It's really simple - I hate forced overtime.

I know that it's just part of my mental make up, but if I'm forced to stay longer in work than I'm contracted to be there I start to get itchy and fed up.

It can't be helped though - sometimes we just get that 'late job' which means that we are dealing with a patient after we should have clocked off. I'm somewhat more used to that, it is one of those things that just happens, and we get paid overtime to make up for it.

(I think it's flat rate overtime mind).

The one thing that really annoys me though is when the clocks go back.

All because our ancestors were afraid of demons that might attack them after the sun goes down (or some such, I don't really care) the clocks go forward in Spring and go backwards in autumn.

Which is fine if you work normal hours - it means you get an extra hour in bed.

Lovely.

However if you are one of those stupid <illegitimate child>'s that work shift work it means so much more...

It means that if you are working a twelve hour shift, suddenly you find yourself working a thirteen hour shift - and that's not counting any extra you have to work if you are unlucky to get stuck with a late job.

I'm working night shifts this weekend...

Some time ago my crewmate told me that the clocks go back on Sunday.

I thought I would be a cunning swine and book annual leave. I really despise working that extra hour (oh, it might not make sense, but in my head it does).

So I booked Sunday night off.

Because that's when the clocks go back.

Isn't it?

No - of course they <copulation>ing don't. They <copulation>ing go back on <turf>ing Sunday morning.

Which means the <female genitalia>ing Saturday night shift.

Like a dozy <male genitalia> I took the wrong <illegitimate child> shift off.

<Male genitalia>.

So - because I'm a daft <person who copulates>, who takes his crewmate at her word, I get to work a thirteen hour shift on Saturday night.

<Copulate> it!

I may not be in the best mood.

The patients had better need an ambulance - or I may well be educating some of them as to the best use of an ambulance service.

£5.4 million pounds. For artwork to showcase 'British Culture'.

With £5.4 million pounds spent on the ambulance service I might not be left looking for a spare ambulance on my late starts.

We might have enough blankets for the coming winter.

I might have a fully kitted ambulance.

Looking wider - we might be able to look after our returning soldiers without needing charity.

We might be able to get some people out of poverty - thus saving lives.

Instead we'll have,

'LED panels on the roofs of bus stops aim to provide Londoners with a new way to display their creativity, express what is special about their London and to talk to one another.'

Oh well.

Neenaw has written recently of 'banana man', in that post she mentioned someone dribbling on my arm...

There is a person on my patch who takes great pleasure in calling out an ambulance - I suspect that he likes the attention that he gets from us. The other night we were sent to him on four separate occasions.

For the first call he'd already left the scene, which was perhaps unsurprising as the call was over an hour old.

The second call was made from outside a pub - we rolled up and he wandered over to us to have a chat. The complaint was one of his regular reasons for calling us - 'feeling suicidal'. He never appears suicidal with me, laughing and joking, telling me how he is a trained scientist and therefore is a genius.

I suspect that he doesn't actually have a mental illness, although he is an alcoholic with liver failure.

It was this call that had him dribbling and spitting over my arm. Not good, as I understand that he has hepatitis.

While talking to him another one of our regulars staggered over and started shouting at him for wasting the ambulance service time, which made me laugh as he's used up more than an average number of ambulances himself.

Our 'scientist' decided not to go to hospital and instead head back into the pub - so we drove off into the night.

Two hours later we were back at his house, this time saying that he was bleeding from his anus. We arrived and, once more, he decided not to go to hospital.

I'm fully aware that one of these days an unlucky crew will go to him, he'll refuse to go to hospital, and then he will die - dropping the last crew to see him in the brown sticky, smelly stuff.

It's like a game of Russian roulette.

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Our final call to him came down the MDT as this.

You will notice that the 'Determinant' - the thing that is used to triage the call says that he does have a weapon.

A nuclear weapon.

(I know that calltakers have to put down what the person calling says - although I'd like to know if the calltaker was serious, or having a joke).

Needless to say, I cancelled the police who would have attended due to weapons being used - told Control to look out for the mushroom cloud in the East and trotted around there again.

After a bit of an argument he finally agreed to go to the hospital - with him now in the A&E waiting room we know that he is...

a) Safe, and

b) Not going to call us for the next few hours, thereby letting us deal with actual genuine calls.

As we dropped him off at the hospital his 'friend', who had berated him earlier for his misuse of ambulance resources was pissing up the wall of the A&E waiting area - having called an ambulance himself.

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The thing is - he has been known to be violent in the past. While he has been nothing but nice to me (except of course the dribbling on me) he has been nasty to nurses and other ambulance crews. I'm happy to go to him without wasting the police's time, but there are some crews who - more wisely - ask for a police escort.

I've written about him before.

Currently I think that there is a team looking at him to try and reduce his calls to the LAS and his attendances at hospital - it's a process that has worked in the past, so I'm keeping my fingers crossed.

This is a post about how chasing government targets impacts directly on patient care.

I've often written about our chasing of our 'Cat A' targets - that we are tasked by the government to reach 75% of these calls within eight minutes. I've also written about how I think our senior management have put this priority above many others.

There is another target that we should be hitting - calls that are given 'Cat B' (serious but not immediately life threatening), we should be reaching these calls within 19 minutes.

In my part of the LAS we have been failing in this second 'Cat B' target.

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One of the things that really surprises me is that someone having a CVA, also known as a stroke is normally given a 'Cat B' priority. Given that the move is for better treatment for strokes - going so far as to rename them 'brain attacks' to put them on a par with 'heart attacks'.

It is a good thing that we are starting to treat strokes more seriously - I can remember when I was a nurse that we would essentially put people who had just had a stroke into a bed and arrange for physiotherapy - there was no treatment then, only rehabilitation.

Things have changed a little but there is still an amazingly long journey before we can start offering the same level of treatment as we do to people having heart attacks.

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Due to our poor performance in 'Cat B' our senior managers have decided that we should have 'Amber Ambulances', these are ambulances that are to be tasked with bringing our 'Cat B' response times up.

These are extra ambulances that are staffed with the same skill level as our 'regular' ambulances, but they are only supposed to attend to 'Cat B' calls.

All in order to meet that government target.

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We were sent on a possible CVA/Stroke - a 'Cat B' call. So I put on our lights and sirens and headed off to the call.

Partway there were were canceled for a nearer vehicle, so I turned off the lights and sat in the normal traffic. I got stopped by a set of red lights.

As the house we were going to was on our way back to station We would drive past it and see who had been given the job.

As I drew up to the street it was obvious that there was no ambulance there.

I called up Control and let them know that we had beaten the 'nearer' ambulance and that we were more than happy to take the job. After all if someone had suffered a stroke they needed to be in hospital, not waiting for another ambulance.

I was told that I should continue driving and not attend to the patient as 'the amber ambulance is nearly there'.

Four minutes later the 'amber ambulance' arrived.

An identical ambulance, with an identical skill level, but four minutes behind us - even though we had travelled most of the way observing the speed limit.

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Needless to say, I was absolutely fuming. Here we were, already on scene and yet being told not to enter the house because it was more important that the target-busting 'amber ambulance' would do the call.

An identical ambulance, but one that is to be used to hit this other government target.

Why were we canceled? We were canceled because it is not good enough to have an ambulance, it has to be the right ambulance in order to reach that government target. Because they are only to go to 'Cat B' calls, and if we attended then what would happen if there was a 'Cat A' around the corner? They couldn't send the 'amber ambulance' because then they wouldn't be free to hit the target.

And the government would be unhappy.

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I reported this through our clinical incident reporting procedure.

We managed to return to station where I saw one of my Station Officers, I told him about the situation and he phoned the top person in Control for that day. Top person in Control agreed that it shouldn't have happened and would look into it.

To be fair , this was the first day that the 'amber ambulances' were being run and this was probably just teething problems, but I still think it highlights how fixated on chasing these targets we have become.

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Every person in the ambulance service who works out on the road understands the simple fact that, if you want to get ambulances to patients quicker you need more ambulances. It's not rocket science, there is no way that we are going to make any appreciable difference in the number of people calling for an ambulance, so we need more ambulances to deal with the year on year growth in demand.

What doesn't help is bringing in more ambulances (in itself a good idea), but then limiting the flexibility of those ambulances over an artificial target that, I suspect, has no basis in science.

This is one of the worst cases of government targets directly impacting patient care that I have personally witnessed. And it shames me to think that actual patient care comes after pleasing the government.

However, sadly, it doesn't surprise me.

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Thanks to Lordneil for reminding me that the 'Cat B' target is destined to be scrapped and that better clinical indicators are to be put in it's place. This was supposed to be done in 2009 but has been put back to April 2010 for some reason. (It's here on page 40). This is something that I suggested in this blogpost although I am yet to hear what clinical indicators will be put in it's place.

He has told me that he has taken a large overdose of tablets, that he wants to die.

He reclines on the ambulance trolley refusing to talk to me, of what he has taken we are not sure. We've done some detective work and from the empty packets it looks like it might be a lethal dose.

Luckily for him, this lethal dose can be treated in hospital.

I ask him why he wants to kill himself.

'I've got nothing', he tells me, 'nothing to live for'.

He's eighteen and already he thinks that his life isn't worth anything.

He lies there, hood drawn over his head, repeating how he has nothing and how he wants to die.

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We arrive at hospital and he is put into the resuscitation room.

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In the next bed over there is a ten year old girl. She has a lot of medical problems and one of them has gotten suddenly, severely worse.

She struggles for her next breath. The anaesthetist is called and they prepare to intubate her and take over her breathing.

Every breath she draws in is fought for, every moment is now a battle for her to stay alive - and she continues to fight.

Her parents want nothing more than for her to see tomorrow. They pray, her doctors and nurses work, she continues to fight.

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Across the world people die - they die because they don't have food, beccause they don't have clean water, because they aren't vaccinated against the childhood diseases that we in the developed world conquered years ago.

People in tin shacks struggle to make it through a life of crushing poverty, they take what joy they can in the little things in life.

And across the world, in a country where you are fed and clothed and housed, where you have access to good quality medical care a teenager who 'has nothing' takes a handful of pills and calls an ambulance.

Yesterday I pointed out some of the things that I think the LAS are doing wrong with respect to the post-qualification training of ambulance crews.

Today I hope to be a lot more positive and provide some solutions.

The one solution that I'm not going to discuss is the need to provide many more formal, multi-day and single day, training courses as I think that goes largely without saying.

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The first problem is that we are still intent on chasing the pointless ORCON target, with too many calls, calls that are inappropriately triaged and not enough staff and ambulances training takes a back seat to pleasing the government.

One thing that has been mentioned a lot internally of late is that there are 400 new staff joining the service. If this is true then there should be enough staff to enable in-service training to really take off - if not then how have we managed to cope with the current number of staff?

Increased numbers of staff means that perhaps we might be able to take crews off the road for protected training days - days where Control won't be ringing constantly to see if the training is finished.

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One day a month should be a protected training day. Lets assume twenty weekdays in a month - that means that 1/20th of staff could be trained every day. Surely we have enough capacity for 1/20th of staff to be off the road at once - with 400 people joining the service and plenty of people wanting to do overtime to pay their mortgage there shouldn't be a reduction in active road staff.

We should employ people who have a background in education to come up with a syllabus or framework for training. The syllabus should be reviewed every few months to take in new research and practice methods.

How much could you fit into twelve days of training throughout a year? Make them twelve-hour training days and you are looking at 144 hours of training a year. That should be enough to keep us up to date as well as reinforcing skills that we don't practice that often.

How would we pay for this? If we removed a few assistant to the assistant of the assistant director of operations (East London) and returned them to the road we would not only save money, but also get a few more road staff back.

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The officers who provide this training should be educated outside of the service - they should be put on education courses that aren't connected to the NHS. This is how you bring in new ideas on educational theory.

Why, for instance, aren't the current training department investing in e-learning that staff can do on their own time? Why aren't they doing a podcast for crews to listen to as they commute into work? Why aren't they building a library of texts and research that we can use? Why aren't we all given an ATHENS account so that we can look up things ourselves?

Our service phones are capable of playing MP3 files - why aren't we using that to deliver training?

Should I really have to resort to looking up things on Wikipedia on my iPhone during my shift?

We need fresh new ideas that stretch the method of learning from the current 'Powerpoint slides being read out in a classroom' into something more engaging.

Why aren't we spending time in hospital to learn more from our colleagues there? I know that my experience of working in a hospital all those years ago makes me a better EMS.

An example of how this works really well are the heart attacks that we take into the angioplasty labs. When you take in your first one the staff ask if we would like to stay and watch - then they would talk us through what they were doing - and crews enthusiastically embraced this. It was interesting, useful knowledge presented in a really good way.

Then the crews, normally a cynical bunch, return to station and talk about how 'cool' it is and share their expanded knowledge with enthusiasm.

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I've often called for the ORCON target to be scrapped - but for that to happen I think I'd need to kidnap the minister for health and demand it before I start sending him back in small pieces.

We should set up an internal standard for educating our staff - all staff should have X amount of hours training every year. That no more than 2% of training days can be cancelled. That staff should expect professional tuition. Standards that show everyone that the service is serious about training and maintaining it's staff.

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It's not enough to throw education at people and expect it to stick. At least once every year staff should be assessed on their skills and knowledge and (with no risk of disciplinary action) should then, if they are found to be below standard, go for further training.

Currently if you have poor practice it is not recognised until a patient complains or dies. Then the person is disciplined and is either sacked or given 'advice and guidance' which means re-training. By assessing people regularly you can prevent these adverse outcomes and the need to 'punish' staff.

I've seen people with their hand position in the wrong place for CPR, I've seen people placing the leads for an ECG on the patient incorrectly - by assessing people we would be able to pick this poor practice up and correct it, hopefully before it becomes a problem.

I emphasise that this mustn't be a disciplinary procedure - instead it should be a way to re-train people before they end up being disciplined for poor practice.

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By reaching out to other parts of the NHS we should get better at getting feedback to ambulance crews - was that patient I brought in getting the right care from me or did the doctors and nurses at the hospital just roll their eyes at my treatment of them and say nothing?

It is part of the job that I have only a limited time of patient contact and no real way of knowing if what I did for them was the right thing to do. The patient vanishes into the hospital and unless I make a real effort (and probably breach data protection legislation) I have no idea if my treatment of them was correct.

We should build a pathway from the hospital back to us road staff so that we can gain confidence in our treatment of patients and also so that any training issues can be flagged up.

It shouldn't just be restricted to hospitals - we should be sent out with social carers, district nurses and community psychiatric teams. We should be entering GP surgeries and learning about their jobs. Why aren't we going into medical education institutions to share our knowledge with the students there? The learning could go both ways there.

At present some of our patient report forms are audited - the last time I looked I'd had three report forms audited over the last two and a half years. The only feedback that I got was in a meaningless 'compliance' percentage, which if you look at it closely is incredibly statistically flawed.

(For example - for someone with a diabetic problem you get marked down if you don't treat for hypo- and hyperglycaemia at the same time. Which is impossible as they are mutually exclusive conditions. Also the marking criteria is out of date as the treatment has changed).

What we need is more regular feedback on our report forms by not forcing the team leaders who are supposed to do this onto the road to make ORCON targets.

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We have an internal magazine - mostly it concerns itself with ambulance crews who have delivered a baby, or the survivor of a cardiac arrest meeting the crew who saved their life. Lots of little pieces about a crew treating someone for smoke inhalation following a house fire. Only a small part of it's content is concerned with training issues.

I would suggest that this balance needs to be flipped around. It's true that it's nice to celebrate our successes, but once you've read that type of story once or twice it gets old fast. Instead the training department should have a larger say in what goes into the magazine. New policies should be highlighted and case studies and foundations for home study should be more available. Isn't that more important?

We get a printed bulletin every week, but we don't always get it delivered to the station, nor do we always get the time to read it, there is only one printed copy per station (although it is also on the internal website) - meanwhile the internal magazine is sent individually to each member of staff. Which of these two approaches is more likely to reach the road staff? And which one is filled with 'feel good' stories instead of more important clinical updates?

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Touching once more on communication - how can I learn about best practice, or even just simple little tricks from my fellow road colleagues? Currently there is no way to communicate our knowledge between us.

As an example I met an FRU from our of area on a recent job and he tied a head bandage in a new way that I'd never seen before and it worked really well. Without that chance meeting how else could he have shared that knowledge?

Our communication at the moment is very 'top down', what we need to have is some way of communicating around our own level and an easier way to communicate back up the management structure.

The easy way of doing this would be via an internal forum - we are many staff spread over a large geographical area - isn't that what internet communication was designed for?

Where is the internal training blog that allows comments? Where is the wiki of best practice? Where is the forum where ideas can be shared?

I can tell you from experience that blogs, wikis and forums are incredibly easy to set up and with the proper community rules are also easy to maintain.

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So, in summation, what we need is protected training times that can't be cancelled, a and high standard for our education. We should use all the methods that modern teaching uses, including learning at a distance, e-learning and podcasts or videocasts that can be viewed on station or at home.

We should partner with hospitals, GP surgeries and medical education establishments to expand our experience beyond the back of our ambulance as this is something where knowledge could flow both ways. We should make feedback, both internally and externally, much simpler and encourage this discussion as much as possible.

We should use our existing communication pathways to better educate staff - there are huge problems at the moment due to the large area that we cover although by setting up the communication tools we can pretty much guarantee education.

Finally we should put education as a much higher priority than it is at the moment - without education all we road staff feel that we are doing is 'stopping the ORCON clock'. With education you will be able to get a highly motivated workforce that will result in improved performance, and more importantly, improved care.

Am I a taxi driver with bandages whose job is to get to a location in eight minutes, or am I a well trained, well equipped professional with the ability and knowledge to provide effective medical care in emergency situations?

At the moment I feel like a taxi driver.

Today I am going to tell to you about in service training, and where I see the LAS as failing - tomorrow I'll give my ideas for how we can improve this situation.

Across the NHS workers receive in-service training where they learn new skills, refresh old skills, get updated on new equipment and policies and even get assessed on how well they currently perform those skills.

In the LAS that just doesn't happen.

I went looking for my 'continuing professional development' folder so that I could tell you the last time I had some training. I can't find it, I suspect that it is buried somewhere up in my loft, which gives you an idea of when I last used it.

I have a clinical guidelines book - it's dated 2006.

I honestly can't remember the last bit of training I had - I think that it was some years ago and was about how to escape from an attacker.

Actually that isn't true - the last training session I had was on how to use the new radios, I had this training a few weeks after the radios had been 'rolled out', lasted an hour and we were constantly interrupted by Control asking when our ambulance would be available to go back on the road. This was the third time I'd tried to get trained, the first time I tried to get trained it was cancelled ten minutes into the session, the second time it was cancelled before I arrived at station.

My last CPR training was when the number of compressions per breath was changed to 30:2 (whenever that was)- this was given to me in a ten minute presentation from a team leader.

The last time we were given a new drug to play with I had a single sheet of A4 paper which I was to sign and return to say that I had understood the information on it.

Policies change and unless I see the one bulletin on station directing me to the incredibly poorly-designed internal website (that I seldom have a chance to check because we are so busy) I'll never hear about it.

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The problem is that a well trained staff doesn't help the service hit it's governmental ORCON target. Remember that the ORCON target means that reaching someone who is dead beyond any hope of resuscitation in under eight minutes is a success, while reaching a patient in eight minutes and one second yet saving their life is a failure.

When our REAP level goes too high, due to a high volume of calls, or the service not meeting our ORCON target, training is one of the first things to be cancelled. Sadly 'too high' is the normal REAP level these days.

Training is not given the priority that I think it needs - the service wants ambulance crews to leave patients at home (it saves us money and time - meaning that we can get back on the road to continue hitting that ORCON target). But how can crews be confident about leaving patients at home when our post-qualification training is so woefully inadequate?

Since leaving nursing can you guess how many times I have been taught to wash my hands? Handwashing is incredibly important in infection control and you need to be taught how to do this properly, even assessed using a gel that glows under ultraviolet light. There is a specific, effective way to wash your hands that is taught in hospitals in order to make sure it is effective.

I have, since joining the ambulance service, never been taught how to wash my hands.

We have new vehicles being rolled out across the service, there are some big changes as to how the equipment on them is to be used. The training session for these new vehicles takes two hours. I've attempted to get trained on these vehicles on four occasions - on all four occasions the training has been cancelled.

The reason for this training to be cancelled? Someone in Control has decreed that you can't be trained during the rest-break window of your shift.

If we don't get a rest break then we get paid £10. If we are being trained for two hours of that window then the chances of us having a rest break are reduced and the service will have to pay us £10

So, we don't get trained because of the expense of £10.

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When I started in the ambulance service we were hit over the head with sixteen weeks of intensive classroom training that turned plumbers, housewives, carpenters and office workers into ambulance people. It wasn't much fun but it seemed effective - we were taught by ambulance people who'd become training officers.

I'd like to tell you how the training has changed, I think it's now more central and people are trained over the period of (I think) three years to be paramedics. Carpenter to paramedic in three years is... quite fast. You could do it in the 'old days' but by then you'd have had around three years 'on the road' learning the basics of your craft, not around a year.

My knowledge of the current training is informed only by the students who are coming out of the training school - and it's not good. Courses are rewritten as they are being taught, days back in the classroom to consolidate knowledge gained on the road are cancelled (most likely due to trying to reach the ORCON target), students are coming out of training to do practical placements with some rather strange ideas of how we work on the road.

We sometimes get students being put on a placement with us - my crewmate is a paramedic and she is supposed to educate the student in how to practically do our work. She is supposed to have a PPED course under her belt, a course that teaches her how to teach student paramedics. She doesn't. She's asked to be put on this course for a number of years (longer than I've been working with her) and she keeps getting no answer.

How is this being fair, or maintaining the quality of training, for the student paramedic?

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I've personally noticed that my skills have decreased since joining the ambulance service. My knowledge of drugs has started dripping out my ears, my understanding of medical conditions is decreasing and the physical skills of medical care are atrophying.

The reason is that, for 80% of our jobs there is no need for an ambulance, nor for hospital treatment. We arrive, I chat with the patient and then tell them to take a seat in the ambulance. By rote I check their blood pressure and pulse and then we take them to hospital. With such an influx of uncomplicated cases (drunks, colds, runny noses, babies with a high temperature) it is obvious that there is going to be a loss of skills.

Unfortunately, with no training or regular assessment, this skill decay goes unchallenged.

I try to keep my skills up, but with no support from work it's incredibly difficult - so I find myself turning to American EMS sites and podcasts to try and maintain some sort of education.

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One of the ways that you build a motivated work force is through training - something that isn't happening. We get up, turn up to work and do our best to work 'safe'. In this case 'safe' means working so that we don't get any complaints or lose our jobs.

There is no enthusiasm to learn more about our job, about medical conditions or how to do things more effectively.

Hardly anyone reads research on pre-hospital care. After a twelve hour shift I'm seldom in the mood to hit the books myself. The service doesn't provide any encouragement for us to learn on our own, we don't have any libraries, the internal website doesn't have any links with e-learning or educational sites (not that I think any UK based ones exist for ambulance workers) and we don't have any protected time where we can feedback with our peers.

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So, in summary - I think that in the pursuit of pointless targets we do not get the training that we deserve. We do not get the training that the public would expect us to have. Training courses are incredibly rare and are cancelled more often than they are run. What post-qualification training we do get is on an ad hoc basis and doesn't take account of modern training techniques.

Current training of trainees also seems inadequate and it seems that all that is wanted is 'bums on seat' (although this is only my impression that I've had from the students I've spoken to).

There is no counter for skills decay, nor any assessment of the skills that we do occasionally use in order to make sure that we are providing best practice.

In essence I feel like a taxi driver with bandages - not someone educated to provide pre-hospital care beyond the very basics.