Sometimes, normally around this time of year as I lay in my bed thinking of reasons not to get out of it, I get a melancholy upon me. So I watch the hours tick away, huddled under the duvet while things that I should be doing get put aside for another day.

And I think of the ambulance jobs I've done and I get a little sad.

I think of the twenty-something victim of drunken driving who we pulled from the seat of his car because we knew he was dying. Of the blood pissing from his ears, an obvious huge head injury. Of our ambulance becoming a mortuary for two bodies.

I remember the thirteen year old girl whose heart just stopped. Of the futile attempts to save her, of her mother wailing outside the Resus room.

The only time I've cried actual tears, my first sudden infant death. Carrying the tiny baby in to the waiting doctors, knowing that there was nothing that could be done.

Thinking on how sad I was when one of our pleasant semi-regulars died in a way completely unrelated to her long term health problems. I wonder how her husband, also not a well man, will cope.

I think of all the Ethels and Alberts I've been to, laid on their beds in lonely 'nursing' home rooms. The ones who have died, and the ones who would wish themselves dead.

The woman, beaten by her husband and promising my crewmate that she wouldn't go back to him, walking hand in hand with him out the A&E department.

The house full of twenty year old alcoholics, wasted lives, refusing help, happy to be unwell and dirty and dying. Just so long as that next drink is around the corner.

The good man who loved his son and who died suddenly with no ID on him. The family only finding out after they went to the police.

The mother of two young children - dying on Christmas eve.

The stream of lovely old folk, with cancer, with dementia, with other fatal and painful diseases.

The things I can't change, the small neglects that one person visits on another, the luck of the draw.

These are the things that stop me getting up when I have no work to do, and when the days are like nights. These are the things that I think of when all motivation to 'do something' has left me.

This is why I wait for Spring.

Sod that Dr. Crippen - he's only gone and posted on what I'm writing on today.

Now, I have to be careful how I write this as I have sent various official documents to people about this incident. Also, should I need to make a statement I can just print out this post...

We were sent to 'psychiatric patient - feeling violent' and as he was known to carry weaponry we decided to hang back until the police got there - they have much better kit for dissuading people from stabbing them than us.

The police were there first, so we walked into the house - our patient was sitting in a chair looking very distressed, but thankfully not violent.

I spoke to him and he told me that he'd been discharged from the local Mental Health unit the week before. Now he was wanting to go into the street and beat someone up, and then kill himself.

He was crying as he said this - so I let him know that we would look after him and take him somewhere safe.

When asked if he would be kind enough not to beat me up, he couldn't guarantee it, so a police officer would travel with me in the back of the ambulance, with his partner following in the response car.

During transporting the patient he told me that he was seeing things, and that he was hearing voices. On several occasions he became very agitated and it was only the complicated seatbelt that stopped him from leaping around the back of the ambulance.

He then told me that if he were to be taken to the A&E department he'd probably 'kick off' as the department is too crowded and too noisy with people who don't 'understand him'.

I've mentioned in the past how an A&E department is a completely inappropriate place for people with mental health problems - so I could see his point.

As we can't take people straight to the mental health unit I would have to take him to A&E. But then I had a cunning thought of a way around the problem.

We would park outside the A&E department, my crewmate would go into the department and phone the mental health unit to see if they would directly assess the patient.

It came as no surprise when the Mental Health unit told us that they wouldn't accept the patient unless he was under a Section, and that A&E would have to see him.

My patient was still in the ambulance refusing to enter the A&E department and looking more distressed.

I turned to the policeman.

"This place is accessible to the public", I indicated the open doors to the ambulance, "and anyway, if he leaves the ambulance he won't enter the A&E department".

The policeman agreed, I think he knew what I was getting at.

"How about we Section 136 him here, then he can get to the place where he needs to go?", I suggested.

The policeman agreed, he went to his partner, had a quick discussion and started filling in the Section 136 form.

A "Section 136", allows the police to take someone who is mentally ill and in a public place (and is a danger to themselves or others) to a 'place of safety' for assessment.

So we let the mental health unit know that we would be bringing in a Sectioned patient for assessment and drove the 200m up the road to the unit.

We rang the bell and waited, and waited, and waited...

Finally a person who I assumed to be a psychiatric nurse came to the door. He took one look at the patient and sighed loudly, "Oh. It's him! Take him to A&E".

I explained that the patient warned me that he would become violent in A&E, but that he wouldn't if he were in the care of the Mental Health unit. I explained that he was seeing and hearing things and that there was no physical injury to himself.

The nurse then accused me of lying about the patient's symptoms, "He never said that", he told me.

The nurse then turned on the policeman, "I don't believe that you Sectioned him in a public place - I think you did it in his house". The nurse was accusing the policeman of (a) Breaking the Law, and (B) Lying.

When the policeman pointed this out, and pointed out that he could be seen filling the form in on the unit's own CCTV the nurse backed down a little.

"He's drunk", the nurse said, "he always is when he comes here".

Now, admittedly, the patient had drunk two cans of lager during the morning - he'd admitted it to me, but there was no way he was 'drunk'. As one of my mates put it, "Two beers is breakfast for a lot of folks 'round here".

So now the nurse began accusing the patient of lying about how much he'd drunk, about the symptoms that he was having and of the need to call an ambulance.

By now I was severely tempted to punch this nurse on the nose for the instant, horribly incorrect, assessment he'd made of the police, the patient and me.

As an aside, I'm aware that when someone starts to get me angry I start to pace, and flap my arms about like a stereotypical homosexual from an early eighties sit-com. The flapping is because I want to punch the person annoying me, while knowing that I can't. This is why I was gripping the handrails of the ambulance very tightly.

But somehow - possibly because I asked the nurse his name for the complaint form, the clinical risk form and for the form where I think that a hospital has had an 'untoward incident' - he accepted the patient.

The police officer and I had a quick 'debrief'. Then it was back to station to fill out the forms and have a quick chat with a Station officer over the phone who congratulated me on not punching the nurse.

He also confirmed that I had done the correct thing all the way down the line.

This is nice to know as I have the same tendency towards pig-headedness as the next person.

Anyway, my boss talks to the boss of the mental health unit on a regular basis, so I expect that this incident will be mentioned.

In thirteen years of working for the NHS I've only once known a referal to a mental health team go as expected. Like GPs, I know there must be good ones out there - but it seems that I never get to meet them.

Zarathusa - if you'd like to pitch in I'd like your take on this.

Dr Crippen had to call an ambulance for one of his patients and he wrote it up here.

I've already left a few comments on the post, but I thought that it might be interesting to answer some of his points on here. All on the basis of understanding each other. I invite Dr. Crippen to do the same.

This isn't an attack on Dr. Crippen, but I do think that there is a bit of a misunderstanding on the role of the ambulance worker. So this is an attempt to show the situation from the other side. Also blogs are all about the conversation.

Dr Crippen starts,

I know, I know, it seems melodramatic, but I can’t take the risk that Andrew might have another attack on the dual carriageway. So I call the ambulance service. A very friendly operator answers on the second ring. I give all my details, my code number, then all Andrew’s details, his address, date of birth and then I am asked "the question". The same glorious question I am always asked read, as always, from the protocol.

“Is there a medical need for an ambulance?”

I resist the temptation to say “WTF do you think I am phoning” and merely say, “Yes.”

Well, it might be that someone is calling for an ambulance to take a non-ambulatory patient to hospital, so it's not a silly question. Maybe I'm being churlish but 'WTF' Means 'What The Fuck', which isn't a nice thing to say to one of our call-takers, they hear it quite enough from 'civilians'.

Even now, I know that there is about to be a problem. What is your provisional diagnosis? The word "provisional" is irritatingly gratuitous. “Unstable angina”. Silence. Operator switches to a different protocol. Do you want an immediate ambulance? Well, I certainly do not want to wait two hours, but this was not dire enough for me to have dialled 999. “Yes, please, but you don’t need to arrive with sirens and flashing blue lights”.

A lot of GPs call an ambulance to take someone to hospital because they aren't sure what is wrong with the patient - a lot of GP letters that I read end with something like "?Angina ?MI ?PE, please do the needful". This isn't a problem, that's why the patient is going to hospital, for further investigation. Were the call-taker to ask for the diagnosis and you were unsure, would you be annoyed by having to say "I'm not sure, that's why he's going to hospital"?

There is no such option on the protocol sheet and so my request is ignored. I am switched to the 999 “pathway”. I am told that the ambulance is on the way but I have to answer some more questions.

"Are you with the patient?" Of course I am.

You'd be surprised at the number of GPs who sit their patients out in the waiting room, sometimes when said patient is near death. More than one patient put out in the waiting room has been 'blued' straight into resus by me.

“Is the patient conscious?”. Yes, of course he is, if he was not, I would have dialled 999. In fact, he is sitting in front of me smiling. “Is he breathing.” “Has he changed colour.” And so it goes on. These are the 999 protocol questions for the layman. They are not questions for experienced doctors but they are always asked and have to be answered. By the time I get to the end of the ludicrous questionnaire I can hear the siren and soon I see the flashing blue lights through the window.

Ah, the wonders of AMPDS, or Automated Medical Priority Dispatch System. Designed so that an ambulance trust doesn't have to employ expensive medically-trained call-takers. It was designed in America and so it's biggest selling point is that no-one has successfully sued a trust because of it. There are not Doctor specific versions of it.

If the call-taker doesn't follow the 'script' then they get marks against their performance, too many marks and they get disciplined or passed over for promotion. they have no power to change this, or to use common sense when talking to a caller. See Nee-Naw for more details on this.

I go out to meet the paramedics. Two very keen young men. I give the history to them, and tell them the important things. Andrew is pain free, stable, in sinus rhythm, with a normal blood pressure. Then we have to play the ECG game.

“Have you done an ECG, doctor.”

Reasonable question for a patient with chest pain. The hospital A&E department will do one as part of the diagnostic process, if the GP surgery had the time/staff/equipment then there is no reason not to do one.

“No”.

“Do you have an ECG in your practice?”

Tempting to say mind your own business, or ask if they have oxygen in their ambulance. We have both an ECG machine and a defibrillator but neither has been needed, thank God. It is not possible to make paramedics understand that it is not necessary nor even helpful in this situation to do an ECG.

“Why on earth would I want to do an ECG?” I ask

The paramedics look at each other and back at me. “To see if he has had a heart attack, and to see what rhythm he is in.”

I know what heart rhythm he is in (well, OK, he could be in steady atrial fibrillation or even compete heart block but it is not likely) and you cannot exclude a heart attack at this stage by doing an ECG so, whatever it shows, he needs to be in hospital. Might as well just take him. We are not on Dartmoor. The paramedics do not carry clot busting drugs. The hospital is only a few minutes away.

"He could be in steady atrial fibrillation or even compete heart block but it is not likely", not likely but I've been surprised by patients having unusual things happen to them. I've no problem with GPs not doing ECGs but there is a reason why we do them. Actually a few reasons.

1) We diagnose ST elevation MIs - heart attacks, and take them to the 'gold standard' cath-lab rather than to the A&E department. It's one of the real success stories in the NHS.

2) We are told by our management and training to do ECGs on chest pain patients. If we take a patient like this to hospital without an ECG, the hospital will look strangely at us. If we don't document a *very* good reason for not doing an ECG then we can expect to be asked some pointed questions by our management.

3) In most cases it doesn't hurt - and can turn up something like complete heart block, or an asymptomatic MI.

The paramedics huff and puff.

Andrew refuses to get on a trolley and insists on walking to the ambulance. The paramedics do not like this and huff and puff some more. I keep a straight face. Not a sign of schadenfreude from me.

Then I shall not have any schadenfreude over any of your patients. The reason why the paramedics didn't like this is because it is a disciplinary offence to 'walk' a chest pain. We can lose our job over it (and I personally know one crew that has lost their job over walking a chest pain). So yes, it makes us nervous.

The ambulance then sits in the car park for eleven minutes (just over). I timed it. Stay and play. Do an ECG. Follow the ritual. The ambulance service insisted on sending a blue-light ambulance which, all power to them had it been needed, arrived in less than five minutes. They then waste eleven minutes doing unnecessary tests. Stay and play probably killed Princess Diana. Fortunately it did not kill Andrew.

You have eleven minutes to spare? The tests are not unnecessary if there had been something wrong with the patient at that moment in time. They probably did a blood sugar measurement (as per our medical director's instructions). Actually all the clinical procedures and policies have been created by doctors, JRCALC and the individual trust Medical Directors. This includes doing ECGs on chest pain patients.

If he had another bout of chest pain while in transit the crew would have given him a spray of GTN. To do that safely you need a recent blood pressure. And no, we don't always trust the GP's measurements. You've mentioned yourself the weirdness about writing 120/80 on a referral letter, and how it implies that the blood pressure has been made up.

So, much of the problem you have with the ambulance crew is because of things we have been told to do by doctors. It's just that you don't understand the policies, guidelines, pressures and culture of us ambulance workers. It's not a problem, I'm not an expert on QoF targets or how to get through a thorough assessment in twelve minutes. It's one of the reasons why I read your blog.

What I would remind you is that ambulance workers have a lot less power than doctors, we don't have the letters after our names to go toe-to-toe against MPs, even though they know less than us about medical matters. We do as we are told, we use common sense when we aren't told what to do and we learn from other professionals and from our experiences.

Sometimes we are told to do silly things, but we have no way of changing this. Like you have silly things thrust upon you by your masters, so are we.

Oh and do stop going on about Diana - it was doctors who 'stayed and played'. Any crew I know would have splinted, C-spined, stuck in a cannula and ran to the hospital.

UPDATE:Garth has also entered the discussion

On a more serious note, the police and us work together closely, so it's always sad to hear when one of them is having trouble. I would ask you to go and have a read of the difficulties that one particular police family are having because of a very sick child.
What is curious to me is that there is apparently a treatment for the child's illness, but that the NHS don't offer it. If it's due to the cost couldn't we do with a few less NHS pen-pushers and box-tickers? How about MPs having a below inflation pay rise like the rest of us? Or how about claiming back the money on the awful 'Connecting for Health' fiasco?

We've had a bulletin going around telling us about the Norovirus, or "Winter Vomiting Bug".

The bulletin gives the details of the virus, that it lasts up to three dyas, that unless you are very young or very old it will pass with no long term effects and that the most important thing is to keep hydrated.

It also mentions that you shouldn't prepare food, or be around vulnerable people for forty-eight hours after the symptoms have gone.

(I wonder if this will be taken into consideration should staff members become sick?)

We are being asked to give this information to patients and to leave them at home in order to stop the virus spreading through hospitals.

All good advice and it's god to see us as a trust looking at the bigger picture, but unfortunately in the real world it doesn't quite work that well.

Lets say that I go to a patient and then a few days later they drop dead (of whatever reason, it doesn't really matter), I'll be the person who the Coroner's office looks at closely. I reckon I'd get a suspension at the least.

But that doesn't matter - It all comes down to risk management, it is riskier for more people for me to take such patients to hospital. So I'll leave them at home.

When I can.

The other major problem is that when someone calls an ambulance they often want to go to hospital. All the advice I can give about staying at home is for naught if they 'demand' to go to hospital. I can't refuse them this.

The only time I can refuse someone an ambulance is if they are violent or abusive towards me.

So, the other night I found myself in a patient's front room. They had been suffering from a presumed Norovirus infection. They were otherwise fit and healthy, but for one day had been having episodes of diarrhoea and vomiting. I explained that they didn't need to go to hospital.

But they insisted. They wanted to see a doctor because they were fed up with this one day worth of illness.

I tried to persuade them to stay, but they were having none of it. So I had to take them.

And this is why the policy will fail - because all you need is one infected person to insist that you take them to hospital and it all falls apart.

Oh well, maybe for the next epidemic my bosses will let us refuse to take people.

Of course then we'll have worried relatives threatening to beat us up if we don't take them.

That or they'll get a cab...

We'd just started our shift yesterday (twelve hours) when we heard on the grapevine that the local hospital wanted to transfer a patient across London to Ealing. As we had just started our shift we offered up for it - that way someone who is looking to go home i a few hours doesn't get stuck halfway across the world.

The patient was quiet - well, he had no choice, he was paralysed and intubated, and we had an anaesthetist travelling with him. So it was a simple case of loading him up and shuttling him, on blue lights, across London.

16.9 miles might not seem too far, and I can hear rural ambulance people sniggering as I type this, but it is unusual for us. London is a funny old place and for a lot of us 5 miles is considered a long way...

Relying on the Sat-nav in our ambulance, we had an uneventful trip and our patient was soon unloaded.

Once more I came to meditate on the difference between hospitals in the West of London and the East. While both our local hospital and Ealing hospital are NHS hospitals, it seems that Ealing has had a lot more money to spend on it. It seemed cleaner, more modern and more up to date. As well as less busy. I had cause to think the same when I did a similar transfer to the Chelsea and Westminster hospital.

It seems that postcode lotteries apply to hospitals as well, as all our local hospitals have troubles with their budgets and look...well...a bit rubbish.

Heading back we got sent to two jobs, both really nice elderly people - and one of them gave me and my crewmate a bar of chocolate each. Nice chocolate as well, none of that Cadburys stuff.

Eventually we made our way back to our own area and noodled around doing our usual calls. Of which I will write of later, when I'm not running late for work...

My memory is poor, but I'm sure that, when I was a nurse, the NMC had it as a condition of being the sort of nurse who gives drugs to people that the aforementioned nurse understand what a drug does and what it's side effects are.

It's 3am in the morning and I'm miles out of my area on the FRU*. I have been sent, as a blue light response, to a nursing home where one of their 'clients' is sleeping.

Yep - sleeping.

I get there and the patient is in the reception area of the home sitting in a wheelchair. He is... asleep.

The 'nurses' at the home tell me that normally he is very active at night and often comes to see the night nurses and sits chatting with them. He's ninety-eight years old and mildly demented.

I bite my tongue and do all the checks that I can to make sure that there isn't anything obviously medical going on. All his observations are fine and he responds somewhat when I try to wake him. I'm sure that if I provided enough pain stimulus I could fully wake him up, but it would just seem cruel.

I look at the patient's drug chart. Two days ago he was prescribed a rather strong sleeping pill.

I ponder, for about 2 milliseconds, if this might be the cause for his sleeping. At 3am in the morning.

I suggest this to the nurse.

She shrugs.

The staff don't say anything, but I get the distinct impression that they have been getting tired of this patient being awake while they are at work. If all your patients are sleeping then the night shift has little to do. If this patient has been awake, then they actually have to talk to him. In a lot of the nursing homes that I've been to the nursing staff don't like talking to the patients.

In a fair few nursing homes that I've been to the staff and the patients rarely share a language, and so everyone just 'gives up'. As a digression, the good nursing homes that I've been to have been those where the staff and patients do talk to each other, and the care of the patients is considered to be more of a 'partnership'.

The nurses, who I suspect have got exactly what they asked for, aren't happy. They've already rung the elderly relative of our patient (at 3am!) to let her know that he is heading into hospital.

The ambulance crew arrive and I have a real problem explaining to them why we have been called.

"The nurses wanted this patient to sleep at night. They have given him a sleeping pill, and now he's asleep", doesn't really seem reasonable for a trip to the hospital.

But the 'customer' is always right - and so the patient is driven off to the hospital.

I talk to the crew a few days later and they tell me that the receiving nurse at the hospital was as befuddled as the rest of us.

I don't know, jobs like this make me despair at the general intelligence of people, not less the intelligence of the sorts of people who look after the elderly.

Oh well, at least one of us had a bit of a kip that night.

*I really need to tell you about FREDA one day - perhaps a joint post with Nee Naw.

I'd like to apologise, blogging has been a bit slow of late. Mostly this is due to working on the sequel to 'Blood, Sweat and Tea' - I'm needing to put some concentrated effort into it. this is not easy with twelve hour shifts accompanied by the utter lack of energy I have at this time of the year.

Medgadget are running their annual Medical Blog Awards - you should go over there and have a look at the nominees, there are some really good ones there. Also there is no other motive for suggesting you visit the link. No. None at all...

Due to my crewmate skivving off over the holiday period I found myself with no-one to work with. The resource centre rang me up and asked if I wouldn't mind working on the FRU. I've found that it's in my best interests to do as they ask, otherwise there is a fear that they'll send me to the other side of London for a giggle...

So I loaded my kit onto the car and got ready for a busy night.

Fifteen calls in a twelve hour period later and I was glad to be heading home.

Luckily for me, a lot of the calls were for 'Man-flu' and in one case the female version of the same - 'Bird-flu'.

Ahem.

Blame fellow 'twitterers' for that joke.

With all this man-flu going around I wasn't surprised when I saw a call come down to my FRU. "27 year old male, unwell ?cause". So I whizzed round to the address and was met by a woman I would find out to be the wife of the patient. She led me into their one room flat where my patient was lying on the bed.

My immediate impression was that he was fine. No obvious difficulty in breathing, no rolling around in pain. As I entered he looked at me and his gaze followed me around the room. So unlikely to be anything serious then.

I looked at the wife, she'd started crying.

"Don't worry, he'll be fine", I said.

"No he won't", she sobbed, "He's going to die".

Well, he didn't look like he was going to die to me, and I'm normally a pretty good judge of people who are likely to stop breathing.

So I asked the patient,"What seems to be the problem?"

"I'm going to die tonight", he said with utter conviction, "God is calling me".

Oh great.

"What makes you think that?", I asked.

"I just know, I've already phoned my family back home and told them".

So now his family halfway across the world would be worried. Happy Christmas!

After some prompting from me he continued, "In my religion, Islam, God sometimes calls people. That is why I know I'm going to die tonight".

"Look mate", I told him, "I work round here, so I meet a fair few Muslims, none of them have ever mentioned that before".

I spoke to his wife, they had just come back from shopping, there hadn't been an argument or anything unusual that day. He'd just taken to his bed and declared that he would die.

At this moment the ambulance crew arrived. I explained what was happening and we all agreed that he needed to go to hospital. While he (almost certainly) wasn't going to die that night we were worried that he might take matters into his own hands.

Rather predictably he didn't want to go to hospital.

So now we were looking at arranging a Section. Which needs two GPs and an approved social worker. At 3am in the morning. Over the Christmas holidays.

The chances of arranging that were slightly less than him actually being right and God beaming him directly into Heaven that night. I contacted our Control - they had the same view that we were pretty much stuck on our own.

Our hands were tied, if he were in a public place we could get the police to emergency section him, but as he was in his own house, they were as powerless as us. Except... There is a bit of information floating around in my head that with enough high-ranking officers we can maybe section him anyway.

Time to turn on the charm.

"Look mate", I said, "the thing is that we think you are having a psychotic episode. So we'd like to take you to hospital. I don't feel happy leaving you here. So I'm going to give you a choice. I'm all about choice me. Choice 'A' is that you come with us now - spend some time at the hospital and have a chat with someone. Choice 'B' is that we contact the police and ask them to come down and see if they are able to persuade you to come to hospital. Either way I think you'll be going to hospital".

"Ok", he said and got his shoes on and walked out to the ambulance.

There is a line between persuading someone, coercing someone and forcing someone to do something. I think that this was persuasion rather than coercing, as I truly would have called for the police and often they can persuade someone to go to hospital. I would have been really unhappy to leave him at home as if he wasn't suddenly suffering from a mental health problem it could have been something more physical and life-threatening. Either way his life could have been in danger and, while I don't have the power to force him to come to hospital, I can do my best to persuade him.

I've not had a note from the coroner's office yet - so I don't think that his God's plan was for him to die that night.

So far I've been keeping my 'Photo a day' thing over at Mental Kipple. Thanks to those who have offered services, but I'm pretty well set up with Flickr and my Wordpress blog.