So - two weeks off work and while I should be feeling nice and relaxed, instead I have a feeling of impending doom. Lots of things on my plate and suddenly not enough time to do anything about it. Funny how everything happens along just as I'm about to go back to twelve hour shifts.

Today I'm on a training course, something to do with patient assessment I think - whatever it is it means sitting in a classroom, which means I better get in my supply of Red Bull.

Two weeks without thinking about ambulance stuff. Well almost not thinking about it.

I was staying in a hotel in Salisbury and was about to head out (at silly o'clock in the morning) to see the Summer solstice sun come up over Stonehenge. As I left my room I came across some slightly agitated young men. I walked past them and then I heard one of them mention that he had already called an ambulance.

I gritted my teeth, turned round and, explaining what my day job is, asked if I could be of any help.

Their friend had been riding motorcross and had come off his bike earlier in the day, now he'd woken up and vomited all over the bed and floor and was feeling 'grotty'. So I popped into the room and checked him out while we waited for the ambulance to arrive. My investigation suggested that he had a stomach infection rather than a head injury, so I left the patient in the more than capable hands of the ambulance FRU who turned up.

Yesterday I was woken up by a loud banging on my door - throwing on my pyjamas/lounging around clothes, I stumbled out of my bed and down the stairs to open my front door. If they had been religious people I would have taken violent offense to them disturbing my rest.

Instead it was one of my neighbours asking for help for another of my neighbours. My 'patient' had cut her varicose vein and there was a fine spray of blood spurting out from her foot. A dressing and a bit of pressure soon brought it under control and we decided to leave it at that.

Until it started bleeding again - this time she would need a bit of wound closure that I didn't have the equipment for - so I called for an ambulance and, after letting the excellent calltaker know that I was a fellow LAS person, suggested that they send down one of our ECPs as an ECP carries the sort of equipment that can close these wounds without having to take the patient to hospital.

And who should ring back but a mate of mine from my own station. He was more than a bit surprised to hear my voice on the phone.

He needed to ask permission to come out this far (as there was no-one manning the ECP post where I live), and with that permission granted he soon arrived.

Then got me to do the work while he did the paperwork...

So it all ended well, my elderly neighbour didn't need to go to hospital and everyone was happy. It's nice when a job like that comes together - even when you aren't actually working.

I often joke with parents that their children enjoy scaring them.

When they are a few weeks old, they hold their breath and go blue.
When they are a year old they get high temperatures and have febrile convulsions.
When they are two years old they fall over and cut their head.
When they are seven they fall and break a bone.
When they are fourteen they either get pregnant, or make someone pregnant.

One of our commonest calls for children is the 'traditional', two year old who has fallen over and cut their head on a wall/radiator/stone/passing dog. The mother is often panicking because 'it's a lot of blood!' (even though it isn't) and we pop them down the hospital for patching up.

Sometimes a child will fall over and get a bump on the head. I take them to hospital because it's an easy job and they get to sit there for a few hours before being sent home by the A&E doctor. Simple.

Sometimes however the parents just want the child 'checked out', they don't want to wait at the hospital so they will call an ambulance and not go to hospital.

Occasionally the ambulance crew will feel kind to the parents and child and suggest that they don't need to go to hospital.

I don't know what scenario played out in this story, but unfortunately the child died. Now the father is aiming to sue the service.

I have no details of this job, or what happened - but I can talk in generalities.

If, on examining a child, they are happy, alert and interested in what is going on around them and there is no history of a loss of consciousness, then they are almost certainly going to be fine. If you take them to hospital they will be sent home most likely without an x-ray or CT scan.

I can imagine that in this instance, even if the ambulance crew had taken the child to hospital the outcome would have been the same. Only the headline would be 'Hospital in probe over boy's death'. I don't think that the child would have been examined differently by a hospital doctor than by the ambulance crew.

There is a saying among those of us at the bottom of the medical hierarchy - 'always leave another medical professional between you and the patient', or 'don't be the last medical professional to see the patient alive'. If I take a patient to the hospital, then it's the hospital's fault if something goes wrong. If the patient wants to stay at home, then I'l try and arrange the GP - so if something goes wrong it's the GP's fault.

It's medical arse covering at it's worst.

In part it's due to the media - in this story above, do you imagine that the BBC would print a story following the investigation where the ambulance staff are found to be without fault? I doubt it.

We ambulance folk are being subtly encouraged to leave people at home, and most of us are blatantly ignoring this hinting for the exact reason above. We don't want to be the last people to see a patient alive.

If I go to a patient with a sore toe I'll still take them to hospital - because if they die of an unconnected heart attack, I'll be the one to blame.

And soon, with the 'front end' model, solo responders will be expected to leave patients at home, somewhere in the vicinity of 60% of patients should be left at home, or have 'alternate pathways' for care.

I can't see many ambulance people being happy doing that.

Mental Nurse often has very interesting and thought provoking blogposts. There has been a recent two-parter called 'My brother the alcoholic' - I would recommend that you give both parts a read so you can see exactly how the mental health system tends to treat people with mental health problems who also have an alcohol addiction.

And this is from a family member who knows the system - if you don't know the 'tricks' then you can guess what sort of service you get.

Read Part One.

Then Part Two.

Over the last few days I've been bashing carers in the community, so I think I need to end the week on a happy note, places where carers are doing their jobs properly.

The first was in a group home for severely mentally disabled people - one of them had wet the bed and while they were removing the mattress to clean it and let it dry out in the garden our patient had become agitated. He'd ended up falling against a door frame and had a cut to the back of the head.

We arrived and the house was clean, the residents were clean and well looked after and there was a general 'good vibe' about the house that was hard to put a finger on. The staff were happy and interacted with the residents and it just seemed like a nice place.

Once more (see Mavis in yesterdays post), we considered the patient suitable for wound cleaning and closure at home - dragging him off to the hospital would only distress him. So our ECP came and sorted him out. The staff at the home were grateful for this and we left with a feeling of a job well done.

The other place that I want to celebrate is the John F. Kennedy Special School in Newham (who it would appear don't have a website). This is a special needs school that teaches severely disabled pupils. Every time I go there it reduces my cynicism level by a couple of notches. The staff there all know the children - they look after them and when they call us, its for a good reason.

As every staff member knows every child it's never a problem to find someone to accompany one of the children to hospital and the way that they interact shows us that they aren't just 'performing' in front of us.

Once more it's a good vibe that I can't quite describe - but I just know that this is a good place for the children and the staff alike.

There. I can be positive sometimes.

Last post I mentioned how we seem to be throwing resources at the 'non-emergency' side of our work, sometimes though it does work out in the patient's best interest.

Take Mavis for example, she gets a bit wobbly on her feet sometimes and had a fall - she picked herself up and got back into bed. When the first carer of the day arrived she found blood everywhere and Mavis with an inch long cut to the back of her head.

The carer called us and as soon as we arrived disappeared out the door.

Chatting with Mavis it was obvious that she didn't want to go to hospital, she'd lived in this flat all her life and didn't trust hospitals, or doctors. Fair enough really, they aren't my favourite places either.

So we called out our ECP, 'Emergency Care Practitioner' - a Paramedic who has been taught a few more things like how to close wounds or how to diagnose urinary infections. He turned up and after chatting with Mavis for a while started to clean the wound and glue it shut.

As Mavis is fairly mobile there was blood all over her flat, and when the cleaning carer arrived she sucked her teeth, said, "I don't do blood", and disappeared sharpish.

So while our ECP friend was washing Mavis' hair, I went around the flat with a damp cloth cleaning the blood while my crewmate pointed out the bits that I missed (we work well together like that).

With the wound cleaned and treated we left Mavis a very happy customer in her own home. Our ECP returned a few hours later to check up on Mavis, and she was still healthy and still happy with the treatment we gave her.

It is nice when we can avoid taking vulnerable people into hospital - it's a place full of nasty communicable diseases. And yes, I am fully aware that I may be contradicting what I wrote about in my last post - that we perhaps shouldn't be this overly accommodating to patients. But I just think that it highlights just how much this job, and healthcare in particular isn't so black and white sometimes.

The difference of course is that Mavis would have normally needed treatment in an A&E department, while the sore throat or verruca patient can normally survive without a trip to the hospital.

As I've mentioned many, many time before it would seem that the world of healthcare just stops once the sun goes down leaving just us ambulance folks and the A&E departments to deal with everything. The weekends are the same.

We had a perfect example earlier this week, while my regular crewmate was off watching the Foo Fighters at Wembley (lucky cow...) I was working with another EMT chasing around the Hackney area.

We were called by the district nurse service to attend to a woman who had been cannulated, but the cannula had come out.

Our patient was being treated for a long running infection, no-one really wanted her in hospital because it is really easy for her to catch another infection there, so she was being treated at home. A splendid idea.

She needed a small needle (cannula) in her vein so that she could be given antibiotics straight into the bloodstream, and the district nurse service came around twice a day to administer this.

Unfortunately this cannula had started to fail on the Saturday night. Unfortunately for the patient the service who inserts them in the community doesn't work on a weekend, or after the sun goes down. The district nurses couldn't resite it, they don't have that training in this area.

So they call an ambulance and expect us to put a cannula in the patient and leave them at home.

Unfortunately neither me or my guest-star crewmate are paramdics, so we aren't allowed to put in cannulas either (despite me doing it regularly in my previous life as a nurse). Meanwhile the patient really didn't want to go to hospital.

"How do you think I got this infection in the first place?", she said to me, and I couldn't really disagree with her.

The family were lovely, so it wasn't a hardship to go that extra mile for them. We called up our control and asked them to send us a paramedic who soon arrived. I was glad to see that it was one of my mates and I knew he'd be happy to do it.

However... Are we legally covered to cannulate someone and leave them at home, normally when we stick a needle in someone we take them to hospital. So my paramedic friend phoned up our control and asked for the 24 hour clinical advice desk.

He was on a break.

So we chatted to the family of the patient, not a great hardship as they were your classic, traditional, East-end family while we waited for the clinical advice desk to phone us back.

He did so and gave us the go-ahead to pop that needle in and leave the patient at home.

Which we did.

And the patient and her family were extremely grateful.

This is just one more example of how the ambulance service and the A&E departments pick up the slack for the other agencies that have decided not to work after dark, or on weekends, or on bank holidays.

Part of us being run ragged at night is due to people expecting treatment when they want it, when it is most convenient for them. When 80% of our jobs can be treated by GPs or walk in centres, why do these patients wait until most of these services have closed? Because it's most convenient for them. The health service then expects us accident and emergency services to pick up this slack.

"I want treatment for my sore throat now", said the great unwashed public at 2 a.m. in the morning and phones 999 for an emergency ambulance. Then they moan when they have to wait at the A&E department while they deal with real emergency cases.

And so what happens? The ambulance services start reconfiguring to meet this demand for trivial work, we train and employ ECPs who do the GP scut-work, and we start converting the fleet to cars, all the better for taking the minor illnesses to hospital.

We aren't an accident and emergency service any more, we are the "coughs, colds, bumps and grazes" service, open 24 hours a day we will bring the hospital to your door - free of charge and no waiting needed. Meanwhile the seriously ill can go waiting because we are so busy dealing with your minor case at a time of your choosing.

"You really do get upset at crap carers", one of my station officers said to me.

We were sent to a young woman living in a group home. There are carers there as this woman has some severe mental health problems and there are a number of similar people living in this home.

Not that I would know as the carer opened the door and essentially pushed the patient at me.

All I could tell was that the patient was confused and uncommunicative. She reached out and took my hand and started walking towards the ambulance.

I explained to the carer that I'd settle her down in the back of the ambulance and then come back to get some information.

The patient sat in the ambulance, due to the way she was holding her head and breathing she was spraying spittle everywhere. The carer was nowhere to be seen.

I went back to the house and banged on the door.

"What happened?", I asked.

"She wanted me to call an ambulance", said the carer, "I don't know why".

"Did something happen?"

"Her eyes rolled back in her head".

"Did she shake at all?", I asked.

"Oh... Yes", said the carer, appearing a little dazed herself.

"What can you tell me about the patient's normal condition?", I continued.

"I don't really know her", she said. When I pressed her on how long our patient had been at the home she told me it was only "four or five months".

Shaking my head in disbelief that in a small house like this the carers took so little interest in the people living there that they knew nothing about them after four months I asked what medicines she takes.

"Two little white pills in the morning, and two purple ones at night".

I let the carer know that my psychic powers weren't that good and she'd have to be more specific than that. She couldn't.

The patient was unkempt, appeared to have someone else's underwear on and her hair hadn't been washed in some time. The 'carer' didn't know anything about her and refused to have anyone come to the hospital with the patient. By now the patient was starting to wander around the back of the ambulance and I wanted to get her to hospital.

On the way to hospital the patient kept standing up, so I had to hold her hand and get her to sit down again - I didn't want her falling over should my crewmate need to stop suddenly. While she was doing this she was unconsciously spraying spittle up my body, over my arms and in my face. She wouldn't keep an oxygen mask on, so I was getting covered.

By the time I got to the hospital I was fuming at the lack of care that this patient had been receiving from this 'care home', I was angry that no-one had travelled with her, I was angry that she had been 'dumped' on my with the carer not telling me anything about her and I was a little annoyed that I'd been covered in her drool.

Then I booked the patient in and discovered that she has 'open' tuberculosis, which means that I may be needing six months off work at some point in the future.

Again, this was a thing that the 'carer' had neglected to tell me.

So it was back to station for me for a long shower, followed by filling in paperwork for my risky exposure and a 'vulnerable adults' form to highlight what I considered neglect going on at that home. Someone higher up on the food chain than me will take on having a look at the home and seeing if my fears are justified.

As I reported it to my station officer he said to me, "You really do get upset at crap carers".

"Yes", I said, It's one of the few things that still fires my blood, that 'carers' can get away with doing such a shoddy job while I feel that us ambulance people are the only ones who still give a damn about people. I wish I met more people who were good carers.

A little time ago I met the private secretary for Ivan Lewis, the minister for social care - he told me that they don't have much to do with ambulances as we supposedly don't deal with that much social care. I put him right on that score, that around 80% of our jobs involve social care. This is what we see, this is what we deal with - we are that safety net that deals with everything when the other services throw up their hands and don't know what to do. When the sun goes down and everyone else goes home, we and the A&E departments must deal with everything and anything - and that is why we see the flaws in the system.

Looking at my list of future blog-posts I think that this week will have the failure of the care system as a bit of a theme, not for any real reason, just because that's what I've been getting of late.