Seasonal Affective Disorder - You know it's getting bad when you look at the blank, white page of your blogging software and your mind just shuts down.

So lets tell you about the future of the NHS, and how it's going to drive me crazy.

On my patch we have a hospital. This hospital has two buildings, one is the traditional hospital that all UK residents know and love, corridors, wards, doctors, porters, nurses, radiologists and others walking around. Slightly grubby, dodgy café, doctors running clinics.

The other building, 400 yards down the road is shiny and new. It is 'nurse led', there are posh coffee bars, the floors and walls are clean. Not much in the way of wards, but this building is only supposed to be used for day-case surgery. Nurses run the clinics and there is a sculpture outside. This is the future of the NHS, a pre-polyclinic polyclinic.

Which is why I'm surprised to find myself responding to a standard 'chest pain' inside this building.

The patient is there to see one of the nurse clinics, she develops a bit of chest pain and the first thing that the nurse in charge does is dial 999 for an ambulance.

I get there second as one of our FRUs was parked within sight of it. As I enter the room, not only have they moved the patient (resulting in us having to do a bit of searching) but there is a bit of a flap going on.

You se, a doctor has been called and he is panicking. He's shouting orders to the FRU, orders which could be extremely dangerous (for the medics in the audience he wants us to give GTN/NTG before checking a blood pressure). Our patient is sitting quite happily in her wheelchair watching our FRU take quiet control of the situation.

This is an absolute 'meat and potatoes' call for us, we deal with this sort of thing day in and day out - just by observing the patient and listening to her we suspect that it isn't her heart that is causing the pain.

But the doctor is screaming about getting 'crash carts' into the room and the nurses are running backwards and forwards like headless chickens. A manager from the other site arrives looking flustered - they confide in me that they turned up because they were worried about what these staff 'were up to'.

After a little more kerfuffle we wheel the patient down to the ambulance, do an ECG (which is normal) and transport her the very short distance to the A&E department where, after some more ECGs and blood tests, is diagnosed with indigestion.

I'm reminded of my nursing days when I saw a GP doing the world's worst CPR on a woman who had pretended to faint - I would have thought her trying to fight him off may have given him a clue that it wasn't a cardiac arrest.

This isn't a post about daft doctors and silly nurses though, after all if I were called upon to anaesthetise someone I'd certainly make a pig's ear of it. We do have our own area of expertise and I can't expect everyone to be as expert in the emergency treatment of chest pain as myself.

But.

This was a 'nothing' call, even without the benefit of hindsight - but as it was seen as an 'emergency', the best thing that the staff could think of was to call and ambulance and then a 'crash doctor' (and heaven alone knows why he was the only one to turn up, perhaps that's all they have staffing the crash team).

This points to there being a distinct lack of planning around what happens when something unusual happens, I'd dread to think what would happen if the patient had suffered a full cardiac arrest - they would have been little better off than collapsing in the street.

So, this is the future - you go to the nice, clean, artistically designed hospital for a minor treatment - but if you have a serious complication or something untoward happens the first thing they'll do is call for two blokes in a clapped out van.

Maybe it's just cheaper to 'outsource' emergency care to the ambulance service, maybe the next big thing for the NHS will be ambulances being called to deal with in-hospital cardiac arrests because then you won't need to pay for a full 'Crash team'.

I'm hopeful that somewhere in the planning for this 'healthcare centre' a manager getting paid a serious multiple of my pay-packet didn't think, 'well, if there is an emergency we can save money by just calling for an ambulance'.

I hope.

Almost completely unrelated - my mum went to her hospital a few days ago and was told by a doctor that she should 'drink lots of water so that she doesn't catch diabetes', at which point she walked out in disgust. The same doctor recommended physiotherapy for something that would only be made worse by it. So its not just me that sees this sort of thing.

Even more unrelated - does anyone know a good (or want to set up a) heavy RP guild on Warhammer:Age of Reckoning Ellyrion EU server? Edited to say *Obviously* for the side of Order...

(You can click through to Flickr to see the notes that I've added to my notes)

Just some notes that I made before going on Radio 5 Live to talk about this story.

Donal MacIntyre devoted part of his radio programme to it (and you can download and listen to it here, I don't know how long it will last).

So I got on the radio and said a few words (here for a few days - the section starts 1:03 in and again I suspect it only lasts a few days and won't let nasty foreign types listen to it).

But I didn't get a chance to say as much as I wanted to. But I have an audience here - so here goes...

Sadly we don't tend to flag addresses for people who are just verbally abusive to us, as I said in the radio segment, I'm working next Friday, Saturday and Sunday nights and I fully expect to be sworn at on every one of those shifts. If I were to fill in forms for that sort of abuse I'd never get any work done. Instead we fill in the forms for those people who have either physically abused us, or have acted in such a way that there is a high chance of them physically abusing people in the future.

We fill out the form, explaining why we are flagging it as a dangerous address and then fax it off to Control (using the hospital fax machine, our station doesn't have anything so high tech as a fax machine...)

So the dangerous addresses are flagged by people who have actually been there. And trust me, if someone dies as a result of a delay by us waiting for the police, the person initially flagging the address will get some serious questions asked.

The flagged address system is a warning system, it informs and compliments our 'at scene' risk assessment. Sometimes we ignore it, sometimes we wait for the police. It all depends on the situation. If someone is reported as not breathing then we'll probably go in, if they are calling because someone in the house is drunk then we are more likely to wait for the police. An example of when it was right to enter the address is this one, while in this example it was right for me to wait outside for police assistance.

It's that sort of risk assessment that we make all the time, often without consciously thinking about it.

The address is reviewed every six months, taken off the register if there have been no further reports, at least that is how it was explained to me.

So why are people violent towards us? Obviously drink and drugs play a huge part, mostly drink. But I think that there is a more subtle thing in action here.

When I wear my uniform people do as I say, they don't see me as a slightly overweight bloke - they see me as a figure of authority, that I know what I'm doing and that it is in that person's best interests to do as I suggest. Conversely, the uniform dehumanises me - it makes me a 'thing' rather than a person and it's much easier to hit someone if you think about them as just being a 'uniform' rather than a living, thinking, feeling human being.

A lot of arguments are started because of the raised expectations of people to be looked after by the state, they don't want to wait for their treatment and they want an instant cure - this is why I would suggest that actual violence against staff is higher in A&E departments, although they do have security guards posted there now.

The dangers for ambulance staff have only increased - there are more solo responders now, and they go into situations where the police would turn up mob-handed. While solo's aren't supposed to be sent to assault cases on their own, I know that I attended a fair share of such things - often waiting ages for a proper ambulance to arrive. I remember one stabbing I was sent on and it took forty minutes for the ambulance to arrive. I'm just glad that the assailant didn't return to finish off the job he'd started.

The other huge danger is Call Connect.

Due to "call connect", the government's new way of measuring the "success" of ambulance trusts, we are finding ourselves going into houses without any idea of the possible dangers. Once we are out of the ambulance, there is no way for control to contact the crew.

The new 'Airwave' radios have been delayed, so there is still no way for Control to contact us once we are out of the ambulance. We are often sent calls that just give the address.

An example,

I'm sent a call to a house I'm just driving up to - no further information is given. If I'd got out of the vehicle then I would have been met by a house full of drunks, one of whom had been cutting herself open with a kitchen knife and was arguing with the other occupants. Thankfully I don't give a damn about the government's ORCON target so I waited until more information came down - then waited for the police. If I hadn't done that there was a good chance that I wouldn't be here today writing this post.

To be honest, I would be very surprised if an ambulance person isn't killed in service before the end of next year.

Edited to add that I found the Unison's comments in the original BBC story particularly unhelpful, seeming to care more for the people who hit us than the members of their own union, then realising that there was a fence that they had to go and sit on.

Now, I accept that in terms of the human body and the weird and wonderful things that it does, I am an expert. I have training - intense training on all functions of the body. I have training on the effect that drugs and chemicals have on people. I am aware of the natural progression of the normal life cycle.

I'd like to think that some other people might have a basic idea of such things - I know we don't come with an operators manual for this sack of meat and bone that we drive around, but I'd like to think that at some point you get the general gist of certain things.

Perhaps you might even recognise in another person something that you may indulge in a little yourself.

So it annoys me somewhat when I'm forced to drive, at speed on blue lights, to something that I know is going to be nothing serious. Especially when there is an adult who can be deemed intelligent enough to be responsible for forty other people already on scene.

It annoys me that some companies write prescriptive policies that rely on 999 emergency services to do their work for them in the name of 'risk management'.

It annoys me when workers for said companies refuse to step outside their policies for cut and dried cases - when they are so fearful of being disciplined for doing the right thing that they need to call an emergency ambulance to do something that all two year olds can do.

It annoys me that our computer system (and management) in Control won't allow a calltaker to use their common sense in grading a call's response, resulting in me being a threat to other road users as they send me haring off on a call apparently only a smidgen less serious than someone who is dead, and about as serious as someone having a heart attack.

And much more 'important' than a gran with a broken hip.

What didn't annoy me was the patient - he'd had a little bit to drink but wasn't unconscious for it. In fact he'd done something that I've done myself in the early hours of the morning.

He'd fallen asleep on the bus.

I walked up to him, said hello and shone my torch in his face. He opened his eyes, looked around apologised profusely for falling asleep, then walked off the bus.

The bus driver looked sheepish.

It drives me bloody crazy - a person falls asleep on the bus and the bus driver isn't allowed to touch them. They call for an ambulance and because the patient is 'unconscious' it's a top priority call. Because of the eight minute target we are forced to respond at speed, ignoring other, almost more certainly deserving, calls. We get to the scene and wake the 'patient' up, often they are drunk, but sometimes they are just tired. We are then forced to do a full work-up on them and take them to hospital (unless the patient refuses).

I personally do at least one of these a week if I'm working late or night shifts. Often it's more.

Now, despite what our policy says, we'll normally persuade the person that they don't want to be checked out and go to hospital - this is because we have 'common sense', sure we could be bitten on the arse by thinking for ourselves - but I'd like to think that I can recognise the difference between someone who is about to die and someone who is merely asleep.

Unfortunately this common sense doesn't extend to bus drivers who are scared of accusations of assault.

We ambulance types often work outside our policies sometimes because it's in the best interest of our patients, sometimes because we would otherwise be without food and drink for twelve hours and sometimes because it's just the right thing to do.

(An example, we are supposed to wait for the police to turn up at violent incidents - if it's in a public place that we can safely reconnoitre I'll not bother waiting for the police, if it gets hairy we can always drive away).

Or maybe the drivers are scared of being assaulted themselves, in which case lets call for someone who's job it is to get assaulted, what with our intensive training of 'run away! run away!'

The LAS sometimes suggests that certain calls are unnecessary and would be better dealt with by a GP or Walk In Centre - perhaps we might try an education campaign directed to bus company executives and drivers, explaining that it is often possible to wake someone up without needing an ambulance for medical support.

Things that I have done this week.

• Resisted punching a patient after they became incredibly abusive towards me because the nurses at the hospital decided that they were perfectly suitable to sit out in the waiting room.

• Got a painful back and arm after trying to stop a drunk driver from breaking their neck after they had driven their car, at speed, into the back of a parked car.

• Breathed in aerosolised blood from a patient with a high risk of having a blood-borne disease.

• Dealt with a middle-aged woman who thought that her lifespan had been cut in half after being pushed over by a reversing car. Then wanted us to take her home before taking her to the hospital. She had no injury at all.

• Called the police to someone who was beating his Staffordshire terrier in the street, winding it up and letting it chase young girls.

• Picked up our regular, smelly, occasionally abusive drunk on three separate occasions.

• Had someone cough all over me when I had my face next to their mouth.

• Spent twelve hours sat in the seat of a Mercedes sprinter ambulance feeling my back slowly seize up. Every damn shift.

• Kicked a bucket.

• Had a grand total of three patients thank me when I settled them safely into hospital. That's out of approximately forty patients. Incidentally about the same ratio of patients who actually need an emergency ambulance.

• Inserted one cannulae, gave one dose of Salbutamol, one patient oxygen and argued with one 'carer'. Did not have to engage my brain with anyone or any situation.

And I get to see what happens tonight...

(I'm going to try and follow rule #1)

It would seem that you just can't trust those people who misuse illegal drugs...

We were called to someone who'd smoked some heroin, drunk some beer and also smoked some crack cocaine. He was... 'not alert', hardly surprising really.

The flat was full of drug users, our patient was the one being propped up by a woman.

“He'll be alright”, she said, “I've been taking heroin for over twelve years”, she proudly announced.

Our patient was semi-conscious, sweaty profusely and was breathing rather slower than is normally considered healthy.

A quick shot of Naloxone, a drug that reverses the effects of Heroin, and our patient was a bt more responsive. With the aid of some police we managed to spend the next hour getting the patient out to the ambulance.

Once outside his 'friends' disappeared back into the flat and locked their front door. The police were no longer needed and so we sent them off to deal with a fight in a pub (probably) and started checking out the patient.

“I'm not going to hospital without my jacket and bag”, he told me.

But what would you know? It would appear that some people who take illegal drugs are perhaps a little bit untrustworthy. His 'friends' wouldn't open the door to us or to the patient.

So he refused the ambulance and our offer to call the police back. Instead we left him standing outside the flat, swaying slightly from the effects of the alcohol, no doubt until he got bored and stumbled back to his hostel down the road.

Strange thing about this 'client group', they are all very “I love you bruv”, until you give them the chance to steal something from you.

Incidentally, the reason why our patient had such a strong effect from the drugs? He'd been released from prison that very day, and so his tolerance for drugs had dropped during his time inside. Being released from prison has led to the death of more than one Heroin addict from this mechanism.

In some fluffy way it seems that victims are sometimes victims to other victims.

Or something.

I had my first letter of thanks yesterday, the first one I have ever had.

It was a simple little job, one of those jobs that you tend to do a lot of. The call was to an elderly woman who had maybe collapsed behind her locked doors. The problem that faces us was that front doors are often locked and it's hard to gain entry. We never really know what to expect from this sort of job, sometimes the person is fine and they've just fallen over. Sometimes the person is seriously ill and this is the reason behind the collapse.

Occasionally the person will have died in the night.

The patient's sister, who was also elderly, had gone to the house and was unable to raise her sister. She'd then gone to the police station and they had contacted us.

We arrived to find the police already there, as the door was sturdy they were waiting for the officers who had the battering ram. The sister had also returned with one of the police officers.

The battering ram arrived and the door splintered inwards. The police officers entered the flat and we followed them in to listen and see who found her first.

Thankfully the patient was alive and well and lying on the bedroom floor.

She's a stick of a thing and well into her late eighties. We quickly check her over to make sure that she doesn't have any injuries, then pick her up and lay her in bed. What then follows is little more than a more extensive examination of her and a bit of the old 'chat'. We talk to her and her sister while checking her blood pressure and the like about such diverse subjects as dead husbands and playing 'knock down ginger', about how out patient hates doctor yet how kind her GP is.

It's nothing unusual, it's nothing that we don't do for all our patients in order to put them at ease. They will often refuse to go to hospital so, assuming nothing too obviously wrong with the patient, we arrange a GP to come and visit then leave and make ready for our next job.

But somehow a card of thanks makes it's way to us. The younger sister had walked up to the hospital and asked the ambulance crews parked outside to make sure that we got it.

So I return to work, look in my letter tray and find the card. It's a simple little thing, it just says 'thank you', but it means a lot to my crewmate and me.

It's rather strange how things work out.

Take the job that we had recently - it was given as a woman who'd fainted but was breathing fine and had nothing else wrong with her.

We were pretty much round the corner, so it wouldn't take us long to get there.

We arrived at a junction smack bang in the middle of the road that we wanted. Do we turn right or left? We turned right and found the address.

The address was a bunch of flats, the name that we had been given was spelt wrong but as we are clever ambulance workers we went straight to the correct address.

I walked into the house, for some reason I was carrying pretty much all our equipment with me, I can't say why I was doing this, some sort of intuition I would guess.

And our patient was on the floor and wasn't breathing. Her heart was beating a quarter of the speed it should have been and she was not so much knocking on Death's door, but halfway down Death's hallway hanging up her coat*.

So we set about doing a few things for her, breathing for her and monitoring her heart. After we'd pushed some oxygen into her she started to breathe for herself and her heartbeat sped up to more normal speeds.

We left her at hospital with a pretty good prognosis.

But that only came about because of good luck - if we had been further away she would have died. If we'd turned left instead of right she could have died. If I hadn't carried some of our weirder bits of equipment into the house she could have died. If she lived on the top floor of the flats instead of the ground floor she could have died.

With the exception of her stopping breathing in the first place, it would seem that luck was with her.

*Stolen from the rather excellent Alan Moore.