It's cold and dark, and for the next few days I'm working nightshifts, this will either result in a 'sense of humour failure'* on my part or I'll suddenly find myself sobbing in the corner of the room. Place your bets on what it'll be...

With it getting cold it becomes 'Homeless season' for the ambulance service. People who are normally happy** sleeping rough, drinking the day away on a park bench and having a nap wherever they can suddenly realise that it gets a bit chilly and that their normal lifestyle is a bit... uncomfortable.

So, as a service, or at least in my part of the world, we find ourselves being called to more homeless folk than is normal, at the risk of sounding politically incorrect let me just define 'homeless' for the purposes of this article as those people who are long-term homeless, normally due to alcoholism (caused in some part by the lack of 'wet' hostels for them) or the mentally ill (caused in some part by Thatcher). I'm not referring to the homeless who seek to improve their condition, but instead the outliers who either refuse help or who cannot keep the rules that are expected of them.

An example of how things change with the weather - in the last cold snap I was queuing up to hand over my homeless patient, also queuing up were another three ambulances with patients similar to mine. One was incontinent while waiting and another had been incontinent in the ambulance. Actually incontinent is perhaps the wrong word, one of the men whipped out his 'member' and urinated up the wall of the department.

Welcome to the world of healthcare.

But, you know, the homeless are people as well and they deserve as much care and consideration as anyone else, even if their sole contribution to society seems to be limited to turning cider into urine.

My patient, for example, told me that he had been vomiting blood - something that can be the sign of something serious, especially in the alcoholic patient. I listened to his history in the back of the ambulance, took his vitals and started my paperwork. I looked him up and down and wrote 'Patient complaining of vomited blood, no evidence seen'.

I stopped and looked at what I'd just written.

There wasn't any sign of blood or vomit on the man's clothing so what I had written was factually true. What stopped me was wondering if I would have written such a thing if I'd picked this patient up from a clean house? If he hadn't been an alcoholic?

I'd treated him with respect, I'd done all the same things that I would have done for anyone else complaining of the same thing, but still I'd written those words on my report form.

I may as well have written 'patient says he vomited blood but I don't believe him'.

So we took him to hospital. When we got there I started handing over to the nurse, as soon as I mentioned the vomiting of blood she turned round and asked me, "Was there any evidence of this?".

This isn't a 'harsh' nurse, she's pretty good actually - caring and considerate and definitely hardworking, yet she'd also asked me the same thing that I'd written down on my paperwork without thinking.

The patient went out to the waiting room.

I wonder if he would have been put out into the waiting room if he hadn't been homeless.

It's not a criticism of the nurse, trolleys are in short supply in the A&E department and the handover nurse has to make decisions between who gets to stay in the main department to be seen soon and those who can go out in the waiting room. While the various professional organisations that look after nursing and ambulance people would have us treat every word that comes forth from the patient's mouth as complete truth, there comes a time when you start to watch for people trying to 'trick' you for whatever reason they have.

It might be the junkie looking for narcotics, it might be the person playing up their illness in an effort to get seen sooner or it might be the person who lies about not being able to get an appointment at the GP as the reason for dialling 999.

One of the 'classics' is the patient who tries to convince you that their pain score is 'ten out of ten', and as the NMC*** say, 'pain is what the patient says it is', which is hard to believe when the source of their pain is a tiny shaving cut...

While I can normally tell a lie, I'm more than happy to give the benefit of the doubt to a patient, regardless of their background. I'd rather give analgesia to a junkie than withhold relief from someone in genuine pain.

Which is why I wondered why I wrote 'no evidence seen' on my report form.

*Sense of humour failure is a term that some people use to indicate losing their temper. I may well be using it in a similar way...

**'Happy' is perhaps the wrong word here.

***Who live in happy fairy land it would seem and when I was a nurse seemed to publish a lot of twaddle about any old rubbish. They may have got better. I doubt it though. They'd be very unhappy about me calling everyone either 'Luv' or 'Mate' for instance.

I'm a bit busy at the moment (although my lurgy has mostly cleared up and my Measles blood test has come back negative, so I can return to work tomorrow starting at 'Oh my God o'clock').

I just want to draw your attention to this newstory - it's something I'm currently researching by trawling through official papers.

The short version is that in a few years time the people who 'buy' health services in the UK will be required to contract out some of the 999 A&E ambulance services to private companies.

I happen to think that this is a bad idea, and the BBC has picked up on it recently as well.

More on this once I've had a chance to research it properly.

BBC Links here.

Utterly unconnected, but there is an interesting Guardian article about how the government might deal with internet and social networking communication during a terrorist attack - I'd hope that this has no basis in fact as to do what is suggested would (a) probably not work (b) cause more problems than it solves and (c) almost certainly be illegal.

As I hinted in previous posts I was exposed to a case of Measles, it all seemed to be a normal job, a young child with a high temperature, but the hospital confirmed Measles a few days later. The hospital contacted the Health Protection Agency who then contacted the LAS, then my DSO contacted me.

My mum writes down everything that happens to me, so when I asked her if I'd been immunised and she found no details of it I have to assume that I wasn't. This is backed up by the note she made that I had Measles on December 24th 1977 (I told you, she notes down everything). However, according to the Occupational Health nurse I went to see, childhood exposure to Measles doesn't grant an immunity.

Unfortunately, as I'm still suffering from the lurgy/man-flu I couldn't have the MMR vaccine due to it being a live vaccine. Anyway, the MMR would be the second dose of Rubella vaccine I'd get as I was given that particular jab when I started my nursing career (which caused my GP no end of confusion as he had no idea why a man would need the vaccine - I told him that I would be treating pregnant women, but I still had to fight for the jab).

Of course, Measles is in the news at the moment as there is a rise in Measles cases, particularly in London where I work. And, yes, I blame the idiot media who would rather print an 'interesting' story than actually employ a journalist who has some basic scientific/statistical knowledge. Even the Observer got in on the act last year. As an aside I cannot recommend Ben Goldacre's website enough as an antidote to the utter wibble that is being passed around as 'fact'.

So, as I apparently have become potentially infectious from midnight last night, I have been stood down from work for the next two days pending the result of a Measles IGG blood test. It might give me time to get over the lurgy that I'm still coughing up as well as some time to answer the emails that have been building up in my inbox.

It has been said that us ambulance staff don't have enough patient contact to contract Measles - although they haven't tried explaining it to the two staff who caught it from a patient a year or two ago...

Still, as I'm 'stood down' rather than 'sick' I won't be expecting any disciplinary action for my sickness. Kudos to my local management team for being generally supportive and for following the HPA's advice.

I shall now spend the next two days looking for spots showing up against my hairy, white belly and being a general hypochondriac.

I'd also like to mention in dispatches my stationmates and their patient who were hit by a car while they were loading the patient on the back of the ambulance. It was a hit and run and while the staff were flung about they don't seem to have been seriously injured - I have no news on the patient but hopefully they are alright as well. The crew's first thought was for their patient and they should be commended for that.

How do you hit an ambulance which is big and yellow, with a fully lit interior? My guess would be 'while drunk' and 'with no driving license' - the police investigation is in progress.

I walked through the door to the house, the door had been kicked open and I stepped over the splinters of wood. Turning left I climbed the stairs and saw one of my favourite police officers standing at the top. He's one of the older officers on the street and eminently sensible, I know that a job is going to be fine if he's there.

"That your handiwork?", I asked him.

"Yep, I've arranged someone to come and fix it". He was kneeling down next to our patient.

It's one of our usual calls, an elderly neighbour doesn't answer the door and someone who 'pops' in sometimes, or buys their bread and milk for them calls for us, or the police.

The police arrive to knock down the door - or we get there first and I get to kick it in. On this occasion the police had beaten us and so the officer had been on his own with the patient waiting while we'd cleared from our last patient. He'd already put a pillow under the woman's head and was arranging to let the relatives know - as is common these days the relatives lived in a different county.

'Edna' had the classic pose of a broken hip. Lying flat on her back with one leg obviously shorter than the other.

"You won't take me to hospital will you? It's just a little tumble", she asked looking up at me with pleading eyes.

"We'll see how you are after I've had a look at you", I told her in an effort to give me some time to work out how to break the news to her that she would be going to hospital.

A further examination and it was even more obvious that she had broken her hip. I looked around, we'd need to strap her to our scoop stretcher firmly as we'd need to carry her down the stairs and tip her nearly upright in order to get her out the front door.

I looked Edna in the eye, "I'm sorry luv, but it looks like you might have broken your hip, you'll need to go to hospital".

A tear formed in each eye, "Oh no. I suppose I don't have a choice do I?"

So we set about strapping her up - the police officer helped my crewmate get some equipment from the ambulance. What I really wanted to do was give her some Morphine for the pain - it was obviously going to be painful with the manoeuvres that we were going to be forced to do.

But our Morphine stores were out of stock, we had nothing stronger than Entonox. At least we had some of that.

So we spent our time carefully strapping her to the scoop while trying to dose her up with 'gas and air', it didn't seem to be having much effect; essentially her pain relief would be dependant on how well we had strapped her to our scoop.

My crewmate is only little, but surprisingly strong, so she refused the officers offer to carry her end of the scoop, instead he would continue to guard the house until the workmen would come to fix the door that he'd kicked in.

Carefully, so very carefully, we lifted her up and carried her down the stairs, there were some little noises of pain from Edna but she seemed to be coping well. Then at the bottom of the stairs we tilted the scoop up almost to the vertical.

Not a peep from Edna.

We got her out the front door and put her on the trolleybed that my crewmate had already positioned in the street. Then it was a simple matter of driving as carefully to hospital as possible with me holding her hand all the way.

This job gnawed at my mind for some days - Edna was such a lovely lady, with a clean house, neighbours who cared and a real sparkle about her - but because of her other health problems the chances of her getting out of hospital weren't good. Essentially, this 'little tumble' would almost certainly be the cause of her death.

In part I think it's because we spent so much time with her, chatting to her, explaining what was joining on, trying to reassure her that it hit me so hard. In the grand scheme of things we hardly knew her, but for us spending half an hour on scene is a lot longer than we normally have to get to know our patients.

Can I thank everyone who left a comment on the previous post. I've read every single one of them, even though I haven't had time to reply. I can understand that sometimes it can be difficult to talk about subjects such as these, but keeping them in the dark seldom does anyone any good. I can say that I think I've learned a few things about attempted suicides, as well as confirming my fears that they are often not treated well on psychiatric followup.

I'd like to hope that everyone who wrote about their own experiences gets the help that they need.

I'd also like to hope that one day mental health is taken as 'seriously' as physical disease - sadly I think we are some way off from that.

I'm trying to work it out, but I can't. It's a common job of ours but I can't see why people do it - I doubt that I ever will.

I'm talking about suicide attempts.

Specifically I'm talking about people who hurt themselves, either cutting at their wrists or taking a handful of pills then pretty much immediately either call an ambulance or call a friend who then calls us.

Take a recent example - a young woman had cut at her wrists, nothing too serious, but it was only a minute after doing it that she called for an ambulance. She then did nothing but cry throughout our assessment, treatment and transport to hospital. If she was still upset, why call an ambulance?

Another example, a young man who took a handful of pills, they'd barely had time to hit his stomach before he picked up the phone to us.

Is suicide a nanosecond of madness that corrects itself as soon as it occurs?

We have our repeat customers in this as well, the young woman who takes what she considers a 'safe' overdose of paracetamol, calls her friends around and then argues with us that she just wants to die and not go to hospital.

I don't often go to people who succeed at suicide, barring the occasional hanging, most people who seriously chose to kill themselves go somewhere where they won't be discovered and then take a huge amount of pills. These tend to be found days later where it is more a job for the police than it is for us.

So I don't understand - is it all just a 'cry for help'? Is parasuicide just a coping method, a way to be the centre of attention or a way to regain the sympathy of friends and family?

When it becomes incredibly sad is when a parasuicide steps over the line from a 'failed' to a successful attempt - I'm mindful of more than a few jobs where people have overdosed on what they thought were 'safe' levels of Paracetamol only to later develop liver failure and die, or the one person that fatally drank Paraquat in a moments anger during a stupid argument.

I'm curious, after the psychiatric services have seen the patient in A&E once the medical treatment is done, are they referred to a long term care team - or is it a case that they are sent back to their GP in order to arrange a referral?

So no, I don't understand it - all I can do is support and transport; perhaps I don't need to understand.

A question - is there anyone out there who works in infection control willing to contact me? I have a question to ask regarding gaffa tape.

Pondering - In the TV adverts for recruiting into the army, why do none of them involve shooting at bad guys? It's all humanitarian work, dancing at nightclubs or playing football.

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.

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.

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..