I've mentioned before about the superb care the people of London get in respect to heart attacks. They get diagnosed in the ambulance by a twelve-lead ECG, they will then get taken to a specialist centre for the gold standard treatment of an angioplasty. It is excellent and I love it, it improves the patient's outcome and gives us ambulance crews a warm fuzzy feeling to have done something other than pick up a drunkard.

I've had two such cases recently - both of them men in their early forties, both of them not recognising what was happening to them. Neither of them had any sort of medical history, it had just struck out of the blue. Both of them waited before they got treatment.

The first was an Eastern European chap who'd had pain in his chest since the morning, he'd gone to work and feeling unwell waited until his work was finished before walking to the hospital. It was only when the nurses there did the ECG that it became apparent that he was having a heart attack. We were called to 'blue light' transfer the patient to the angioplasty centre. He'd already been transferred to the CCU, so we also had a nurse coming with us. Like all CCU nurses she was excellent with the patient's care, all the paperwork was up to date, she kept explaining things to the patient to keep him informed and she treated us like professionals.

All throughout the patient didn't want to 'be a problem', he'd agree to anything, offered to help us (including walking to the ambulance!) and when he reached the angioplasty centre he told the doctor that they could 'do whatever they want with him'. He kept apologising that his English wasn't too good, but we muddled along fine.

The Consultant who performed the operation told us that once a patient had been through an angioplasty they normally gave up the smoking that nearly killed them. As this was the only risk factor the patient had, and as he was a really pleasant chap, I hoped he would find the strength to give up.

A really nice job.

The second job was picked up from the patient's place of work. Our FRU was already there and as soon as he saw us he shouted across that the patient would need a stretcher. As soon as you laid eyes on him it was obvious that the patient was having a big heart attack. He was sweating, he was clutching at his chest and he was scared that he was going to die. It was a perfect 'Hollywood heart attack'.

We wheeled him onto the ambulance where a very rapid ECG showed a big heart attack. My crewmate put the pedal to the floor while I tried to gather as much information as possible. The chest pain had started a few hours earlier, but the patient had ignored it and driven to work. He also had a phobia about needles, but the angioplasty centre managed to get the required needles into him through a combination of persuasion and brute force.

It's amazing to watch the screens as you see the blood flow return to the heart when the blockage is cleared. To know that the patient's chance of recovery is very good makes you feel that you have done a 'proper' job.

Both of these patients had a 'widowmaker' - a Left Anterior Descending Myocardial Infarction. These are the sorts of heart attack that can cause you to suddenly drop dead. Both were very lucky, despite their waiting to get treatment.

Both of these lives have been saved - but their outcome would probably be better if they had called an ambulance when they first got the symptoms.

Seriously - don't hang around with chest pain. If it's not obviously a pulled muscle (from lifting heavy objects or from coughing too much) then call an ambulance - the worst thing that can happen is that you get effective treatment quickly, the best thing is that you get a clean bill of health.

Oh - and quit smoking and/or taking cocaine.

As a public service announcement here is the British Heart Foundation description of the symptoms of a heart attack

“The most common symptoms of a heart attack tend to be pain in the centre of the chest which can spread to the neck, arm or jaw. It is often associated with nausea and shortness of breath.

“While women can experience the classic symptoms of a heart attack, they often present with more vague symptoms. These include a dull ache or heaviness in the chest, indigestion like pain, or feeling light headed with chest pain."

You only have one heart, don't take it for granted.

I have the physical manuscript of the American version of Blood, Sweat and Tea - the one where they take out all the letter 'u's. Every page as a column of red copy-edit changes. I don't think that the copy-editor likes ellipsises much either...

What strikes me as amusing is that the American publishers sent me (by FedEx) the printed out manuscript and want me to send it back with my alterations on it. Wouldn't it have been much simpler, cheaper and kinder to the environment, to just email it to me? They want it back in nine days - for the next four 'days' I'm on night shifts. I'm tempted to just fire off an email saying that they can do whatever they want with it.

Recent news means I get to comment on this again...

Sorry.

In the dumbing down of the NHS, other healthcare professionals are to take over the job of doctors - these people normally have the word 'practitioner' tagged onto the end of their job title. There are Emergency Nurse Practitioners (who look at minor injuries in the A&E) and there are Medical Nurse Practitioners (who do most of the scut-work that House Officers used to do).

Now we have Emergency Care Practitioners who are Paramedics with some extra qualifications who are tasked to go out to out 'minor' calls and dissuade the people from going to hospital.

Research has shown that half of the people who call an ambulance don't need hospital treatment and that only 10% of our calls are 'life threatening'. ECPs are sent out to these 'non-emergency' calls in a desire to stop patients from going to hospital and to cover the lack of GPs providing out of hours cover.

I've talked about this previously, here and here.

But what has me thinking about this again is two recent news stories. In the first a Paramedic has been suspended by the Health Professions Council (on which I shall probably write later) because a young woman died.

The second is that the BMJ report that Paramedic treatment at home is 'viable' (I don't have a BMJ subscription so I can't read the original report).

It is obviously awful that a young woman died, but I honestly can't see that the Paramedic did anything worthy of being suspended. You can read the HPC report here. The patient, who had been having headaches for weeks previously and had been checked out twice and nothing had been found. Then when the patient became worse an ambulance was called and she was taken to hospital. She died five days later.

The Paramedic gets the blame.

I don't think that the treatment that he gave the patient was awful, certainly not worth suspending him in preparation for possibly sacking him. I've heard that he's previously been a damn fine 'medic.

This isn't the point of this post.

The point is that two other people saw the patient, that a hospital saw the patient - yet it is the ambulance Paramedic who is getting disciplined.

This is the tightrope that I walk every day. If I make even the slightest mistake (as in this case, not recording the patient's 'pain score'), then I can easily lose my job. I think that the reason why we are the ones to catch the hatchet is because we are reasonably cheap to train. It would also seem that ambulance trusts want to do anything to avoid bad publicity - so they suspend or sack crews in order to show that 'something has been done'.

So on one hand the government wants us to do more with some extra training (but not the 8+ years that GPs have), yet if something goes wrong we'll lose our jobs.

This government is going to have a rude shock when they realise that there aren't going to be a lot of ambulance staff willing to train up to be an ECP.

There is a simple rule that we tend to follow in order to keep our jobs.

'Take them to hospital'.

By taking the patient to hospital we are avoiding the responsibility if they later die. It is incredibly sad that we need to 'cover our backs' in this fashion, but it's the only way we keep our jobs.

Who is going to want to take that responsibility for another £2,000 a year? I know I wouldn't, and I have my nursing experience to back me up.

We do what we do incredibly well - we deal with drunks, trauma, chronic and acute medical problems. We deal with these by stabilising them and taking them to hospital. We do this very well. A bit of extra training will not turn us into Doctors, and we are fully aware of this fact. We are also mostly sensible people, and the feedback that we have got from the first set of ECPs won't have us running to join up.

Birmingham was lovely, highlights were seeing Paul Cornell (a writer I greatly admire) speak and watching Alan Davis, Staz Johnson and Mark Buckingham work their astounding artistic magic on flipcharts.

Now I start on a run of four nights. I may be grumpy. Actually, no, I will be grumpy.

There is a GP out there that I'm not very happy with. But I'm not sure what I want to do about it.

Our call was to a sixty year old female who'd had a seizure in the GP office. Now, if you were a doctor, what would you do with someone having a fit? Would you provide the immediate care of giving them oxygen? Would you check more of their vital signs than their blood pressure, maybe even their blood sugar? Once the fit had subsided would you then lay them on the couch in your examination room in case they had another fit? Would you write a good letter to the hospital explaining what had happened? Would you volunteer to talk to the ambulance crew when they arrived in order to provide a professional handover?

Or would you leave the patient sitting in the busy waiting room with the receptionists to 'keep an eye on'?. Would you scribble a letter that had just a blood pressure written on it - no description of the actual seizure, how long it lasted for, no previous medical history or current medications? Would you write that the patient smells strongly of alcohol even when they don't? Would you hide in your consulting room when the ambulance arrives and let the receptionists deal with us?

Guess what decisions this doctor made?

I did challenge the doctor, he hand-waved about 'being busy' (the three other patients in the waiting room were obviously more important than the woman having a seizure). I decided to talk to the doctor about the presentation of the seizure - I'm not entirely sure that he was truthful to me. He told me that she was on no medications, something I later found out to not be true.

I'm sure that he's very good at dealing with sore throats and nappy rash - but surely his medical training wasn't so long ago that he's forgotten how to deal with a seizure?

It's too late for me to put in a formal complaint against him - but should I have done more than been sarcastic to him, if only because I think said sarcasm probably went straight over his head...

I mean, I'm just a big white taxi driver.

It's Eid tomorrow, so...erm... Happy end of Ramadan? What this means in a more practical fashion for me, as I start work on a run of night-shifts, is that hopefully some of the people of Newham might actually be asleep at night and not calling me. I live in hope.

Lets call her Gladys. I meet a lot of people called Gladys in my work. Gladys is in her eighties.

Gladys had taken a tumble but not your average tumble, she had fallen down the escalators at one of our tube stations.

Not just a few steps. She'd fallen down at least 30 of the hard metal stairs.

Two members of staff met us at the now familiar 'Rendezvous Point'. You can spot them outside the stations, they are the little plaques with 'RVP' written on it.

I arrived to see Gladys sitting on the now stationary escalator surrounded by Underground staff. I'd come fully expecting to see someone covered in blood who would need to be 'collared and boarded' out.

Instead she was sitting up, apparently not in pain and in good spirits.

Now, I'm a bit of a 'nervous Nelly' when it comes to people injuring themselves in such a manner - I have a strong desire to take them to hospital to be looked over by a doctor.

Unfortunately Gladys was refusing.

I checked her out. She had a lovely lump on the back of her head, and that was about it. I checked her neck and she told me that there was no pain. I wanted to make sure that she hadn't collapsed or fainted, she told me that it was her luggage that made her fall backwards. I let her know that I wanted to take her to hospital, she refused.

I did manage to persuade her to come to the ambulance for a blood pressure check, and there I was able to confirm that, apart from the bump on her head, she seemed unhurt.

A little trick for my fellow ambulance personnel. After an accident people will often feel fine and this is the effects of adrenaline pumping around the body. Then, as the adrenaline leaves the bloodstream, the person becomes a lot more 'shaky', and may feel sick. It's best to wait until this 'shaky' time is over before you leave them. Sometimes the effects of this will let you persuade the patient to come to hospital.

Gladys didn't get shaky.

I sat chatting to her for twenty minutes, and she was fine throughout. She was adamant that she be allowed to continue on her train journey home. If she'd lived in London I would have taken her home myself. Unfortunately I think that Control would have a dim view of me wandering across into Kent.

And this is where I was impressed by the staff at the Underground station - not only had they looked after her really well while they called for the ambulance, but they then arranged to have her met by staff at the other end of her tube journey. The staff would also talk to the tube driver so that he could keep an eye on her. Then one of the Underground staff stayed with her on the platform until she got on the train.

Top service.

I wasn't hugely happy about her heading off on her own, but she seemed a sensible soul and she wouldn't be on her own sitting in a busy tube train. She also promised to call an ambulance if she felt unwell at any point, and as she lives in a warden controlled flat she wouldn't be alone there either.

All that was left to do was the paperwork (meticulously written to cover my back should anything happen to Gladys), then get ready for the next job.

Over the weekend both my brother and I will be at the Birmingham Comic Convention. Where I may be pimping a script idea for a comic about ambulances. If you are around feel free to say hello.

There is nothing I like better than coming back from an exhausting shift to find that someone has personally dropped spam comments all over my blog. They aren't even good spam messages as the person placing them appears to have forgotten to link to the 'Online pharmacy drugs' that they are supposed to be promoting.

What they don't realise is that every comment made gets emailed back to me, so I get notice of those spam comments even if you try burying them in posts I made three years ago.

There are fewer pleasures in this job than being able to sit down and relax a bit. It's not often that we get the chance while we are with a patient.

We had been working all day and after a pretty long dry spell the heavens had opened up and it had absolutely poured down with rain.

"We'll have an RTA next", stated my crewmate as the rain stopped.

Our ambulance terminal buzzed and the job appeared on the screen - 'Three car RTA, man unconscious, multiple injuries'.

The location was one of our local 'A' roads, it's easy to hit 50, 60 or 70mph on these stretches of road, and it was obvious that the recent rain would make the roads more slippery.

So we drove off, lights and sirens going, not knowing what we would expect.

It was indeed a three vehicle accident, two cars and a van. The ambulance service were the first on the scene, an FRU was already there and looked fairly relaxed, we were the first 'proper' ambulance' on scene. Luckily it would seem that we wouldn't have a repeat of the triple death we'd gone to a few days earlier. The FRU told us that there was one patient in the middle car and one in the lead car. Neither of them seemed seriously injured, definitely there was no-one unconscious. We left the FRU to arrange with the police to close off the road (so we could work without getting run over by an inattentive rubbernecker), also to call off the helicopter ambulance as it wouldn't be needed.

While my crewmate checked the lead car I went to the car in the middle, it had been struck from behind by the van and shunted into the car in front. So both the front and the back of the car was pretty mashed up.

My patient seemed not badly injured, he hadn't lost consciousness, nor did anything seem to be broken. He only complained of some pain in his neck and back. I had a quick feel down his neck and couldn't rule out a serious neck injury. He needed a hard neck collar and spinal immobilisation. Putting the collar on was the easiest bit, but you can't just leave someone waggling their head with just a collar on - they don't work like that.

So I pulled open the back door for the car (with a bit of effort as it was jammed due to the damage), sat myself in the back seat, carefully avoiding the broken glass, and grabbed his head in my hands.

"It's alright mate", I said, "All we are going to do is keep your neck nice and still so that it protects your spine. Then we'll open the car up around you".

We called for the Fire Service while I chatted to the driver, he was a nice bloke - but the car was his wife's. I explained that 'Trumpton' would cut the roof off the car so that we could get him out safely. Meanwhile he joked about how his wife always wanted a convertible.

The Fire Service arrived and did the things that they do; chocking the wheels so that it doesn't move, spraying shaving foam on the windscreen where they cut in order to protect against glass fibres, and placing protection around the patient and myself. Meanwhile I was having a relaxing time of it, explaining what was happening to the patient while holding his head still. The great thing was that I was able to do all this while sitting on my backside.

I don't know if you've ever been cut out of a car, but it gets a bit noisy, even if you are wearing one of the wonderful LAS safety helmets which block both your ears and, because the visor is so scratched, your vision. My job was simply to keep the patient happy and minimise any head movement.

Snip, snip, snip, snip went the pillars of the car and, by sliding a back board behind him, we soon had the patient out nice and smooth. The patient was happy (well, happyish), the Fire Service were happy (they like cutting cars into small pieces), and I was happy (because I had got the chat to sit down and natter for half an hour).

A smooth ride to the hospital and I believe that the patient was released an hour or two later with no serious injuries.

The only problem was that the traffic, which we had stopped, was still tailing back when it came for us to go home. So I had the pleasure of sitting in the traffic jam that I had 'created'.

I think that it's Ambulance Law #17 that states, 'In a fight with a 90 year old patient, the ambulance crew will always come off worse'.

Our call was to a ninety year old woman described as, "Not getting out of bed, not eating, not washing. Suffers from dementia".

Now, this might not actually require an emergency ambulance but I'm getting soft in my old age and am more forgiving of certain types of 'non-emergency' calls.

It was the patient's daughter-in-law who had called us, normally her husband looked after his mother (our patient), but he'd had to go into work that day and had delegated the task to his wife.

The first thing that I noticed was that the daughter-in-law looked to be at the end of her tether, the patient was soaking in her own urine and was resisting all attempts to change her clothes. The daughter-in-law told us that the patient's dementia had become worse over the past few days. My highly trained nostrils suggested that the reason behind this sudden deterioration may well have been caused by a urinary infection.

Urinary infections can cause all sorts of symptoms and, especially in the elderly, can cause people to become confused. With the already demented patient it can increase their confusion.

As our patient was quite happy to sit in urine drenched clothes I wasn't hopeful that she would happily toddle off to the ambulance to go to hospital.

I wasn't wrong.

She refused *everything*, we tried persuasion, we tried reason, we tried bribery. None of it would work.

The daughter-in-law suggested that we leave and 'go help someone more deserving'. I let her know that this patient, and her, were our concern right now. I promised that we would get something 'sorted'.

I wanted to take the old woman to hospital for two reasons. The first, and most obvious was that if our patient did have a urine infection, and it was left untreated, then there were serious concerns for her health.

Secondly and thinking more long-term, I wanted her to go to hospital because then the hospital would help her. The patient's family were unable to care properly for her, so they were looking for a care home place for her. The social services had promised an assessment, but that it would take over a month to arrange. Then there would be the waiting while a suitable place was found, etc, etc...

It would take a long time.

By taking the patient to hospital, and hoping that they would admit her, we would be forcing the social services to deal with the patient a lot quicker than they otherwise would.

I imagine that the social services do their own prioritising. As this patient was 'safe' in her own home and is being looked after by her family she is a low priority. If she is 'bed blocking' in hospital then they will arrange the care she needs more urgently, probably because of some governmental target.

And why was I 'cheating' the system this way? It was because I could see the eyes of the daughter-in-law as she told me the strain that it was placing on her and her husband. It was because I could hear the tone of her voice as she explained the trouble they had in caring for the patient. And it was because I could see the bruises on the wrists of the patient where she had been restrained from attacking the people caring for her.

So taking her to hospital was the only real option. But how? We had already spent an hour trying to talk her into coming to hospital.

We'd have to kidnap her.

It is legal for us to forcibly remove someone to hospital if they are deemed 'not competent' to refuse and if they have a serious illness. As I mentioned earlier, a urine infection can become very serious in the elderly. In addition she was refusing to eat. This, in my view, means that her well-being was in danger. Her dementia was so far advanced that I considered her unable to understand the consequences of remaining at home.

So legally and ethically we were on safe ground.

I don't like forcibly removing people, it's a lot of aggravation and there is always the fear that someone will get hurt. Sometimes we will get the police to attend in order to help us remove the patient. In this case I didn't think that police would be able to do anything different to what we would do.

But...

Any confrontation would be rather one sided. Us, as an ambulance crew, are trying our best not to hurt the patient - it'd look bad if we broke her arm. Our patient on the other hand is more than happy to punch, bite, spit, claw and go for my testicles.

Which she did even though we had wrapped her in our blanket. Never underestimate the strength of a demented patient.

She managed to draw some blood from me (an inconsequential scratch on my arm), but at least we managed to safely get her downstairs into the ambulance. When she got in the vehicle she calmed down a little and she didn't seem hugely upset to be in the hospital.

The daughter-in-law couldn't thank us enough.

I knew that the patient would get medical care, I'm just hoping that she also got the social care that was desperately needed.

I've been a bit slack posting of late due to that nasty old 'black dog' that comes around in these shorter months. With a bit of luck I'll shake it off soon.

It's not often that a patient drives his own ambulance to the hospital.*

For the past two weeks I've been having a little 'bumps' in my heart rhythm, once or twice a day I'd feel my heart skip a beat. Not a problem I thought it would resolve itself.

However last night I was getting run after run of these missed beats, this made me feel a little nervous and I thought that a quick assessment at the local hospital would rule out anything scary.

So we waited until we had we took a patient into the hospital (a woman who'd fainted and was refusing to talk or open her eyes) and I let the nurse in charge that I would be booking myself in.

A few moments later I was in the resus room being poked and prodded. A twelve lead ECG was done, which showed nothing unusual (as the missed beats are intermittent).

I've put in a countless number of cannulas into patients - for the first time ever I had one stuck into me.

I was hooked up to a heart machine that does printouts and when I felt the missing beats I'd shout to the resus nurse who would come running and hit the 'print' button.

This is what I got.

Unifocal bigeminy

Now, in the big scheme of things this isn't that worrying a rhythm. As my bloods came back all normal I was discharged and will have a 24 hour ECG recording which will be arranged by my GP.

I'm still getting them, but not half as many as I was.

The staff at the hospital were great, they looked after me really well. On more than one occasion I had one of the nurses come in to see how I was. They'd have a laugh and a joke with me, and I could hear my fellow patients in the resus room also having similar chats with the nursing staff.

(They'd also look at the tracing and mutter 'Oh shit!' under their breath. Which is nice of them).

I also had one of our station officers come down to see me, and he couldn't do enough to help me out. We shared gossip on the big fire in Plaistow, the smoke of which that was making the meridian laser beam look really pretty.

Also there were a fair few stabbings and shootings in the area which was making life 'interesting' for the local police.

The nice thing about it was that the station officer stood me down from working tonight (he also wanted to drive me home, something I refused, I was driving around on blue lights for most for the shift, a little run home in my own car wasn't going to be a problem.)

It is a bit weird to be a patient, especially when you don't know what is causing your illness. I normally self treat my own illnesses, but in this case I needed some help and the hospital and my workmates were all excellent. Just goes to show that the NHS can work well.**


*Big tip of the hat to my crewmate who pointed this out.
**Of course, if I suddenly drop dead then I may change my opinion...