One of the jobs that I both enjoy and hate is for a "collapse behind locked doors" - this is when a (normally elderly) patient hasn't answered the front door or the telephone, and is presumed to be in some trouble. What we often get is someone who has died during the night. Although I hate having people die, the one good thing about this type of job is that I get to use my size 12 boots to kick down a door.

There is a skill to kicking down a door - and I was taught by the best, a policeman. The police also have a huge ram that they can use when their boots aren't enough. These are very heavy, but also very fun to use

We got called to a house where the daughter could see her elderly mother laying on the floor - shouting through the door and banging on windows didn't get any response, so we assumed the worst. The daughter was (understandably) crying, so I had an attempt at kicking the door down.

Unfortunately for me, the woman had been burgled earlier in the year, and so had two locks, and a bolt holding the door shut - so it took a couple of minutes of prolonged (and eventually painful) kicking to get the door open. I managed to wake up all the neighbours, and it's always fun to be the centre of attention...

Finally the door gave up and we gained access, we were greeted by the elderly woman sitting on the floor smiling at us earlier in the morning she had fallen and couldn't get up. When we had tried banging on her windows she had been asleep, and it was only the repeated bashing of my foot against her door that had caused her to wake up.

This was a good job in a number of ways; the lady was happy and healthy - and just needed a hand to get up off of the floor, I got to kick in a door and get away with not causing any serious damage, and finally we looked like heroes to the two daughters of our patient - there were smiles all round and we left the job feeling that we had really been of some use today.

In an update to the great and wonderful new I.T. programme that is being implemented in our local hospital, I have an example into how the providers think...

...They are going to install a palm scanner on the door so the staff can book in and out. Of course, biometrics work wonderfully, and this is an obviously essential system to help patient care. Sarcastic? Moi?

During today's shift I had to pick a patient up at a local Nursing Home, and very nearly became one of those "Under Investigation". The GP had visited this patient, an 88 year old male with Dementia and Parkinson's disease, who had not been eating and drinking. The GP had left the patient in the care of the nursing home, and had arranged a 'non-urgent' ambulance.

A 'Non-Urgent' ambulance is the sort of job where you take a wheelchair bound patient into hospital for his out-patient eye check. There are no blue lights and sirens involved here...

My crewmate and I turned up to take this patient into the nearest hospital and found him in a collapsed state, extremely dehydrated and with a very faint pulse. I asked the staff what the patient was normally like and they looked at each other and shrugged. It seemed that no-one on that floor had any information about the patient, even though he was a long term patient. The staff didn't know his previous medical history, or even what regular medications he took. So I asked for the letter that would be accompanying the patient to the hospital, which is written by the GP. On it the GP had written the patients Blood Pressure as 100/60, which is a bit low - when I checked the blood pressure it was 80/60, a much more worrying result.

We transported him into hospital, where even the medical students, who have recently descended on A&E like over-enthusiastic teddy-bears, spotted that this man was seriously ill. I left the patient, and the escorting nurse in the tender mercies of the triage nurse and a trio of medical students who all agreed that he 'needed access'.

"Needs access" is a shorthand way of saying that the patient needs an intravenous cannulae so that drugs and, more importantly in this case, fluids can be given. In this case, although they were right, I suspect that their main motive may have been to get cannulation practise on an uncomplaining patient.

Perhaps if we had been a bit busier today, and the patient had died, I too would be 'under investigation' for not reaching the patient quickly enough - even though he was supposedly receiving care from a doctor and nursing staff...

Imagine, if you will, getting sent to a job where a 15 year old boy is threatening suicide. You turn up at the address and discover that it is a care home. Meeting with one of his carers she hands you a list of the boy's medications and it reads like a 'Who's who' of psychiatric drugs. You talk to the boy, and he seems calm, collected and very polite. He explains that he wants to jump out of a window and kill himself, and agrees that he would like to go to hospital. You take him into the paediatric department of a local hospital. As this does not feel like the normal "Teenager wants to kill themselves" you have a chat with the children's nurse and you ask them to let you know what happens to the patient. You leave, and continue with your shift. The next day you ask the children's nurse about the patient and she tells you - "The boy wanted to die because he wants to have sex with, and kill small children - and that he knows that it is wrong".

I hate paedophiles as much as any other member of society - but in front of me that day, I saw a victim.

This is a terrible story, in which a 16 year old boy waited for two hours for an ambulance to transfer him from the ward he was on into the ITU ward. The reason for the wait? The three ambulances parked outside the A&E department couldn't offload their patients onto hospital trolleys, because the department was too busy.

I'm curious why the doctor couldn't arrange to push the patient the 300 yards to the ITU, granted the patient was on oxygen, but I've personally done longer and more critical transfers than this.

A Staffordshire Ambulance Service NHS Trust spokesman said: "We are supporting a complete investigation.

Which sounds familiar...

...there was an extensive investigation into events of that day. Doctor goes to patient, doesn't recognise a heart attack - calls for an 'Urgent' (not Emergency) ambulance patient then has to wait seven hours for ambulance - Ambulance trust is blamed for her death

...and said the incident was being reviewed Ambulance not available, so fire fighters (who have a defib) are sent - patient ends up dead

...and are holding an investigation. No one should have to wait half-an-hour." Patient collapses and dies, waits 30 minutes for an ambulance

...said the service was investigating the matter. GP calls for 'Urgent' Ambulance, leaves patient and patient waits 8 hours for ambulance

They have said that an investigation into the incident is planned. Elderly woman in nursing home cuts her leg and waits 7 hours for an ambulance

Your homework is to find more of your own - just type "ambulance investigation" into your favourite news-site search box.

Investigation is underway, is normally a euphemism for "The crew have been suspended", whether it is the crews fault or not. Gps call for a non-emergency ambulance for patients who are critically ill - then leave the patient alone in their house. Community Psychiatric Nurses refuse to visit patients, Midwives send home women who are about to give birth, nursing homes have no idea how to treat minor injuries and illnesses, people can't get to see their GP, so are told to phone for an ambulance - and the government expects us to reach children under the age of two who have runny noses before 70 year olds who have just had a stroke.

Realise that most of these complaints are because of delays in getting to patients. There is a reason for this - we are getting 'overflow' from other health services...

All the other health services have someone else to call, at all hours of the day,

GPs who are busy tell their patients to call and ambulance.
CPNs who finish their shift tell their patients to call an ambulance.
NHS Direct tell people to call an ambulance because they are scared to offer decent self-treatment advice.
GPs no longer have to go out at night, so guess what - call an ambulance.
Catheter blocked? District Nurse won't come out? Don't worry, they'll call an ambulance.

Unfortunately we don't have this luxury, the ambulance services and A&E are the 'safety net', every bad job comes down to us, and because we are the last to see people it is often seen as 'our fault'. We are overworked, underfunded, understaffed and don't have the vehicles we need. We are seen as being 'always there', both by the public and other health care providers and they can always pass their jobs down to us.

Is it any wonder so many things are 'our fault', and that our management are always 'investigating'?

Mozrat, over at Beer And Speech wrote about the NPfIT, which is the National Programme for Information Technology in the NHS.  It's a good post, in which he explains that the the cost has soared to £30 billion pounds which will make patient care suffer.

The idea behind the programme is that modern computers, networking and databases will enable GPs and hospitals to become more linked, allowing GPs and hospitals easy access to the normally separate medical notes.  It will also mean that operations and consultations over an electronic booking system.  It will also provide an centrally managed email and directory service and will eventually mean that GPs can electronically send prescriptions to pharmacists.

But there are problems... 

A lot of GPs are unhappy with the system, in fact only 7% of the 500 GPs asked felt they had been adequately consulted.

As mentioned before, the original cost was estimated to be £6.2 billion, now the cost is expected to rise to between 18 and 31 billion pounds.  It has gotten so expensive, the National Audit Office is to investigate the way in which the contract was awarded.

I am personally worried about the security of the system, and my personal experience in the new system at Newham hospital doesn't inspire me.

Newham has currently implemented an EPR system (Electronic patient record from Cerner. This means that when the patient enters through the doors of A&E they are booked onto the computer, and all treatments, tests, x-rays and the like are recorded on the computer system. Instead of having to manually track the patient through the department there is a huge monitor on the wall that lets the nursing staff know where each patient is.

This was the first thing that I noticed, that the computer screen in the main area had the patients name, and what was wrong with them, which isn't too good for patient confidentiality. I told the nursing staff this, and a little later that day the 'complaint' field had disappeared.
I'll not mention how it is taking over a month for the nursing/medical staff to get used to the new system, for the first two weeks after it was implemented our Control were so distressed at the amount of ambulances sitting outside the A&E, they kept calling us up to make sure that we were 'alright' (for 'alright', read 'ready for another job'). We had to keep telling them that it was taking us much longer to hand our patients over to the nursing staff because the staff were unfamiliar with the new computer system. Extra trainers have since been brought in, and things are running a little smoother.
Finally, there is the thing that amuses me the most... Security for such a system must be high, mainly for patient confidentiality reasons, but also because you don't want some bright spark hacking the system so that they get seen out of order. The system has a number of laptops, so a wireless network has been used to link the various systems together. Admittedly I'm no hacker, or even a wireless network expert - but a little investigation with Ministumbler and my Pocket PC has shown that they aren't broadcasting their SSID, and I can only assume that they are using WEP. But, and this is the problem with any system where non-geeks are expected to use it. Every computer has magically grown a sticker, upon which is the Username and Password to log into the system.

Gah!

Hardly secure, and the implementations for patient confidentiality is terrible - can you imagine this system rolled out across the UK, with the full functionality of the NPfIT system up and running? Break into a GP's office, use the password that is conveniently stickered to the monitor, and gain access to nearly anyone's medical records. I mentioned this to the staff in the department, but they seem happy to let this huge security flaw continue.

So I'm now sending a letter to the hospital directors - hopefully they will get the message.

We were asked go to the local police station to help with arresting someone. The arrestee (is that a real word?) was an 80+ year old male who was accused of recently committing a crime that I would suggest required some amount of physical strength. We were to follow along because the person had heart and breathing problems - so much so that he had bottled oxygen in his house.
We met with the police officers (9 in total, and all rather scary looking plains clothes types) at the police station, before following them to the address in question.
Once the police had made their entrance we were called forward to give the patient a clean bill of health. We watched as this frail man slowly dressed, needing help from his son to tie his shoelaces, we watched as he struggled around the house and wondered how he could possibly be guilty of any crime that needed any form of physical exertion. The patient’s son was also a bit put out by the allegations, and promised to have a good laugh at the police's expense when the truth came out.
Throughout the arrest the police were polite, helpful and behaved in a thoroughly professional manner at all times.
The patient/arrestee was also calm throughout and the whole thing went, as far as I could see, very smoothly, and our ambulance followed the car in which he was taken, until it entered the police station and the police F.M.E took over.

Then the next job we went to was to outside the same address, a woman had been mugged and the police who were searching the address had called us as she had a rather large bump on her head. Unfortunately the mugger managed to get away. It surprises me that you can get mugged outside a house full of police and the mugger can still escape.

There were two interesting jobs today, I'll tell you about one now and let you wait until tomorrow for the other one.

We got called to the very common "Male Drunk - Police on scene", I'll not moan about how often we get called to this type of job, you've heard it all before...
We arrived on scene and were met by a policeman who firstly apologised before leading us to a man who was approximately 30 years old. The man was obviously drunk, and smelt heavily of alcohol, along his arms were the scars of a "cutter" - something else we are seeing more and more of these days. The policeman told us that the patient was refusing to give his name or medical details, only that he was called "John". We approached "John" and he agreed to come to hospital with us. I got him into the back of the ambulance and he refused to let me touch him - so I couldn't do my usual battery of tests (Blood pressure, pulse, blood sugar, oxygen saturation, respiratory rate). In fact he didn't want to talk to me at all, and sat in the back of the ambulance not talking, at one point he threatened to leave the ambulance - but I managed to persuade him otherwise. Don't ask me why, I normally let drunks go as soon as they say they don't want to go to hospital.
All went as normal until we rounded the corner to the hospital, where he got off of the chair and laid on the trolley-bed. One hundred yards later and we pulled up to the hospital and I told him to get up, then I told him louder, then I did a sternal rub to wake him up - and there was no response! I then slipped an oropharyngeal airway into his mouth, this would wake anyone up - but not a flicker...he was deeply unconscious. This meant he was due for the resus room.

We rolled him (rather quickly) into the resus room and was met by a rather angry Sister - she wanted to know why we hadn't pre-alerted the hospital, I explained that he had just lost consciousness outside the department. She then asked me why he didn't have oxygen on him, again I repeated that he collapsed as we were outside the hospital. We got him onto one of their resus trolleys while the doctors in the department ran into the room.
For the third time I explained what had happened, and that I had no vital sign observations - and this time they paid attention, and accepted what had happened.

To be honest I don't blame them, the A&E department rarely has any surprises - the hospital is forewarned about any "nasty job" we are bringing them - to suddenly have a seriously sick patient turn up without any warning is always a bit of a jolt

Now the patient was unconscious the nurses were able to do those vital observations that I was unable to do - and they were all normal. His pulse, blood pressure and blood oxygen levels were all better than mine, his blood sugar was also well within normal limits and there was no obvious reason why he was in such a deep state of unconsciousness.

He was quickly intubated, and we left the department. I've spent some time thinking if I missed anything, if there was anything I would have done differently, but to be honest I don't think there was. Even if I had managed to get a full set of vital sign observations, they would have all been normal and there was nothing that indicated his condition changing so quickly. I can't 'assault' a patient who has refused a procedure (like observation taking), and all I could do was exactly what I did do - watch him while we took him to hospital.

The current idea is that he had taken an overdose of some sort along with the alcohol, and that it had started to work. Because the patient hadn't spoken to me, I had no way of knowing if he had taken an overdose.

It's one of those jobs that you want to find out what happened to the patient, and tomorrow I shall be asking exactly that - and I'll let you know.