Cautiously optimistic

Just a quick update on my throat cancer. For new readers, during the summer, I got to see an otorrino (Ear Nose and Throat specialist) and, after a few tests he said I had a throat cancer. He passed me to an oncólogo (Cancer specialist). They ordered up a few tests, decided that the cancer was just in my throat and lymph nodes and set me up for a course of 33 sessions of radiotherapy and three of chemotherapy. The radio sessions were in Alicante and the ambulance service took me there for most of the sessions. The chemo was in Elda. Along the way I had a picc port installed in my arm so they could take blood from my veins and put other liquids in. They also put in a PEG tube so I could put "milk shake" type food directly into my stomach when my throat became too inflamed to eat through my mouth. There have been a couple of snags along the way; I ended up on a hospital ward for three or four days because I kept throwing up and the dehydration was damaging my kidneys, but, generally it's been plain sailing.

The last of the sessions of radio or chemo was on 19 October so going on two months now. In the past few days I have seen the oncólogo, the otorrino, nurses in the chemotherapy day centre and a nutritionist. 

The oncólogo didn't really have much to say, but he wasn't worried about me either. He had a good feel of my neck and said he was pretty sure the lymph nodes were no longer swollen. He's going to order a CAT scan and I'm back to see him in about a month. He did say they could remove the picc port from my arm which was taken out by the perpetually cheerful nurses in the chemo day centre. They were also very nice about my Spanish. With the picc gone I was able to have a shower this morning without a plastic sleeve on my arm to protect the dressing for the first time since the beginning of September

The nutritionist said it was about time that I started to eat solid food instead of just feeding through my stomach. She only actually wants me to eat things like rice pudding, custard, creme caramel and the like. I do as I'm told and I've eaten a couple of those things today. They taste odd because my mouth is still slimy but I ate them alright.

The otorrino put his camera up my nose and down my throat and said "I don't see the lesion today that I saw in the Summer". He said my throat was still inflamed from the radio, which I think was to add a bit of caution to his earlier comment. He doesn't want to see me again till March.

And the problems I still have, as an effect from the treatments, are that my mouth is either bone dry or covered in horrible, foul tasting mucus nearly all the time, that I get tired quickly and that I feel dizzy quite often. Not exactly serious concerns. So, not so bad at all.

Submarines in the harbour

Done it then. The prescribed treatment for my throat cancer and inflamed lymph nodes was three sessions of chemotherapy in Elda and thirty three sessions of radiotherapy in Alicante. Today I had the last session - everything finished. The medics tell me that I'll still feel sick, not be able to eat through my mouth, continue to have skin peeling off my neck, and whatnot, for a month or two yet. My next appointment with the oncologist isn't until 11 November (not at 11am) and the next time to speak to the ear nose and throat people who did the original biopsy isn't until mid December. But, for the moment I won't have to get up at 5.30 am to be ready for the ambulance to take me to Alicante every weekday and nobody is going to poison me with vile chemicals or bombard me with particles for a while.

Of course nobody has suggested what will happen if it hasn't worked. I don't know whether they wade in with more of the same or if they give it up as a lost game and just do the occasional round of chemo to hold it all at bay for as long as possible. Along the way I have lost a fair bit of weight and one of the consequences of that was that they needed to make me another full face mask to use for targeting the x-rays (or whatever rays they bombard me with). That meant a second CAT scan and the doctor in Alicante commented today, that when they had done that second scan, the swelling in my lymph nodes had subsided significantly - I think that was a sort of snippet of good news. 

I don't feel well. I'm not really in such a bad way though I suspect I smell badly. More than anything I feel a bit sorry for myself. I feel cold even when it obviously isn't. I haven't drunk or eaten anything for a whole month now. In fact, at the cinema on Tuesday evening there was an advert for Coca Cola. I'm not a  huge Coke fan, it's OK, but, as I was watching that advert I'd swear my tongue was hanging out and I could imagine the taste. I do keep trying to eat or drink. I have a spoonful of yogurt or a mouthful of tea and instead of the expected, pleasant taste I find myself spitting out the acrid fluids and spending the next 10 minutes doing a Barney Rubble impersonationation - urgh, urgh. I'm told to expect another month or two feeding through the stomach tube which often makes me vomit or if it doesn't actually make me vomit it makes me wretch and cough and spit and curse the creation of humankind. 

Sleeping is good except that the downside is the state of my mouth when I awake. I've learned that my best bet is to do nothing. No water to lubricate my throat, no brushing my teeth, no mouthwash. Just wait for an hour or so until my mouth is a sort of acceptable cauldron of terrible tastes and then have a go with the brushing, gargling etc. If I don't throw up in the process then that's a definite win. And, just to finish off my neck has started to peel. If you've always lived with factor 50 sun protection you won't understand this but the old style holiday suntan was to peg yourself out, when you got your fortnight off, until your skin turned bright red. You'd try to ameliorate the pain with camomile lotion (long before after sun treatments) but, if you'd overdone it you'd pay with blisters and boils on your skin full of liquid. As those burst your skin would peel off leaving various coloured blotches. The radio has done something similar but the effects have only really shown up big time in the last couple of days.

And that's just me. Living alongside someone who goes to bed at 10 pm, who hasn't done a stroke in the garden or been shopping or done any of the other tens and tens of household upkeep and maintenance jobs for six or seven weeks and who doesn't want to go to get a drink or a meal or to a fiesta must be a little wearing to say the least for my long suffering partner.

Ambulances

I've been riding around a lot in ambulances recently. I remebered an earlier blog about ambulances, back in 2019. I re-read it and it's much better than this one. It flows more easily and it's reasonably interesting in a Big Chief I-Spy sort of way. The sort of simple information with which you can amaze your friends and confound your enemies. So far as I can see there have been no basic changes to the legislation since I wrote that blog but that didn't stop me publishing this rewrite.

This piece is about the ambulances that are contracted by the Generalitat Valenciana, the Regional Government in, the region I live in. Every now and again Valencia put a contract out to tender and anyone interested enough to bid has the potential for providing the ambulance fleet for the requirements of the region. There are other ambulances, private and NGO ((Non Governmental Organisation). The private clinics and hospitals need ambulances to move their customer/patients around and other groups, for instance the Red Cross, run ambulances which can be hired out to provide part of the safety cover at events from half marathons to encierros.

There is national legislation about the construction, status and identification of ambulances and within that legislation there are some regional variations but, in general, everywhere follows a similar sort of classification which is pretty simple, pretty logical and easy to understand.

The first thing is that, discounting helicopters, rapid response vehicles and the like there are two broad classes of ambulance - those that can provide medical care en route, classes C and B, and those that don't, Class A.

The non-care ambulances, classes A1 and A2, are used to transport ill people around and are not designed to offer medical care to patients en route. These are the ambulances that take people to rehab sessions, to visit physiotherapists and the whole range of appointments at hospitals, outpatient clinics and the like. In the legislation these ambulances are divided into those that transport people on stretchers and those which are collective transport but nearly all the ambulances I've been in over the past six weeks have been halfway between. They have space for one stretcher, space for a standard sort of wheelchair and six or seven individual seats. They also have things like oxygen and defibrillators on board. The drivers will have a qualification as drivers and as first aiders having done a course that lasts about 350 hours. Sometimes these ambulances bear the letters TNA for non assisted transport. These ambulances are predominantly white in colour and have side windows in the rear of the van. 

The Assistance ambulances, class B or class C, are equipped to take care of sick people en route. These are the ambulances that will turn up if you dial the emergency number 112. There are a range of other numbers but 112 is the foolproof one for any emergency service.

The Class B or SVB ambulances are designed to provide basic life support. As a minimum they will have a crew of two, the driver and another person both of whom will have at least the Emergency Health Technician, TES in Spanish (Técnicos en Emergencias Sanitarias) qualification that requires a couple of thousand hours of study over a two year period and with regular updates and refresher courses along the way. These ambulances are SVB, Soporte Vital Básico (in Castilian) or Suport Vitál Basic (in Valenciano) and those letters are usually very obvious on the side of the ambulance. They carry a lot of medical kit on board.

The Class C or SVA ambulances (Soporte Vital Avanzado or Suport Vital Avançat) are designed to provide an advanced life-saving service. Again these ambulances will have a driver who holds the TES  qualification and, at least a qualified emergency nurse. The course to become a nurse in Spain is a four year university degree course. Most SVA nurses also do a further two years masters in nursing on top of the basic qualification. On occasions the nurse may be replaced by an emergency doctor or there may be three, or more, crew on the ambulance. A Spanish SVA Doctor will have done six years at university, a couple of years on a Masters in Emergency Medicine and another four years or so on a specialism like cardiology or intensive care medicine. By the time we're at that sort of staffing level we're into ambulances which are "medicalizadas", they're basically intensive care units on wheels and will sometimes bear the letters SAMU Servei d'Ajuda Mèdica Urgent, Servicio de Ayuda Médica Urgente Urgent.

It seems to me, though it may not be a figment of my imagination that as the ambulances become more serious the colour scheme utilises more yellow, there are still the red roofs and red lettering but the SVA/SAMU ambulances have swathes of yellow while the SVB only have a band of yellow colour.

One last thing thing came from chatting to one of the drivers who normally drove B and C class but had been drafted in for the transport ambulances to cover a sick colleague. It was about the use of lights and horns. If it's a real emergency, urgencia in Spanish because we lay folk know when something is urgent but it may or may not be an emergency, they will put the blue lights on but they really only use the horns to protect themselves when, for instance, crossing red traffic lights. The driver told me that time after time Spanish drivers would react in a very haphazard way if they suddenly found multi tone horns behind them and, as well as drop their mobile phone, they might do any sort of daft thing - so, better to arrive safe and a bit later rather than be the first vehicle on scene having been involved in another road traffic accident.

Eat up your gruel

I wasn't going to do this again. Not for a while. In fact I have a very slight blog ready to go about ambulances, but a number of people have asked or sent me messages so, I'll do my best to make it short and sweet. Yet another update on me and throat cancer.

Nothing has changed in the treatment stakes. I've now done 25 of the 33 sessions of radiotherapy. An ambulance collects me from home and deposits me back here a few hours later. It can be as few as four hours from start to finish and as many as six and a half. The treatment takes about twenty minutes and the rest of it is waiting or travelling time and the occasional medical Q&A. Yesterday the ambulance from Alicante brought me home via Biar. Locals can gasp and chortle. 

I've done two of the three chemotherapy sessions. The third and, hopefully, final session is on Monday 14th provided that there is no medical reason for not going ahead - apparently things like anaemia, lack of platelets, reduced kidney function etc., can make the process unsafe which is why I have to get a blood test a few days before to check that I'm up to it.

This morning I got a bit of a pep talk from the nurse at the radiotherapy unit. She seems to be the person charged with keeping an eye on me. Her main concern is that I am losing weight. In fact my face had thinned out so much that the original "death mask" that they use to strap me to the table and to target the rays, was no longer up to the job. I had to have a new mask made and a new CAT scan done so they could pinpoint the tumours in relation to the new mask. We had a bit of a chat about this weight loss. As I pointed out I'm still hardly skinny - teetering on the boundary between overweight and obese using that Body Mass Index system. The nurse guffawed when I told her that. She checked. She seemed genuinely surprised when I was right. I explained, in Spanish, about the English word moobs. It didn't stop her though. She wants me to "eat" more. Now I haven't actually eaten anything since 19 September. Since then I have been connecting a squelchy plastic bag full of some all in one food supplement to the tube that comes out of my stomach. The bag is hung on high and it just drip, drip, drips into my stomach. the original plan was for three feeds a day, 600 calories a go. I've now been told to go for four feeds a day. It's a laborious process and the food stinks but I'll do what I can.

Actually saying the food stinks is something else. Cooking food, kitchen waste bins, the porridge residue in the plug hole etc., smell absolutely disgusting. Maggie tells me that things are no more smelly than normal though she says I have fetid breath. I'm not surprised. Nowadays I go to bed early, alone, in the guest room. I get to sleep easily enough but however long I stay asleep, till the first time I wake up, is usually the major part of the sleep I'm going to get. From there on in it's just tossing, turning and maybe a bit of snoozing. When I wake up, at say 3am, my mouth is lined with mixtures of phlegm, slime, and blood or snot tinted gobs of something horrible. Then again, someone has lined my mouth with sawdust. So I'm choking on dust and something as slimy as that Creature from the Black Lagoon at the same time. I can try to brush and mouthwash my mouth back into action but, if any of the liquids, including the "medical" mouthwash which, if it were sold in a standard size whisky bottle, would come in at 85€, touches the back of my throat I am wont to retch and throw up on the yellowy liquid I put into my stomach. It is a singularly unpleasant experience. 

The radiotherapy people are adamant that the majority of my problems are being caused by the whole body treatment which is chemotherapy. They accept that the radiotherapy has reddened my skin caused quite a lot of exfoliation but not much else. And that was the point of the pep talk from the nurse to tell me that with my only real complaints being my throat, a fair amount of throwing up with a bit of side grumbling about the ringing in my ears and how the lowering of my blood pressure makes me wobble, literally, from time to time, I was getting away with this almost consequence free so far. So, my lad, buck your ideas up and make sure you lose no more weight.

"Yes, Lourdes", was all of my reply.

Ambulance chasers

We were following an ambulance. It wasn't in a hurry and neither were we. On the back door was the symbol of the Generalitat, the Regional Government, and the name of a private firm. Along the side, in big letters, SAMU, obligingly decoded for us even in Valenciano (Servei d'Ajuda Mèdica Urgent), the English would be something like Emergency Medical Care Service. I think, though I'm not absolutely sure, that just as people in care homes wear name tags in their cardigans, writing SAMU on an ambulance says who they are and where they belong. Use SAMU or SAMUR (which is the service for the emergency ambulances in Madrid) and you mean ambulance: the sort of ambulance that comes for heart attacks and road traffic accidents and not the sort of ambulance that comes to take you for your appointment with the urologist.

Health Services in Spain are devolved to the seventeen Regional Governments. Ours, in Valencia, is called the Generalitat Valenciana. Hence the logo on the ambulance. But I wondered about that name of the private firm. Obviously there are private ambulances to move people to and from private clinics and to deal with patients who are paying through their insurance companies or health plans. Mutual societies, which work with the Social Security Department to cover work place health, might also use private ambulances. But that wouldn't be the case for an ambulance with the Generalitat logo. Google of course knew. It seems that, in the modern world, the Health Authorities usually outsource their ambulance services. So there's a tendering and contracting process for outsourced fleets of ambulances. Staff can also be outsourced though it seems that the doctors and nurses aboard the ambulances are, usually, Health Authority Staff whilst the drivers and paramedics come with the ambulance.

I know there are Red Cross, Civil Protection and yellow DYA ambulances. I'd also read a story recently, in the local press, about our Town Hall buying a new ambulance. So how did this all fit together?

I think the Red Cross ambulances are, much like the Red Cross or St John in the UK. I saw a Red Cross ambulance crew in action only a few weeks ago in Aspe. They were covering a fiesta and somebody was taken badly ill. I presume that event organisers have to cover emergency first aid and one of the potential options is the Red Cross. The DYA is another example of a charitable organisation that raises money in any number of ways, including selling its services. The DYA was originally set up to cover the shortage of ambulances to deal with road traffic accidents in Spain but, I think, it now generally operates through arrangements with Regional Health Authorities. Obviously when push comes to shove, in a train crash or terrorist attack, all the ambulances from everywhere become available. So then, what about our Town Hall ambulance? Checking back in the local press the ambulance was described as a TNA. Google said TNA is Ambulancia de Transporte no Asistido. The penny dropped.

There are two basic types of ambulances. Emergency Response Ambulances and Transfer Ambulances. Emergency Response Ambulances come in two types and with three crewing levels. Transfer ambulances come in two variations with two crewing levels. There are plenty of other sorts too, like rapid response vehicles, but I'll just stick to the principal types.

Generally, when someone calls 112 (there are other numbers too but 112 is foolproof), the ambulance that turns up will be an SVB - Basic Life Support ambulance. It will be crewed by two TES, técnicos en emergencias sanitarias, or emergency health specialists which are probably equivalent to UK paramedics. They will have spent a couple of years at college getting their qualification and they will probably have done lots of short ancillary courses. The SVB vehicles are kitted out with defibrillators, all those immobilising braces, oxygen, drips and a long etcétera.

The next step up is an SVA - Advanced Life Support ambulance. These SVA vehicles carry more medication on board than the SVBs and more sophisticated kit. The real difference though is not in the vehicles, it's that SVAs come with more qualified staff. The SVA Sanitarizada (the lowest level of SVA) comes with an Emergency Health Specialists (TES) and an Emergency Nurse. The course to become a nurse in Spain is a four year university degree course. Most SVA nurses also do a further two years masters in nursing.

The most sophisticated vehicles and crew is also an SVA but, this time, it's called Medicalizada. These ambulances are sometimes referred to as Mobile Intensive Care Units. The on board equipment doesn't usually vary much from the Sanitizada but this time the TES and the Nurse have a Doctor with them. A Spanish SVA Doctor will have done six years at university, a couple of years on a Masters in Emergency Medicine and another four years or so on a specialism like cardiology or intensive care medicine.

Away from the full blown, nobody dies on my watch, vehicles there are the two types of transport or transfer ambulance. The first of these is what my dad and his mum would have recognised as ambulances. The patient will probably be on a wheeled stretcher. Their lives are probably not in danger but they are not well. It's possible, though not likely, that the transfer could become an emergency so the vehicles are equipped with horns and lights. The patient will be accompanied by one TES paramedic and a driver. The driver may just have first aid type knowledge from a couple of months course or they might be a TES as well.

The last and simplest type, the TNA, the sort of ambulance that our Town Hall just leased, may have a first aider or a TES type driver but there is no expectation that the run will become an emergency. Often these vehicles are minibuses.

In re-reading various articles about transfer ambulances it looks as though there are often arrangements between local Town Halls to share access to the SVB ambulances. I was talking to one of my students about this and she said that before Pinoso sorted out its own local arrangements people could die whilst they waited for an ambulance to arrive from Elda, which is where our hospital is, some 28 kilometres away.

There is all sorts of legislation about how a vehicle qualifies to be an ambulance, from simple things like having the word ambulance painted back to front so that any driver looking in their rear view mirror will be able to read that they have an ambulance on their tail through to what it needs to carry, how it can operate and how long it can take to get such and such a distance.

Just one last thing. Spanish ambulances have traditionally had amber flashing lights, they've only just started to use blues and twos. Ambulances could have blue lights from August 2018 and all of them will have to carry blue lights by August 2020.