him breathing. Jane.' And then shouting out to us: 'Can I have some help here, please? Some oxygen?'
I pull out a cylinder and D. takes it through. Some long seconds later, then the baby's first cries echo through the house.
'Thanks' she says. D. comes back out, and we both go back into the living room.
Eventually the midwife comes into us. She tells us that Jane will not be having syntometrine to deliver the placenta, so it may take some time. We're near the end of our shift, so the midwife says she's happy to let us go. If she needs any further help she can always call for another ambulance.
We say goodbye to her, and leave.
I pull up round the corner, turn the radio down, lean back in the seat.
D. gets out and rolls a cigarette.
The sky is lightening now, but I don't feel tired.