We were sent to, let's call her 'patient A', who been assaulted and had a supposed broken jaw (she didn't). This was following a pub fight in a well known 'dodgy' pub. It was half past midnight on what felt like the coldest night of the year.

We arrived on scene, we found an FRU on scene and a police van that was just heading off to the pub where the mass fight had taken place.

'A' got onto the ambulance, crying and snivelling, 'B', her boyfriend, a big lad full of anger, followed her. Another crying woman 'C' joined us, I think she was the sister of 'A', or was it 'B'? All of them were 'proto-adults' - older than teenagers, but still behaving like them.

'A' wanted to know where 'D' was, another woman (a sister or a friend?); meanwhile 'B' was proving that he was a man by punching his fists together and shouting loudly about how he was going to return with a gun and shoot them all in the head. In front of the police who, like me, have heard it all before.

'A' decided to jump off the ambulance to look for 'D' so 'B' followed her. 'C' realised that not only was 'D' missing, but so was 'E', who I think was her boyfriend, or maybe the boyfriend of 'D'.

Down the road 'A' and 'B' were screaming at each other, then fell into each other's arms, 'C' meanwhile was fielding phonecalls.

'A' and 'B' came back, then 'E' phoned up 'C' and told them that he had two broken legs and was laying in an alley - 'C' who seemed the most sensible of the lot tried to get him to describe where he was. Meanwhile 'B' continued to show that he was a real man by stomping around and swearing bloody revenge.

The police returned, then went to look for 'D' and 'E'; 'B' stomped a bit more, then decided to go look for them as well, 'A' shouted at him that she didn't want him to leave her, waited until he was out of sight and then hopped off the ambulance to follow him.

It was about now that I called for another ambulance to give us a hand - if there were five patients that's one more than we can handle...

'C' went off to look for 'A' and for a short moment peace returned to the inside of my ambulance.

'A' and 'C' managed to find 'D' and had a bit of a hug outside of the ambulance before getting on board to escape the cold.

A car drove past with snow on it's roof.

I wasn't surprised that they were cold, there dresses they were wearing barely showed under their belts. Which just goes to show how old I'm getting.

They sat in the back of the ambulance, took more phone calls, cried and hugged and waited.

My headache got worse.

The police returned with 'B' and 'E'; 'E' looked like he'd been given a mild kicking, nothing too serious, but he wasn't dealing with it that well.

'E' went onto our trolleybed, 'B' continued to posture, 'A' shouted at 'B' to shut up, 'C' told everyone to calm down and 'D' needed to have a wee.

The second ambulance arrived and took two of our patients - 'A' and 'B'; 'B' was under strict instructions to behave himself.

'E' continued to let everyone think that he was dying while we drove to hospital. 'C' was sensible and 'D' crossed her legs.

At the hospital 'E' made a remarkable recovery and started whispering to 'B' about revenge while 'A' and 'C' told them not to be stupid and 'D' went to the loo.

We left them there, it was our last job of the shift and as I sat chewing down some painkillers I wondered what had started it all of in the first place.

Then I realised that I just didn't care.

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Pondering - If we had a military draft of our young people, we'd largely be screwed. Although to be honest I do tend to see the worst sides of people. Or people at their worst.

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The lurgy laid me out for two days (thankfully two days that I was off work anyway, so my sickness record is safe...). I then spent two days at work coughing and spluttering over people while dealing with a banging headache - I think I'm going to take on a new nickname - 'Typhoid Mary', and now I have another day off where I appear to have lost my voice. I leave it as an exercise for the reader to guess the effects of making probably still infectious health workers return to work in an effort to avoid disciplinary procedures. Let's just say I'm not visiting my mum on my day off..

Yet more reasons why large scale IT projects containing sensitive data are prone to failure. IT projects like the NHS Database.

Firstly the BNP had their membership list published on the internet, and this has led to some nastiness. While some people may think that publishing a list of these odious people is some sort of 'justice', I happen to think that data security should apply to everyone, no matter how nasty their legal views are.

It's though that this was an inside job from a disgruntled former employee. It's hard to protect against such things, and with the NHS being such a large employer, it will only be a matter of time before one person decides to open the floodgates and open up the system to abuse.

The second example is the virus infecting the Royal London Hospital. This was the Mytob worm that disables anti-virus software, shuts down firewalls and allows remote access. It's been around since early 2005.

All I know is that for a large part of Tuesday, the Royal London Hospital wasn't accepting ambulance patients into A&E. While I wasn't there, I can't see how the failure of a computer system meant that they couldn't deal with emergency patients. Even worse, this came a day after all the local hospitals were inundated with patients. At my local hospital there were no beds available at half past six and there were nine ambulances waiting to handover their patients into the packed out A&E.

Therefore, hospitals that were still recovering after an exceptionally busy Monday had more pressure put on them because the Royal London went on divert.

I know of one critically injured patient who should have gone to the Royal London, as it's a trauma centre, but instead had to go to another hospital. So, despite the official statement, I would suggest that "By using back-up systems, manual procedures and working flexibly, we have continued to provide high quality care to our patients.", isn't true for all patients.

All this was caused by an old worm that should be fully protected against - imagine if it were something specifically written to take advantage of the NHS computer systems. Imagine if the whole computer system was linked and the worm had access to the entirety of the NHS via a joined up database?

If you have been to the Barts and London Trust can you be sure that the remote access feature of this worm hasn't been used and that your medical details aren't now out there?

But of course the NHS IT programme won't be doomed to failure, because they are using the best of the best to design the system, not the cheapest or most politically expedient...

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Today was supposed to be my 'getting things done' day, but instead I have the lurgy (which may explain some things if this post is utterly unreadable).

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Pondering - I wonder if there is a market for insulated and waterproofed Burkhas? I imagine that they'd be quite nice in the worst of the English weather. A cross between a Parka and a Burkha - but what would I call it?

Peter Canning has written another excellent post, this time about fractured hips.

We get a fair few fractured hips (or #NOF for 'fractured neck of femur), most common among the elderly, it's one of those things that I feel that we as an ambulance service don't deal with as well as we should.

Apparently the thought is that this isn't a 'medical emergency', but explain that to 'Doris' when she has been lying on a hard floor for six hours with a broken bone causing excruciating pain.

Part of the problem is how we prioritise calls, using much the same computer triage system as Peter mentions these calls often come out as one of the lowest, or 'green' categories.

This means that they have to wait while our limited resources deal with 'Red' and 'Amber' calls - an example of a recent 'Red' call for me would be the man in his twenties suffering from a hangover.

So Doris continues to get pressure injuries from the floor because every move is agony.

'Green' calls don't need to be attended to on a 'blue light and siren' response unless they are in a public place (because people waiting for an ambulance in view of the public is obviously a clinical risk...ahem).

Personally as soon as I see that there is an elderly person on the floor I'll respond on blue lights, call me old fashioned but I think that leaving old people on the floor, sometimes in their own urine (for many fall after getting out of bed at night to visit the toilet), is just not the right thing to do.

Of course, I also think that a blue light response to a hangover is a bit excessive, but then we do tend to over-prioritise most calls.

Peter talks about the lack of painkillers being given to these patients, like his service we also have Morphine to give and, I would suspect that some paramedics are a little reluctant to give such 'strong' analgesia to a frail patient - but I have no experience or evidence of this.

My pet Paramedic and I are more than happy to dose up little old ladies with some high grade narcotics...

(No prizes for guessing the Prodigy song that runs through our heads when we do this)

When I was a nurse we set up a pathway for #NOF, we would x-ray, give fluids and analgesia, refer to the surgeons and book the orthopaedic bed all in one go - it was designed to get these patients, vulnerable to pressure sores, off the hard A&E trolley as quickly as possible. All of which boosts their chance of survival.

Yet, in the ambulance service we leave them on the floor.

It's one of the things that I've mentioned before - that the government grades us on how quickly we get to calls, but it doesn't grade us on the relief of pain, or the appropriateness of our telephone triage system.

Perhaps that needs to change.

It's not because she's young.

It's not that she's seriously ill

It's not that I don't know what it is that's made her helpless.

It's not that the only reason that she is standing is because her husband is struggling to hold her up.

It's not when she goes into a seizure and becomes incontinent.

It's not me being covered in her urine as I help her husband lower her to the floor on the crowded landing.

It's not the possibility that she could die from this illness or be permanently disabled.

It's not the way she looks at me with utter terror in her eyes.

None of those things kept me awake tonight.

It's the sound of her four young children behind me, wailing in fear as they realise that their mother isn't playing a game.

We ambulance people are finding ourselves called to the Barkantine centre quite a bit these days. Amongst other things it is a birthing centre.

It's really rather nice actually - it's clean and airy, the rooms are large and have all the amenities like an en-suite bathroom, birthing pool, televisions and big bouncy inflatable balls (I have no idea, the midwife who taught us how to catch a baby never told us what that could be used for).

The staff are lovely, when I have seen them dealing with medical situations their clinical skills have been good, they also seem very happy at their job, something that is a rarity in some of the hospitals I visit, and yet I find it incredibly important. Their bedside manner has also seemed excellent, again something that I've found lacking with some staff in some hospitals.

So, why do I find myself going to such a paragon of 'how things should be done'.

Well, we are used as a a transport service when things start to go a bit wrong.

To be fair, from the policies that they have they do tend to err on the side of caution. For example if the labour is progressing too slowly we will get called to transport the mother to the Royal London Hospital Maternity department (and that department is quite a change from the Barkantine I can tell you), the Barkantine midwife will travel with them.

A little while ago I took a mother and baby to the hospital because the baby was a little strange and needed some medical attention that the Barkantine couldn't provide. Hopefully nothing too serious, but my knowledge of neonatal medicine is rather thin.

So, while it is indeed a superb place to give birth, I have just one small problem with the Barkantine - it's not in a hospital.

While they only accept patients with no expected complications, such things can always occur which is when we are needed, and while I don't begrudge them using us as a transport service, because we do this for other hospitals, it does seem to be a bit wasteful of resources.

I'd also hate to see something bad happen to a mother or child because of a delay brought about by the wait for an ambulance and the following transport through the streets of London.

The Barkantine is excellent, it's just in the wrong place - it should be in a hospital, with access to theatres and a SCBU, Consultants and 'Crash teams'. These options should not be twenty minutes away by blue light transport and dependant on there being an ambulance nearby that isn't dealing with yet another drunk.

So, when the new Royal London Hospital is built, can we transplant the Barkantine to the roof there please?

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I'm working Friday, Saturday, Sunday nights - so don't expect an answer soon to any comments or emails.

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.

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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.

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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.

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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.