The wife looks at my me and my crewmate as we lift the chair with her husband in it onto the back of the ambulance.

"You both must be very strong", she says.

I reply with a joke, normally about how my crewmate, half the size of me, is actually the stronger of the two of us.

-----

But what I want to say is that the lifting is the easy part, the real strength is needed with the things we see and the patients that we deal with.

It's the strength that you need when you have picked up the fourth severely demented patient in a row, they curl up on our trolley having been unable to move for many years, their arms and legs contracted into the foetal position. Their bodies are skin and bone, as we pick them up their joints creak and crack and they shriek in our ears, long nails dig into our arms.

It's the strength that you need when driving the ambulance and you hear them start to cry in the back, your crewmate holds their hand and tries to reassure them but they can't get through. Instead all you can hear is the sobbing and the noises that are left them now that language has gone. they can't tell you if they are in pain or are scared - instead all they can do is moan, and cry and scream.

It's when you walk into a nursing home full of the demented elderly. Stuck on the walls outside the doors to their room are photographs from their prime. Happy mothers holding their children, proud men standing to attention in military uniform. Sepia memories from the past, what they were, not what they are. You open the door and the person in the photographs is lying on urine sodden sheets, legs heavily bandaged from ulcers that will never heal, with hands constantly grasping for something imaginary that floats just out of reach. The person that they were is gone, all that is left is the shell, no expression behind the face that smiled all those years ago for the photo outside the door.

Then one takes hold of your hand and looks up at you with bright blue eyes and asks if you are their dad, long since dust.

And your heart breaks.

I don't know how much longer I can do this.

Mostly linking to other people this week because these particular sets of night shifts are knocking me silly.

A couple of days ago I wrote about some attitudes towards homeless folks - there is another group of patients that engender a similar response, that of the heroin overdose.

Peter Canning writes (another) excellent post about the use of Narcan in opiate overdoses. I've got to admit that I've been guilty of 'punishing' overdoses in the past when I was a bitter and twisted A&E nurse, although in part that was in collusion with the A&E doctors.

Now I've taken a much more relaxed attitude to heroin overdoses, a nice slow administration of Narcan while I breathe for them with my ambu-bag, a chilled out little job with the overdose waking gently and peacefully. If you can maintain the patient's airway for them, and keep them well ventilated then there is no rush for the Narcan at all.

Makes life better for the patient, and better for the ambulance crew. Because who really needs to be the person put into instant drug withdrawal, or be the person who gets punched because they put someone else into instant withdrawal.

And if, as a crew, you are nice and relaxed then the patient's fellow junkies tend to be nice and relaxed as well - and I like nice and relaxed.

I don't know Fred (or at least I don't think that I do). But I hope that he's well and that his local management don't hassle him for being sick.

Now I'm off to sleep as I have had no food, drink or rest since starting last night's shift.

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.