With New year's eve night approaching the LAS has put out it's usual call for people to be sensible.

Our head of Emergency Preparedness says this,

“Alcohol-related calls put extra pressure on the Service, so I’d ask people to be sensible. Every minute that we spend looking after somebody who is simply drunk, is a minute that could have been spent helping a patient who is seriously ill or injured. We want people to enjoy themselves, but they should think carefully before dialling 999. It should only be used for emergencies.”

Because. for us - New year's eve is an emergency.

Note that he does say what I'd like us to do - "If you call an ambulance for someone who is drunk, or has had their drink 'spiked' (normally their tenth or eleventh pint), don't expect an ambulance, instead expect the street sweepers to come around and wake you up in the morning".

But no, instead we will continue to mollycoddle people for whom 'I drank so much last night I can't remember anything' is a good night out.

The Saint - commenter and all round good egg has come up with the following campaign, in order to educate the public as to someone being 'pissed' as opposed to 'collapse - unknown cause' or 'life status questionable'

With the stunning success of the Department of Health's FAST campaign, to identify whether a patient has suffered a CVA (Stroke), it has been decided to extend this further for the festive season. The table below may be used by the public to identify whether their mates have suffered a medical or traumatic collapse, or are simply drunk. This will be known as the PISSED scale, and will differ slightly for young males and young females.

	MALE	FEMALE
P	Punchy: Picks fights with inanimate objects, like walls.	Pants: Usually found around her ankles, unless ankles are behind ears.
I	Irritating: Is really fucking annoying, but thinks he is up for a British Comedy Award.	Identity: Is usually called Sharon, Tracy, Chantelle or Chardonnay.
S	Speech: Keeps saying "You're my best mate - I love you" to total strangers.	Spiked: Insists her drink has been spiked. Never states which one of 17 she means.
S	Staggers: Staggers off pavement into heavy traffic.	Sex: Seeks out men for immediate casual sex, despite her targets not being remotely interested.
E	Enuresis: Urinates over himself and anyone/anything else within 5 feet.	Erection: Is not able to engender this reaction in said casual sex partner.
D	Denial: Despite the above, states he hasn't touched a drop of alcohol.	Dead: What she plays when she realises no-one is interested in her.

If the patient scores 1/6 or more then he or she is seriously pissed and you MUST act FAST. call a cab IMMEDIATELY.


As an aside - can I show you this press release made on the 21st of December.

Londoners are being urged to only call 999 with life-threatening emergencies this evening.

The London Ambulance Service is continuing to receive a large volume of calls, and combined with the road and traffic conditions across the capital it means that the emergency system is coming under extreme pressure.
To enable us to provide the fastest response we can to patients with serious or immediately life-threatening illnesses and injuries, we are not currently sending ambulances to callers with minor injuries or illnesses.

Here's an idea. Make this a constant message. That you shouldn't pick up a phone, dial 999 and when asked which emergency service you require ask for an ambulance because you have vomited once, or you have a cough, or a runny nose, or for the last three days have had a painful knee (all calls I've been to in the past few days).


Before I turn out the lights on my 2009, I'd like to wish every ambulance crew working NYE and to all the suckers volunteers working central London that night the very best and a safe shift.
To everyone else, both ambulance crews and 'normal people', I wish a happy and safe new year.
Talk to you in 2010.

He's ninety years old, ex-army.

He's slipped on the ice coming out of his house, we are sent to the call as 'Fallen over, leg is at a funny angle'.

We get there, he's broken his leg all right. He's lovely, the family are lovely.

He has waited one and a half hours for an ambulance.

I am furious. He has been laying on the ice for that long without an ambulance. I've just come from the hospital - the police have been bringing in patients with possibly broken ankles because there are not enough ambulances.

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Apparently it doesn't matter, as the 'public perception' of the service is high.

That doesn't mean we provide a good service - it just means that our PR department is good at making us look good.

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It's not a hard problem to solve, I can see what it is and I'm on the bottom rung of the ladder.

We do not have enough ambulances to meet demand

It's that simple.

We don't need 'initiatives' where a driver and an ECP go around to a house to see if the call really needs an ambulance.

We don't need 'smarter ways of working' - because it won't work, the reasons are many and varied - but it won't work.

What we need are more ambulances and more road staff.

You don't have to be a genius to work that out.

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Year on year the increase of our calls is around 12%.

Our Boss, Peter Bradley seems proud that we will soon be dealing with one million calls in a calendar year.

He's crazy.

The number of calls increase but the number of ambulances, the number of hospital beds don't.

"But there are 400 students being trained at the moment", our PR department will say, "It will all be fine".

Ask how many leave the course, ask how many finish the course and then leave because they are already disillusioned with the job, ask how many regular road staff are leaving the service, retiring, getting the sack, or changing careers?

Is it really a 'huge influx' of staff once you take all that into account?

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Even if we have the staff we don't have the vehicles.

The other day my colleagues at my station were waiting five hours for an ambulance. This is not unusual.

We've ordered more, but it takes too long - we spent too long without getting new ambulances.

There aren't enough ambulances on the road.

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The population of London is increasing, a large amount of this increase comes from immigration, or the expanding of immigrant populations.

Immigrant populations tend to be both poor and under-educated.

Can you tell what the two big causes of poor health are?

Poverty and a lack of education.

We aren't doing too well at getting these populations out of poverty, so it's no wonder that the number of people wanting an ambulance is increasing.

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We aren't going to get people not calling ambulances.

People want ambulances to take them to hospital for free, and no matter how much we tell people otherwise they will continue to call us when they should be using other modes of transport, or not going to hospital at all.

(Today a nurse made an announcement at one of our A&Es that the waiting time was four hours; more than a few people moaned that it was too long and went home - how much of an 'emergency' was their reason for being there in the first place?)

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It's simple - More Calls Need More Ambulances.

It's not rocket science.

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"Unusual weather conditions" the PR department will say, "Lessons will be learned" they will say when someone dies waiting for an ambulance.

Here is a lesson that seems to have escaped those way above my pay scale - In winter, demand for ambulances goes up. We should then provide more ambulances.

Not blokes on pushbikes, not community responders, not FRUs to stop the clock in order to keep the government happy.

More ambulances to take people to hospital.

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If I screw up, I could lose my job.

If I say the wrong thing I could lose my job.

If I'm sick too much I could lose my job.

Apparently if I can't produce enough ambulances, if I can't ensure that they are equipped properly, if I can't promise to get an ambulance to an elderly person with a broken leg in the ice within a reasonable time - well, my job is safe.

I'll probably even get a promotion.

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What is important? It's not the 'public perception' that management and the government go on about, it's not about meeting a pointless target.

It's about not leaving a ninety year old man freezing on ice for an hour and a half.

Simple.

I've not died - my plan was to blog at least every second day, but that has gone for a burton as my internet connection is up and down more times than a *insert metaphor*. I'm trying to get it fixed, but of course that means some time after the bloody waste of time that is Christmas.

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I must admit that I saw this on the BBC, and thought it sounded somewhat familiar.

The government has been urged to review its targets for ambulances responding to 999 calls, following claims that patient care is being affected.

The NHS Confederation, which acts for ambulance trusts, said that targets can produce "unintended consequences" and "may not be benefitting patients."

Ahem .

However Mr Edwards added: "Any narrow target which focuses on one measure does have the potential for producing unintended consequences and maybe not benefitting patients.

"A solution might be to move to a measure in which we measure the outcome of what's done rather than just the process, so what was the outcome for the patient? Did they receive the emergency care that they should have done?

"And if we could move to a situation which was better at measuring that, then we might avoid some of the unintended consequences of these very tight timescale based targets."

He was backed by academic Janette Turner, from the Sheffield University's Medical Care Research Unit.

Cough.

She told the BBC: "The only proven clinical value of an eight-minute response is for patients with cardiac arrest, where a really fast response really can make the difference between whether they survive or whether they die, but for the other patients there's no proven relationship between how quickly the ambulance gets there and whether they survive.

"The problem that creates for ambulance services is if they get there in seven minutes and the patient dies, they have succeeded because they have met a target and if they get there in nine minutes and the patient lives, they have failed because they haven't reached the target."

How's 2004 for warning people about this?

The question that I need to ask now is, seeing as I've been saying this for as long as I've been blogging, I must be an expert on this situation - so can I have a nice paying non-shiftwork job at the DoH?
No, of course not - what do I know about ambulance work anyway? Better to have a someone who has been a teacher and solicitor as the 'expert' on ambulance work?

I've mentioned before in passing my call where I was told that 'Patient wants a cup of tea'.

An 'amber' call - lights and sirens if you please. Drive down the wrong side of the road as well.

Our 'patient' was an eighty year old woman who got up and opened the front door when we arrived. Trying to be as polite as possible I asked her what the problem was.

'My carer hasn't arrived, I need a cup of tea'.

My immediate thought was that this patient wouldn't have much problem making her own cup of tea, but I'm not paid to be an occupational therapist, so I kept my opinion to myself. I tried to feel as much sympathy towards this patient as possible.

I enquired as to how many times a day she would have a carer, what they did for her, and when the carer was expected.

All in all it seemed like a pretty light care package - someone to make sure that she was awake in the morning and someone to put her to bed in the night, meals on wheels and help taking her medicines. Nothing too serious.

But... I know full well what some of the 'carers' on my patch are like, so I looked around for the care notes and rang their office.

'Hello there - London Ambulance Service, I'm with a Mr's Smith and I'm ringing to find out about her carers'.

There was an apologetic cough down the phone, 'Hello ambulance. She's wondering where her carer is isn't she? Sorry about this but she does this all the time - we are a bit short handed at the moment because I've lots of people off with the 'flu - I called her this morning to say that the carer would be half an hour late, but she calls you, the police or the fire service if the carer is more than five minutes late. I'm terribly sorry she's wasted your time.'

The nice lady on the other end of the phone let me know that the carer was on her way there now.

So we watched our 'patient' get up and make herself a cup of tea, and just as she finished the carer arrived, looking somewhat overworked.

I don't know if she was 'mad' or 'bad', but she had caused an A&E emergency ambulance to rush to her aid - for nothing more than a cup of tea.

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What annoys me is that the people up in our Control aren't allowed to use any sort of common sense in triaging calls - for example if someone rings up and says they are the patient then say they have 'difficulty in breathing' despite talking constantly and without apparent difficulty to the calltaker, we are still sent on blue lights and sirens to this 'high priority' call.

Meanwhile the granny who has been laying on the floor in her own urine for eight hours is still a 'low priority' call.

I don't blame the calltakers, they are forced to work to a system that simply does not work - if it worked then I wouldn't find myself rushing to twenty year olds with runny noses on sirens while being cancelled from people who have had strokes.

The solution, while simple, would cost money - as you'd have to train and pay people to have some clinical skills rather than the poor unfortunates who have to robotically read questions and answers from a computer screen while being watched over by officers who have never worked on the road or as calltakers themselves.

But then, little Doris with her broken hip isn't as important as saving money, is she?

I find myself going to a lot of 'victims of crime' that are nothing of the sort - people who have been assaulted by 'some bloke', often 'some big black bloke' who has beaten them up for no reason whatsoever.

Now, while there is random violence and muggings on the streets of Newham and Tower Hamlets, I rarely see it - often the causes of the injury are blatantly obvious.

Normally it's gang activity, or rival drug dealers, or more often X's girlfriend has got off with Y, while X was shagging Z at W's house all because V is T's baby daddy.

Or some such.

Sure, not everyone is some sort of criminal, but it's so common that Im surprised when I see someone that is genuinely innocent.

But, you ask yourself, how do I know who is innocent?

Well dear reader, allow me to give you a generic example how such a call might go...

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"22 year old male, assaulted in street", sometimes outside a pub, more often down some anonymous side street.

We arrive and the injured male is, for want of a better word, sulking. Normally they have minor injuries, a bump to the head, a cut under the eye. Often they will have a 'friend', or rather 'pack of friends' with them.

They go into the back of the ambulance where I professionally assess and treat them.

Either the police are already there, or less commonly the police arrive after us. I let the police treat the back of my ambulance like an interview room. It's warm, dry and well lit - better than the side of the road at 3am in the morning.

The patient gives his name and address, then tells the police that he didn't recognise the assailants, that he didn't see them, that he couldn't give a description (or that he was 'knocked out', and therefore has amnesia of the event) and anyway 'nuffik will happen'.

The more experienced officer will ask the patient if they would like to press charges against the assailant should they get caught - the patient will say no.

The police complete their paperwork and leave, off to another call that has been waiting for them.

Once the police are gone, the patient will either call his 'friends' over, or start talking on his phone. They seem to forget that I'm sitting in the back with them.

The conversation goes something along these lines, "Get Steve and Dwayne, meet me at the hospital - them we'll go over to Ricks house and beat him up".

Sometimes it's in another language, but the intent is clear.

They don't realise that confidentiality doesn't apply to the commission of criminal acts.

If it's a serious threat, rather than the face saving words of someone who has 'had a slap' then I'll inform the police, but normally it's just words, designed to give the impression that the assaulted patient (who whinges at the tightness of the blood pressure cuff) is still 'da man', and therefore not worth bothering the police.

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Another example, that did have me calling the police was for a young male who'd been run over.

He called an ambulance, then left the scene, went home and called us again from there - so, after spending the better part of 45 minutes looking for him I wasn't in the best of moods.

He had a minor injury, probably needed a bit of hospital treatment, but it wouldn't kill him if he didn't get it.

On the way to hospital he told my crewmate that the car had been stolen, that his 13 year old 'cousin' had been driving it, and that they had already burnt the car.

(Those of you with memories may remember that my cars have been stolen on seven separate occasions, mostly by folk like this).

He whinged all the way to the hospital, and when he was told that he would have to wait became belligerent - demanding instead to go home.

I pointed him towards the door and he insulted me for 'being cheeky'.

As he had admitted the commission of a crime, and that it was likely that more such crimes would be committed (and that someone else might get seriously hurt) I reported that chappy to the police.

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I doubt that it would be seen as legal, and (probably quite rightly) privacy groups would be up in arms about the implications, but if the police installed a bug in our ambulances that recorded just the five minutes after they left our vehicle after taking their statements - they'd clear up a lot of crime.

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No, i'm not being serious; but a lot of the 'crime' I find myself going to is 'criminal on criminal', both us and the police take criminal activity against people who don't... 'deserve' is the wrong word... maybe 'expect' it much more seriously.

Once more I find myself concerned with Capacity and Consent.

Capacity and Consent are two linked words that govern how I can treat patients and it always needs to be at the forefront of my mind.

Capacity Is the ability for someone to understand what I am telling them and to be able to make a decision based on being able to understand the risks of choices that they make now.

Consent is my patient allowing me to do things to them, be that blood pressure measurements, giving them medicine or taking them to hospital.

For most of my jobs both capacity and consent are implied - someone calls an ambulance, I arrive, I do certain medical things to them and they do not complain and then I take them to hospital - the patient, for their part goes along with this and everyone is happy.

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In short,

If a patient gives both consent and has capacity - everyone is happy.

If a patient refuses consent, but still has capacity - then I am less happy, but I will leave them alone (and write reams of documentation in order to 'cover my arse')

If a patient consents, but doesn't have capacity, I find myself acting in a parental role - in which I trust that I will do what is best for my patient.

However, If a patient refuses consent but doesn't have that capacity to understand what refusing treatment may do in the future I'm on a bit of a sticky wicket.

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Take the drunk alcoholic who has sunk a couple of bottles of Jack Daniels, swallowed some pills and scrawled what he considers to be a suicide note (but is actually just some wavy lines as he is too drunk to write). He has then thrown himself down in the living room in front of his wife.

We arrive and, after he's already told us to 'fuck off' and taken a swing at us, he refuses to go to hospital.

I'm now dealing with someone who does not consent to treatment, but who - because of the effects of alcohol - can't be considered to have the capacity to refuse treatment.

He may get violent if I try to forcibly remove him to hospital - so I ask for police assistance.

The police may be able to forcibly remove someone to a 'place of safety' (normally an A&E dept.) under Section 136 of the mental health act, but the person needs to be in a public place.

My options come down to (a) Leaving him at home where he could die, and he probably doesn't really want to die, he was just temporarily suicidal because he's drunk, or (b) I drag him off to hospital against his will where he can then try suing me for kidnapping him against his will.

I'd like to think that the law was certain in this point, and while I have no doubt that I'm right and that the law would protect me, I may still lose my job.

(I direct you to the case of a nurse who lost their job after swearing at a patient after the patient had punched him in the face as evidence of how easy it is to lose your job, I also invite you to read my account of 'my first complaint')

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So what did I do in this circumstance? Luckily for me the patient pretended to become unconscious after performing one of the least effective 'fits' I've ever seen, so we managed to cart him off to hospital.

If he hadn't decided to make it easy for me, well I'd have used the help of the police to forcibly remove him and worry about my job later - after all I'm more scared of the Coroner than my bosses.

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The very next day I had a similar situation - someone so drunk that they could barely stand, teetering on the top of a long flight of stairs complaining of chest pain, but refusing to come to hospital because they wanted to have transport home.

He also said that he'd rather die than have to make his own way home from the hospital.

Again, his reasoning impaired by virtue of alcohol, I was left in a dilemma - do I leave him at home when he then dies and I'm up before the coroner, or do I 'trick' him into coming to hospital by saying that they will get him home, thereby risking a complaint and my job.

Once more the imaginary coroner sitting on my shoulder asking me why I left someone vulnerable at home to die won out, and I took him to hospital on the promise that tey would give him transport back home.

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So yes, when a patient doesn't have capacity, but may well complain later - I'll take the route that has them less likely to die. Even if it does risk my job.

A mentally ill, suicidal teenager was ferried around for hours by an ambulance crew because no NHS unit would accept her, the BBC has learnt .

The girl eventually had to be taken to a police cell, documents revealed under the Freedom of Information Act show.

This is just shameful.

Sadly I have often said that of all the psychiatric referrals I have made over the years first as an A&E nurse, and then for the ambulance service - only a handful have gone without incident.

I've had units refuse patients that they should be taking, and one unit had a mental health nurse accuse me, and the police, of lying in order to get them to see a patient. This goes without mentioning the sometimes awful 'care' that they get for existing medical problems. Or the inability of trained staff to do CPR should one have a cardiac arrest.

Sadly it seems that mental health is still the unwanted child of the NHS.

Today I attended a man with obvious (though undiagnosed) mental health issues. He'd had a fall and had been unable to get up for two days. When we arrived he was laying in his own urine in an unlit bedroom.

The flat in which he lived had no electricity and no heating. It was freezing. There was no food in the fridge.

Needless to say we have referred him to our 'vulnerable adult' team and with luck and a fair wind he'll get a proper psychiatric assessment and then social care input.

For those ambulance people who want to learn a new tool - thank the EMS Garage in an upcoming podcast for highlighting the PEAT scale. (I would have scored this patient as a 21 - referral for assistance).