I've reached that point in my blogging career where if an ambulance story is in the media I'm phoned up to provide comment.

So this BBC article about solo responders and the concerns about using them so extensively has already had me woken up by one newspaper.

I don't mind - after all it's something I've been shouting about on this blog for ages. Please remember though that I'm just a worker on the road, if you want real information you should talk to the LAS Press office 020 7921 5113 (and who are a bunch of top folks by the way).

Still it is nice to have something that I'm concerned about in the news. For more on this subject you may want to check out the following links.

A simple description of ORCON (The government target we are desperate to meet)

Why I think that splitting crewed ambulances to man solo responders is a bad idea for patient safety.

Where I describe the plan to increase solo responders and decrease double crewed ambulances. (I'm a lot less enamoured of the idea now than when I wrote this).

One concern for staff and patient safety that often isn't thought of.

Where I moan about some of the hoops we have to jump through to get our targets - but the comments section has more information.

My solution to the 'target' question that will actually benefit patient care.

To summarise things as I see them (and remember - these are my views alone, not those of my employer).

The government wants to measure the performance of ambulance trusts. The main way of doing this is to see how many of our 'high priority' calls we get to in under eight minutes. There are often more calls than there are ambulances, so solo responders effectively double your workforce with respect to reaching this target. Once a responder reaches a patient, the clock stops.

Solo responders can't safely transport patients. They also are unhappy to leave people at home because they are scared they will die. Solo responders therefore can spend a lot of time at scene waiting for a double crewed ambulance to arrive.

Sick people need to be in hospital - it is better to get there in nine minutes and be able to transport them than to get there in seven and have to wait half an hour for a proper 'truck'. The government does not agree.

The eight minute target is from research over 20 years old - and it only deals with cardiac arrest patients, not with 'high priority' calls. The department of health has no copies of the ORCON paper on record -although there is one in the British library. Modern research says that eight minutes is too long to get to a cardiac arrest.

Although our ORCON response percentage in London is roughly the same as has been every year, our cardiac arrest survival rate has more than tripled. Doesn't this show that other initiatives (which aren't tallied up by the government) are far more important?

Getting to patients quickly is never a bad idea, but in concentrating resources on solo responders at the expense of double-crewed ambulances I firmly believe negatively impacts patient care. Sick people need to be in hospital.

In London we are about to start running community responder posts - first-aiders from the public sent to calls. This is so deeply wrong that I can't get my head around it. Again I suspect that this is to help us meet these targets. It's not like we are in the wilds of Scotland where it physically takes you an hour to get from one place to another.

This is just the beginning of the discussion - the plan is to have all but the most serious calls (like confirmed cardiac arrest) attended to by just a solo responder, a double-crewed ambulance won't be sent - once the solo is on the scene they will make the decision as to the patient needing an ambulance to transport them, or if they need a GP, or can make their own way to hospital.

The simple solution is that we need more ambulances and more ambulance crews - but the government won't reach into their pocket and give us what we need, so instead the ambulance trusts have to make these difficult decisions.

It's not the ambulance trusts fault that we are heading down the solo responder route - it's purely the government's focus on this out-of-date target and lack of motivation to give us the funding we need to continue giving Londoners the care that they expect.

Oh and people call us for utter rubbish like veruccas - which is why we are under so much strain at the moment.

I'm hoping that this will run and run and might cause some form of change - unfortunately I suspect that this story will soon be ignored because of some celebrity drug 'sensation' or we find someone else who has faked their own death.

A bit of a moan this one - I know, I know, I almost never moan...

Our job was to a middle aged man with sudden severe back pain. We arrived and soon determined that it was simple sciatic back pain. Our patient didn't speak much English but his wife was fluent (and given her East end accent she was probably born in England).

The thing about sciatic back pain is that gentle movement often helps it - so what we, as an ambulance service, do is fill the patient up with painkillers and walk them gently out to the ambulance. Then we transport them to hospital.

The thing about sciatic back pain is that we tend to see only the people with the severe version of it. They are often lying on the floor clutching their back, unable to move. Part of our treatment is explaining what is happening to the patient and building up a relationship so that they can trust us. It also helps with the pain.

We spent an hour on scene with the patient - giving him blasts of nitrous oxide (laughing gas) and slowly persuading him to get to his feet, and then, with more analgesia, getting him to walk out to the ambulance. Luckily he was pretty good with just the gas - it's not unheard of for us to give morphine in order to get the patient moving.

By the time we reached the ambulance we were all having a joke about it, with his wife explaining to him that this is what it is like to squeeze out a baby...

Then, as carefully as possible, we drove to the hospital.

Once at the hospital we put our patient in a wheelchair, the reasoning behind this is that sometimes you'll get trollies, or patients, that need to be moved around at speed and it's not good to have a slow moving patient blocking the corridor.

We think ahead like that. For us ambulance people are not dumb, we is smart!

The problem that I had was that of the attitude of two of the senior nurses (the type of nurse who, half the time, doesn't wear a nurse's uniform). There was a general rolling of the eyes that we were giving the patient pain relief.

"Why are you giving him nitrous oxide?", one said.

(Here is a clue - if I write on my report form that a patient is in severe pain, but don't do anything about it then one of my managers has a damn good reason for calling me into the office for a chat. Plus it's also the human thing to do).

"Why did you bring him here? All we can do is give him pain relief", one asked.

Well - I generally thought that this is the point of hospitals.

Patient in pain = patient needing painkillers.

The patient had already been taking regular painkillers for a grumbling back pain - so it wasn't as if he hadn't tried self treating.

Out of earshot of the patient these two nurses tutted and grumbled about him. They actually treated him well, but it was the attitude that I found incredibly annoying.

I'm more than happy to have nurses unhappy when I bring them the umpteenth drunk of the shift - heaven knows I used to get fed up with that when I was an A&E nurse. Also nurses, like the rest of us, can have 'bad days', but two of them? At the same time? In this case the patient had a genuine medical need, primarily for pain relief and secondly so that a doctor could assess him properly to determine the cause of the pain.

What annoys me, a few days later, is that I didn't challenge the nurses. I was feeling really rather grotty with (yet another) bout of man-flu, so I just let it slide. Nothing happened that would warrant a formal complaint as the patient was treated as he should have been and the nurse (in a proper nurses uniform) who actually looked after him was her usual excellent self - but the attitude of the senior nurses just rubbed me up the wrong way. If I'd been feeling more myself I might have asked when the NMC/RCN guidelines on pain management had changed, or why they thought that he deserved to be in excruciating pain.

I don't know, maybe I'm getting soft in my old age. Or maybe it's because I'd spent an hour getting to know him and his wife, and didn't see them as 'just another face blocking up the department, causing a breach'.

I've written before on how the future of the ambulance service is to have solo responders in cars go to calls, rather than ambulances, firstly to assess and then, if possible, to transport the patient themselves.
It's partly the reason why we have the Zafiras as our FRU's now rather than the Vauxhall Astras. The Zafiras have started to sprout removable seat covers, the implication is that we shouldn't be scared of transporting patients.
I've spoken before of some of the safety implications for this, solo responders get attacked and patients can get suddenly more unwell and need a proper ambulance.
I was working on the FRU the other day and I came across another concern for my safety.

I was sent to a woman in her thirties who had collapsed in the street. She was laying in the middle of the road, shivering from the cold. A couple of bystanders had started to look after her as best as they could, so I suspect that they were glad to see me turn up.

There wasn't an obvious cause for her collapse, although the woman was extremely thin everything checked out.* To leave her lying in the street as the sun disappeared below the horizon would only add hypothermia to her problems.

So I made the decision to sit her in the FRU with the heater turned up full.

Here is my safety issue - all witnesses had disappeared, all it needed was for the patient to make a complaint of sexual misconduct against me and I'd be out of a job. It's dangerous in this world to be sitting in a darkened street alone with a female patient.

I was very grateful when the ambulance turned up.

As someone who had to deal with a frivolous complaint, and as someone who trained as a primary school teacher, I'm always aware of the potential for someone to make a complaint of sexual misconduct against me. It's one of the reasons why I like working as a mixed crew - my female crewmate can deal with anything intimate with women, I can deal with the men.

Imagine if I needed to do a twelve-lead ECG on a young woman - as a solo responder how safe would I feel in exposing the woman's chest? Not very, I can tell you.

It's a dangerous world out there - especially if you value your career.

*It turned out that she had collapsed due to drinking too much - once more I curse my inability to smell alcohol.

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I have a day off - so I'll be doing my 'clear my email inbox' today. If you have sent an email and don't get a response by the end of the day, I'd send it again.

...Because I know that the readers here are superb.

Request One - Unison had a press release the other day about dirty ambulances. I've had a look on their website for some actual *data*, or some other form of real information, such us their method of surveying, but all for nought. Does anyone have access to this actual information?

Request Two - I'm interested in joining a *serious* roleplay guild in one of the following MMORPGS, World of Warcraft, Eve Online, City of X, Tabula Rasa or some other free game. I'm looking for a group that doesn't mind me being an infrequent player (due to my shift work) - I'm looking for a group of people I can relax with.

Thanks in advance.

Remember I was telling you about the new function on our display terminals in the vehicles, the one that counst how long you have been at hospital? This is a picture that my crewmate took while I was away playing on the FRU the other day. It shows that she was waiting to hand over their patient for two hours.
It's been crazy the last few days - we leave the station at the start of our shift to attend to a patient who has been waiting for us to start work. Then we spend the rest of the day out, running from patient to patient. While doing my paperwork at hospital or on the way to a patient all I've heard is our dispatchers doing 'general broadcasts' to see if there are any ambulances available to attend to the 'many emergency calls across the sector'.
It's not even your usual winter pressures - I'm yet to see much of the traditional winter illnesses. It's not like there is a sudden increase in 'flu' cases, there hasn't been an outbreak of Norovirus. It's been the usual run of people with chest pains, old people collapsed, drunks, abdominal pains - all the usual stuff, just much more of it.
I was speaking to a hospital site manager the other day, she agreed that there isn't any apparent reason for the increase in people coming to hospital. It's the normal stuff, just more of it.
So we have been waiting at the hospitals, which have been filling up with patients - this means that patients have been waiting for ambulances.
Which was why an lovely old fella was waiting for an ambulance for an hour on the floor of a shop with a broken hip.
Then he had to wait for two hours on an ambulance trolley in order to be handed over to the hospital.
I can't see a solution to this - there will always be periods where more people need emergency healthcare. While I think that we should have more ambulances - this isn't a solution to these short term increases in demand.
Hopefully it'll be better in a few days.

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I was spoken to by a reporter from 'The People' newspaper in order to get my comments on the winter pressures. I explained that, as an organisation, we have a pretty good process in place to deal with the demand. As pressure increases we do various things to increase the number of ambulances on the road. Overtime also becomes available - which is nice for us poorly paid people.
The strange thing is that the day after the People article (by Tom Carlin) is published, an very similar article is front page news in the Daily Express. This article is by Mark Reynolds, and contains the same quotes (and a fair bit of the same sentences). Except that they misattribute comments from a nurse as comments from me.

Isn't this plagarism? Or just the 'echo chamber' that blogs are often accused of being.

Have a look and decide for yourself -
Original article in The People.
Second article in the Daily Express. (The comments to that article are both scary and hilarious)

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Finally - I managed to persuade my brother to buy himself a Macbook Pro (better than my Macbook, the swine! The next person to say that teachers are paid rubbish will get a severe talking to from me). It was a right struggle to get him to open his wallet - but he's now really rather glad that he did. It especially made an impact as to how easy it was to set the Mac up with his home network as opposed to the swearing I was doing trying to get his Vista machine to work.

Does anyone have any 'killer apps' that they would like to suggest? He's impressed with the ease of Handbrake and iSquint to get video ready for his iPhone. I've already got him admitting that Quicksilver is 'greased loveliness' and he has Delicious library installed but I'd love to hear what other people are using.

Lets talk about something nice for a change.

The LAS, not only doing well against nasty infectious diseases in the backs of ambulances, are also doing pretty well in the fight against people dying from cardiac arrest.

The latest figures for the cardiac arrest survival rate are out and we are doing really rather quite well.

In 2001-2002 of the people having a cardiac arrest, only 5% survived to be discharged from hospital.

in 2005-2006 it was 10.9%

Last year the survival chance is up to 15.8% - more than a three-fold increase from 2001-2002.

We must be doing something right. I would suspect that it's partly down to the change in the resuscitation guidelines. We've moved from the old (and very easy) five chest compressions at a time, to a much more knackering, but also much more effective 30 chest compressions at a time. Also our people who answer the 999 calls are moving towards giving people who call ambulances for cardiac arrests better instructions how to start CPR - we are currently in the middle of a research project based around improving these instructions.

The LAS has also been working in putting public access defibrillators in place in addition to training staff, such as rail and tube workers, in their use.

This is funded, not by the government, but by lottery money...

It's good to see us doing something right, just because it is right - even though the government doesn't 'mark us' on it.

There is only one slight downside to this - and it's because of the simplistic way in which the press reports things. The cardiac arrest survival rate is calculated using the Utstein* method. This means (very simplistically) that it is only the people who realistically have a chance of surviving that are counted. Poor old Doris whose heart stopped two days ago doesn't get counted. This is unfortunate in that this reporting still gives some family members a heightened expectation of their relative surviving - in which case it is up to the crew's people-skills to explain what has occurred.

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*The cardiac arrest survival figure is calculated using the Utstein method, which takes into account the number of patients discharged alive from hospital who had resuscitation attempted following a cardiac arrest of presumed cardiac aetiology, and who also had their arrest witnessed by a bystander and an initial cardiac rhythm of ventricular fibrillation or ventricular tachycardia (From the LAS release).

I arrive on station to work with my crewmate, she's back after a day or two of sickness so I'm happy to see her.
Unfortunately there is someone else on station, a member of staff who has been tasked to cover her sickness.
So we have a spare member of staff. He rings the resource centre (the offices that organise manning resourcing.
They ask to have a chat with me.

I'm trained on the FRU, so they ask me nicely to leave my crewmate to work with the other member of staff. They want me to work on the FRU as it is currently un-manned un-resourced.
So now I find myself working on my own as a solo responder rather than working with my crewmate. This makes me sad, as one of the reason why I like my work is because I get on really well with my crewmate and we have a good laugh together.
As it is, I'm now stuck for twelve hours on my own.

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As a vague aside about the new FRU motors - they are all Zafira models (presumably so that we can start transporting patients in them - a post for another day methinks).
The problem with the Zafiras is that they drive like a hippopotamus. Actually they drive like a hippo that you are trying to stear by poking sharp sticks in it's ears. The 'A frame' sits right in the line of vision that I need in order to see the people who leap out at me when I'm on blue lights. Finally the seat is incredibly uncomfortable, it feels like someone is punching me in the kidneys. This is not good considering that we are supposed to be on the road for the full twelve hours of our shift.

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Ok, a question. Lets imagine I go to a patient who is either pretending to be unconscious, or is just refusing to speak to me. How do you write that in medical terminology? Without being rude, or using terms that could be seen as politically incorrect. I tend to write 'Patient apparently feigning unconsciousness', but it still doesn't seem right.

Somehow on my 'week off' I'm busier than I would be if I were just going to work. How am I ever going to get my full Spellfire set or my next six million ISK?

(OK, nerd episode over).

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I've been spurred into writing this post for two reasons - the first is this post of mine and the associated comments, the second is this article in the Financial Times. Two quick notes on the article, if the government want to employ a blog expert I can be had for a salary of, oh lets say £25,000+. Also if they want to invite me to talk to them, I'm more than happy to spill my brains the general direction of anyone in government.

To recap - the main target that the government has set ambulance services around the country is that of ORCON. This, at it's simplest, states that we should reach our high priority calls in under eight minutes and our medium priority calls in under fourteen minutes.

The problem that I have with this is twofold. Firstly, in a supposed 'evidence-based' NHS there is little clinical reason for the eight minutes as opposed to four minutes. Secondly, and much more importantly in my opinion it directly impacts on patient care.

In order to meet the eight minute target ambulance services are removing double-crewed ambulances from the road in order to increase the number of Fast Response Units (FRUs). The reasoning is that if an FRU is on scene then the 'clock stops' and the job is a success. It's not a success for the FRU if they are stuck on scene with a stabbing, unresponsive asthmatics or with a child with meningitis.

People who are seriously sick need to be in hospital, not having a solo responder holding their hand while praying in desperation for an ambulance.

Ambulance folk can do a lot to stabilise a patient, but as a trainer of mine wisely says, "the place for a sick patient isn't the back of an ambulance". Nor is it in their own home waiting for an ambulance to turn up.

So, what are we to do? We need to check on the performance of NHS trusts, that much is certain.

My solution is to have more targets.

But targets which will have an impact on patient care.

Lets have a target where we improve the number of heart attacks that we diagnose in the home and transfer to the 'gold standard' treatment centre. I think we are at 95-97% on that at the moment. How about improving the call to treatment time.

Lets have another target where we diagnose strokes (or 'brain attacks' in the jargon of today) and transport them to a specialist centre. Of course we might need a few more places to become specialist centres first, but isn't the NHS a 'joined up' organisation?

Lets have a target where we try to reduce the number of patients with asthma who need admitting to hospital. Better, lets reduce the number of people who need to stay in ITU because of asthma. Of course it isn't the sole job of the ambulance service to do this, but our targets should inform other aspects of the NHS, just as theirs affects ours.

How about improving the measurement and treatment of pain - its something that we aren't too good at, given that in most cases our choice of pain relief is restricted to entonox or morphine. We carry aspirin, but that is for heart attack treatment, not the treatment of minor pain. We also have paracetamol for children. How about nasal diamorphine? Improving the measurement and treatment of pain will directly improve patient's experiences.

How about improving cardiac arrest survival rates. We've managed to improve this greatly over the past few years and I'll be talking about this in a later post. Unfortunately the government doesn't 'reward' us due to our improvements in this area, perhaps they should.

Time until a patient is reached is important in some cases, so we'll keep a target for reaching patients, but lets change it to only having the clock stop when a proper double-crewed ambulance arrives on scene. The other targets (like cardiac arrest survival) will be met by FRUs getting there quickly, but this will mean that there is less chance of FRUs being manned at the expense of proper ambulances.

How about a target of increasing the amount of paramedic cover in an area. Or how about a target of improving the training of people on the road? Better trained staff means better care for patients.

Maybe a target to increase the number of ambulances on the road. Even better would be a target to have a certain amount of spare ambulances. Ambulances that are waiting for a call from a patient rather than the other way around. We should have a slight excess capacity of ambulances at all times, not have people waiting for ambulances to finish with one patient before they can be attended to.

Finally, how about a 'staff satisfaction' target - a happy workforce is a more effective workforce.

Some of these targets are more important than others and by giving individual targets a separate weighting we could come up with a total 'score' that will show improvement, but can also be broken down to show where further improvement can be made. For example the number of people who get diagnosed and treated at a specialist centre for a stroke could be worth ten times as much as the number of people who get painkillers for their broken arm.

We could even keep the ORCON target, but give it a more reasonable weighting of importance.

This system would have the advantage of being better based on current evidence and would highlight areas where changes can have an immediate effect on patient care and outcome.

There is a reason why I get a warm and fuzzy feeling when I diagnose and take to a specialist centre someone having a heart attack. It's because I've done something that will have an effect on the patients well-being. It's a feeling that I don't get when I reach somewhere in under eight minutes or meet an FRU who has been on scene for forty minutes.

Right - how do I get to be Minister In Charge of Sensible Ideas for Ambulances?

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I've fiddled around a bit with this blog in an attempt to resolve some of the issues some people have had with getting a black screen when accessing the site. Let me know if it works out.