Does The End Justify The Means?

"36 year old make threatening to jump of balcony. HE IS VIOLENT"

Oh goody goody gum drops! Some mental health to end the shift! It'd been at least two hours since we had dealt with some! This time however, there was a little more gravity to the situation (excuse the pun). These 'jumping' jobs could literally be anything. I could be a Holby City'esque dramatic scene where we spend ages waiting while the patient is 'talked down'. It could be a cry for help where the patient has no intention for jumping and moves away from the balcony when asked. Or, it could be a major trauma waiting to happen and we don't know whether to leave our bags downstairs or go upstairs. The latter would be the least appealing and by far the most stressful but as always, it's a mystery until we arrive. These are things we think about on route to jobs like this. You need a plan for each outcome so you're not caught off guard!

We pulled up behind the police cars that were already there and looked up! Sure enough, about 4 stories up was a man leaning up against the railings of a balcony. About 20ft away were the police. Do we go up, do we stay down?! We went up and joined the police. The patient was shouting that he was going to jump and said he was fed with everything. The conversations between him and police went back and forth for a little while. Apparently this wasn't the block of flats he lived in so if he could be coaxed away from the railing s136 could be used to get him to a place of safety. Suddenly, without warning he ran! He ran down a stairwell, across a covered walkway and into the adjacent  block of flats! We all followed. By the time we caught up with the police, they were inside a flat. 

Inside was our patient sitting on his bed. His mood had changed from utter despair to one of anger and he would not be reasoned with. The police were explaining that he had to come to hospital to he indignantly replied:

"No I bloody don't!"

The 'yes you do', 'no I don't' playground argument went on for some time but at no point did he budge from his stance that he was going nowhere.

"You have no right to take me anywhere without a warrant. I'm in my own home, you need a court order to get me out of here."

He knew his stuff, the only power to remove him here and now was ours if we could prove that he lacked capacity under the Mental Capacity Act. His life wasn't in imminent danger now he was in his flat despite what had occurred previously. That was at least by the letter of the law. I went through the motions knowing full well that he would pass! And he did! He was able to rationalise his decision, he was able to retain information and he was able to explain in clear language that he didn't want to go to hospital and why! It is a frustrating part of mental health law. The only power available to the police was a s135 magistrates order that would need to be applied for by an AMHP to force someone to have a mental health assessment. We were stuck! Or were we......

We had a discussion with the police outside regarding what to do. No amount of pleading would make him come to hospital but the copper who seemed to be running the show said:

"We'll have to 136 him."

Alarm bells started ringing in my head! I'm no expert like @MentalHealthCop is but I know this can't be right!

"But he's in his own home so s136 is useless here."

"No, he was in a public place when we arrived so we can still remove him."

He said it with authority but I wasn't remotely convinced. Time to bring in reinforcements! Ah, the joys of social media and the professional connects Twitter gives us! Time to ask the expert! So, I texted @MentalHealthCop for some tactical advice!

Just what I thought! Needless to say I got bantered on Twitter for interrupting the rugby but I'll take that! It was what I thought but needed to be sure before I let me thought be heard. Before the times of Twitter there would be no immediate contact with people from other professions and I think it's great that it can be used in such a positive way. 

So, back into the flat I went. 

"Section 136 can't be used, he's exercised his liberty to remove that option. We'll need another plan. I know he's vulnerable and we've all heard him threatening suicide but I don't see there is much we can do now he's here."

"We are sectioning him, we are just waiting for the van to arrive."

Clearly I wasn't going to be listened to so we stood outside with our tails between our legs and watched the illegal kidnapping unfold. It wasn't a pleasant thing to watch, distressing to say the least. Seeing someone restrained in their own home, removed against their will and screaming for all and sundry to see was not in the patients best interest by any stretch of the imagination. He was already in a very fragile state, how will this impact on his future treatment? I don't know how the police involved documented and justified their actions but they certainly won't have said they sectioned him from inside his own dwelling. We watched as he was loaded into the van and my crew mate travelled with them while I followed. 

I know that the patient needed hospital, and as it was he was taken (albeit under an illegal section) to the mental health unit but it is NOT a case of the end justifies the means. Or is it? The mental healths laws and police powers that are there, are there for a reason. Breaking these rules only goes to put further barriers between patients the services available to them. This patient will never have trust in the police. I trust the police and I know this was one decision made my one policeman but a patient wouldn't see it like that. He knew his rights and he knows his rights have been illegally removed. Unfortunately, it will be his word against the police and who would believe a depressed, schizophrenic with a long history of crime and drug use. Rules are rules and laws are laws. He has been punished previously for breaking the law. What example does it set when the people who uphold the law are technically breaking it? The flip side is that in this instance the police were doing what they felt was right and were trying to act in the patients best interest. 

This job will also damage the image of the ambulance service in this patients eyes. We were party to it, guilty by association if you will. Sure, it's only one patient but that's not the point. Mental health is a challenging thing for all services to deal with. Like I have said many times before, working together and having an open dialogue with all services is essential but each service has its own responsibility to adhere to the rules, apply them within the framework that already exists and always act in the patient's best interest. The latter is where the grey area engulfs us all. Who really knows what is in a patients best interest? It will always be personal opinion and that will never change. You tell me, does the end justify the means?

Not Again

"84 year old female, fall"

It was the start of the shift and this particular patient had been lying on the floor for about two hours. Not a priority right?! Patient care is the ambulance services number one focus right? Hmmm. Anyway, grumbles about the right and wrongs of making an 84 year old wait on the floor for two hours, off we went! We were let into the house by our patients husband who clearly suffered with dementia. He shuffled up and down the hallway for most of the time we were there. Very sad to see. Our patient was lying on the floor in piano / bedroom. Her bed was now downstairs and placed a few feet away from a wonderful grand piano. She used to be a professional pianist and this way she could still lose herself in her music without the need to struggle with the stairs. 

We assessed her whilst she was on the floor and quickly determined that there were no injuries. The only problem was that she had been incontinent. We got her up and onto the chair. The evening carer hadn't shown up which is what had caused her to venture to the toilet in the first place so we were left doing the carers work. We undressed her, gave her a flannel wash and re-dressed her in her night clothes. She hadn't been wearing an incontinence pad when we found her so I assumed it was because she'd been on the floor so long. She was so thankful and grateful and apologetic, it must be so horrible to lose your dignity in such a way. Hospital wasn't on the agenda because she cared for her husband who was still shuffling up and down the corridor.

Once it was established that she would normally help her husband to bed, we said we'd put him to bed, then come and put her to bed, to save her walking around with her frame too much. So, for the second time we did the work that the carer  that they pay for should have done. We took her husband to his bedroom, undressed him, washed him, re-dressed him, gave him his pills and put him to bed. Job done! Now, back to our patient.

My crew mate had prepared her medication and a glass of water. We gave her all the pills which she took so now it was just a case of bed and goodbyes. We stood her up and immediately noticed the wet patch on the chair. A cursory glanced down made it clear she'd wet herself. Not again! Remember that assumption I made?! They really are the mother of all f**k ups! It was then that I noticed I pile of incontinence pads stacked behind the door! So, we undressed her, washed her, re-dressed her and got her into bed. Again, she couldn't stop thanking us and apologising despite my threat of charging her £5 for of every time she said 'sorry'! We packed up our stuff and said our goodbyes when she said:

"I'm really sorry, but I think I need the toilet."

Bags down, duvet off, swing legs around, help up with frame and usher quickly towards the toilet. Unfortunately, at 84 'quickly' wasn't something that was going to happen. She slowly shuffled, one step at a time towards the toilet. 4 meters, 3 meters, 2 meters, fart, 1.5 meters, fart, 1 meter.....

"Sorry, I didn't make it."

The smell confirmed our fears. Not again! We got her onto the toilet, we undressed her, we extensively cleaned her, we got yet more clothes and redressed her, we got her back into bed and we put a load of washing on. I finished off my paperwork including a vulnerable adult form (she clearly needs more help and commode) and then said our goodbyes. On cue, the front door opened and in walked the carer......

An Ode To Will

"Happy Birthday to my little friend that likes boys"

This is a short blog and has no medical relevance and nothing whatsoever to do with my job! It is simply to say happy birthday to my friend and loyal reader @halloikbenwill! He's been a reader since day 1 from the age of 17 as aspires to become a Paramedic! Today he turns 19 (which I hate him for) but I promised to post him a Happy Birthday blog for all his help with getting my out there! 

So.......

Happy Birthday Will!!!

Have a fab day and don't forget to post my blog on your Facebook page. If you don't I will hunt you down! If you don't follow him already, I suggest you do! This is why I love him!

"Who the FUCK decided to call it a sphygmomanometer? WHO?"

"Your mothers fathers fathers uncles great grandmothers aunt was Irish... You're American. Not Irish."

"I want a giraffe"

"If you get cat pee in your eye you will get pregnant and die"

"I don't like bowling. Or Beyonce #Superbowl2013 #SuperbowlXLVII#SuperBowl"

"I want to show Tom Daley my tweets and by tweets I mean my penis"

Need I say anymore?! Happy Birthday young William! And don't forget, a bear is for life, not just for birthdays.

Getting Schooled

"71 year old female, fall"

Elderly fallers are our bread and butter jobs. We do them day in and day out and unlike drunks, I don't get bored of them. They are always appreciative and more often than not it's a case of getting them up, making a tea, having a chin wag and leaving! Who wouldn't like that?! Sometimes of course they do injure themselves, head injuries, neck of femurs (NOF), hips and wrists. One slight saving grace, is as we get older, we feel pain less and less!

We pulled up outside the house, navigated the overgrown path and got the torch out to open the key safe on the wall. Key safes are wonderful things but I don't like them! I like that you get into the house when someone is in need, but I don't like letting myself into a dark house! It creeps me out! I always open the door with a very tentative 'Hello, ambulance' desperate to hear a response. Luckily, today, I got a response so followed the noise!

Lying on the floor was the loveliest of ladies. We were greeted with a huge smile and despite her clearly broken ankle she was full of the joys of spring. That was a good thing for me because at 1am on a Friday night my joys of spring were somewhat waining! We chatted away whilst we did what we do! Check for neck pain, pulse, respiratory rate, blood pressure, temperature, blood sugar, look at pupils, head to toe survey, check for pain down the back, assess the injury, check for a pulse in the foot, find it and mark it with a cross and place foot in a box-splint. While this was all going on, chat about life through the haze of the Entonox, laugh when she laughs, stick a cannula in her vein, give some morphine and when she starts feeling sick give an anti-imetic. Once ready to move, lift her up onto our chair, grab an overnight bag of stuff, carry her down the stairs, lock up the house, load her onto the ambulance, quick ECG due to medical history and off we go to hospital! Simple! 

Despite her blood pressure being very good on arrival, the morphine and dropped it a fair bit so we raised her legs on the bed. We wheeled her into the A & E department and 'offloaded' her (it's a phrase that makes her sound like a Tesco delivery but it's the term that is used!) onto the hospital bed whilst being watched by the handover nurse. I then went to give my handover, complete with a smile on my face. 

Before I continue, bear in mind the patient is in her nightie, her legs are raised and her left leg is in a huge, bright yellow box splint. It was pretty  obvious what was wrong, roughly speaking! 

Anyway, the handover, I put on my best smile and my cheeriest voice! 

"Good evening"

"Hardly"

"That good eh?! 

"Right, what's the problem?"

"Ketamine overdose......." I said with a rye smile.

*cue the awkward silence and a death stare from the Matron*

Wow! If looks could kill! She glared at me like I had just drowned a kitten. Clearly I'd picked the wrong crowd to waste my best gags on! I'm sorry, THAT IS FUNNY! Maybe it isn't! Maybe I just think I'm funny! Surely though, a bit of light humour at an appropriate time isn't a bad thing. Obviously I wouldn't do it on a blue call or when I've got a patient who wouldn't find it funny but this one had a wicked sense on humour and shrieked with laughter! It's part of the job! If you can't have a laugh to cheer up your patients or a grumpy looking nurse, what can you do?! 

I completed a very mundane, highly factual handover, the nurse vaguely listened and then left. We bid farewell to are patient who was still smiling and very thankful and off we went. As we walked away my crew mate turned to me and said:

"You got schooled!"

That I did. And there was me thinking that laughter was the best medicine!

Private Parts

"79 year old female, abdo pain"

For a change from the norm, I wasn't working on an ambulance. Tonight I was on the FRU (Fast Response Unit) car on my lonesome. A typical 12 hour car shift generally consists of sitting on standby waiting for the higher priority of calls to come through. You generally stay in your area so that you can be on scene quickly for the patients (and to stop the clock before the 7 minute 59 second deadline). Unlike the ambulance you are not sent to anything and everything which is a pleasant change but you do often have to wait some time, often with a sick patient, for an ambulance to arrive. When the ambulance arrives you hand over and leave your patient in their more than capable hands. If there is no paramedic on the ambulance and you either have concerns about the patient or need to administer drugs etc  then you may travel with the crew but more often than not it's a simple handover and off you go.

I arrived within about 3 minutes of the call coming in, grabbed all my kit (so much heavier on your own) and trundled up to the front door. Once inside I was taken to the patient who was sat on the toilet. She was obviously in pain so offered her some Entonox which worked well. The basic aim for the FRU is to a) stabilise the patient and get us much information, history and observations as possible before the crew arrives. I checked her over and most of her observations were OK. Her heart rate was raised a little and her temperature was a little high but other than that it was just a pain problem. I suspected from the way she was describing it, it was an inflamed stomach ulcer or something similar and she had a history and medication list to match that. I couldn't give morphine as she had a known sensitivity to it so it was a case of waiting for a crew to take her in. Simples!

Then, the crew arrived. Not a crew from my NHS Ambulance trust but a private ambulance service. The two middle ages guys were rude to the relatives who were trying to tell them what was happening on their way up the stairs. 

"We'll find out what going from the car driver if it's OK."

What a douche bag! Sure, clinically, you'll find out what is happening from the FRU but there is no harm is at least pretending to be interested in what the family have to say. Also, 'car driver'?! Seriously?! Two middle aged guys stood in the door to the bathroom, the one who appeared to be attending had his arms in his pockets and was chewing gum in a hugely grotesque way. I started my handover with full history, observations and differential diagnosis and it was clear he wasn't listening to a word I was saying. In fact, half way through, he turned to his crew mate to say 'reckon she can walk'. I ended my handover with, 'so if one of you could grab a chair that would be great'.

"I reckon she'll be alright on her feet"

"Well I'd like her to go in chair, so could you get a chair please."

He didn't bother hiding his displeasure and rolled his eyes. They BOTH went to go and get the chair, clearly to have a bitch about me. I've been on scene for 25 minutes, if they had listened to my handover they would have heard me describe her pain and would have heard me say that the Entonox is helping but is making her dizzy. They would have also heard me mention her usual mobility is slow and she uses a frame. A lifetime of tax and national insurance and being unwell entitles a 79 year old to god dam chair in my opinion. These numpties would just have to suck it up. 

After helping carry her down the stairs because one of them 'had a bad back' we got her onto the ambulance. The driver got in the front and the attendant sat behind the head of the patient. I find this impersonal and rude but that didn't surprise me from these two. 

"Are you going to monitor her and give her some more Entonox?"

"We don't have any and what are supposed to monitor?"

"Her pulse, oxygen saturation, her blood pressure etc."

"But you've said they were OK"

"But it could change!"

Again he rolled his eyes and reached for a blood pressure cuff. I'd had enough, I didn't want to spend any more time with them but I also didn't want to leave this lovely elderly lady in their 'care'. I decided to travel with them, bring my Entonox and monitor the patient myself much to the annoyance of Tweedle Dum and Tweedle Dee. Eventually, we go to hospital, I handed over to the nurse and managed to grab another FRU to take me back to my car. Before I left I told the private crew what I thought of their lacking professionalism and told them in no uncertain terms I'd be lodging a complaint. They didn't seem to care one iota. 

This job is not an isolated case unfortunately. If you speak to any FRU who has come across one of the ever increasing amount of private ambulance services you will hear similar tales. At busy periods, my service is becoming more and more reliant on them rather than using the money to staff their own ambulances. There is little or no quality control and you also have a situation where vast numbers of staff who have been sacked for a wide number of reasons from drink driving, drug offences, misconduct, patient complaints and having sex in ambulance service vehicles are now working for the service again through the private companies who's only motivation is money. 

This is having an effect on patient care and it is only getting worse. The training these private ambulance services provide to their staff is minimal at best, they are generally staffed with much less qualified members of staff because it is cheaper that way. They also are picking from a much smaller talent pool because generally, and there are exemptions, the people looking for work in the private sector are not qualified or not allowed to work for NHS trusts. i.e.: criminal records and those previously struck off by the HCPC. As the role of Emergency Medical Technician, Emergency Care Assistant etc are not protected or registered titles, anyone can do them. I met one crew who between them had had 6 days of training before stepping foot on the ambulance. It's a liability. They are a bunch of cowboys and chancers. 

In my opinion these companies need to be irradiated. Where money is the primary focus, patient care will suffer. That's a fact. Sure, it may be cheaper for the government to gradually privatise the ambulance services but at what cost. I certainly wouldn't want these imbeciles to go to a member of my family. Would you want them to come to yours? It seems that the budget cuts are being used to undermine the ambulance services for the ulterior motive of future privatisation. If you cut our staff and cut our budgets we cannot work as efficiently with the ever increasing call volume. Then, to blame us and say private ambulances are the way forward because we are not providing the level of cover required is absurd. Put the money to where it is needed. Well trained staff on well equipped ambulances. What do I know, I'm just a bum on a seat, I probably can't see the big picture. 

By the way, that 'Big Picture' the Tories tell you all about is this...... A picture of our elected MPs and our unelected Lords sitting round a big table, raising a glass to the stroke of genius that led them to all own shares in private medical companies and then sell of the NHS to the highest bidder, thus making them all richer than they were. Great picture from down here.

I'm just a Fire Starter

"25 year old female, mental breakdown, setting fire to her room"

This had all the ingredients to be 'one of those jobs'. By that, I mean a job needing diplomacy, co-operation from mental health services and patience. It may also need police and fire, the latter of which I could happily do without! Mental health jobs kind of excite me in a weird way. I know that it will be tough to deal with, I know I will end up getting frustrated and wound up by the lack of options available to me and ultimately I know I'll probably end up blogging about the shoddy mental health care that patients have access too! Then again my fascination with mental health and psychology makes me gluten for punishment!

We pulled up outside to see a police car parked up. As we got out Trumpton pulled into the road, sirens blaring, causing curtain twitches galore to appear in their windows. Bear in mind it was 2am. There was absolutely no need for sirens on residential streets, but that's 'pet rescue' for you. As we approached the front door one of the coppers came out. 

"Evening ladies, she's upstairs, I'll send Trumpton back to bed!"

It's as if he was reading my mind! I headed up the stairs and followed the noise that was coming from one of the rooms. It was a halfway house for people recently discharged from the local mental health unit and there was an office at the end of the landing with a rather fed-up looking woman sitting inside. She just pointed at the room where the noise was coming from with a shake of the head. 

The police explained that she had been discharged for the mental health unit about 6 hours previous and had been 'freaking out' ever since she arrived here. She had been setting fire to documents and her mediation and was doing so because the voices in her head were telling her to do so. I made various attempts to talk to her without success. I like to think I can talk to mental health patients, some can and some can't. Normally I am able to, but sometimes patients either won't engage at all or will only engage with people who have gained their trust. In this case, she wouldn't engage with anyone. Stupidly I turned my back to talk to my crew mate and a water bottle came flying across the room and got acquainted with the back of my head. No cut, no lump, no harm done, but still.....uncalled for!

The police were savvy enough to know that jumping on her for assaulting me would have been of little benefit so it was ignored. She was scared, unsettled to say the least and was surrounded by police and an ambulance crew. We were all there to help her but I imagine it didn't feel like that. She said she wanted her case worker and that he was back at the mental health unit. As far as we were concerned, that's where she should be and as she had only just been discharged the plan was to take her back. With that suggestion she frog marched herself out of the room and downstairs towards the ambulance. I simply followed! That was easy!

Once on board we convinced her that it was in her best interest to let us check her over medically so that the unit would have no qualms about accepting her. She was medially fit as far as I was concerned. No alcohol in her body, no unauthorised drugs, no injuries, nothing! Excellent! Off we went, police in toe! 

So, there we were, 1 x patient, 2 x ambulance staff, 5 x police officers and 1 x mental health worker from the half way house. All 9 of us bundled into the lobby of the mental health unit. Behind the security glass that would rival most banks was a collection of staff. We were ushered round to the door to hand over. I explained what had happened and why we were her. Her response:

"She's not coming in here."

"Why not?"

"She's been assessed and discharged. There is nothing wrong with her mentally. It's just behavioural problems and attention seeking."

"We are called to a young woman, discharged from a mental health unit hours previous who states she is hearing voices and is setting fire to her room. She has anti-depressants and anti-psychotic medication. She clearly does have some kind of mental health problem and that is why we are here."

"Well she doesn't. I assessed her myself, we aren't here to sort out peoples behavioural problems."

"But you are here to help sort out voices in someones head."

"She doesn't have voices."

"She says she does."

At this point, one of the coppers took over.

"We believe she is suffering a manic episode, the employee at the mental health half-way house agrees. If she doesn't have any mental health problems why are you putting her in a building for people recovering from mental health problems?"

After a brief pause..... "She'll have to go to A & E first. We can't accept her until she has been cleared by A &E"

"A minute ago you said you couldn't accept her because he hadn't got anything wrong with her! We have brought her here to you, this is the most appropriate place for her and the fact you discharged her less than 5 hours ago, to me, makes it a failed discharge. I suggest you re-assess her because your initial lack of diagnosis has been found wanting."

Another brief pause...... "Bring her through."

HURRAH!!!! Oh the joys of a mental health unit! To be fair, I knew it was never going to be easy! With my blood pressure suitable raised and my mood suitable lowered we trundled off to the ambulance so I could have an expletive filled rant in private! Good times!

ICE ICE Baby

"14 year old female, unconscious"

Getting sent to an unconscious 14 year old in a park on a Saturday night means drunk! OK, I'm sure there will be an anonymous commenter who will list all the other possible causes of unconsciousness in a teenager and tell be it is negligent to suggest it's alcohol but let's face it. She's drunk. If I'm wrong, I'll eat my hat! 

We found the entrance to the park, chucked ALL the bags on the trolley bed to cover ALL possibilities and headed off into the darkness. We followed the noise and illumination of cigarettes to a group of 6 drunk teenagers. Lying on the floor, covered in vomit was our patient. Not only was she drunk, she was freezing cold. We briefly assessed her, got her on the bed and off into the warm. None of the friends were willing to come with her and none of them knew her parents phone number. That puts us in an awkward position of transporting a minor, to a hospital which is possibly further away from her home and unable to let her parents know she was safe.

Her blood pressure was extremely low so we raised her legs and gave her some fluids. We only had her first name and she was well and truly out of it. If I was her, I'd be on the hunt for some new friends when I came round! Useless! We opened her vomit covered bag and got out her mobile phone to hunt for 'Mum' or 'Dad' in the phone book. If we were really lucky we'd find an ICE (In Case of Emergency) contact. For those not aware, ICE contacts was something that started in 2005 and the idea is that everyone has a contact in their phone book called ICE so that in the case of an emergency an ambulance crew, police or hospital staff can contact your next of kin. A very easy, simple solution, especially as everyone has mobile phones these days! There is however, a problem! Screen Lock! 

Most people have their phone locked. Despite the issue being brought to the attention of phone companies no solution has yet been found and therefor we were left in a situation like tonight. An unconscious teenager, no idea where she is from, no way of contacting her parents and no access to her phone! Luckily, she was drunk and it was more than likely that within the hour she would be awake enough to talk to hospital staff. Suppose though, she had been hit by a car and was fighting for her life. How would her parents find out? 

We got her to hospital and left her in the safety of the staff. All we had for them was that she was possibly 14 and her first name. 1am is no time for a girl of that age to be out, let alone drinking. I wonder where her parents thought she was!

This job did make me think about the ICE system and how widely used it is. I have an ICE contact on my phone but I also have my phone locked, so it's useless! Only once have I ever been able to contact a relative via an ICE contact so does the campaign need some new attention?!

Do you have an ICE contact in your phone?

Do you have a phone lock on?

Perhaps now, you'll ensure your children have them on theirs or at least have the ICE contact on their screen saver. Let me know! I'd be interested to hear if the novelty has warn off or if it never got going.

Fat vs Fag

"56 year old male, chest pain, DIB"

Despite a large number of pedestrians trying their very best to throw themselves in front of my ambulance and numerous cyclists doing their uppermost to raise my blood pressure we made it to the address without any deaths on our conscious! Loaded up like a travelling circus, we headed round to the entrance to the flats and staggered up the stairs and knocked. The smell of stale smoke hit me even before the door was opened. Eventually, we were let in by our very breathless patient. He slowly walked back into the flat, pulling his oxygen tubing with him. 

Home oxygen is given to people with severe respiratory problems and our guy was a long term COPD (Chronic Obstructive Pulmonary Disease) sufferer. Sitting in his chair he panted for about 30 seconds until he was able to speak. The upshot of the story was his lungs were pooped. He was having a particularly bad day of 'pooped lungs' and it was causing him real discomfort. Whilst my crew mate was doing his ECG etc my Detective Columbo eyes were wondering around the room. On the table next to the patient was a blue inhaler, a purple inhaler, a brown inhaler, various tablets, a bowl with spit in it, a tin of Fisherman's Friends, a lighter, an ashtray and a pack of 20 Superking. 

"You're still smoking?!"

"Yeah, I know I shouldn't."

"How many a day?"

"Maybe 30 or 40"

"No wonder you're breathless!"

"I know I know, save the lecture, I've heard it before!" he said with a grin!

"You know I have to say something! We call it health promotion, you call it nagging!"

We had a good chuckle about flogging dead horses! He was a really nice guy with plenty of tales to tell which made the journey to hospital a lot more enjoyable than usual. Then he said something that firstly took me back a bit and then got me thinking.

"So, you wag your finger at me for smoking, do you wag your finger at fat people for over eating?"

It took me a good while of thinking to reply:

"No!"

"Well don't you think it's unfair to pick on us smokers! Besides, you're one to talk. If I'm not mistaken that's a pack of cigarettes in your top pocket!"

BUSTED! He had me hook, line and sinker! Nothing I could say now would have any credibility when it came to smoking! I felt like saying "Do as I say, not as I do" but I was laughing to much! I could hear my crew mate in the front laughing away too! 

"You just got schooled!" he shouted through.

It's true! I had indeed got schooled! We dropped him off at hospital to get the treatment he desperately needed and left. I could hear him chuckling as we walked away! He was awfully proud of himself! 

He had a bloody good point though. Why don't we berate obese people? Why is it acceptable to say 'filthy habit', 'can't stand the smell of smoke', 'do you have to do that near me?', 'it will kill you' and make the smokers smoke outside to be made a spectacle of?

Why is NOT acceptable to say to someone who is obese who is stuffing a burger into their face 'that's a filthy habbit' or 'I can't stand the sight of you shovelling food into your gob' or 'do you have to do that near me' or 'eating that stuff will make you fatter' or 'being so fat will kill you?' Why can't we tell them that their fatness is disgusting? Why can't we make them eat fast food standing outside under a gazebo and make a spectacle of them?

Because, as a country we are not quite there yet and too many of us love a Big Mac! Before you all tell me I am being harsh and horrible, I don't actually think all that stuff, nor would I want to say it but it is an interesting talking point. Smoking kills. That's a fact. As a result smoking has been made less and less appealing. Tobacco companies can't sponsor anything, their packets are covered in 'SMOKING KILLS' slogans and images of tumours. It costs more and more to buy them, you can't smoke anywhere in public and rightly so. Smoking costs the NHS in excess of £5 billion a year and that's not including the cost of lost productivity. It also causes 1 in 5 of all deaths. Why wouldn't we try and stop people smoking and make it as unappealing as possible?!

How about if I told you that but next year, obesity will be costing the NHS £6.3 billion a year. At the moment 1 in 10 deaths are caused by obesity but within 10 years that number is expected to treble. If that is the case obesity will be costing more and causing more deaths than smoking. Will it then be acceptable to malign the obese like we malign smokers?! Will Big Macs have photos of fat people on them with slogans like 'BIG MAC KILLS' plastered across them?! Will there be a huge tax added to all foods that make people fat?! Will companies like McDonald's be banned from advertising?! Will all fast food have to be served in plain packaging?! 

What do you think?! Should smokers be vilified? Should fat people be vilified? Do we allow free choice in this country only when it suits current political motives? When do we do with obesity what we have done with smoking? Do we wait 15 years until 70% of the UK population is obese or overweight? I don't know what to do. I would certainly feel uncomfortable sitting in the back of an ambulance telling someone they are too fat. I feel bad enough telling smokers not to smoke! Being a fat smoker myself doesn't put me in a good position to lecture either!!

Alternatively, you could scrap everything I've just said, promote smoking and encourage over eating because some studies say making the population healthy would cost the country more in the long term from a longer life expectancy and care costs! Basically, we are screwed whatever we do so I'm just going to eat, smoke, drink and be merry! You?!

Me, Myself and Ambulances

"27 year old female, bored, hacked off, fed up and tired"

This is my blog. I have have been writing it for about 15 months and it has helped me no end. It gives me focus at work, it has made me a better clinician and has helped my health in a number of ways. I may be opinionated, I may be judgemental and I may be hot headed but that is my way of venting about what I see. This blog isn't real life. Look on it as a work of fiction if you will loosely based on real events. 

I'm bored of having to tell a select few people that I AM NOT breaching patient confidentiality when I write. I'm not stupid. I would never write anything which could be linked back to specific person. 

I'm fed up with people leaving insults and threats because they disagree with me. If you have a different opinion, share it. Ask me a question. Don't spit feathers at me, don't climb on a high horse and get all your mates to leave similar comments and don't patronise me.

I'm hacked off with having to write this post to explain myself AGAIN. I have never received a complaint letter. I have received plenty of thank you letters. I have received commendations. I act professionally at ALL times and treat ALL others how I'd like to be treated.

I'm tired of losing sleep because of trolls, bullies, intimidators and those that threaten me. No more. Until now I have never blocked anyone on twitter and I have never deleted a comment on my blog. That ends today. I'm not taking crap from a tiny, tiny minority. It may only be about 5 people who have moaned out of the 70,000 who have viewed by blog this month but it's those 5 that have ruined various days and various much needed sleeps. 

So, to everyone who is unclear and thinks I'm full of hatred, classist, unprofessional, discriminatory and whatever other term of endearment you can come up with, this is ME from the 'about me' page on my blog. Read it, absorb it and if you don't like me, or my blog please please please go away and don't come back. 

*          *          *          *          *          *          *

My name is Ella Shaw. I work on ambulances somewhere between Lands End & John O'Groats and in my spare time, own a 5 year old boy. 

Ambulances: I didn't always want to do this. I'm not going to lie and say it was something I dreamt of, in fact, until I saw the advert in 2008 the thought hadn't crossed my mind. I suppose I applied on a whim; just looking for something to get me out of the dead end 9-5 I'd been in. To my amazement I got the job. I completed my training and off I went into the big wide world of ambulances, and I haven't looked back since. It was by far the best decision I have ever made.

I have always been the type of person that questions right and wrong and in this job you experience a lot of both: politics at local level, government policy, patient behaviour, staff attitudes, life or death and everything in the middle, and I find myself asking questions. Invariably that involves an indignant rant and grumble but that's me. I'm a full time cynic, part time pessimist and a conspiracy theorist at weekends. I love a good moan but I can't stand moaners. That's my right. Deal with it.

The Boy: The boy means everything to me, part of why I wanted this job was to have a career to support him, the security of a job that will always be needed and the regular salary and pension to provide for him. I am immensely proud of him, he is funny, intelligent and happy. He has also sleeps through the night which has helped with shift work! He is a huge part of my life and when you ask him what I do he replies

"My mummy is a paramedic, she works on the ambulances and looks after the ouch. And if someone falls of their bike you call 999 and my mum comes. And looks after the ouch."

Need I say anymore!

The Blog: I’m writing this blog to vent frustrations, share experiences, provoke debate and educate people as to what life is really like on the road as I see it. I don't have the wealth of experience that many do but I don't think you need that so much to form opinions. I may have only been on the road for 4 years or so but in that time I've seen and learnt more than my entire life before that. I’m lucky enough to have a great job; I work with great people and strive to be the best I possibly can be for my patients. Some patients were sent to test me, some were sent to amuse me and some just baffle me, and despite my ramblings I generally look forward to work each day. I love my job. 

All my blogs are loosely BASED on real experiences and feelings, though I do use poetic license to protect the identity of my patients, their families and my colleagues. All names, ages, nationalities and locations have been changed as to uphold their anonymity. Please do not read a post and think that I am talking about an actual patient. I use my experiences to create a post to express how I felt at the time or how I feel about a certain topic. It's my way of dealing with what I see. All opinions shared are mine and mine alone. I hope you enjoy reading and welcome any comments and opinions. That said, there is a big difference between offering a different opinion and having a debate, to trolling, bullying and threatening me. That WILL NOT be tolerated. I am not representing any particular ambulance service (I work for 3) or any professional body. 

You can also follow me on Twitter @diagnosisLOB or join me on my Facebook page. If you don't like what I have to say, don't read it. I will make no apologies for my opinions. Though I welcome all comments, good and bad, if you over step the line, insult, patronise or get all high and mighty on me, your comment will be deleted. I write this blog for me and the people who enjoy it. It's that simple!

Thanks for taking the time to read,

Ella x

Oh to be Bi-Lingual

"9 year old female, fever, DIB"

I know I seem to start most posts with 'it was the middle of the night' but in all seriousness, it normally is! People don't generally call ambulances at school finishing time, dinner, time, prime-time TV and bed time! They call when nothing else is happening and they are left alone with their own thoughts and fears! Take this job for example. A 9 year old girls with a fever! No biggie! Girl says 'I don't feel well' when she gets home from private tutoring. Mum thinks 'you'll be fine'. Serves dinner. Girl eats dinner and forgets she's under the weather. After dinner, child is pre-occupied with playing and watching TV. Then it's bath time and bed time. All goes according to plan. Because the child is slightly unwell she sleeps restlessly. When she wakes she wants mummy. 'Mummy, I don't feel well'. Now it's 1am. There is nothing to distract her, no TV, no food, no entertainment. Mum's comforting doesn't work. 'Mummy, I don't feel well'. Mummy phones 999.

Now, this apartment was in an very expensive part of town. Probably the most expensive there is! The family were eastern european but spoke excellent english and were very polite. Our patient, the 9 year old had an americanised accent and from what we were told they moved around a lot around the dad's job. In the flat was our patient, her mother and a neighbour / friend. We managed to obtain a history from our patient and it appeared she may have had the start of a chest infection. She had been given Calpol earlier on and was due another dose. We asked about referring her on to her GP but her mum didn't understand. 

Her friend stepped forward. 

"Let me translate for you, what do you want to know?"

"Can you ask her if they are registered with a GP in this country and if she is, would she be happy for us to refer her daughter onto the GP?"

"OK, no worries."

He turned to the mother and to my surprise, annoyance and embarrassment said the following in English..........slowly.

"Do...you...have...GP...or Doctor? Can...ambulance...driver...call...them...for...you?"

Are you serious?! That is your translation?! In that case I can speak fluently in every bloody language! I can say 'Hello' in Russian. By his linguistics I can speak the language! It's just a vocabulary issue! And don't even get me started on "Ambulance Driver"!I decided to bypass him and speak to the mother again. She understood the GP bit, just not the referral! I asked the daughter to help! She spoke fluently in Russian to the mum, who then answered in English to me! She was registered with a GP but it was a private medical centre. A quick phone call and I was assured that a GP would be at the house within half an hour! It's amazing what money gets you!

We left the mother and daughter with their 'translator' to it with advise to call back if needed. It was a bit of a waste of time call but I got the impression she had called 999 for advise but despite her good grasp of the english language, being prompted about difficulty in breathing etc had ended up with an ambulance arriving. I don't mind these calls so much when there is an outcome other than hospital. In this case we assessed and referred on with only half an hour of time used. If we'd had to go to hospital that would be an hour + of ambulance time then 4 hours minimum at a hospital. Luckily my grasp of 'slow english' was enough to make this possible! 

This job also highlighted just how embarrassingly awful we are in this country at second languages! We really do need to buck our ideas up!

A Real Emergency

Let me paint you a little a picture. We had just taken a 97 year old to hospital. This 97 year old had just fallen down 17 stairs from top to bottom. She had a head injury, she had a broken wrist and she had broken ribs. She didn't want to go to hospital. She didn't want to call an ambulance. She did, because she couldn't get herself up. She apologised 12 times whilst in our presence for getting us out and wasting our time when we could be dealing with REAL emergencies. It took a lot of convincing to get her to agree to hospital and despite the pain she was in she felt she was burden. She had lived through 2 world wars. She had been employed full time from the age of 14 to 75. That's 61 years of taxes and national insurance since its inception. She has no carers at all and still does her own shopping. She costs the country her Freedom Pass and her medication which consisted of a daily Aspirin. She really was an inspiration. We left her at hospital to go and do a REAL emergency.

"25 year old female, pain in back after carrying baby and changing nappy"

What is there to say? I could rant about this for 10, 000 for even needing a breath, but I won't. I will not pass judgment, I will not share my thought. I was just explain what happened, what was said and what we did. Then, I will open it to the floor!

We arrived on scene at the patients flat. It was a council flat. 3 bedrooms. Nice kitchen. HUGE TV in the living room. Ashtray on the coffee table full of fag buts. Childs dummy 6" away. We had let ourselves in as the door was ajar. Sitting on the reclining black leather sofa was our patient. She had a pain'd expression across her face. Jeremy Kyle was on the TV (I'm being serious).

"Hello my dear, what's the problem today?"

"My back hurts."

"Where about?"

"Right here" she said, rubbing her lower back.

"When did it start?"

"About half an hour ago?"

"And what were you doing when it came on?"

"I'd been carrying me baby round and then put her down to change her and as I leaned down it started hurting real bad."

"Do you suffer with back problems?"

"Nah"

"Have you taken any painkillers?"

"Nah"

"It sounds muscular, you may have strained it slightly, what would you like to do today?"

"Go up hospital to get it checked out."

"I don't think hospital is necessary. You can probably treat it at home with pain killers and rest. Hospitals aren't the best place for babies, especially as they will probably tell you what i'm suggesting."

"Nah, i'd sooner go up there and get it checked out."

So that's what we did. She got all her stuff together and we headed out to the ambulance. As we were walking down the stairs her boyfriend / partner arrived. He followed us up to hospital in his car. It was a 2011 BMW with a personalised number plate. He lived at the same address. 

In the ambulance I established she was normally fit and well. No medical history to speak of. No allergies. She smokes 20-30 a day. She is unemployed. Her partner is also unemployed. We arrived at hospital, handed over to the nurse and were promptly sent to the waiting room.

So, for a change I will refrain from saying too much and leave it there!  That is for YOU, my readers to do! Thoughts on a postcard please! 

Black Wednesday

“77 year old female, everything is fine.....no wait.....she’s dead”

The first wednesday in August each year is known as Black Wednesday and so begins the ‘killing season’. It is the day that junior doctors start working in a hospital. It is also when a lot of other doctors change job role and as such, this day results in a significant increase in mortality of emergency patients. It is fair to say that Black Wednesday and the two days that follow are the worst days to fall gravely ill in the NHS. Saying that, is there ever a good one?! Up to 7000 graduates enter the halls of their respective hospitals and with it, the sudden burden of responsibility of the lives of their patients. The death rate in these three days each year rises by 6%. 

I don’t blame the newbies for this, they are thrown in at the deep end, they are made to do operations and procedures on patients way beyond their capabilities. On top of that they end up working the graveyard shifts when there are little or no senior staff around. They are in charge of wards, departments and health and wellbeing of all patients inside them. Someone who has just passed their driving test drives off and starts learning how to drive, someone who passes their law exams then goes off to learn how to be a lawyer. These kids, and they are kids, have spent years with their heads buried in text books. Their only patient contact and bedside manner has been learnt from corpses so it’s no wonder the proverbial shit hits the fan. 

I’m all for a steep learning curve. In those situations you learn a lot. In most walks of life, when you are learning, the mistakes that are made, end up costing time and money. In health care, the mistakes that are made, end up costing lives. It was daunting the first time I was in an ambulance as a crew of two! I didn’t really have a clue what I was doing. I always had a safety net. Firstly, I was never alone, secondly I was always with someone better trained than me and finally, if the shit really did hit the fan we were never more than a short drive to a hospital where the grown up could take over! Junior doctors don’t always have that safety net. The buck stops with them and that added pressure probably has a lot to do with labeling of ‘killing season’.

Personality has a lot to do with it to. Becoming a doctor is very competitive and as such there are egos at play. When we have dealing with a junior doctor there are generally three types that we me. 

• The Flapper: These newbies are terrified. They know their stuff but don’t show it! The pressure is all to much. They look around to everyone else for the answers and are yet to have any confidence in their abilities. They drop things and actually look scared. Their patients will likely die from their inaction.

• The Ego: These ones think they have made it. They know all there is to know. They walk around looking the part, walking the walk and talking the talk. They won’t ask for help because let’s be honest, they don’t need it. They talk down to nurses and ambulance staff because they are a DOCTOR. They try to do to much over and above their ability. Then patients die. They are ignored by all and they slowly realise they are not god.

• The Awkward: These guys have all the social skills of grizzly bear. They know their stuff, they were probably top of every class they have ever been in. The problem is, they have absolutely no people skills and no bedside manner. They will not spot a sick person because they won’t look at their patients. They will not talk to their patients because they don’t know how to. They just look at numbers.

All three will learn and all three will improve, however once an arrogant arse, always an arrogant arse in my experience. 

This year during Black Wednesday week the A & E was absolute chaos. We were coming and going every hour on the friday night with another puzzle for the newbies to solve, as was every other ambulance in the area. Although they didn’t take the handover I could see them looking as the double doors swung open, hopeful there was nothing majorly wrong with them. At about 3am, we’d handed over our patient to the nurse, my crewmate was booking them in and I was changing the sheet on the bed. Suddenly, in a cubicle a few feet away there was a commotion. A junior doctor was in there with a patient and her son. 

“What do you mean she’s dead?”

“Sorry”

“You said 3 hours ago that she was fine.”

“I know”

“You said she was asleep.”

“I know”

“How can you not know she was dead?”

“...................”

*awkward*

I left the department so as to avoid the furore. Ah.....Killing Season, and so it begins with a key lesson......check your patient is breathing at regular intervals and ensure the monitoring equipment you have connected them to is switched on!

Feeling Sick

“48 year old male, nausea”

Yes, you read correctly, nausea, nothing else; no other symptoms, or at least no other symptoms that we were privy to. I hoped there was something else; surely nausea was not something worthy of an EMERGENCY ambulance. After waiting 5 minutes for the recycling lorry to edge down the road we were trying to access, we pulled up outside the house. The garden was overgrown; an old sofa, upside-down, was protruding from the hedge, and various pieces of broken wood and piles of rubbish were scattered up the crazy-paved path. The flaking paint around the rotten doorframe told us all we needed to know about what the house was like inside. There was a porch stopping us from accessing the front door so we rang the bell. Then we rang it again. And again. Eventually our patient, sporting a lovely string vest and trousers held high up his mid-drift, appeared. Using a tissue he opened the door, and then dropped said tissue on the floor. I looked down, carefully stepping over the sea of clean tissues and into the hallway. 

The smell was grim! It was kind of stale with a hint of ammonia and rotten food; nothing new to my senses but unpleasant all the same. Clearly there were social issues at play here as well as medical. We went into the living where our patient had wondered off.

“Take a seat”

I looked around… "I’m OK thank you, been sat down for ages” (massive lie!)

“So, what’s the problem today?”

“I feel really sick”

“How long have you felt sick?”

“Since I woke up”

“And how long ago was that?”

“About an hour ago”

“Have you phoned your GP?” (my tone was already quite short and frustrated!)

“Yes”

"And…"

“There was a queue on the phone so I couldn’t get through”

“So what do you want us to do?”

“I don’t know”

Well if he didn’t know why he called an ambulance, what the hell do we know?! There was no way I was going to take him to hospital. Despite me asking about every symptom I could think of he had none. No vomiting, no pain, no dizziness, no headache, no urinary symptoms, nothing! I saw an old PRF on the sideboard.

“You had an ambulance last night?”

“Yes”

“Why?” I asked whilst I was reading.

“I felt sick”

I decided to phone the GP, there was indeed a queue to talk, and I was 16^th in line. There was no way I was going to wait. 

“OK then sir, let's go to the ambulance and we’ll pop you round to the GP, grab your shoes and your keys”

I started scribbling my paperwork to hand to the Doc as we drove off down the road. 100 yards and we turned left, 50 yards and we stopped. Yep… journey time to the GP by ambulance was 42 seconds. It would have taken a whole 2 minutes to walk... Just sayin’.

I sat him in the waiting room and went for chat with the receptionist. After a slight battle to let me see a GP rather than divulge his entire medical history to her, she buzzed me through. I told the Doc that the string vest in the waiting room was feeling sick and had had 2 ambulances because there was no answer on the phone. He rolled his eyes and said a sarcastic thank you! We bid farewell to our time-waster and went grumbling back to our truck.

Seriously… TRIAGE. I know it’s a French word but surely that call could have been downgraded to ‘make your own way’. As much as I want to scream at the people who pick up the phone, dial 999 and say ‘I feel sick’, I equally want to scream at the person who says ‘sure thing, an ambulance is on the way’. What is the problem with saying ‘No’?! This guy didn’t need an ambulance; he didn’t even need the GP. He said what was wrong, he felt sick. So what! We are humans, we feel sick from time to time.  We live in far too much of a nanny-state where the fear of something going wrong far outweighs common sense. One of the drawbacks of a totally free health care system is that it is vulnerable to abuse, and abuse it gets. I think the ambulance service in general needs a new PR department. The Fire Service got it right with their various fire safety campaigns. We need to follow suit with educating people what is and isn’t an emergency.