Some days on the RRV are slow. This wasn’t one of them.
It was one of those shifts where the calls just kept coming, no gap between them, no chance to reset yourself. You’re clear from one job, and before you have even properly gathered your thoughts, the next call is already waiting. You don’t really walk to the door on those days — you arrive at it already thinking, your hand not yet on the handle and your mind already running through what could be waiting on the other side. Cardiac, respiratory, or something else entirely — you’re working through it before you’ve even knocked, checking whether you’ve covered everything or whether something obvious has slipped past you. And although everything looks calm from the outside, inside your brain is moving at a completely different speed.
The equipment comes with you every time, all of it. There is no crewmate beside you to share the load, nobody grabbing one bag while you grab another. The bags, monitor and kit all come with you across car parks, up flights of stairs, along garden paths and into whatever situation is waiting. On days like that, you would happily sell your soul for a wingman — someone whose entire job was to appear beside you, hand you exactly what you needed before you even asked, and say absolutely nothing while you worked. But there is no wingman. There is only you.
You introduce yourself at the door the same way you always do — your name, the service, a calm voice and reassurance. The patient and family see someone who appears controlled, but behind that calm exterior, your mind is already several steps ahead, assessing, eliminating, considering and reconsidering. You are making decisions quickly while also reminding yourself to slow down, check your thinking, and make sure nothing has been missed. Because mistakes happen. Everyone knows that. But in this job, mistakes carry a different weight – they don’t just affect you professionally; they affect the person lying in front of you. The person who called for help and got you. Just you. And they are trusting that you are enough.
There is a strange kind of silence that comes with being the only clinician there. It is not silence because nothing is happening — far from it. The room can be noisy, chaotic and emotional. It is the silence created by not having someone beside you sharing that responsibility. No second pair of eyes. No immediate second opinion. Nobody is giving you that small nod that says they are thinking the same thing or quietly challenging you when they are not. It is just you, the situation in front of you, and the knowledge that whatever happens next depends on the decisions you make.
That feeling does not arrive all at once.
Early in an ambulance career, you are rarely alone in that way. Even as an EMT, some of the responsibility is usually shared. There is normally someone else to look towards, someone carrying the final clinical decision, someone who absorbs part of the weight when things become uncertain. You learn inside that environment. You build your confidence with that safety net of shared decision-making beneath you.
Then slowly, almost without noticing, things change. You become the person, or the Paramedic, others look to. It stops being only about experience and becomes about expectation. People direct their questions at you. Decisions find their way to you. The silence, when it appears, becomes yours to fill. Even when you are working alongside others, there are moments where you are effectively standing alone — the situation has moved faster than the support around it; the crew is occupied; backup has not arrived; and the person in front of you needs something to happen right now, not later. That is when you feel the weight move.
Being alone is not always about physically standing there by yourself. Sometimes it is about being the point where the decision stops — the person who interprets what is happening, prioritises what matters, and chooses the next step without anyone immediately confirming that the choice is right. No training scenario can completely prepare you for that moment, because knowing something and owning something are two very different things. You might know the answer. You might have read the situation correctly and chosen exactly the right course of action. But when nobody else is there to carry part of that decision with you, you have to own it yourself, completely, in real time, with a person in front of you depending on you getting it right.
That ownership changes the way the job feels. Decisions stop being something you discuss in a classroom or work through in a training scenario. They become real. Immediate. They have consequences. You understand, in a way that is difficult to explain to someone who has never stood in that position, that what you decide to do — or sometimes decide not to do — can completely change what happens next. There is no safety net. No second layer of approval. Nobody is standing in the corner, watching to see who can stop everything and reset the scenario if it starts going wrong. There is only what you do, and you have to do it.
Early in my career, those were the calls that stayed with me the longest. They were not always the dramatic ones, not always the jobs people would imagine when they think about emergency work. Sometimes it was something fairly routine in ambulance terms — a medical call, a collapse, a patient who was frightened or unwell. What made it different was the realisation that I was the one making the decisions. Nobody was immediately there to check my thinking or to stand beside me and say they agreed. Every decision felt bigger. Every choice felt more visible. More exposed. More mine.
That feeling is uncomfortable at first. You question yourself. You look for reassurance that is not there. You carry the weight differently because you have not yet built the kind of confidence that only comes from experience — the confidence that comes from having been there before, dealt with it, learned from it, and walked into the next call carrying those lessons with you. That is how you learn to manage the responsibility — not suddenly, but slowly, shift by shift and job by job. You build the quiet steadiness that the role eventually demands from you.
It isn’t arrogance, and it isn’t pretending you know everything or acting like nothing affects you. People just need enough calm from you to believe there is someone in the room who knows what needs to happen next. When you are the only clinician there, your presence becomes part of the treatment. The way you speak matters. The way you move matters. The way you carry yourself in that room matters. The patient notices. The family notices. The people standing around the edges of the situation, looking for reassurance, are noticing. Sometimes they are not only listening to your words; they are watching your face, your body language, and your reaction, trying to work out how worried they should be. Nobody really explains that part in the classroom.
You are taught clinical skills — assessment, treatment pathways, medication, decision-making and protocols. All of those things matter. But nobody can fully teach you how to keep your face calm when your brain has already realised the situation is much worse than everyone else in the room understands. That skill comes from experience. You learn it the same way you learn so many things in this job — by being placed in situations where you have no choice but to develop it.
There are moments when you walk through a door, and you just know. Not “big sick” as a phrase from a textbook or a lecture but the kind your gut recognises before your brain has finished putting all the pieces together. Something feels wrong. The room feels wrong. The patient looks wrong. Your stomach turns like a washing machine on a full cycle — fast, relentless, and impossible to ignore. It is your body trying to warn you before you have finished processing everything in front of you. But your face cannot show it.
Inside, the fear and the knowledge pull against each other. Part of you understands exactly what needs to be done. Another part of you understands just how serious this could become. And while all of that is happening, the family are watching every move you make, looking for a sign. So you hide it. You have to. The sweat that runs down your back or collects under your arms stays hidden under the uniform — not the sweat from carrying bags up three flights of stairs or running between calls all day, but the kind that arrives when you realise exactly what you have walked into, the moment when your training, experience and instincts all start telling you the same thing. This one is serious. But nobody else in the room knows that yet.
The lip you are biting on the inside stays invisible. The anxiety that appears without invitation gets pushed somewhere behind the calm voice and controlled movements because everyone is watching you. The patient is watching. The family is watching. They are looking to you for reassurance, sometimes without even realising it, trying to judge the situation based on how worried you look. They need to believe the person standing there with the uniform, the equipment and the training has control of what is happening — even on the occasions when holding that control is one of the hardest things you have ever had to do.
I have stood in rooms where things were much worse than my face was allowing anyone to see, where the clinical picture forming in my head was more serious than I wanted it to be, where I was still putting the pieces together, still working through possibilities, while at the same time trying to provide enough calm that the room did not tip from worried into frightened. Because once panic enters a room, everything becomes harder. The patient feels it. The family feels it. The atmosphere changes.
There is a balance you learn over time. Patients and families deserve honesty, and sometimes that means having very difficult conversations. But there is a difference between giving people the information they need and transferring your own fear onto them. Learning where that line sits takes time. You learn to carry two versions of the same situation at once — the one happening inside your own head, with the assessment, the concerns, the possibilities, and the things you are preparing for if everything changes; and the version everyone else sees: calm, measured and controlled. That is not pretending. It is not being dishonest. It is a skill, built through years of walking into rooms where people are scared, situations are uncertain, and everyone is quietly hoping the person who has just arrived knows what to do next.
Over nineteen years, I worked alone in ways that evolved as my career did. As an EMT in the early years, even being the senior person on scene for a short time could feel like a huge responsibility. Maybe it was only while waiting for another crew. Maybe it was only for a few minutes. But those minutes could feel very long when everyone was looking towards you. The protocols were there. The training was there. But there is a gap between knowing what should happen and standing there as the person expected to make it happen, and you feel that gap the first time you step into it.
Later, as a paramedic, that responsibility grows. The decisions become more complicated. The situation becomes more challenging. The medications you carry can make a huge difference, but they also bring greater responsibility. The system trusts you with more. Patients trust you with more. Families trust you with more. And while you earn that trust through years of experience, sometimes the weight of carrying it is heavier than people realise.
The ambulance service does not always create space for that pressure to be spoken about. The culture has always been built around carrying on — you go to the call, you deal with what is in front of you, you clear from it, and then you move on to the next one. It is a culture built on resilience, and that resilience creates some genuinely incredible people who walk into difficult situations every day, who make decisions under pressure, and who carry responsibility that most others will never see or fully understand. But the same culture that makes us strong can sometimes make it harder to admit when something has been heavy.
You become very good at this job of reducing something difficult down to a few simple words. “Tough one.” “Hard day.” “Glad that’s over.” Everyone who has worn the uniform understands what those words can actually mean. They often carry far more than they say. Nobody needs the full explanation. Sometimes nobody asks for it either. The kettle goes on. The next call comes in. Life moves forward.
Most of the time, that way of coping works. The resilience is genuine, built through experience and through years of dealing with things most people only ever see from the outside. But sometimes a call comes along, or a run of shifts comes along, where the usual way of dealing with things is not enough. Sometimes the weight gets heavier than you expected. Those moments need something different — not pretending everything is fine, not pushing it down and hoping time sorts it out. Sometimes it just needs the honesty to admit that what you carried was heavier than normal.
Counselling taught me something that nineteen years of shifts had not managed to – not a clinical skill or a new piece of knowledge but something much simpler and something I probably found much harder to accept. I was allowed to be upset.
The culture I started in did not always leave much room for that. A call was a call. You went, you did the job, you came back. If something affected you, it usually appeared as something else — frustration, annoyance, anger at equipment that failed, resources that were not there, or a system that sometimes made an already difficult job even harder. But actual sadness, actual grief, that quiet feeling sitting in your chest on the drive home after a call — that was different. That was the part people tended to keep private.
Nobody wanted to be the person who admitted something had got to them. Nobody wanted to be seen as the one who struggled. The unspoken rule was that you dealt with it somehow, wherever that happened to be, then came back for your next shift and did it all again.
I remember a trainer called Mickey Hughes during my EMT training. He was one of those people who leave an impression without even trying. Standing at the front of a lecture theatre, he said something that I heard at the time but probably did not truly understand until years later: never be afraid to show your emotions or cry. If you need to, find a quiet corner and let it out. Everyone does it. They are just afraid to admit it. Especially men.
He was right.
I have cried. Maybe not standing in the middle of a scene, and maybe not when there was still a patient who needed a family looking towards me or me. But afterwards. In the car on the way home, when the radio is switched off, and there is nothing left to distract you from what you have just seen. At home later, when a call appears in your thoughts again without warning. When a face, a family, or a moment finds its way back.
For a long time, I saw that as a weakness. I worried it meant I could not handle the job, that maybe everyone else was managing something that I wasn’t. Counselling changed how I looked at it. Crying does not mean you are weak. It means underneath the uniform, the training and the experience, there is still a person there—a person who has witnessed things, who has cared, who has spent years doing a job that asks you to step into some of the worst moments of other people’s lives and somehow walk back out unchanged. Except nobody really walks out completely unchanged. Some moments come with you.
The particular pressure of being the only one there does not always stay neatly at the scene. Sometimes it follows you further than you realise. It does not always appear loudly or obviously. It does not always arrive in a way you immediately recognise. But a mind that has spent an entire shift making decisions, carrying responsibility, and constantly assessing situations does not suddenly stop because the uniform comes off and the shift ends. It keeps going.
You replay things. You think about the decisions you made. You wonder if there was something else you could have done or noticed earlier. You find yourself going back over moments that everyone else has probably already moved on from. Most of the time, that process is actually useful – reflection is part of how we improve, recognise patterns, develop our judgement, and become better clinicians. Looking back at a job and asking yourself questions is not a bad thing. In many ways, it is one reason experience matters.
But there is a point where reflection can quietly become something else. It stops being about learning and starts becoming doubt. It stops being a healthy review of what happened and becomes a search for something to blame yourself for. The difficult part is that the person doing it is usually the last person to recognise when that change has happened, because questioning yourself has become such a normal part of how you practise. That deserves to be talked about more.
Nineteen years in the ambulance service change your relationship with responsibility. You get used to carrying it. You find ways of managing it. Over time, you develop a level of calm under pressure that is genuinely one of the most impressive things about the people who do this job. You become the person others want walking through the door when everything is going wrong — not because you have every answer; nobody does, but because you have learnt how to keep functioning when the answers are not immediately obvious.
That is what experience really gives you. It does not give you certainty. It does not remove doubt. It does not create someone who never feels the pressure. What it gives you is the ability to work despite uncertainty — to take the information you have, make the best decision you can, act on it, and then adjust when the situation changes. Written down, that sounds simple. Standing in someone’s house, with a patient in front of you, a family watching you, decisions needing to be made, and nobody else immediately there to look towards, it is anything but simple.
That ability is built from every call that came before. Every time you walked into something uncertain. Every time you felt the weight of a decision. Every time you wondered afterwards whether you got everything right. Every call teaches you something, even if you do not realise it at the time. The confidence you eventually build does not come from stopping yourself from questioning yourself. It comes from the knowledge that, somewhere underneath those questions, you have been here before. You have faced difficult moments before, and you found a way through them.
That is what nineteen years looks like from the inside. It isn’t someone who has become unaffected by the job, or stopped caring, or walks into every situation free of doubt and worry. It’s someone who has learnt how to carry it – the good calls and the bad ones; the shifts where everything goes right, you finish on time, and nothing follows you home; and the shifts where you sit in silence afterwards because something about that day was heavier than usual.
You still come back. You still answer the next call. You still walk through the next door carrying the hope that your knowledge, your experience and your judgement will be enough for whoever is waiting on the other side. That is the real version of the job. It has nothing to do with the television version, the dramatic scene with music building in the background and everything solved before the credits roll. It’s a person, a patient, a moment, and a responsibility. The quiet understanding that sometimes there is nobody else. And when that happens, you have to believe you will be enough.
Most of the time, you are.
For the times when it isn’t – when carrying that responsibility leaves a mark you don’t talk about at handover – it’s worth saying plainly that the person behind the uniform is still just a person. Not a machine built to take pressure without consequence, but someone who turns up shift after shift, call after call, year after year, and somehow makes something remarkable look completely ordinary.
Nobody hands you a medal for that. Most nights, the only proof it happened is the empty passenger seat where a crewmate would have been and the fact that you drove home, got some sleep, and turned up for the next one anyway.
Nineteen years of solo decisions built a confidence I trusted completely — until someone sat me down and asked me to prove it was there. That essay is here: What You Know.
