A quick recap for those who haven't yet seen me write about ORCON. ORCON is the government target that tells all ambulance services that they have to keep the time between the phone ringing up in Control and the ambulance arriving on scene to under eight minutes for our highest priority calls. There is also a nineteen minute target for not-so-serious calls. For the low priority calls, like grannies with broken hips, we can leave them on the floor for up to four hours.

This eight-minute target is based around outdated research and has little clinical significance for the majority of our patients, something admitted by our own chief executive as 90% of our calls come from people who do not need an emergency ambulance. This 90% figure is based on the London Ambulance Service's own research¹.

It's easy to tell when to 'start the clock', as soon as the BT operator connects the 999 call to our Control, but when do you 'stop the clock'?

The target states that the ambulance should be on scene. Does this mean when the ambulance pulls up outside your house and I hit the big 'At Scene' button? Does it mean when the keys are out of the ignition of the ambulance (because we track that)? Does it mean when I poke my ugly mug around the bedroom door to find you on your bed with bellyache (and if you live in a block of flats with no working lift it might take me over a minute to actually reach you)?

All these are reasonable ways of measuring the time. When we pull up, or when the keys are out the ignition are easily measured due to the tracking devices in our ambulances. Being face-to-face with a patient would need us to have an accurate watch and to note the time ourselves, so accuracy would be a problem but it would better match the 'patient experience'.

How about marking us as 'on scene' when we are within 200 meters of the address? This is what many of us on the road suspect of happening - when we get within 200 meters or so of the address our MDT 'updates'.

It doesn't matter if you have crashed your car on one side of the dual carriageway and we have to drive an extra five miles to get on the correct side. It doesn't matter if we have to creep around tiny winding estate roads, wary of knocking off the wing mirrors of parked cars. It doesn't matter if the address is a bit wrong, if we are where the computer says we should be then we are 'on scene'.

As the time arrives when we have to finally collate our ORCON success rate approaches (appropriately enough April the 1st), so we find the percentage of calls that we make on target start creeping up towards the magic 75% mark.

Why is this? Well, in the words of our own Chief Executive,

"...our Management Information team check all our records to ensure we capture everything correctly. [The] team are checking every missed call, and with over one million calls, inevitably they are finding some that can be legitimately included."

Which makes me think that they go over every call, and if we were within 200 meters of the address when the eight minutes are up, they then count us as being 'On scene' and therefore the job can be seen as a 'success', regardless of patient outcome.

As always, the LAS and LAS management have the full right to reply to anything that I write here. It would be nice if they could confirm, or deny, us being within 200 meters as being part of hitting our targets, and to what 'legitimately included' means.

¹Taking healthcare to the patient: Transforming NHS ambulance services (Page 8)

Two cases, one I, sadly, have come to expect, the other was a bit more surprising.

In the first we find ourselves going to an elderly man who has fallen out of bed, normally a nice simple job that doesn't require much from us apart from a quick dusting off, a check to make sure that they aren't hurt and to make sure that this simple 'mechanical' fall isn't the start of something more serious.

Being the eagle-eyed medical professionals that we are, we notice that our patient has a lot of sores on his body - so we ask him about them.

He's been getting them for a while and the district nurses have been out to dress the sores on his legs for a few weeks now. The sores have since spread to his arms, but the nurses won't dress them as it's not in their care plan. He has been trying to dress them himself - with little success.

Once upon a time I did a nursing placement with a district nurse service, one of the things that you get very good at very quickly is the ability to dress leg wounds. You see so many ulcerated legs you start thinking that everyone over the age of sixty must have them.

You learn how to dress these wounds so that the dressing stays on, so that it is clean, and you make sure you use the best dressing for that particular type of wound.

I look at the dressings on the man's legs. These dressings are awful. They are secured (and I use that word loosely), not with medical tape, but with Sellotape. The bandages are the wrong sort of bandages so they are just falling off his legs. I wasn't too impressed with the underlying dressing either, the layer that is supposed to promote the healing of these sores.

I could maybe understand the dressings not being of high quality if the patient were the type to undo his dressings but he isn't. Couple this with the open sores on his arms that hadn't been dressed at all and I could only really say that this was a very poor example of nursing care.

So I did the only thing that I could, I took him to hospital so that his wounds could be treated properly, and then I filled in one of our 'vulnerable adult' forms, hopefully someone higher up the food chain will take notice of my concerns and do something about the terrible treatment of this patient.

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I'm used to poor care in the community, I expect better in hospitals.

We were called to transfer a patient with many broken bones from a ward in one hospital to another hospital, a fairly simple job although the journey would take over an hour. Little did I know we'd take about the same amount of time picking the patient up from the origin ward.

We arrived on the ward and found that our patient was quite a chirpy fellow, he was covered in plaster casts and had an external fixator through his pelvis. No problem, this wouldn't be a tricky transfer.

I asked the handover nurse what sort of pelvic fracture he had, while it's been some time since I studied orthopaedic treatment (in a non-emergency setting), I suspected that due to the presence of the fixator it would be a an 'open book' fracture.

The nurse told me that she didn't know, and handed the notes at me.

Non-plussed at this lack of knowledge about the patient that she was looking after I asked what else he'd broken.

"Dunno", I was told by the nurse.

I gritted my teeth.

There was a strange contraption attached to the patient's leg - to be honest I wasn't sure what it was, so I asked the nurse.

I wasn't altogether surprised when she told me that she had no idea what the device was for.

It was about then I started to see red - as a nurse you need to know about your patients, you should definitely know what the various bits of equipment hanging off the patient are for and how to look after them. Imagine if this bit of kit needed to be removed once an hour - without knowing this you could put the patient at risk of serious harm.

If you get a patient arrive in your ward with something unusual you find out what it is and how to look after it, to do otherwise is, in my eyes, a basic failure of nursing ability.

The nurse noticed I was getting annoyed at her lack of knowledge and at her apparent apathy towards the care of her patient.

"It's not like I've lied to you", she said referring to the machinery, "I could have said I knew what it was for".

"That's not the point", I replied, "the patient came down from ITU with it attached to them, you should have asked how to look after it when it was handed over to you - or you could have rung up ITU at any point during the day and asked them over the phone. It's hardly rocket science".

She stomped off in a strop. I don't think that she understood the point I was trying to make.

I checked the notes that we'd been given - there wasn't a CD of the patent's x-rays in there.

"The orthopaedic nurse will have it", I was told by another nurse, "she'll have gone home by now".

"Can you not get another copy", I asked.

"I don't know how".

"Tell you what", I offered, "bleep the Ortho SHO and get them to burn you a new copy, because otherwise the receiving hospital will think you are all idiots here".

"Oh - that's a good idea", she agreed.

So finally - after an hour at the hospital we were ready to move the patient onto our trolley. I looked at the patient's drug chart.

"He last had his painkillers seven hours ago", I told the nurse.

"Yes?", she said, "he's not in pain".

"Ah, but just think", I explained, "we are going to drag him from his bed across to our trolley, then wheel it through the hospital and into the back of an ambulance. We are then going to drive that ambulance over the horribly bumpy streets of London for an hour. Might he not benefit from a bit of pain relief before we head off?"

'Oh.... Yes".

After an injection of what I wold consider a homeopathic dose of analgesia I then had to browbeat some of the nurses to help us move this immobile man across onto our trolley. I also had to teach them how to safely move someone who has half a tonne of metal holding them together .

So... I know that this isn't a specific orthopaedic ward - but all I was looking for was a bit of common sense, even for someone to realise that their current knowledge isn't good enough for this patient and ask for help. But, sadly, there wasn't any of that self-awareness that I'd hope to see in a sentient life-form, let alone a professional.

I don't know - sometimes I feel like returning to nursing so I can stalk the wards with my 'Big Stick o' Learning' gently tapping people on the head until they realise that NHS shouldn't be a watchword for slapdash care.

Or is it just me, is this acceptable care these days? Should I stop being so harsh on other people, expecting them to do at least as well as I would think I could do? Am I just judging these others as being incompetent while blind to my own inadequacies? Would I really prefer a return to 'old fashioned' matrons who would tear you off a strip in public, thus humiliating you and making the lesson stick in your head - or are the 'modern matron' with their clipboard and 'softly, softly' approach in fear of 'stressing out' an employee the way forward?

I dunno - I just drive a van.

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The Peter Principle is the principle that "In a Hierarchy Every Employee Tends to Rise to His Level of Incompetence.", something that seems particularly apt in the NHS. However, I sense that this works in all forms of life and work. Consider this my Monday Question - What is the worst sort of incompetence you have come across lately.

Commentors who just post 'The Government' will be mocked for their stating of the obvious and their lack of imagination.

Go on, have a moan...

It's only when I get close to the address that I recognise where I'm going. I've been to her a couple of times, a seven year old who has regular fits - the mum never panics and it's normally a pretty easy job to get the child out to the ambulance and down to the hospital. It's the end of our shift so for us it looks like it's going to be a nice little 'off job'.

The mum waves at us from the front door, she seems unconcerned which is always a good sign, she's seen her child fit before and obviously it can't be too bad an episode. She directs us upstairs.

Lucy, the little girl, is apparently asleep on the bed, a damp patch near her head means that she has either vomited or drooled during her fit.

I start with the basics, airway and breathing - it's a check that we do without thinking, almost all of our patients are breathing.

This one isn't.

'Pass me the ambu-bag', I ask my crewmate.

'That can't be right', I think. I bend down, sitting on my haunches so that my eyeline is level with Lucy's chest, it must just be a trick of the light.

Nope, she's not breathing.

Still thinking that my eyes are playing tricks on me I put my hands on either side of her chest, hoping to feel the rise and fall of the chest.

There isn't any.

So I start breathing for her. My crewmate has already put the oxygen monitor on Lucy's finger, it's showing 78%, much, much lower than it should be.

As I 'bag' her, my crewmate asks the mother what happened. Lucy was having a fit so her mother gave her some medication to stop her coming out of the fit. She used to have one type of medicine but it was discovered that she was over-sensitive to it and as well as stopping the fit it would also stop her breathing.

The doctors, being wise, realise that perhaps another drug would be advisable. Perhaps this drug other drug wouldn't stop her breathing.

No such luck.

However, I'm fairly relaxed. Lucy's oxygen levels have come up to 100% and she's moving around under her own steam. It's always weird to have a patient who isn't breathing for themselves start moving around under you, it's even weirder if you are doing CPR on someone and they are trying to fight you off.

She's still not making any effort to breathe for herself but that's no problem - she's got a nice open airway and it's an easy job to breathe for her.

Time to go, so I pick her up, sling her over my shoulder and have a quick trot down the stairs and out to the ambulance.

She must have had a growth spurt as I can't remember her being this heavy...

I put her down on the ambulance trolley, re-check her airway and continue bagging her. She's still got a bit of a gag reflex so we can't pass a breathing tube into her airway. We are only a few minutes away from the hospital, so we decide to have a nice relaxed 'Blue Call' into a pre-alerted hospital

Nice and easy, bag her all the way in, no problem.

And then, that beautiful, clear, open airway disappears under a mountain of vomit. All hope of getting air into her lungs vanishes with it.

I reach for the suction, with a bit of effort I clear away the debris of dinner - whole chunks of food that were in her airway and now spread around the floor of the ambulance.

A part of my brain asks why, at this late stage of the night, there is so much undigested food in the girl's stomach.

The airway is now clear and I can resume breathing for her, sadly our ambulance is now covered in chunks of partly-digested stew. It's going to take quite a while to get it clean.

We roll up to the hospital and are met by my favourite paediatric nurse (actually, that's a lie - all the paediatric nurses at this hospital are my favourite).

'I knew it would be Lucy', she says to me as we wheel the trolley through the Resus doors. By now she is making some effort to breathe, so it's all looking rather good.

My crewmate and I are happy, even though we have a big clean up job ahead of us because this is what we get paid for.

Another call from the police, another assault in the street that was somewhat unusual as it was given as an injury sustained in the course of a mugging. Despite what the media would have you think I would suspect that the fear of mugging is much worse than the actual rates of muggings.

I base this on no evidence apart from the distinct lack of assault calls that I go to where mugging is a motive.

We arrived to find the police already there and a young man sitting, somewhat battered, by the side of the road. Cuts and bruises from a couple of punches to the face, nothing too serious, but painful nontheless.

What made us smile was that this was the mugger, not the victim.

In broad daylight this scumbag decided to steal a woman's handbag. He'd grabbed it and started running down the busy street.

What he didn't reckon on was a bit of 'community policing' and someone gave chase, punched him in the face a couple of times and disappeared before the police arrived.

Not a serious injury, but our 'victim' was left whinging about the pain while we, and the police, contemplated the mugger's bad luck. He'd need some stiches to his face, but was otherwise not seriously hurt.

Obviously I treated him clinically as I would any other patient, but perhaps without the same 'bedside manner' as I would give to, say, a little old lady who'd spent a few hours on her bedroom floor.

The police officer and I discussed how much of the money that I pay as taxes would go towards this person's treatment.

I don't think (and hope) that the police will look too hard for the person that stopped this thief.

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Monday's question - In your own work, or day to day life, what events give you joy? Obviously the above story made me happy for the rest of the day, but I also like going to patients that say 'Thank you' at the end of their time with us. I also like transfers to the country, where there is green stuff, trees and the like. I'd think that even if I worked in an office there would still be something that would make my day, so, what is yours?

We had an exceptionally pleasant day last week, far removed from the usual belly aches and drunks that we normally find ourselves attending.

'SCBU transfer - Newham to Oxford'

In all the years that I've been in this job I've never had to do a SCBU (Special Care Baby Unit) transfer. Normally it is the job of BETS (Baby Emergency Transfer Service... I think), they have a special vehicle, special staff and they do this sort of thing all the time.

What this meant for us was that we would have to store our normal trolley-bed at station, pick up the special straps that are used to secure an incubator in the ambulance and then transfer the baby in the incubator along with the Doctor and nurse team to the other hospital.

I don't mind telling you that neonates, especially sick neonates scare the living hell out of me. It's purely a lack of experience thing, when I was working in A&E I almost never saw any child under the age of six months or so, in the ambulance service the aforementioned BETS deal with these very young, very sick patients.

A couple of my friends have done secondments on the BETS team and they have all enjoyed it and learned a lot from it - the Doctor and nurse team like to involve the ambulance crew as much as possible so that you aren't just 'the driver'.

I'm not entirely sure of the reason behind the BETS team needing a frontline A&E ambulance to do their work that day, through conversation, I suspect that they are a bit short of their normal ambulance staff because local ambulance managers are refusing to release them from their normal duties to work on BETS. 'Losing' a member of staff to a secondment doesn't help with the much more important ORCON eight-minute target.

We arrived at Newham hospital in good time, having just been taught how to use the straps to secure the incubator - the bags the straps come in have illustrated instructions on how to fit them, which is good for us slightly dense ambulance staff.

Sadly for my crewmate and I, who like a nice drive out to the country now and again to see the trees, the transfer location had been changed to a local hospital.

The BETS Doctor and Nurse (and departing night-shift ambulance person) were incredibly nice, and very jolly. They involved us in the baby by explaining what was going on with it - they don't need to because in this situation all we are is essentially a very specialised taxi-driver, the Doctor and nurse look after the patient, all we have to do is (a) Not get lost, and (b) Don't crash. However it's very nice to be involved with the patient, and in those few minutes I learned some new things.

The transfer itself went very smoothly and the team told us to grab a cup of tea from the receiving SCBU tea-room. It would be rude to refuse such an offer.

The doctor then informed us they they had another transfer if we were interested...

I called up Control and explained the situation, as we already had the securing straps and had left our trolley-bed on station I thought that it would be worthwhile for us to continue with this second transfer rather than faff around getting another ambulance ready. Control agreed, as they often will do when 'on the ground' knowledge seems to make sense.

So we drove to a hospital on the edge of London and transferred another neonate into a specialist unit.

These two transfers were so involved that, with the exception of an early morning back pain call, they were the only jobs we did that day.

It also gave us the warm fuzzy feeling that we rarely have, the feeling that you are actually helping someone who needs serious medical care. Both these patients were incredibly sick and we were playing a little part in the chain of care that they were getting from the midwives, Doctors, nurses, HCAs, radiographers, haematologists and all the others in order to give them the best chance of life.

I doubt anyone from the BETS team read this, but if they do I'd just like to thank them for an exceptional day and for making us feel welcome in their world. They aren't often talked about in public, but with around seven transfers a day, they do an incredibly important job.

The police officer met us outside the station. Both ourselves and the FRU had driven fast through the traffic to reach the station. To be honest, our driving fast may have been because we we due off shift in around twenty minutes. We don't like having to go home late.

"Sorry gents", the officer apologised, "we nicked him for shoplifting, then he said he had difficulty in breathing and our Doc said he's not fit to detain".

"No worries mate", I told him, "where is our punter".

The officer pointed to a dishevelled man sitting on the bench.

"He's a heroin addict", the officer told me.

Never mind, I thought, do the necessary and pop him into hospital no skin off my nose.

The man, our patient, stood up and gathering his things walked towards me.

"What seems to be the problem?", I asked.

The man then proceeded to puff air out his mouth in what I can only describe as the world's worse attempt to fake an difficult. I took a step back to get away from the cone of foul smelling junkie breath that washed over me.

"I. Can't. Breath." He whispered between puffs. "Asthma.", he added as a coda.

"That ain't what asthma sounds like", I told him, "C'mon out to the ambulance. Is he still under arrest?", I asked the officer.

"Nope, we bailed him - he's free to go".

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Once we got in the ambulance, the man's attitude changed completely - from apparently being unable to breathe he started to breathe normally and a big grin spread over his face.

"So", I asked, knowing the answer before the question left my lips, "How long have you had problems with your breathing".

He cackled, "Since I got arrested".

"Are you telling me you faked it?", I asked, again not needing to hear the answer.

"Yeah, well I wouldn't have got bail would I?".

Images of murder flashed through my head, lingering a little longer than normal on the incredibly painful ones.

I took a deep breath. Then another one because the first one didn't calm me.

"What does it say on the side of this ambulance", I demanded.

"Ambulance?", he said.

"What else?"

"Dunno".

"It says 'Emergency', not 'get out of jail free'. It's a good job you convinced the doctor, otherwise I'd march you right back in the for wasting my time."

"Why would you do that?", he whinged, "that's not very nice".

"Because, you idiot, I could be going to someone who is really sick, not someone who's faking it to get out of trouble". I didn't add that I could have escaped going home late after a twelve hour shift with no break as well.

I continued, "All my patients today have been lovely, but you had to go and ruin a pleasant day".

"Don't be like that", he whined.

I decided to spend the rest of the journey in silence. Just in case I said something that I would later regret. It was obvious that this person's universe began and ended with him. Consideration of other people just wasn't in his programming. It was this that made me angry, not the thought that he considered himself smart enough to fool us into treating him.

I still did all the clinical things that I would be expected to do, but instead of my normal kind words and a gentle explanations I did them in silence. Quite literally biting my tongue.

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We got to the hospital where he tried lighting up a cigarette in the waiting room - until I told him to take it outside. You could almost hear his brain thinking 'but it's cold out there''. So we left him, sitting in a waiting room for a 'cough' that only barely existed.

I left, knowing full well that were he so inclined, he could complain about my 'attitude' and I'd end up disciplined. Meanwhile I write it here, in the public domain, to show you the sorts of things we really have to put up with.

So the next time you hear about people waiting too long for ambulances, consider for a moment the patient above. That might be why the ambulance arrives later than expected.

It is a proven scientific fact that people who make hoax calls to the emergency services have much smaller than average penises.

Just thought you'd like to be made of that fact.

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We had found ourselves on station, something of a rarity, and like all good emergency workers at 5am in the morning had dropped off to sleep within seconds of sitting down.

I'd like to say that I'd been asleep long enough for my drool to stick my face to the sofa that I was laying on, however in all honesty I tend to drool before I go to sleep.

But then, as is always the case, the activation phone went - we were being sent on a stabbing!

Of course I've given away the surprise twist to this story, I wouldn't be dealing with something interesting that actually required an ambulance, instead we would be driving up and down the road looking in vain for what I was hoping would be an interesting blogpost.

The thing that made us think that it was the genuine article is that there have been an ton of stabbings in my patch at the moment, probably, but not limited to, fallout over the boy who was stabbed to death a few streets down from our ambulance station.

For a while it seemed that everywhere we drove there would be police tape across the road, cordoning off another stabbing.

But not for us, no blue lighting to a trauma centre. Instead a search of the area and a message to Control of, 'Area searched, no trace'.

And then, the very next day, someone was stabbed to death around the corner.