As is normal these days the nursing home that we went to was 'well known' to us. The patient had the normal 'difficulty in breathing' which I have learnt means anything from a cold to the patient not breathing at all.

As we arrived I spotted two Healthcare Assistants standing outside smoking. "Another ambulance", one of them commented, "This place is a right dump".

I couldn't really disagree with them.

So we made our way up to the patient - no-one was there to show us where to go, again not unusual. Our FRU was already there, he's a good bloke and I trust his clinical skills completely. He'd already done a full assessment and was talking to the nurse in charge. From the sound of the patient's breathing and his high temperature it was obvious that he had pneumonia.

So I asked the nurse how long he had been coughing and having trouble with his breathing.

"Ten minutes", she replied.

Now, you don't need to be a medical genius to realise that his breathing must have been horrible for quite some time. But given the amount of times I've heard that "the patient was fine until five minutes ago" from a nursing home nurse I suspect that there is a whole load of medical books that need rewriting.

The patient was seriously ill, and you don't get like that in ten minutes. My guess would have been that he was unwell for at least a day, yet no-one thought to call a doctor or us until it looked like the patient might die.

Yet again the nurse in charge of his care didn't seem to know anything about the patient, when I asked about the patient the nurse seemed to think that giving me a list of their medicines counts for this. Sadly this is also not unusual. I did my usual trick of pretending not to know what a certain drug does, then ask the nurse to see if they know. It is essential that a nurse knows about the medication that they are giving someone so that they understand the effects and side effects that can occur. Unfortunately in many of the nursing homes we go to this is a rarity.

In this case she was unsure as to why he had been recently prescribed some antibiotics.

I used my 'ex-nurse' knowledge to write a quick entry in the patient's nursing notes - that way nothing can be added after we have left. It's a little trick of mine that satisfies my bloody-mindedness.

So we moved the rather ill patient to the ambulance and while treating him waited for the accompanying member of staff. We waited and we waited, I was considering just driving off. Eventually one of the usual foot-shuffler 'nurses' made an appearance and we left for the hospital.

It's depressing, and I've written about this before, but it's all too common to find this sort of neglect going on in nursing homes. The companies who run these places make huge amounts of profits, yet the care is what I, in fact what most people, would call sub-standard. If the number of people with dementia continue to increase, then more people will need nursing care, and if the care isn't there at the moment I dread to think what it will be like in the future.

Two links to finish off - one is to Inspector Gadget who tells us of a terrible story where two scum who left a police officer brain-damaged have just had their sentences reduced. The other link is to a great work of fiction by Rocky Mountain Medic.

Oh, and hello if you came here from the Daily Mirror.

For those in the UK Panorama tonight has a programme on violent patients in the NHS (BBC One 20:30).

Us ambulance crews are verbally and physically abused on an almost daily basis – it has gotten that we tend to ignore the verbal abuse that we get.  It’s only with the increasingly common physical assaults that we fill in the required forms.

Let me give you an example from my last night shift, a not unusual job.

We were called to ‘woman collapsed in the street’ at gone midnight.  We arrived to discover our ‘patient’ lying under a bus stop with what appeared to be her worldly possessions in a plastic bag.  There was no-one else around except for the minicab driver who had called us from hi office that she had ‘collapsed’ in front of.  While my nose can no longer detect alcohol my crewmate for the shift was able to tell me that the patient smelt as if she had been dunked in a brewery sewer.

A quick check in her bag revealed nothing obviously medically wrong with her (medicalert bracelets or ‘I am an epileptic’ cards).  It did however reveal that the woman had been released from custody earlier in the day.

I tried to wake her, but she screwed her eyes tight and refused to talk to us.  The problem is that we can’t leave her on the street; someone else would call us and we would be back and forth all night.  Likewise if she froze to death we would be to blame and, if she were stabbed later in the night we’d also probably be to blame.  The police also wouldn’t be interested, they have stopped taking people who are drunk, one too many deaths in custody is to blame for this.  So, as she refused to go home or to her hostel, the only place that we could take her was to hospital. 

I was in a good mood, so I explained all this to her, that we couldn’t leave her here, and that if she didn’t come with us the police would probably be called and that they might take a dim view of her drunkenness (a bit of a bluff, but it sometimes works).

So she started to swear at us, she threatened to hit me and she was generally rather rude…

Again, this is all water off a ducks back to me.  At one point she tried to kick me, but I’m an old hand at drunks in the street and by the cunning tactic of stepping out the way managed to avoid a scuffed shin.

Eventually we managed to hoik her up and into the back of the ambulance where, after a bit more swearing, she settled down.

She did give me a dirty look at the end of the journey though.

I would say that I get a patient who is verbally abusive at least once or twice in a shift.  I don’t mind violence from people who are medically unwell (e.g. diabetics with low blood sugars, post seizure epileptics).  But can I really count ‘drunk’ as a medical problem?

I also count myself lucky that I work where I do – unlike the hospitals where people become frustrated by long waiting times and percieved injustice I’m often seen as a friendly stranger who makes everything better.

For further stories of assaults you can look here, here, here and here. Unfortunately these won’t be the last.

The first job of our nightshift was to an overdose. Sometimes these are nasty, sometimes they are easy. Sometimes you know what the job is going to be like from the information sent down to our ambulance.

"55 year old man, overdose on diazepam and alcohol ?how long ?amount".

My psychic powers kicked in and I predicted an alcoholic who had taken many tablets of a small dose of diazepam (a muscle relaxant and sedative) with rather a lot of alcohol. Probably nothing too serious in a physical sense, but it never hurts to get there as quickly as is safely possible.

The FRU was already there, along with the patient's sister. Our patient had drunk a *huge* bottle of whiskey along with around forty tablets of very low dose diazepam. He'd taken about double the daily dose which meant that he was going to be sleepy but it wasn't likely to be life-threatening. He'd still need to go to hospital to be sure and so he could have a psychiatric referral.

I asked the sister about the patient, was he a heavy drinker? She replied that he wasn't just a heavy drinker but that he was an alcoholic, it's not that I really needed to ask - one look at the patient's house told me that.

The patient had taken the overdose in the morning, then rung his girlfriend to tell her what he had done. She was out at work and so the message was left on the answerphone. In the evening his girlfriend had returned home from work, heard the message and phoned the sister who lived closer. The sister had called us and went around to open the door.

What I wanted to know was, did the patient really want to kill himself and left phoning his girlfriend until he knew she would be out in order to make sure he was dead before she got the message? Or, more likely, was he so drunk while taking the tablets that he didn't know what the time was when he made the phone call?

It never ceases to surprise me how people who take an overdose act. They take a handful of tablets, then phone a friend. They then act surprised when the ambulance arrives.

Thankfully this patient was drowsy and compliant (he was a big man and I didn't fancy wrestling him into the ambulance). He'd slept the day away, spent some time sleeping in the A&E department and the last I saw of him was him walking into the patient toilet.

So an easy job, a sensible sister and a puzzle on the nature of a phone call.

There might not be a post tomorrow - you'll find out why on Friday.

Once more a shortage of ambulances makes the news...

A man stabbed outside a pub was taken to hospital in a fire engine because the area's three ambulances were busy...

...An ambulance service spokesman said: "The three vehicles on duty in the Maesteg area were already committed.
"The nearest available ambulance was at the Royal Glamorgan Hospital and this was dispatched but was stood down when police responders informed control that they would convey the patient in a fire brigade vehicle

Full article here.

What strikes me as amusing is that I heard of a fire engine bringing a traffic accident in my local hospital only a few days ago - once more because of a lack of ambulances, and this is in London, not Maesteg. Once more the demand for ambulances far outstrips the actual number of ambulances we have available.

At the moment the London Ambulance Service is at 'level 3' in our 5 point scale of how busy we are. So, despite not having the money for it (thanks to the government taking a large chunk of our budget away from us to pay another hospital trusts bills), we are having to pay people for overtime in order to keep the service running to the standard that the government and the public expect.

It's long been known that the ambulance service runs on it's overtime, and our ORCON times have been dropping through the floor because until now we haven't had the funds to pay for overtime (due to the aforementioned government taking money away from us). Now it is reaching a crisis it seems that we have found the money for overtime somewhere - I suspect by 'robbing Peter to pay Paul'.

It's a simple formula, 'Too many calls (often for rubbish) + not enough ambulances + high expectations from the public of the service we provide + demoralised staff = long waiting times for ambulances, delays getting to genuine life-threatening calls and an unhappy public/government'.

Large swathes of the population expect an ambulance for every cough, cold and sniffle - the government is unwilling to pay for this expectation and so the ambulance service gets squeezed from both sides.

In April we tell the government if we have made our targets. I hope that we don't make them this year. If we make the targets after the government has cut our budget, then what incentive do they have for giving us our pre-cut budget back?

If we make our targets, then we will have made a rod for our own backs.

UPDATE: Edited to correct my mistake - we are actually at level 3, not level 4 as originally written.

Warning - written after 26 hours of not sleeping.

I heard a great story last night, it had my crewmate, my patient and myself in fits of laughter.

We were called to a patient I've been to previously, they are a nice family and the patient is lovely, unfortunately the patient has a long list of medical problems and needs an electric wheelchair to get around. He had been taken ill and, after a four hour wait, had finally got me to pick him up.

He was in his bed and we would use our carry chair to get him out of the house. First though we needed to move the patient's own electric wheelchair. Now I'm experienced enough to know that I really shouldn't touch these things because I'll only end up breaking them, so we called for the patient's son to come and move it.

He tried moving it by standing next to it, but the patient said something to him in his own language and the son climbed into the wheelchair and steered it away.

As he did this he told us the story of having to take the wheelchair to the hospital on his fathers previous visit.

You see it's hard to stand next to a wheelchair to steer it via the joystick, so he climbed in it a rode it to the bus stop.

The problem was that there was a load of people standing waiting for the bus watching him.

So he felt too embarrassed to climb out - it would look a bit...well...'funny'.

So the bus came and the bystanders helped him get on it, then they helped him get off at the other end of his journey. He even gave them a wave of thanks as the bus pulled away.

The son told this story so well we were nearly wetting ourselves with laughter, his animated demonstration of the wave at the end was a sheer brilliant flourish.

Even the father had a (slightly gaptoothed) smile.

The thing that was so funny was that we could all put ourselves in his place and we couldn't really say that we wouldn't do exactly the same thing. It's like a Basil Faulty sketch, a weird playing up of not wanting to offend people and so getting yourself into a silly situation.

As I say, the patient and his family are really nice people and his son was interested in talking to me while waiting for a nurse to take our handover of the patient at the hospital. He was one of the very few people who said 'thank you' at the end of the job.

For those that are interested, blogging of BarCampLondon2 is starting over at Mental Kipple.

When dealing with children in a basic ambulance job there are two types of parents - the calm sensible ones, and the flappers. Calm sensible parents are preferred, they keep the child calm, can give you a full and complete history and are a pleasure to have in the back of the ambulance. Flappers are another matter.

Our call was to a nine year old girl with a nosebleed, they lived less than two minutes from their local hospital and the presence of a car in their driveway had me rolling my eyes. The front door was opened by the patient's mother, she was literally running backwards and forwards with tears streaming from her eyes. She could hardly talk because she was so upset and her breathing was just a shade short of becoming full blown hyperventilation.

Obviously I had a moment where I though that the child was more seriously ill than a simple nosebleed.

Then our patient walked around the corner, she had a bit of kitchen towel held up to her nose, but there wasn't any active bleeding. There was one or two drops of blood on her blouse and otherwise she looked fine.

I finally got the mother to calm down enough to explain what had happened. Well, I say calmed down, what she actually did was thrust a piece of paper into my hands. The child had ITP, an often mild clotting disorder. Examining the child it seemed that the nosebleed had already stopped and there was a large jelly-like clot in her nose. The best thing to do is to leave well enough alone and give the wound plenty of time to clot - if you start fiddling around with it then the chances are good that the bleeding will start again.

There wasn't enough blood loss to fill an eggcup.

But still the mother cried, ran up and down and generally did her best to inadvertently scare the child. While the child seemed quite sensible (she'd done the right thing in clamping the kitchen towel to her nose) she was obviously frightened by the mother.

So I turned on my 'everyone keep calm' demeanour. I tried to calm the mother down, I told her how it wasn't serious, how the bleeding had stopped and how the blood loss was tiny. I showed both of them the vital signs that I took and explained how they were all fine and if it were anything serious then the pulse would be higher, the blood pressure would be lower and the breathing more rapid. But the mother didn't listen.

Instead of going to the local hospital (with a perfectly fine paediatric department) the mother demanded that they go to the Royal London where the child was under the haematologists. I explained that the Royal London didn't have any paediatric beds (because we'd just come from a transfer from there to another hospital) and that the local hospital would be able to cope just fine. But the mother flapped and fretted and so I agreed that we would drive past the local hospital and down the road a few miles so she could go to the Royal London.

So we set off for the hospital, the bleeding remained stopped and the mother seemed to calm down a bit. But then every few minutes she would dart forward and scream 'It's red!' and pluck the kitchen towel from the child's nose causing the patient to cry.

Later in the day I could contrast it with a 10 month old baby who had two febrile fits in the space of two days, the parent s were sensible, calm and a pleasure to deal with. The baby was fine by the time we got there and the parents were more than happy to go to the local hospital for a check-up. The calmness of parents tends to keep the child calm - and a calm child makes for a happy ambulance person.

Some jobs are just *hard*, not because the patient is heavy or even particularly ill but just because of the circumstances.

We were called to a care home, one of the good ones in the area which deals with people with learning difficulties, ('learning difficulties' is one of those politically correct terms that seemingly came from nowhere as a way to describe people who we used to call 'mentally handicapped'). The patient was a 50 year old man with a nasty case of pneumonia, the GP had been out to see him and had decided that hospital treatment would be in the patient's best interest. We were called to transport the patient to hospital.

Our problem was that the patient point blank refused to go to hospital. We tried persuading him, the staff tried persuading him, I tried reasoning with him and the staff even tried bribing him. I may have even thought about threatening him. He would sit there, coughing occasionally, and refusing to go.

What we have to determine in a case like this is if he has the 'capacity' to refuse treatment. I often tell patients that I'm not allowed to kidnap anyone and this is true. If you were to take a fatal overdose and refuse to go to hospital knowing full well what the overdose would do to your body then I couldn't force you to attend hospital*

However, this relies on the patient having the capacity to understand what a lack of treatment would do, in this patient's case I wasn't too sure. He'd been in and out of hospital for much of his life, he knew what would happen should he go there - but did he have enough understanding that without treatment there was a reasonable chance that the pneumonia could kill him?

If the patient doesn't have capacity then we can force a removal to hospital, normally with police assistance - this is something that we don't like to do as it isn't very nice on the patient, nor on their relatives. So we do everything we can to avoid this. It's not very good to have half a dozen coppers frog marching a sick person out to an ambulance.

Well, in situations like this there is/should be an officer around to come and advise us on what to do. It also means that we have someone who is paid more than me taking responsibility for the patient, so should that patient die I know I've done everything I can and it's the officers 'fault'. So I trotted out to the ambulance to radio Control to find us an officer.

I was waiting for them to come back to me when my crewmate, wheeling the patient on our carry chair, came trundling out of the house.

I was astounded, it had looked like the patient had no intention of travelling and yet my crewmate had managed to get him out of the house. In awe I asked him how he'd done it.

He told me that the carers had told the patient that they wanted to change his clothes, he did have a bit of a problem with drool being coughed down his jumper. They had stood him up, changed his top, put a coat on him and then sat him straight back down into our carry chair. Good thinking on their part and on the part of my crewmate. As he was wheeled out he realised what we were doing, he wasn't hugely happy but seemed resigned to going to hospital.

It's not nice to take someone to hospital against their will, but he really needed to go. Some people might think that it's bullying to do this, but without the mental capacity to understand what might happen to him, we sometimes have to be cruel to be kind.

*A simple version and there are tricks around this, some of which I've mentioned before.