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.

For those that don't read the comments Pandop mentioned a column showing this problem from the other side of the fence. Thanks Pandop.

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.

I'm 'third manning' at the moment, which is a way of easing me back into work. I'm a third person on an ambulance, which means I get to see how other people work.

We were called to a man who had been pushed over following an arguement over payment at a shop. The man (the customer) was sitting on the floor wailing and shouting as our patients who feel aggrieved often do.

My mate attempted to get a history from the patient, but he refused to talk to us. He would talk to his friend, but not to the ambulance crew who were trying to help him. He was being generally obstructive.

We gathered, from other people, that he had a painful leg - he didn't tell us this himself, he just ranted about how he wanted the person who had pushed him over arrested.

So, without being able to get a verbal history my mate decided that he would physically examine him - so he got out his scissors and cut the trousers off of the patient so that he could examine the injured leg. The patient still refused to talk to us, he was too busy trying to get the other man 'nicked'.

I mean - he'd been pushed over, he was hardly going to hurt himself in anything but a most minor way...

Except that his femur - the strongest bone in the body had snapped.

We have no idea how this could happen in a middleaged man with no other illnesses and (after the x-ray) no sign of pathological bone disease. It's the sort of job that you pick the person up off the floor, dust them off and they refuse to go to hospital.

So we got him into the back of the ambulance to discover that the traction splint that we would normally use was missing a small, but vitally important, bit.

So I got the job of hanging on his leg providing traction while my mate gave him some excellent painkillers and *his* crewmate drove us into hospital.

The hospital was impressed as well.

It's a good job my mate decided to be 'evil' and cut his trouser legs off. The patient didn't have an accident history to suggest a broken bone, the patient themself didn't suggest a broken bone and we could have quite happily taken to lifting him off the floor.

There is a reason why we don't cut the clothes off everyone who falls over, it costs them money, it's very cold at the moment and it's frankly undignified. But now I'm wondering if I need to start stripping everyone I come across...

I’m back to work later this afternoon – three shifts as a ‘third man’, it’s part of LAS policy that those of us daft enough to injure ourselves for long periods of time should be eased back into work.  I’m just looking forward to a lovely Newham Friday Saturday night…

I can finally stop moping around being bored and get some new material.

Laura had a nasty job earlier and she’s written it up on her blog as an incredibly moving post.

Update: Date changed because I had no idea what day I was writing this - the perils of shiftwork.

Have a look at this,

Two ambulance paramedics in North Yorkshire have been sacked because they did not respond to a 999 call while on a meal break, the BBC has learned.
The two men had been on duty for about six hours during a shift last month when the emergency call came in and they said they were unable to respond.
The Yorkshire Ambulance Service sacked them and they are appealing against that decision, the GMB union said.
Managers said they would not comment on the case during the appeal process.
Details of the emergency call or how it was eventually dealt with are not yet known.

The story then goes on to give another example of someone dying due to 'being on a break' (which I believe that I have debunked previously). I don't know anyone in the trust involved so I can't make the story any clearer than what has been released to the media.

The way in which this story would result in a justified sacking would be if the crew consciously refusing to go on a job by lying about their break status. But the story doesn't say this, it has no further details. For the record we can get the sack for 'preventing the public access to an ambulance' as is right.

What annoys me is that this story has been published in the media in the first place. The headline says as much as the body of the story, '999 Crew sacked in meal break row'. The crew have been sacked and the story doesn't give us any more information than that. Everything is 'no comment' or 'details are not known', the story is a headline and nothing more beyond that. The simple fact is that we don't know what has happened and won't until the appeal has been completed. I'm interested in how they got hold of the news in the first place.

Once the reasons are known - That is when the story should be published. When there is enough information to tell us the story, not just a 'Man bites dog' headline.

Unfortunately it seems that the BBC website and the media in general has a problem with ambulance crews having breaks, apparently it has become news that meal break=death. It isn't good news that there aren't enough ambulances, or that we are being sent to people who don't need an ambulance (apart from the annual New Year stories). It's a 'nice' headline and that is what counts.

But what do I know - I'm not a journalist.

If I find out more I'll set the record straight here.

UPDATE: I've had someone closer explain some more about the story - but I'm not going to write about it because it's still under appeal. More perhaps as stuff enters the public domain.