Tuesday 28 February 2012

Wearing Green & Living the Dream......

"25 year old female living the dream"

What is the dream? Is it even a dream? Maybe it's just a perception! People see the ambulance service with an air of glory, they see you flying through the streets with blue lights flashing and sirens blaring. Every job we go to is a dead person in urgent need of revival or a traumatic cardiac arrest. We save lives, we are heroes, we are an elite group of well trained medical professionals. If you join the ambulance service you'll be in for real excitement and could make a real difference in the lives of everyone you see. You will be treated with respect and not abused by the public because you are ambulance staff, not the police. Everyone loves the ambulance. It could be middle of the day or middle of the night, you call 999 and we will be there in no more than 8 minutes. Whatever is wrong, we will fix it. That's what we do!

Sadly, it isn't! Far from it. Sure, we help people and we save people but for the amount of work we do it isn't many. I love my job, I real do but I have a thick skin and I'm not squeamish. It can be a great job but before you consider this path you should know the truth. All of things on the list below have happened to me since I joined the service, in fact, most have occurred in the past month or so and will continue to occur on a regular basis for the rest of my career. This is what they don't put in the advert!

  • I have been verbally abused.
  • I have been punched.
  • I have been kicked.
  • I have been spat at.
  • I have been hospitalised by a patient.
  • I have been flashed.
  • I have been threatened.
  • I have had blood in my eye.
  • I have been vomited on.
  • I have been pissed on
  • I have worked 84 hour weeks.
  • I work for 12 hours without a break.
  • I worked 7/10 weekends for 2 years.
  • I got divorced because of it.
  • I now work 5/10 weekends.
  • I work night shifts.
  • I have my weekends midweek.
  • I have spent Christmas with violent alcoholics.
  • I have no social life.
  • I have knelt in urine.
  • I have knelt in poo.
  • I have seen dead people.
  • I have picked up body parts.
  • I have watched people die.
  • I have held a dead child.
  • I have held a dead baby.
  • I have had knifes pulled on me.
  • I have had tampons thrown at me. 
  • I have insomnia.
  • I have a terrible diet.
  • If I want hot food on shift it's fast food only.
  • I have seen people fake their injuries.
  • I have seen open heart massage at the road side.
  • I have seen mutilated bodies.
  • I have worked 17 hour shifts with no break.
  • I don't feel valued as an employee.
  • I fear going off sick.
  • I'm exposed to many infectious diseases.
  • I've seen neglect and depravity.
  • I pick up drunk people every day.
  • I have knelt in brain matter.
  • I have seen bones sticking out of limbs.
  • I have seen an arterial blood spray.
  • I have felt helpless.
  • I go to time wasters every day. 
  • I would say 90% of people don't need an ambulance.
  • I know I'm at the bottom of the NHS food chain.

On the other side of the coin, I went to a 92 year old last night who had fallen down some stairs. She had no injuries and she refused hospital. I got her up off the floor, made her a cup of tea and chatted to her for 20 minutes. As I was about to leave, she stood up and hugged me. She then said thank you. That's why I love my job. That is wearing green and living the dream.

Monday 27 February 2012

Don't ask, just do.......

"2 x Doctors acting like arrogant tits"

Some time ago I wrote a post entitled 'To Blue or Not to Blue'  about how sometimes doctors and nurses question us putting a pre-alert to a hospital and bringing our patient in on blue lights. In my opinion, our decision to do this should really be beyond reproach. The fact of the matter is they are not there when we arrive. They don't see our patient at their worst and they don't take into account that on route to hospital we are treating them. With treatment often comes improvement and therefor a GCS 3 may indeed be conscious and talking by the time we arrive at hospital 10 minutes later. We shouldn't be criticised or made to feel stupid because the doctor is annoyed that they have had to walk from one part of A & E to another for what they don't deem to be an emergency. All blue calls are placed in good faith. At the time we put them in the patient is either dead, about to die or in our opinion would hugely benefit from being seen immediately rather than sit in a corridor for an hour waiting to hand over. If the patient has improved and they don't need to be in resus then move them. Simple.

The reason I am bringing up this subject again is I have been criticised / questioned twice in two days and quite frankly, it pissed me off. We were called to a guy fitting. When we arrived he had stopped. A precautionary cannula was placed in case he had another, and seeing as he had now had three seizures in the last hour it was likely he'd have another. We got him to the truck and started monitoring and set off to hospital. Within about a minute he started seizing again. My crew mate pulled over and jumped into the back to help me. We got him on high flow oxygen and tried to give him the IV Diazepam. Due to the violence of the seizure we couldn't access the cannula. Not wanting to waste time we gave the drug PR (up the arse for want of a better phrase) and within a minute or so he stopped! And breathe! We monitored him for a couple of minutes with the idea of continuing our journey but off he went again. Status Epilepticus is defined as a seizure lasting more than 20 minutes (depending where you read) or repeat seizures without a period of recovery between. Seeing as these seizures were not normal for our patients epilepsy and the diazepam wasn't stopping them I put in a blue call. You won't find many ambulance crews who will say we did the wrong thing. We arrived at hospital, took him into resus and began transferring whilst handing over to the team. By now our patient had begun coming round. I finished my little speech and the doctor replied:

"I understand that but I don't get why it was blue call. It's a seizure, you should know that doesn't warrant a crash team"

I didn't bite but I was clearly pissed! I explained my reasons,  chucked my paperwork on the side and walked out, tail between my legs. If this wasn't bad enough, the same thing happened he following day!

This time a middle aged lady with bad asthma. She was unresponsive to Salbutomol and Atrovent and despite repeat doses and adrenaline she appeared to be having failing respirations. As far as we were concerned it was Life Threatening Asthma and given her history of ITU admissions we were not going to take any chances. The blue call was placed and we headed off to hospital. On route however, there was a marked improvement. All the drugs were doing their thing and by the time we arrived she was able to talk. Good job well done. The handover was given to the waiting team and again, I got a stupid question. This time however I did bite!

"Why did you put in a blue call?"

"Why are you Doctor?"

Everyone looked at me, crew mate included. I just shrugged my shoulder and walked off! She shoots.....she scores! How dare they? We don't do it to annoy them. We do it so our patients get definitive treatment at the earliest opportunity by people much better equipped than we are in the back of an ambulance. No one has ever got in trouble for putting in a blue call and no one will. If you don't and someone dies the hospitals are only too quick to point the finger and blame us. We've done our job now you do yours.  Don't ask, just do! Rant over!

Some things should remain unsaid.......

"43 year old female, face pain"

Some things go together. Cheese and wine, pie and mash, tea and biscuits, pen and paper, burger and chips. They just work. You rarely see one without the other and why would you! The same applies to council estates and time wasters. They go hand in hand.  (OK, as per usual i'm generalising but after doing 9 jobs on the same estate in 1 shift, none of which needed hospital I was left rather jaded). Today was no different. We arrived at the heart of the estate and began looking for the badly signed block amongst all the identical red bricked buildings in front of us. Eventually we found it. I'm not going to lie, the prospect of a 43 year old with face pain wasn't that exciting and on meeting her she didn't change that. It was a flat typical of the estate. Dirty, cluttered, smelt of stale smoke, had the token Staff barking away and it's occupants were unemployed. She had been called us for tooth ache. Why the Ivory Tower had deemed it suitable for an emergency ambulance on blue lights I don't know, but we were here now so I had to make nice!

She was sitting in her armchair, hair a mess, hygiene didn't appear high on her list of priorities, she had missing teeth and bags under her eyes. She was wearing a dressing gown and smoking her Superkings. I asked her to put the fag out while we spoke and after rolling hers eyes she obliged. I explained that tooth ache isn't something that an ambulance deals with, nor is it something that the hospital will deal with. I told her she would need a dentist and if she couldn't wait she would have to find her an emergency one. I got onto Google and wrote down the numbers for 5 local dentists and the nearest one offering 24/7 emergency treatment.

"But I got no money and no credit to call 'em"

I didn't bite, I offered to call one for her but in terms of payment for treatment that was something she would have to discuss with the dentist. I made an appointment for the following day for her and advised what painkillers she should take in the mean time. 

"Take Paracetomol every 4 hours, if you want anything stronger, go to the chemist and see if they have anything for teeth"

"Alright then, fanks for coming"

"Thats OK, not a problem, would you like anything else before we leave?"

"Yeah can you pass me the Femfresh, its on the table over there"


"Femfresh, you know, for my bits"

I heard her the first time and knew what it was for. The 'sorry' was my way of stalling as I didn't know how to react to that. In silence I walked over to the table, picked up said Femfresh and handed it to her, all the while dragging my jaw along the floor. 


Absolutely no shame whatsoever. I felt sick. There are some interactions that should never occur between patient and clinician. This was one of them. In fact, there are some things that should never be an interaction between two people. With that, I left her and her dog too it. I never want to think about it again. Gross.

Getting Egged.........

"25 year old male, burns whilst cooking"

We were due to finish work in ten minutes, so getting sent a job wasn't greeting with joy if i'm brutally honest. In fact, it was greeted with expletives the words 'stich-up'! Nevertheless we set off on the 11.3 mile journey to the far reaches of the city fully expecting to be cancelled for a nearer vehicle. Wishful thinking! We pulled up outside already x-ray (our shift was finished), grabbed our stuff with the addition of the burns kit and headed in to the flats. The flat was crowded to say the least, 10 or so 20 something Romanian guys filled the corridor leading to the kitchen. I could hear our patient groaning in pain and swearing in Romanian as I got to the door. Drama queen was what I was thinking, how wrong I was!

This guy had been cooking dinner for his friends. Spaghetti Bolognese to be precise. He had cooked the sauce in a huge industrial pan, and I mean huge. For some strange reason he had been cooking in just his boxer shorts. Whilst transferring the pan from the hob to the table he had slipped and the entire contents of the boiling pan had gone over him. He was scalded on his face, neck, chest, arms and hands covering 40% of his body. The hot oil in the sauce made it worse too, his skin was bubbling and peeling everywhere and he was in agony. With burns we always advise running under cold water for 10 minutes but invariably different cultures have different ideas. There are old wives tales for what is best thing to do with burns, most commonly potato skins or butter are what we find! Trust me, neither are a good idea! Today however I saw something new and completely bizarre. Our patients friends were under the impression that the best thing to do was crack eggs on the burns. So they did. 24 of them to be precise. Quick question: What happens when you add raw egg to heat?! Just sayin'!

That is how we found our patient. Lying on the kitchen floor, just wearing boxers, surrounded by bolognese sauce, badly burnt and covered in fried / scrambled egg. It looked like he was mummified in an omelette! We helped him up and marched him (slowly) to the bathroom and sat him in the bath where we showered him in cold water for 10 minutes trying to get the bolognese soufflĂ© off his body. Once dry we started the arduous task of dressing his burns as best as we could. After the first futile attempts we decided to wait until on the truck to dress them properly. We carried him downstairs and got him on the bed. The adrenaline was wearing thin and he was in a lot of pain. He was chuffing away on the Entonox but it was having little effect. He needed Morphine and lots of it. Our main problem was he had circumferential burns to both arms where we would normally cannulate and burns to his hands and wrists. Our only other option was his foot, something that is very rarely done but on this occasion had to be. We got fluids running to combat the likely hypovolemic shock that would occur from this percentage of burns and loaded him up with morphine. We now started to dress the wounds with water-gel burn dressings and cling-film. 

Ambulance services in this country work to guidelines. That basically means we work to a set rules but at our discretion can deviate from them. If it works it was a justified deviation, if it doesn't, well, do the maths! Hung out to dry springs to mind.  In this case there is a guideline about only using water-gel dressings to cover a maximum of 12.5% of burns as there is a possibility of causing hypothermia. We had been reminded of this by CSD but they were not with us or with our patient. They couldn't see the pain he was in and the relief he was getting from the water-gel. We covered all of his burns on the basis we can keep him warm with blankets and monitor his temperature but there is nothing else we could do for the pain. Friday night rush hour traffic for 14 miles to the nearest trauma centre could take 35-40 minutes. I for one wasn't going to deny him an opportunity to be in less discomgort. Fluids flowing, Morphine in, burns wrapped and dressed, blue call placed, we headed off. 42 minutes, 2 bags of fluids, 2 cylinders of Entonox and 20mg of Morphine later we arrived at the hospital. I handed him over to the waiting trauma team, explaining the soufflĂ© mishap that had occurred and our ignoring of guidelines. The staff were more than happy that we had dressed all the wounds and said the guideline we had ignored was pre-hospital health and safety nonsense! We felt vindicated. Regarding the eggs......

"Eggs?! Are you bloody serious?! 

People do the strangest things to treat medical problems and I will never cease to be amazed. Needless to say, we were almost 4 hours late off but I didn't care one bit. Very few ambulance staff would care for that matter. It was a great job. If someone genuinely needs us, being late off is the least of our worries. 

Saturday 25 February 2012


With an ambulance service comes expectations. Expectations from the public, from its employees and the expectations it has from it's staff. Following a difference of opinion with my employers I found myself asking three open questions. 

  1. What do the public expect when they call an ambulance?
  2. What do ambulance staff expect when they arrive at work?
  3. What does an ambulance service expect from their employees?

They are open because I can only assume what peoples answers would be. They might disagree. I'd very much like to gather an opinion on all three. This blog is in no means a criticism of the company for which I work. Far from it. It's questioning the system and pressures in which they are forced to operate. Unfortunately, opinions and agendas between managers and road staff will always differ. If they didn't, what would we moan about!

This was the actual side cupboard on the day in
question. A solitary, empty Entonox cyclinder!
My shift was due to begin at 07:00. As always, I arrived at 06:30 to sign drugs out etc and VDI the vehicle. On this particular day, there were 4 crews starting and there were 4 ambulances in the garage. Perfect! We grabbed our stuff and went to sign out drugs. There were no technician drugs left but we had everything else we needed so headed over to the truck. We swung the back door open to be greeted by a lack of trolley bed. Not only that, a lack of carry chair. There was no Lifepack, no defibrillator, no response bags at all. No Entonox, no maternity pack, no dressing pack, no burns kit and no infection control pack. No collars, no head blocks, no rescue board and no scoop! No straps, no splints, no manual handling kit, no suction unit and no helmets! No main oxygen cylinders, no bins, no blankets and no traction splint! Do you see a theme here? We had nothing! It was a shell. We explained our situation to the DSO and were told to hunt around station for missing kit. There was none. A new system is in place whereby all the vehicle were kitted elsewhere and then delivered where needed. Clearly, it's working wonders! We were told to head to the other station and re-stock there. Before we left we were told that we had to make ourselves available for a job as we could 'render aid'. Apparently, the policy states all we need is a BVM and we can attend calls. Obviously I tried to argue and say how could we possibly do our job to the best of our abilities with no kit. Unfortunately I don't have pips on my shoulder! So be it! Off we went!

Sure enough, not 30 seconds from station and we got a job. We explained we had no kit AGAIN but were told we were the nearest vehicle so we had to go. We arrived at the address and wandered in with nothing. The guy had chest pain. We gave him aspirin but that was it. Then we waited. And waited. Ordinarily we would do his blood pressure. We didn't have a cuff. If his blood pressure was OK, we'd have given him GTN to reduce the pre-load on his heart. If we had a Lifepack, we'd do 12-Lead ECG. We didn't have one. Normally, we would check his oxygen saturation, temperature and blood sugar. Maybe even monitor his carbon dioxide levels. He would be constantly monitored. Instead we sat there with our BVM taking a history. After half an hour a second crew arrived and took over. It was embarrassing. Really embarrassing. We were used to stop the clock, that is all. I can see no other reason we were sent. Who's fault is it though? The DSO for not showing us Off The Road (OTR)? How can he, the policy says we only need a BVM, we had one. The dispatcher for sending us? How can they not? We were the nearest resource for someone with a life threatening condition. The Operation Control Manager? They have an 8 minute target to meet, miss it and get a financial penalty. It's the system (the poxy government), but that brings us back to expectations. When Joe public picks up the phone and calls 999 he / she expects the following:
An ambulance, manned by a well trained, uniformed, courteous crew, capable of dealing with any situation and with the necessary kit to do so.
I think it is as simple as that. That should be what is sent to a job. Anything short of that is a failure. That is what the service should be judged on. That is what there should be financial penalties for not adhering to. 

Regarding our vehicle, we made it to our destination. We then spent the next hour re-stocking the vehicle from scratch. An hour that could have been spent hitting that precious target. That's the problem, short term fixes for long term problems. That vehicle was delivered because it ticked a box for the people delivering it. No thought to what the consequences would be because they had ticked their box. Quick fix. We couldn't go straight to fix the problem because we could stop the clock on one job. No thought to the consequences of wasting two ambulance crews on one call. Quick fix. We couldn't take one of the fully kitted vehicles because of station politics. No thought to the childish nature of what was happening because their crews had vehicles sorted for the rest of the day. Quick fix. That brings us back to expectations. When an ambulance crew arrive at work they expect the following:
A clean ambulance, fully stocked, fully kitted and mechanically working to enable them to go and do their job to the best of their ability.
That shouldn't be a rarity. That should be a matter of course. Sadly it isn't. Because of a lack of kit many staff bring in their own kit, even their own bag. Myself included. It makes things easier at the start of a shift, you know you have all the diagnostics you need, you know you have a fully stocked response bag. If you have a shell to work on at the very least you can do some tests and find out what is going on with your patient. Unfortunately, there is now a policy that under no circumstances are staff aloud to use their own diagnostics kit or bag. This is because all the kit we need is provided!! Clearly!! This brings us back to expectations. When an ambulance crew arrives at work the employer expects the following:
To be punctual, well dressed, work within their scope of practise and provide the clinical excellence one expects from a world class ambulance service.
A wry smile crept across my face as I wrote that! We can't do what we are expected to do, without having what we expect to have, which prevents us from providing what the public expect from us! I expect that confused you, but read it twice an I expect you'll understand.

Tuesday 21 February 2012

Mental Health in an Ambulance......

I recently posted a guest blog by MentalHealthCop entitled Safe & Well? This was a joint venture between the two of us and my response to the same question was posted on his blog. As hoped, the posts threw up a lot of questions and commentary on the issue, but for me, one of the most poignant ones came from an anonymous reader.

Whilst you are dealing with patients with mental health problems, how is the mental health of the ambulance service employees handled and is the support there if it's needed?

A very good question indeed and one I decided to answer in full. Mental health is always a 'hush hush' subject when it comes to sick leave. The idea of someone going off with long term stress is not uncommon but is often made light of and even suggested it's just a way to get blag months off work. In all fairness, this has been the case with a number of people and I'm sure the system has been abused, but stress, amongst other mental disorders is a real issue that should be highlighted. 

The job we do is stressful at times and for me personally, it is often a struggle to deal with some of what we see emotionally. We see a lot of acutely ill people and this itself is stressful due to the fact that invariably there will be bad outcomes. As a result of this, there is a distinct possibility of self-recrimination amongst ambulance staff and a likelihood of suffering intrusive thoughts for a prolonged period of time. A number of studies have been done on the prevalence of Post-Traumatic Stress Disorder (PTSD) amongst ambulance staff and it has shown as high as 20% of staff suffers with this condition with 65% thought to have shown some degree of psychiatric morbidity. Although a large proportion of our job is dealing with drunk people and time wasters, seeing dead children, mutilated bodies and neglect leaves an imprint in one's mind. Anyone who says they have never had a job that has affected them is a liar. We all have our coping mechanisms be it sharing, crying, laughing or writing. We do what we need to do to be able to go out again and do our job.

Below are a few facts and figures that I have compiled, from a number of studies, which highlight just how common these issues are within EMS:

  • 22% reported probable clinical levels of anxiety.
  • 20% are indicative of a diagnosis of PTSD.
  • 10% had clinical levels of depression.
  • 45% of respondents reported current troubling memories.
  • 15% reported having had them in the past.
  • 68% report suffering insomnia
  • 21% of which consider it to be chronic insomnia
  • 5% admitted to having had suicidal thoughts.
  • Suicide rate in EMS is 1:3500 compared to 1:10000 amongst the general public.

Cheery stuff isn't it! A large proportion of instances of mental health issues can be attributed to the job we do, however, I feel it is perpetuated by the environment in which we work. Many staff feel overworked, undervalued and mis-treated by management. This isn't limited to my service; this is country wide and goes a long way to explain morale being at its lowest. Despite significant reforms staff still report a lack of respect and bullying tactics used to make the prospect of going off sick untenable. I have seen it first hand, the meetings, the letters, the phone calls, the home visits. It is bullying, make no bones about it. A welfare check always seems to have an undertone of mistrust about it. Whilst I appreciate that sickness needs to managed if you tell a manager you are off sick because you are stressed, not sleeping or you are depressed it's a black mark against your name; a black mark that will stay. You're considered to be 'pulling a fast one'. Mental health, despite the propaganda, is not taken seriously or respected within the ambulance service. Counselling is available but the system isn't trusted. There are LINC workers (internal councillors) who are rarely used due to confidences being breached and everything leads to people lying about the reasons they are off sick. In turn, this pushes mental health further under the carpet.

In a recent survey, 75% of ambulance staff felt they had been disrespected in the last 12 months by a manager. 52% felt they had been bullied and harassed. 83% said there was no concern for employees and 92% said there was a poor relationship between staff and management. 80% said stress wasn't managed effectively & 75% believe they have excessive workloads. Is it any surprise that mental health problems are so common? What amazed me was just how high these figures are. Obviously, sick leave costs money, but for anything to change there needs to be a change in the mindset. If someone says they are stressed it should be taken seriously. Being told to 'go and have a cuppa' after a baby has died in front of you simply isn't good enough. These feelings and images can last for months and I really don't think that this is appreciated and I don't think enough help or follow up support is offered. I have suffered anxiety, stress, intrusive thoughts and depression in the past but I have an outlet, a coping mechanism. Not everyone does. Some of the things we are subject too can be truly harrowing and it didn't take me long to compile a small list of jobs I've attended in the last 3 years that will stick with me forever:

  • Doing CPR on a 7 year old girl after she drowned in her bath.
  • Delivering a still born baby and having to tell the parents.
  • Climbing under a train to find a man mutilated and twister around the wheels.
  • Trying to revive a man you had fallen 60ft and landed face down.
  • Trying to stop the arterial bleed of a man stabbed in the neck.
  • Finding a man hanging in a park.
  • Watching a woman get hit at speed by a car.
  • Declaring a woman dead after being crushed by a bus.
  • Seeing the remains of a man crushed by a JCV.
  • Attending a family of 4 in an RTC. Parents dead. Children orphans.
  • Finding a child, covered in excrement, left on her own.
  • Seeing a man's chest cut open and heart massaged.
I could go on for hours. The reason I mentioned the above jobs was apart from the first one, we weren't stood down for any. We were expected to carry on as if nothing had happened. No follow up support. Nothing. It is of no surprise that PTSD is so common amongst staff when so little compassion and understanding is shown. We aren't robots. These things DO affect us.

Clearly, mental health is a problem that is prevalent within the ambulance service but clearly what we see and what the management see are two different things. My hope is that as mental health is becoming more of a public concern, the acceptance of its severity within the service will trickle down to the managers. It is only when staff feel supported and valued that the true impact that mental health is having can really been seen.

To see how mental health affects our police officers check out MentalHealthCop new blog 'Who is protecting the protectors?'.

Monday 20 February 2012

A Home to go to........

"41 year old male, seizure, will be met at station by staff"

It was rush hour on a Thursday evening. It was already dark and we had only just started. We got the shout to one of our local underground stations about two miles away. Normally a seizure on a train is indeed a seizure on a train. Today was no different. We arrived at the station after a few minutes and with the help of a very friendly station supervisor bundled all our stuff down the steps to the platform. To save on repeat journeys we brought the chair and life pack just in case. If he refused treatment as is common with epileptics we could leave him in the station and if he was in a bad way we could get him back up to the truck quickly. Most of the passengers had piled off the train to get some fresh air or find alternative transport. We were waved over to one of the middle carriages by a group of them. The closer we got the more I became aware of an argument going on. Indeed there was, between the driver and a passer-by. I say passer-by as for all intents and purposes he was but to me he was a colleague. Off duty but rendering aid. Very nice to see! This is what I heard as I got to the doors.

Paramedic: "Quite frankly I don't care about your train, this man is fitting and until he has a) stopped and b) the ambulance arrived nobody is moving him"

Driver: "We all have homes to go to as well, this is my train and we need to get it off the platform, it's causing chaos" 

Paramedic: "I don't care"

Driver: "You idiots think you are so special, I don't care who you said you are, get him off the train."

Me: "This man isn't moving anywhere until I say so and until then I would like you to leave for patient confidentiality reasons. If there is a problem I will get the police"

Driver: "Look at you all fucking sticking together"

With that, he stomped off down the platform to a hail of abuse from various other passengers. Can anyone actually be that uncaring and selfish?! It appears so. Would he drag off a dead body? Probably. Would he wake up a drunk instead of calling us? No! 

Our patient had stopped fitting and was beginning to come round. After about 5 minutes he was back to his normal self and gave us his full epileptic history. This seizure followed his normal pattern and he did not want to go to hospital. We were checking him over so we could send him on his way. The driver was by now loitering again at the door and sheepishly asked how long we would be. 

"We'll be done when we are done"

My bluntness had the desired effect. He stomped off again down the platform telling someone over the radio that the obnoxious ambulance crew were dragging their heels as part of a power game. Maybe we were, maybe we could have removed our patient a few minutes sooner. On the other hand though, maybe he could have shown some compassion and respect. Maybe he should have just let us do our job. Maybe he should think very carefully before criticising us when he works for the greediest bunch of lazy, good for nothing scroungers this country has in its workforce. It really does make me livid.

My feelings about tube drivers are no secret. The way they repeatedly hold our country to random sickens me as I've pointed out in Tube Strikes: The Cost of Greed and this day was no different. It only went to reaffirm my feelings about them. The public will only put up with their nonsense for so long before there is a serious backlash. It took one search of Google for 'Tube Drivers' to find 5 negative stories about them on the opening page.

They are not held in high regard by anyone. I wasn't able to find any positive stories about them which speaks volume for contempt in which they are held by the public. There was no purpose to this blog other than to make myself feel better and showcase  the moral fibre from which they are made. I do feel better now! I just wish one would have the guts to comment and stick up for their actions. Bet they don't........

I've added a video of a song about the London Underground by the parody music due Amateur Transplants (Adam Kay - @amateuradam & Suman Biswas - @amateursuman). This song has amused on on many occasion so hopefully it does the same to you. Genius!

"London Underground"

Safe and Well?

It is with great pleasure that I can introduce MentalHealthCop as a guest blogger.  After a question was posed to me by him on twitter my instant reaction was 'here goes the #no. 2 emergency service trying to palm work off on to us'. However, in the intrest of fair play we agreed to answer the same question on each others blog with a mind to provoke debate from service users and health care professionals alike. Whether we come to the same conclusions I don't know, you'll have to check out his blog for my response!

Why do the ambulance service not undertake “safe and well checks?”

I should explain, I operate a 'rule of thumb' that 'RAVE risks' are the cue for the police to become involved in supporting or temporarily leading health and social care matters, to mitigate risks and keep people safe. It is an operational mnemonic for 'Resistance, Aggression, Violence or Escape'. A far from perfect model, but helps to point the police in the right direction.
Health and social care functions, we'd all agree, are best left to people who know what they're doing, but where they would be exposed to risks, the police should either support them or temporarily lead a situation, until the risks are managed. Once mitigated or found not to exist, the police should begin to disengage and let the professionals take over.

For those who've not read my blog: I've been interested in how we police incidents involving mental health issues since I joined the police and as I've become more involved in it, I've found that frontline police officers like clarity around when a 'mental health job' is a police responsibility.
Egon Bittner (criminologist) said, "There is nothing which could not become the proper business of the police." Of course, this is not the same thing as saying that everything IS the proper business of the police! So where's the line; and who draws it?!

The start of my conversation is usually, "Is there a RAVE risk?" If not, using the police needs to be balanced off against the potential to stigmatise and criminalise the person concerned and it needs to be considered against other police priorities, because we are a finite resource and currently getting smaller.

This is important: the police are frequently accused - as am I personally - of perpetuating the myth that people with mental health problems are violent, when this mostly nonsense.
The police have a certain level of frustration with issues involving mental health: when one is asked to recover an AWOL patient from their home address, despite a Code of Practice saying that this should be done by a mental health professional (who does have legal authority to do so, regardless of what they may tell frontline cops who know no better!) it feels like the existence of the police as a generic 24/7 social service is being taken advantage of. That said, sometimes this frustration is inappropriately placed for if that AWOL patient has a history of aggression and violence, it may be quite appropriate for the police to do it.

So where's the line and who draws it?! And how do you bring about finality to that debate if it emerges that the police and the NHS have drawn their 'battle lines' at different places, leaving a gap between their expectations of each other?

So who should do a "quick safe and well" job? Such checks are often necessary and for a range of reasons: mental health services for community mental health patients who may have failed to attend an outpatient's appointment; general hospital patients or those who have attended A&E who left before treatment or self-discharged before proper explanation of the medical risks involved; other agencies such as education or children's social services asking the police to do checks for children absent from school or not seen.

So in theory, ambulance services could do it for the health situations as they are part of the NHS. For that matter, community mental health teams could do it and Crisis Teams could do it out-of-hours. The NHS is an employer of over 1 million people, working 24/7 and the numerous ways of addressing this issue. So why the police?

None of the scenarios necessarily involve what the public may regard as core police responsibilities: prevention of crime; detection of crime; protection of life and property and maintenance of the Queen's Peace. Especially in those first two scenarios - there are obvious links to health. If health action is required; if explanation of health risks is necessary, surely there can be no question that health professionals of one type or another would be are better suited than a police officer with a first-aid certificate? "But what about [RAVE risks]?" OK, the police should support this to keep you safe, but it remains a health issue at its core.

So I ask, if orientated around health concerns, why not ask the ambulance service to do it? I am being deliberatelyprovocative: apart from their obviously being part of the National Health Service, they are not necessarily any better placed to do this than the police. However outrageous it seems to me (and it does), the ambulance service have no more access to out of hours GPs, community mental health or health services than the police. I once heard a senior social care director within mental health shouting at an ambulance service mental health lead who wanted to do better for patients, "You will NEVER have direct referral access to crisis teams!" Not even, apparently, if the ambulance service knew they were dealing with a person who was currently open to that director's mental health services. I wouldn't have believed it if I hadn't been there. You would rather have a patient coerced by the police or taken by the ambulance to A&E - not a great place to be mentally ill - than have your Crisis Team respond to a mental health crisis involving a current patient?! Bonkers.

Where a safe and well checks leads either emergency service to find a person who is mentally ill in a private dwelling only three things can result:

  • Whether Police or Ambulance - if a person found safe and well; messages can be passed or warnings conveyed but if they are capacitous and are left there or taken to A&E or back to hospital.
  • Ambulance only - person found; not safe and well and especially if uncooperative and / or where capacity is questioned, the get called and then neither agency have a legal power to do anything about it at all (unless Mental Capacity Act can be applied, which will be rare.)
  • Police only - person found; not safe / well and ambulance get called to this health situation and then same predicament: no powers to intervene.As such, NHS Commissioners need to plan for demands we KNOW we will face: how do you respond to spontaneous mental health crisis in a private dwelling where there is no criminal offence? Parliament says, healthcare professionals leading to MHA assessment by an AMHP / DR, if need be for admission under s4 MHA.

We know that the police and ambulance service will be managing these things tonight - regardless of what day you're reading this. The answer is not necessarily 'police' or 'ambulance' and sending these professionals to safe and well checks creates exactly such a scenario. Even if you send them - maybe send the police to the RAVE risks, and the ambulance to the other jobs - they will still need necessary pathways available to them.

So it emerges asking for a "quick safe and well" is too simplistic a description of a fairly complex problem that neither police nor ambulance are necessarily best placed to solve. And so this post is not for paramedics and cops: it is for NHS Commissioners and Service Managers and for inpatient nurses who ask for this to be done.

To read DiagnosisLOB's thoughts go and have a look @MentalHealthCop website!

Friday 17 February 2012


"41 year old female. DIB. Lung cancer patient"

In health care, no one really wants responsibility. We are bottom of the food chain and from us, upwards, there is a long line of people to pass the buck onto. We pass the buck to a nurse, who passes it to an HCA, who passes it back to a nurse. The nurse in turn passes it to a House officer (junior doctor) who passes it onto a Senior House officer who passes it to a Registrar. If the Registrar doesn't know what to do he passes the buck onto a Consultant; top of the food chain. If they don't know what to do, you'll probably die. Sometimes however, this marvellous system of avoiding blame is scuppered by someone not going to hospital. The problem here is that if the GP has been to see them and wants them to go to hospital he or she will phone an ambulance. If the patient refuses you end up with the buck stopping with the lowest level of the NHS. The only place we can turn is our illustrious Clinical Support Desk. However, those who have had contact with our CSD will know they have a phrasebook consisting of only three phrases:
  1. That's a decision you'll have to make.
  2. I'm afraid that's a grey area
  3. Please hold the line..................That's a decision you'll have to make.
Needless to say, when the buck stops with us there is nowhere to turn making these jobs some of the most difficult to deal with.

This particular job was a case in point. We were sent to a private residential address where the GP had already visited. He had assessed our patient and been told by the family that our patient did not wish to go to hospital and would not go to hospital. Needing to pass said buck, we were called. Whether he thought we could convince her to go or just didn't want the responsibility of leaving someone struggling to breathe I don't know but the end result was the two of us entering Amy's bedroom armed with our bags and a smile. Amy had lung cancer. The very late stages of the disease. The disease that had manifested itself throughout her body. A disease that can attack anyone without cause. She'd never smoked, lived a healthy life and worked hard. Where is the justice? She was in palliative care, at home, with her family at her side. When we walked in we were introduced to her two daughters and her husband. Her mother and father were also present. It was a very sombre affair.

"Please don't take her to hospital, she wants to die at home, please" 

"We won't take her anywhere she doesn't want to go"

As I said that, Amy took hold of my hand and gently squeezed it. She didn't have the strength to speak but mouthed 'thank you' to me. She was struggling to breath, her resp rate was high and her SpO2 was very low so with her permission we gave her some oxygen. We spent a while talking to her family while checking her over and it was a very humbling experience. They were such a lovely family, at peace with the inevitable but had called the GP because their mother / wife / daughter was suffering. She was on a syringe driver for pain and everyone was just waiting for her last moments to come. I felt like an impostor that didn't belong there. This family needed to say their goodbyes in private but we couldn't leave our oxygen with them. Obviously when Amy was comfortable we could leave but in taking the oxygen away I didn't want to be the cause of her passing. I phoned clinical support and got a combination of answer 2 & 3 from their book of knowledge. We agreed that we'd go and do our paperwork then come and get our oxygen before we needed to leave. I told Amy what we were going to do and in a moment that I'll never forget she closed her eyes with a smile. As she opened them a tear trickled down her cheek. Being left at home with her family was her only wish and we were able to give that to her. In all honesty we should never have been there but that's the system. 

We sat in the ambulance for a little while doing our paperwork, it was a very sad job and one that frustrated us. It wasn't the fact we were called knowing there was nothing we could do, it wasn't that the buck was past. It was the fact that we'd intruded on a families precious last hours and had to stick around so we could tick all of our boxes and cover our asses. For every job there is a paper trail. One that is scrutinised by our service and what our performance is judged on. That was frustrating. We went back in to get our O2 and leave a copy of our paperwork. I was halfway up the stairs when an unmistakable sound engulfed the landing. It was the sound of sobbing, the sound of pain, the sound of grief. In the fifteen minutes that we had been gone Amy had passed away. Passed away with everyone she loved, and who loved her, at her bedside. Her suffering was over. We sat on the stairs for twenty minutes feeling rather numb. Her husband came back out of the room, tears pouring from his face, yet he was smiling. He was happy his childhood sweetheart could hurt no more. I entered the room to confirm death so I could fill out our Recognition Of Life Extinct form. She looked asleep still with the half smile on her face. She was at peace. I felt the lump in my throat so decided just to grab by bits and make my excuses. I'm sure there is some procedure I didn't follow to the letter and a box I didn't tick but I don't care. There was nothing for us to do and we had no place being there now. I left the paperwork on the dining table so the family could make the arrangements they needed to. Us? We went to go and do another job.

A special relationship......

"22 year old male. Unconscious and bleeding heavily"

A weekend in the city wouldn't be the same without drink, drugs, violence, vomit, blood and blue lights. More often than not, all the above are on the first job of the night. Today was no different. We were on station but our shift hadn't started yet. In a garage that holds 8 ambulances and 8 cars, our truck sat alone & being a Sunday night there was no management around and no admin staff. It was just us doing our VDI when the phone rang. We had already spoken to control to give our fleet number and skill level so they knew we were there so we had to answer! It was a begging phone call pleading for us to start early as there was a Cat A call and no other resources to send. Obviously we obliged, so not really knowing if we were missing anything we shot out the garage. It was only 3 miles we had to travel but doing that at 18:00 on the day of a Spurs vs Arsenal match and heading to Tottenham causes bit of a tricky drive. That aside, we arrived about 15 minutes later to a sea of blue lights. In the road was a guy lying on his back surrounded by police. As I stepped out the vehicle I could see a considerable amount of blood on the WPC's hands. The closer I got, the more blood I could see on all of their hands. What a mess!

The guy had been stabbed numerous times in the leg and once in the stomach and he wasn't in good way. He was pale, sweating and very drowsy. The police were applying fantastic pressure to the wounds so I took a moment to come up with a plan whilst listening to a vague handover. No one was exactly sure of what happened but what they did know was that a large crowd of 'anti emergency service' youths was gathering and were shouting abuse at us and the police. I called for HEMS back up or an FRU. In fact I believe I actually said "send me anything". If ever there was a reply which summed up David Cameron's reign of terror on front line services this was this:

"Sorry, we a spread thin. HEMS are tied up and there is nothing else available at the moment. We've got A & E support running from 13 miles away but until then you'll have to make do. As soon as something comes up I'll send them. Sorry guys"

Still think cuts to emergency services is wise? Hmmm! I wanted someone who could assist in major trauma. No disrespect to A & E support but they are not even aloud to do an ECG or give Calpol. They would be as useful as a chocolate teapot. It was us and the police. I started cutting the guys clothes off. He was panicking but we were far to pre-occupied with his life threatening injuries to be able to talk to him. Cue the police. Not only are their 12 officers trying to keep the crowd back, trying to protect us from some missiles that were being thrown but were applying pressure to wounds, opening dressing, passing us kit and constantly re-assuring our patient. No instructions needed. They just did it. The main source of bleeding was his groin. It was an arterial bleed and was taking all of my energy to apply the pressure needed to slow it down. My crew mate was placing orange cannulas (wide bore cannulas for trauma) in both his arms and drawing up fluids. It was a real mess. 

I was aware of two things. Firstly, the crowd was becoming angrier by the minute and things were getting rather volatile between them and the officers who were now almost making a cordon around us. Secondly, our patient may well die where he lay if we didn't move soon. Again, without prompting the trolley bed appeared. The police knew we had no hands to do it our self. Normally we'd use a scoop or sheet to lift someone but with the number of bodies we had at our disposal it was just a case of lift and run. We got him on board and put in the blue call to the trauma centre. As we were about to leave an FRU turned up. He dumped his car and at our request, drove the ambulance. In the back was me and my crew mate and three cops. The three who had saved our patients life. We arrived at hospital and bundled into resus. The guy was transferred and hospital staff took over from us. Off we went to the blood bath that was our truck. There was blood everywhere, everyone was saturated but it was a good job done by all. 

This job itself would have stood up well as a blog in it's own right but for me it was a great example of the special relationship between the ambulance service and the second best emergency service; the police! (sorry guys, couldn't miss out on the banter). No matter what the job is, there is a respect and admiration between the two of us. We wave as we pass each other on the road (take note fire brigade) and there is always a welcoming look of relief when one of us arrives at the others scene. This was a perfect example of two public services working well together for one purpose. The police come under a lot of stick and put up with much more abuse and violence than we do and normally shrug it off as being part of the job but that isn't good enough. They are a fantastic bunch of people who do the toughest job in the most difficult of circumstances. This country is lucky to have such an outstanding force and the sooner that is recognised by the mindless minority the better. This guy WOULD have died, I have no doubt, if the police hadn't done what they did but it won't gain them any respect or thanks from the idiots who abuse them. It wasn't their job. It was ours but they did what they had to do. I wrote a letter of thanks to their police station, only knowing their shoulder number. I hope it got to them. That's the funny thing. There are so money different police and so many different ambulance crews, most of the time we are working along side officers we have never met yet the respect and professionalism never wavers. Time after time, we call them when there is even a hint of danger and they come running. I'll always be in their debt and as such will always be more than willing to give my call sign, even on the ninth time of asking. Bless 'em!

Wednesday 15 February 2012

Care Homes: Take Note

"Care homes of various standards acting like muppets"

Care homes. The word 'care' isn't meant in any way to be ironic however we have all been to 'that care home'. As sad as that is the standard in care homes is generally poor. That's not to say there are not good ones, there are, however normally where I say the good outweigh the bad, I don't think this is the case. Good care homes seem few and far between and to say you get what you pay for isn't exactly true. It's more pot luck. The care given ranges from excellent to sheer negligent and for the latter we end up having to alert social services through vulnerable adult forms. It's horrible to see the elderly who have spent a lifetime serving the country and paying taxes left in squalor because the care staff don't give a crap. Invariably there are two sides to every care home. The side that the relatives see during visiting hours and the graveyard shift. During the day, patients are paraded in social areas, full of Amitriptyline and polite, English speaking nurses tend to their needs in full view of anyone who pops by. At shift change they are replaced by a bunch of miserable mis-fits who don't care one iota about the people they are supposed to be looking after. OK, I'm generalising massively and tarring the good ones with a bad brush but in all honesty the good homes rarely call us so I we don't see them. They care for their patients as they should and as a result their patient rarely go to hospital. When they do, they are clean, we get a handover, a full history with matching paperwork, an escort and a smile. Sadly we are more likely to get a seriously ill patient, be greeted with a grunt, no handover, no paperwork, no history and no escort. Our patient is likely to have soiled themselves and been left to suffer. These are the homes I want to Take Note. These are the ones that need investigating. These are these are the homes that should face the strictest sanctions. So, with that in mind to avoid a confrontation with us and avoid an inspection from the local council, social services and the police the following should be noted and followed:

  • Don't leave your patient lying in their own faeces.
  • Don't tell us they were fine an hour ago when they've been dead for 6.
  • Don't put your patient to bed after they have gone into cardiac arrest.
  • Don't negate to start CPR because "We are short staffed"
  • Don't negate to start CPR because "I forgot"
  • Don't call yourself a 'care home' if you're not going to care
  • Don't put coded doors on every corridor and look annoyed when we knock.
  • Don't call 999 just because your patient fell over. Check them first.
  • Don't allow a catheter bag to fill to bursting point.
  • Don't allow a colostomy bag to fill to bursting point. 
  • Don't put tea in the mouth of someone who is dead to cover your arse.
  • Don't call yourself a 'care home' if you're not going to care
  • Don't wait until your patient is septic before calling us. 
  • Don't leave your patient uncleaned for days on end. We can tell. We can smell.
  • Don't look at me blankly when I ask what room we need to go to.
  • Don't look at me blankly when I ask what is wrong with the patient.
  • Don't look at me blankly when I ask for a medical history. 
  • Don't call yourself a 'care home' if you're not going to care
  • Don't look at me blankly when I ask for a medication list.
  • Don't look at me blankly when I tell you the patient has been dead for a long time.
  • Don't hide from me. I will find you. 
  • Don't call us because you want less patients on your night shift.
  • Don't leave your care home staffed by all non-english speaking nurses. 
  • Don't call yourself a 'care home' if you're not going to care
  • Don't refuse an escort to hospital when they have paid for an escort to hospital.
  • Don't forget to feed your patients.
  • Don't wait 15 minutes to call us for someone who has gone into cardiac arrest.
  • Don't lock the patient who is in cardiac arrest in their room and wander off.
  • Don't kiss your teeth at me. 
  • Don't call yourself a 'care home' if you're not going to care
  • Don't refuse to give me your name. 
  • Don't tell me it wasn't your job for whatever question I ask you.
  • Don't lie to me. 
  • Don't let relatives come in and watch us doing a resus.
  • Don't let other residents stand and watch us do a resus. 
  • Don't call yourself a 'care home' if you're not going to care
  • Don't leave your residents sat in the same chair for 15 hours a day. 
  • Don't tell me you're a "residential home, not a care home" as an excuse.
  • Don't take me to the wrong patient.
  • Don't give me the paperwork and medication of the wrong patient. 
  • Don't call us and then wait 15 minutes to let us in the building.
  • Don't call yourself a 'care home' if you're not going to care
  • Don't tell me a patient who is hypo had a BM of 10, 20 minutes ago. 
  • Don't drop your patients.
  • Don't blame your patients. They are in your care.
  • Don't be rude or dismissive to us.
  • Don't blame everything on dementia.
  • Don't call yourself a 'care home' if you're not going to care
  • Don't wait a month to change your patients bed sheets. 
  • Don't forget humans need water. We can tell if you forget.
  • Don't be a carer if you don't care.
This are not me or ambulance crews being pedantic, these are basic human rights. Treat others as you'd like to be treated. Some of the places we visit are verging on inhumane and the sooner something is done to prevent this third world squalor the better. Every single one of the above I have witnessed and can only comment on what I see. Like I said, I don't see enough of the good homes because the patients are well cared for and rarely need an ambulance!

Click the Take Note photo at the top to see the other posts in the series!