Domestic violence is obviously a big and nasty problem; but you know...sometimes you have just got to laugh.

We were called to a case of domestic violence, injuries unknown but the husband was still on scene - so we waited for the police to arrive before us. There are a number of times I'll happily turn up to a job with a chance of violence, but domestic violence gives me the willies. There is way too much chance for very angry people to be carrying knives.

We arrived on scene and I think the police had been there for some time, there was a male shouting, waving his hands and talking into a mobile phone. The police were looking more than a bit fed up with this person.

As we got out of the ambulance it soon became apparent that this male was our patient as he waved a finger in our faces - a finger with the barest of cuts on it. It also soon became obvious why the police were looking so fed up - he was one of those people who simply wouldn't listen to you, he was more interested in running back and forth while ranting and raving about whatever was on his mind.

It seemed that he and his girlfriend had been arguing, he had grabbed her and in return she had bitten his finger. The way our patient was carrying on you would think that his finger had been bitten off. Well...the 'cut' was more like a scrape than anything, it would need a clean and maybe some prophylactic antibiotics, but hardly a suitable job for an ambulance.

After some trouble we managed to get him into the ambulance and warned him that if he didn't calm down we'd throw him out the back. Well, he calmed down a bit, but he was still shaking and ranting when we got to the hospital, but at least the volume was a bit more sociable.

What struck me is that he moaned and cried about his bite wound by an order of magnitude more than the patient who had degloved her finger.

Utter rubbish, but when someone calls for an ambulance we have to go, even if it is for a scrape to the finger.

Blair has been speaking about 'personalised' services,

"Other proposals include introducing more NHS "walk-in" centres, especially in places where there are not enough doctors"

Because, rather than employ doctors to provide primary health care, you can employ less skilled people for less money to provide a sub-standard service. How will this impact the ambulance service? Well if people want to see a doctor, they'll call us to take them to A&E because it's free and they think they'll get seen sooner.
That and we will be the ones providing the sub-standard care, because people will have the 'choice' to be treated at home by an ambulance Emergency Care Practitioner with a bit of extra training. ECPs are cheaper than doctors, especially when the Primary Care Trusts stop funding them and the ambulance service keeps running them anyway.

First off - Go buy this book, huge amounts of the money you spend will go to Comic Relief.
Although Comic Relief on telly gets me trying to hibernate for a whole week to escape it; I suspect that this book is actually a good thing, and funny as well.

We found ourselves going to a woman who had a 'broken finger, bone sticking out'. This looked like it was going to be a pretty simple job, finger injuries are normally pretty simple.

Not this one.

As we entered the room we could tell that it wasn't a 'standard' broken finger. The workmen in the room had wrapped her hand as best they could and then held it above her head.

The patient had completely degloved the finger - her ring had got caught on a fence and had torn the skin off the finger. The skin of her finger was bunched up around the top joint of the finger, held in place by her ring. There was no way that we were going to be able to remove the ring and the skin was white and chalky - what this needed was immediate medical treatment before the tissue completely died.

So we 'blued' her into the local hospital where they cut her ring off and started to arrange transfer to a plastic surgery centre. Unfortunately the first choice was unavailable as they had no beds. So the next nearest facility is actually outside of London; my crewmate and I volunteered to take the patient there and Control agreed. It's nice if you can keep up this 'continuity of care' and I soon found myself driving 28 miles on blue lights to the hospital.

Of course, when I got there I didn't have any idea where the ward we were transferring the patient was - so I asked one of the local ambulance crew directions and he jumped into the ambulance to direct us. The patient was soon safely on the ward, slightly dazed on morphine, and with the best chance that she has (however slim) to save her finger.

The paramedic who helped me emailed me the day after to apologise for not taking us straight up to the ward, but his Control were already on his back. I still find it a bit weird to be 'recognised' if only because people talk to me after I've left them...

I've just spent the last five hours trying to polish 800 words; it's not easy this writing lark when you aren't writing for a blog, but instead for a format you've never tried before.

I think I've got the 'blog post' format down pretty well, but to write for something else when you have never really studied writing is harder than you would imagine.

I'm looking forward to my 'day job' tomorrow, as I can do that job pretty easily.

Over the radio today I heard what sounded like a nasty job. It started as our Control asking for any free ambulances to deal with a 24 year old female who was having a seizure; I couldn't take it as I was dealing with my second 'maternataxi' of the day (waters intact, contractions every few hours).

After dropping off this walking, healthy and not about to give birth any time soon patient at the hospital we heard a crew 'blueing in' a 24 year old female who wasn't breathing.

I don't need to explain how this would be reported in the media as I've written enough about it in the past.

It's still a damn tragedy though.

We have a number of policies concerning the care for patients, what we should do to them and what should happen if we don't take them to hospital. Sometimes we come across situations that fall outside our policies - it's for that we have to rely on our experience and our common sense.

We were called to a sixteen year old with 'learning difficulties' who was refusing to eat. The address seemed familiar and, sure enough, as we pulled up outside the door I recognised that I had been here a few days ago.

On that first visit the girl was complaining of leg pain, she was lying on the floor and very upset. I'm no expert but it seemed that the mental age of this girl was somewhere around that of a four year old. She was looked after by her mother, the father hadn't been seen since the birth of the child. She was screaming in pain and seemed, at first, to be inconsolable.

That all changed as we looked after her, she brightened up and was laughing and joking with us by the time we reached the hospital. The pains in her legs seemed to have vanished. She doesn't have good mobility at the best of time, so it's always hard to assess any change.

So we were returning to the same girl. This time her mother was telling us that she wasn't eating, the girl was lying on the same spot on the floor covered with a blanket and crying. As soon as we walked into the room a large grin broke out across her face and she started laughing. It seemed pretty obvious that the girl wasn't sick.

Her mother told me how the girl had cried when she had to leave the hospital. She had returned to hospital twice more in the last two days, so it seemed that this was a repeating pattern.

It seemed pretty obvious to me that the girl was manipulating her mother so that she would go to hospital where she was the centre of attention. Of course this was all assumption and I wondered if there was any way I could get proof of this.

I get on really well with the receptionists at our local hospital, they are all *extremely* lovely people. So I phoned them up and asked me what the girls previous medical notes said. This is probably going against a whole load of guidelines and protocols, but I needed to know if, by taking the patient in, we would be reinforcing her behaviour.

The medical notes basically agreed with my assessment of the situation - she had told the doctors that she liked being in hospital because, 'home is boring'.

The hospital was arranging for a follow-up appointment with the paediatricians and were also liaising with the social services to get the mother and her daughter the help that they needed.

So after some discussion with the mother we came to an agreement that we would leave her daughter at home, her mother would keep watching her and we would see if it could break the pattern. We agreed to help the mother wash her daughter for bed, even though her daughter was now throwing a 'bit of a strop' as she now knew that she wouldn't be going to hospital.

So she was left at home, a risk for us because if she were to drop dead it'd be us to blame - even if it were for a completely unrelated cause. But I'm of the mind that sometimes you have to be cruel to be kind.

(And kudos to my crewmate - as the female in our party got the job of helping the mother clean her daughter while all I had to do was talk on the phone).

We had another 'returnee' that same night. A twenty year old man who called us with abdominal pain. He didn't tell me that he had been to the hospital earlier that day but had left after ten minutes. I think he'd have a bit more waiting to do after that particular abuse of the service...

Laura is worth £7.52 an hour, I’m worth £10.09 an hour.  This is the sort of thing we have to deal with.

On the plus side we do get to drive down the wrong side of the road.

It's actually a bit of a question the reason why I write this. I know that there are doctors and similar who read this blog and I'm kind of hoping that they can answer the question that I have.

First a little background. Our patient is a 93 year old female who lives in a nursing home; she'd been discharged from hospital earlier this week following a chest infection. Over the past day she had gone off her food and was refusing to drink. The nursing home's GP was called and he prescribed something that scared the hell out of us ambulance folk.

One TSP of table salt, stirred into lemon juice to be taken three times a day.

I'm hoping that 'TSP' is teaspoon and not tablespoon.

Is it any wonder that she is refusing to drink when the next thing past her lips could be incredibly salty. I would also imagine that this would upset her stomach.

I know that if someone has a low amount of salt in their blood it is a problem - but I've never seen it treated in this fashion before. I would actually consider this 'treatment' abuse.

We contacted the LAS HEMS doctor (note their new website, they are even having a go at a blog, although they should get rid of the helicopter sound). He was also shocked by this 'treatment'.

So - before I put in a formal complaint about what I consider an inappropriate and possibly dangerous treatment, I just want to be sure that I haven't missed some brilliant new research that shows giving salty drinks to little old ladies is preferable to the way we normally treat a low salt content in the blood.

It has been in the news recently that the BBC has hold of documents showing a large increase in the number of 999 ambulance calls. This is the reason why my phone hardly stopped ringing yesterday as various BBC radio stations wanted interviews. (I had to turn two of them down because I was going to be spending a rare evening with Laura).

One of the reasons given for the increase in calls was the recent British Heart Foundation urging people to call for ambulances if they get chest pain. In my own experience there hasn't been a huge increase in calls due to this, I suspect that the LAS has the official figures, but in my area people don't need any encouragement to call us out.

When I started working for the ambulance service we would get around 2,500 calls across London each day - now it isn't unusual to get 4000+. While a government spokesperson says that there are more ambulance staff than in the past (which is true), it doesn't follow that there are more ambulances. Ambulances which were covered by staff on overtime now staffed by reliefs.

I don't think that there has been an increase in the actual number of ambulances in the last fifteen years; yet we have increasing call numbers and our ever expanding role.

I would say that there are a number of reason why there is an increase in calls.

• The lack of GP services 'Out of hours', since GPs were allowed to stop covering out of hour services the quality of primary care during the hours of darkness have plummeted. Due to decreased GP cover we are going to more and more 'primary care' situations, jobs that would normally be under a GP remit.
• The increasing 'I have the right' brigade - people who know that they have a 'right' to an ambulance as a free taxi to hospital. All thanks to the 'Patient's Charter'
• People want healthcare when they want, rather than when it is available. Waiting for an appointment to have your foot wart removed is such a chore, you want it off now? Call an ambulance to take you to hospital.
• A general lack of education - a simple chest infection in an otherwise healthy person isn't going to kill you; but some people do believe that a cough is something life-threatening.
• A lack of magic cures - I've lost count of the number of people I've been to recently who have seen their GP for a chest infection, have taken two of the prescribed antibiotics and yet they aren't feeling better. Then they call an ambulance. Here is a hint - there is a reason why there are 28 tablets in the pack...
• Increased population, more and more people are living in smaller places, buildings are being thrown up all over London, yet there isn't a corresponding increase in healthcare provision. And the government is closing two A&E departments in our area, because, you know, they are full all the time.
• 24 hour licensing, I know it's an unpopular view in some circles, but we are going to more drunks, and alcohol related calls than ever before.

One of the problems is that we are trying to solve all these problems by throwing ambulances at them. We are covering for reduced GPs by implementing ECPs (Emergency Care Practitioners, GPs on the cheap). Who is going to want to get an appointment for a GP when you can dial 999 and have someone turn up at your door when you want. We aren't refusing ambulances to people who don't need them, partly for fear of being sued or making a mistake. As a whole, health education in this country is dreadful - barely going beyond 'safe sex' and 'stop smoking' messages. Drunks in the street are going to a nice friendly A&E department rather than a less comfortable police cell where they are charged with an offence.

Part of it is that we are mollycoddling people for fear of being sued, and having bad press. If the ambulance service continue this way then I can't see things getting any better. Because of the lack of funding from the government we are having to change the way we work in order to meet those useless targets; this will lead to problems with patient and crew safety - but that is a post for another day.

Without a sea change in society as a whole and in the funding and measurement of targets in the ambulance service, despite the LAS' best intentions, things aren't going to get any better.

The BBC news forum has some hilarious comments (and it does point out some of the weird ideas that people have about the ambulance service).

As I type this there is an *awful* segment on blogging on the BBC breakfast news.