First off, the first "Grand Rounds" are at Blogborygmi - quite a few top-rate medical articles there, go and have a look.

As I promised yesterday, I'll explain what the LAS Major Incident policy and procedure is, and why you won't get me running towards two collapsed people.

First off, lets define a "Major Incident" is, from the little book I was given, "Any occurrence which presents a serious threat to the health of the community, disruption to the service, or causes (or is likely to cause) such numbers or types of casualties as to require special arrangements to be implemented by the health service", basically this means anything that has, or will cause, a large number of casualties. Anyone in the emergency services can declare a Major Incident, and to be honest its the one thing that makes me a little nervous, because you never know what you are going to see on scene until you get there.

The Potters Bar train crash was phoned into the Ambulance Service as a "Chest Pain"...

If I'm first on scene at a Major incident, then if I am the attendant I need to run around the scene to do a quick bit of reconnaissance, I'm not there to treat anyone. I then get back in the ambulance and radio in a "CHALET" report. This is...

C - Casualties (number and severity).
H - Hazards on the scene.
A - Access, meeting points, vehicle parking area.
L - Location, the map reference and best directions to get to the parking area.
E - Emergency services required.
T - Type of incident.

I'm then to work out the ambulance parking points, loading area and casualty clearing areas. Well, I say "I", but I'm hoping that an officer turns up to do all that. When a fair ride collapsed in Alexandra palace and a Major Incident was declared officers outnumbered road-crews.

There is a big part in the LESLP (London Emergency Services Liaison Panel) booklet about how to set up a well run Major incident scene. Its a good site, run by the people who tell us what to do in a Major Incident, and you can even download the manual that we use. (Large .PDF)

Part of the LAS responsibility is for the first people on scene to do a Triage Sieve, this is essentially deciding who is most 'deserving' of our immediate treatment. This is only done when there are more casualties than there are rescuers. We do this so that we don't 'waste our time' dealing with someone who will probably die, to the detriment of being able to save other people.

We use a flowchart to decide which category patients fit into.



You start at the top left of the card and work your way through it for each patient. For example, if someone isn't breathing, and by opening their airway (tilting their head back) their breathing doesn't start then they are a 'Dead'. In a normal situation we would try to resuscitate a patient in this condition, but with a large number of casualties 'Dead stays Dead'.

We have on our ambulances a number of tags that you tie to the patient as you walk along making these snap decisions, it's something I hope I never have to do - walk amongst the wounded, ignoring their calls for help just tying tags on people...

'Immediates' get seen to as quickly as possible, as there is a chance we may save their lives, they are also normally the ones who get first transport to hospital. Then come the 'Urgent' patients, while the 'Delayed' can wait until last, and/or can make their own way to hospital.

It is important that we don't overload the local hospitals, so the two nearest hospitals are normally nominated as the 'receiving' hospitals with other nearby hospitals marked as 'overflow'. The 'receiving' hospital(s) tries to clear it's A&E department as quickly as possible and closes to normal 'walking wounded' patients.

The planners have thought long and hard about every major incident they can imagine, we have hundreds of contingency plans, training is ongoing, and every hospital in London has a decontamination unit. When I was working in hospital, I got training on how to use the NBC suits - and I'll tell you this, they are not the cheap and nasty ones...

If/when/should terrorists do something spectacularly nasty, I would like to think that we are as well prepared as we can be, but every incident is different in a million ways.

Why won't you catch me running towards two collapsed people? We use STEP 1,2,3 which means if there is one person on scene collapsed we proceed as normal, if it is two people then we proceed with care, if there are three people collapsed, then we hold back and get the chemical team in to have a look.

So...I saw the BBC's programme 'Dirty War' last night along with the after programme live audience discussion, and I must say I wasn't very impressed.
The programme itself was poorly written, not knowing whether to deal with the 'detection' of the bomb, the capturing of the terrorist cell or with the emergency planning around the event itself. It would have been better if they had focused on how, with their 'extensive' research, the emergency services would/would not cope with such an event. I'm not even going to start talking about the firefighter who removed his protective clothing to continue fighting a fire in a part of London that would be a 'no-go' area for the next 50 years...

The programme started with an exercise set in an office block, and here the makers were clearly referencing the Bank exercise that ran last year. It was during this exercise that the limitations of the protective suits, and the communication gear became apparent. Hopefully these problems will have been solved before we need to do this for real.

I did notice that the terrorists decided to irradiate East London, which is a bit of an 'own goal' as most of East London is Muslim in population, rendering Brick Lane uninhabitable would be a bit stupid...It's called Banglatown for a reason you know. I also found it amusing that they would blow up a bomb in my 'patch', if that day were anything like previous major incidents that I should have been involved in - I'd be sitting in the pub/someones party getting quietly drunk, and therefore being in no fit state to work.

There was a minor mention of the ease of gaining radioactive materials, for example in America 840 radioactive sources have been lost since 1997. Caesium has been offered for sale in Thailand, Bangladesh and Chechnya. All the usual suspects have shown serious interest in a 'Dirty bomb'.

There then followed a live discussion panel, which reminded me (as if I needed it) that the public are often really rather dense. Kudos to the representative from the Muslim Council of Britain for congratulating the programme makers for a balanced drama (although he couldn't see any Muslim victims of the bomb, which given the area it was detonated in, was laughable). Some of the callers however still moaned that the BBC was stirring up Islamaphobia. "Why couldn't it be unnamed terrorists" asked one caller, well I'm sorry to sayit but most of the terrorists in today's world (with a few exceptions) are indeed extremist Islamics. Then a member of the audience wanted to shout up a 'class war' point that it would be only the politicians who would be safe, which is a reasonable point - but not one that needed quite as much shouting and ranting.
Then discussion turned to the 'Preparing For Emergencies' booklet, which over half the audience said they had received and were critical of. However when asked how many had actually read it, a lot of hands went down...
One of the main complaints was that the booklet was 'patronising', well I'm sorry, but dealing when with the geniuses of the general public, I'd say it had to be written simply so people could understand it.
There then followed a lot of repeating the same questions, followed by repeating of the same answers and from then on I sat there grinding my teeth in despair at the great British public.

So at the end of the evening, very little was shown about terrorist threats or what to do in the event of a dirty bomb and nothing new was known about the governments response to such an event. I would suggest that most people went away from the programme more frightened than before, and with very little to reassure them.

My next large post will be about what the LAS (and by extension, myself) will be doing in the event of a Major Incident.

First off, thanks for all the suggestions on what to do with my time off, none of them were rude, and some of them I'll take up. I've replied to some of your comments over there - when I could think of something amusing to write in reply. Also thanks to those that sent private emails, I'll get around to replying to them as soon as I can.

This is post number two from the "your vote" post I ran a while ago...

We were (as ever) running to a call on the other side of our 'patch' when suddenly my crewmate told me to pull over and stop (I was driving). Wondered what had happened, he leapt out of the ambulance and I saw that he was heading towards a bus that I'd just overtaken. Leaning out of the window was the driver, blood gushing out of his nose looking very sorry for himself.
Apparently a car had pulled up to the drivers window, and accused him of cutting him up, the other driver had then said "I'm a bus driver as well", and then punched the bus driver on the nose before driving off. We soon managed to stop the bleeding, and the bus managers came down to investigate, along with the police. Luckily our patient had managed to get the number plate of the man who had hit him, and I can only imagine that if what he said is true, there will soon be one out of work bus driver.
Violence against transport staff has gotten silly, did you know that they carry DNA swab kits for collecting DNA evidence from people who spit at them?

That same night we went to a youngster who had been hit by a car while trying to cross the areas busiest 'A' road (the notorious A13, the fourth most dangerous road in London). This youngster was wearing black trousers, black trainers and a black hoodie and baseball cap (hoodie pulled up), he was also black himself, the only thing that could have been more dangerous would have been if he was wearing sunglasses. Luckily he wasn't badly hurt, and as one of the police that attended commented, "Nice camouflage".

Anyone remember "Be Safe, Be Seen"?

The London Ambulance service doesn't just deal with emergency calls to people's houses, we also do hospital transfers, patients who go from hospital to hospital because the original hospital hasn't the expertise to deal with that person's medical problems. An example of this would be the transfer I recently did from Newham to the Royal London because Newham's CT scanner is broken, and the patient needed an emergency scan.

One of the regular places that we find ourselves transferring people to is St Joseph's Hospice, or as we call it "Holy Joe's". Sometimes we will be picking up patients from one of the nearby hospitals, sometimes from the patients own home. It's one of those jobs most of us don't mind doing. The patients are, by definition of needing hospice treatment, actually sick - and we aren't so hard hearted that we would begrudge an ambulance to someone who is ill. Then there is Holy Joe's itself...

Holy Joe's is a religious place, it used to be run by nuns, but now they are a bit few and far between. To be honest I saw my first nun there yesterday, and she was picking her nose... But, you walk into the place, and it just seems nice, it is clean, the staff are all friendly, the patients all seem happy and there is a really good social atmosphere there. I don't know if it is because of it's ties to the religious orders (I hate all religions, but the best nursing homes always seem to have nuns running the place), but the hospice just seems to exude calm.

My crew-mate and I had just transfered a terminally ill patient into Holy Joe's and were having a cup of tea in their tea bar (hot drinks are free to the LAS, another reason to love Holy Joe's), sitting in this clean comfortable area, we were watching the patients chat with relatives, staff and other patients, giving the place a real friendly atmosphere quite unlike anywhere in the NHS. It is very rare to see a doctor sitting down with a patient, chatting about nothing in particular, and having a cup of tea together. We both agreed that this has got to be one of the better places to see out the end of your days, and that it is a real shame that there aren't more places like this.

It is a shame that in this increasingly 'technical/evidence based/audit/professional development/governmental targets' style of health service, we seem to have forgotten that sometimes we simply, and honestly, need to care.

Many thanks for all the condolences in comments and sent privately in respect of our colleague who died on Tuesday, they are all appreciated. His family has decided to have a Service funeral, which has pleased a lot of the staff here, because it lets them do 'something' to help out the family, even if only as part of a parade of remembrance.

This is a post that I knew I'd be writing at some point, but it is also the post that I didn't want to write.

Last night, after a long battle with illness, one of our station crew died. He was 43.

We came into work this morning to hear the news, and even though it has been expected it still shocked us, a few eyes filled with tears, and the normal jovial attitude that we have has been dampened. Thankfully the day has been very busy, so we haven't had any chance to sit down and think about it.

We all knew that the end was near, we had seen him become progressively more unwell, every day we heard from visitors how his health was getting worse.

To their credit, the firm had helped him out as much as possible, they kept him employed until the very end of his life, so that his wife will get a full pension payout, rather than the much smaller amount she would get if they had passed him 'unfit'. In the last few weeks, when he was in hospital, our Control would let crews run over to the hospital to visit him, even letting us go 'off the road', to do so.

A while ago we had a benefit night, which raised a couple of thousand pounds for him, and just before his final stay in hospital, he and his family had a holiday, thanks to the LAS benevolent society.

We deal with death regularly, but it is very different when it is one of your own. I would imagine that we will get back to normal after the funeral, but until then the mood on station is one of quiet reflection.

We got called as a 'second crew' to an address. Sometimes, when a situation is beyond the capability of one crew to deal with, they will request another crew - normally this is because they have two patients, or the one patient that they have is too heavy for one crew to lift on their own.

We got the job as "female giving apple to 7 day old baby", which had us wondering...

As we turned up we saw the other ambulance and a police car, on entering the flat we saw two policemen standing in the corner, with a 5'2" female ambulance crew sitting on a young woman (Patient Number 1), her crewmate was dealing with a male who had a nasty bite on his arm (Patient Number 2). The police were talking between themselves deciding what to do, as we got a quick briefing from the crew who was sitting on the woman.

It turned out that the woman (who had a previous mental illness episode), had given birth by Cesarean section seven days earlier, and today had tried to feed the baby apple pie, she had then 'freaked' (note the professional medical terminology) shouting that the man wasn't her husband and had attacked him. The ambulance crew had been called and as they arrived the woman had sunk her teeth into her husband's arm. The crew had fought the woman to, ahem, disengage her teeth, and this is why they were sitting on her. The police had been called, but were reluctant to do anything (I got the impression that they were a rather crap pair of coppers) and the second crew (us) had been called to deal with the husband (with new teeth-mark wound) and baby.

This woman was (brace yourself for more medical terms) 'completely bonkers', she had the rolling eyes, the delusional thoughts and the inability to communicate that separates the mildly strange from those who need immediate medication. It was actually quite sad to see this family come apart at the seams, the husband was shell-shocked, the wife was completely detached from reality and the police weren't being very helpful (which is unusual).

We got the husband and baby out of the house and into the back of our ambulance, and then returned to see the police (finally) manhandling the woman out of the house, and into the back of the first ambulance. She was securely strapped down (although we don't have restraints and so she could have easily gotten free if she so desired), and we had to lend the first crew a belt-strap as the one on their trolley was broken. The first crew then forewarned the hospital about what they were bringing in (violent schizophrenic female) and we all set off for the hospital.

We got there first and advised the nurse in charge that this was a 'real' warning, and that security guards would be needed, along with the private 'psychiatric' room. It took her twenty minutes to arrange both, while the ambulance took less than five minutes to get to the hospital. So while the secure room and security was being arranged this very disturbed woman was laying on the ambulance trolley...Not a good situation, and it made the job a lot harder than it should have been.

The husband was completely stunned, he had no idea how to look after a baby and quite simple couldn't cope. Social services were informed, and the child was admitted to the paediatric ward for a while, until the husband could be taught how to look after a baby. The woman was sent to the local psychiatric unit for assessment and treatment, hopefully this is a temporary condition brought on by childbirth (Puerperal psychosis). The husband had his wound treated, and was sent home.

Oh, and the baby is a hermaphrodite.

You may remember that I've mentioned before how working day shifts are different from night shifts, in the way that I meet less drunks, and more people who may actually be ill.

Yesterday I did three jobs. "only three jobs?" I hear you ask, well it's only because of much faffing around trying to find an ambulance that not only worked, but was also stocked with some of the essential kit that we need (you know, stuff like defibulators, blood pressure machines, bandages - essential stuff like that).

So the first job of the day was a woman suffering from morning sickness, her nausea prevented her from walking or talking, in fact all she suceeded in doing was to annoy my crewmate and myself... Her 'constant vomiting' consisted of her spitting into a bowl. I don't begrudge her an ambulance, but she just couldn't get her head around the idea that lying on the floor groaning wasn't helping us get her onto the ambulance.

Then we went to a drunk, who had 'collapsed' in the street. Damn those good Samaritans who call ambulances for drunks who are having a kip after a bit of a drinking session. No problem, although she was incontinent and so smelt a bit, and piddled on the floor of the ambulance. We had to return to the ambulance station to mop out the back of the ambulance, and enjoy a cup of tea.

Our third job of the day was something that we are seeing more and more of recently - an alcoholic had been kicked out of his hostel, so he had an 'epileptic fit' on the doorstep of the hostel. Police were called to remove him, but because the hostel thought they were taking too long, they also decided to call for an ambulance. We are being called to remove more and more people being thrown out of hostels, often the reason is given as "abdominal pain", but when we turn up the 'patient' is making no such complaint.
This particular fellow was (surprise) drunk, and with my practiced eye I saw a kitchen knife sticking out of his back pocket - which using my finely tuned pickpocket skills, was soon in my possession and was handed to the police who were now on scene. There was a bit of a stand-off, but the police didn't want to arrest him because, well frankly, he smelt very bad. So we found ourselves removing the 'patient' to hospital, there was no reason for him to go to hospital, but where else could we have taken him? We aren't really allowed to take people to the homeless persons unit - but it is just a bit down the road from the hospital, so we managed to get him a bit closer to the help he needed (if only geographically).

A crew has just gone out to a job that was described on the mobile terminal in the ambulance as, "Patient confused, pulling out knives, 'going off her rocker', cannot get anymore sense from caller". What an exciting life we lead...